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

4 CLINICAL PARTICULARS 4.1 Therapeutic Indications Trimetazidine is indicated in adults as add-on therapy for the symptomatic treatment of patients with stable angina pectoris who are inadequately controlled by or intolerant to first-line antianginal therapies. 4.2 Posology and method of administration Oral administration. Posology The dose is one tablet of 35mg of trimetazidine twice daily during meals. Special populations Renal impairment In patients with moderate renal impairment (creatinine clearance [30-60] ml/min) (see sections 4.4 and 5.2), the recommended dose is 1 tablet of 35mg in the morning during breakfast. Elderly Elderly patients may have increased trimetazidine exposure due to age-related decrease in renal function (see section 5.2). In patients with moderate renal impairment (creatinine clearance [30-60] ml/min), the recommended dose is 1 tablet of 35mg in the morning during breakfast. Dose titration in elderly patients should be exercised with caution (see section 4.4). Health Products Regulatory Authority

Summary of product characteristics

Objective: To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures. Background: New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use of minimal invasive surgical access have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated. Methods: We searched Medline for the period of 1980 to the present using the key terms fast track surgery, accelerated care programs, postoperative complications and preoperative patient preparation; and we examined and discussed the articles that were identified to include in this review. This information was supplemented with our own research on the mediators of the stress response in surgical patients, the use of epidural anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach. Results: The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs. Conclusions: Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of an operation, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Developments and improvements of multimodal interventions within the context of "fast track" surgery programs represents the major challenge for the medical professionals working to achieve a "pain and risk free" perioperative course.

Multimodal strategies to improve surgical outcome.

Depression is less prevalent among older adults than among younger adults, but it can have serious consequences. More than half of cases represent a first onset in later life. Although suicide rates in the elderly are declining, they are still higher than in younger adults and are more closely associated with depression. Depressed older adults are less likely to endorse affective symptoms and more likely to display cognitive changes, somatic symptoms, and loss of interest than are depressed younger adults. Risk factors leading to the development of late-life depression likely comprise complex interactions among genetic vulnerabilities, cognitive diathesis, age-associated neurobiological changes, and stressful events. Insomnia is an often overlooked risk factor for late-life depression. We suggest that a common pathway to depression in older adults, regardless of which predisposing risks are most prominent, may be curtailment of daily activities. Accompanying self-critical thinking may exacerbate and maintain a depressed state. Offsetting the increasing prevalence of certain risk factors in late life are age-related increases in psychological resilience. Other protective factors include higher education and socioeconomic status, engagement in valued activities, and religious or spiritual involvement. Treatments including behavioral therapy, cognitive-behavioral therapy, cognitive bibliotherapy, problem-solving therapy, brief psychodynamic therapy, and life review/reminiscence therapy are effective but are too infrequently used with older adults. Preventive interventions including education for individuals with chronic illness, behavioral activation, cognitive restructuring, problem-solving skills training, group support, and life review have also received support.

Depression in Older Adults

The principal function of the serotonin transporter is to remove serotonin from the synapse, returning it to the presynaptic neuron where the neurotransmitter can be degraded or re-released at a later time. A polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) has been found to affect the transcription rate of the gene, with the short (s) allele transcriptionally less efficient that the alternate long (l) allele. In 2003, Caspi and colleagues examined the relationship between 5-HTTLPR, stress and depression using a prospective, longitudinal birth cohort and found that subjects carrying the less functional 5-HTTLPR s allele reported greater sensitivity to stress1.

This study has been cited over 2000 times in the scientific literature and generated a great deal of excitement and controversy around the potential of gene × environment interaction studies2. To date, there have been 55 follow-up studies, exploring whether 5-HTTLPR moderates the relationship between stress and depression, with some studies supporting the association between the 5-HTTLPR s allele and greater stress sensitivity and others not. Two recent meta-analyses have assessed a subset of these studies and concluded that there is no evidence supporting the presence of genetic moderation3, 4.

Since their publication, these meta-analyses have been criticized for only including a subset of the studies investigating the relationship between 5-HTTLPR stress and depression5–9. In fact, while 56 primary data studies have assessed whether 5-HTTLPR moderates the relationship between stress and depression, the Munafo and Risch meta-analyses included only 5 and 14 of those studies respectively10–48. Further, Uher and McGuffin have demonstrated that the larger, Risch meta-analysis included a significantly greater proportion of negative replication studies than positive replication studies8.

