Caregiver availability for severe stroke results in improved functional ability at discharge from inpatient rehabilitation.

PURPOSE: To evaluate the predictive capacity of caregiver availability on functional ability at time of discharge from inpatient rehabilitation in individuals with severe first-time stroke. METHODS: A retrospective chart review was conducted of severe stroke inpatients admitted to a stroke rehabilitation unit between April 2005 and December 2009. Follow-up telephone interviews were conducted with patients to determine caregiver availability at time of discharge. Hierarchical linear regression analysis was performed to assess the predictive capacity of caregiver availability on functional ability at discharge from an inpatient rehabilitation unit after controlling for covariates. RESULTS: Data from 180 individuals were included in the analysis. Individuals with a caregiver had significantly higher levels of functional ability at discharge compared to those without (85.8 ± 23.6 versus 72.9 ± 20.3; p < 0.01), although both groups achieved a minimal clinically important difference. After controlling for age, gender, admission Functional Independence Measure, and length of hospital stay, caregiver availability explained 1.3% of additional variance, with the final model explaining 41.3% of total variance for functional ability at discharge (F (5,174) = 26.21, p < 0.001). CONCLUSIONS: The presence of a caregiver at time of discharge from inpatient rehabilitation is predictive of significantly higher functional ability at discharge in individuals with severe stroke. Implications for rehabilitation The availability of a caregiver at time of discharge from inpatient rehabilitation is predictive of improved functional ability at discharge in individuals with severe stroke. The presence of an available caregiver positively influences the functional recovery of individuals with severe stroke and may be an important element to successful rehabilitation.

Toning it down: selecting outcome measures for spasticity management using a modified Delphi approach.

OBJECTIVE: To identify a set of clinically useful outcome measures for assessment of adults receiving treatment for spasticity. DESIGN: A modified Delphi process was conducted. In round 1, key areas of spasticity assessment and associated outcome measures were identified. In round 2, participants were presented with reviews of eligible outcome measures and were asked to select the tool they believed to be the "best" in each area. Consensus was achieved if there was at least 70% agreement among participants. In round 3, participants rated measures based on feasibility, ability to capture change, and usefulness of information gained for areas where consensus was not achieved in round 2. SETTING: The Modified Delphi process was conducted online using survey software. PARTICIPANTS: Clinicians (N=32) from centers across Canada participated in this study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Of 51 tools identified initially, 8 were selected. Tools related to body structure and function included the visual analog scale, manual muscle testing, Penn Spasm Frequency Scale, and goniometry. Activity level measures included the Berg Balance Scale, Goal Attainment Scaling (GAS), and the FIM. The Modified Caregiver Strain Index was selected for the assessment of caregiver burden, while GAS was selected for participation level outcomes. CONCLUSIONS: A standardized set of outcome measures will assist with better documentation and standardization of assessment practices of clinicians who manage spasticity.

A systematic review of studies reporting multivariable models to predict functional outcomes after post-stroke inpatient rehabilitation.

PURPOSE: This systematic review summarizes the utility of variables available at acute discharge after stroke for predicting functional independence at discharge from inpatient rehabilitation. METHODS: A systematic review of four electronic databases (Medline, EMBASE, PsycINFO and CINAHL) was conducted to identify studies reporting multivariable models predicting post-rehabilitation Barthel Index (BI) or Functional Independence Measure (FIM®) scores. In studies meeting inclusion criteria, the frequency with which candidate predictors were found statistically significant was calculated and summarized. RESULTS: A total of 3260 articles were screened, of which 27 were included and 63 multivariable models of discharge BI or FIM® were reported. In all, 126 candidate predictors of BI or FIM® were explored. Variables found to be significant most frequently included admission functional level (BI or FIM®), National Institute of Health Stroke Scale (NIHSS), dysphasia, impulsivity, neglect, previous stroke, and age. CONCLUSIONS: Only a selected group of variables have repeatedly proven to be significant predictors of functional ability after post-stroke inpatient rehabilitation. [Box: see text].

