Joel Stein

High-Intensity Resistance Training Improves Muscle Strength, Self-Reported Function, and Disability in Long-Term Stroke Survivors

Background and Purpose— To evaluate the efficacy of supervised high-intensity progressive resistance training (PRT) on lower extremity strength, function, and disability in older, long-term stroke survivors. Methods— Forty-two volunteers aged 50 years and above, 6 months to 6 years after a single mild to moderate stroke, were randomized into either a control group of upper extremity stretching or a PRT group that received a 12-week supervised high-intensity resistance training program consisting of bilateral leg press (LP), unilateral paretic and nonparetic knee extension (KE), ankle dorsiflexion (DF), and plantarflexion (PF) exercises. Functional performance was assessed using the 6-minute walk, stair-climb time, repeated chair-rise time, and habitual and maximal gait velocities. Self-reported changes in function and disability were evaluated using the Late Life Function and Disability Instrument (LLFDI). Results— Single-repetition maximum strength significantly improved in the PRT group for LP (16.2%), paretic KE (31.4%), and nonparetic KE (38.2%) with no change in the control group. Paretic ankle DF (66.7% versus −24.0%), paretic ankle PF (35.5% versus −20.3%), and nonparetic ankle PF (14.7% versus −13.8%) significantly improved in the PRT group compared with the control. The PRT group showed significant improvement in self-reported function and disability with no change in the control. There was no significant difference between groups for any performance-based measure of function. Conclusions— High-intensity PRT improves both paretic and nonparetic lower extremity strength after stroke, and results in reductions in functional limitations and disability.

Noise-enhanced balance control in patients with diabetes and patients with stroke

Somatosensory function declines with diabetic neuropathy and often with stroke, resulting in diminished motor performance. Recently, it has been shown that input noise can enhance human sensorimotor function. The goal of this study was to investigate whether subsensory mechanical noise applied to the soles of the feet via vibrating insoles can be used to improve quiet‐standing balance control in 15 patients with diabetic neuropathy and 15 patients with stroke. Sway data of 12 healthy elderly subjects from a previous study on vibrating insoles were added for comparison.

Functional recovery following rehabilitation after hemorrhagic and ischemic stroke

OBJECTIVESnTo quantify recovery after rehabilitation therapy and to identify factors that predicted functional outcome in survivors of intracerebral hemorrhage (ICH) compared with cerebral infarction.nnnDESIGNnRetrospective study of consecutive ICH and cerebral infarction admissions to a rehabilitation hospital over a 4-year period.nnnSETTINGnFree-standing urban rehabilitation hospital.nnnPARTICIPANTSnA total of 1064 cases met the inclusion criteria (545 women, 519 men; 871 with cerebral infarction, 193 with ICH).nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnFunctional status was measured using the FIM trade mark instrument, recorded at admission and discharge. Recovery was quantified by the change in FIM total score (DeltaFIM total score). Outcome measures were total discharge FIM score and DeltaFIM total score. Univariate and multivariate analyses were performed.nnnRESULTSnTotal admission FIM score was higher in patients with cerebral infarction than in patients with ICH (59 vs 51, P=.0001). No difference in total discharge FIM score was present. Patients with ICH made a significantly greater recovery than those with cerebral infarction (DeltaFIM total score, 28 vs 23.3; P=.002). On multivariate analysis, younger age, longer length of stay, and admission FIM cognitive subscore independently predicted total discharge FIM and DeltaFIM total score. The severity of disability at admission, indicated by total admission FIM score, independently predicted total discharge FIM score, but not DeltaFIM total score. The ICH patients with the most severely disabling strokes had significantly greater recovery than cerebral infarction patients with stroke of similar severity.nnnCONCLUSIONSnThe patients with ICH had greater functional impairment than the cerebral infarction patients at admission, but made greater gains. Patients with the most severely disabling ICH improved more than those with cerebral infarction of comparable severity. Initial severity of disability, age, and duration of therapy best predicted functional outcome after rehabilitation.

