Management of stroke risk factors during the process of rehabilitation. Secondary stroke prevention.

Epidemiologic and prospective cohort studies have shown a strong correlation between risk factors and stroke morbidity and mortality. The reduction or control of risk factors, on the other hand, can reduce stroke morbidity and mortality. Rehabilitation professionals involved in comprehensive rehabilitation of stroke patients may include the management of risk factors in the scope of their practice and thus contribute to longer life expectancy and improved quality of life of these patients. Decreasing disability, improving quality of life, and prolonging life are chief goals of the rehabilitation process. This article reviews the rationale for risk management and stresses the value of aerobic and conditioning exercises and is intended to supplement the article on stroke prevention co-authored by Daryl Gress and Vineeta Singh.

Localization of nerve depolarization with magnetic stimulation.

The specific location on the magnetic stimulation (MS) coil that may correspond to the area of nerve depolarization has not been determined. In order to localize such an area, MS with 9-cm and 5-cm diameter coils was compared with conventional percutaneous electric stimulation (ES). On the 9-cm coil the distribution of points of nerve depolarization corresponded to that quarter of the coil which was placed over and parallel to the median nerve, whereas on the 5-cm coil, this area also extended outside the coil. The points of median nerve depolarization with MS were distributed over a distance of 7 cm on the stimulator head and was nearly identical for the 2 coil sizes at the wrist and elbow. Ulnar nerve costimulation was less frequent with the smaller coil at the wrist. A calculated reference point on the coil is suggested for more accurate NCV determinations.

Prospective payment for rehabilitation: effects on hospital readmission, home care, and placement.

Suspected benefits of a prospective payment system (PPS) in which hospitals are paid by diagnosis-related groups (DRGs) are that hospital lengths of stay and costs may be reduced. The US Department of Veterans Affairs is one of the first agencies to adopt PPS funding for rehabilitation; this early adoption of PPS provides a unique opportunity to test for both beneficial and adverse outcomes. This study compared hospital stay, readmission rate, and incidence of nursing home placement before and after introduction of PPS on a 22-bed rehabilitation service. Hospital stay decreased from 29.3 days to 26.4 days, but 64% more patients were discharged to nursing homes. Findings suggest that PPS may overlook home care in favor of placement, which neutralizes the cost benefits of the proposed reimbursement system. Further research on the effects of PPS is needed to determine (1) impact on clinical aspects of rehabilitation and (2) whether other funding mechanisms are more appropriate.

Effects of prospective payment financing on rehabilitation outcome.

A suspected benefit of paying hospitals per diagnostic related groups (DRGs), i.e. the prospective payment system (PPS), is that lengths of stay (LOS) and costs may be reduced. A potential adverse effect is that providers may discharge patients to reduce costs regardless of clinical consequence. The Veterans Administration (VA) is one of the first agencies to adopt PPS for rehabilitation. This study analyzed the effects of PPS on LOS, readmission rate, nursing home placement (NHP), and referral for Home Health Care (HHC) on a 22 bed rehabilitation unit. One hundred and eighty-seven patients discharged in 1987, prior to the program, were compared (using t-tests) with 215 discharges in 1988, after PPS was established. There were no significant differences in demographics, self-care ability, or in readmissions. Referrals for HHC decreased significantly. LOS decreased from 29.3 days (SD = 16.4) in 1987 to 26.4 days (SD = 14.1) in 1988 (t = 5.3, p less than 0.01). However, 24 more patients were discharged to nursing homes in 1988 (N = 54, 25%) than in 1987 (N = 30, 16%), which represents an increase of 64% (p less than 0.05). Findings suggest that PPS may defer home care in favor of placement. Clinicians need to assess whether reducing inpatient LOS justifies increased use of nursing homes. Further research on the effects of PPS is needed to determine: (a) impact on clinical aspects of rehabilitation; and (b) if other funding mechanisms are more appropriate.

Sensory perception threshold measurement: an evaluation of semiobjective testing devices.