Discharge destination of individuals with severe stroke undergoing rehabilitation: a predictive model.

PURPOSE: To determine the predictive value of age, stroke severity and caregiver availability for discharge destination of individuals with severe stroke following inpatient rehabilitation. METHODS: Telephone interviews were conducted with individuals recovering from a severe stroke (Rehabilitation Patient Groups 1100 and 1110), who were discharged from a specialized inpatient stroke rehabilitation unit between April 2005 and December 2009, to determine caregiver availability at the time of discharge. Age and Functional Independence Measure (FIM®) scores were obtained retrospectively by chart review. These three variables were analyzed using logistic regression as potential predictors of discharge destination (home versus long-term care). RESULTS: Data from 189 individuals were analyzed. Younger age, higher admission FIM® scores and the presence of a willing and able caregiver were significantly associated with discharge home. Only one individual was discharged home in the absence of a caregiver. CONCLUSION: Age, admission FIM® and caregiver availability were significant predictors of post-rehabilitation discharge destination. Results of this study suggest that for individuals with severe stroke, discharge home is unlikely in the absence of an available caregiver. Implications for Rehabilitation Age, stroke severity at admission and the availability of a caregiver play an important role in determining post rehabilitation discharge destination of individuals with severe stroke. These factors must be considered to assist with appropriate goal setting and discharge planning during inpatient rehabilitation.

Treatment with botulinum toxin improves upper-extremity function post stroke: a systematic review and meta-analysis.

OBJECTIVE: To examine whether treatment with botulinum toxin type A (BTX-A) is associated with improvements in activity capacity or performance associated with poststroke spasticity in the upper extremity. DATA SOURCES: MEDLINE, EMBASE, Scopus, and ISI Web of Science databases were searched from 1985 to November 2011. DATA SELECTION: Studies were included if (1) the study design was a randomized controlled trial comparing injection of BTX-A with placebo or a nonpharmacologic treatment condition; (2) at least 60% of the sample was composed of adult subjects recovering from either first or subsequent stroke; (3) subjects presented with moderate to severe upper-extremity spasticity of the wrist, finger, or shoulder; and (4) activity was assessed as an outcome. Studies were limited to those published in the English language. DATA EXTRACTION: Data pertaining to participant characteristics, treatment contrasts, and outcomes assessing activity limitations were extracted from each trial. The World Health Organization's International Classification of Functioning, Disability and Health was used to identify outcomes that captured the domain of activity used within each of the included studies. Where possible, a treatment effect size was calculated for each study using the standardized mean difference ± standard error (95% confidence interval) and the results pooled. DATA SYNTHESIS: Sixteen randomized controlled trials were identified, 10 of which reported sufficient data for inclusion in the pooled analysis (n=1000). Six different outcomes that assessed activity limitations had been used, including the Disability Assessment Scale, the Action Research Arm Test, and the Barthel Index. Overall, BTX-A was associated with a moderate treatment effect (standardized mean difference=.536±.094, 95% confidence interval=.352-.721, P<.0001). CONCLUSIONS: The use of BTX-A was associated with moderate improvement in upper-extremity activity capacity or performance after stroke.

Cardiovascular conditioning for comfortable gait speed and total distance walked during the chronic stage of stroke: a meta-analysis.

