I Perez

The Influence of Visual Neglect on Stroke Rehabilitation

BACKGROUND AND PURPOSE The poor outcome observed in stroke patients with visual neglect may be due to greater stroke severity or nonspecialist management. METHODS The effects of visual neglect were studied prospectively in 150 consecutive stroke patients with comparable stroke pathology and motor severity managed on a stroke unit. A randomized study was subsequently undertaken in 50 stroke patients with visual neglect to evaluate the effectiveness of spatial cueing during motor activity on functional outcome and resource use in these patients. RESULTS Visual neglect was present in 47 (32%) of a selected group of 146 patients (mean age, 77.0 +/- 8.2 years; 42% men) with moderate stroke severity. There were no differences in demography, prestroke function, or motor power in the arm (2.6 +/- 1.7 versus 2.3 +/- 2.1) or the leg (3.2 +/- 1.4 versus 3.0 +/- 1.6) on the affected side compared with 99 patients with no visual neglect. Although patients with visual neglect had lower median initial (4 versus 5, P < .01) and discharge (14 versus 16, P < .01) Barthel Index scores, equal proportions of patients were discharged home (60% versus 65%) or to institutions (34% versus 33%) in both groups. The durations of hospitalization (64 versus 36 days, P < .001) and therapy input (47.7 versus 27.8 hours; P < .01), however, were significantly greater in patients with visual neglect. The randomized controlled study showed a trend toward higher Barthel scores at 12 weeks (14 versus 12.5, P = NS) and significant reduction in median length of hospital stay (42 versus 66 days) in patients receiving spatiomotor cueing and early emphasis on functional rehabilitation. CONCLUSIONS Patients with visual neglect managed on a stroke unit have similar destination of discharge despite lower Barthel Index scores compared with patients of equal stroke severity who do not have this deficit. Spatiomotor cueing and early emphasis on function can improve outcome and reduce resource use in these patients.

Integrated Care Pathways and Quality of Life on a Stroke Rehabilitation Unit

Background and Purpose— Integrated care pathways (ICP) may not reduce disability, institutionalization, or duration of hospitalization compared with conventional multidisciplinary team (MDT) care in organized stroke rehabilitation. Their potential to improve patient heath status or satisfaction with care is not known. Methods— A comparison of quality of life, caregiver strain, and patient/caregiver satisfaction at 6 months after stroke was undertaken in 152 stroke patients randomized to receive ICP or MDT care. Differences in processes of care were recorded with the use of a predefined schedule. Multivariate analyses were undertaken to identify the effect of age, sex, stroke severity, functional status, mood, and use of care pathway on quality of life score. Results— The 2 groups were comparable for baseline characteristics of age, sex, stroke severity, and initial disability. MDT care was characterized by greater emphasis on return of higher function and caregiver needs compared with ICP. EuroQol Visual Analogue Scale (EQ-VAS) scores were higher in the MDT group (median, 72 versus 63;P <0.005), who also had higher scores for EuroQol dimension of social functioning (P =0.014). Higher EQ-VAS scores were independently related to MDT care (P =0.04), Rankin score (P =0.01), and psychological function (P <0.0001) but not to age, sex, or stroke severity. There were no significant differences in patient or caregiver satisfaction between the 2 settings. Conclusions— Better quality of life in patients receiving conventional MDT care may be attributable to improved social functioning and greater attention to higher function and caregiver needs during rehabilitation.

Stroke risk management: changes in mainstream practice.

