Posts Tagged Prognosis
[Abstract] Predicting Long-Term Global Outcome after Traumatic Brain Injury: Development of a Practical Prognostic Tool Using the Traumatic Brain Injury Model Systems National Database
For patients surviving serious traumatic brain injury (TBI), families and other stakeholders often desire information on long-term functional prognosis, but accurate and easy-to-use clinical tools are lacking. We aimed to build utilitarian decision trees from commonly collected clinical variables to predict Glasgow Outcome Scale (GOS) functional levels at 1, 2, and 5 years after moderate-to-severe closed TBI. Flexible classification tree statistical modeling was used on prospectively collected data from the TBI-Model Systems (TBIMS) inception cohort study. Enrollments occurred at 17 designated, or previously designated, TBIMS inpatient rehabilitation facilities. Analysis included all participants with nonpenetrating TBI injured between January 1997 and January 2017. Sample sizes were 10,125 (year-1), 8,821 (year-2), and 6,165 (year-5) after cross-sectional exclusions (death, vegetative state, insufficient post-injury time, and unavailable outcome). In our final models, post-traumatic amnesia (PTA) duration consistently dominated branching hierarchy and was the lone injury characteristic significantly contributing to GOS predictability. Lower-order variables that added predictability were age, pre-morbid education, productivity, and occupational category. Generally, patient outcomes improved with shorter PTA, younger age, greater pre-morbid productivity, and higher pre-morbid vocational or educational achievement. Across all prognostic groups, the best and worst good recovery rates were 65.7% and 10.9%, respectively, and the best and worst severe disability rates were 3.9% and 64.1%. Predictability in test data sets ranged from C-statistic of 0.691 (year-1; confidence interval [CI], 0.675, 0.711) to 0.731 (year-2; CI, 0.724, 0.738). In conclusion, we developed a clinically useful tool to provide prognostic information on long-term functional outcomes for adult survivors of moderate and severe closed TBI. Predictive accuracy for GOS level was demonstrated in an independent test sample. Length of PTA, a clinical marker of injury severity, was by far the most critical outcome determinant.
via Predicting Long-Term Global Outcome after Traumatic Brain Injury: Development of a Practical Prognostic Tool Using the Traumatic Brain Injury Model Systems National Database | Journal of Neurotrauma
[ARTICLE] Moderate Traumatic Brain Injury: Clinical Characteristics and a Prognostic Model of 12 Month Outcome – Full Text
The moment you hear the doctor say you have a brain injury your life stops, no different than if you were told that you have Cancer. Your first reaction is numbness, and then fear sets in. I know personally, for I was diagnosed with both!
The first question that you ask is, “Am I going to get better?’ And most PCPs, neurologists and rehabilitation clinicians will say, “Wait and see.” The usual prescription for a concussion is to go home and rest, limit your activity, especially TV, electronics and sports. Nothing is said about changing your diet, or treatments such as water therapy which can actually help you heal your brain. Since this advice is typically not given, most people who sustain a Concussion, a mild traumatic brain injury, are sent home. Without proper treatment, these symptoms not only don’t go away, they worsen, leading to Post-Concussion Syndrome (PCS).
In my previous blog, I mentioned both a patient who fell off a horse and her symptoms were dismissed, and the Customer Service Representative, who has had symptoms for 8 years, without any help or relief. Because concussions are generally misdiagnosed, undiagnosed, and misunderstood, there are unfortunately many more people out there with experiences like theirs who are living with PCS.
Help and Hope! – There is a Way!
Long before my brain injury on March 5, 1990, I opened the first integrative health team in New England in 1979. The practice was called Lafayette Counseling, Inc. We had three locations and over 256 patients at the time of my accident. Our integrative team was unique because it included conventional, complementary and alternative approaches to treatment for trauma, educational, health issues and sports. We treated many issues were from chronic pain, chronic illness, including Cancer, Irritable Bowel Syndrome (IBS), learning disabilities, ADD, ADHD, incest, rape, abuse, and Post Traumatic Stress Disorder (PTSD). Also, we did hypnosis for Pain Control during Childbirth, which I’m published in the field, and for work in Cancer, along with methods for Peak Performance Training.
