Iuly Treger

Return to work following traumatic brain injury: Trends and challenges

Purpose. The aim of this paper is to present the current knowledge regarding return to work (RTW) following traumatic brain injury (TBI). Method. Based on a Medline search, the authors reviewed the current TBI rehabilitation literature regarding (a) predictive factors for successful RTW, and (b) current concepts in rehabilitative strategies for successful RTW. Results. The functional consequences to the victim of traumatic brain injury (TBI) can be severe. Intensive rehabilitative efforts typically emphasize the early phase and address mainly the accompanying functional deficits in the realm of basic activities of daily living and mobility. An otherwise successful medical rehabilitation may end unsuccessfully because of the failure to return to work, with profound consequences to the individual and family, both economic and psychosocial. Even mild TBI may cause lasting problems in tasks calling for sustained attention. There appears to be a complex interaction between pre-morbid characteristics, injury factors, post injury impairments, personal and environmental factors in TBI patients, which influences RTW outcomes in ways that make prediction difficult. Injury severity and lack of self-awareness appear to be the most significant indicators of failure to RTW. Several medical, psychosocial and rehabilitative therapies are currently being implemented in rehabilitation settings which improve the chances of returning to work. Conclusion. Accurate prediction of whether a particular TBI patient will successfully return to work is not feasible, with RTW rates in the 12 – 70% range. A significant proportion of TBI patients, including those who are severely injured, are able to return to productive employment if sufficient and appropriate effort is invested. A comprehensive approach – medical and psychosocial – eventually entailing adequate vocational rehabilitation with supported employment can improve outcomes.

Return to work in stroke patients

Purpose. To present the current state of knowledge regarding return to work (RTW) following stroke. Method. A comprehensive review of the current stroke rehabilitation literature pertaining to prognostic and treatment factors for RTW following stroke. Results. Stroke is a major healthcare problem and one of the most expensive diseases in modern society. Stroke results not only in impairment and limitation in basic daily activities; it also impacts on participation in community activities, such as returning to work. Return to work in post-stroke patients has been reported to range between 19% and 73%. Various studies report on return to work in diverse populations, using different follow-up periods, while utilizing variable definitions of stroke and successful work outcomes. The factors positively related to RTW in stroke patients, as found in the literature, are age less then 65 years, high education level and white-collar employment. The significant negative predictor is the severity of stroke. This is indicated by neurological parameters including functional measures of the presence and extent of motor and cognitive impairment. Significantly, the side of the brain damaged and stroke location were not found to be correlated with RTW. Social and financial factors also significantly influence RTW. Conclusions. RTW in stroke patients should be considered one of the indicators of a successful rehabilitation as it influences self-image, well-being and life satisfaction. There is still a considerable lack of knowledge regarding effective assessments and interventions in vocational rehabilitation in stroke patients.

Neuroprosthesis for Footdrop Compared with an Ankle-Foot Orthosis: Effects on Postural Control during Walking

OBJECTIVES We sought to compare the effects of a radio frequency-controlled neuroprosthesis on gait stability and symmetry to the effects obtained with a standard ankle-foot orthosis (AFO). METHODS A total of 15 patients (mean age: 52.2 +/- 3.6 years) with prior chronic hemiparesis resulting from stroke or traumatic brain injury (5.9 +/- 1.5 year) whose walking was impaired by footdrop and regularly used an AFO participated in the study. There was a 4-week adaptation period during which participants increased their daily use of the neuroprosthesis, while using the AFO for the rest of the day. Gait was then assessed in a 6-minute walk while wearing force-sensitive insoles, by using the neuroprosthesis and the AFO in a randomized order. An additional gait assessment was conducted after using the neuroprosthesis for a further 4 weeks. Gait speed and stride time (inverse of cadence) were determined, as were gait asymmetry index and swing time variability. RESULTS After the 4-week adaptation period, there were no differences between walking with the neuroprosthesis and walking with the AFO (P > .05). After 8 weeks, there was no significant difference in gait speed, whereas stride time improved from 1.48 +/- 0.21 seconds with the AFO to 1.41 +/- 0.16 seconds with the neuroprosthesis (P < .02). Swing time variability decreased from 5.3 +/- 1.6% with the AFO to 4.3 +/- 1.4% with the neuroprosthesis (P = .01). A gait asymmetry index improved by 15%, from 0.20 +/- 0.09 with the AFO to 0.17 +/- 0.08 with the neuroprosthesis (P < .05). CONCLUSIONS Compared with AFO, the studied neuroprosthesis appears to enhance balance control during walking and, thus, more effectively manage footdrop.