Five semiobjective devices for testing sensory perception thresholds were concomitantly used on 36 normal subjects to determine normal threshold values, intersubject variability, and their correlation with age. The five devices include the Semmes-Weinstein monofilament (touch); three-point esthesiometer (two-point discrimination); Pfizer thermal tester (temperature); biothesiometer (vibration); and Optacon tactile tester (vibration). Each subject was tested at 12 upper extremity (UE) and ten lower extremity (LE) sites. The threshold was determined by the two-alternative forced choice method. Results showed that the mean threshold for each sensory perception modality in the UE sites was significantly lower than in the LE sites. The means of distally located sites for two-point discrimination and vibration thresholds were significantly lower than the means of the proximal sites in the UE. In the LE, touch perception threshold was significantly higher distally than proximally. Distally located nerves (median and ulnar) showed lower mean threshold values than proximally located nerves for two-point discrimination. There were also similar findings for the other sensory modalities in the UE and LE. The mean threshold of dermatomes showed significant variation across the trials for two-point discrimination and vibration sensation. Distally located dermatomes showed lower threshold values than those located proximally. The means of most sites tested for each sensory modality (except vibration tested by the Optacon) showed correlation with age. There was no difference in threshold values between men and women for any sensory modality. The mean values of standard deviation were provided for each peripheral sensory nerve and dermatome.(ABSTRACT TRUNCATED AT 250 WORDS)

Prestroke family interaction as a predictor of stroke outcome.

The Family of Assessment Device and clinical data for 60 stroke patients were used to predict outcome at six months and one year poststroke. Ratings of behavior control and affective responsiveness of the family predicted number of days of rehospitalization during the study. Problem solving scores, family communication skills, and patient self-care ability predicted family-rated patient adjustment. Family function was a better predictor of hospital stay than baseline ratings of typical predictors of stroke outcome. Family function represents an area for potential stroke intervention that may have more relevance to efficient health care delivery and the clinical status of stroke patients than has previously been noted.

Family interaction and treatment adherence after stroke.

Caregivers of 60 stroke patients were assessed five months after patient discharge from a stroke care unit to determine the relationship between family function and poststroke treatment adherence. Areas of family interaction which were significantly related to ratings of treatment adherence included problem solving, communication, and affective involvement. Better functioning families were consistently high on signs of treatment adherence. Findings suggest that families with specific dysfunction may not be as capable of helping patients comply with rehabilitation efforts as families who function more effectively. Thorough family assessment to identify which areas of family interaction are most problematic in relation to adherence issues is recommended.

Cognitive therapy to achieve personal goals: results of telephone group counseling with disabled adults.

Physical disability alters a person's lifestyle and can be detrimental in its effects on mood and activity. We describe a counseling program for severely disabled persons who participated in cognitive therapy by telephone. Therapy involved solving problems related to personal dissatisfaction, loneliness, or depression. The treated group reported significantly less loneliness after treatment and were observed by their families to demonstrate more social role skills than the control group. High goal attainment reported by the treated groups was significantly correlated with decreased loneliness, positive changes in social role skills, and family expectations. Treating affective problems with scheduled telephone contact should be further evaluated because of the observed effectiveness and potential for reaching homebound clientele.

Physical activity: its influence on nerve conduction velocity.

In a group of 40 healthy subjects, distal and proximal latencies of the median, tibial, and peroneal motor, and sural sensory nerves and their respective skin surface temperatures (Tsk) were measured before and after walking or bicycling. The baseline tests were performed 30 minutes after resting in a constant room temperature of 24C. The ambulation or bicycling task was continued for 30 minutes at a constant rate. Postactivity tests were performed within 30 minutes and between 45 to 60 minutes after termination of activity. Another test was done 75 to 90 minutes after bicycle exercise. After walking, there was a significant increase in Tsk in all lower extremity nerves tested (p less than 0.01). The increases were accompanied by faster distal and proximal latencies in both testing periods (p less than 0.01). Median nerve Tsk, distal and proximal latencies did not differ significantly from baseline values initially, but 45 minutes after walking Tsk was elevated and proximal latency had become faster (p less than 0.01). Following bicycling, lower extremity Tsk was significantly reduced over tibial, peroneal, and sural nerves by the third testing period (p less than 0.01) but only sural latencies were significantly prolonged (p less than 0.05) by this time. In the upper extremities median Tsk was significantly elevated and distal latency had become significantly faster 45 minutes after bicycling. Our data suggest that activity significantly influences nerve conduction latency results due to tissue temperature alteration. In addition, 30 minutes of rest after activity may not be sufficient time for the lower extremity temperatures to become stable.

Predicting outcome of group counseling with severely disabled patients.

