Meheroz H. Rabadi

Admission Ambulation Velocity Predicts Length of Stay and Discharge Disposition Following Stroke in an Acute Rehabilitation Hospital

Poststroke functional outcome and discharge disposition are influenced by age, lesion location and size, severity of neurological insult, prior functional ability, and social support. The effect of admission ambulation velocity on length of stay and discharge disposition has not been previously reported. Design. Prospective, cohort study. Setting. Designated acute stroke rehabilitation unit. Method. 373 patients consecutively admitted to a designated inpatient stroke rehabilitation unit were studied. The study sample was divided into 2 groups, based on admission ambulation velocity (meters/second) during a 2-min timed walk test. Fast ambulators had an ambulation velocity of greater than 0.15 m/s, whereas slow ambulators had an ambulation velocity of 0.15 m/s or less, and also included nonambulators. Interventions. None. Outcome Measures. Primary outcome measures were length of stay and discharge disposition. Secondary outcome measures were change in the Functional Independence Measure (FIM) scores and change in ambulation velocity per week. Continuous, ordinal, and nominal variables were analyzed using the Student t test, Mann-Whitney U test, and chi-square test, respectively. Sensitivity, specificity, and positive and negative predictive values assessed admission ambulation velocity as a predictor of discharge disposition. Results. Patient variables for slow ambulators (n = 226) versus fast ambulators (n = 147) were as follows: age (68 ± 13 SD vs. 69 ± 12, P = 0.32), male-female ratio (100:126 vs. 78:69, P = 0.09), admission total FIM score (52 ± 17 vs. 77 ± 16, P < 0.0001), change in total FIM score (20 ± 12 vs. 16 ± 12, P < 0.003), change in ambulation velocity per week (0.05 ± 0.06 vs. 0.13 ± 0.30, P < 0.0001), length of stay in days (30 ± 28 vs. 17 ± 19, P < 0.0001), and discharge disposition: home/skilled nursing facility (133/91 vs. 133/13, P < 0.0001). Sensitivity, specificity, and positive and negative predictive values (based on chi-square analyses) for admission fast ambulators as a predictor of home discharge were 0.5, 0.87, 0.91, and 0.41, respectively. Admission ambulation velocity alone correctly identified discharge disposition in 78% of the patient population, based on logistic regression analysis (P < 0.0001). Conclusion. Admission ambulation velocity can predict length of stay and discharge disposition poststroke. This effect is independent of age and admission total FIM score.

Effect of Wheelchair Tilt-in-Space and Recline Angles on Skin Perfusion Over the Ischial Tuberosity in People With Spinal Cord Injury

OBJECTIVE To investigate the efficacy of wheelchair tilt-in-space and recline on enhancing skin perfusion over the ischial tuberosity in wheelchair users with spinal cord injury (SCI). DESIGN Repeated-measures, intervention, and outcomes-measure design. SETTING A university research laboratory. PARTICIPANTS Wheelchair users with SCI (N=11; 9 men, 2 women; mean ± SD age, 37.7±14.2y; body mass index, 24.7±2.6kg/m(2); duration of injury, 8.1±7.5y). INTERVENTIONS Protocols (N=6) of various wheelchair tilt-in-space and recline angles were randomly assigned to participants. Each protocol consisted of a 5-minute sitting-induced ischemic period and a 5-minute wheelchair tilt-in-space and recline pressure-relieving period. Participants sat in a position without tilt or recline for 5 minutes and then sat in 1 of 6 wheelchair tilted and reclined positions, including (1) 15° tilt-in-space and 100° recline, (2) 25° tilt-in-space and 100° recline, (3) 35° tilt-in-space and 100° recline, (4) 15° tilt-in-space and 120° recline, (5) 25° tilt-in-space and 120° recline, and (6) 35° tilt-in-space and 120° recline. A 5-minute washout period (at 35° tilt-in-space and 120° recline) was allowed between protocols. MAIN OUTCOME MEASURES Laser Doppler flowmetry was used to measure skin perfusion over the ischial tuberosity in response to changes in body positions caused by performing wheelchair tilt-in-space and recline. Skin perfusion response to wheelchair tilt-in-space and recline was normalized to skin perfusion of the upright seated position (no tilt/recline). RESULTS Combined with 100° recline, wheelchair tilt-in-space at 35° resulted in a significant increase in skin perfusion compared with the upright seated position (no tilt/recline; P<.05), whereas there was no significant increase in skin perfusion at 15° and 25° tilt-in-space (not significant). Combined with 120° recline, wheelchair tilt-in-space at 15°, 25°, and 35° showed a significant increase in skin perfusion compared with the upright seated position (P<.05). CONCLUSIONS Our results indicate that wheelchair tilt-in-space should be at least 35° for enhancing skin perfusion over the ischial tuberosity when combined with recline at 100° and should be at least 25° when combined with recline at 120°. Although smaller angles of wheelchair tilt-in-space and recline are preferred by wheelchair users for functional purposes, wheelchair tilt-in-space less than 25° and recline less than 100° may not be sufficient for effective pressure reduction for enhancing skin perfusion over the ischial tuberosity in people with SCI.