The team worked seamlessly together, promoting the welfare of each person who came to the practice the team. We consulted each other and conducted team meetings for every one of the 256 patients we served. We had a psychiatrist, neuropsychologist, psychologist, neurologist, gastroenterologist, endocrinologist, physical therapist, speech and language pathologist, polarity therapist, massage therapist, acupuncturist and homeopathic practitioner as well as psychiatric nurses and social workers. It was during this time I developed Dr. Diane®’s 5 Prong Approach to treatment. It was a thriving practice… until my accident occurred.
After My Brain Injury
During the four years following my accident, I was not offered any services or treatments to help me progress in my rehabilitation and to help me regain my life. In 1991, I had to close my practice since I could no longer manage it. In 1994, I was told by one of the neurologists that I needed to see a psychiatrist to help me deal with the fact I was permanently brain damaged and that I would never walk or talk properly every again. I remember initially wishing I had died in the accident. I even contemplated suicide. I was no longer the wife or mother I wanted to be. I had 3 young children at home, and I could not function. It was a dark and lonely place. Then after a period of grieving, I decided, “Doc, you are going to heal yourself”. It was then I realized the amazing professionals that once made up the integrative team at my practice. I contacted the various team members and engaged them in my own rehabilitation, starting with polarity and acupuncture. Prior to my brain injury I had gone on a 6-month elimination diet to deal with food allergies. From this information, I realized after my brain injury that if I ate certain foods that my symptoms would get worse. I realized that changing my diet was improving my symptoms. Yet, no doctor could have given me that advice. I followed those same guidelines from the earlier elimination diet. I started with one food and noted, along with the family members, who were living with all my symptoms, if that food made my symptoms better or worse. After 6 months, it was extremely clear that certain foods only made my symptoms worse, while others truly did help. With this knowledge, I developed my brain food diet, which to this day has helped every single patient.
During this period, I was introduced to Dr. Igor Burdenko, Ph.D., the founder and chairman of the Burdenko Water and Sports Therapy Institute. Dr. Burdenko developed The Burdenko Method, a practical application of water and land exercises based on holistic approach to rehabilitation, conditioning, and training. The Burdenko Method changed my life, as did being on my brain health diet and being introduced to neurofeedback.
I learned about neurofeedback through a presentation given at a brain injury support group by Janet Bloom, who trained with Dr. Margaret Ayers. I had been trained in hypnosis and biofeedback, yet I had never heard of neurofeedback. I am so grateful I attended that brain injury support group and discovered neurofeedback. These three methods were the vital forces integral to regaining my life.
With all the information I acquired from these methods and with the help of my previous integrative team, I set out to write a book to help other like myself to regain their life again. I co-authored, Coping with Mild Head Injury that was later changed to Coping with Mild Traumatic Brain Injury. The entire focus of this book was and is about the integrative approach that helped me rebuild my life. The book contains Conventional, Complementary and Alternative approaches to taking back your life after brain injury. The book was released in 1997, the same year I was able to resume my practice, as a solo practitioner. I still was not ready cognitively to resume all of the responsibilities of having an integrative team of experts working with me.
From 1997 until 2007, I worked alone, yet was gradually meeting and working different practitioners developing a new integrative team with the current brain health experts.
Major Difference with Integrative Brain Injury Team
Just as the previous integrative team prior to my brain injury, this new team of brain health experts works seamlessly together, in true integrative fashion. One of my biggest complaints own with medical team treating my brain injury was they never spoke to one another. I can’t tell you how many times I was informing a specific doctor on what the other doctor had said or was doing. They did NOT communicate with one another. There was NO joint documentation of my files. And often there was disagreement of methods of medication or procedures.
