Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS): A single-center RCT.

BACKGROUND: Constraint-induced movement therapy (CIMT) is among the most developed training approaches for motor restoration of the upper extremity (UE). METHODS: Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS) was a single-blind phase II trial of CIMT during acute inpatient rehabilitation comparing traditional UE therapy with dose-matched and high-intensity CIMT protocols. Participants were adaptively randomized on rehabilitation admission, and received 2 weeks of study-related treatments. The primary endpoint was the total Action Research Arm Test (ARAT) score on the more affected side at 90 days after stroke onset. A mixed model analysis was performed. RESULTS: A total of 52 participants (mean age 63.9 +/- 14 years) were randomized 9.65 +/- 4.5 days after onset. Mean NIHSS was 5.3 +/- 1.8; mean total ARAT score was 22.5 +/- 15.6; 77% had ischemic stroke. Groups were equivalent at baseline on all randomization variables. As expected, all groups improved with time on the total ARAT score. There was a significant time x group interaction (F = 3.1, p < 0.01), such that the high intensity CIT group had significantly less improvement at day 90. No significant differences were found between the dose-matched CIMT and control groups at day 90. MRI of a subsample showed no evidence of activity-dependent lesion enlargement. CONCLUSION: Constraint-induced movement therapy (CIMT) was equally as effective but not superior to an equal dose of traditional therapy during inpatient stroke rehabilitation. Higher intensity CIMT resulted in less motor improvement at 90 days, indicating an inverse dose-response relationship. Motor intervention trials should control for dose, and higher doses of motor training cannot be assumed to be more beneficial, particularly early after stroke.

Factors associated with withdrawal of mechanical ventilation in a neurology/neurosurgery intensive care unit.

OBJECTIVE: The objective of this study was to identify factors associated with the decision to withdraw mechanical ventilation from patients in a neurology/neurosurgery intensive care unit. Specifically, the following factors were considered: the severity of the neurologic illness, the healthcare delivery system, and social factors. DESIGN: Retrospective analysis of prospectively collected clinical database. SETTING: Neurology/neurosurgery intensive care unit of a large academic tertiary care hospital. PATIENTS: Patients were 2,109 nonelective admissions to the neurology/neurosurgery intensive care unit who received mechanical ventilation over a period of 82 months. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The average age was 56 +/- 19.7 yrs, 53% were male, and 81% were functionally normal before admission. The median Glasgow Coma Scale score was 14, the average Acute Physiology and Chronic Health Evaluation II severity of illness score was 13.5 +/- 8.3, and probability of death was 18.2 +/- 22.0%. Mechanical ventilation was withdrawn from 284 (13.5%). Factors that were independently associated with withdrawal of mechanical ventilation were as follows: more severe neurologic injury [admission Glasgow Coma Scale score (odds ratio 0.86/point, confidence interval 0.82-0.90), diagnosis of subarachnoid hemorrhage (odds ratio 2.44, confidence interval 1.50-3.99), or ischemic stroke (odds ratio 1.72, confidence interval 1.13-2.60)], older age (odds ratio 1.04/yr, confidence interval 1.03-1.05), and higher Acute Physiology and Chronic Health Evaluation II probability of death (odds ratio 1.03/%, confidence interval 1.02-1.04). Mechanical ventilation was less likely to be withdrawn if patients were African-American (odds ratio 0.50, confidence interval 0.36-0.68) or had undergone surgery (odds ratio 0.44, confidence interval 0.2- 0.67). Marital status, premorbid functional status, clinical service (neurology vs. neurosurgery), attending status (private vs. academic), and type of health insurance were not associated with decisions to withdraw mechanical ventilation. CONCLUSIONS: We conclude that decisions to withdraw mechanical ventilation in the neurology/neurosurgery intensive care unit are based primarily on the severity of the acute neurologic condition and age but not on characteristics of the healthcare delivery system. Care is less likely to be withdrawn from African-American patients or those who had surgery.

Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke?

