Assessment Of Stroke Patients Research Articles

Remote Assessment of Stroke Using the iPhone 4

Therapy with recombinant tissue plasminogen activator is underused in the treatment of ischemic stroke in rural hospitals, due to a lack of local stroke expertise. Telemedicine solutions for stroke are a level I, class A recommendation when a vascular neurologist is absent. However, current solutions require exorbitant startup costs, which are prohibitive for the rural hospitals in which they are needed most. This study demonstrates the efficacy of using the relatively inexpensive iPhone 4 in telestroke management. Twenty patients with stroke were assessed at the bedside using an iPhone 4, and each examination was directed remotely on another iPhone 4. Both the physician performing the bedside exam and the remote physician calculated a National Institutes of Health Stroke Scale (NIHSS) score for each patient. Each physician was blinded to the other's NIHSS score. In the 20 patients assessed, NIHSS scores ranged from 0 to 22. Interrater reliability assessed using the κ statistic demonstrated excellent agreement in 10 items (level of consciousness, month and age, visual fields, right motor arm, left motor arm, right motor leg, left motor leg, sensation, language, and neglect), moderate agreement in 3 items (gaze, facial palsy, and dysarthria), and poor agreement in 1 item (ataxia). Total NIHSS scores obtained remotely and at bedside showed an excellent level of agreement (intraclass correlation coefficient, 0.98). Our findings indicate that the iPhone 4 is an economical mobile solution that can be used to assess stroke patients remotely with high fidelity and can be readily incorporated into a telestroke network.

Emergency Department Nurses' Perceived Barriers and Facilitators to Caring for Stroke Patients

Stroke is currently the 3rd leading cause of death in the United States and is the leading cause of severe, long-term disability. With the advent of recombinant tissue plasminogen activator/alteplase, there is a treatment option for ischemic stroke. Unfortunately, only a small number of eligible patients receive this treatment. Whereas much research has been performed on barriers to treatment related to prehospital delays, less research has been performed on in-hospital delays related to hospital staff's perceptions of stroke patients. In this qualitative exploratory study, focus group interviews were conducted to examine emergency nurses' experiences in caring for stroke patients. A convenience sample was recruited using flyers distributed in the emergency department. Three groups of emergency nurses were interviewed in a private location within the facility. The 30-minute, semistructured interviews included 2 to 4 emergency nurses and were moderated by the investigator. Individual transcripts were analyzed for trends, patterns, and recurring themes. Three major themes regarding barriers to and facilitators of stroke care emerged: (a) nurses' comfort with assessment of stroke patients, (b) feedback regarding nurse performance and patient outcomes; and (c) environmental issues such as staffing, competing priorities, and patient and family needs. Despite the various challenges facing emergency nurses, all groups verbalized a desire to provide excellent care to these patients. Further research is recommended to address these challenges and to explore potential solutions identified in this study to improve the care of stroke patients.

The pivotal role of echocardiography in cardiac sources of embolism

Stroke is a leading cause of morbidity and mortality and is the third commonest cause of death in Europe. Clinical history examination and basic investigations including an electrocardiogram may shed light on the potential cardiac cause. Echocardiography plays a pivotal role in the assessment of embolic stroke. The hierarchy of echocardiography investigations begins with a standard transthoracic echocardiography study and may be proceeded by a bubble contrast transthoracic and a transoesophageal echo study. This article discusses the crucial role echocardiography has assumed in the assessment of stroke patients and describes the cardiac sources responsible.

Clinical effect of targeted assessment and intervention in patients with dysphagia

Objective To explore the effect of targeted assessment and intervention in acute stroke patients with dysphagia.Methods 101 cases of patients were randomly divided into two groups, the experimental group (n=51) and the control group (n=50). The control group was given conventional nursing. The experimental group was given improved swallowing test procedure, including assessment of swallowing function, water swallowing test and puree test. Therapy effect, occurrence of aspiration pneumonia and cases of gastric tube requirement were compared between the two groups.Results Compared with the control group, the swallowing capability of experimental group was improved(Z=4.433,P<0.01), and occurrence of aspiration pneumonia(χ2=5.156,P<0.05), cases of gastric tube requirement and duration of gastric tube retention was lowered(t=56.877,P<0.01). The differences were statistically significant.Conclusions Targeted assessment and intervention in acute stroke patients is superior to the conventional method. Key words: Deglutition disorders; Apoplexy; Nursing assessment

Evolution of Risk Evaluation and Mitigation Strategies and impetus for class wide opioid analgesic REMS