Having had this awful experience, I vowed that this would never happen to any patient we consult with or treat in our practice. The Dr. Diane Brain Health team each has their own private practice, and are throughout the US. Also, I’m extremely fortunate that since 1997, I met and personally know a network of national and international practitioners that we work with. Hence, where ever you are located in the world, we can either refer you to a specialist in your area or we can provide remote, virtual, now called (tele-health) services.
COPING WITH CONCUSSION AND MILD TRAUMATIC BRAIN INJURY
In 2011, Penguin Publishing asked me to write another book. I agreed if the book’s focus was on the integrative treatment approach that was working so well in my practice. They agreed. Thus, Barbara Albers Hill and I set out to write a book with the main focus of an integrative approach of treatment for brain injury. The book came out in 2013.
Susan Connors, the president and CEO of the Brain Injury Association wrote the following review which appears on the back cover of the book: “Coping with Concussion and Mild Traumatic Brain Injury” is a long-awaited prescription for the millions who experience a so-called mild TBI and for their families and care providers. Incorporating detailed information, practical suggestions and personal insight, Dr. Stoler, has compiled a must-have encyclopedia for managing life after a Concussion.”
DR. DIANE®’S 5 PRONG APPROACH TO TREATMENT
My 5 Prong Approach evolved as part of my own journey in regaining my life after my brain injury, and with working with the brain injury patients and consult clients upon my return to active practice. What I realized is that even though there are common symptoms related to injury to the brain, each person is unique. Because of this, each treatment program for similar symptoms has to be different in order to achieve an excellent outcome. I believe the key to healing is to view and treat each person from the five distinct views that make up our approach: physical, psychological, emotional, spiritual and energy while looking for the core issue. Often these areas are connected and each needs to be addressed to ultimately reach your goal, Each integrative team member brings their own specialty and together we develop customized treatment programs based on the individual’s unique needs and goals and symptoms, using a wide-range of traditional, alternative, and complementary methods.
LIST OF INTEGRATIVE SERVICES
- Neurofeedback, Biofeedback, and QEEG
- Nutrition Education and Nutrition Response Testing
- Physical Therapy/CranioSacral Therapy
- Water Therapy/Burdenko Method
- Speech-Language Pathology
- Cognitive Remediation Therapy
- Energy Psychology
- Energy Healing
- Other Energy Healing Treatments- Tom Tam, Evan Pantazi
- Hypnosis and Relaxation Techniques
- Massage and Muscular Therapy
- Psychiatry and Psychopharmacology
- Cognitive Behavioral Therapy
- Bach Flower Essence
- iListen Therapy™
- Interactive Metronome
- Irlen Method
- Light Therapy + Photonic Modulation
- The Tomatis Method®
- Care Management
MEET THE DR. DIANE INTEGRATIVE TEAM OF BRAIN HEALTH EXPERTS
In the following weeks, my blogs will be focused on introducing you to the various individual team members, their background, beliefs and philosophy about specific treatment and the importance of being a part of an integrative team. Here is a brief introduction of the team members. For more detailed information about each member and the services they offer, please click on the links.
Dr. Diane® is a Neuropsychologist, Board Certified Health Psychologist, and Board Certified Sports Psychologist with a focus on brain fitness and brain rehabilitation. She has worked with amateur, professional and Olympic athletes to help them achieve Peak Performance and be in “The Zone”.
Certified Speech-Language Pathologist with over 19 years’ experience working with acquired brain injuries, learning disabilities and other social and communication disorders. Amy’s approach emphasizes understanding what someone needs to improve quality of life, task efficiency and effectiveness and maximizing independence.
Clara practices several forms of energy healing, including Reiki, HBLU, and techniques for emotional processing. She is a Reiki Master trained in the Usui Shiki Ryoho tradition by John and Lourdes Gray.