OBJECTIVE: To examine the effectiveness of cardiovascular conditioning on comfortable gait speed and total distance walked when initiated in the chronic stage of stroke through a meta-analysis. METHODS: MEDLINE, CINAHL, EMBASE, and Scopus databases were searched from 1980 to June 2012. A study was selected if (1) it was a randomized controlled trial; (2) individuals in the study were entered into the study at or over 6 months post stroke; (3) cardiorespiratory training was initiated during the chronic stage of stroke; and (4) study participants were ≥18 years of age. A standardized mean difference (SMD ± SE and 95% confidence interval [CI]) was calculated for comfortable gait speed and/or 6-minute walk test (6MWT). results from all studies were then pooled using a random effects model. Treatment effect sizes were interpreted as small, ≯0.2; moderate, ≯0.5; or large, ≯0.8. Methodological quality of studies was assessed using the Physiotherapy Evidence Database (PEDro) tool. RESULTS: Seven studies met inclusion criteria. The analysis demonstrated a moderate and significant effect on 6MWT post treatment (SMD = 0.581 ± 0.277; 95% CI, -0.037 to 1.125; P = .036) with an improvement of 111.4 m to a pooled average of 357.7 m. No significant improvement in comfortable gait speed was noted post treatment (SMD = 0.159 ± 0.124; 95% CI, -0.085 to 0.402; P = .202) or at follow-up (SMD = 0.248 ± 0.256; 95% CI, -0.253 to 0.750; P = .332). CONCLUSION: Cardiovascular conditioning resulted in clinically relevant gains in walking distance of over 100 m post treatment on the 6MWT when initiated during the chronic stage of stroke. These results demonstrate that individuals in the chronic stage of stroke can still benefit from interventions to improve gait and mobility. This has important implications for outpatient and community-based programs.

Resistance training for gait speed and total distance walked during the chronic stage of stroke: a meta-analysis.

OBJECTIVE: To conduct a meta-analysis examining the effectiveness of resistance training on comfortable gait speed and total distance walked when initiated in the chronic stage of stroke. METHODS: MEDLINE, CINAHL, EMBASE, and Scopus databases were searched from 1980 to June 2012. Studies were selected if they met the following criteria: (1) they were randomized controlled trials; (2) individuals in the studies were entered into the studies at or over 6 months post stroke; (3) resistance training was initiated during the chronic stage of stroke; and (4) study participants were ≥18 years of age. A standardized mean difference (SMD ± SE and 95% confidence interval [CI]) was calculated for at least 1 of the following outcomes in each study: comfortable gait speed and/or 6-minute walk test (6MWT). Treatment effect sizes were interpreted as follows: small, ≯0.2; moderate, ≯0.5; or large, ≯0.8. Study quality was assessed using the Physiotherapy Evidence Database (PEDro) tool. RESULTS: Ten randomized controlled trials met inclusion criteria. Significant improvement was seen for gait speed with a small effect size (0.295 ± 0.118; 95% CI, 0.063-0.526; P < .013) and a pooled post mean speed of 0.79 m/s, and for the 6MWT (0.247 ± 0.111; 95% CI, 0.030-0.465; P = .026) with a pooled post mean total distance walked of 271.9 m. CONCLUSION: This meta-analysis demonstrated that providing lower limb resistance training to community-dwelling individuals who are 6 months post stroke has the capacity to improve comfortable gait speed and total distance walked.

Functional electrical stimulation for improving gait in persons with chronic stroke.

BACKGROUND: The long-term management of stroke is an area of increasing clinical interest, and it is important to identify therapeutic interventions that are effective in the chronic phase post stroke. OBJECTIVE: To conduct a systematic review on the effectiveness of functional electrical stimulation (FES) in improving lower extremity function in chronic stroke. METHODS: Multiple databases (PubMed, CINAHL, EMBASE, and Scopus) were searched for relevant articles. Studies were included for review if (1) ≥50% of the study population has sustained a stroke, (2) the study design was a randomized controlled trial (RCT), (3) the mean time since stroke was ≥6 months, (4) FES or neuromuscular electrical stimulation (NMES) was compared to other interventions or a control group, and (5) functional lower extremity outcomes were assessed. Methodological quality was assessed using the PEDro tool. A standardized mean difference (SMD ± SE and 95% confidence interval [CI]) was calculated for the 6-minute walk test (6MWT). Pooled analysis was conducted for treatment effect of FES on the 6MWT distance using a fixed effects model. RESULTS: Seven RCTs (PEDro scores 5-7) including a pooled sample size of 231 participants met inclusion criteria. Pooled analysis revealed a small but significant treatment effect of FES (0.379 ± 0.152; 95% CI, 0.081 to 0.677; P = .013) on 6MWT distance. CONCLUSION: FES may be an effective intervention in the chronic phase post stroke. However, its therapeutic value in improving lower extremity function and superiority over other gait training approaches remains unclear.

