Stefano Paolucci

Early versus delayed inpatient stroke rehabilitation: A matched comparison conducted in Italy

OBJECTIVE To assess the specific influence of onset-admission interval (OAI) on rehabilitation results. DESIGN A case-control study in consecutive stroke inpatients, enrolled in homogeneous subgroups, matched for age (within 1 year) and Barthel Index (BI) score at admission, and different for OAI to the rehabilitation ward. The short OAI group began rehabilitation treatment within the first 20 days from stroke, medium OAI group between days 21 and 40, and long OAI between days 41 and 60. SETTING Rehabilitation hospital. PATIENTS One hundred forty-five patients with sequelae of first stroke. MAIN OUTCOME MEASURES Efficiency (average increase in BI per day), effectiveness (proportion of potential improvement achieved during rehabilitation) of treatment, and percentage of low- and high-response patients, calculated on BI, were evaluated. Odds ratios (ORs) of dropouts and of poor and excellent therapeutic response were also quantified. RESULTS The short OAI subgroup had significantly higher effectiveness of treatment than did the medium (p < .05) and the long OAI groups (p < .005). Beginning treatment within the first 20 days was associated with a significantly high probability of excellent therapeutic response (OR = 6.11; 95% confidence interval [CI], 2.03-18.36), and beginning later was associated with a similar risk of poor response (OR = 5.18; 95% CI, 1.07-25.00). On the other hand, early intervention was associated with a five times greater risk of dropout than that of patients with delayed start of treatment (OR = 4.99; 95% CI, 1.38-18.03). The three subgroups were significantly (p < .05) different regarding the percentage of low and high responders. CONCLUSION Our results showed a strong association between OAI and functional outcome.

Functional Outcome of Ischemic and Hemorrhagic Stroke Patients After Inpatient Rehabilitation: A Matched Comparison

Background and Purpose— The goal of this study was to assess the specific influence of stroke etiology on rehabilitation results. Methods— This was a case-control study of 270 inpatients with sequelae of first stroke who were enrolled in homogeneous subgroups and matched for stroke severity, basal disability, age (within 1 year), sex, and onset admission interval (within 3 days) who were different only in terms of stroke origin, infarction versus hemorrhage. We compared the groups’ length of stay, efficiency and effectiveness of treatment, and percentage of low and high responder patients. Odds ratios of dropouts and of low and high therapeutic response were also quantified. Results— Compared with ischemic patients, hemorrhagic patients had significantly higher Canadian Neurological Scale and Rivermead Mobility Index scores at discharge; higher effectiveness and efficiency on the Canadian Neurological Scale, Barthel Index, and Rivermead Mobility Index; and a higher percentage of high responders on the Barthel Index. Hemorrhagic patients showed a probability of a high therapeutic response on the Barthel Index that was ≈2.5 times greater than that of ischemic patients (odds ratio, 2.48; 95% confidence interval, 1.19 to 5.20; accuracy on prediction, 87.06%). Conclusions— The results of this study provide further evidence of better functional prognosis in stroke survivors with hemorrhagic stroke.

Effectiveness of neglect rehabilitation in a randomized group study

The effectiveness of neglect rehabilitation training has been studied in two randomly selected groups of right brain-damaged patients. All patients proved heminattentive on a standard battery 2 months or more after the CVA. One group received 2 months of treatment immediately after admission to a clinic, and the other group received only general cognitive stimulation for the same amount of time. At the end of this period a comparison showed significant improvement in the first group, based on a standard test battery and a functional scale. The second group was then given rehabilitation training for neglect for the same amount of time and obtained similar improvement. It is concluded that the rehabilitation program produces significant results, which generalize to situations similar to those of everyday life. The importance of the duration of training on the generalization of learning is briefly discussed with reference to previous negative reports in the literature.

Functional Outcome in Stroke Inpatient Rehabilitation: Predicting No, Low and High Response Patients

The aims of this study were: (1) to identify reliable prognostic factors for detecting subgroups of no, low and high response in consecutive patients admitted for rehabilitation of first stroke sequelae, and (2) to quantify the relative risk of poor or excellent prognosis on both Activities of Daily Living (ADL) and mobility for each significant variable. We prospectively studied 440 of 475 patients. From a group of 32 independent variables, those significantly associated with no, low and high effectiveness on both ADL and mobility were selected by means of multiple regression; then, the relative risk was calculated for each variable that significantly entered the multiple regressions. Patients with severe impairment or with global aphasia showed a relative risk of no response 4–6 times higher than that of other patients. An interval before rehabilitation longer than 2 months was associated with an increasing risk of no response. Elderly patients had a significantly higher relative risk of low response both on ADL and mobility. The presence of hemineglect and depression was associated with an increasing risk of low response on ADL but not on mobility. The absence of hemineglect and a short interval are prerequisites for an excellent functional prognosis on both ADL and mobility. A minor impairment, employed status, the absence of global aphasia and age ≤65 years increased the risk of high response. At the beginning of treatment, clear prognostic factors for the detection of subgroups with poor or excellent rehabilitation prognosis can be identified.

