Daniela Morelli

Early versus delayed inpatient stroke rehabilitation: A matched comparison conducted in Italy

OBJECTIVE To assess the specific influence of onset-admission interval (OAI) on rehabilitation results. DESIGN A case-control study in consecutive stroke inpatients, enrolled in homogeneous subgroups, matched for age (within 1 year) and Barthel Index (BI) score at admission, and different for OAI to the rehabilitation ward. The short OAI group began rehabilitation treatment within the first 20 days from stroke, medium OAI group between days 21 and 40, and long OAI between days 41 and 60. SETTING Rehabilitation hospital. PATIENTS One hundred forty-five patients with sequelae of first stroke. MAIN OUTCOME MEASURES Efficiency (average increase in BI per day), effectiveness (proportion of potential improvement achieved during rehabilitation) of treatment, and percentage of low- and high-response patients, calculated on BI, were evaluated. Odds ratios (ORs) of dropouts and of poor and excellent therapeutic response were also quantified. RESULTS The short OAI subgroup had significantly higher effectiveness of treatment than did the medium (p < .05) and the long OAI groups (p < .005). Beginning treatment within the first 20 days was associated with a significantly high probability of excellent therapeutic response (OR = 6.11; 95% confidence interval [CI], 2.03-18.36), and beginning later was associated with a similar risk of poor response (OR = 5.18; 95% CI, 1.07-25.00). On the other hand, early intervention was associated with a five times greater risk of dropout than that of patients with delayed start of treatment (OR = 4.99; 95% CI, 1.38-18.03). The three subgroups were significantly (p < .05) different regarding the percentage of low and high responders. CONCLUSION Our results showed a strong association between OAI and functional outcome.

Functional Outcome of Ischemic and Hemorrhagic Stroke Patients After Inpatient Rehabilitation: A Matched Comparison

Background and Purpose— The goal of this study was to assess the specific influence of stroke etiology on rehabilitation results. Methods— This was a case-control study of 270 inpatients with sequelae of first stroke who were enrolled in homogeneous subgroups and matched for stroke severity, basal disability, age (within 1 year), sex, and onset admission interval (within 3 days) who were different only in terms of stroke origin, infarction versus hemorrhage. We compared the groups’ length of stay, efficiency and effectiveness of treatment, and percentage of low and high responder patients. Odds ratios of dropouts and of low and high therapeutic response were also quantified. Results— Compared with ischemic patients, hemorrhagic patients had significantly higher Canadian Neurological Scale and Rivermead Mobility Index scores at discharge; higher effectiveness and efficiency on the Canadian Neurological Scale, Barthel Index, and Rivermead Mobility Index; and a higher percentage of high responders on the Barthel Index. Hemorrhagic patients showed a probability of a high therapeutic response on the Barthel Index that was ≈2.5 times greater than that of ischemic patients (odds ratio, 2.48; 95% confidence interval, 1.19 to 5.20; accuracy on prediction, 87.06%). Conclusions— The results of this study provide further evidence of better functional prognosis in stroke survivors with hemorrhagic stroke.

Post-Stroke Depression, Antidepressant Treatment and Rehabilitation Results

The aim of this study was to assess the specific influence of poststroke depression (PSD) on both basal functional status and rehabilitation results. We performed a case-control study in 290 stroke inpatients, matched for age (±1 year) and onset admission interval (±3 days) and divided in two groups according to the presence (PSD+) or absence (PSD–) of PSD. All PSD+ patients were treated with antidepressants (AD), mainly with fluoxetine. PSD+ patients, despite similar severity of stroke, showed greater disability in coping with activities of daily living (ADL) on admission and greater disability both in ADL and mobility at discharge than PSD– patients. Although both groups exhibited similar average functional improvement during rehabilitation, PSD– patients were nearly twice as likely to show excellent recovery both on ADL and mobility as PSD+ patients (OR = 1.95, 95% CI = 1.01–3.75 and OR = 2.23, 95% CI = 1.14–4.35, respectively). All AD drugs improved depressive symptoms. Few relevant side effects were observed: fluoxetine was discontinued in 2 patients because of insomnia and in 2 patients because of nausea; paroxetine was stopped in 1 patient because of nausea and dry mouth. Our results confirm the unfavorable influence of PSD on functional outcome, despite pharmacological treatment.