Systematic review and meta-analysis of constraint-induced movement therapy in the hemiparetic upper extremity more than six months post stroke.

OBJECTIVE: To conduct a systematic review and meta-analysis of the available evidence on the effectiveness of constraint-induced movement therapy (CIMT) in the hemiparetic upper extremity (UE) among individuals who were more than 6 months post stroke. METHODS: A literature search of multiple databases (PubMed, CINAHL, and EMBASE) was conducted to identify articles published in the English language up to and including July 2012. Studies were included for review if (1) ≥50% of the sample had sustained a stroke, (2) the research design was a randomized controlled trial (RCT), (3) the mean time since stroke was ≥6 months for both the treated and control groups, (4) the treatment group received CIMT, (5) the control group received a form of traditional rehabilitation, and (6) functional improvement was assessed both pre and posttreatment. Methodological quality was assessed using the PEDro tool with a score out of 10. RESULTS: Sixteen RCTs (PEDro scores 4-8) met inclusion criteria and included a pooled sample size of 572 individuals with a mean age of 58.2 years (range, 30-87). The meta-analysis revealed a significant treatment effect on the amount of use and quality of movements subscales of the Motor Activity Log ( P < .001, for both), Fugl-Meyer Assessment ( P = .014), and Action Research Arm Test ( P = .001); however, there was no significant treatment effect demonstrated by the Wolf Motor Function Test ( P = .120) or FIM ( P = .070). CONCLUSIONS: CIMT to improve UE function is an appropriate and beneficial therapy for individuals who have sustained a stroke more than 6 months previously.

Evidence for therapeutic interventions for hemiplegic shoulder pain during the chronic stage of stroke: a review.

OBJECTIVE: To determine the effectiveness of therapeutic interventions targeting hemiplegic shoulder pain (HSP) more than 6 months post stroke. METHODS: A literature search of multiple databases (PubMed, CINAHL, Ovid, and EMBASE) was conducted to identify articles published in the English language from 1980 to April 2012. Studies were included if (1) all participants were adults who had sustained a stroke; (2) research design was a randomized controlled trial (RCT) that examined the effectiveness of any treatment for HSP; (3) all participants had experienced stroke at least 6 months previously; and (4) an assessment of pain had been conducted before and after treatment using a standardized method. The following data were extracted: patient characteristics (ie, age, gender, time since stroke), sample size, study design, measurement of pain pre and post treatment, and adverse events. RESULTS: Ten RCTs (PEDro scores 4-9) met inclusion criteria and included a total sample size of 388 individuals with a mean age of 53.2 years (range, 43.6-73.2). Mean time post stroke was 18.4 months. Three studies addressed the use of botulinum toxin type A (BTx-A); 2 studies examined electrical stimulation; 3 studies focused on intraarticular glenohumeral corticosteroid injections; 1 studied subacromial corticosteroid injections; and 1 study looked at massage therapy. CONCLUSIONS: Positive outcomes were noted with the use of corticosteroid injections and electrical stimulation and conflicting results were seen regarding the use of BTx-A. Overall, these targeted therapies provide benefit in the treatment of HSP in individuals who are more than 6 months post stroke.

Time to rethink long-term rehabilitation management of stroke patients.

