Michael Reding

Medical and neurological complications during inpatient stroke rehabilitation.

BACKGROUND AND PURPOSEnWe sought to assess the type, frequency, and clinical predictors of neuromedical complications occurring during inpatient rehabilitation after stroke.nnnMETHODSnOne hundred consecutive patient records were reviewed. All medical and neurological complications requiring a physicians order for further evaluation or treatment were recorded.nnnRESULTSnComplications were urinary tract infection (44 cases), depression (33), musculoskeletal pain (31), urinary retention (25), falls (25), fungal dermatitis (24), hypotension (19), diabetes mellitus (16), hypertension (15), and other neuromedical problem (194). The mean +/- SD numbers of medical and neurological complications per patient were 3.6 +/- 2 and 0.6 +/- 0.8, respectively. Complications were independently related to both the severity of functional disability as judged by Barthel score (r = -.42, P < .001) and length of rehabilitation hospital stay (r = .54, P < .001). Cardiac complications were predicted by New York Heart Association class 3 or 4 symptomatology on admission (P < .05). The age, sex, interval from stroke to rehabilitation hospital admission, and ischemic versus hemorrhagic etiology of the stroke were unrelated to the number of complications observed. Thirteen patients required transfer back to an acute-care hospital, one of whom died within 24 hours of transfer. There were no deaths on the rehabilitation unit.nnnCONCLUSIONSnWe have defined the type and frequency of neuromedical complications during inpatient rehabilitation after stroke. Their frequency varies with the severity of stroke, cardiovascular comorbidity, and length of stay.

Functional outcome for patients with hemiparesis, hemihypesthesia, and hemianopsia. Does lesion location matter?

BACKGROUND AND PURPOSEnPatients with hemiparesis, hemisensory loss, and hemianopsia (HHH deficits) due to stroke may have large cortical lesions caused by middle cerebral trunk vessel occlusion or smaller subcortical lesions due to lenticulostriate involvement. We studied the usefulness of lesion location in predicting functional recovery within this syndrome.nnnMETHODSnWe reviewed our records and found 41 patients who had a single ischemic hemispheric stroke, HHH deficits, and an available CT scan performed more than 24 hours after the onset of symptoms. CT scans were read independently and blindly by the authors. Lesions were initially categorized by arterial distribution on the basis of CT templates published by Kinkel. The numerous combinations of arterial branch vessel occlusions observed did not allow for statistical analyses because of the small number of subjects within each subgroup. Lesions were therefore classified as cortical (C), subcortical (S), or mixed (M).nnnRESULTSnThere were no significant differences among the three anatomic groups for age, sex, interval after stroke, Mini-Mental Status Examination score, or admission Barthel Index score. Functional outcome measures did not differ significantly for the three groups: mean +/- SD discharge Barthel score (C, 64 +/- 31; S, 47 +/- 20; M, 57 +/- 21), length of stay ([days] C, 64 +/- 25; S, 77 +/- 24; M, 73 +/- 28), and frequency of nursing home placement (C, 4/8; S, 3/6; M, 2/16).nnnCONCLUSIONSnFor patients with HHH deficits, the anatomic location of the lesion (C versus S versus M) does not affect functional outcome.

Clinical examination tools for lateropulsion or pusher syndrome following stroke: a systematic review of the literature:

