Acute Stroke Rehabilitation Research Articles

A Backward Walking Training Program to Improve Balance and Mobility in Acute Stroke: A Pilot Randomized Controlled Trial.

Strategies to address gait and balance deficits early poststroke are minimal. The postural and motor control requirements of Backward Walking Training (BWT) may provide benefits to improve balance and walking speed in this population. This pilot study (1) determined the feasibility of administering BWT during inpatient rehabilitation and (2) compared the effectiveness of BWT to Standing Balance Training (SBT) on walking speed, balance, and balance-related efficacy in acute stroke. Eighteen individuals 1-week poststroke were randomized to eight, 30-minute sessions of BWT or SBT in addition to scheduled therapy. Five-Meter Walk Test, 3-Meter Backward Walk Test, Activities-Specific Balance Confidence Scale, Berg Balance Scale, Sensory Organization Test, and Function Independence Measure-Mobility were assessed pre- and postintervention and at 3 months poststroke. Forward gait speed change (BWT: 0.75 m/s; SBT: 0.41 m/s), assessed by the 5-Meter Walk Test, and backward gait speed change (BWT: 0.53 m/s; SBT: 0.23 m/s), assessed by the 3-Meter Backward Walk Test, preintervention to 1-month retention were greater for BWT than for SBT (P < 0.05). Group difference effect size from preintervention to 1-month retention was large for Activities-Specific Balance Confidence Scale, moderate for Berg Balance Scale and Function Independence Measure-Mobility, and small for Sensory Organization Test. Individuals 1-week poststroke tolerated 30 min/d of additional therapy. At 1-month postintervention, BWT resulted in greater improvements in both forward and backward walking speed than SBT. Backward walking training is a feasible important addition to acute stroke rehabilitation. Future areas of inquiry should examine BWT as a preventative modality for future fall incidence.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A193).

Interim analysis of randomized controlled trial to maximize motor scores of the functional independence measure among patients following stroke in acute rehabilitation

Background: Previous research on acute stroke rehabilitation reported the effects of intensity of rehabilitation or augmented exercise therapy time on improving functional recovery. However, an efficient resource use (i.e. therapists) to improve ADL independence has not been tested. We assessed the degree of patient’s need for leading to extra functional gains in acute stroke, and designed a randomized controlled trial.

Combining levodopa and virtual reality-based therapy for rehabilitation of the upper limb after acute stroke: pilot study Part II.

This study aimed to evaluate the safety and efficacy of a combination of levodopa and virtual reality (VR)-based therapy for the enhancement of upper limb recovery following acute stroke. This was a pilot single-blinded case series of acute stroke patients with upper extremity hemiparesis. Patients were randomised to standard care with concomitant administration of either levodopa alone (control group) or combination therapy consisting of VR-based motivational visuomotor feedback training with levodopa neuromodulation (VR group). Main clinical outcome measures were the Fugl-Meyer Upper Extremity (FM-UE) assessment and Action Research Arm Test (ARAT). Kinematic measurements of affected upper limb movement were evaluated as a secondary measure of improvement. Of 42 patients screened, four patients were enrolled in each of the two groups. Two patients dropped out from the control group during the trial. Patients receiving combination therapy had clinically significant improvements in FM-UE assessment scores of 16.5 points compared to a 3.0-point improvement among control patients. Similarly, ARAT scores of VR group patients improved by 15.3 points compared to a 10.0-point improvement in the control group. Corresponding improvements were noted in kinematic measures, including hand-path ratio, demonstrating that the quality of upper limb movement improved in the VR group. Our results suggest that VR-based therapy and pharmacotherapy may be combined for acute stroke rehabilitation. Bedside acquisition of kinematic measurements allows accurate assessment of the quality of limb movement, offering a sensitive clinical tool for quantifying motor recovery during the rehabilitation process after acute stroke.

The diagnostic accuracy of the Montreal Cognitive Assessment in inpatient stroke rehabilitation

