[ARTICLE] Impact of Somatosensory Training on Neural and Functional Recovery of Lower Extremity in Patients with Chronic Stroke: A Single Blind Controlled Randomized Trial – Full Text

Abstract

Recovery of lower extremity (LE) function in chronic stroke patients is considered a barrier to community reintegration. An adequate training program is required to improve neural and functional performance of the affected LE in chronic stroke patients. The current study aimed to evaluate the effect of somatosensory rehabilitation on neural and functional recovery of LE in stroke patients. Thirty male and female patients were recruited and randomized to equal groups: control group (GI) and intervention group (GII). All patients were matched for age, duration of stroke, and degree of motor impairment of the affected LE. Both groups received standard program of physical therapy in addition to somatosensory rehabilitation for GII. The duration of treatment for both groups was eight consecutive weeks. Outcome measures used were Functional Independent Measure (FIM) and Quantitative Electroencephalography (QEEG), obtained pre- and post-treatment. A significant improvement was found in the FIM scores of the intervention group (GII), as compared to the control group (GI) (p < 0.001). Additionally, QEEG scores improved within the intervention group post-treatment. QEEG scores did not improve within the control group post-treatment, except for “Cz-AR”, compared to pretreatment, with no significant difference between groups. Adding somatosensory training to standard physical therapy program results in better improvement of neuromuscular control of LE function in chronic stroke patients.

1. Introduction

Stroke is a common cause of disability in the world [1]. Almost three-quarters of cases occur in low- to middle-income countries, leading to residual motor disabilities and intensive rehabilitation needs [2,3]. After stroke, many functions are affected, including both basic and instrumental daily living activities [2] and sensorimotor skills [4]. Lower extremity (LE) deficits are present in two-thirds of stroke patients, affecting motor control, gait, and balance, which in turn lead to poor quality of life and various degrees of dependence [5,6], which in turn require effective treatment and are considered a priority in rehabilitation [7].Many approaches of rehabilitation are recommended to enhance motor recovery in stroke patient [8,9,10,11]; among them is the somatosensory stimulation approach, which is a new noninvasive intervention that stimulates the motor cortex through its connections with the sensory cortex, acting on the somatosensory system neuroplasticity [8,12]. It includes sensory stimulation and sensory retraining/re-education [13,14,15,16,17]. Sensory stimulation includes various methods, such as electrical stimulation (e.g., transcutaneous electrical nerve stimulation/TENS) [18], proprioceptors training, constraint-induced movement therapy (CIMT) [8], and thermal stimulation (TS) [19].In normal individuals, TS causes greater brain area activation, compared to tactile and mechanical stimuli [20,21]. TS is a cheap and convenient technique that can be used in rehabilitation and home settings. It depends on stimulating cold and hot receptors alternatively, sending signals to the lateral spinothalamic tract through the spinal cord and up to the thalamus, to the somatosensory cortex [21]. Adding TS to the standard rehabilitation program in stroke patients resulted in significant improvement in outcome measures of both upper and lower extremities, compared to the standard rehabilitation program alone [19,22,23,24,25,26,27].Electroencephalography (EEG) is a neurophysiological technique that measures cortical activity and brain waves. It can determine the effect of a treatment approach used in stroke patients [2]; that is why this safe technique can be of great help in detecting which treatment modality can lead to better improvement in patients’ performance. EEG has four frequency bands: delta, theta, alpha, and beta, with frequency ranges of (1–4 Hz), (4–8 Hz), (8–12 Hz), and (12–30 Hz), respectively. Brain status of the stroke patient can be characterized by Quantitative EEG (QEEG), which is very valuable for decision-making in clinical practice, as reported by many authors [28,29,30].Despite the effectiveness of TS, only two studies were performed on LE function in chronic stroke patients: One of them measured functional outcomes, post-treatment, with no objective evaluation [26], and the other one used a different TS protocol, wherein thermal pain receptors were stimulated [25]. Because stroke recovery is a very complicated process [8,11], and multiple methods of rehabilitation techniques are used, therapists may find it difficult to decide which approach to adopt in patient management in order to achieve the greatest functional improvement with minimal cost of time and money.This study aimed to investigate the influence of adding TS augmented with visual, auditory, and tactile somatosensory rehabilitation to standard rehabilitation on the functional recovery of LE in chronic stroke patients and how that can affect brain activity, using QEEG.[…]

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[ARTICLE] Factors predicting clinically significant functional gain and discharge to home in stroke in-patients after rehabilitation – A retrospective cohort study – Full Text

Abstract

Objective

This study explored factors which predict stroke survivors who could achieve “clinically significant functional gain” and return home when being discharged from a local hospital after in-patient stroke rehabilitation programme.