An analysis of falls occurring in patients with stroke on an acute rehabilitation unit.

&NA; Falls are a common occurrence in stroke patients admitted to a rehabilitation unit. This study evaluates the effect of current fall risk screening and prevention strategies on the number of falls in stroke patients admitted to an acute rehabilitation facility. All stroke patients admitted to a designated acute rehabilitation unit were considered at risk for falls by virtue of their diagnosis. These patients were studied retrospectively during a 24‐month period. Wheelchair lap belts and bedrails were provided to all patients admitted to the unit. Further measures consisting of bed and chair alarms, enclosed beds, and placement in rooms close to the nursing station were implemented with high‐fall risk patients. One hundred seventeen (15.5%) of the 754 patients in this study fell. The fall index rate was 8.2 falls, based on patient care days during the study period. No injury was observed in 143 of 159 fall cases (90%). In 13 cases (8%) there were only minor injuries, and 3 falls (2%) resulted in serious injuries. Current preventive strategies decrease the number of falls and the severity of fall‐related injuries. Patients who do fall are cognitively impaired on admission and have lower ambulation speed.

Randomized Clinical Stroke Rehabilitation Trials in 2005

This article reviews randomized control trials (RCTs) undertaken in stroke rehabilitation in the year 2005. A Medline search generated 31 RCTs in stroke rehabilitation in the year 2005 in the English language. These trials were primarily efficacy studies of a number of treatments: medications such as folate, vitamin B12 and bisphosphonates in preventing osteoporotic related hip fractures, compression stockings in preventing deep vein thrombosis (DVT), use of mechanical robots and positioning of the upper limb to help improve function; and, transcranial magnetic coil stimulation, acupuncture and neural tissue transplant to enhance motor recovery in post-stroke patients.

Does race influence functional outcomes in patients with acute stroke undergoing inpatient rehabilitation

ObjectiveRace has been shown to affect stroke-related morbidity and mortality. The purpose of this study was to determine the influence of race on rehabilitation functional outcomes in patients with an acute stroke admitted to a designated stroke rehabilitation unit. DesignA 2-yr prospective study was conducted of 670 patients admitted to an acute stroke rehabilitation unit within 30 days after an acute stroke. Demographic data along with admission and discharge Functional Independence Measure scores were recorded in a computerized stroke database. Patients participated in a standardized rehabilitation program 5 days a week for a length of stay dependent upon their individual needs. ResultsThe distribution of patients by race was 504 whites, 115 blacks, 38 Hispanics, and 13 Asians. The mean age of the study population was 70 yrs. Whites had a higher prevalence of atrial fibrillation, and blacks, Hispanics, and Asians had a higher prevalence of hypertension and diabetes mellitus. The primary and secondary functional rehabilitation outcomes were similar for all four groups after similar intensity of therapy (3.5 hrs daily). ConclusionsThis study suggests that race does not influence rehabilitation functional outcomes in patients with acute stroke undergoing rehabilitation for the same intensity of therapy if admitted soon after their acute stroke.

Randomized Clinical Stroke Trials in 2006

This article reviews randomized control trials (RCTs) published in 2006 of various medications evaluated for stroke patients. These trials were primarily efficacy studies. These included aggrenox (an antiplatelet agent), magnesium (to treat arterial spasm after an aneurysmal subarachnoid hemorrhage), NXY (a free radical trapping agent) and albumin which were both tested as a neuroprotectant, amphetamine (to aid motor recovery), fluoxetine (an anti-depressant and anxiolytic) and low molecular weight heparin (for prevention of deep vein thrombosis post-stroke).

Predictors of Mortality in Veterans with Multiple Sclerosis in an Outpatient Clinic Setting

BACKGROUND Examining factors that increase risk of death in veterans with multiple sclerosis (MS) may help reduce MS-related mortality. We sought to determine predictors of mortality in veterans with MS attending an outpatient clinic. METHODS Review of electronic medical records of 226 veterans with MS regularly followed up from January 1, 2000, through December 31, 2014. RESULTS Mortality at the end of the 15-year study period was 14%. Patients with MS died prematurely, with a standardized mortality rate of 1.35 relative to the general (Oklahoma) population. The main causes of death documented were MS disease itself (57% of cases), infection (43%), and cancer and respiratory failure (18% each). Cox regression analysis using the whole cohort showed that progressive MS type; older age at entry into the study; presence of sensory, cerebellar, or motor (weakness and/or ataxia) concerns on presentation; more disability on presentation; higher body-mass index; being diabetic; never received disease-modifying therapy; and presence of pressure ulcers or neurogenic bladder were significant predictors of higher mortality. CONCLUSIONS Initial presentation by MS type (progressive MS), higher level of disability, and associated motor, sensory, and cerebellar concerns are significant predictors of MS-related mortality. The main causes of death were MS disease itself, infection, respiratory disease, and cancer. More attention should be given to preventive strategies that delay mortality, such as yearly immunization and aggressively treating MS-related complications and diabetes mellitus.

