Toby B. Cumming

Very Early Mobilization After Stroke Fast-Tracks Return to Walking Further Results From the Phase II AVERT Randomized Controlled Trial

Background and Purpose— Regaining functional independence is an important goal for people who have experienced stroke. We hypothesized that introducing earlier and more intensive out-of-bed activity after stroke would reduce time to unassisted walking and improve independence in activities of daily living. Methods— A Very Early Rehabilitation Trial (AVERT) was a phase II randomized controlled trial. Patients with confirmed stroke (infarct or hemorrhage) admitted <24 hours after stroke and who met physiological safety criteria were eligible. Patients randomized to the very early and intensive mobilization group were mobilized within 24 hours of stroke and at regular intervals thereafter. Control patients received standard stroke unit care. The primary outcome for this analysis was the number of days required to return to walking 50 m unassisted. Secondary outcomes were the Barthel Index and Rivermead Motor Assessment at 3 and 12 months after stroke. Results— Seventy-one stroke patients with a mean age of 74.7 years were recruited from 2 hospitals. Adjusted Cox regression indicated that very early and intensive mobilization group patients returned to walking significantly faster than did standard stroke unit care controls (P=0.032; median 3.5 vs 7.0 days). Multivariable regression revealed that exposure to very early and intensive mobilization was independently associated with good functional outcome on the Barthel Index at 3 months (P=0.008) and on the Rivermead Motor Assessment at 3 (P=0.050) and 12 (P=0.024) months. Conclusions— Earlier and more intensive mobilization after stroke may fast-track return to unassisted walking and improve functional recovery. Clinical Trial Registration— This trial was not registered because enrollment began before July 2005.

Stroke, cognitive deficits, and rehabilitation: still an incomplete picture

Cognitive impairment after stroke is common and can cause disability with major impacts on quality of life and independence. There are also indirect effects of cognitive impairment on functional recovery after stroke through reduced participation in rehabilitation and poor adherence to treatment guidelines. In this article, we attempt to establish the following: • whether there is a distinct profile of cognitive impairment after stroke; • whether the type of cognitive deficit can be associated with the features of stroke-related damage; and • whether interventions can improve poststroke cognitive performance. There is not a consistent profile of cognitive deficits in stroke, though slowed information processing and executive dysfunction tend to predominate. Our understanding of structure-function relationships has been advanced using imaging techniques such as lesion mapping and will be further enhanced through better characterization of damage to functional networks and identification of subtle white matter abnormalities. Effective cognitive rehabilitation approaches have been reported for focal cortical deficits such as neglect and aphasia, but treatments for more diffusely represented cognitive impairment remain elusive. In the future, the hope is that different techniques that have been shown to promote neural plasticity (e.g., exercise, brain stimulation, and pharmacological agents) can be applied to improve the cognitive function of stroke survivors.

The Montreal Cognitive Assessment Short Cognitive Evaluation in a Large Stroke Trial

Background and Purpose— Cognitive function is often ignored in stroke research trials. The brief Montreal Cognitive Assessment (MoCA) may be sensitive to stroke-related cognitive deficits. Methods— We evaluated the feasibility of administering the MoCA at 3 months in a large stroke trial (A Very Early Rehabilitation Trial [AVERT]). Results— Data (blinded to intervention group) are presented for 294 patients with mean age of 70.6 years (SD, 12.8); 220 (75%) completed the MoCA, 54 (18%) had missing data, and 20 (7%) had died. Of those surviving to 3 months, the MoCA was completed by 87% with mild stroke, 79% with moderate stroke, and 67% with severe stroke on admission. Mean MoCA score was 21.1 (SD 7.5) out of 30; only 78 of 220 (35%) patients attained the “normal” cutoff (≥26). Conclusions— The MoCA is a feasible global cognitive screening tool in stroke trials. Clinical Trial Registration— URL: www.anzctr.org.au/trial_view.aspx?ID=1266. Unique identifier: ACTRN12606000185561.