There are multiple reasons that the studies included in the meta-analyses were limited. First, the primary study data needed for traditional meta-analysis was often not available, either in the original publications or in follow-up email inquiries to study authors. For instance, Munafo and colleagues reported that 15 studies met criteria for inclusion in their meta-analysis. However, they were only able to obtain the primary study data needed for inclusion for five of those studies. There is no evidence that the studies that were able to be included in the meta-analyses were of higher “quality” than those not included.

Another reason why many studies were not included in the Risch and Munafo meta-analysis is that both meta-analyses focused exclusively on studies that explored an interaction between 5-HTTLPR and stressful life events (SLEs) in the development of depression. The original Caspi article, however, not only reported an interaction between 5-HTTLPR and SLEs, but also an interaction between 5-HTTLPR and childhood maltreatment stress. Nine studies have attempted to replicate this interaction with childhood maltreatment, but these studies were not included in the meta-analyses.

Some observers have noted that the SLE study design may have limited power to detect genetic moderation effects because they are susceptible to biases introduced by impaired recall of stressors by subjects and highly variable stressors between subjects9, 45. A newer class of studies has attempted to bypass these potential problems by focusing on specific populations that have experienced a substantial, specific stressor. These studies test whether 5-HTTLPR moderates the relationship between a specific stressor and depression. Eighteen studies have employed such specific stressor designs, but like the childhood maltreatment studies, these studies were excluded from the previous meta-analysis.

In this study, rather than focus on a limited of studies, we sought to perform a meta-analysis on the entire body of work assessing the relationship between 5-HTTLPR, stress and depression. Unfortunately, different types of studies have generally used different study designs to explore this question, rendering it very difficult to combine the studies into a single traditional meta-analysis. An approach useful in situations where equivalent raw data are not available across all studies, is to combine the studies at the level of significance tests 49. The Liptak-Stouffer Z-score method is a well-validated method for combining p-values across studies that has been utilized widely across genomics and biostatistics 50–56. In this study, we utilize the Liptak-Stouffer Z-score method to combine the results from studies investigating whether the 5-HTTLPR variant moderates the relationship between stress and depression.

/pdf/the-serotonin-transporter-promoter-variant-5-httlpr-stress-1dalduwj08.pdf

The serotonin transporter promoter variant (5-HTTLPR), stress, and depression meta-analysis revisited: evidence of genetic moderation.

Context.—Inpatient rehabilitation after elective hip and knee arthroplasty is
often necessary for patients who cannot function at home soon after surgery,
but how soon after surgery inpatient rehabilitation can be initiated has not
been studied.Objective.—To test the hypothesis that high-risk patients undergoing elective hip
and knee arthroplasty would incur less total cost and experience more rapid
functional improvement if inpatient rehabilitation began on postoperative
day 3 rather than day 7, without adverse consequences to the patients.Design.—Randomized controlled trial conducted from 1994 to 1996.Setting.—Tertiary care center.Participants.—A total of 86 patients undergoing elective hip or knee arthroplasty
and who met the following criteria for being high risk: 70 years of age or
older and living alone, 70 years of age or older with 2 or more comorbid conditions,
or any age with 3 or more comorbid conditions. Of the 86 patients, 71 completed
the study.Interventions.—Random assignment to begin inpatient rehabilitation on postoperative
day 3 vs postoperative day 7.Main Outcome Measures.—Total length of stay and cost from orthopedic and rehabilitation hospital
admissions, functional performance in hospitals using a subset of the functional
independence measure, and 4-month follow-up assessment using the RAND 36-item
health survey I and the functional status index.Results.—Patients who completed the study and began inpatient rehabilitation
on postoperative day 3 exhibited shorter mean (±SD) total length of
stay (11.7±2.3 days vs 14.5±1.9, P<.001),
lower mean (±SD) total cost ($25891±$3648 vs $27762±$3626, P<.03), more rapid attainment of short-term functional
milestones between days 6 and 10 (36.2±14.4 m ambulated vs 21.4±13.3
m, P<.001; 4.8±0.8 mean transfer functional
independence measure score vs 4.3±0.7, P<.01),
and equivalent functional outcome at 4-month follow-up.Conclusion.—These data showed that high-risk individuals were able to tolerate early
intensive rehabilitation, and this intervention yielded faster attainment
of short-term functional milestones in fewer days using less total cost.

https://jamanetwork.com/journals/jama/articlepdf/187345/JOC71370.pdf

Early Inpatient Rehabilitation After Elective Hip and Knee Arthroplasty

Objectives
This study examines the effects of depression and cognitive impairment in elderly hip fracture patients receiving inpatient rehabilitation. Our goal was to determine whether any association of depression and cognitive impairment with rehabilitation outcome is accounted for by more immediate effects of these variables on rehabilitation participation.