Risk factor management is the key to stroke prevention. Although several studies have assessed the awareness of different risk factors in the general public, there are limited data available on how well acute stroke patients know their own risk factors. The aim of this study was to assess stroke patients' informedness of their own stroke risk factors.All consecutive eligible acute stroke and transient ischemic attack patients hospitalized at the Tartu University Hospital, Department of Neurology, during 9 months in 2010 were interviewed about different stroke risk factors within 72 hours from hospitalization. The respective information was also retrieved from medical records.Of the 341 patients admitted during the study period, 195 were eligible for the interview. Diabetes was the best known risk factor (89%) followed by hypertension (80%), atrial fibrillation (78%), previous stroke (77%), and heart failure and/or ischemic heart disease (66%).We found that acute stroke patients are best informed of their diabetes and worst informed of their ischemic heart disease and/or heart failure. There is, however, room for amelioration in the awareness of all of the studied risk factors. More attention should be addressed to explaining the risks and treatment options to patients at risk of stroke and the general population.

Who Sees Visual Impairment Following Stroke?

Introduction: The aims of this survey were to determine the extent of orthoptic involvement in stroke services throughout the United Kingdom and what constitutes a vision assessment.Methods: A non-validated questionnaire was sent to 134 orthoptic departments in the United Kingdom asking information on stroke services in their trusts and provision of orthoptic input and vision assessments in these services.Results: A return rate of 42% was achieved. Sixty-two percent of departments were aware of adherence to the National Service Framework for Older Persons in their trusts and its section on stroke services. Fifty-five percent of trusts with stroke services confirmed that a vision assessment was provided by either orthoptists, occupational therapists, physicians, or nurses. Only orthoptic led screening provided quantitative assessment of visual acuity, ocular motility and visual fields.Conclusions: Forty-five percent of stroke services provided no formal vision assessment for stroke patients. Of those providing vision assessment, 15% were basic qualitative assessments.

Risk Scores for Predicting Post–thrombolysis Intracerebral Hemorrhage

Post-thrombolysis hemorrhage is a major concern for physicians treating acute ischemic stroke. Two scoring systems that incorporate factors associated with post-thrombolysis hemorrhage have been developed in an attempt to estimate the risk of developing post-thrombolysis hemorrhage among stroke patients. In this article we discuss these scoring systems and their utility in the clinical assessment of stroke patients.

Assessing stroke patients with the International Classification of Functioning, Disability and Health core sets

Objective To investigate the functional states of stroke patients using the International Classification of Functioning, Disability and Health (ICF) core sets for stroke. Methods Fifty in-patients with stroke participated in this study. Twenty-five patients less than one month after a stroke were assigned to the acute group, and another 25 patients with more than one month since their stroke were assigned to the sub-acute and chronic group. All the patients were assessed using the Glasgow coma scale, Rankin grading and the Barthel index. The ICF core set for stroke assessment was also used with both groups. The data was analyzed by using a Chi squared frequency test. Results Rankin grades and Barthel indices were significantly different between the two groups, and the functional states in the acute group were better than those in the sub-acute and chronic group. Some of the items, such as consciousness state, functions of structures adjoining the eyes, hearing, substitutive sound, accessory respiration, temperature regulation and protection function of the skin had no significant difference between the groups. The number of patients suffering from disorders of joint motion, joint stability, muscle endurance and control of voluntary movement was significantly greater in the sub-acute and chronic group than in the acute group. Both groups were influenced to different degrees by most of the environmental factors. Conclusion The ICF core sets correctly indicated joint motion, joint stability, muscle endurance and control of voluntary movement difficulties of stroke patients. Key words: International Classification of Functioning, Disability and Health; Stroke; Motor function

The effectiveness of interactive computer assisted instruction compared to videotaped instruction for teaching nurses to assess neurological function of stroke patients: A randomized controlled trial

