Post-acute Stroke Research Articles

Weight-shift ability significantly correlates with walking velocity in post-acute stroke patients.

The ability to shift weight toward the paretic leg has been considered an essential ability to restore independent walking for post-acute stroke patients. However, few data are available regarding the relationship between the weight-shift ability and gait performance. No clear mechanism has been provided as to why and how the weight-shift ability improves walking performance in stroke patients. We therefore investigated changes in the weight-shift ability and kinematic and kinetic parameters of walking gait in post-stroke patients during rehabilitation. Eight male inpatients undergoing rehabilitation for moderate hemiplegia participated in this study. Measurements were taken every 4 weeks from when the participants were able to walk at least 10 m until they were discharged from the hospital. Our results demonstrated a significant overall correlation between the weight-shift ability and walking velocity, indicating that the improvement in the weight-shift ability toward the paretic leg by lateral tilting of the thorax is fundamentally important to improve walking velocity. We also found that the upward impulse and vertical ground reaction force exerted by the paretic leg were significantly correlated with the walking velocity to cope with the downward impulse due to gravity and to allow sufficient time to swing the non-paretic leg forward during walking. Therefore, improvement in the weight-shift ability is crucial for restoration of walking velocity. We believe that weight-shift training for the paretic leg while instructing the patients to laterally tilt the thorax should be advocated as an effective protocol during rehabilitation of post-acute stroke inpatients.

Hospital recruitment for a pragmatic cluster-randomized clinical trial: Lessons learned from the COMPASS study

BackgroundPragmatic randomized clinical trials are essential to determine the effectiveness of interventions in “real-world” clinical practice. These trials frequently use a cluster-randomized methodology, with randomization at the site level. Despite policymakers’ increased interest in supporting pragmatic randomized clinical trials, no studies to date have reported on the unique recruitment challenges faced by cluster-randomized pragmatic trials. We investigated key challenges and successful strategies for hospital recruitment in the Comprehensive Post-Acute Stroke Services (COMPASS) study.MethodsThe COMPASS study is designed to compare the effectiveness of the COMPASS model versus usual care in improving functional outcomes, reducing the numbers of hospital readmissions, and reducing caregiver strain for patients discharged home after stroke or transient ischemic attack. This model integrates early supported discharge planning with transitional care management, including nurse-led follow-up phone calls after 2, 30, and 60 days and an in-person clinic visit at 7–14 days involving a functional assessment and neurological examination. We present descriptive statistics of the characteristics of successfully recruited hospitals compared with all eligible hospitals, reasons for non-participation, and effective recruitment strategies.ResultsWe successfully recruited 41 (43%) of 95 eligible North Carolina hospitals. Leading, non-exclusive reasons for non-participation included: insufficient staff or financial resources (n = 33, 61%), lack of health system support (n = 16, 30%), and lack of support of individual decision-makers (n = 11, 20%). Successful recruitment strategies included: building and nurturing relationships, engaging team members and community partners with a diverse skill mix, identifying gatekeepers, finding mutually beneficial solutions, having a central institutional review board, sharing published pilot data, and integrating contracts and review board administrators.ConclusionsAlthough we incorporated strategies based on the best available evidence at the outset of the study, hospital recruitment required three times as much time and considerably more staff than anticipated. To reach our goal, we tailored strategies to individuals, hospitals, and health systems. Successful recruitment of a sufficient number and representative mix of hospitals requires considerable preparation, planning, and flexibility. Strategies presented here may assist future trial organizers in implementing cluster-randomized pragmatic trials.Trial registrationClinicaltrials.gov, NCT02588664. Registered on 23 October 2015.

Abstract TP169: Knowledge of Hypertension as a Stroke Risk Factor and Use of Home Blood Pressure Monitoring. A Preliminary Report From Comprehensive Post-Acute Stroke Services (COMPASS) Study