ABSTRACTThe Montreal Cognitive Assessment (MoCA) is a commonly used screening measure for cognitive impairment; however, the diagnostic accuracy and optimal cutoff points in inpatients with mild stroke severity is unknown. We examined the diagnostic accuracy of the MoCA in an acute inpatient stroke rehabilitation unit (N = 95). The criterion neuropsychological assessment was the 30-minute National Institute of Neurological Disorders and Stroke-Canadian Stroke Network battery, modified to include the Symbol-Digit Modalities Test and Trail Making Test A & B. The MoCA had moderately strong diagnostic accuracy in receiver operating curve analyses, with areas under the curve ranging from .80 to .89 depending on the threshold for defining cognitive impairment. Sensitivity ranged from .72 to .87, and was generally greater than specificity, which ranged from .60 to .81. The optimal cutoff on the MoCA for detecting mild or greater cognitive impairment was <25/30. The optimal cutoff using more conservative definitions of cognitive impairment ranged from <23–24/30. Exploratory analyses of MoCA subgroups (“normal,” “mildly impaired,” and “functionally impaired”) differed in the frequency and magnitude of impairment on the criterion neuropsychological assessment. These findings inform the clinical use of the MoCA in individuals with mild stroke in an inpatient rehabilitation setting.

Poster 14: Randomized Supplemental Therapeutic Conventional or Robotic Upper Limb Exercise in Acute Stroke Rehabilitation

Poster 14: Randomized Supplemental Therapeutic Conventional or Robotic Upper Limb Exercise in Acute Stroke Rehabilitation

Poster 350: Acute Stroke Rehabilitation Complicated by New Onset Unilateral Cerebellar Kinetic Tremor: A Case Report

PM&RVolume 9, Issue 9S1 p. S242-S243 Neurological Rehabilitation Poster Hall: Case Report Poster 350: Acute Stroke Rehabilitation Complicated by New Onset Unilateral Cerebellar Kinetic Tremor: A Case Report Anna Rozman DO, MBA, Anna Rozman DO, MBA Montefiore Medical Center, New York, NY, United StatesSearch for more papers by this authorYuriy O. Ivanov DO, Yuriy O. Ivanov DO Montefiore Medical Center, New York, NY, United StatesSearch for more papers by this authorMaria A. Jouvin-Castro MD, Maria A. Jouvin-Castro MD Montefiore Medical Center, New York, NY, United StatesSearch for more papers by this author Anna Rozman DO, MBA, Anna Rozman DO, MBA Montefiore Medical Center, New York, NY, United StatesSearch for more papers by this authorYuriy O. Ivanov DO, Yuriy O. Ivanov DO Montefiore Medical Center, New York, NY, United StatesSearch for more papers by this authorMaria A. Jouvin-Castro MD, Maria A. Jouvin-Castro MD Montefiore Medical Center, New York, NY, United StatesSearch for more papers by this author First published: 19 September 2017 https://doi.org/10.1016/j.pmrj.2017.08.289Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume9, Issue9S12017 AAPM&R Annual Assembly AbstractsSeptember 2017Pages S242-S243 RelatedInformation

Abstract TP155: Weight Loss and Functional Outcomes After Stroke

Introduction: It is a well described fact that elderly hospitalized patients lose weight, and this weight loss has been attributed to loss of muscle mass. On our acute Inpatient Stroke Rehabilitation Unit, patients with more severe deficits on admission appear to lose more weight than patients who are fairly functional. With this retrospective cohort study, we examined whether weight loss during stroke rehabilitation was associated with stroke severity as measured with the Functional Independence Measure (FIM) Score, and due to poor nutrition due to dysphagia or otherwise decreased food intake (estimated by Percent of Meal Consumed (PoMC)). Methods: 420 ischemic stroke patients, admitted to the Burke Rehabilitation Hospital Inpatient Stroke Unit between 12/14 and 12/15, were included in this retrospective cohort study. Weight change per admission day, as well as motor, cognitive and total FIM Scores was recorded. Patients who had mechanically altered diet orders or thickened liquid orders were judged to be dysphagic, and nutritional intake was estimated by PoMC. Results: Weight change per day during inpatient stroke rehabilitation was not correlated with gains in motor FIM (Pearson correlation 0.07, p=0.89) or cognitive FIM (Pearson Correlation -0.053, p=0.29) scores. Weight change per day was also not correlated with admission cognitive or motor FIM scores, indicating that stroke severity did not predict weight loss during admission. Of note, weight change per day was also not correlated with dysphagia, indicating that patient with swallowing difficulties were able to meet their nutritional needs through dietary modifications. Conclusion: Weight changes after stroke do not appear to be correlated to stroke severity and stroke outcomes, as measured by the FIM Score. In our cohort, dysphagia was not an independent risk factor for weight loss. Future prospective trials will be required in order to assess which patients are at risk for weight loss, and whether weight loss is correlated with other measures of impairment.

The Use of Telehealth to Reduce Inequalities in Cardiovascular Outcomes in Australia and New Zealand: A Critical Review.