BACKGROUND AND PURPOSE: Motor dysfunction after unilateral deafferentation in primates can be overcome by restraining the unaffected limb. We asked whether a constraint-induced movement (CIM) program could be implemented within 2 weeks after stroke and whether CIM is more effective than traditional upper-extremity (UE) therapies during this period. METHODS: Twenty-three persons were enrolled in a pilot randomized, controlled trial that compared CIM with traditional therapies. A blinded observer rated the primary end point, the Action Research Arm Test (ARA). Inclusion criteria were the following: ischemic stroke within 14 days, persistent hemiparesis, evidence of preserved cognitive function, and presence of a protective motor response. Differences between the groups were compared by using Student's t tests, ANCOVA, and Mann-Whitney U: tests. RESULTS: Twenty subjects completed the 14-day treatment. Two adverse outcomes, a recurrent stroke and a death, occurred in the traditional group; 1 CIM subject met rehabilitation goals and was discharged before completing 14 inpatient days. The CIM treatment group had significantly higher scores on total ARA and pinch subscale scores (P:<0.05). Differences in the mean ARA grip, grasp, and gross movement subscale scores did not reach statistical significance. UE activities of daily living performance was not significantly different between groups, and no subject withdrew because of pain or frustration. CONCLUSIONS: A clinical trial of CIM therapy during acute rehabilitation is feasible. CIM was associated with less arm impairment at the end of treatment. Long-term studies are needed to determine whether CIM early after stroke is superior to traditional therapies.

Documenting productive behaviors. Using the functional behavior profile to plan discharge following stroke.

The Functional Behavior Profile (FBP) is presented as a clinically useful measurement tool to guide placement decisions following stroke. The measure provides the practitioner with a tool to identify the nature and extent of the behavioral capabilities and problems caregivers will face if they choose to manage their loved ones at home. The FBP yields information for planning treatment. Individuals with scores of 84 or lower were five times more likely to need supervision after discharge than those with scores of 85 or higher. The FBP was able to correctly classify 69% of the 45 patients in this study. Additionally, the FBP identified key behaviors that discriminated between patients who go home compared to those who require supervised care.

Home-based multidisciplinary diagnosis and treatment of inner-city elders with dementia.

The Memory and Aging Project Satellite (MAPS) of the Washington University Alzheimer's Disease Research Center was developed to meet the medical, social, and housing needs of minority and medically underserved elders with cognitive impairments. MAPS is located in the offices of the St. Louis Area Agency on Aging (AAA). This program provides multidisciplinary outreach, as well as home-based diagnosis, treatment, and case management. It differs from most other satellite programs in that it seeks to provide service to individuals who do not voluntarily seek help for dementia. Cognitively impaired clients had numerous, unmanaged medical conditions and social problems. Few clients were adequately served by health and social service systems. Despite recent contact, only 10% of clients received a formal diagnosis of dementia from a physician. Treatment was hampered by the absence or limitations of caregivers. Despite the complexities of these cases, the MAPS staff have been generally successful in addressing client problems.

Artificial neural networks improve the prediction of mortality in intracerebral hemorrhage.

BACKGROUND: Artificial neural network (ANN) analysis methods have led to more sensitive diagnosis of myocardial infarction and improved prediction of mortality in breast cancer, prostate cancer, and trauma patients. Prognostic studies have identified early clinical and radiographic predictors of mortality after intracerebral hemorrhage (ICH). To date, published models have not achieved the accuracy necessary for use in making decisions to limit medical interventions. We recently reported a logistic regression model that correctly classified 79% of patients who died and 90% of patients who survived. In an attempt to improve prediction of mortality we computed an ANN model with the same data. OBJECTIVE: To determine whether an ANN analysis would provide a more accurate prediction of mortality after ICH when compared with multiple logistic regression models computed using the same data. METHODS: Analyses were conducted on data collected prospectively on 81 patients with supratentorial ICH. Multiple logistic regression was used to predict hospital mortality, then an ANN analysis was applied to the same data set. Input variables were age, gender, race, hydrocephalus, mean arterial pressure, pulse pressure, Glasgow Coma Scale score, intraventricular hemorrhage, hydrocephalus, hematoma size, hematoma location (ganglionic, thalamic, or lobar), cisternal effacement, pineal shift, history of hypertension, history of diabetes, and age. RESULTS: The ANN model correctly classified all patients (100%) as alive or dead compared with 85% correct classification for the logistic regression model. A second ANN verification model was equally accurate. The ANN was superior to the logistic regression model on all objective measures of fit. CONCLUSIONS: ANN analysis more effectively uses information for prediction of mortality in this sample of patients with ICH. A well-validated ANN may have a role in the clinical management of ICH.

Predictors of acute hospital costs for treatment of ischemic stroke in an academic center.