Background Teaching inexperienced nurses to assess neurologic function of acute ischemic stroke patients poses challenges to educators in Taiwan. Objectives The purpose of this study was to examine the effectiveness of two programs that teach nurses the use of the Chinese version of the National Institute of Health Stroke Scale (C-NIHSS), and to evaluate the level of learner satisfaction with these teaching programs. Design An experimental research design with two groups, one pre-test and two post-tests was utilized. Setting Six neurology and neurosurgery wards at two hospitals in southern Taiwan. Participants Participating nurses were stratified based on their clinical level of experience and prior training on the National Institute of Health Stroke Scale (NIHSS). They were randomly assigned to either the experimental C-NIHSS interactive computer assisted instruction (ICAI) group ( n = 44) or the Instructor-led videotape learning program (IVLP) group ( n = 40) to learn the C-NIHSS. Methods The measurement tools included the score verification unit (SVU) (score range from 0 to 45, content validity index, CVI = 0.96, percentage agreement = 84%) and the learner satisfaction scale (CVI = 0.92, Cronbach's alpha = 0.97). Results Both groups’ scores on the assessment of correctness significantly increased ( F = 35.50, p = 0.00) after intervention. However, there was an insignificant difference between the changes in the two groups ( F = 0.02, p = 0.89). After using one-way ANCOVA analysis, and adjusting for the length of experience in neurological nursing, the results showed that in the second post-test, the ICAI group's score was significantly higher than that of the IVLP group ( F = 4.81, p = 0.03). There was a positive correlation between assessment correctness on the second post-test and length of experience in neurological nursing ( r = 0.35, p < 0.05). It was concluded that nurses with less experience in neurological nursing, who receive ICAI will perform a better assessment of stroke patients than those who received IVLP. Conclusion The C-NIHSS ICAI teaching program contributed to better assessment correctness after adjusting for the length of experience in neurological nursing, and to some extent increased satisfaction for the participating nurses. Therefore it is worth promoting the use of ICAI for in-service education of nurses, especially for nurses with less experience in neurological nursing, in order to enhance long-term effects of learning.

Validation of the use of the ROSIER stroke recognition instrument in an Irish emergency department

A study was performed to determine the utility of the 8-point recognition of stroke in the emergency room (ROSIER) instrument as a diagnostic tool in a large Irish emergency department. Fifty patients had ROSIER scores completed by doctors. Diagnoses achieved using the score were compared with discharge diagnoses. Relations between ROSIER score, impairment and length of stay were assessed. Forty-seven patients (94%) had a ROSIER Score > or =1 indicating a stroke, 44 (94%) of these had stroke confirmed on investigation. Two patients with stroke were missed and three were wrongly identified. Positive predictive value for the ROSIER was 94%. ROSIER correlated with Scandinavian neurological stroke score. (r = -0.414, p = 0.003) and was associated with increasing length of stay in survivors (p = 0.16, one-way ANOVA. F = 3.116, df = 6). The ROSIER is a suitable and useful adjunct in the assessment of stroke patients in Ireland.

Der WHODAS II in der Anwendung bei Schlaganfallpatienten und ihren Angehörigen: Reliabilität und Inter-Rater-Reliabilität

The WHODAS II (World Health Organization Disability Assessment Schedule II) is a questionnaire derived from the ICF classification system (International Classification of Functioning, Disability and Health) for the evaluation of disabilities and handicaps. Data on its validity and reliability with respect to the consequences of stroke are largely lacking. The present study aimed at measurements of reliability of the WHODAS II in its application to stroke patients and their closest others. Eighty-four patient-relative pairs were assessed six months after stroke with the self- and observer-rating versions. From the patients' and relatives' judgements, Cronbach's alpha was computed as measurement of internal consistency, intra-class correlation coefficients as measurements of the inter-rater reliability of subscales and total scores, and Spearman's rho (rho) for the inter-rater reliability for single items. In addition, the inter-rater correspondence was calculated as the percentage of responses. The internal consistency was found to be good to excellent (alpha=0.81-0.99) both for patients' and relatives' judgements. Inter-rater reliabilities ranged from satisfactory for the subscale Understanding and Communication to excellent for the total score (ICC 0.64-0.94). However, the inter-rater reliability of the items as well as their percental correspondence was hardly satisfactory, with few exceptions in the realms of Life Activities and Self-Care (rho=0.24-0.90 and percental correspondence 29.6%-75.7%). Our results demonstrate that the WHODAS II is a reliable instrument for the assessment of stroke patients, both as a self- and an observer-rating questionnaire. Whereas the correspondence between patient and relative may be disparate with respect to single items - especially those not directly observable -, subscale and total scores seem to allow predictions based on observer judgements. The assessment of stroke patients' disabilities and handicaps through relatives' judgements with the WHODAS II scales is reliable.