Telehealth, the delivery of health care services at a distance using information and communications technology, is one means of redressing inequalities in cardiovascular outcomes for disadvantaged groups in Australia. This critical review argues that there is sufficient evidence to move to larger-scale implementation of telehealth for acute cardiac, acute stroke, and cardiac rehabilitation services. For cardiovascular chronic disease and risk factor management, telehealth-based services can deliver value but the evidence is less compelling, as the outcomes of these programs are variable and depend upon the context of their implementation.

Management of hyper-acute Ischaemic Stroke: Current status, challenges and opportunities in Northern Sri Lanka

Stroke is one of the leading causes of chronic disability and death worldwide1. However, over the last two decades, this trend has been changed by twin advancement in management of acute ischeamic stroke (AIS); especially in thrombolytic therapy and multidisciplinary dedicated stroke unit2. AIS is distinguished by the sudden loss of neurological functions due to acute interruption of blood circulation to an area of the brain. It is commonly caused by thrombotic or embolic occlusion and less often by rupture of a cerebral artery. Stroke is the fourth commonest killer and major cause of disability among adults in Sri Lanka3. Annual expenditure on the management of acute stroke and neuro rehabilitation has been mounting due to increasing cardiovascular risk factors such as hypertension, smoking, diabetes mellitus, dyslipidemia, excessive alcohol intake and sedentary lifestyle concomitantly with ageing population3. There has been an increasing trend of all the above-mentioned non communicable diseases in recent past in North, mainly because of sudden lifestyle transformation by adopting habits introduced by visiting diaspora. Thrombolytic management at dedicated stroke unit plays a crucial part in minimizing its serious outcomes. This paper primarily reviews the indications and contraindications in choosing patients for the administration of intravenous Recombinant tissue plasminogen activator (rtPA), facilities currently available but underutilized, and the challenges faced in AIS management in Northern part of Sri Lanka.

Building Bridges between healthcare professionals, patients and families: Acoproduced and integrated approach toself-management support in stroke.

Programmes providing self-management support for patients and families are gaining attention and have shown promising outcomes with regards to reducing long-term unmet needs post stroke. However, notions of what good self-management support looks like can differ depending on professional opinion, individual preferences, skills and experiences of patients and their families as well as on how care and rehabilitation is organised in a particular healthcare setting. This resonates with the perspective of patient-centred care, according to which the meaning of good care is not universal, but rather jointly shaped between healthcare professionals and patients in everyday interactions. While self-management support is continuously co-produced in care and rehabilitation practices, most self-management programmes are typically provided as an 'add-on' to existing statutory care. This paper aims to deepen the understanding of how self-management support can be made an integral part of everyday care and rehabilitation using Bridges methodology. The authors provide a self-reflective account on 'Bridges' an integrated approach to self-management support, which is used by healthcare professionals within acute and community stroke rehabilitation across the UK, and in some parts of New Zealand and Australia. Bridges is based on self-efficacy principles, but has a central aim of professionals sharing decision-making and expertise with patients and families in every healthcare interaction. Methodologically, the co-production of a Bridges support package with local healthcare professionals and patients is critical. The authors present the values articulated by the support package and how it engages professionals, patients and Bridges training facilitators in a continuous process of adjusting and re-adjusting situated self-management support practices. Our reflections reveal the need to consider development and implementation of self-management support as one and the same on-going process, if we are to facilitate successful engagement and interest from healthcare professionals as well as their patients and families.

The Relationship Between Pedometer Feedback and Gait Speed Improvements in Acute Stroke Rehabilitation- Preliminary Results

The Relationship Between Pedometer Feedback and Gait Speed Improvements in Acute Stroke Rehabilitation- Preliminary Results

Relationship of Hopkins Rehabilitation Engagement Rating Scale to Baseline Cognition and FIM Change in Acute Inpatient Stroke Rehabilitation

Relationship of Hopkins Rehabilitation Engagement Rating Scale to Baseline Cognition and FIM Change in Acute Inpatient Stroke Rehabilitation

Early Sitting in Ischemic Stroke Patients (SEVEL): A Randomized Controlled Trial.