Background: Self-monitoring blood pressure (BP) among persons with hypertension is associated with lower BP. The prevalence of BP self-monitoring and factors that may predict this behavior in the early post-acute stroke setting are unknown. Our aim was to identify whether knowledge of high BP as a stroke risk factor, social support, or primary care visits would be independently associated with BP self-monitoring 30 days after discharge in stroke patients. Methods: We utilized data from consenting intervention participants in the Comprehensive Post-Acute Stroke Services (COMPASS) Study, who attended the post-discharge clinic visit, and had a 30-day follow-up call (N=528). The primary outcome was self-reported BP monitoring assessed at the 30-day call. The clinic visit included assessment of risk factor knowledge, social support and other clinical and neurological factors. Odds ratios were obtained using logistic mixed models that adjusted for confounders classified as demographic characteristics and clinical factors. Results: Among 528 patients (mean age 67 (SD=14), 50.9% female, 80.1% white), 435 (82%) reported self-monitored BP at 30 days. Fifty-seven percent of those who noted high BP as a stroke risk factor monitored BP vs 43% of those who did not acknowledge this risk factor. Knowledge of BP as risk factor was significantly associated with monitoring after adjustment for demographic, but not after adjustment for clinical factors (Table). Those with social support and recent PCP visits also had higher odds of self-monitoring than those without support or PCP visits, respectively, though estimates were highly imprecise. Conclusions: Among participants, acknowledging high BP is a stroke risk factor may lead to greater use of self-home BP monitoring at 30 days, although the magnitude of this effect is diminished when adjusted for having a history of hypertension. The COMPASS Study will determine whether BP self-monitoring leads to improved BP control at 90 days.

Abstract WMP110: Building Successful Hospital-Community Networks for Stroke Survivors and Their Family Caregivers

Introduction: Stroke patients, caregivers and providers are often frustrated by a lack of knowledge about community resources to optimize post-acute stroke care and recovery. To address this gap, an innovative model of care is being tested in the COMprehensive Post-Acute Stroke Services (COMPASS) Study, a PCORI-funded cluster-randomized pragmatic trial in North Carolina (NC). Hospital-based post-acute nurse care coordinators (PAC) and advanced practice providers partnered with community organizations to build 20 community resource networks (CRNs) providing transitional care to stroke survivors and caregivers. Community organizations include Area Agencies on Aging, Community Care of NC Community Pharmacy Enhanced Services Network, and NC Department of Health and Human Services. Methods: In May 2017, 337 members from 19 CRNs were surveyed to assess the utility of the CRNs and their impact on connecting survivors to community-based services. COMPASS team members, including PACs from all intervention hospitals and 36 community representatives from 17 CRNs responded (N=85, 25% response rate). Results: 80% of the PACs had contacted CRN members for help connecting patients to community-based services; 65% found the CRN very useful or useful. By working together hospital and community members felt their CRN was able to respond to stroke / TIA patients’ needs and problems: 30% to a great extent, 41% mostly, 9% sometimes, 11% a little, 10% not at all. In open-ended comments, streamlined referrals and partnerships with community pharmacists were identified as beneficial. Lack of transportation services in rural areas was a barrier. Some community service providers reported not being contacted again after the initial convening with the hospital. Conclusion: PACs were able to build local CRNs to integrate medical services with community-based services as a strategy for addressing functional and social determinants of health. The majority reported that working with their CRN helped them optimize patients’ recovery after stroke. Future analyses will assess patient utilization of recommended community services. A quality metric assessing hospital-community partnerships may help solidify significance of this important and often overlooked part of care.

Abstract 26: Disparities in Post-Acute Stroke Rehabilitation Services Delivery: Preliminary Findings From the COMprehensive Post-Acute Stroke Services (COMPASS) Study

Background: Timely rehabilitation after stroke is essential for optimizing recovery. Patients discharged home can experience unnecessary service delays and gaps in care. Our aim was to examine sociodemographic characteristics associated with receipt of rehabilitation services within 30 days after discharge home in stroke or transient ischemic attack (TIA) patients. Methods: COMPASS is a cluster-randomized pragmatic trial measuring the effectiveness of the COMPASS model of care vs. usual care on functional status 90 days after stroke or TIA for patients discharged home. We analyzed data from 369 participants who enrolled in the intervention arm of the COMPASS trial, completed the post-acute clinic visit within 14 days, and the 30-day call between July 2016 and May 15, 2017. For those who were referred to rehabilitation services at hospital discharge or at the clinic visit, receipt of home health (HH) and outpatient (OP) rehabilitation services was reported by the participant during the 30-day call. Sociodemographic differences between those who did and did not receive these services were evaluated. We computed adjusted odds ratios with 95% confidence intervals using logistic regression to identify factors associated with receipt of rehabilitation services. Results: Of the 369 patients, 176 (47.7%) had ascertainment of receipt of services. Of the 115 patients referred to HH, 50 (43.5%) received it, and of 85 patients referred to OP therapy, 29 (34.1%) received it. There were no statistically significant differences in sociodemographic characteristics related to receipt of HH, but non-whites were less likely (3 of 20, or 15%) than whites (25 of 64, 34.9%) to receive OP therapy. After adjustment for NIHSS, ambulatory status at hospital admission, and age, non-white participants had a 78% decreased odds (OR 0.22; 95% CI 0.05, 0.95; p=0.04) of receiving OP therapy. Conclusion: These findings indicate that a significant gap exists between referral to and receipt of recommended post-acute stroke rehabilitation services. In addition, despite the small sample size, our results suggest that there may be a disparity in receipt of OP therapy for non-white patients relative to white patients.

