Bent Indredavik

Early supported discharge services for stroke patients: a meta-analysis of individual patients' data

BACKGROUND Stroke patients conventionally undergo a substantial part of their rehabilitation in hospital. Services have been developed that offer patients early discharge from hospital with rehabilitation at home (early supported discharge [ESD]). We have assessed the effects and costs of such services. METHODS We did a meta-analysis of data from individual patients who took part in randomised trials that recruited patients with stroke in hospital to receive either conventional care or any ESD service intervention that provided rehabilitation and support in a community setting with the aim of shortening the duration of hospital care. The primary outcome was death or dependency at the end of scheduled follow-up. FINDINGS Outcome data were available for 11 trials (1597 patients). ESD services were mostly provided by specialist multidisciplinary teams to a selected group (median 41%) of stroke patients admitted to hospital. There was a reduced risk of death or dependency equivalent to six (95% CI one to ten) fewer adverse outcomes for every 100 patients receiving an ESD service (p=0.02). The hospital stay was 8 days shorter for patients assigned ESD services than for those assigned conventional care (p<0.0001). There were also significant improvements in scores on the extended activities of daily living scale and in the odds of living at home and reporting satisfaction with services. The greatest benefits were seen in the trials evaluating a coordinated multidisciplinary ESD team and in stroke patients with mild to moderate disability. INTERPRETATION Appropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as shortening hospital stays.

Epidemiology of Stroke in Innherred, Norway, 1994 to 1996 Incidence and 30-Day Case-Fatality Rate

BACKGROUND AND PURPOSE In Norway, as well as other industrialized countries, mortality from stroke has declined over the past decades. Data on stroke morbidity are lacking. This study was conducted to determine the incidence, case fatality, and risk factors of stroke in a defined Norwegian population. METHODS During the period 1994 to 1996, a population-based stroke registry collected uniform information about all cases of first-ever and recurrent stroke occurring in people aged > or = 15 years in the region of Innherred in the central part of Norway (target population 70,000), where the prevalence of cardiovascular risk factors was screened in 1984 to 1986 and 1995 to 1997. RESULTS During the 2 years of registration (September 1, 1994, to August 31, 1996), 432 first-ever (72.8%) and 161 recurrent (27.2%) strokes were registered. The crude annual incidence rate was 3.12/1000 (2.85/1000 for males and 3.38/1000 for females). Adjusted to the European population, the annual incidence rate of first-ever stroke was 2.21/1000. The annual incidence rate of cerebral infarction was 2.32/1000, intracerebral hemorrhage 0.32/1000, subarachnoid hemorrhage 0.19/1000, and unspecified stroke 0.38/1000. The 30-day case-fatality rate was 10.9% for cerebral infarction, 37.8% for intracerebral hemorrhage, and 50.0% for unspecified stroke. Fourteen percent of the patients were found outside the hospital, and only 50% of the suspected stroke cases in the hospital (at admission or reviewed discharge diagnosis of ICD-9 codes 430 to 438) fitted the final inclusion criteria. CONCLUSIONS This first population-based stroke register in Norway revealed incidence rates of stroke similar to other Scandinavian countries, and comparison between other European countries did not indicate regional variations within Western Europe.

Benefit of an extended stroke unit service with early supported discharge: A randomized, controlled trial.

Background and Purpose Several trials have shown that stroke unit care improves outcome for stroke patients. The aim of the present trial was to evaluate the effects of an extended stroke unit service (ESUS), with early supported discharge, cooperation with the primary healthcare system, and more emphasis on rehabilitation at home as essential elements. Methods In a randomized, controlled trial, 160 patients with acute stroke were allocated to the ESUS and 160 to the ordinary stroke unit service (OSUS). The primary outcome was the proportion of patients who were independent as assessed by the modified Rankin Scale (RS) (RS ≤2=global independence) and independent in activities of daily living (ADL) as assessed by Barthel Index (BI) (BI ≥95=independent in ADL) after 26 weeks. Secondary outcomes were RS and BI scores after 6 weeks; the proportion of patients at home, in institutions, and deceased after 6 and 26 weeks; and the length of stay in institutions. Results After 26 weeks, 65.0% in the ESUS versus 51.9% in the OSUS group showed global independence (RS ≤2) (P= 0.017) , while 60.0% in the ESUS versus 49.4% in the OSUS group were independent in ADL (BI ≥95) (P =0.056). The odds ratios for independence (ESUS versus OSUS) were as follows: RS, 1.72 (95% CI, 1.10 to 2.70); BI, 1.54 (95% CI, 0.99 to 2.39). At 6 weeks, 54.4% of the ESUS group and 45.6% of the OSUS group were independent according to RS (P =0.118), and 56.3% versus 48.8% were independent according to BI (P =0.179). The proportion of patients at home after 6 weeks was 74.4% for ESUS and 55.6% for OSUS (P =0.0004), and the proportion in institutions was 23.1% versus 40.0%, respectively (P =0.001). After 26 weeks, 78.8% in the ESUS group versus 73.1% in the OSUS were at home (P =0.239), while 13.1% versus 17.5% were in institutions (P =0.277). The mortality in the 2 groups did not differ. Average lengths of stay in an institution were 18.6 days in the ESUS and 31.1 days in the OSUS group (P =0.0324). Conclusions An ESUS with early supported discharge seems to improve functional outcome and to reduce the length of stay in institutions compared with traditional stroke unit care.

