Features and predictors of activity limitations and participation restriction 2 years after intensive rehabilitation following first-ever stroke.

BACKGROUND: Although stroke-related disability has been extensively studied, only few studies have investigated Participation restriction in chronic stroke survivors. AIM: To identify features and predictors of Activity limitation and Participation restriction in the chronic phase of a first-ever stroke. DESIGN: Cross-sectional observational study. SETTING: Comprehensive stroke unit with outpatient rehabilitation facility. POPULATION: Subjects submitted to intensive rehabilitation after first-ever stroke, from 1st January 2009 to 31st December 2010. METHODS: Participation was investigated through the Frenchay Activity Index (FAI) and the Functional Status Questionnaire (FSQ) at 2.4±0.5 years after the event. Basic activities of daily living (ADL) and mood were also assessed through the Modified Barthel Index (MBI) and the Beck Depression Inventory (BDI). A retrospective search of the medical records looked for: type/side of brain lesion, stroke clinical syndromes, comorbidities and functional condition at discharge from intensive rehabilitation (upper limb motricity index-ULMI-, Functional Ambulation Category-FAC, MBI, cognitive deficits). RESULTS: Forty-five subjects (17 female, age 70.1±11.5 years) were enrolled. They showed a striking restriction in their Participation, mainly for FAI-outdoor activities (median FAI score was <50% of the theoretical maximum). A poor gait function (FAC) and an impaired mood (BDI) were the only independent predictors of FAI indoor (F=6.1; p=,005; R^2= 64%) and outdoor activities (F=4.1; P=0.01; R^2=48%), respectively. The univariate analysis showed a strong dependence of all FSQ scores from global disability (MBI), motor function impairment (ULMI and FAC) and cognitive deficits. Depression influenced "psychological function" score, whereas gait capacity was the only factor significantly associated with the "work performance" score. The gait function level, achieved after intensive rehabilitation, was extrapolated by the multivariate analysis, as the most powerful independent predictor of the chronic activity limitations, as measured by MBI (F=33.8, P<0.0001, R2=0.539). CONCLUSION: Gait dysfunction is the main factor of Activity limitations and Participation restriction in chronic stroke. Participation is restricted by global disability, depression, older age and dementia. More than 50% variance of Participation measures cannot be explained by the quoted factors. CLINICAL REHABILITATION IMPACT: The study results support the need to integrate the standard rehabilitation approach with vocational rehabilitation in order to reduce Participation restriction.

Short daily hemodialysis: blood pressure control and left ventricular mass reduction in hypertensive hemodialysis patients.

Several retrospective and uncontrolled prospective studies reported blood pressure (BP) normalization and left ventricular mass (LVM) reduction during daily hemodialysis (DHD). Conversely, the burden of these major independent risk factors is only marginally reduced by the initiation of standard thrice-weekly dialysis (SHD), and cardiovascular events still represent the most common cause of death in hemodialysis patients. Therefore, we performed a randomized two-period crossover study to compare the effect of short DHD versus SHD on BP and LVM in hypertensive patients with end-stage renal disease. We studied 12 hypertensive patients who had been stable on SHD treatment for more than 6 months. At the end of 6 months of SHD and 6 months of DHD in a sequence of randomly assigned 24-hour ambulatory BP monitoring, echocardiography and bioimpedance were performed. Throughout the study, patients maintained the same Kt/V. A significant reduction in 24-hour BP during DHD was reported (systolic BP [SBP]: DHD, 128 +/- 11.6 mm Hg; SHD, 148 +/- 19.2 mm Hg; P < 0.01; diastolic BP: DHD, 67 +/- 8.3 mm Hg; SHD, 73 +/- 5.4 mm Hg; P = 0.01). The decrease in BP was accompanied by the withdrawal of antihypertensive therapy in 7 of 8 patients during DHD (P < 0.01). LVM index (LVMI) decreased significantly during DHD (DHD, 120.1 +/- 60.4 g/m(2); SHD, 148.7 +/- 59.7 g/m(2); P = 0.01). Extracellular water (ECW) content decreased from 52.7% +/- 11.4% to 47.6% +/- 7.5% (P = 0.02) and correlated with 24-hour SBP (r = 0.63; P < 0.01) and LVMI (r = 0.66; P < 0.01). In conclusion, this prospective crossover study confirms that DHD allows optimal control of BP, reduction in LVMI, and withdrawal of antihypertensive treatment. These effects seem to be related to reduction in ECW content.