Abstract WP304: Clinician-User Satisfaction With Compass-cp for Stroke

Introduction: COMPASS-CP is a patient-centered electronic application that includes real-time, patient-reported measures of functional and social determinants of health (PROMs). Algorithms assess PROMS and immediately generate actionable, individualized care plans. Algorithms may also trigger a caregiver assessment. COMPASS-CP identifies relevant local community resources tailored to the needs identified on the care plan. COMPASS-CP is administered by a nurse during a 7 to 14 day post-stroke transitional care clinic visit which meets CMS requirements for transitional care management codes. COMPASS-CP is being evaluated in a PCORI-funded pragmatic trial of COMprehensive Post-Acute Stroke Services (COMPASS). Scalability and sustainability of COMPASS-CP will require high user satisfaction. The purpose of this study was to evaluate clinician/user satisfaction with the COMPASS-CP application. Methods: We surveyed 56 clinicians (nurses, NPs or PAs) from 20 hospitals utilizing COMPASS-CP to assess satisfaction with the application in (1) efficiency in care plan development, (2) identifying factors impacting patient self-management and caregiver needs, (3) patient/provider communication, (4) patient/caregiver engagement, and (5) patient satisfaction with care. Clinicians rated their satisfaction on a 5-point Likert scale as either Strongly Agree , Agree , Neither Agree Nor Disagree , Disagree , Strongly Disagree . Results: Forty-four clinicians (79%) from 19 hospitals (95%) responded. Thirty-nine responders (89%) had used COMPASS-CP for 3 months or more. Conclusions: Successful implementation of electronic applications requires high levels of clinician/user satisfaction. The majority (66 %) of users agreed that they were satisfied with the COMPASS-CP application and 58% reported it made their job easier. Future analyses will determine if individualized care plans improve patient satisfaction and outcomes.

Potential link between post-acute ischemic stroke exposure to hypoglycemia and hemorrhagic transformation.

Hemorrhagic transformation is a severe complication of acute ischemic stroke owing to its limited treatment options and poor prognosis. In the last decade, the rates of hemorrhagic transformation incidence have been associated with blood glucose levels. In particular, hyperglycemia at the time of admission has been associated with increased rates of hemorrhagic transformation in acute ischemic stroke patients. Recent pilot clinical trials have attempted to use intensive insulin therapy during stroke treatment to reduce the severity of cerebral infarction and possibly alleviate the risk of hemorrhagic transformation. However, the results of these studies have shown no clear clinical benefit. In addition, intensive insulin therapy has increased rates of hypoglycemia which may be associated with larger infarct growth. We hypothesize that hypoglycemia, similarly to hyperglycemia, is a risk factor for worse outcomes in acute ischemic stroke by promoting hemorrhagic transformation. This review serves to call attention to patterns present within intensive insulin therapy trials and shed light into the pathophysiological effects of hypoglycemia. It is critical that efforts be directed toward the prevention of hemorrhagic transformation by optimizing insulin therapy during the treatment of acute ischemic stroke.

Acute Poststroke Depression Is Associated with Thalamic Lesions and Clinical Outcomes: A Case–Control Study