Client characteristics associated with outcome of group counseling were identified in a sample of physically disabled persons using standardized self report inventories. Thirty-eight subjects were tested before and after an 8 week treatment interval for signs of emotional disorder, inactivity, and social problems related to being severely disabled. Treatment consisted of group conference phone calls using self determined task assignments as a focus for discussion. Change in report of life satisfaction was predicted reliably from pretest data. Loneliness accounted for 73% of the variance in posttreatment life satisfaction scores. Other significant predictors included signs of depression, alcohol use, and constructs related to social support. Using regression analysis, persons with adjustment problems could be identified and prognosis for treatment predicted with acceptable reliability.

H-reflex changes following spinal cord injury.

Changes in both central synaptic excitability (CSE) and peripheral sensitivity of muscle spindle stretch receptors have been hypothesized to contribute to hyperactive stretch reflexes of spasticity. To assess CSE, the monosynaptic H-reflex to the triceps surae muscles was tested serially over the first six months after traumatic spinal cord injury (SCI). Six clinically complete SCI patients were compared to age-matched control subjects. As a measure of H-reflex excitability, H/M ratios were calculated by dividing maximum H-reflex by maximum M-response amplitude. Analysis of variance over the testing trials showed significant change in H/M ratios for SCI patients (p less than 0.01). T-tests comparing mean H/M ratios at different time periods after SCI revealed a significant increment after three months (p less than 0.01). H-reflex amplitude also increased significantly over this time period (p less than 0.04), but M-response amplitude did not change significantly. These increases in H/M ratio and H-reflex amplitude suggest that an increase in CSE may contribute to the appearance of hyperreflexia after SCI.

Family stroke education.

To increase families' involvement in rehabilitation, an informational session called Family Stroke Education Class was implemented at a 305 bed medical center serving disabled veterans and their families. After a year, a study of questionnaires completed by family and patients at the meetings showed that anxiety level about their illness had decreased significantly. Twenty-six (86.7 percent) of thirty participants felt more comfortable about approaching team members with questions in the future, and 76.7 percent felt more informed as a result of taking the class. Knowledge scores improved significantly on the post tests. Thus it appears that the educational format is a practical way of including the needs and soliciting participation of families as well as a means for providing basic information to patients on stroke rehabilitation.

Electrodiagnostic values through the thoracic outlet using C8 root needle studies, F-waves, and cervical somatosensory evoked potentials.

Mid-humerus cadaver determinations of ulnar F-wave, C7 spinal somatosensory evoked potential (SEP), and modified C8 root stimulation (RS) were performed bilaterally on 20 normal subjects to standardize technique and obtain normal values for the segment from mid-humerus to cervical spine. Our cadaver study shows that the best position for upper extremity measurement of mid-humerus-cervical spine distance is at 60 degrees of shoulder abduction, 45 degrees of internal rotation, and at the distance of 35cm, measured by caliper. Using this position and distance the following normal values were obtained: 1) Mid-humerus F-wave minimal, maximal, and mean latencies, and minimal nerve conduction velocity (NCV) were 21.8 +/- 1.2msec, 22.3 +/- 1.2msec, 22.3 +/- 1.1msec, and 59.7 +/- 2.4m/sec, respectively. Latency difference between minimal and maximal F-wave was 1.4 +/- 0.4msec. 2) Cervical spine SEP was 5.1 +/- 0.4msec, with left to right difference of less than 0.9msec. 3) C8 RS and mid-humerus ulnar nerve (UN) pick-up latency and NCV were 4.9 +/- 0.2msec and 71.4 +/- 2.2m/sec, whereas C8 root pick-up and mid-humerus UN stimulation latency and NCV were 5.2 +/- 0.4msec and 66.9 +/- 5.2m/sec, respectively. To evaluate proximal nerve conductivity through the thoracic outlet, the sequential use of the three modified techniques for 35cm mid-humerus-cervical spine distance is recommended.

Group treatment of physically disabled adults by telephone.

Physical disability threatens a person's life style and can be detrimental in its effects on mood and activity. We describe a counseling program for severely disabled persons who were involved in telephone support groups in order to solve problems related to feeling discouraged, lonely, or being too inactive to remain healthy. A majority of the participants reported being less anxious and more socially involved as a result of the intervention. Ease with which groups were conducted and positive feedback from participants suggests that research should evaluate the cost effectiveness of phone intervention and explore potential of treating affective problems with scheduled phone contact.

Nerve conduction studies in upper extremities: skin temperature corrections.