BACKGROUND Research shows that identification and control of risk factors reduces ischemic stroke. The impact of this evidence and health initiatives on mainstream practice remains unknown. METHODS The purpose of this observational study was to investigate prior management of risk factors (hypertension, atrial fibrillation, previous stroke/transient ischemic attacks) in patients with acute cerebral infarction. Data were collected on the frequency of known risk factors before the incident stroke and their management compared with predefined criteria for appropriateness. The proportion of patients receiving treatment for risk factors before the acute episode was studied over 3 years. RESULTS One thousand seventy-four patients (median age, 76 years; 60% women) were included in the study over 3 years. The proportion of patients with known hypertension (41% to 46%), diabetes (12% to 13%), previous stroke or transient ischemic attack (TIA) (21% to 31%), and atrial fibrillation (16% to 21%) remained stable. Overall, approximately 45% patients with atrial fibrillation, 60% patients with hypertension, and 70% with cerebrovascular disease were being actively managed. Time trends analysis showed a significant increase in the proportion of patients being treated for risk due to known cerebrovascular disease (59% to 85%), atrial fibrillation (18% to 59%), ischemic heart disease (35% to 72%), and carotid disease (13% to 85%) between the first and third year. The proportion of patients receiving treatment for hypertension remained unchanged. Patients with preexisting symptomatic vascular disease were more likely to receive appropriate risk management compared with asymptomatic patients (72% versus 46%, P<.001). CONCLUSIONS Although a significant number of ischemic events remain potentially preventable, there appears to be a positive trend in improved control of stroke risk.

The Process of Rehabilitation and Discharge Planning in Stroke A Controlled Comparison Between Stroke Units

BACKGROUND AND PURPOSE Stroke units improve outcome for stroke patients. Comparative controlled studies between stroke units are required to determine which components of stroke unit rehabilitation influence outcome and which may be investigated further in randomized controlled trials. This study compares 2 stroke units with regard to the effect differences in practice have on functional recovery (Barthel Index score) and discharge planning (length of stay). METHODS Stroke unit patients with moderate disability (Barthel score of 4 to 10 at week 1) admitted over 18 months were studied. Barthel measurements were obtained weekly from week 1 to discharge. Details of stroke unit function were recorded. The core features of stroke units were in place in both units. Rehabilitation was impairment focused (theoretically driven) on one unit and disability oriented (pragmatic) on the other. RESULTS Numbers of patients were comparable (85 versus 99). Median Barthel score at week 1 (6 versus 6), time to maximal Barthel score (14 versus 14 weeks), discharge Barthel score (14 versus 14), and institutionalization (32% versus 28%) were similar in both units. Median lengths of stay differed (68 versus 49 days; P<0.001). CONCLUSIONS Comparisons with regard to the rehabilitation process can be made between stroke units. Differences in rehabilitation process between 2 units showed no effect on the rate of functional recovery. Length of stay was significantly different between units, an effect that cannot be attributed to functional recovery and therefore reflects differences in discharge planning, including postdischarge support.

Risk Assessment and Anticoagulation for Primary Stroke Prevention in Atrial Fibrillation

BACKGROUND AND PURPOSE Risk assessment before anticoagulation is important for effective stroke prevention in atrial fibrillation (AF). METHODS A study was undertaken in patients with AF to investigate the contribution of clinical and echocardiography (ECHO) criteria to treatment decisions on anticoagulation. Patients were stratified by age and stroke risk; contraindications to anticoagulation and warfarin use were assessed. The value of ECHO in treatment decisions, effect of age, and existing anticoagulation practice were evaluated. RESULTS The mean+/-SD age of 234 patients was 67.1+/-11.8 years, and 122 (52%) were women. Clinical risk factors were present in 74 of 80 patients (92%) aged >75 years compared with 99 of 154 patients (64%) </=75 years (P<0.01). ECHO risk was identified in 94 of 154 patients (61%) </=75 years, 16 (17%) of whom had no clinical risk factors. ECHO risk was present in 71 patients (88%) >75 years of age, and was associated with clinical risk factors in all patients. Eligibility for anticoagulation was seen in 72 of 154 (47%) to 105 of 154 (68%) patients aged </=75 years, depending on the criteria used, and in 66 of 80 patients (83%) >75 years, regardless of criteria used (P<0.01). Warfarin was being used in 55 of 105 patients (51%) </=75 years and 8 of 66 patients (12%) >75 years (P<0.001). Anticoagulation was being undertaken in 7 of 49 patients (14%) </=75 years despite no clinical or ECHO risks. CONCLUSIONS Accurate assessments of eligibility and appropriateness of anticoagulation in AF can be made on clinical criteria alone, especially in older people. The value of ECHO in treatment decisions is limited to patients </=75 years of age with no clinical risk factors.