Objective: To examine the clinimetric properties and clinical applicability of published tools for `quantifying the degree of lateropulsion or pusher syndrome following stroke. Data sources: Search through electronic databases (MEDLINE, EMBASE, CINAHL, Science Citation Index) with the terms lateropulsion, pushing, pusher syndrome, validity, reliability, internal consistency, responsiveness, sensitivity, specificity, posture and stroke. Databases were searched from their inception to October 2008. Review methods: Abstracts were selected by one author. A panel of experts then determined which should be included in this review. Five abstracts were reviewed and the panel agreed to omit one abstract because those authors did not write a full manuscript. The panel critiqued manuscripts according to predetermined criteria about clinical and clinimetric properties. Results: Four manuscripts referencing three tools for examining lateropulsion were found. Validity and reliability data support the clinical use of the Scale for Contraversive Pushing, the Modified Scale for Contraversive Pushing and the Burke Lateropulsion Scale. The Scale for Contraversive Pushing has the most extensive testing of clinimetric properties. The other tools show promising preliminary evidence of clinical and research utility. More testing is needed with larger, more diverse samples. Reviewers conclusions: The Scale for Contraversive Pushing, the Modified Scale for Contraversive Pushing and the Burke Lateropulsion Scale are reliable and valid measures with good clinical applicability. Larger, more varied samples should be used to better delineate responsiveness and other clinimetric properties of these examination tools.

Validation of a lateropulsion scale for patients recovering from stroke

Objective: To determine the validity and reliability of a clinical scale for assessing lateropulsion following stroke. Design: Serial observational study of Lateropulsion Scale scores. Setting: Inpatient stroke rehabilitation unit. Subjects: A convenience sample of 85 patients examined 19 ± 2 SEM days post stroke. Main outcome measures: An empirically derived 17-point Lateropulsion Scale was used to assess and follow postural responses to rolling, sitting, standing, transferring and walking. Intraclass correlation coefficients were calculated by having patients evaluated twice by their primary physical therapist (days 1 and 3), and once by an alternate physical therapist (day 2). Concurrent validity was estimated by computing Spearmans rank order correlations between the lateropulsion score and other markers for motor control dysfunction: Fugl-Meyer balance subscore, the Functional Independence Measure (FIM) mobility subscore, and length of rehabilitation hospital stay. Results: Inter-rater and intra-rater reliability were r = 0.93 (p < 0.001) and r = 0.94 (p < 0.05), respectively. Concurrent validity estimates showed the initial lateropulsion score to be correlated with the Fugl-Meyer balance subscore (r = -0.57 p < 0.001), with the admission and discharge FIM mobility subscores (r = -0.56, p < 0.0001 and r = -0.58, p < 0.0001), respectively, and with length of rehabilitation hospital stay (r = 0.6, p < 0.0001). Conclusions: The Lateropulsion Scale is both a reliable and a valid assessment of lateropulsion following stroke.

Time to recovery from lateropulsion dependent on key stroke deficits: a retrospective analysis.

Background. Lateropulsion, a postural control disorder, delays recovery following hemispheric stroke. The number of stroke impairments may lead to differential recovery rates, depending on the intact systems available for recovery from lateropulsion. Objective. To study the impact of key postural control deficits on lateropulsion rate of recovery following stroke. Methods. Through retrospective analysis: 169 patients with hemispheric stroke in an in-patient rehabilitation facility were divided into 3 groups: (1) motor deficits only; (2) motor and hemianopic or visual–spatial deficits or motor and proprioceptive deficits; and (3) motor, proprioceptive, and hemianopic or visual–spatial deficits. Kaplan–Meier survival analysis determined if time to recovery from lateropulsion (achieving a score of 0 or 1 on the Burke Lateropulsion Scale) differed by group. Results. Log rank tests showed that time to recovery from lateropulsion differed based on the number of deficits (group, P = .012). Post hoc analyses by lesion side showed that group differences only occurred in right brain lesion (P < .05) as compared with left brain lesions (P = .34). Patients recovered from lateropulsion during in-patient rehabilitation if they had only motor deficits; those with all 3 postural control deficits showed the most protracted recovery. Conclusions. Rate of recovery from lateropulsion after stroke is dependent on the side of lesion, and number of key motor, proprioceptive, and/or hemianopic or visual–spatial deficits. The more postural control systems affected, the slower the recovery. Our data identify patients likely to need protracted rehabilitation targeting key postural control deficits.

