Stroke Care 2: Stroke rehabilitation

See related commentary by Kanis, page [1829][1]

Since the publication of the Osteoporosis Canada guidelines in 2002, there has been a paradigm shift in the prevention and treatment of osteoporosis and fractures. [1][2],[2][3] The focus now is on preventing fragility fractures and their negative

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2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary

Purpose—The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. Methods—Writing group members were nominated by th...

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

ContextSingle-site studies suggest that a 2-week program of constraint-induced movement therapy (CIMT) for patients more than 1 year after stroke who maintain some hand and wrist movement can improve upper extremity function that persists for at least 1 year.ObjectiveTo compare the effects of a 2-week multisite program of CIMT vs usual and customary care on improvement in upper extremity function among patients who had a first stroke within the previous 3 to 9 months.Design and SettingThe Extremity Constraint Induced Therapy Evaluation (EXCITE) trial, a prospective, single-blind, randomized, multisite clinical trial conducted at 7 US academic institutions between January 2001 and January 2003.ParticipantsTwo hundred twenty-two individuals with predominantly ischemic stroke.InterventionsParticipants were assigned to receive either CIMT (n = 106; wearing a restraining mitt on the less-affected hand while engaging in repetitive task practice and behavioral shaping with the hemiplegic hand) or usual and customary care (n = 116; ranging from no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions); patients were stratified by sex, prestroke dominant side, side of stroke, and level of paretic arm function.Main Outcome MeasuresThe Wolf Motor Function Test (WMFT), a measure of laboratory time and strength-based ability and quality of movement (functional ability), and the Motor Activity Log (MAL), a measure of how well and how often 30 common daily activities are performed.ResultsFrom baseline to 12 months, the CIMT group showed greater improvements than the control group in both the WMFT Performance Time (decrease in mean time from 19.3 seconds to 9.3 seconds [52% reduction] vs from 24.0 seconds to 17.7 seconds [26% reduction]; between-group difference, 34% [95% confidence interval {CI}, 12%-51%]; P<.001) and in the MAL Amount of Use (on a 0-5 scale, increase from 1.21 to 2.13 vs from 1.15 to 1.65; between-group difference, 0.43 [95% CI, 0.05-0.80]; P<.001) and MAL Quality of Movement (on a 0-5 scale, increase from 1.26 to 2.23 vs 1.18 to 1.66; between-group difference, 0.48 [95% CI, 0.13-0.84]; P<.001). The CIMT group achieved a decrease of 19.5 in self-perceived hand function difficulty (Stroke Impact Scale hand domain) vs a decrease of 10.1 for the control group (between-group difference, 9.42 [95% CI, 0.27-18.57]; P=.05).ConclusionAmong patients who had a stroke within the previous 3 to 9 months, CIMT produced statistically significant and clinically relevant improvements in arm motor function that persisted for at least 1 year.Trial Registrationclinicaltrials.gov Identifier: NCT00057018

https://jamanetwork.com/journals/jama/articlepdf/203876/joc60147_2095_2104.pdf

Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial.

Measurement of recovery after stroke is becoming increasingly important with the advent of new treatment options under investigation in stroke rehabilitation research. The Fugl-Meyer scale was developed as the first quantitative evaluative instrument for measuring sensorimotor stroke recovery, based on Twitchell and Brunnstrom’s concept of sequential stages of motor return in the hemiplegic stroke patient. The Fugl-Meyer is a well-designed, feasible and efficient clinical examination method that has been tested widely in the stroke population. Its primary value is the 100-point motor domain, which has received the most extensive evaluation. Excellent interrater and intrarater reliability and construct validity have been demonstrated, and preliminary evidence suggests that the Fugl-Meyer assessment is responsive to change. Limitations of the motor domain include a ceiling effect, omission of some potentially relevant items, and weighting of the arm more than the leg. Further study should test performance o...

The Fugl-Meyer Assessment of Motor Recovery after Stroke: A Critical Review of Its Measurement Properties

Objective. The aim of the study was to present a systematic review of studies that investigate the effects of robot-assisted therapy on motor and functional recovery in patients with stroke. Method...

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Effects of Robot-Assisted Therapy on Upper Limb Recovery After Stroke: A Systematic Review

Background and Purpose— To improve the accuracy of early postonset prediction of motor recovery in the flaccid hemiplegic arm, the effects of change in motor function over time on the accuracy of prediction were evaluated, and a prediction model for the probability of regaining dexterity at 6 months was developed. Methods— In 102 stroke patients, dexterity and paresis were measured with the Action Research Arm Test, Motricity Index, and Fugl-Meyer motor evaluation. For model development, 23 candidate determinants were selected. Logistic regression analysis was used for prognostic factors and model development. Results— At 6 months, some dexterity in the paretic arm was found in 38%, and complete functional recovery was seen in 11.6% of the patients. Total anterior circulation infarcts, right hemisphere strokes, homonymous hemianopia, visual gaze deficit, visual inattention, and paresis were statistically significant related to a poor arm function. Motricity Index leg scores of at least 25 points in the fi...

http://www.luzimarteixeira.com.br/wp-content/uploads/2010/01/probability-of-regaining-dexterity-in-the-flaccid-upper-limb-impact-of-severity-of-paresis-and-time-since-onset-in-acute-stroke.pdf