Specializing in Biofeedback, Brain Training, Listening Training, and Neurofeedback, Paul earned his certification in the first authorized Tomatis training in the US at Spectrum Center in Bethesda, MD, and was trained in neurofeedback and neuroscience at ESII and BrainMaster Institute.
Offering a muscle testing technique is used to choose the most appropriate specific nutrition products for each person. The specific nutritional program thus chosen enhances that individual’s immune system function which then helps the brain to function more efficiently.
Joan is certified in CranioSacral Therapy from the Upledger Institute. She has an intuitive and insightful approach to her work. She treats chronic pain, stroke, alignment disorders, and most orthopedic problems.
Wendy is a Nationally Licensed Massage Therapist and Muscle Release Therapist. Muscle release technique can break down scar tissue, lengthen a muscle, restore muscle memory and relieve pain.
With over ten years’ experience, Jennifer specializes in Deep Tissue, Swedish Eflurage and Sports Massage. Using Reflexology and Shiatsu in addition to traditional massage, she intuitively combines these techniques to release muscle tension and promote relaxation and wellness.
Care management can increase the quality of life for the senior or disabled adult, improve the quality of care, and to reduce caregiver stress. Karen specializes in care management working with seniors, adults with disabilities, and the families that love them.
Dr. Burdenko, founder and chairman of the Burdenko Water and Sports Therapy Institute, is one of the world’s leading authorities on the use of water for rehabilitation, conditioning, and training.
William specializes in TBI, Headaches/Migraines, chronic pain, chronic illness, sleep and insomnia issues. He is nationally board certified by the National Association of Acupuncture and Oriental Medicine (NCCAOM) and licensed in Massachusetts.
David founded a series of Integrative Medical clinics that pioneered the then uncommon practice of a combined conventional and integrative medical staff. Focus areas include: Breaking the Wellness Barrier with solutions for stress, anxiety and depression, Developing Patient Medical Leadership Skills, Healthy Aging at Home, Successful Engagement with Wellness at Work and Ancient Solutions for Modern Problems.
Paul obtained his undergraduate training in Biology at the University of Connecticut followed by graduate education at the National College of Chiropractic in Lombard, Illinois. He graduated cum laude, with a doctorate in Chiropractic in 1992. He complements his chiropractic education with an extensive postgraduate program in rehabilitation, which help patients manage some of the most complicated and/or chronic cases of musculo-skeletal pain.
Primary area of interest centers on head injuries, migraines, seizures, movement disorders, neuropathies, and the injection of botulinum toxin (botox) in the treatment of migraines, headaches, and similar forms of pain, muscle contractions and movement disorders, as well as Alzheimer’s disease, stroke, and epilepsy. One of the many qualities that set Dr. Gonzales apart from the rest is his acceptance of alternative approaches to migraine treatment and palliation.
Board Certified adult psychiatrist with over 25 years’ experience treating people with Brain Injury, Fibromyalgia and Chronic Fatigue Syndrome. She is a graduate of Emory University School of Medicine, and completed her residency at the Beth Israel Deaconess in Boston, Massachusetts.
Dr.O’Neil-Smith is a magna cum laude graduate of Boston University Medical School. She completed an internship in pathology at Massachusetts General Hospital followed by an internship and residency in internal medicine at the Brigham and Women’s Hospital in Boston. Dr. O’Neil-Smith has an extensive background in nutrition, applied physiology and sports medicine.
Tom is a licensed Acupuncturist who has also practiced Tai Chi and Chi Gong since 1975, specializing in Acupuncture, Qui Gong. Tom formed his own healing system, and wrote the Tom Tam Healing System (1995). Also, he wrote a Chinese healing book, An Zhen – The Palpation diagnose (2005). This book combined the west and east medical knowledge and formed a new theory for the understanding and healing the difficulty disease.
Evan has formulated a new and highly advanced method of Kyusho (Vital Point) for use in Health, Martial, Intimacy Enhancement and Law Enforcement. Based on the ancient understanding of acupuncture and pressure point massage methods, but adapted with modern science… the vital point is that all of us can easily rid the body of common ailments.