We investigated the role of acute-phase stroke lesions and patient characteristics in poststroke depression (PSD) and its effect on the clinical outcome. Five and 30 days after admission, 175 patients self-reported their depressive symptoms on the Patient Health Questionnaire-9. We compared the clinical characteristics and outcomes in patients with (n = 41) and without PSD (n = 134). Stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS); the modified Rankin Scale (mRS) was used to determine the functional outcome. There was no significant difference between patients with and without PSD in the age, gender ratio, lesion side, and the history of hypertension, diabetes mellitus, alcohol and tobacco use, and previous stroke. Thalamic lesions were significantly associated with PSD (P = .03), although there was no significant difference in both the NIHSS score and the final mRS score of patients with thalamic lesions. Backward stepwise logistic regression analysis showed that a higher NIHSS score and thalamic lesions were independent predictors of PSD. Total hospitalization was significantly longer in patients with PSD. At the time of admission, the NIHSS score was significantly higher in patients who developed moderate to severe PSD than in those with mild PSD or without PSD. PSD in the acute phase was associated with thalamic lesions and severe stroke. Hospitalization was significantly longer in patients with PSD and their functional disability was more severe, suggesting that PSD played a role in the unsatisfactory results of poststroke rehabilitation.

Race and Post-acute Stroke Recovery: More Similarities than Differences

Race and Post-acute Stroke Recovery: More Similarities than Differences

Three years of the nationwide post-acute stroke care program in Taiwan

Prolonged hospital stay and readmission are prevalent problems for stroke patients in Taiwan after the acute stage, partly due to the unmet need of post-acute care. In March 2014, Taiwan's National Health Insurance Administration launched a nationwide Post-Acute Care-CerebroVascular Disease (PAC-CVD) program. The Taiwan Stroke Society, coordinating 11 allied disciplines, took responsibility for the preparation and implementation of the program. As of June 2016, 6839 consecutive stroke patients were enrolled. On discharge from the PAC program, the functional status had improved in 87.5% of patients, with a significant decrease in the mean modified Rankin Scale score from 3.7 to 3.0. The rates of readmission and mortality in the PAC group were also lower than in the control group. In conclusion, the Taiwan's PAC-CVD program is an innovative and essentially effective national program of post-acute stroke care. We believe such experience should be helpful for policy makers of stroke care worldwide.

Difference in coagulation markers in acute and one year post acute ischemic stroke

Difference in coagulation markers in acute and one year post acute ischemic stroke

P 66 Transcranial DC stimulation enhances recovery of swallowing function after stroke – a randomized clinical and MEG trial

Introduction Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation tool that has shown some potential to aid motor rehabilitation following stroke. In the present clinical and neuroimaging study we evaluated whether tDCS is able to speed up the recovery of swallowing function in acute dysphagic stroke patients. Besides relating clinical effects with neuroplastic changes in cortical swallowing processing we aimed to identify factors influencing treatment success. Material and methods In this single-center, double-blind, randomized study (NCT01970384), 60 acute dysphagic stroke patients received anodal tDCS (20 min, 1 mA) or sham stimulation over the contralesional swallowing motor cortex on four consecutive days. If the patient’s condition allowed it, swallowing exercises were performed during stimulation. Swallowing function was thoroughly assessed before and after the study intervention using the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS), the dysphagia limit swallow test and two clinical scores, the Dysphagia Severity Rating Scale (DSR) and the Functional Oral Intake Scale (FOIS). In 15 patients, cortical swallowing-associated activation could be recorded during a volitional swallowing task applying 270-channel whole-head MEG before and after the treatment intervention. Results 59 patients completed the study. One patient suffered from recurrent stroke during the study period and was therefore excluded. Study groups did not differ according to demographic data or stroke characteristics. Time from admission to study intervention was 116 h in mean in both groups. Baseline FEDSS, FOIS, DSR and dysphagia limit were comparable. Following stimulation, patients from the treatment group showed significantly greater improvement in FEDSS (1.3 vs 0.4 points, p When looking for indicators of treatment success in the stimulation group only, there was a trend towards a greater improvement of all assessed swallowing scores with early treatment initiation (p Discussion According to our clinical and neurophysiological data, application of tDCS over the contralesional swallowing motor cortex supports cortical swallowing network reorganization, thereby leading to faster rehabilitation of acute post stroke dysphagia. The positive effect was independent of patient age and stroke characteristics, suggesting tDCS as a suitable treatment option for a broad patient population. Early treatment initiation within the suspected time window of maximum neuroplasticity after stroke seems to be beneficial.