Methods

This study included 562 inpatients with stroke who were residing at community dwellings before onset of stroke, and transferred to a convalescent hospital for rehabilitation from four acute hospitals over one year. The main outcome variables of prediction were (a) achieving “clinically significant functional gain” as measured by (a1) achievement of “minimal clinically important difference” (MCID) of improvement in Functional Independence Measure Motor Measure (FIM-MM)”, (a2) one or more level(s) of improvement in function group according to the patients’ FIM-MM, and (b) discharge to home. Sixteen predictor variables were identified and studied firstly with univariate binary logistic regression and those significant variables were then put into multivariate binary logistic regression.

Results

Based on multivariate regression, the significant predictors for “clinically significant functional gain” were: younger age <75 years old, higher Glasgow Coma Scale score at admission, with haemorrhagic stroke, intermediate FIM-MM function group. Those significant predictors for “discharge to home” were: living with family/caregivers before stroke, higher FIM score at admission, and one or more level(s) of improvement in FIM-MM function group.

Conclusions

This study identified findings consistent with overseas studies in additional to some new interesting findings. Early prediction of stroke discharge outcomes helps rehabilitation professionals and occupational therapists to focus on the use of appropriate intervention strategies and pre-discharge preparation.

Introduction

Stroke is a major cause of disability with an indication for long term rehabilitation, which includes an in-patient phase as well as a community phase (Feigin et al., 2003). Despite the incidence rate of stroke in Hong Kong has decreased, the number of stroke survivors remains large due to reduction in mortality rate and population aging (Woo et al., 2014). That implies there is an increasing demand for stroke rehabilitation services. Early and accurate prediction of rehabilitation outcomes, such as discharge destinations, better functional improvement, etc. can facilitate the rehabilitation team to customize their plans of care (e.g. triage to different wards, intensive training versus reinforcing skills of care-givers, etc.) and allow more time for liaison and/or making referrals between transitions of care. Subsequently, it may improve patients’ outcomes, decrease length of stay, lower costs, and, improve utilization of resources (Summers et al., 2009).

Outcomes of stroke are associated with various factors including sociodemographic characteristics, clinical characteristics of the stroke incident, comorbid conditions, functional performance at the beginning of the treatment and rehabilitation process. Previous studies and systematic reviews reported that age, marital status, time from stroke onset to rehabilitation, aphasia, neglect, stroke severity presented in National Institutes of Health Stroke Scale, cognitive function, and motor function such as walking distance were associated with the gain score in Functional Independence Measure (FIM) after stroke rehabilitation (Brown et al., 2015; Fung, 2004; Leung et al., 2010; Meyer et al., 2015; Scrutinio et al., 2015). On the other hand among these variables it was found that functional independence was the most determinant factor of discharge destination in majority of studies (Mees et al., 2016). Furthermore, stroke survivors were more prone to institutional care if they had the characteristics of older age, living alone, having pre-existing comorbidities such as atrial fibrillation, severe stroke, dysphagia, cognitive, motor or functional impairment (Brown et al., 2015; Itaya et al., 2017; Mees et al., 2016; Nguyen et al., 2015). This study aimed to explore if these predictor variables of different aspects stated above showed similar positive association with achievement of clinically significant functional gain and discharge to home for stroke patients in a local rehabilitation hospital.[…]

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[Case Study] Improved functional independence measure facilitates return to home after paralyzed upper-limb training: a case report – Full Text PDF

Abstract.

[Purpose] We report a case in which rehabilitation that targeted the paralyzed side’s upper limb in a hemiplegic stroke patient remarkably accelerated the patient’s ability to perform activities of daily living, improved her Functional Independence Measure score, and facilitated the patient’s return to home.

[Subject and Methods] We provided rehabilitation training to a female patient who experienced a cerebral infarction at a nursing home for the elderly and was admitted to the Kaifukuki recovery phase rehabilitation ward in order to improve her activities of daily living and return home. An intensive rehabilitation program incorporating occupational therapy and physical training for upper-limb function on the affected side was instituted over 170 days.

[Results] At presentation, the patient had functional disorders and load-induced pain in both lower limbs requiring her to walk with a fixed-type walker. After the intensive rehabilitation program, her activities of daily living improved and she was able to return home.

[Conclusion] This case suggests that activities of daily living training and simultaneous active training of upper-limb function on the affected side in patients with functional disorders or lower-limb pain could effectively improve their Functional Independence Measure scores, promote functional recovery, and facilitate their return to home.