BACKGROUND: It has long been assumed that stroke patients plateau in their recovery within 3 to 6 months of their stroke, and evidence for rehabilitation during the chronic stage is limited. As a consequence, rehabilitation resources for the management of chronic stroke are minimal. OBJECTIVE: The primary objective was to identify randomized controlled trials (RCTs) across the continuum of stroke rehabilitation for interventions initiated 6 months or more following the onset of stroke. The secondary objective was to determine whether treatments provided post 6 moths are effective in improving outcomes among stroke survivors. METHODS: Multiple databases were used to identify all RCTs published from 1970 to June 2012 in English language where the stroke interventions were initiated more than 6 months after the onset of the stroke. Data abstraction was performed using standardized data abstraction form that included general citation information, study participant characteristics, methodology, outcomes accessed, and overall findings. RESULTS: The results of our analysis revealed 339 RCTs. The mean number of subjects per study was 73. Two hundred fifty-six RCTs were related to motor recovery, 39 to cognitive function, and only 19 to psychosocial issues and community reintegration. The majority of the RCT s demonstrated a significant positive benefit. CONCLUSIONS: There is a robust evidence-base for stroke rehabilitation interventions in chronic stroke. This research synthesis reveals a paradox, whereby an impressive evidence-base contrasts with the limited optimism and resources available for rehabilitation in chronic stroke.

Effectiveness of psychological interventions in chronic stage of stroke: a systematic review.

OBJECTIVE: To examine the effectiveness of interventions for psychological issues faced by individuals post stroke when initiated in the chronic stage of stroke. METHOD: MEDLINE, CINAHL, EMBASE, and Scopus databases were searched from 1980 to July 2012. A study was included if (1) the study was a randomized controlled trial (RCT); (2) at least 50% of individuals in the study were entered into the study at over 6 months post stroke; (3) the study examined the effect of an intervention on psychological functioning; and (4) study participants were ≥ 18 years of age. Similar interventions were grouped and results summarized. Data on the study design, participant characteristics, interventions, outcomes, and adverse events were extracted from each of the selected studies. RESULTS: Nine RCTs met inclusion criteria. All 9 studies examined effectiveness on mood and 3 on adjustment. Repetitive transcranial magnetic stimulation had the strongest evidence of effectiveness in improving mood followed by pharmacotherapy; whereas exercise appeared to be effective in improving adjustment and coping among individuals in the chronic stage of stroke. CONCLUSION: Overall, interventions provided in the chronic stage of stroke appear to be effective in improving mood and adjustment up to 3 months post intervention. The use of multidisciplinary interventions and acceptance models may be important in the overall adjustment process.

Evidence to practice: botulinum toxin in the treatment of spasticity post stroke.

INTRODUCTION: Spasticity is a significant problem following stroke. Although there is extensive research examining the efficacy of botulinum toxin as a treatment, there are challenges in implementing its use. METHODS: The results from previously published randomized controlled trials and systematic reviews examining the use of botulinum toxin as a treatment for poststroke spasticity of the upper and lower limb and the shoulder are summarized. Several barriers to implementation are discussed. RESULTS: There is strong evidence that denervation of muscles, in the lower extremity and upper extremity post stroke, with botulinum toxin reduces focal spasticity. There is also strong evidence that it is associated with a small but significant improvement in gait velocity based on a recent meta-analysis. However, evidence that botulinum toxin injections are associated with improved function and improved quality of life is not as compelling. There is evidence that botulinum toxin injected into the subscapularis muscle can reduce spastic shoulder pain and improve passive range of motion of the hemiplegic shoulder. There are a number of challenges with botulinum toxin, including uncertainty over its role in improving motor dysfunction following stroke, the determination of which subsets of patients may benefit, the cost of treatment, and the identification of meaningful outcome measures. CONCLUSIONS: Botulinum toxin has been shown to be an effective treatment in reducing tone and managing spasticity post stroke. However, its effectiveness in improving function has been more controversial.

Rehabilitation of individuals with severe stroke: synthesis of best evidence and challenges in implementation.