Rehabilitation Outcomes in Patients with Brain Tumors and Acute Stroke: Comparative Study of Inpatient Rehabilitation

Greenberg E, Treger I, Ring H: Rehabilitation outcomes in patients with brain tumors and acute stroke: Comparative study of inpatient rehabilitation. Am J Phys Med Rehabil 2006;85:568–573. Objectives:To investigate functional outcomes after hospital rehabilitation of patients surviving craniotomy for primary brain tumor excision compared with poststroke patients. Design:The database of the Neurological Rehabilitation Department “C” of Loewenstein Rehabilitation Center was used to investigate primary brain tumors and first ischemic and hemorrhagic stroke patients admitted for hospital rehabilitation during an 11-yr period, between January 1993 and August 2004. Particular attention was paid to age and sex distribution, onset-to-admission interval, length of stay, functional status at admission and discharge, functional gain (&Dgr;FIM™ change) as measured by the FIM™ instrument. Results:A total of 168 patients with craniotomy for primary brain tumor excision (128 intracranial meningiomas and 40 cerebral gliomas) and 1660 first-stroke patients were admitted to the department for rehabilitation during the study period. Mean patient age was 59.9 yrs in meningioma group, 54.1 yrs in the glioma group, and 60.4 yrs in the stroke group. In the meningioma and stroke groups, male patients were in the majority (62 and 70%); in the glioma group, there was equal sex distribution. On average, patients were admitted to rehabilitation treatment 13 days after meningioma excision, 34 days after glioma operation, and 21.6 days after stroke. Functional variables during inpatient rehabilitation were found to be similar in the all groups. Average FIM™ rating at admission was 80.07 in the meningioma group, 68.2 in the glioma group, and 70.4 in the stroke group. Average discharge FIM™ rating was 90.3 for patients with meningiomas, 80.7 for patients with gliomas, and 87.8 for stroke patients. Functional gain was 17.9 for meningioma patients, 17.2 for glioma patients, and 21.8 for stroke patients. Average length of stay was 24 days for the meningioma group, 23 days for the glioma group, and 75.4 days for stroke patients; 88.1% of stroke patients, 91.7% of meningioma patients, and 82.7% of glioma patients were discharged to their homes, and 5.4, 3.4, and 8.6%, respectively, were discharged to nursing homes. Conclusions:Patients with brain tumors can achieve good functional outcomes with a shorter length of stay.

Modified Constraint-Induced Movement Therapy Improved Upper Limb Function in Subacute Poststroke Patients: A Small-Scale Clinical Trial

Abstract Background: Constraint-induced movement therapy (CIMT) has been advocated as a means of facilitating motor function in poststroke patients; however, the evidence for its efficacy is controversial. Objective: To evaluate the effect of modified CIMT on improving paretic arm function in poststroke patients during a subacute rehabilitation period. Methods: A single-blinded randomized controlled trial was conducted at the Loewenstein Rehabilitation Hospital, Israel. Twenty-eight subacute stroke patients with arm paresis after a first ischemic stroke in the middle cerebral artery area were randomized into a modified CIMT or control group by a 1:2 ratio. The modified CIMT group received 1-hour daily physical rehabilitation sessions for 2 weeks. The unaffected arm was restrained during the sessions. Subjects were encouraged to wear a restrictive mitten up to 4 hours a day. The control group received similar intensive regular rehabilitation. Three upper limb function tests, developed for this study, were used as outcome measures. The subjects were asked to perform the following tasks, with the affected hand for 30 seconds: (1) transfer pegs from a saucer to a pegboard; (2) grasp, carry, and release a hard rubber ball; and (3) “eating,” using a spoon to remove the jelly from the plate, bring it towards the mouth, and then place it on another plate. The number of repetitions in each test was recorded as an outcome. Results: The modified CIMT group showed significantly higher changes in all 3 tests compared to the standard rehabilitation group. Conclusion: Our study provides additional support for the use of modified CIMT during a subacute rehabilitation period of poststroke patients. CIMT may facilitate functional improvement of a plegic hand.

Association between apolipoprotein E4 and rehabilitation outcome in hospitalized ischemic stroke patients

OBJECTIVE To determine the value of apolipoprotein E4 (APOE*E4) allele in predicting discharge impairment and disability in ischemic stroke patients after acute rehabilitation. DESIGN Prospective study comparing results of rehabilitation in patients with different APOE genotypes. SETTING Acute neurologic rehabilitation department in Israel. PARTICIPANTS One hundred one consecutive patients 75 years old or less with a first ischemic stroke. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Impairment, as measured by the National Institutes of Health Stroke Scale (NIHSS), and disability, as assessed with the FIM trade mark instrument. RESULTS On admission, there was no significant difference in the FIM or NIHSS measurements between the apo E4 group and other patients, but the prevalence of aphasia was 2.07 times more frequent in those with the APOE*E4 genotype (95% confidence interval, 0.98-4.4). A logistic regression model demonstrated that score measurements on admission were highly predictive of the NIHSS score at discharge (receiver operator curve=96.1%), whereas the presence of the APOE*E4 genotype did not add significantly to the model in predicting poorer rehabilitation treatment outcome as measured by the FIM or the NIHSS. CONCLUSIONS The presence of the apo E4 allele did not predict a poorer outcome of rehabilitation treatment after ischemic stroke, but it was associated with an increased prevalence of aphasia. Further studies are warranted to confirm this association.

Hospital disposition after stroke in a national survey of acute cerebrovascular diseases in Israel.