BackgroundExtended immobility has been associated with medical complications during hospitalization. However no clear recommendations are available for mobilization of ischemic stroke patients.ObjectiveAs early mobilization has been shown to be feasible and safe, we tested the hypothesis that early sitting could be beneficial to stroke patient outcome.MethodsThis prospective multicenter study tested two sitting procedures at the acute phase of ischemic stroke, in a randomized controlled fashion (clinicaltrials.org registration number NCT01573299). Patients were eligible if they were above 18 years of age and showed no sign of massive infarction or any contra-indication for sitting. In the early-sitting group, patients were seated out of bed at the earliest possible time but no later than one calendar day after stroke onset, whereas the progressively-sitting group was first seated out of bed on the third calendar day after stroke onset. Primary outcome measure was the proportion of patients with a modified Rankin score [0–2] at 3 months post stroke. Secondary outcome measures were a.) prevalence of medical complications, b.) length of hospital stay, and c.) tolerance to the procedure.ResultsOne hundred sixty seven patients were included in the study, of which 29 were excluded after randomization. Data from 138 patients, 63 in the early-sitting group and 75 in the progressively-sitting group were analyzed. There was no difference regarding outcome of people with stroke, with a proportion of Rankin [0–2] score at 3 months of 76.2% and 77.3% of patients in the early- and progressive-sitting groups, respectively (p = 0.52). There was also no difference between groups for secondary outcome measures, and the procedure was well tolerated in both arms.ConclusionDue to a slow enrollment, fewer patients than anticipated were available for analysis. As a result, we can only detect beneficial/detrimental effects of +/- 15% of the early sitting procedure on stroke outcome with a realized 37% power. However, enrollment was sufficient to rule out effect sizes greater than 25% with 80% power, indicating that early sitting is unlikely to have an extreme effect in either direction on stroke outcome. Additionally, we were not able to provide a blinded assessment of the primary outcome. Taking these limitations into account, our results may help guide the development of more effective acute stroke rehabilitation strategies, and the design of future acute stroke trials involving out of bed activities and other mobilization regimens.Trial RegistrationClinicalTrials.gov NCT01573299

Partial body weight support treadmill training speed influences paretic and non-paretic leg muscle activation, stride characteristics, and ratings of perceived exertion during acute stroke rehabilitation

BackgroundIntensive task-specific training is promoted as one approach for facilitating neural plastic brain changes and associated motor behavior gains following neurologic injury. Partial body weight support treadmill training (PBWSTT), is one task-specific approach frequently used to improve walking during the acute period of stroke recovery (<1month post infarct). However, only limited data have been published regarding the relationship between training parameters and physiologic demands during this early recovery phase. ObjectiveTo examine the impact of four walking speeds on stride characteristics, lower extremity muscle demands (both paretic and non-paretic), Borg ratings of perceived exertion (RPE), and blood pressure. DesignA prospective, repeated measures design was used. MethodsTen inpatients post unilateral stroke participated. Following three familiarization sessions, participants engaged in PBWSTT at four predetermined speeds (0.5, 1.0, 1.5 and 2.0mph) while bilateral electromyographic and stride characteristic data were recorded. RPE was evaluated immediately following each trial. ResultsStride length, cadence, and paretic single limb support increased with faster walking speeds (p⩽0.001), while non-paretic single limb support remained nearly constant. Faster walking resulted in greater peak and mean muscle activation in the paretic medial hamstrings, vastus lateralis and medial gastrocnemius, and non-paretic medial gastrocnemius (p⩽0.001). RPE also was greatest at the fastest compared to two slowest speeds (p<0.05). ConclusionsDuring the acute phase of stroke recovery, PBWSTT at the fastest speed (2.0mph) promoted practice of a more optimal gait pattern with greater intensity of effort as evidenced by the longer stride length, increased between-limb symmetry, greater muscle activation, and higher RPE compared to training at the slowest speeds.

Abstract TP149: Utilization of a Robotic Exoskeleton to Provide Increased Mass Practice for Gait Training and its Impact on Discharge Destination for Individuals With Acute Stroke