BACKGROUND AND PURPOSE: We sought to determine predictors of acute hospital costs in patients presenting with acute ischemic stroke to an academic center using a stroke management team to coordinate care. METHODS: Demographic and clinical data were prospectively collected on 191 patients consecutively admitted with acute ischemic stroke. Patients were classified by insurance status, premorbid modified Rankin scale, stroke location, stroke severity (National Institutes of Health Stroke Scale score), and presence of comorbidities. Detailed hospital charge data were converted to cost by application of department-specific cost-to-charge ratios. Physician's fees were not included. A stepwise multiple regression analysis was computed to determine the predictors of total hospital cost. RESULTS: Median length of stay was 6 days (range, 1 to 63 days), and mortality was 3%. Median hospital cost per discharge was $4408 (range, $1199 to $59 799). Fifty percent of costs were for room charges, 19% for stroke evaluation, 21% for medical management, and 7% for acute rehabilitation therapies. Sixteen percent were admitted to an intensive care unit. Length of stay accounted for 43% of the variance in total cost. Other independent predictors of cost included stroke severity, heparin treatment, atrial fibrillation, male sex, ischemic cardiac disease, and premorbid functional status. CONCLUSIONS: We conclude that the major predictors of acute hospital costs of stroke in this environment are length of stay, stroke severity, cardiac disease, male sex, and use of heparin. Room charges accounted for the majority of costs, and attempts to reduce the cost of stroke evaluation would be of marginal value. Efforts to reduce acute costs should be monitored for potential cost shifting or a negative impact on quality of care.

The use of one-arm crank ergometry in the prediction of upper body aerobic capacity.

OBJECTIVE: To determine whether a submaximal one-arm cranking test could be used to predict an individual's upper body aerobic capacity. This issue has potential importance for the fitness assessment of individuals with neurological disease or damage who have hemiplegia. METHODS: Nine healthy male volunteers (33+/-2.4 years) and nine female volunteers (27+/-1.9 years) performed a two-arm maximal, two-arm submaximal test and a one-arm submaximal arm crank ergometry test. Heart rate (HR) was monitored via a three-lead electrocardiogram (ECG) and expired air was analysed every 30 seconds throughout Prediction of peak oxygen consumption (Vo2peak) was calculated by linear extrapolation to an age-adjusted HRpeak. RESULTS: Heart rate and Vo2 were highly correlated in each test, and there were no significant differences between the Vo2peak values obtained from maximal crank ng and Vo2peak predicted from one- and two-arm submaximal tests for males and females. As expected, males were found to have significantly (p<0.001) higher actual and predicted Vo2peak values, indicating that separate regression equations should be used for males and females. CONCLUSIONS: Heart rate values obtained during one-arm submaximal cranking have the potential to predict arm cranking Vo2peak, and therefore provide an estimation of an individual's aerobic capacity, in addition to those obtained from the more traditional two-arm tests.

Hydrocephalus: a previously unrecognized predictor of poor outcome from supratentorial intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Although several factors have been identified that predict outcome after intracerebral hemorrhage (ICH), no previous study has investigated the impact of hydrocephalus. The purpose of this study was to determine whether the presence of hydrocephalus after ICH would predict mortality and functional outcome. METHODS: Patients with spontaneous supratentorial ICH were identified in our prospectively collected database to determine the following: age, sex, race, past medical history; Glasgow Coma Scale (GCS) score and blood pressure on admission; use of mechanical ventilation, mannitol, and ventriculostomy; and medical complications. CT scans performed within 24 hours of hemorrhage were retrospectively analyzed to determine lesion size and location, pineal shift, cisternal effacement, intraventricular hemorrhage (IVH), and hydrocephalus. Outcome was determined with use of hospital disposition (dead, nursing home, rehabilitation, home) and functional outcome (Functional Independence Measure [FIM]) at 3 months. Patients with and without hydrocephalus were compared and univariate and multivariate analyses performed to determine whether hydrocephalus was an independent predictor of mortality. Data are presented as mean+/-SD. RESULTS: Of the 81 patients studied, 40 had hydrocephalus. Those with hydrocephalus were younger (57+/-15 versus 67+/-15 years), had lower GCS scores (8.2+/-4.2 versus 11+/-2.9), were more likely to have ganglionic or thalamic hemorrhages, and were intubated more frequently (70% versus 27%). Hospital mortality was higher in patients with hydrocephalus (51% versus 2%), and fewer patients went home (21% versus 35%). Those who died had higher hydrocephalus scores (9.67+/-7.1 versus 5.75+/-4.5). Outcome was no different if a ventriculostomy was placed. The final logistic regression model included hydrocephalus score, gender, GCS, and pineal shift, and it correctly predicted 85% of patients as dead or alive. Multivariate analyses indicated that hydrocephalus is an independent predictor of mortality. CONCLUSIONS: We conclude that hydrocephalus is an independent predictor of mortality after ICH.