Medical Complications in a Comprehensive Stroke Unit and an Early Supported Discharge Service

Background and Purpose— The aims of the study were to examine the frequency and timing of predefined medical complications in unselected acute stroke patients treated in an acute comprehensive stroke unit and an early supported discharge service. Methods— Four hundred eighty-nine acute stroke patients were included and followed up with assessments of 16 prespecified complications during the first week. Two hundred forty-four of the patients were randomly allocated to a 3-month follow-up. Results— During the first week, 312 of 489 patients (63.8%) experienced 1 or more complications. The most common complications were pain in 117 patients (23.9%), temperature ≥38°C in 116 (23.7%), progressing stroke in 90 (18.4%), urinary tract infection in 78 (16.0%), troponin T elevation without criteria of myocardial infarction in 57 (11.7%), chest infections in 55 (11.2%), nonserious falls in 36 (7.4%), and myocardial infarction in 22 (4.5%), whereas stroke recurrence, seizure, deep venous thrombosis, pulmonary embolism, shoulder pain, serious falls, other infections, and pressure sores were each present in ≤2.5% of patients. During the 3-month follow-up, 201 of 244 patients (82.4%) experienced at least 1 complication, the most common of which was pain, which occurred in 134 patients (53.3%), followed by urinary tract infection in 68 (27.9%) and nonserious falls in 61 (25.0%). The severity of stroke on admission was the most important risk factor for developing complications. Conclusions— This is the first study of complications in unselected acute stroke patients treated in a comprehensive stroke unit and early supported discharge service and shows that pain, progressing stroke, infections, myocardial infarction, and falls are common complications, whereas others occur infrequently. Most complications occur during the first 4 days, and stroke severity is the most important risk factor.

Evaluation of a Body-Worn Sensor System to Measure Physical Activity in Older People With Impaired Function

Background There is limited information on reliable and valid measures of physical activity in older people with impaired function. Objective This study was conducted to compare the accuracy of single-axis accelerometers in recognizing postures and transitions and step counting with the accuracy of video recordings in people with stroke (n=14), older inpatients (n=14), people with hip fracture (n=8), and a reference group of 10 adults who were healthy. Design This was a cross-sectional study, evaluating the concurrent validity of small body-worn accelerometers against video observations as the criterion measure. Methods Activity data were collected from 3 sensors (activPAL) attached to the thighs and the sternum and from registration of the same activities from video recordings. Participants performed a test protocol of in-bed, transfer, and walking activities. Results The sensor system was highly accurate in classifying lying, sitting, and standing positions (100%) and in recognizing transitions from lying to sitting positions and from sitting to standing positions (100%). Placement of a sensor on the nonaffected leg resulted in less underestimation of step counts than placement on the affected leg. Still, the sensor system underestimated step counts during walking, especially at slow walking speeds (≤0.47 m/s) (limits of agreement=−2.01 to 16.54, absolute percent error=40.31). Limitations The study was performed in a controlled setting and not during the natural performance of activities. Conclusions The activPAL sensor system provides valid measures of postures and transitions in older people with impaired walking ability. Step counting needs to be improved for the sensor system to be acceptable for this population, especially at slow walking speeds.

Stroke Unit Care Combined With Early Supported Discharge. Long-Term Follow-Up of a Randomized Controlled Trial

Background and Purpose— Early supported discharge from a stroke unit reduces the length of hospital stay. Evidence of a benefit for the patients is still unknown. The aim of this trial was to evaluate the long-term effects of an extended stroke unit service (ESUS), characterized by early supported discharge. The short-term effects were published previously. Methods— We performed a randomized controlled trial in which 320 acute stroke patients were allocated to either ordinary stroke unit service (OSUS) (160 patients) or stroke unit care with early supported discharge (160 patients). The ESUS consists of a mobile team that coordinates early supported discharge and further rehabilitation. Primary outcome was the proportion of patients who were independent as assessed by modified Rankin Scale (RS) (RS ≤2=global independence). Secondary outcomes measured at 52 weeks were performance on the Barthel Index (BI) (BI ≥95=independent in activities of daily living), differences in final residence, and analyses to identify patients who benefited most from an early supported discharge service. All assessments were blinded. Results— We found that 56.3% of the patients in the ESUS versus 45.0% in the OSUS were independent (RS ≤2) (P =0.045). The number needed to treat to achieve 1 independent patient in ESUS versus OSUS was 9. The odds ratio for independence was 1.56 (95% CI, 1.01 to 2.44). There were no significant differences in BI score and final residence. Patients with moderate to severe stroke benefited most from the ESUS. Conclusions— Stroke service based on treatment in a stroke unit combined with early supported discharge appears to improve the long-term clinical outcome compared with ordinary stroke unit care. Patients with moderate to severe stroke benefit most.