Integrative Brain Injury Consult
There are many practices that call themselves “integrative”. However, if you call and ask you will typically find the integrative team keep does not keep the same notes or meet to discuss your individual needs or treatment. This is norm at Dr. Diane Brain Health, not the exception.
Whether you are looking for help restoring your Brain Health and regain your life again……There is a Way! ®
GET HELP TODAY!
With over 30 years of experience as a Neuropsychologist, Board Certified Health Psychologist, Board Certified Sports Psychologist and brain injury survivor Dr. Diane can help you!
SCHEDULE A CONSULT
Schedule a personal consult today with Dr. Diane®
[ARTICLE] Can Neurological Biomarkers of Brain Impairment Be Used to Predict Poststroke Motor Recovery? – Full Text
Background. There is growing interest to establish recovery biomarkers, especially neurological biomarkers, in order to develop new therapies and prediction models for the promotion of stroke rehabilitation and recovery. However, there is no consensus among the neurorehabilitation community about which biomarker(s) have the highest predictive value for motor recovery. Objective. To review the evidence and determine which neurological biomarker(s) meet the high evidence quality criteria for use in predicting motor recovery. Methods. We searched databases for prognostic neuroimaging/neurophysiological studies. Methodological quality of each study was assessed using a previously employed comprehensive 15-item rating system. Furthermore, we used the GRADE approach and ranked the overall evidence quality for each category of neurologic biomarker. Results. Seventy-one articles met our inclusion criteria; 5 categories of neurologic biomarkers were identified: diffusion tensor imaging (DTI), transcranial magnetic stimulation (TMS), functional magnetic resonance imaging (fMRI), conventional structural MRI (sMRI), and a combination of these biomarkers. Most studies were conducted with individuals after ischemic stroke in the acute and/or subacute stage (~70%). Less than one-third of the studies (21/71) were assessed with satisfactory methodological quality (80% or more of total quality score). Conventional structural MRI and the combination biomarker categories ranked “high” in overall evidence quality. Conclusions. There were 3 prevalent methodological limitations: (a) lack of cross-validation, (b) lack of minimal clinically important difference (MCID) for motor outcomes, and (c) small sample size. More high-quality studies are needed to establish which neurological biomarkers are the best predictors of motor recovery after stroke. Finally, the quarter-century old methodological quality tool used here should be updated by inclusion of more contemporary methods and statistical approaches.
There is growing interest in establishing stroke recovery biomarkers. Researchers define stroke recovery biomarkers as surrogate indicators of disease state that can have predictive value for recovery or treatment response.1 Specifically, previous studies have suggested that better understanding of neurological biomarkers, derived from brain imaging and neurophysiological assessments, is likely to move stroke rehabilitation research forward.1,2
Recovery biomarkers acquired during the acute and subacute phases (acute—within 1 week after onset; subacute—between 1 week and 3 months after onset) may be vital to set attainable neurorehabilitation goals and to choose proper therapeutic approaches based on the recovery capacity. Furthermore, motor recovery prediction using neurological biomarkers in the chronic phase (more than 3 months after onset) can be useful to determine whether an individual will benefit from specific therapeutic interventions applied after the normal period of rehabilitation has ended. Hence, use of recovery biomarkers is likely to improve customization of physical interventions for individual stroke survivors regarding their capacity for recovery, and to facilitate development of new neurorehabilitation approaches.