The relationship of skin to near nerve (NN) temperature and to nerve conduction velocity (NCV) and distal latency (DL) was studied in 34 normal adult subjects before and after cooling both upper extremities. Median and ulnar motor and sensory NCV, DL, and NN temperature were determined at ambient temperature (mean X skin temp = 33 C) and after cooling, at approximately 26, 28, and 30 C of forearm skin temperature. Skin temperatures on the volar side of the forearm, wrist, palm, and fingers and NN temperature at the forearm, midpalm, and thenar or hypothenar eminence were compared with respective NCV and DL. Results showed a significant linear correlation between skin temperature and NN temperature at corresponding sites (r2 range, 0.4-0.84; p less than 0.005). Furthermore, both skin and NN temperatures correlated significantly with respective NCV and DL. Midline wrist skin temperature showed the best correlation to NCV and DL. Median motor and sensory NCV were altered 1.5 and 1.4m/sec/C degree and their DL 0.2 msec/C degree of wrist skin temperature change, respectively. Ulnar motor and sensory NCV were changed 2.1 and 1.6m/sec/C degree respectively, and 0.2 msec/C degree wrist temperature for motor and sensory DL. Average ambient skin temperature at the wrist (33 C) was used as a standard skin temperature in the temperature correction formula: NCV or DL(temp corrected) = CF(Tst degree - Tm degree) + obtained NCV or DL, where Tst = 33 C for wrist, Tm = the measured skin temperature, and CF = correction factor of tested nerve. Use of temperature correction formula for NCV and DL is suggested in patients with changed wrist skin temperature outside 29.6-36.4C temperature range.

Diabetic neuropathy: a clinical, laboratory and electrodiagnostic study.

The objective of this study was to determine the relationship between nerve conduction velocity (NCV) and hyperglycemia and to assess the extent of NCV changes in adult-onset diabetic patients before and after diabetic treatment. Twenty-five diabetic males (mean age = 50.9 years) were tested twice prior to beginning diabetic treatment. Eighteen of these 25 were also tested at 1, 3, 6, and 12 months after initiation of therapy. Both groups were compared to 23 age-matched controls. Each test session consisted of NCV and clinical sensory and blood chemistry testing. The findings revealed that, before treatment average NCVs of the median, peroneal sural, and tibial nerves and H-reflex latency results were all significantly impaired in diabetic subjects (p less than 0.025). No difference was found between right and left NCVs of the same nerve (p less than 0.05) and NCVs in the lower as well as the upper extremities were significantly reduced (p less than 0.05). Thus, it appears that the neuropathy in these patients was symmetrical and diffuse. Peroneal and median motor nerves showed the greatest amount of NCV slowing when compared to normal values. Furthermore, median, peroneal, and tibial motor NCVs and H-reflex latencies correlated significantly with the degree of hyperglycemia in diabetic subjects before treatment. After initiation of diabetic treatment, median motor NCVs after 1, 3, 6 and 12 months showed significantly improvement when compared to baseline NCV values (all p less than 0.05). Also, the improvement in median NCVs after 3 and 13 months and peroneal NCV after 3 months directly correlated to decreased fasting plasma glucose levels (p less than 0.05).

Peroneal nerve conduction velocity: the importance of temperature correction.

The relationship between skin surface temperature, near nerve temperature and nerve conduction velocity (NCV) of the peroneal nerve was studied in normal and diabetic subjects to determine a peroneal NCV-treatment correction factor and to investigate whether temperature correction of NCV reduces its variability. Twenty normal subjects (age 21 to 72 years, mean 44, SD 17) were tested for peroneal NCV, skin and near nerve temperatures bilaterally at ambient temperature (mean 26.6C). Tests were repeated after cooling the lower extremity to a skin temperature of 26C, and at skin temperatures of 28 and 29C as the legs were allowed to gradually warm. An additional 20 normal and 20 diabetic subjects were tested weekly at ambient temperature for peroneal NCV and skin temperature, measured at 15cm above the lateral malleolus. The results showed a linear relationship between skin temperature, near nerve temperature and peroneal NCV (p less than 0.001). Peroneal NCV was altered 2.0 meters per second per degree (C) change in skin and near nerve temperature (p less than 0.001). When using our formula, peroneal motor NCV corrected = 2.0 [32 - skin temp(C)] + NCV (m/sec), for correction of peroneal NCV to a standard skin temperature of 32C, it was found that temperature corrected NCV were less variable (p less than 0.05) than noncorrected NCV in the same diabetic subjects. These results indicate that temperature corrected NCV should be calculated routinely during clinical NCV examinations of patients with peripheral neuropathies.