Methods
We measured depression using the Hamilton Rating Scale for Depression (Ham-D), cognition using the Mini Mental State Examination (MMSE), and rehabilitation outcomes using the motor scale of the Functional Independence Measure (motor FIM) in a prospective observational study of 57 elderly rehabilitation hospital patients admitted to a university-affiliated, freestanding rehabilitation hospital with primary diagnosis of hip fracture. We also assessed rehabilitation participation, to determine whether this accounted for (mediated) any relationship of depression and cognitive impairment with rehabilitation outcome.

Results
Baseline Ham-D and MMSE scores were correlated with motor FIM efficiency—those with higher depressive symptoms had lower efficiency (r = −0.44, p < 0.001); similarly, those with more cognitive impairment had lower motor FIM efficiency (r = 0.52, p < 0.001). Rehabilitation participation was a mediator of this association: greater depressive symptoms and cognitive impairment predicted poorer rehabilitation participation which, in turn, predicted lower motor FIM efficiency. Ham-D and MMSE scores were predictors of discharge location: subjects with high depressive symptoms and greater cognitive impairment were more likely to go to a nursing home or personal care home upon discharge.

Conclusions
Depression and cognitive impairment are predictive of negative outcomes in elderly patients' rehabilitation from hip fracture. This effect is mediated by rehabilitation participation, and ratings in this area may serve as a potentially useful clinical and research tool for the rehabilitation environment. Copyright © 2004 John Wiley & Sons, Ltd.

Adverse effects of depression and cognitive impairment on rehabilitation participation and recovery from hip fracture.

https://www.archives-pmr.org/article/S0003-9993(03)00892-X/pdf

The Pittsburgh Rehabilitation Participation Scale: Reliability and Validity of a Clinician-Rated Measure of Participation in Acute Rehabilitation

https://www.archives-pmr.org/article/S0003-9993(09)00929-0/pdf

Cognitive and Affective Predictors of Rehabilitation Participation After Stroke

Shoulder pain and rotator cuff tears are highly prevalent in individuals with paraplegia (PP). The purpose of this study was to use magnetic resonance imaging (MRI), plain radiographs, questionnaires, and physical examination to gain insight into the prevalence of shoulder disorders in individuals with PP. A total of 28 individuals with PP was recruited (mean age=35; mean year from injury=11.5). Each subject completed a questionnaire designed to identify arm pain, had a standard physical examination focusing on the shoulder, and underwent imaging studies (radiographic and MRI). Nine of the thirty-two subjects (36 percent) experienced shoulder pain in the month prior to testing. The MRI studies documented only one rotator cuff tear. Five subjects showed osteolysis of the distal clavicle by plain radiographic study. In two subjects this was seen bilaterally. Although no relationship was seen between pain and imaging abnormalities, stepwise linear regressions found a statistically significant positive relationship between imaging abnormalities and body mass index (BMI) (radiographic: beta= 0.56, p<0.01; MRI: beta=0.52, p<0.01). This study found a low prevalence of rotator cuff tears and a high prevalence of distal clavicle osteolysis in a sample of relatively young individuals with PP. Although there was only one tear identified by MRI, a number of subclinical abnormalities were seen and found to correlate with BMI.

/pdf/shoulder-imaging-abnormalities-in-individuals-with-oxf9pt6azk.pdf

Michael C. Munin

Papers

Early Inpatient Rehabilitation After Elective Hip and Knee Arthroplasty

Adverse effects of depression and cognitive impairment on rehabilitation participation and recovery from hip fracture.

The Pittsburgh Rehabilitation Participation Scale: Reliability and Validity of a Clinician-Rated Measure of Participation in Acute Rehabilitation

Cognitive and Affective Predictors of Rehabilitation Participation After Stroke

Shoulder imaging abnormalities in individuals with paraplegia.