Does modification of the Innsbruck and the Glasgow Coma Scales improve their ability to predict functional outcome?

BACKGROUND: The accurate prediction of functional outcome requires the development of multivariate models. To enhance their contribution to such models, the predictive power of each component must be optimized. OBJECTIVES: To improve the predictive power of coma scales as the first step in building more sophisticated multivariate models to predict specific levels of functional outcome. DESIGN: Prospective descriptive study. SETTING: Neurology and neurosurgery intensive care unit (NNICU) in a tertiary care academic center. PATIENTS: Eighty-four patients with acute traumatic brain injury, intracerebral hemorrhage, subarachnoid hemorrhage, or ischemic stroke. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The Glasgow Coma Scale (GCS) and Innsbruck Coma Scale (ICS) were administered within 24 hours of admission to the NNICU and then at 48-hour intervals until discharge of the patient from the NNICU. The assessments were performed by 3 occupational therapy graduate students working under the supervision of the medical director of the NNICU. The functional outcome at 3 months after discharge from the hospital was assessed by telephone by the same nurse using the following categories: (1) dead, (2) receiving nursing home or custodial care, (3) home with help, or (4) independent. Cronbach's alpha estimates of reliability for each scale were computed using all scores obtained during the study. The analyses indicated that the verbal response item of the GCS and the oral automatisms item of the ICS were less reliable in this patient population. The scales were modified by deleting those items, and predictive validity for the original and modified scales was computed using a discriminant function of the admission scores. RESULTS: Before modification, both scales were best at predicting independence (GCS and ICS, 71% correct) and mortality (GCS, 60% correct; ICS, 56% correct). The modifications produced a modest improvement in the ability of both scales to better predict levels of outcome (modified GCS: home with help, 33% correct, independent, 71% correct; modified ICS: home with help, 0% correct, independent, 74% correct). CONCLUSIONS: By deleting items with low reliability from the ICS and the GCS we achieved improved reliability and predictive validity. The improvement in predictive power, however, was inadequate to accurately predict functional outcome. Combining clinical scales with other demographic, physiological, functional, and radiographic data will be needed to achieve useful predictions of functional outcome.

Relation of preoperative nerve-conduction values to outcome in workers with surgically treated carpal tunnel syndrome.

Ninety-three workers having undergone carpal tunnel decompression were assessed 16 to 100 months after surgery. The results of outcomes pertaining to symptoms of numbness, nocturnal awakening, and pain as well as job status were compared to the patients' preoperative nerve conduction study findings. Significant differences in preoperative nerve-conduction values (NCVs) were found between groups reporting poor results and those reporting good results. These differences were such that those reporting poor results had more normal NCVs. Those reporting job changes because of carpal tunnel syndrome also had more normal preoperative nerve-conduction results. Data indicate that those with terminal latencies 1 ms greater than the testing facility normal value or with sensory conduction velocity 10 ms less than the facility norm were more likely to benefit from surgery. This study suggests the need for caution when considering carpal tunnel surgery in workers with normal or near normal nerve-conduction results.

Unified Neurological Stroke Scale is valid in ischemic and hemorrhagic stroke.

BACKGROUND AND PURPOSE: The growing interest in testing new therapeutic agents for acute brain injury has lead to increased use of stroke scales. The reliability and validity of these measures need to be examined more completely. We used structural equation modeling, a technique that merges the analytic procedures of factor analysis and multiple regression, to examine the reliability and construct validity of the Middle Cerebral Artery Neurological Scale and the Scandinavian Neurological Stroke Scale used together as the Unified Neurological Stroke Scale. We also analyzed the predictive validity, sensitivity, and specificity of the scales in predicting mortality and functional outcome. METHODS: We prospectively studied 84 consecutive patients admitted to a neurology/neurosurgery intensive care unit with intracerebral hemorrhage (n = 30), subarachnoid hemorrhage (n = 15), ischemic stroke (n = 15), and traumatic brain injury (n = 24). Patients were evaluated within 24 hours of admission and at 48-hour intervals until intensive care unit discharge. A total of 386 assessments were obtained. The Functional Independence Measure was administered by telephone 3 months after hospital discharge. RESULTS: High levels of reliability and construct validity were observed for the majority of the Unified Stroke Scale items. Facial palsy and eye movement items had the lowest reliability and validity. Both the Middle Cerebral Artery and Scandinavian Scales were significant predictors of outcome. Sensitivity and specificity varied by diagnosis. Predictive validity of functional outcome was best in groups with ischemic and hemorrhagic stroke rather than traumatic brain injury and subarachnoid hemorrhage. CONCLUSIONS: The Unified Stroke Scale demonstrates reliability and construct and predictive validity, and its use is supported in ischemic and hemorrhagic stroke. Structural equation modeling is an appropriate technique for use with scales of this type.