PURPOSE: The rehabilitation of patients who are recovering from severe stroke is associated with a substantial use of resources but limited potential for functional improvement. As a result, these individuals are not perceived as being ideal candidates for inpatient stroke rehabilitation. The objective of this review was to describe the evidence for and discuss some of the challenges of providing inpatient rehabilitation services for individuals with severe stroke. METHODS: A literature search was conducted to identify relevant studies. Studies were included if (a) inpatient rehabilitation was compared to other rehabilitation settings and (b) the study population included individuals with severe stroke-related disability. Following data abstraction, the methodological quality of randomized controlled trials (RCTs) that met inclusion criteria was assessed using the PEDro scale. RESULTS: Fourteen studies (including 4 RCTs) met inclusion criteria. Despite making limited functional improvement, persons with severe strokes who received inpatient rehabilitation had reduced mortality, decreased lengths of hospital stay, and increased likelihood of discharge home when compared to those who received rehabilitation in other settings. Rehabilitation on specialized stroke units resulted in better outcomes than other forms of inpatient rehabilitation for this group. CONCLUSION: Inpatient rehabilitation is beneficial for individuals with severe stroke. However, for this group, it may be necessary to rethink the emphasis on functional improvement and focus more on discharge planning. These individuals may still have restricted access to rehabilitation as a result of limited resources, the perception that they have poor rehabilitation potential, limited understanding of the goals of rehabilitation for this population, and a lack of research.

Are recommendations regarding inpatient therapy intensity following acute stroke really evidence-based?

BACKGROUND: Recommendations regarding the daily minimum dose of therapy that patients should receive following stroke are included in many clinical practice guidelines. We examined the related literature to determine whether a specific evidence-based recommendation could be supported. METHOD: Six clinical practice guidelines were retrieved and examined to determine what recommendation, if any, had been made regarding the daily provision of therapy during inpatient rehabilitation. All studies cited by the guideline authors to support their recommendations were identified and retrieved. Studies in which treatment was (a) focused on motor recovery, (b) initiated during inpatient rehabilitation, and (c) provided within 3 months of stroke onset were reviewed in greater detail. RESULTS: Three of the 6 identified guidelines recommended daily minimum amounts of therapy, ranging from 45 to 60 minutes each day of occupational (OT) and physiotherapy (PT), and 3 made general statements indicating that increased intensity of therapy was either recommended or was not recommended. Among the 6 guidelines, 37 studies had been cited to support the recommendations. Of these, 15 were reviewed in detail. On average, patients in the control condition received 48 minutes of therapy per day while those in the experimental group received 63% more, or 78 minutes per day. Patients in the experimental group performed significantly better on the primary outcome in only 5 (33%) studies. CONCLUSIONS: We believe the evidence base cannot support a specific recommendation related to therapy intensity during inpatient rehabilitation following stroke.

Organized stroke rehabilitation in Canada: redefining our objectives.

INTRODUCTION: Evidence suggests that patients who receive care in organized stroke units experience better outcomes compared to patients who receive care in general rehabilitation units. As such, the Canadian Stroke Strategy has consistently included provision of "organized" stroke rehabilitation in their best practice recommendations for stroke care. However, recent research in Ontario suggests that development of organized stroke rehabilitation units has not led to the better patient outcomes that had been expected. METHODS: In this article, we review the evidence in favour of organized stroke rehabilitation units, assess the state of organized rehabilitation in Canada (as exemplified by care in Ontario), and discuss potential solutions for better application of best evidence and guideline recommendations for organized stroke care in Canada. RESULTS: The most up-to-date evidence in Canada suggests that best practice recommendations around organized stroke care are currently not adhered to well. However, further exploration suggests that some of the recommendations themselves may not be attainable as currently defined. CONCLUSIONS: It appears that organized stroke care is not available to many Canadians, and better application of recommendations is necessary. Still, re-evaluation of current recommendations may also be necessary to ensure that they fit with the reality of providing care in Canada.