Effect of Transcranial Direct Current Stimulation on Severely Affected Arm-Hand Motor Function in Patients After an Acute Ischemic Stroke: A Pilot Randomized Control Trial

Objective The aim of this article was to determine whether cathodal transcranial direct current stimulation (c-tDCS) to unaffected primary motor cortex (PMC) plus conventional occupational therapy (OT) improves functional motor recovery of the affected arm hand in patients after an acute ischemic stroke compared with sham transcranial direct current stimulation plus conventional OT. Design In this prospective, randomized, double-blinded, sham-controlled trial of 16 severe, acute ischemic stroke patients with severe arm-hand weakness were randomly assigned to either experimental (c-tDCS plus OT; n = 8) or control (sham transcranial direct current stimulation plus OT; n = 8) groups. All patients received a standard 3-hr in-patient rehabilitation therapy, plus an additional ten 30-min sessions of tDCS. During each session, 1 mA of cathodal stimulation to the unaffected PMC is performed followed by the patients scheduled OT. The primary outcome measure was change in Action Research Arm Test (ARAT) total and subscores on discharge. Result Application of c-tDCS to unaffected PMC resulted in a clinically relevant 10-point improvement in the affected arm-hand function based on ARAT total score compared with a 2-point improvement in the control group. Conclusions Application of 30-min of c-tDCS to the unaffected PMC showed a 10-point improvement in the ARAT score. This corresponds to a large effect size in improvement of affected arm-hand function in patients with severe, acute ischemic stroke. Although not statistically significant, this suggests that larger studies, enrolling at least 25 patients in each group, and with a longer follow-up are warranted.

Admission C-reactive protein does not predict functional outcomes in patients with strokes in a subacute rehabilitation unit.

Rabadi MH, Coar PL, Lukin M, Lesser M, Blass JP. Admission C-reactive protein does not predict functional outcomes in patients with strokes in a subacute rehabilitation unit. Am J Phys Med Rehabil 2008;87:731–739. Objective:Because serum C-reactive protein (CRP) levels correlate with the extent of inflammatory reactions, including acute strokes, we tested whether serum CRP levels on admission to a stroke rehabilitation unit help to predict functional outcome at discharge. Design:We measured serum CRP level within 72 hrs of admission to an inpatient stroke rehabilitation unit in 102 successive patients transferred to rehabilitation within 4 wks following stroke and who met inclusion criteria. Results:Patients with normal levels of serum CRP (≤9.9 mg/dl) on admission to our rehabilitation service were more likely to be discharged home rather than to an institution (66% vs. 44%, P < 0.03). These patients with normal serum CRP had higher absolute values for total functional independence measures and functional independence measures motor scores on admission, as well as on discharge (i.e., less disability). They also had fewer infections or other medical complications. However, the absolute magnitude of improvement (&Dgr;FIM) and length of stay were similar in the normal and elevated CRP groups. Multivariable logistic regression model did not show serum CRP level on admission to predict rehabilitation functional outcomes. Conclusions:Serum CRP level does not predict functional outcome at discharge on inpatient rehabilitation for stroke.

Effect of Chronic Medical Conditions in Veterans with Multiple Sclerosis on Long-Term Disability.

Background The goal of this observational study was to examine the effect of common chronic medical conditions (CMCs) on long-term disability (activity limitation) in veterans already diagnosed with multiple sclerosis (MS). Material/Methods We retrospectively reviewed the electronic charts of 124 veterans with MS who have been regularly followed in our MS clinic for 10 or more years. General linear model analysis examined whether MS-related severity as measured by the Expanded Disability Status Scale (EDSS) and the presence of CMCs affected long-term disability as measured by the total score on the Functional Independence Measure (TFIM). Results Commonly encountered CMCs were increased BMI (61%), hyperlipidemia (78%), hypertension (65%), current smokers (47%), and arthritis/arthralgia (24%). Results suggest that the number of CMCs was not predictive of final TFIM scores; of the variables examined, only initial EDSS score was predictive of final TFIM scores. Conclusions The presence of CMCs did not affect the long-term disability in veterans diagnosed with MS, this was due mainly to CMCs being closely monitored and co-treated with other medical specialties.