Integrated care improves risk-factor modification after stroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model

Objective: Despite evidence demonstrating that risk-factor management is effective in reducing recurrent cerebrovascular disease, there are very few structured care programmes for stroke survivors. The aim was to implement and evaluate an integrated care programme in stroke. Methods: 186 patients with stroke were randomised to either the treatment (integrated care) or control (usual care) group and were followed up over 12 months. The Integrated Care for the Reduction of Secondary Stroke (ICARUSS) model of integrated care involved collaboration between a specialist stroke service, a hospital coordinator and a patient’s general practitioner. The primary aim was to promote the management of vascular risk factors through ongoing patient contact and education. Results: In the 12 months poststroke, systolic blood pressure (sBP) decreased in the treatment group but increased in controls. The group difference was significant, and remained so when age, sex, disability and sBP at discharge were accounted for (p = 0.04). Treatment patients also exhibited better modification of body mass index (p = 0.007) and number of walks taken (p<0.001) than controls. Rankin scores indicated significantly reduced disability in treatment patients relative to controls in the year poststroke (p = 0.003). Conclusions: Through an integrated system of education, advice and support to both patient and GP, the ICARUSS model was effective in modifying a variety of vascular risk factors and therefore should decrease the likelihood or recurrent stroke or vascular event.

Montreal Cognitive Assessment and Mini-Mental State Examination are both valid cognitive tools in stroke.

To determine the validity of the Montreal Cognitive Assessment (MoCA) and the Mini–Mental State Examination (MMSE) as screening tools for cognitive impairment after stroke.

The effect of very early mobilisation after stroke on psychological well-being.

OBJECTIVE The immobility common to patients after acute stroke has the potential to increase negative mood symptoms. We evaluated the effect of very early mobilization after stroke on levels of depression, anxiety and irritability. DESIGN AVERT is a randomized controlled trial; patients in the very early mobilization group receive mobilization earlier (within 24 h of stroke) and more frequently than patients in the standard care group. PATIENTS Seventy-one patients with confirmed stroke were included. METHODS Patients were assessed on the Irritability, Depression and Anxiety (IDA) scale at multiple time-points. RESULTS At 7 days, very early mobilization patients were less depressed (z=2.51, p=0.012) and marginally less anxious (z=1.79, p=0.073) than standard care patients (Mann-Whitney test). Classifying IDA scores as normal or depressed, and using backward stepwise multivariable logistic regression, very early mobilization was associated with a reduced likelihood of depression at 7 days (odds ratio 0.14, 95% confidence interval 0.03-0.61; p=0.009). CONCLUSION Very early mobilization may reduce depressive symptoms in stroke patients at 7 days post-stroke.

An Early Mobilization Protocol Successfully Delivers More and Earlier Therapy to Acute Stroke Patients: Further Results From Phase II of AVERT.

Background. The optimal physical therapy dose in acute stroke care is unknown. The authors hypothesized that physical therapy would be significantly different between treatment arms in a trial of very early and frequent mobilization (VEM) and that immobility-related adverse events would be associated with therapy dose. Methods. This study was a single-blind, multicenter, randomized control trial. Patients admitted to a stroke unit <24 hours of stroke randomized to standard care (SC) or intervention, SC plus additional early out-of-bed therapy (VEM). Timing, amount, and type of therapy recorded throughout the trial. Adverse events were recorded to 3 months. Results. A total of 71 patients (SC n = 33, VEM n = 38) received 788 therapy sessions in the first 2 weeks of stroke. Schedule (hours to first mobilization, dose per day, frequency and session duration) and nature (percentage out-of-bed activity) of therapy differed significantly between groups (P ≤ .001 for all components). Mobilization was earlier, happened on average 3 times per day in those receiving VEM, with the proportion of out-of-bed activity double in VEM session (median SC 42.5%, VEM 85.5%). SC consisted of 17 minutes of occupational and physiotherapy per day and was the same between groups. Number of immobility-related adverse events 3 months poststroke was not associated with therapy dose or frequency. Conclusions. The authors detailed usual care and intervention therapy provided to patients from admission to 14 days after stroke. The therapy schedule was markedly different in the intervention arm, but whether this schedule reduces complications or improves outcome is unknown.