Predictors of survival after severe dysphagic stroke.

AbstractBackground and PurposeDysphagia is estimated tonoccur in up to 50% of the strokenneurorehabilitation population.nThose patients with severe neurogenicnoropharyngeal dysphagian(NOD) may receive feedingngastrostomy tubes (FGT) if noninvasiventherapies prove ineffectivenin eliminating aspiration or sustainingnadequate nutritional intake.nOur aim was to quantify the recoverynof swallowing function, and tonidentify variables predictive ofnsurvival after dysphagic strokenrequiring FGT placement.MethodsWe identified consecutive strokenpatients with severe dysphagicnstroke requiring FGT placement admittednto a rehabilitation hospitalnbetween May 1998 and Octobern2001. The medical records were reviewed,nand demographic, clinical,nvideofluoroscopic (VSS) and neuroimagingninformation werenabstracted. A follow–up telephoneninterview was performed to determinenwhether the FGT was still innuse, had been removed,or if the patientnhad died. State death certificatenrecords were reviewed to ascertainndate of death for subjects whonhad expired by the time of follow–up.nUnivariate and multivariatenanalyses were performed.Results11.6 % (77/664) of stroke patientsnadmitted during the study periodnhad severe dysphagic stroke withnFGT insertion. Follow–up wasnavailable for 66 (85.7 %) of thesenindividuals at a mean of two yearsnafter acute stroke. On follow–upn64% (42/66) of the patients werenalive and 45 % had had the FGTnremoved and resumed oral diets.nOn univariate analysis patients whonwere alive at the time of follow–upnhad received FGT feeding for anshorter period of time (p < 0.0003),nshowed no signs of aspiration onnthe Clinical Assessment of Feedingn& Swallowing (CAFS,p < 0.020) andnon the Videofluoroscopic SwallowingnStudy (VSS, 0.001), had a betterndischarge FIM–Score (FunctionalnIndependence Measure) for eatingn(p < 0.0002) and cognitive functionn(p < 0.002) as well as better dischargenFCM–Score (FunctionalnCommunication Measure) fornswallowing (p < 0.0001). On multivariatenanalysis we developed anmodel consisting of FGT removal atndischarge from the rehabilitationnhospital (p < 0.011) and non–aspirationnduring VSS (p < 0.040) thatnwas significantly associated withnlonger survival time during follow–up.ConclusionsSevere dysphagianrequiring FGT is common in patientsnwith stroke referred for neurorehabilitation.nPatients who had anFGT in place at the time of dischargenfrom the stroke rehabilitationnunit or aspirated during VSSnwere substantially more likely tonhave died by the time of follow–upncompared to those who had had thenFGT removed and had no signs ofnaspiration on VSS. However functionalnoutcome measurementsn(FIM, FCM) including the cognitivenfunction (attention, concentrationnetc.) could play an important rolenfor prediction of swallowing regenerationnand survival in neurorehabilitation.nThese findings may havenpractical utility in guiding physiciansnand speech language pathologistsnwhen advising patients andnfamilies about prognosis in strokensurvivors with severe dysphagia.

Using wearable sensors to measure motor abilities following stroke

Motor abilities of stroke survivors are often severely affected. Post-stroke rehabilitation is guided by the use of clinical assessments of motor abilities. Clinical assessment scores can be predicted by models based on features extracted from the wearable sensor data. Wearable sensors would allow monitoring of subjects in the home and provide accurate assessments to guide the rehabilitation process. We propose the use of a wearable sensor system to assess the motor abilities of stroke victims. Preliminary results from twelve subjects show the ability of this system to predict clinical scores of motor abilities

Motor Recovery Strategies After Stroke

Abstract Impaired motor function after stroke is a major cause of disability in young stroke survivors. The plasticity of the adult human brain provides opportunities to enhance traditional rehabilitation programs for these individuals. Younger stroke patients appear to have a greater ability to recover from stroke and are likely to benefit substantially from treatments that facilitate plasticity-mediated recovery. The use of new exercise treatments, such as constraint-induced movement therapy, robot-aided rehabilitation, and partial body weight supported treadmill training are being studied intensively and are likely to ultimately be incorporated into standard poststroke rehabilitation. Medications to enhance recovery, growth factors, and stem cells will also be components of rehabilitation for the young stroke survivor in the foreseeable future.