There have been fundamental changes in recovery biomarkers from simple clinical behavioral biomarkers to brain imaging and neurophysiological biomarkers. In particular, a number of recent studies have shown that neurologic biomarkers (ie, neuroimaging and/or neurophysiological measures of brain) are more predictive of motor recovery than clinical behavioral biomarkers.3–5
Although there is some evidence that neurological biomarkers are more valuable as predictors of motor recovery than clinical behavioral biomarkers, there are significant gaps between the published evidence and clinical usage. First, there is no consensus on which specific neurological biomarkers would be best for prediction models.4,6,7 Viable neurological biomarker of motor recovery have evolved from lesion size and location, prevalent in the early 1990s8 to more contemporary complex brain network analysis variables.9 Despite this evolution, there is a paucity of high-level evidence for determining the most critical neurological biomarkers of motor recovery. A number of literature reviews and systematic reviews of studies published since the 1990s aimed to identify the most appropriate biomarkers of motor recovery or functional independence.8,10–12 Among these reviews, only one by Schiemanck and colleagues8 assessed the evidence quality of neurologic biomarkers, while many focused on clinical measures (ie, clinical motor and/or functional measures).11 Their review was limited to only 13 studies that employed structural magnetic resonance imaging (sMRI) measures of lesion volume as neurologic biomarkers. Besides lesion volume derived from structural MRI, there are other viable neurological biomarkers of brain impairment. Therefore, this systematic review includes a broad set of relevant biomarkers for consideration as critical predictors for inclusion in motor recovery prediction models.
Furthermore, there is some evidence to suggest that multivariate prediction models that use neurological biomarkers in addition to clinical outcome measures are more accurate than those that use clinical outcome measures alone.2,13 However there is still no consensus about whether incorporating behavioral and neurological predictors in a multimodal prediction model is superior (ie, more accurate) to a univariate model that includes either behavioral or neurological predictors alone.
Taken together, this systematic review has 2 aims. The first is to conduct a critical and systematic comparison of selected studies to determine which neurological biomarker(s) is likely to have sufficient high-level evidence in order to render the most accurate prediction of motor recovery after stroke. The second aim is to identify whether adding clinical measures along with neurological biomarkers in the model improves the accuracy of the model compared to the models that use neurological biomarkers alone.
[ARTICLE] Effects of Unilateral Upper Limb Training in Two Distinct Prognostic Groups Early After Stroke – Full Text
Background and Objective. Favorable prognosis of the upper limb depends on preservation or return of voluntary finger extension (FE) early after stroke. The present study aimed to determine the effects of modified constraint-induced movement therapy (mCIMT) and electromyography-triggered neuromuscular stimulation (EMG-NMS) on upper limb capacity early poststroke.
Methods. A total of 159 ischemic stroke patients were included: 58 patients with a favorable prognosis (>10° of FE) were randomly allocated to 3 weeks of mCIMT or usual care only; 101 patients with an unfavorable prognosis were allocated to 3-week EMG-NMS or usual care only. Both interventions started within 14 days poststroke, lasted up until 5 weeks, focused at preservation or return of FE.
Results. Upper limb capacity was measured with the Action Research Arm Test (ARAT), assessed weekly within the first 5 weeks poststroke and at postassessments at 8, 12, and 26 weeks. Clinically relevant differences in ARAT in favor of mCIMT were found after 5, 8, and 12 weeks poststroke (respectively, 6, 7, and 7 points; P < .05), but not after 26 weeks. We did not find statistically significant differences between mCIMT and usual care on impairment measures, such as the Fugl-Meyer assessment of the arm (FMA-UE). EMG-NMS did not result in significant differences.
Conclusions. Three weeks of early mCIMT is superior to usual care in terms of regaining upper limb capacity in patients with a favorable prognosis; 3 weeks of EMG-NMS in patients with an unfavorable prognosis is not beneficial. Despite meaningful improvements in upper limb capacity, no evidence was found that the time-dependent neurological improvements early poststroke are significantly influenced by either mCIMT or EMG-NMS.