Can stroke cause neurodegenerative dementia

Stroke and dementia have typically been housed in different taxonomies. They are considered to be exemplars of very different forms of brain injury: stroke as an acute vascular injury and dementia as a progressive degenerative disease. Yet there is definite overlap between the two conditions: stroke increases the likelihood of developing dementia. Recent work has confirmed that vascular risk factors such as diabetes and hypertension predispose to dementia. However, in the absence of any clear findings of a direct pathway from stroke to degenerative dementia, the separation has persisted. In this review, we summarize the evidence relating to whether stroke can initiate or promote degenerative dementia and, in particular, Alzheimers disease. The evidence comes from autopsy studies, from brain imaging studies, from studies of patients with symptomatic stroke and from studies in CADASIL. A number of studies have demonstrated that stroke can lead to changes in brain volume and cognitive performance, although generally of a different profile to the atrophy and cognitive decline seen in Alzheimers disease. Much of the evidence is circumstantial, and does little to support a claim that stroke triggers neurodegenerative dementia. The question, then, remains open. None of the studies reviewed included the necessary longitudinal follow-up of stroke patients incorporating cognitive assessment, imaging and pathology. Given the high prevalence and substantial burden of dementia, there is much to be gained from identifying prognostic markers and it remains an exciting idea that we might be able to identify a subgroup of stroke patients who are at high risk.

The NIH Stroke Scale Can Establish Cognitive Function after Stroke

Background: Cognitive impairment is an important but underrecognised consequence of stroke. We investigated whether a subset of items from the NIH Stroke Scale (NIHSS) could yield valid information on cognitive status in a group of stroke patients. Methods: 149 stroke patients from the Göteborg 70+ Stroke Study were investigated after 18 months. We extracted 4 items corresponding to the NIHSS items on orientation, executive function, language and inattention. Scores on this subset of 4 NIHSS items (Cog-4) and the Mini-Mental State Examination (MMSE) were evaluated against a reference diagnosis of severe cognitive impairment. Results: The area under the receiver-operator curve (AUC) plotted for the Cog-4 scale against the diagnosis of severe cognitive impairment was 0.78; the MMSE had a slightly better diagnostic precision, with an AUC of 0.84. Making the executive task more difficult increased the precision of the Cog-4, raising the AUC to 0.81. Conclusions: A composite score based on 4 NIHSS items is almost as good as the MMSE in detecting severe cognitive impairment. Ideally, dedicated measures of cognition should be employed as a matter of course after stroke, but in their absence, the Cog-4 subscale provides an indication of cognitive functioning.

The positive effect of integrated care on depressive symptoms in stroke survivors

Background: Depressive symptoms occur in approximately one-third of stroke patients. We sought to evaluate whether an integrated model of stroke care and secondary prevention reduced depressive symptomatology in stroke survivors. Methods: The integrated care (IC) model is a multifaceted program that provides ongoing collaboration between a specialist stroke service and primary care physicians, using telephone tracking, a bi-directional information feedback loop, management of vascular risk factors, and regular screening for depressive symptoms. Results: Patients exposed to the IC model exhibited significantly fewer depressive symptoms than controls at 12 months post stroke (as measured by the PHQ-9 screening tool; p = 0.006). At 12 months, 30/91 (33%) of the treatment group had depressive symptoms, compared to 52/95 (55%) of the control group (p = 0.003). With other variables adjusted for, the major associates of being depressed at 12 months were group allocation and physical disability. Conclusion: The integrated care approach provides a framework for detecting and monitoring depressive symptoms, and appears to be protective against post-stroke depression.