Risk Factors for and Correlates of Poststroke Depression Following Discontinuation of Antidepressants

Risk Factors for and Correlates of Poststroke Depression Following Discontinuation of Antidepressants

Clinical neuroimaging: a matter of biophysics and logistics

Technological and methodological developments in the area of molecular imaging are reshaping the role of the different imaging techniques in neurological disorders. Molecular imaging methods validated for research purposes are entering clinical practice, having been readapted to this end. These developments have led to the widespread use of magnetic resonance imaging (MRI) for the assessment of stroke patients, and single-photon emission computed tomography (SPECT) and positron emission tomography (PET) for the evaluation of patients with movement disorders or the various forms of dementia. As such consolidated techniques enter the clinical domain, new and more refined methods of analysis are being explored to make the available techniques more robust and amenable for clinical use. Furthermore, researchers are continuing in their quest for new, more specific and sensitive methods that will allow progressively more accurate and early diagnosis. A few papers in the recent literature serve as examples of the progress being made in the areas of stroke assessment, differential diagnosis of movement disorders and early diagnosis of neurodegenerative diseases.

Prognosis assessment in stroke patients at discharge from hospital

accurate prognostic assessments of need of help, health and dwelling situation in stroke patients are important for patient management, rehabilitation, discharge planning, and for providing reliable information to patients and their relatives. to analyse factors affecting the accuracy of discharge prognosis assessments. prospective study of stroke patients discharged from hospital. two cities in central Sweden. three hundred and ninety stroke patients, 65 years or older, living in their own homes and having no dementia diagnosis prior to hospital admission. at discharge, physicians, nurses, occupational therapists and physiotherapists in the Departments of Internal Medicine and Geriatrics were asked to make an individual prognosis assessment regarding patients' need for help, health and dwelling situation at 3 and 12 months after admission to hospital. the prognosis assessments were on average accurate in 68.4% (3 months) and 61.5% (12 months), far better than chance (33.3%). There were no significant differences between staff categories. The accuracy was influenced by a number of patient linked factors, such as activity degree, household situation before admission, and Mini Mental State Examination level and need of help measured 1 week after discharge, and ranged from 22 to 89%, depending on factor combinations. prognosis assessments based on clinical judgement were on average quite accurate but the accuracy varied markedly with patient linked factors. Feedback of outcome might be one way to further improve the accuracy of prognosis assessment.

Swallowing assessment for stroke patients

Swallowing assessment for stroke patients

Psychometric properties of the modified Emory Functional Ambulation Profile in stroke patients

Objective: To examine the test-retest reliability, convergent and predictive validity and responsiveness of the modified Emory Functional Ambulation Profile (mEFAP) in assessing gait function in stroke patients undergoing rehabilitation. Subjects: Forty subacute stroke inpatients were enrolled in the validity and responsiveness study. Twenty chronic patients participated in the reliability study. Setting: Rehabilitation department of a medical centre. Design: In the validity and responsiveness study, patients were tested using the mEFAP, 10-m walking speed test, Barthel Index and Rivermead Mobility Index at admission and at discharge. For the reliability study, the patients completed the mEFAP twice one week apart. Results: The patients' performances on the mEFAP were moderately to highly correlated with results of the 10-m walking speed test and Rivermead Mobility Index (absolute correlation coefficients ≥0.67), indicating good convergent validity. Patients' performance on the mEFAP at admission was moderately correlated with the Barthel Index and Rivermead Mobility Index scores at discharge (Spearman's rank correlation coefficients=-0.52 and-0.78, respectively), indicating good predictive validity. The standardized response mean of the mEFAP was 1.1 (P<0.0001), suggesting good responsiveness. The intraclass correlation coefficient ICC(3,1) for the mEFAP was 0.997, indicating excellent test-retest reliability. Conclusions: Our results provide strong evidence that the mEFAP has good reliability, validity and responsiveness for assessing stroke patients undergoing rehabilitation. The mEFAP is a useful scale for measuring walking function and recovery in stroke patients.

Matrix metalloproteinases and their inhibitors in different acute stroke subtypes

The aim of the study was to determine serum levels of selected matrix metalloproteinases (MMPs) and their natural inhibitors (TIMPs) in the acute phase of different stroke types subdivided according to the Oxfordshire Community Stroke Project (OCSP) classification and the possibility of discriminating stroke types according to their levels. The study included 126 patients with acute stroke within the first 24 h of symptom onset, and 124 healthy volunteers. The stroke group had lower MMP-2 concentrations and MMP-2/TIMP-2 ratios (p<0.001) but higher TIMP-2 (p<0.001) than controls. The level of MMP-9 and the MMP-9/TIMP-1 ratio were higher in patients with total anterior circulation infarct (TACI) than in patients with other stroke subtypes according to OCSP classification (p=0.0019, p=0.0065, respectively) or in controls (p<0.0001, p=0.0024, respectively). A negative correlation of MMP-2 levels with MMP-9 and MMP-9/TIMP-1 ratio was recorded in all stroke subtypes except for TACI. Receiver operating characteristic analysis showed similar discriminating power for MMP-9 levels and Barthel index in the differential diagnosis of TACI. High MMP-9/TIMP-1 ratio (odds ratio 3.263) was associated with TACI. Our results demonstrate that the MMP-9/TIMP-1 ratio may provide information to help in assessing stroke patients in the future as a baseline biomarker of infarct extent.