Probability of regaining dexterity in the flaccid upper limb: Impact of severity of paresis and time since onset in acute stroke

Research articles on the prognosis of stroke patients were analysed to identify studies that met sound methodological principles of prognostic research as well as to identify variables capable of predicting functional outcome (ADL) after stroke. Data sources comprised a computer-aided search of published prognostic studies and references to literature used in prognostic studies. Seventy-eight studies were tested for adherence to the following key methodological criteria: reliability and validity of measurement instruments used to assess dependent and independent variables; inclusion of an inception cohort; adequate and uniform end-point of observation; control for drop-outs during period of observation; statistical testing of presumed relationship between dependent and independent variables; sufficient sample size in relation to number of determinants; control for multicollinearity; specification of patient characteristics (i.e. age, type, recurrent stroke and localization of stroke); description of interfering treatment effects during the period of observation, and cross-validation of the prediction model in a second independent group of patients. Only three studies satisfied nine out 11 criteria and ten studies eight criteria for the determination of valid prognostic research. The results of these studies indicate that the following variables are valid predictors for functional recovery after stroke: age; previous stroke; urinary continence; consciousness at onset; disorientation in time and place; severity of paralysis; sitting balance; admission ADL score; level of social support and metabolic rate of glucose outside the infarct area in hypertensive patients. This study supports the general opinion that not only are differences in objectives and heterogeneity in stroke patients responsible for the lack of accuracy in predicting functional outcome, but also the methodological flaws in published prognostic research.

Predicting Disability in Stroke—A Critical Review of the Literature

Background and Purpose—Longitudinal conducted studies show that neurologic and functional recovery show faster recovery in the first weeks poststroke. The aim of the present study was to study the effects of progress of time on observed improvements in motor strength, synergisms, and activities during the first 16 weeks poststroke. Methods—Based on data from a previous study, 101 patients with first-ever ischemic middle cerebral artery strokes were prospectively investigated during the first 16 weeks after stroke. Progress of time was categorized into 8 biweekly time intervals and was used as the independent covariate in a first-order longitudinal regression model. The biweekly time change (progress of time) was related to improvement in upper and lower limb motor recovery assessed with FuglMeyer score and Motricity Index, reduction in visuospatial inattention based on the letter cancellation task, and improvement in walking ability, dexterity, and activities of daily living measured with the Functional Ambulation Categories, Action Research Arm test, and Barthel Index. Results—Time explained a significant change of 8.4 (42%) measurement units on the Barthel Index for the first 10 weeks poststroke, 1.1 (22%) measurement units on Functional Ambulation Categories, and 19% on the Action Research Arm test for the first 6 and 8 weeks poststroke. Approximately 25% (for Fugl-Meyer–arm) to 26% (for Motricity Index–arm) of the significant change in measurements units was explained by time alone for the upper limb compared with 33% for Fugl-Meyer–leg and 39% for Motricity Index–leg of the lower limb. Time accounted for a reduction of 16% in the letter cancellation task. Observed associations did not change after controlling for covariates such as age, gender, hemisphere of stroke, type of stroke, or intervention. Conclusion—Progress of time is an independent covariate that reflects spontaneous recovery of body functions and activities explaining 16% to 42% of the observed improvements in the first 6 to 10 weeks after stroke onset. (Stroke. 2006; 37:2348-2353.)

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Impact of time on improvement of outcome after stroke

Background For total hip arthroplasty (THA), minimally invasive surgery (MIS) uses a smaller incision and less muscle dissection than the classic approach (CLASS), and may lead to faster rehabilitation. Questions/purposes Does minimally invasive hip arthroplasty result in superior clinical outcomes? Patients and Methods In this double-blind randomized controlled trial, 120 consecutive primary noncemented THAs in 120 patients were assigned to one of two groups (MIS or CLASS). The randomization sequence was stratified for two groups of surgeons, ie, those using a posterolateral approach (PL-CLASS or PL-MIS) and those using an anterolateral approach (AL-CLASS or AL-MIS). Length of the incisions was 18 cm for the CLASS procedures. MIS incisions were extended at the skin level to 18 cm at the end of the procedure. The primary end point was the Harris hip score (HHS) at 6 weeks postoperatively. Patient-centered questionnaires were obtained preoperatively and after 6 weeks and 1 year. Results For the patients in the MIS group (average 7.8 cm incision length), statistically significant increased mean HHSs were seen compared with the CLASS group at 6 weeks and 1 year. This difference was small and mainly caused by the favorable results of the PL-MIS. In the MIS group, surgical time was longer. A learning curve was observed based on operation time and complication rate. Although not statistically significant, the perioperative complication rate was rather high in the (anterolateral) MIS

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Boudewijn J. Kollen

Papers

Effects of Robot-Assisted Therapy on Upper Limb Recovery After Stroke: A Systematic Review

Probability of regaining dexterity in the flaccid upper limb: Impact of severity of paresis and time since onset in acute stroke

Predicting Disability in Stroke—A Critical Review of the Literature

Impact of time on improvement of outcome after stroke

A Double-blind Randomized Controlled Trial