Gabriella Antonucci

Cognitive rehabilitation of the hemineglect disorder in chronic patients with unilateral right brain damage

Thirteen patients with a stabilized hemineglect symptomatology due to right-hemisphere lesions were subjected to a rehabilitation training specifically aimed at reducing the scanning deficit. The training consisted of four procedures (visual-spatial scanning, reading and copying training, copying of line drawings on a dot matrix, and figure description) which lasted 40 sessions. By the end of therapy, the patients as a group showed significant improvements on several standard tests of hemineglect. The results on a Semi-structured Scale for the Functional Evaluation of Hemineglect pointed to the extension of exploratory improvements to situations similar to those of daily life. In contrast, patients improved very slightly on a variety of standard visual-spatial tests, indicating the specificity of training in reducing the scanning defect. Seven patients were examined at a follow-up several months after the end of therapy and appeared stable on both standard and functional tests of neglect.

Effect of optokinetic stimulation in patients with visual neglect

Three groups of subjects, normal controls, right brain damaged patients with and without heminattention, were required to bisect a line in presence of a fixed or a moving background. The stimulus moving horizontally toward the left or the right induced an optokinetic nystagmus with a slow phase coherent with the direction of the movement: together with the optokinetic nystagmus, a displacement of the subjective midpoint, as compared to the condition with a fixed background, was observed in all three groups of subjects. Within the right brain damaged with heminattention the displacement of the line bisection was great for stimuli moving toward the right, but a significant reduction of the left bias was present. In the same group of patients the effect of the optokinetic stimulation was present in a very large proportion of cases and proved to be relatively stable in a test-retest presentation. Theoretical relevance of these data and their potential importance for rehabilitation are discussed.

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.

Personal and extrapersonal space: A case of neglect dissociation

Dissociation between personal and extrapersonal neglect has rarely been observed in man. In this study we present a case of severe personal neglect in the absence of a deficit for extrapersonal space. An extensive neuropsychological assessment demonstrates the absence of cognitive impairments in visuo-spatial processing and confirms the selective presence of a severe representational deficit of the left side of the body.

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.

Effectiveness of neglect rehabilitation in a randomized group study

The effectiveness of neglect rehabilitation training has been studied in two randomly selected groups of right brain-damaged patients. All patients proved heminattentive on a standard battery 2 months or more after the CVA. One group received 2 months of treatment immediately after admission to a clinic, and the other group received only general cognitive stimulation for the same amount of time. At the end of this period a comparison showed significant improvement in the first group, based on a standard test battery and a functional scale. The second group was then given rehabilitation training for neglect for the same amount of time and obtained similar improvement. It is concluded that the rehabilitation program produces significant results, which generalize to situations similar to those of everyday life. The importance of the duration of training on the generalization of learning is briefly discussed with reference to previous negative reports in the literature.

Functional Outcome in Stroke Inpatient Rehabilitation: Predicting No, Low and High Response Patients

The aims of this study were: (1) to identify reliable prognostic factors for detecting subgroups of no, low and high response in consecutive patients admitted for rehabilitation of first stroke sequelae, and (2) to quantify the relative risk of poor or excellent prognosis on both Activities of Daily Living (ADL) and mobility for each significant variable. We prospectively studied 440 of 475 patients. From a group of 32 independent variables, those significantly associated with no, low and high effectiveness on both ADL and mobility were selected by means of multiple regression; then, the relative risk was calculated for each variable that significantly entered the multiple regressions. Patients with severe impairment or with global aphasia showed a relative risk of no response 4–6 times higher than that of other patients. An interval before rehabilitation longer than 2 months was associated with an increasing risk of no response. Elderly patients had a significantly higher relative risk of low response both on ADL and mobility. The presence of hemineglect and depression was associated with an increasing risk of low response on ADL but not on mobility. The absence of hemineglect and a short interval are prerequisites for an excellent functional prognosis on both ADL and mobility. A minor impairment, employed status, the absence of global aphasia and age ≤65 years increased the risk of high response. At the beginning of treatment, clear prognostic factors for the detection of subgroups with poor or excellent rehabilitation prognosis can be identified.

Predicting Stroke Inpatient Rehabilitation Outcome: The Prominent Role of Neuropsychological Disorders

This study was designed to determine the role of demographic, medical and cognitive factors in the results of rehabilitation in first stroke patients. In a prospective study on 273 consecutive patients admitted to a rehabilitation hospital for sequelae of first stroke, we used multiple regressions to assess the relationship between 11 independent variables and a battery of outcome measures: mortality, length of hospital stay, Barthel Index (BI) and Rivermead Mobility Index (RMI) scores at discharge and their effectiveness. Severity of stroke at admission and hemineglect were the strongest prognostic factors. In a logistic model, cognitive impairment was a significant independent predictor (OR = 4.10) also after adjusting for age and severity of stroke. Patients with hemineglect had a significantly higher relative risk of poor autonomy [RR = 7.30, 95% confidence interval (CI) 4.04-13.18] and impaired mobility (RR = 9.25, CI 4.63-18.45). Global aphasic patients had similar risks for both autonomy (RR = 4.51, CI 2.74-7.41) and mobility (RR = 4.71, CI 2.79-7.97). This study underlines the crucial role of cognitive disorders as predictors of poor functional outcome in stroke survivors and confirms the need for early neuropsychological screening.

Poststroke depression and its role in rehabilitation of inpatients.

OBJECTIVES To identify the prevalence of poststroke depression (PSD) in a population of patients admitted for rehabilitation of neurologic sequelae of their first stroke, to recognize reliable prognostic factors associated with the occurrence of PSD, and to evaluate the impact of PSD on the results of rehabilitation treatment. METHODS In a prospective study of 470 of 508 consecutive patients admitted to a rehabilitation hospital for sequelae of their first stroke, the relation between 23 independent variables and the development of depression was assessed by using a logistic regression analysis (forward stepwise). In addition, the impact of PSD on basal disability and on rehabilitation results was assessed by multiple measures (length of stay, efficiency, effectiveness, and percent of low responders on activities of daily living [ADL] and mobility). RESULTS PSD occurred in 129 patients (27.4%). Being female and having more than 8 years of schooling were associated with a higher probability of developing depression (odds ratio [OR] = 1.94, 95% confidence interval [CI] = 1.27-2.96, and OR = 1.61, 95% CI = 1.04-2.48, respectively). No association was found with site or side of cerebral lesion. In a logistic model, depression was a significant independent predictor (OR = 1.99, 95% CI = 1.14-3.46) of low response on ADL in spite of treatment. CONCLUSIONS PSD occurs especially in female patients and in patients with a high level of education and, even if treated, may affect rehabilitation results. No association was found between brain lesion location and PSD.

Development of neuropsychiatric symptoms in poststroke patients: a cross-sectional study.

Objective:  The study aimed to characterize neuropsychiatric symptomatology and its evolution in a large group of poststroke patients during their first year.