Case–Control Study of Impairments Associated with Recovery from “Pusher Syndrome” after Stroke: Logistic Regression Analyses

BACKGROUNDnComparing cohorts with similar functional and motor status at admission to inpatient rehabilitation may delineate demographics or impairments associated with recovery from lateropulsion, also known as pusher syndrome, after stroke based on lesion side. The aim of this case-control study was to determine how demographics and severity of stroke impairments at admission to inpatient rehabilitation distinguish patients who recover from lateropulsion from those who do not.nnnMETHODSnPatients with admission motor Functional Independence Measure (FIM) scores less than 31 and contralesional lower extremity Fugl-Meyer motor scores less than 19 out of 34 were included. Burke Lateropulsion Scales score of 2 or higher at the time of discharge from inpatient rehabilitation indicated persistent lateropulsion; a score of 0 or 1 indicated resolved lateropulsion. Logistic regression tests included age, gender, admission Motricity Index score, limb placement error, and cognitive FIM score. χ2 analyses compared groups for neglect.nnnRESULTSnFor patients with left brain lesion, older age and worse admission motor status distinguished those with persistent lateropulsion at discharge. For right brain lesion, related factors were older age, greater admission limb placement error, and lower cognitive FIM scores. Visuospatial neglect did not influence recovery from lateropulsion.nnnCONCLUSIONSnOlder age and severe impairments were associated with delayed recovery from lateropulsion in a manner specific to lesion side in a sample with motor and functional deficits. The study provides evidence that lesion side and admission characteristics are useful in early decision making for the duration of rehabilitation, selection of interventions, and discharge planning.

Effect of Dextroamphetamine on Poststroke Motor Recovery: A Randomized Clinical Trial

Importance Data from animal models show that the administration of dextroamphetamine combined with task-relevant training facilitates recovery after focal brain injury. Results of clinical trials in patients with stroke have been inconsistent. Objectives To collect data important for future studies evaluating the effect of dextroamphetamine combined with physiotherapy for improving poststroke motor recovery and to test the efficacy of the approach. Design, Setting, Participants This pilot, double-blind, block-randomized clinical trial included patients with cortical or subcortical ischemic stroke and moderate or severe motor deficits from 5 rehabilitation hospitals or units. Participants were screened and enrolled from March 2001 through March 2003. The primary outcome was assessed 3 months after stroke. Study analysis was completed December 31, 2015. A total of 1665 potential participants were screened and 64 were randomized. Participants had to begin treatment 10 to 30 days after ischemic stroke. Data analysis was based on intention to treat. Interventions Participants were allocated to a regimen of 10 mg of dextroamphetamine (n = 32) or placebo (n = 32) combined with a 1-hour physical therapy session beginning 1 hour after drug or placebo administration every 4 days for 6 sessions in addition to standard rehabilitation. Main Outcomes and Measures The primary outcome was the difference between groups in change in Fugl-Meyer motor scores from baseline to 3 months after stroke (intention to treat with dextroamphetamine). Secondary exploratory measures included the National Institutes of Health Stroke Scale, Canadian Neurological Scale, Action Research Arm Test, modified Rankin Scale score, Functional Independence Measure, Ambulation Speed and Distance, Mini-Mental State Examination, Beck Depression Inventory, and Stroke Impact Scale. Results Among the 64 patients randomized to dextroamphetamine vs placebo (55% men; median age, 66 years; age range, 27-91 years), no overall treatment-associated difference in the mean (SEM) change in Fugl-Meyer motor scores from baseline to 3 months after stroke was noted (−18.65u2009[2.27] points with dextroamphetamine vs −20.83u2009[2.94] points with placebo; Pu2009=u2009.58). No overall treatment-associated differences in any of the study’s secondary measures and no differences in subgroups based on stroke location or baseline severity were found. No adverse events were attributed to study treatments. Conclusions and Relevance Treatment with dextroamphetamine combined with physical therapy did not improve recovery of motor function compared with placebo combined with physical therapy as assessed 3 months after hemispheric ischemic stroke. The studied treatment regimen was safe. Trial Registration ClinicalTrials.gov identifier: NCT01905371