INTRODUCTION

Motor and cognitive impairments in stroke patients result in disability or dependence during activities of daily living (ADL) among the elderly. ADL performance requires optimal motor function in the trunk and upper and lower extremities. Self-reported disability measures, such as the Functional Independence Measure (FIM), are used to determine functional limitations1) . As it is more difficult to recover function in affected upper extremities than it is in the lower extremities, and since ADL can often be performed with only the unaffected side2, 3) , rehabilitation is aimed at improving function in the unaffected upper extremity4, 5) or switching hand dominance6) . Strategies are designed to improve FIM scores and reduce return-to-home times, as these measures are often also used to evaluate the productivity of rehabilitation clinics and determine budget- and reimbursement-related questions as well7) . In this setting where training to improve function in the affected upper extremity is seldom prioritized, we experienced a rare case wherein functional improvement in the affected dominant upper extremity greatly improved FIM scores and allowed the patient to return home.

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[Abstract] GABAergic drug use and global, cognitive, and motor functional outcomes after stroke.

Abstract

Background

In animal models and healthy volunteers, the use of GABA A receptor agonists (GABA-AGs) seem deleterious for functional recovery. The agents are widely used for subacute stroke, but their effect on functional recovery remains unclear.

Objectives

We aimed to evaluate the association between GABA-AG use and functional recovery after stroke.

Methods

We retrospectively recruited 434 survivors of subacute stroke admitted for inpatient rehabilitation between 2000 and 2013 in our institution (107 with and 327 without GABA-AG use). We used multivariate regression to assess the association of GABA-AG use and successful functional recovery, defined as reaching, between admission and discharge, the minimal clinically important difference (MCID) of 22 points on the global Functional Independence Measure (FIM). Secondary analyses were the associations of GABA-AG with cognitive and motor FIM MCID and constant GABA-AG exposure (24 h/24 GABA-AG) with global, cognitive and motor FIM MCID. A new estimation of the MCID was performed with the standard error of measurement.

Results

Reaching the global FIM MCID was associated with GABA-AG use (adjusted odds ratio [aOR] 0.54 [95% CI 0.31–0.91], P = 0.02) as well as 24 h/24 GABA-AG use (aOR 0.25 [0.08–0.83]; P = 0.02). Furthermore, GABA-AG and 24 h/24 GABA-AG use was inversely but not always significantly associated with reaching the cognitive FIM MCID (aOR 0.56,P = 0.07; aOR 0.26, P = 0.06, respectively) and motor FIM MCID (aOR 0.51, P = 0.07; aOR 0.13, P = 0.01, respectively). The estimated MCID was 19 for global FIM, 4 for cognitive FIM, and 16 for motor FIM.

Conclusions

GABA-AG use is associated with not reaching successful functional recovery during stroke rehabilitation. Randomised trials are needed to formally establish the potential deleterious effect of GABA-AG use on functional recovery.

 

Source: GABAergic drug use and global, cognitive, and motor functional outcomes after stroke

[Research Report] Functional level during the first 2 years after moderate and severe traumatic brain injury – CNS

Research Reports – Functional level during the first 2 years after moderate and severe traumatic brain injury

Brain Inj. 2015 Sep 11:1-8. [Epub ahead of print]

Sandhaug M(1,)(2), Andelic N(3,)(4), Langhammer B(1,)(5), Mygland A(6,)(7,)(8).

BACKGROUND: Long-term outcomes after TBI are examined to a large extent, butlongitudinal studies with more than 1-year follow-up time after injury have beenfewer in number. The course of recovery may vary due to a number of factors and it is still somewhat unclear which factors are contributing.

AIM: The aim of this study was to describe the functional level at four time points up to 24 months after traumatic brain injury (TBI) and to evaluate the predictive impact of pre-injury and injury-related factors.

DESIGN: A cohort study.

SETTING: Outpatient.

POPULATION: Sixty-five patients with moderate (n = 21) or severe (n = 44) TBI.

METHODS: The patients with TBI were examined with Functional Independence Measure(FIM) and Glasgow Outcome Scale Extended (GOSE) at 3 months, 12 months and 24months after injury. Possible predictors were analysed in a regression modelusing FIM total score at 24 months as the outcome measure.