Predictors of Feeding Gastrostomy Tube Removal in Stroke Patients With Dysphagia

Dysphagia is a common consequence of stroke, estimated to be present in 25% to 50% of the stroke rehabilitation population. Relatively few data exist concerning outcome following insertion of feeding gastrostomy/jejunostomy tubes (FGT) in stroke patients with dysphagia. Our aim was to identify variables predictive of FGT removal. We studied stroke patients admitted to a single rehabilitation hospital and identified consecutive stroke patients with FGT placement. Each patients medical records were reviewed, and demographic, clinical, and neuroimaging information were abstracted. Follow-up status was obtained by telephone interviews and review of state death certificates. Univariate and multivariate analyses were performed. Seventy-seven of the 664 (11.1%) stroke patients admitted in the 42-month study period had FGT insertion for dysphagia. Multivariate regression analysis revealed that bilateral stroke (bilateral vs unilateral; P < .022), aspiration during videofluoroscopic swallowing study (VSS; P < .012), and age greater than 52 years (P < .001) were negative predictors of FGT removal prior to discharge from the rehabilitation hospital. We identified three independent variables (bilateral stroke, aspiration during VSS, and age > 52) in stroke patients with severe dysphagia requiring FGT placement that are negative predictors of FGT removal prior to discharge from rehabilitation. These findings may help physicians and speech language pathologists predict who is likely to have a FGT removed before rehabilitation hospital discharge.

Fall-related injuries in anticoagulated stroke patients during inpatient rehabilitation

OBJECTIVEnTo compare the frequency and severity of fall-related injuries in anticoagulated patients undergoing rehabilitation after stroke to nonanticoagulated stroke patients undergoing rehabilitation.nnnDESIGNnRetrospective chart review.nnnSETTINGnFree-standing rehabilitation hospital.nnnPATIENTSn264 patients who sustained falls while undergoing intensive inpatient rehabilitation after stroke.nnnMEASUREMENTSnInjuries, categorized as minor (abrasions and bruises) or major (intracranial hemorrhage, fracture, major bleeding).nnnMAIN RESULTSnA total of 400 falls in 264 patients undergoing inpatient stroke rehabilitation were reviewed. One hundred thirty-one falls were sustained by 93 patients receiving anticoagulation, whereas 269 falls were sustained by 175 patients not receiving anticoagulation. In both the anticoagulation group and the control (nonanticoagulated) group, approximately one in five falls resulted in minor injuries (abrasions or bruises). Three fractures occurred, but no major bleeding events or intracranial hemorrhage occurred in either group.nnnCONCLUSIONSnThe risk for minor injury secondary to fall is comparable between the two groups, and the risk is low in this setting for hemorrhagic injuries in stroke patients falling while receiving anticoagulation.

Failure to Achieve Assent in a Communicative Patient: What Are the Caregiver’s Obligations?

Abstract Disclosure of facts related to an individual’s health care, including level and location of care, are central to the fulfillment of informed consent. When an individual is unable to provide informed consent because they lack the decision-making capacity to process the information and/or they have been deemed legally incompetent, the health care team should obtain assent from the individual whenever possible. Questions remain as to how to proceed when assent cannot be gained and the decision involved causes a level of distress for the individual that is difficult to resolve. A focus on maintaining hope and support with a clear transition and follow-up plan are important variables to consider for an ethical, caring response.