Not All Stroke Units Are the Same A Comparison of Physical Activity Patterns in Melbourne, Australia, and Trondheim, Norway

Background and Purpose— Very early mobilization may be one of the most important factors contributing to the favorable outcome observed from a stroke unit in Trondheim, Norway. The aims of this study were to (1) describe and compare the pattern of physical activity of patients with stroke managed in a stroke unit with specified mobilization protocols (Trondheim) and those without in Melbourne, Australia; and (2) identify differences in activity according to stroke severity between the 2 sites. Methods— Melbourne patients were recruited from 5 metropolitan stroke units. Trondheim patients were recruited from the stroke unit at University Hospital, Trondheim. All patients <14 days poststroke were eligible for the study. Patients receiving palliative care were excluded. Consenting participants were observed at 10-minute intervals from 8:00 am to 5:00 pm over a single day. At each observation, patient location, activity, and the people present were recorded. Negative binomial regression analyses were undertaken to assess differences in physical activity patterns between stroke units in the 2 cities. Results— Patients in Melbourne and Trondheim had similar baseline characteristics. Melbourne patients spent 21% more time in bed and only 12.2% undertook moderate/high activity (versus 23.2% in Trondheim, P<0.001). This difference was even more pronounced among patients with greater stroke severity. The incidence rate ratio for time spent doing standing and walking activities in Melbourne was 0.44 (95% CI: 0.32 to 0.62) when compared with Trondheim. Conclusion— Higher activity levels were observed in Trondheim patients, particularly among those with more severe strokes. A greater emphasis on mobilization may make an important contribution to improved outcome. Further investigation of this is warranted.

Motor Network Changes Associated With Successful Motor Skill Relearning After Acute Ischemic Stroke : A Longitudinal Functional Magnetic Resonance Imaging Study

Background. Motor learning mechanisms may be operative in stroke recovery and possibly reinforced by rehabilitative training. Objectives. To assess early motor network changes after acute ischemic stroke in patients treated with very early mobilization and task-oriented physical therapy in a comprehensive stroke unit, to investigate the association between neuronal activity and improvements in hand function, and to qualitatively explore the changes in neuronal activity in relation to motor learning. Methods. Patients were assessed by functional magnetic resonance imaging and by clinical tests within the first week after stroke and 3 months later. After discharge, all participants were offered functional training of the affected arm according to individual needs. Results. A total of 359 patients were screened, with 12 patients experiencing first-ever stroke, excluding primary sensorimotor cortex (MISI), with severe to moderately impaired hand function fulfilling the inclusion criteria. Laterality indexes (LIs) for MISI increase significantly during follow-up. There is increased cerebellar and striatal activation acutely, replaced by increased activation of ipsilesional MISI in the chronic phase. Bilateral somatosensory association areas and contralesional secondary somatosensory cortex (SII) area are also more active in the chronic phase. Activation of the latter region also correlates positively with improved hand function. Conclusions. Restoration of hand function is associated with highly lateralized MISI. Activity in bilateral somatosensory association area and contralesional SII may represent cortical plasticity involved in successful motor recovery. The changes in motor activity between acute and chronic phases seem to correspond to a motor learning process.

Frequency and effect of optimal anticoagulation before onset of ischaemic stroke in patients with known atrial fibrillation

Background.  The aims of the study were (i) to examine which antithrombotic therapy patients with known atrial fibrillation use at the point of time when they suffer an ischaemic stroke, (ii) to evaluate the effects of optimal antithrombotic treatment on outcome and severity of the stroke.

A Consensus on Stroke Early Supported Discharge

Background and Purpose— Research evidence supporting Early Supported Discharge (ESD) services has been summarized in a Cochrane Systematic Review. Trials have shown that ESD can reduce long-term dependency and admission to institutional care and reduce the length of hospital stay. No adverse impact on the mood or well-being of patients or carers has been reported. With the implementation of many national and international stroke initiatives, we felt it timely to reach consensus about ESD among trialists who contributed to the review. Methods— We used a modified Delphi approach with 10 ESD trialists. An agreed list of statements about ESD was generated from the Cochrane review and three rounds of consultation completed. ESD trialists rated statements regarding team composition, model of team work, intervention, and success. Results— Consensus of opinion (>75% agreement) was obtained on 47 of the 56 statements. Multidisciplinary, specialist stroke ESD teams should plan and co-ordinate both discharge from hospital and provide rehabilitation in the community. Specific eligibility criteria (safety, practicality, medical stability, and disability) need to be followed to ensure this service is provided for mild to moderate stroke patients who can benefit from ESD. Length of stay in hospital, patient and carer outcome measures and cost, need to be routinely audited. Conclusions— We have created a consensus document that can be used by commissioners and service providers in implementing ESD services. Our aim is to promote the use of recommendations derived from research findings to facilitate successful implementation of stroke services nationally and internationally.