RESULTS: FIM scores improved significantly from rehabilitation unit discharge to 24 months after injury, with peak levels at 3 and 24 months after injury(p < 0.001), for the whole TBI group and the group with severe TBI. The moderateTBI group did not show significant FIM score improvement during this time period. GOSE scores for the whole group and the moderate group improved significantlyover time, but the severe group did not. FIM at admission to the rehabilitation unit and GCS score at admission to the rehabilitation unit were closest to being significant predictors of FIM total scores 24 months after injury (B = 0.265 and2.883, R(2 )= 0.39, p = 0.073, p = 0.081).

CONCLUSION: FIM levels improved during the period from rehabilitation unitdischarge to 3 months follow-up; thereafter, there was a ‘plateauing’ of recovery. In contrast, GOSE ‘plateauing’ of recovery was at 12 months.

CLINICAL REHABILITATION IMPACT: The study results may indicate that two of themost used outcome measures in TBI research are more relevant for assessment of the functional recovery in a sub-acute phase than in later stages of TBI recovery.

Source: Traumatic Brain Injury Resource Guide – Research Reports – Functional level during the first 2 years after moderate and severe traumatic brain injury

[ARTICLE] Hybrid Assistive Limb (HAL) Rehabilitation in Patients with Acute Hemorrhagic Stroke – Full Text PDF

Abstract

The efficacy of hybrid assistive limb (HAL) rehabilitation in the acute phase of stroke remains unclear. The purpose of this study was to evaluate the outcomes of patients with acute intracranial hemorrhage (ICH) who were treated with or without HAL rehabilitation. Among 270 patients with acute ICH from 2009 to 2014, 91 patients with supratentorial ICH were included in this retrospective study. Of these, 14 patients (HAL group) received HAL rehabilitation at approximately 1 week after ICH occurrence, while the remaining 77 patients received usual rehabilitation without HAL (N-HAL group). We obtained various patient data from the hospitals where the patients were moved to for further rehabilitation. Statistical comparisons were performed for the characteristics of the ICH patients, and outcomes between the HAL and N-HAL groups. There were no differences in outcomes between the HAL and N-HAL groups. However, patients with right ICH in the HAL group exhibited a significant association with a functional independence measure (FIM) score of ≥ 110 compared with patients in the N-HAL group (HAL group: 81.8%, N-HAL group: 43.9%, P = 0.04). In patients with right ICH, HAL rehabilitation was associated with improved outcomes as evaluated by the FIM score. Thus, HAL rehabilitation may improve outcomes of acute ICH in appropriately selected patients.

Full Text PDF [245K]

Source: Hybrid Assistive Limb (HAL) Rehabilitation in Patients with Acute Hemorrhagic Stroke

[ARTICLE] Comparison of Rehabilitation Outcomes for Long Term Neurological Conditions: A Cohort Analysis of the Australian Rehabilitation Outcomes Centre Dataset for Adults of Working Age – Full Text HTML

Abstract

Objective

To describe and compare outcomes from in-patient rehabilitation (IPR) in working-aged adults across different groups of long-term neurological conditions, as defined by the UK National Service Framework.

Design

Analysis of a large Australian prospectively collected dataset for completed IPR episodes (n = 28,596) from 2003-2012.

Methods

De-identified data for adults (16–65 years) with specified neurological impairment codes were extracted, cleaned and divided into ‘Sudden-onset’ conditions: (Stroke (n = 12527), brain injury (n = 7565), spinal cord injury (SCI) (n = 3753), Guillain-Barré syndrome (GBS) (n = 805)) and ‘Progressive/stable’ conditions (Progressive (n = 3750) and Cerebral palsy (n = 196)). Key outcomes included Functional Independence Measure (FIM) scores, length of stay (LOS), and discharge destination.

Results

Mean LOS ranged from 21–57 days with significant group differences in gender, source of admission and discharge destination. All six groups showed significant change (p<0.001) between admission and discharge that was likely to be clinically important across a range of items. Significant between-group differences were observed for FIM Motor and Cognitive change scores (Kruskal-Wallis p<0.001), and item-by-item analysis confirmed distinct patterns for each of the six groups. SCI and GBS patients were generally at the ceiling of the cognitive subscale. The ‘Progressive/stable’ conditions made smaller improvements in FIM score than the ‘Sudden-onset conditions’, but also had shorter LOS.

Conclusion

All groups made gains in independence during admission, although pattern of change varied between conditions, and ceiling effects were observed in the FIM-cognitive subscale. Relative cost-efficiency between groups can only be indirectly inferred. Limitations of the current dataset are discussed, together with opportunities for expansion and further development.

Continue —>  PLOS ONE: Comparison of Rehabilitation Outcomes for Long Term Neurological Conditions: A Cohort Analysis of the Australian Rehabilitation Outcomes Centre Dataset for Adults of Working Age.