Introduction: Mass practice of task-specific activity, such as repeated stepping for gait retraining, is an integral part of acute stroke rehabilitation. New technologies including the use of a robotic exoskeleton (RE) have recently been introduced to the inpatient rehab facility (IRF). A RE can help skilled physical therapists (PT) provide repetitive stepping practice to patients who have had a stroke. Hypothesis: We hypothesize the use of a RE will enable PTs in an IRF to provide added stepping practice to their therapy program and influence discharge destination as compared to traditional treatment plans. Methods: Fifteen participants with acute stroke (&lt;6 months post, age 58±10; height 66±5in; 176±35lbs; LOS 29±7days) were recruited for RE gait training during inpatient rehabilitation in conjunction with traditional therapy. Participants ambulated in the RE over level surfaces with the assistance of a PT (minimum of 3 sessions in the RE). Participant inclusion requirements: medical clearance, upright standing tolerance (≥15 min), intact skin, and physically fit into the device. A matched sample of participants (n=15) was selected from a hospital database (matching criteria: length of stay, admission motor FIM, age, gender and affected side). The data was analyzed using independent sample and paired sample t-tests. Results: Participants in the RE group walked an average distance of 212 feet in traditional PT where gait training was provided and 551 feet in RE sessions (p=.033). Discharge destination for the RE group: 10 home; 3 subacute; 2 nursing facilty and for the matched sample: 13 home; 2 subacute. Motor FIM scores significantly increased from admission to discharge: RE group (p≤.001) and matched group (p≤.001). Motor FIM gain at discharge in the RE group significantly increased compared to the matched sample, 26.4±6.4 vs. 21.6±5.9, (p=0.044). Conclusions: This exploratory investigation demonstrated the RE provides increased dosing of gait training. Discharge destination was not notably impacted by method of gait training. Improvement of motor FIM scores in the RE group begins to demonstrate the impact of mass practice provided by the RE. Further research is needed to objectively explore the impact of RE on functional mobility and quality of life.

The evaluation tool to predict decreased exercise tolerance in elderly patients with chronic heart failure

Purpose: The purpose of this study is to clarify the effect of CHKB on the walking speed and knee function of stroke patients. Methods: Eleven stroke patients who could walk at least 50m without assistance participated. We used 2-D motion analysis tomeasurewalking speed andminimumkneeflexion angle at mid-stance on the hemiplegic side. The participants walked 10m under two conditions, with a hinged knee brace (KB) andwithCHKB.Themeasurement sequencewas determined randomly. We examined each condition twice, and investigated the average walking speed and minimum knee flexion angle at mid-stance on the hemiplegic side. Results: The average walking speed in the two condition was 0.78m/swithKBand 0.82m/swithCHKB.A significant difference was observed between KB and CHKB. Five of eleven participants hadwalking speed improvements of more than 10%with CHKB compared with KB. Seven participants had abnormal knee-patterns with KB; one had a stiff-knee pattern, two had a buckling-knee pattern and four had an extension-thrust pattern. In five of these seven participants, twowith a buckling-knee pattern and threewith an extensionthrust pattern, the abnormal knee motion was improved with CHKB. Conclusion(s): This study suggests that CHKB can improve walking speed and reduce abnormal knee patterns at mid-stance on the hemiplegic side in stroke patients. Implications: To improve walking speed and abnormal knee pattern,CHKBmight useful in cases ofmild hemiplegia. CHKB may promote acute stroke rehabilitation.

Overcoming practical challenges to conducting clinical research in the inpatient stroke rehabilitation setting

Background:There is a shortage of published empirical studies conducted in acute inpatient stroke rehabilitation, though such studies are greatly needed in order to shed light on the most efficacious inpatient stroke rehabilitation interventions. The inherent challenges of inpatient research may dissuade researchers from undertaking this important work.Objective:This paper describes our institution's experience devising practical solutions to research barriers in this setting.Method:Through concentrated efforts to overcome research barriers, such as by cultivating collaborative relationships and capitalizing on unanticipated benefits, we successfully facilitated conduct of five simultaneous inpatient stroke studies.Results:Tangible benefits realized include increased effectiveness of research participant identification and enrollment, novel collaborative projects, innovative clinical care initiatives, and enhanced emotional and practical support for patients and their families. We provide recommendations based on lessons learned during our experience, and discuss benefits of this collaboration for our research participants, clinical staff, and the research team.

Abstract W MP57: Effects of Wearable Robotic Training of Ankle and Mobility Rehabilitation in Acute Stroke