Inter-rater reliability of the Nottingham method of stereognosis assessment.

To investigate the inter-rater reliability of stereognosis assessment in stroke patients, as measured by the Nottingham Sensory Assessment (NSA). Twenty stroke patients consented to participate in the study. The subjects were aged between 40 and 93 years, and were no more than three months post stroke. The stereognostic ability of the subjects was assessed by two of three examiners within a 24-hour period. The method laid out by the NSA was followed throughout the study. Point to point agreement of scores and therefore reliability levels were assessed between examiners using the kappa coefficient of agreement. The majority of subjects (n = 13) were found to have impaired stereognosis on their affected side. A good level of reliability was found for the majority of items (n = 32), with kappa values being rated as substantial or higher for most of the objects tested. In eight cases the reliability was fair or moderate. These cases included the glass, biro and 10p coin when the affected side was assessed by examiners 1 and 2, and the pencil when the same side was assessed by examiners 1 and 3. These levels of reliability were acceptable, but were not as high as the researchers had hoped. It is concluded that the Nottingham method of stereognosis assessment is a reliable assessment tool between raters.

Relationships of Cognitive Performance and Daily Function of Clients following Right Hemisphere Stroke: Predictive and Ecological Validity of the LOTCA Battery

The purpose of this study was to determine the relationship of cognitive performance, as measured by the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) battery, to daily function in patients following right hemisphere stroke. Furthermore, to explore the predictive power of cognitive performance using the LOTCA at the first rehabilitative stage after stroke to long-term functional outcomes. The method was a longitudinal research design at 3 points in time: admission to rehabilitation; discharge from the rehabilitation hospital; and at follow-up, six months after discharge, which in some cases reached one year post onset. Subjects were 40 consecutive patient admissions to a rehabilitation hospital. All patients were right-handed adults with a CT-proven, first, single, right hemispheric stroke. Based on their total cutoff score in the Behavioral Inattention Test (BIT) for unilateral spatial neglect, patients were divided into 2 subgroups: 19 with neglect and 21 without neglect. Instruments included the LOTCA, the Functional Independence Measure (FIM), the Rabideau Kitchen Evaluation and Phone use. Results showed that right hemispheric stroke patients with unilateral spatial neglect performed at a lower level than patients without neglect on all measures of cognitive skills, as well as daily functional tasks as measured by the FIM and kitchen tasks. Differences were significant in all testing periods. Relationships between cognitive and functional measures showed that visuomotor organization and thinking operations correlated at moderate to high levels in both subgroups. The predictive results from admission to follow-up suggest that unilateral spatial neglect is the major predictor of activities of daily living (ADL) and instrumental activities of daily living (IADL) task performance, however cognitive skills, especially the more complex integrated visuomotor and thinking skills, were significantly related to functional outcomes in the non-neglect group. Thus, they are crucial in the assessment of stroke patients. The predictive and ecological validity of the LOTCA battery was supported.

Fear of falling in patients with stroke: a reliability study.

To examine the scaling properties and test-retest reliability of an expanded version of the Falls Efficacy Scale (FES) and to compare group differences in the scores. The expanded version focuses on more basic, primary activities of daily living (ADL), which makes the scale more suitable for subjects with moderate to low functional ability, e.g. patients with stroke. A test-retest reliability study with one group convenience sample. Two day-care units: a rehabilitation unit and a geriatric rehabilitation unit. A volunteer sample of 30 patients (mean age 65 years, SD 11 years) who had sustained stroke between 5 and 84 months prior to the investigation. A 13-activity questionnaire (the Swedish modification of the Falls Efficacy Scale (FES(S)) comprising the 10 activities of the original FES and three additional activities was used. Falls efficacy was rated on a 10-point visual analogue scale for each activity on two occasions, 5-22 (mean 10, Md 7) days apart. The overall test-retest reliability of the FES(S) was high (intraclass correlation coefficient (ICC) = 0.97). The ICC for the personal ADL (items 1-6) scores was 0.93 and for the instrumental ADL (items 8-13) 0.97. ICC for the individual items ranged from 0.76 to 0.97. On the basis of these preliminary findings, the FES(S) appears to have acceptable test-retest reliability. The test may be a reasonable addition for assessing stroke patients with balance disturbances and risk for falls.