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[WEB SITE] Classification and Complications of Traumatic Brain Injury: Practice Essentials, Epidemiology, Pathophysiology

Practice Essentials

Traumatic brain injury (TBI), also known as acquired brain injury, head injury, or brain injury, causes substantial disability and mortality. It occurs when a sudden trauma damages the brain and disrupts normal brain function. TBI may have profound physical, psychological, cognitive, emotional, and social effects.

According to the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control, in the United States annually at least 1.4 million people sustain a TBI, and approximately 50,000 people die from such injuries.

See Pediatric Concussion and Other Traumatic Brain Injuries, a Critical Images slideshow, to help identify the signs and symptoms of TBI, determine the type and severity of injury, and initiate appropriate treatment.

Essential update: Metabolic biomarkers may help predict TBI severity and outcome

In a study of 256 consecutive adult patients with acute TBI and 36 control patients with acute orthopedic trauma and no acute or previous brain disorders, presented in October 2014 at the annual meeting of the Congress of Neurological Surgeons, Posti et al found 43 potential metabolic biomarkers that differed significantly in expression patterns between TBI patients and control subjects.[1] These differences were most pronounced among patients with severe TBI.

These metabolic biomarkers included small fatty acids, amino acids, and sugar derivatives.[1] Several metabolites (eg, decanoic acid, octanoic acid, glycerol serine, and 1H-indole-3-acetic acid) were significantly upregulated in cerebrospinal fluid and brain microdialysate samples from newly arrived patients with severe TBI, suggesting disruption of the blood-brain barrier. Marked intergroup differences were still evident in samples taken the day after injury. Metabolic profiles were strongly associated with outcomes, as measured by Glasgow Outcomes Scale scores.

Classification

Primary and secondary injuries

• Primary injury: Induced by mechanical force and occurs at the moment of injury; the 2 main mechanisms that cause primary injury are contact (eg, an object striking the head or the brain striking the inside of the skull) and acceleration-deceleration [2]
• Secondary injury: Not mechanically induced; it may be delayed from the moment of impact, and it may superimpose injury on a brain already affected by a mechanical injury [2]

Focal and diffuse injuries

These injuries are commonly found together; they are defined as follows:

• Focal injury: Includes scalp injury, skull fracture, and surface contusions; generally caused by contact
• Diffuse injury: Includes diffuse axonal injury (DAI), hypoxic-ischemic damage, meningitis, and vascular injury; usually caused by acceleration-deceleration forces

Measures of severity

See the list below:

• Glasgow Coma Scale (GCS): A 3- to 15-point scale used to assess a patient’s level of consciousness and neurologic functioning [3, 4] ; scoring is based on best motor response, best verbal response, and eye opening (eg, eyes open to pain, open to command)
• Duration of loss of consciousness: Classified as mild (mental status change or loss of consciousness [LOC] 6 hr)
• Posttraumatic amnesia (PTA): The time elapsed from injury to the moment when patients can demonstrate continuous memory of what is happening around them [5]

Complications

Complications include the following:

• Posttraumatic seizures: Frequently occur after moderate or severe TBI
• Hydrocephalus
• Deep vein thrombosis: Incidence as high as 54% [6]
• Heterotopic ossification: Incidence of 11-76%, with a 10-20% incidence of clinically significant heterotopic ossification [7]
• Spasticity
• Gastrointestinal and genitourinary complications: Among the most common sequelae in patients with TBI
• Gait abnormalities
• Agitation: Common after TBI

Long-term physical, cognitive, and behavioral impairments are the factors that most commonly limit a patient’s reintegration into the community and his/her return to employment. They include the following:

• Insomnia
• Cognitive decline
• Posttraumatic headache: Tension-type headaches are the most common form, but exacerbations of migraine-like headaches are also frequent
• Posttraumatic depression: Depression after TBI is further associated with cognitive decline, [8, 9] anxiety disorders, substance abuse, dysregulation of emotional expression, and aggressive outbursts

Outcome measures

The following tools are commonly used to measure outcome after TBI[10, 11] :

• Functional Independence Measure (FIM): An 18-item scale used to assess the patient’s level of independence in mobility, self-care, and cognition
• Glasgow Outcome Scale (GOS)
• Disability Rating Scale (DRS): Measures general functional changes over the course of recovery after TBI (see the image below)
• Disability Rating Scale (DRS).

Continue —>  Classification and Complications of Traumatic Brain Injury: Practice Essentials, Epidemiology, Pathophysiology.

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