Is Sex a Prognostic Factor in Stroke Rehabilitation? A Matched Comparison

Background and Purpose— We sought to assess the specific influence of sex on rehabilitation results. Methods— A case-control study in 440 consecutive patients with sequelae of first ischemic stroke were enrolled in 2 subgroups (males and females) and matched for severity of stroke (evaluated by means of the Canadian Neurological Scale), age (within 1 year), and onset-admission interval (within 3 days). Functional data, evaluated by means of the Barthel Index and the Rivermead Mobility Index, were compared between subgroups. Logistic regressions were used to clarify the role of sex in affecting global autonomy and mobility. Results— After rehabilitation treatment, a sex-related difference was observed essentially in the higher levels of response. Indeed, more men than women reached independence in both stair climbing and activities of daily living (ADL), with a higher response and effectiveness on mobility. In multivariate analyses, male patients had a 3 times higher probability than female patients of good autonomy in both stair climbing and ADL (odds ratio [OR]=3.22; 95% CI, 1.67 to 6.18 and OR=2.92; 95% CI, 1.63 to 5.42, respectively). Conversely, female patients had a higher risk of walking with a cane (OR=1.69; 95%, CI 1.04 to 2.76) or of partial autonomy with respect to ADL (OR=1.90; 95% CI, 1.25 to 2.91). No significant difference was found for the other functional parameters. Conclusions— Female sex is a mildly unfavorable prognostic factor in rehabilitation results after stroke.

Quantification of the probability of reaching mobility independence at discharge from a rehabilitation hospital in nonwalking early ischemic stroke patients: A multivariate study

Background: This study was designed to quantify the probability of recovery of mobility in admission nonwalking stroke survivors. Methods: We evaluated 437 of 500 consecutive patients admitted for sequelae of first ischemic stroke within the first month. We performed several logistic regressions using mobility status at discharge (independence in stair climbing; walking outside and inside, without aid or supervision; walking with cane or other aid, or need for wheelchair) as dependent variable, and several independent variables, including stratification of patients according to their Barthel Index (BI) score into 6 classes (≤10; 11–20; 21–30; 31–40; 41–50; 51–60). Results: At discharge, 4.58% of patients were independent in stair climbing, 8.70% were able to walk outside, 14.41% to walk inside, and 27.46% to walk with cane or other aid, while 44.85% remained in wheelchair. Very low BI scores at admission were associated with a high risk of need for wheelchair, whereas patients with BI score 51–60 showed a high probability to reach independence in stair climbing (OR = 5.60). Age, severity of neurological impairment, global aphasia, unilateral spatial neglect, male gender and vocational status also played a prognostic role. Conclusions: The probability of potential mobility recovery can be quantified at admission with better accuracy for independence in stair climbing and walking outside without any aid (percentages correctly predicted 95.4 and 91.8%, respectively). Stratification of BI score may be useful to better quantify the risk for each patient.

Stability and Harmony of Gait in Children with Cerebral Palsy.

The aim of this study was to quantitatively assess the stability and harmony of gait in children with cerebral palsy. Seventeen children with spastic hemiplegia due to cerebral palsy (5.0±2.3 years old) who were able to walk autonomously and seventeen age-matched children with typical development (5.7±2.5 years old, p=0.391) performed a 10-m walking test with a wearable device fixed to their lower trunk and included a triaxial accelerometer and three gyroscopes. Three parameters related to gait stability and three related to gait harmony were computed; all of these yielded significant differences between children with cerebral palsy and those with typical development (p<0.020 for all the computed parameters). In the latter group of children, trunk accelerations were found to be negatively correlated with age (partial correlation controlled for walking speed: R(p)<-0.58, p>0.020). Conversely, in children with cerebral palsy, the upper body accelerations were proportionally correlated with their gait speed (R=0.548, p=0.023 in the antero-posterior direction) but not with their age (p>0.05). This finding can be related both to difficulties in managing the higher upper body accelerations involved in rapid walking and to compensation strategies.

One-year follow-up in stroke patients discharged from rehabilitation hospital

This study was designed to evaluate functional status at a 1-year follow-up in consecutive first-stroke patients after discharge from rehabilitation hospital and to identify reliable prognostic factors associated with changes in their abilities. Functional evaluation was made of consecutive patients 1 year after discharge to their own homes. Two multiple logistic regressions (forward stepwise) were performed using both improvement and worsening of the Barthel Index score between discharge and follow-up as dependent variables. Independent variables were medical, demographic and social factors. The final sample included 157 out of 172 patients. During the follow-up, 10 patients (5.81%) died because of a new cerebrovascular event, 1 patient died of myocardial infarction, 2 patients had new strokes and 2 fractured their paretic legs. Functionally, 43.3% of the patients maintained the level they achieved during inpatient rehabilitation treatment, 23.6% improved and the remaining 33.1% worsened. Patients with hemineglect and aged ≥65 years had a higher probability of functional worsening (odds ratio, OR = 3.77, 95% confidence interval, CI = 1.42– 10.0 and OR = 3.93, 95% CI = 1.72–8.95, respectively). Postdischarge rehabilitation (performed for 46.5% of the final sample) was significantly and positively associated with functional improvement (OR = 7.23, 95% CI = 2.89–18.05), and its absence with functional worsening (OR = 12.32, 95% CI = 4.47–37.01). In conclusion, in nearly half of the cases, functional status was still not stabilized at the time of discharge from the rehabilitation hospital. Postdischarge outpatient treatment was useful for preventing worsening of the functional ability achived during inpatient treatment and increased the possibility of further functional improvement. Age ≥65 years and hemineglect were predictors of functional worsening at follow-up.