Several prospective cohort studies among stroke patients have shown that the functional outcome of the upper limb is largely defined within the first 5 weeks poststroke and is mainly driven by (yet poorly understood) mechanisms of spontaneous neurological recovery.1,2 Observational studies showed that the presence of some voluntary finger extension (FE) within 72 hours is a favorable indicator for the return of dexterity poststroke.3,4 This suggests that early control of FE is an important prognostic factor in stratifying patients for upper limb intervention trials early poststroke.2
For those with a favorable prognosis, indicated by some voluntary FE early poststroke, constraint-induced movement therapy (CIMT) or a modified version (mCIMT) may benefit arm-hand activities and self-reported hand function in daily life.5The number of phase II trials on mCIMT within the first days or weeks poststroke is however small and findings are rather inconclusive. For example, Dromerick et al6showed in a proof of concept trial that 1 or 2 hours mCIMT per working day for 2 weeks was not superior to an equal dosage of usual care, whereas a high dose of 3 hours mCIMT per working day resulted in less improvement on functional outcome measured with the Action Research Arm Test (ARAT) at 3 months poststroke.
For those with an unfavorable prognosis for functional outcome at 6 months, that is, patients without voluntary FE,1,3,4 no evidence-based therapies have been reported so far. In subacute and chronic stroke, innovative therapies such as electromyography-triggered neuromuscular stimulation (EMG-NMS) of the finger extensors to improve voluntary control have shown promise in terms of increasing active range of motion.7⇓⇓⇓–11 Furthermore, several studies suggest that EMG-NMS may produce changes in cortical activation patterns and excitability in chronic stroke.12,13 For example, Shin et al13 showed in a small proof of concept trial (n = 14) that a daily 30-minute program for 10 weeks shifted cortical activation patterns as seen in functional magnetic resonance imaging from the ipsilateral sensorimotor cortex to the contralateral sensorimotor cortex in chronic stroke. Despite the growing evidence for enhanced levels of homeostatic neuroplasticity in the first weeks poststroke,14 early started EMG-NMS trials for patients without FE are lacking in this restricted time window.
The first objective of the present study was to investigate the effects of an early mCIMT program on recovery of upper limb capacity during the first 6 months, starting within 14 days poststroke in patients with some voluntary FE. Our second objective was to investigate the effects of early EMG-NMS on the recovery of voluntary FE and upper limb capacity during the first 6 months, starting within 14 days poststroke in patients with no voluntary control of the finger extensors. We hypothesized that an intensive 3-week mCIMT program would result in a clinically meaningful improvement in ARAT scores compared with usual care alone. For the patients with an unfavorable prognosis we hypothesized that a higher percentage of patients (10% or more increase) would regain some dexterity (ARAT score >9 points on a maximum of 57 points) if they received intensive daily EMG-NMS for 3 weeks, compared with usual care alone.
[Abstract] Predicting REcovery Potential of Upper Limb Function After Stroke to Increase Rehabilitation Efficiency
Introduction: The PREP algorithm combines clinical assessment [Shoulder Abduction Finger Extension (SAFE) score], transcranial magnetic stimulation (TMS) and diffusion-tensor imaging to predict potential for upper limb recovery following stroke. Patients’ recovery potential is predicted to be Complete, Notable, Limited or None.
Hypothesis: The PREP algorithm may be used in a ‘real world’ clinical setting to set individual rehabilitation goals.
Methods: This study recruited 194 patients with upper limb weakness within 3 days of stroke. Assessments were made at baseline and 12 weeks by assessors blinded to PREP algorithm prediction. The initial benchmarking phase recruited 85 patients and PREP algorithm information was not shared with clinical teams or patients. The results were used to refine the algorithm and guide implementation in three ways. First, patients with a SAFE score > 7, predicted to have Complete upper limb recovery, were given a self-directed therapy program. Second, patients with a SAFE score of 5-7 could be given a Notable recovery prognosis, without requiring TMS. Third, 19% of patients exceeded their predicted upper limb recovery, so this possibility was conveyed to patients and clinical teams. The implementation phase recruited 109 patients, and PREP algorithm predictions were shared with patients and clinical teams.