Predicting Stroke Inpatient Rehabilitation Outcome: The Prominent Role of Neuropsychological Disorders

This study was designed to determine the role of demographic, medical and cognitive factors in the results of rehabilitation in first stroke patients. In a prospective study on 273 consecutive patients admitted to a rehabilitation hospital for sequelae of first stroke, we used multiple regressions to assess the relationship between 11 independent variables and a battery of outcome measures: mortality, length of hospital stay, Barthel Index (BI) and Rivermead Mobility Index (RMI) scores at discharge and their effectiveness. Severity of stroke at admission and hemineglect were the strongest prognostic factors. In a logistic model, cognitive impairment was a significant independent predictor (OR = 4.10) also after adjusting for age and severity of stroke. Patients with hemineglect had a significantly higher relative risk of poor autonomy [RR = 7.30, 95% confidence interval (CI) 4.04-13.18] and impaired mobility (RR = 9.25, CI 4.63-18.45). Global aphasic patients had similar risks for both autonomy (RR = 4.51, CI 2.74-7.41) and mobility (RR = 4.71, CI 2.79-7.97). This study underlines the crucial role of cognitive disorders as predictors of poor functional outcome in stroke survivors and confirms the need for early neuropsychological screening.

Poststroke depression and its role in rehabilitation of inpatients.

OBJECTIVES To identify the prevalence of poststroke depression (PSD) in a population of patients admitted for rehabilitation of neurologic sequelae of their first stroke, to recognize reliable prognostic factors associated with the occurrence of PSD, and to evaluate the impact of PSD on the results of rehabilitation treatment. METHODS In a prospective study of 470 of 508 consecutive patients admitted to a rehabilitation hospital for sequelae of their first stroke, the relation between 23 independent variables and the development of depression was assessed by using a logistic regression analysis (forward stepwise). In addition, the impact of PSD on basal disability and on rehabilitation results was assessed by multiple measures (length of stay, efficiency, effectiveness, and percent of low responders on activities of daily living [ADL] and mobility). RESULTS PSD occurred in 129 patients (27.4%). Being female and having more than 8 years of schooling were associated with a higher probability of developing depression (odds ratio [OR] = 1.94, 95% confidence interval [CI] = 1.27-2.96, and OR = 1.61, 95% CI = 1.04-2.48, respectively). No association was found with site or side of cerebral lesion. In a logistic model, depression was a significant independent predictor (OR = 1.99, 95% CI = 1.14-3.46) of low response on ADL in spite of treatment. CONCLUSIONS PSD occurs especially in female patients and in patients with a high level of education and, even if treated, may affect rehabilitation results. No association was found between brain lesion location and PSD.

Epidemiology and treatment of post-stroke depression

Mood depression is a common and serious complication after stroke. According to epidemiological studies, nearly 30% of stroke patients develop depression, either in the early or in the late stages after stroke. Although depression may affect functional recovery and quality of life after stroke, such condition is often ignored. In fact, only a minority of patients is diagnosed and even fewer are treated in the common clinical practice. Moreover, the real benefits of antidepressant (AD) therapy in post-stroke depression have not been fully clarified. In fact, controlled studies on the effectiveness of ADs in post stroke depression (PSD) are relatively few. Today, data available suggest that ADs may be generally effective in improving mood, but guidelines for the optimal treatment and its length are still lacking.

Brain-computer interface boosts motor imagery practice during stroke recovery

Motor imagery (MI) is assumed to enhance poststroke motor recovery, yet its benefits are debatable. Brain–computer interfaces (BCIs) can provide instantaneous and quantitative measure of cerebral functions modulated by MI. The efficacy of BCI‐monitored MI practice as add‐on intervention to usual rehabilitation care was evaluated in a randomized controlled pilot study in subacute stroke patients.

Post-Stroke Depression, Antidepressant Treatment and Rehabilitation Results

The aim of this study was to assess the specific influence of poststroke depression (PSD) on both basal functional status and rehabilitation results. We performed a case-control study in 290 stroke inpatients, matched for age (±1 year) and onset admission interval (±3 days) and divided in two groups according to the presence (PSD+) or absence (PSD–) of PSD. All PSD+ patients were treated with antidepressants (AD), mainly with fluoxetine. PSD+ patients, despite similar severity of stroke, showed greater disability in coping with activities of daily living (ADL) on admission and greater disability both in ADL and mobility at discharge than PSD– patients. Although both groups exhibited similar average functional improvement during rehabilitation, PSD– patients were nearly twice as likely to show excellent recovery both on ADL and mobility as PSD+ patients (OR = 1.95, 95% CI = 1.01–3.75 and OR = 2.23, 95% CI = 1.14–4.35, respectively). All AD drugs improved depressive symptoms. Few relevant side effects were observed: fluoxetine was discontinued in 2 patients because of insomnia and in 2 patients because of nausea; paroxetine was stopped in 1 patient because of nausea and dry mouth. Our results confirm the unfavorable influence of PSD on functional outcome, despite pharmacological treatment.

Facilitatory effect of neglect rehabilitation on the recovery of left hemiplegic stroke patients: a cross-over study.

A study of the effect of specific training for visual neglect on the recovery of motor and functional impairment in stroke patients is reported. Two groups of right hemisphere stroke patients with hemispatial neglect and one group without neglect were assessed by means of three functional and neurological scales (Rivermead Mobility Index, Barthel Index, Canadian Neurological Scale). Three evaluations were made at 0, 2 and 4 months from the beginning of physical rehabilitation. During the first 2 months of physical rehabilitation one of the two groups of neglect patients was randomly assigned to specific training for neglect, and the second group to a general cognitive intervention; during the final 2 months of rehabilitation the types of training were switched in the two groups. The non-neglect patients improved steadily during physical rehabilitation. In contrast, the functional recovery of the two neglect groups was time-locked to the period of the specific training for neglect. At the time of admission, the two neglect groups performed at the same level; after 2 months of rehabilitation, the group with neglect training showed higher functional recovery than the group with only general cognitive intervention. When the latter group received neglect training, there was no longer any difference between the two neglect groups. This pattern was present for both of the functional scales used but not for the neurological scale. Motor and functional recovery of stroke patients with neglect seems to be significantly improved by the simultaneous presence of a treatment specifically focused on neglect.