Prognostic factors in multidisciplinary rehabilitation treatment in multiple sclerosis: an outcome study.

The aim of this outcome study was to evaluate the effectiveness and prognostic factors of inpatient multidisciplinary rehabilitation treatment in patients with multiple sclerosis (MS). We analysed 230 consecutive inpatients with MS admitted to an MS rehabilitation ward who followed an individualized, goal-oriented, multidisciplinary rehabilitation program. Every patient was submitted to a neurological examination and evaluated by means of Kurtzke’s Expanded Disability Status Scale (EDSS), with its functional systems (FS), Barthel Index (BI) and the Rivermead Mobility Index (RMI). We observed an effectiveness (percentage of potential improvement achieved during rehabilitation) of nearly 16% on BI and 8% on RMI, corresponding to an improvement in 124 patients (54%) on BI and 113 patients (49%) on RMI. Basal EDSS (β= -0.32, p<0.001), cognitive status (β= -0.15, p<0.05) and disease duration (β= -0.13, p<0.05) were negatively associated with effectiveness of treatment on BI (adjusted R2=0.176), whereas effectiveness on RMI was correlated only with the EDSS score (β=-0.34, p<0.001, adjusted R2=0.113). In the logistic regression analysis, the absence of severe sphincteric disturbances was correlated with the probability of improvement on BI that was nearly twice as high (OR=2.25, 95% CI 1.24-4.08) as that of other patients. Moreover, patients without severe cognitive deficits showed a similar probability (OR-2.37, 95% CI 1.05-5.33) of improvement on RMI. The results of this study provide further evidence that intensive multidisciplinary rehabilitation in MS is effective in the majority of MS patients and that early treatment may favour functional recovery.

Rehabilitation of Left Brain-Damaged Ischemic Stroke Patients: The Role of Comprehension Language Deficits

Background: Aphasia is considered a risk factor for disability after stroke. The aim of this study was to assess the specific influence of aphasia on rehabilitation results. Method: A case-control study in consecutive left brain-damaged stroke inpatients, enrolled in three homogeneous subgroups [nonaphasic (NA) patients, aphasic with comprehension deficit (CD), and without comprehension deficit (NCD)] matched for age and onset-admission interval. Rehabilitation results (gain, efficiency, effectiveness of treatment, percentage and odds ratio of dropouts and of each degree of therapeutic response, assessed by Barthel Index and Rivermead Mobility Index) were compared among the subgroups. Results: Two hundred and forty patients with sequelae of a first stroke were enrolled. CD patients, as compared with NCD and NA ones, had a significantly more severe basal neurological and functional status at admission, minor effectiveness on ADL and mobility, a higher percentage of low responders on ADL and urinary incontinence at discharge, and a risk of low therapeutic response on ADL nearly 4 times higher than the other patients (OR = 4.22, 95% CI = 1.90–9.38). The rehabilitative behavior between NCD and NA was similar. However, all subgroups (NA, CD and NCD) showed a significant improvement (p < 0.001) between their basal and discharge score, both on BI and RMI. Conclusions: Comprehension language deficit was confirmed to be a strong negative rehabilitation prognostic factor despite the speech therapy done by all CD patients.

Functional taping: a promising technique for children with cerebral palsy

SIR–Limitations in the motor activity of children with cerebral palsy (CP) are the consequence of a failure to acquire appropriate motor schemas, caused by arrested normal brain maturation. Nevertheless, some of these children, exploiting their few available resources, manage to walk, thanks to the emergence of atypical but still functional locomotor patterns. However, these patterns can lead to long-term instability, contractures, and deformities. Common treatments for children with CP include botulinum toxin, serial casting, orthopaedic surgery, and orthoses. These somewhat invasive interventions are designed to act at the peripheral level, without particularly aiming at promoting more normal motor development at the central level. Functional taping may be a slightly less invasive solution in trying to reach this objective. This technique, commonly used in sports traumatology and lately proposed for patients with stroke, aims at supporting an injured joint, protecting weak structures, and enhancing sensory feedback. This much less invasive intervention could favour the integration of therapy and daily activities and increase participation in social life. Nevertheless, it has been only applied infrequently in these children and only at upper-body level. A pilot study was performed to test the effects of lower limb taping on the locomotor function of a group of children with spastic unilateral CP. These children were already being treated with conventional physical therapy consisting of 1-hour treatment, repeated two times a week and based on neurodevelopmental treatment (derived from the Bobath concept). It included stretching, weak muscle strengthening, and postural and walking training. However, in the months preceding the study, the above therapy alone was judged to be no longer effective for the children because expected improvements in gross motor function were not being achieved. After the approval of the ethical committee of Fondazione Santa Lucia and the informed consent of both parents, eight children (initial mean age of 4y and 8m, SD 3y, all diagnosed with spastic unilateral CP; Table SI, supporting information published online, who were able to walk independently, were