Results: Interim analyses (n = 135) find that the PREP algorithm correctly predicted upper limb function at 12 weeks for 85% of patients. Implementation of the algorithm decreased length of stay by 7 days (95%CI 2 – 15 days, p < 0.05) and increased the proportion of patients discharged home from the acute stroke unit from 28% to 49% (p < 0.01). Implementation also decreased upper limb therapy dose (p < 0.01), yet patient outcomes were similar between the two phases. Primary endpoint analysis will be complete in November 2015.
Conclusions: Making predictions about the potential for recovery of upper limb function, and setting individual rehabilitation goals accordingly, may increase the efficiency of post-stroke rehabilitation.
[ARTICLE] May clinical neurophysiology help to predict the recovery of neurological early rehabilitation patients? – Full Text HTML
Background: So far, the role of clinical neurophysiology in the prediction of outcome from neurological and neurosurgical early rehabilitation is unclear.
Methods: Clinical and neurophysiological data of a large sample of 803 early rehabilitation cases of the BDH-Clinic Hessisch Oldendorf in Northern Germany have been carefully reviewed. Most patients (43.5 %) were transferred to rehabilitation after stroke, mean age was 66.6 (15.5) years. Median somatosensory (SEP), auditory (AEP) and visual evoked potentials (VEP) along with EEG recordings took place within the first two weeks after admission. Length of stay (LOS) in early rehabilitation was 38.3 (37.2) days.
Results: Absence of SEP on one or both sides was associated with poor outcome, χ2 = 12.98 (p = 0.005); only 12.5 % had a good outcome (defined as Barthel index, BI ≥50) when SEP were missing on both sides. In AEP, significantly longer bilateral latencies III were observed in the poor outcome group (p < 0.05). Flash VEP showed that patients in the poor outcome group had a significantly longer latency III on both sides (p < 0.05). The longer latency III, the smaller BI changes (BI discharge minus admission) were observed (latency III right r = −0.145, p < 0.01; left r = −0.206, p < 0.001). While about half of the patients with alpha EEG activity belonged to the good outcome group (80/159, 50.3 %), only 39/125 (31.2 %) with theta and 5/41 (12.2 %) with delta rhythm had a favourable outcome, χ2 = 24.2, p < 0.001.
Conclusions: Results from this study suggest that loss of median SEP, prolongation of wave III in AEP and flash-VEP as well as theta or delta rhythms in EEG are associated with poor outcome from neurological early rehabilitation. Further studies on this topic are strongly encouraged.
[ARTICLE] Generalizability of the Proportional Recovery Model for the Upper Extremity After an Ischemic Stroke
Background and objective. Spontaneous neurological recovery after stroke is a poorly understood process. The aim of the present article was to test the proportional recovery model for the upper extremity poststroke and to identify clinical characteristics of patients who do not fit this model.
Methods. A change in the Fugl-Meyer Assessment Upper Extremity score (FMA-UE) measured within 72 hours and at 6 months poststroke served to define motor recovery. Recovery on FMA-UE was predicted using the proportional recovery model: ΔFMA-UEpredicted = 0.7·(66 − FMA-UEinitial) + 0.4. Hierarchical cluster analysis on 211 patients was used to separate nonfitters (outliers) from fitters, and differences between these groups were studied using clinical determinants measured within 72 hours poststroke. Subsequent logistic regression analysis served to predict patients who may not fit the model.
Results. The majority of patients (~70%; n = 146) showed a fixed proportional upper extremity motor recovery of about 78%; 65 patients had substantially less improvement than predicted. These nonfitters had more severe neurological impairments within 72 hours poststroke (P values <.01). Logistic regression analysis revealed that absence of finger extension, presence of facial palsy, more severe lower extremity paresis, and more severe type of stroke as defined by the Bamford classification were significant predictors of not fitting the proportional recovery model.
Conclusions. These results confirm in an independent sample that stroke patients with mild to moderate initial impairments show an almost fixed proportional upper extremity motor recovery. Patients who will most likely not achieve the predicted amount of recovery were identified using clinical determinants measured within 72 hours poststroke.