Background and Purpose: Stroke is the fourth leading cause of death in the US and is a leading cause of adult disability. It was reported that the first few months post stroke is critical in neural plasticity and motor recovery. Presently, effective treatment options for ankle impairment and mobility are limited, especially for in-bed acute stroke rehabilitation. In this study, wearable robotic training involving passive stretching and active movement training was investigated to determine its efficacy in improving stroke outcome. Methods: Eleven patients with acute stroke participated. This was completed in a clinical in-patient setting (45 min/session, 3~5х/week, total 18 session). Participants were aged 53.7±17.4 (mean±SD); robotic treatment was given averaged 40.5 days of stroke onset. They continued receiving standard inpatient physical therapy during the study. One way repeated measures ANOVA was used to compare clinical and biomechanical outcome measures across the repeated measures. Results: Preliminary results showed an improvement after the multiple sessions of training with F-M in LE increased from 14.8 ± 8.8 and 19.4 ± 8.2 (p&lt;.01), STREAM score in LE from 32.1±21.4 to 47.9±30.1 (p=.02), the BBS increased from 35.2±17.8 to 38.0±18.2. Ankle active range of motion (AROM) in dorsiflexion increased from -5.7 ± 7.2° to 2.3 ± 8.1°(p=.004), ankle passive ROM in dorsiflexion from 14.0 ± 7.1° to 19.9 ± 5.3° (p=.002). Dorsiflexor strength increased from 0 ± 2.2 N m before training to 2.4 ±3.5 N m after training (p=.003). Plantarflexor strength increased from 6.7±9.9 Nm, to 12.6 ± 11.4 Nm (p=.004). Other measures showed no significant improvements, such as 6MWT increased from 302.0 ± 416.4 and 540.6 ± 563.4 feet, the MAS of ankle was 2.2 ± 1.1 to 1.6 ± 1.2. Conclusions: The use of robotic device demonstrated improvements in selected outcome measures in hospital settings, and it was efficiently administer in the clinic. The results suggest that impaired lower limbs of acute stroke can respond to controlled stretching and movement training in terms of muscle biomechanical properties and improve lower extremity functional activities in acute rehabilitation.The limitation of this study was its small sample size and lack of a control group.

National Institutes of Health Stroke Scale (NIHSS) as An Early Predictor of Poststroke Dysphagia

BackgroundDespite the availability of multiple comprehensive screening methods to detect dysphagia during acute stroke care, consensus is lacking as to the best practice. Our previous study demonstrated favorable sensitivity of the Functional Independence Measure (FIM) compared with a bedside 3-sip test. However, the FIM is challenging to administer during acute stroke care. The National Institutes of Health Stroke Scale (NIHSS) is administered routinely in the emergency department. ObjectiveTo evaluate the utility of the NIHSS as a predictor of clinically relevant poststroke dysphagia compared with FIM data in the same cohort. DesignRetrospective analysis. SettingAcademic medical center. PatientsIndividuals with acute stroke who were admitted for acute care and later transferred to acute rehabilitation within the same institution. MethodsClinically relevant dysphagia was defined as aspiration on modified barium swallow or laryngeal penetration on modified barium swallow requiring diet change, or aspiration pneumonia. NIHSS and FIM scores were compiled for all patients. Main Outcome MeasurementsSensitivity, specificity, positive predictive value, and negative predictive value were calculated for NIHSS and FIM. Sensitivity and specificity of different values of NIHSS and FIM were analyzed via receiver operator characteristic curves. ResultsOf 290 patients admitted to acute stroke rehabilitation, 88 (30%) manifested clinically relevant dysphagia during their rehabilitation stay. Sensitivity analyses suggested cut-off values for the NIHSS and the FIM of >9 and <55, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value for the NIHSS were 75%, 62%, 46%, and 85%, respectively. For the FIM, these parameters were 80%, 72%, 55%, and 92%, respectively. ConclusionsThe NIHSS >9 and FIM <55 are moderately predictive of clinically relevant dysphagia. Although the NIHSS clinical test characteristics are not as favorable as the FIM, NIHSS appears to be more sensitive than some other reported methods such as a 3-sip water test. Further study into development of paradigms that incorporate NIHSS into initial assessment of dysphagia risk may be appropriate.

The future of stroke treatment: bringing evaluation of behavior back to stroke neurology.

Acute stoke interventions and stroke rehabilitation are aimed at salvaging or restoring brain function. How do we know if we have accomplished this goal? We examine the patient. One neurological historian asserted, “Most of the modern neurological examination evolved in a short time span, between 1850 and 1914 …”1. This quote is telling; it implies that the examination itself has not changed much since about 1900. For generations of medical students, residents, and other trainees in neurology, the neurological examination has achieved almost sacred, untouchable status, while at the same time becoming less important, as diagnostic technologies have become ever more sophisticated. Indeed, many of the examination's components have become almost empty ritual. Ask a resident what modern neuroscience has revealed about the mechanisms of, for example, increased tone, neglect, apraxia, and alexia, and how this new knowledge relates to the components of the neurological examination, or how the examination might be updated; you will likely be met with a blank stare. So ironically, even as cognitive neuroscience has advanced, the interest of neurologists in behavior in the broadest sense, and its underlying physiology and anatomy has waned. Thus, current stroke neurologists have largely failed to emphasize the evaluation of the effects of our interventions on brain function.