OBJECTIVE To investigate predictive factors for disposition after acute stroke. DESIGN A nationwide survey (2004 National Acute Stroke Israeli Survey). SETTING All 28 primary general medical centers operating in Israel. PARTICIPANTS Acute stroke patients (n=1583) admitted during February and March 2004 and discharged from the primary hospital. INTERVENTIONS Data collected on baseline characteristics, stroke presentation, type and severity, in-hospital investigation and complications, discharge disability, acute hospital disposition, and mortality follow-up. MAIN OUTCOME MEASURE Hospital disposition to home, acute rehabilitation, or nursing facility. RESULTS Among patients, 58.9% (n=932) were discharged home, 33.7% (n=534) to rehabilitation departments, and only 7.4% (n=117) to nursing facilities. Admission neurologic status was a good predictor of hospital disposition. Patients with severe strokes were mostly discharged to rehabilitation facilities. Patients with significant functional decline before the index stroke, resulting from a previous stroke or another cause, were sent to inpatient rehabilitation less frequently. Disability level at discharge from acute hospitalization had high predictive value in hospital disposition after stroke. In the northern region of Israel, a higher proportion of patients were sent home and a lower proportion to rehabilitation and nursing facilities, probably because of lower availability of rehabilitation care in this region of Israel. CONCLUSIONS This nationwide survey shows that most stroke survivors in Israel are discharged home from the acute primary hospital. Good functional status before the index stroke is an important predictor for being sent to acute inpatient rehabilitation. Severity of neurologic impairment and level of disability after the stroke at discharge from the primary hospital are strong predictors for disposition after stroke in Israel. Our data may be useful in discharge planning for stroke patients by policy-makers and health care providers in Israel.

The Effects of Acupuncture on Cerebral Blood Flow in Post-Stroke Patients: A Randomized Controlled Trial.

BACKGROUND/OBJECTIVE Stroke is a major cause of disability and death in the Western world. Studies have shown a direct relationship between specific mental and motor activity and changes in cerebral blood flow. Acupuncture is often used in post-stroke patients, but there is a lack of sham-controlled studies evaluating the effects of acupuncture on cerebral blood flow following a stroke. This pilot concept-assessment study sought to evaluate the effects of true acupuncture on cerebral blood flow velocity compared with sham acupuncture and lay a foundation for future work in this field. METHODS Seventeen inpatients (age range, 44-79 years) 1-3 months post-stroke were allocated to acupuncture at true acupuncture (TA) points or at sham acupuncture (SA) points. The treatment was 20 minutes long. Transcranial Doppler ultrasonography was used to measure mean flow velocity (MFV) and peak flow velocity (PFV) at both healthy and damaged hemispheres before (T0), in the middle of (T15), and 5 minutes after (T25) treatment. Blood pressure was measured at T0 and T25. RESULTS A statistically significant (p < 0.04) MFV increase in both hemispheres was found during and after TA; this increase was higher than that seen with SA (p < 0.035). Acupuncture had no significant effect on PFV. Systolic blood pressure significantly decreased after acupuncture (p < 0.005) in a similar manner for both TA and SA. National Institutes of Health Stroke Scale score was negatively correlated with MFV at T15 (r = -0.825; p < 0.05). CONCLUSION This pilot study showed a significant influence on cerebral blood flow velocity by TA. This study lays a foundation for larger-scale studies that may prove acupuncture to be a useful tool for cerebral blood flow enhancement during post-stroke rehabilitation.

Physical Therapists Versus Nurses in a Rehabilitation Hospital: Comparing Prevalence of Work-Related Musculoskeletal Complaints and Working Conditions

ABSTRACT The objective of this study was to investigate the prevalence and work avoidance of work-related musculoskeletal complaints and to compare patient handling tasks and psychosocial factors of physical therapists (PTs) and nurses in a rehabilitation hospital. Cross-sectional observational study was carried out using questionnaires relating to basic demographics, prevalence of musculoskeletal morbidity, workload, and job satisfaction. Comparing 26 PTs and 54 nurses, all females, lower back pain was significantly more prevalent in PTs, even after adjusting for the confounding demographic factors; PTs performed full and partial manual patient transfer, as well as trunk bending and walking assistance more frequently than the nurses and were significantly more satisfied. Unique physical load could be the main factor for the high prevalence of lower back pain in PTs. They should urgently initiate a “no-lift policy” in treatment.

Constraint-induced movement therapy alters cerebral blood flow in subacute post-stroke patients.

ABSTRACTWe attempted to evaluate patterns of hemispheric activation, according to cerebral blood flow changes, in post-stroke patients during motor tasks with and without arm restriction. Bilateral continuous middle cerebral artery monitoring of 6 healthy subjects (control group) and 28 post-stroke patients by transcranial Doppler sonography was executed while performing three simple motor tasks using the paretic or nondominant (in controls) hand: ball grasping, pegs insertion, and “eating” with a spoon. The nonaffected or dominant (in controls) arm was free and thereafter restricted. Mean blood flow velocity and flow velocity changes during the tests were estimated. No significant mean blood flow velocity changes were found in the healthy subjects. Significant elevation of mean blood flow velocity in damaged middle cerebral artery was recorded in post-stroke patients after restricting the undamaged hand. This may explain the positive effect of constraint-induced movement therapy on upper limb function.