Detecting cumulative trauma disorders in workers performing repetitive tasks.

On-site testing of 157 poultry processors disclosed that 50% had three or more abnormal upper extremity findings out of a total of 22 possibles. The average worker had five to six abnormal findings. Impaired pinch strength, decreased vibration sensitivity in the fingertips, and reports of current numbness were the most prevalent. Of workers with signs, 25% reported no symptoms, whereas only 8% of workers reported symptoms but had no signs. The investigators concluded that this measurement method has utility for assessments of worker populations to determine prevalence of CTDs and, potentially, for preclinical detection of these disorders to permit early intervention, reduce medical costs, and minimize disability. The need for accurate measurement to enhance early detection and prevention is discussed.

Communicating hydrocephalus in dogs with congenital ciliary dysfunction.

Magnetic resonance imaging (MRI) and radionuclide ventriculography were performed in 5 dogs with congenital ciliary dysfunction (CDD) and 3 normal dogs. Ventricular and brain dimensions and volumes, and CSF flow rates were measured or calculated from the MR images and radionuclide clearance. All CCD dogs had hydrocephalus based on previously published criteria of a percent vertical brain dimension (PVBD) greater than 14%. The PVBD was significantly larger (p = 0.001) in the dogs with CCD (mean +/- SD) 33.00 +/- 5.42% than in normal dogs (11.07 +/- 0.61%. The ventricular volume was significantly larger (p = 0.021) in CCD dogs 10,841 +/- 4,127 mm3 compared to the volume measured in normal dogs 3,069 +/- 1,167 mm3. The CSF flow rate was not significantly different p = 0.876) between CCD dogs (253.00 +/- 147.25 mm3/h) and normal dogs (267.667 +/- 47.61 mm3/h). This suggests that the ventricular dilation in CCD dogs is not due to impedance of CSF flow from the ventricular system by dysfunctional ependymal cilia.

Effects of work and rest on upper extremity signs and symptoms of workers performing repetitive tasks.

The temporal relationship between work and signs and symptoms of upper extremity musculoskeletal disorders among workers at risk is relatively unexplored. The study focused on changes in upper extremity circumference, volume, sensory threshold, and reported symptoms after work and rest. All workers (N=50) performed a repetitive poultry processing task and had exhibited upper extremity signs and symptoms in baseline testing prior to this study. These workers manifested significantly increased upper extremity circumference following a period of rest, with circumferences decreasing during work. Upper extremity volume and reported swelling also decreased during work. Reports of tenderness were significantly greater after work than after rest, while reports of pain were greatest after a short rest interval. Results show that the signs and symptoms observed in these workers were manifestations of occupational cumulative trauma and that further study of the relationship between work and signs and symptoms is needed.

The precision polishing of bismuth silicate and bismuth germanate.

A recipe is given for the polishing of precise surfaces oncrystals of bismuth silicate (BSO) and bismuth germanate(BGO). Using this recipe, crystals having surface figure betterthan 1/10 wave, roughness of 20-50 Å rms, and laserquality parallelism (10 arcsec or better) were obtained withabout 1-2 hours effort.

Age-related differences in measures of upper extremity impairment.

BACKGROUND: Upper extremity cumulative trauma disorders (CTDs) are among the most prevalent and costly occupational injuries. These disorders include nerve compression syndromes, tenosynovitis, epicondylitis, tendinitis, and arthritis. These have been related in the past to repetitive use of the upper extremity. The expected increase in the age of the American work force and the assumption that older workers are more susceptible to the disorders prompted this investigation of the relationship of age to signs and symptoms of upper extremity impairment. METHODS: A battery measuring seven objective signs and four reported symptoms of upper extremity cumulative trauma disorders was administered to two stratified random samples of workers. One group (n = 157) processed cooked poultry and the second group (n = 118) performed data entry at VDT terminals. Workers were separated into three age groups (younger: 20-35 years, middle-aged: 36-50 years, and older: 51-71 years). RESULTS: A series of analyses of variance were computed to determine whether the older workers were more impaired. No significant age differences were found for sign, symptom, or total scores in either sample, and no significant Age x Gender interaction was present. Older workers were more impaired for vibratory sensation, cutaneous pressure, and motor latency. CONCLUSIONS: The results support the hiring of older workers for general tasks in the workplace without significant worry of increased susceptibility to CTDs.