The Safety of Carotid Artery Stenting for Patients in the Acute Poststroke Phase

The efficacy of carotid artery stenting (CAS) for patients in the acute poststroke phase has not been established. We investigated the outcome of CAS for patients with symptomatic internal carotid artery (ICA) stenosis in the acute poststroke phase. We performed a retrospective analysis of all patients who underwent CAS for symptomatic ICA stenosis in our institution. Patients in whom the time interval between neurological deterioration and the CAS procedure was less than 3 days were included in the early group, and the other patients were included in the delayed group. Perioperative complications including major adverse events (MAEs) were compared between the early and the delayed groups. One hundred five patients were included in the study. Forty patients were assigned to the early group and 65 patients were assigned to the delayed group. The overall MAE rate was 4.8%. There was no significant increase in the perioperative MAE in the early group compared with the delayed group (early group 2.5% versus delayed group 6.5%, P = .65). In the early group, 25 of 40 patients (62.5%) were functionally independent (modified Rankin scale [mRS] score of 0-2) at discharge. Significant differences between the independent patients and the disabled patients (mRS score of 3-6) included age (independent 72 versus disabled 79, P < .01) and prevalence of transient ischemic attack (36.0% versus .0%, P = .02). CAS performed within 3 days from the last ischemic event did not increase the risk of perioperative complication. Early CAS may be a useful option for the treatment of symptomatic carotid artery stenosis.

Responsiveness of the functioning and disability parts of the International Classification of Functioning, Disability, and Health core sets in postacute stroke patients.

To study the responsiveness of the International Classification of Functioning, Disability, and Health (ICF) core set with respect to human functioning and disability in stroke patients. Postacute stroke patients who were admitted to the convalescent rehabilitation wards were included in this observational cohort study. The comprehensive ICF core set for neurological conditions for postacute care and the ICF rehabilitation set were evaluated at admission and discharge using five-grade qualifiers. Extension indexes were calculated for entire two ICF core sets. Responsiveness was measured as change in the extension indexes in the ICF core sets. The correlation between changes in ICF core sets and improvement in the Functional Independence Measure (FIM) was analyzed using Spearman's correlation coefficient. The study included 108 poststroke patients (49 women, mean age 70.8 years, mean FIM score improvement: 23.0). The mean percentage of categories that showed changes with at least one qualifier level was 19.5% in the comprehensive ICF core set for neurological conditions for postacute care and 35.9% in the ICF rehabilitation set. Effect sizes in each ICF core set were moderate to large (0.79-0.80). Improvement in the two ICF core sets correlated significantly with changes in the FIM score. Our results indicate that functioning and disability parts of these two ICF core sets can detect changes in functioning and disability in patients who receive an inpatient rehabilitation program for postacute stroke.

SUN-P036: Association of Oral Status with Sarcopenia and Malnutrition in Post-Acute Stroke Patients: Implications for Oral Sarcopenia

SUN-P036: Association of Oral Status with Sarcopenia and Malnutrition in Post-Acute Stroke Patients: Implications for Oral Sarcopenia

Assessment Model to Identify Patients With Stroke With a High Possibility of Discharge to Home: A Retrospective Cohort Study.

Discharge planning for inpatients with acute stroke can enhance reasonable use of healthcare resources, as well as improve clinical outcomes and decrease financial burden of patients. Especially, prediction for discharge destination is crucial for discharge planning. This study aimed to develop an assessment model to identify patients with a high possibility of discharge to home after an acute stroke. We reviewed the electronic medical records of 3200 patients with acute stroke who were admitted to a stroke center in Japan between January 1, 2011, and December 31, 2015. The outcome variable was the discharge destination of postacute stroke patients. The predictive variables were identified through logistic regression analysis. Data were divided into 2 data sets: the learning data set (n=2240) for developing the instrument and the test data set (n=960) for evaluating the predictive capability of the model. In all, 1548 (48%) patients were discharged to their homes. Multiple logistic regression analysis identified 5 predictive variables for discharge to home: living situation, type of stroke, functional independence measure motor score on admission, functional independence measure cognitive score on admission, and paresis. The assessment model showed a sensitivity of 85.0% and a specificity of 75.3% with an area under the curve equal to 0.88 (95% confidence interval, 0.86-0.89) when the cutoff point was 10. On evaluating the predictive capabilities, the model showed a sensitivity of 88.0% and a specificity of 68.7% with an area under the curve equal to 0.87 (95% confidence interval, 0.85-0.89). We have developed an assessment model for identifying patients with a high possibility of being discharged to their homes after an acute stroke. This model would be useful for health professionals to adequately plan patients' discharge soon after their admission.

Having More Daughters Independently Predicts Home Discharge in Stroke Patients Admitted to Inpatient Rehabilitation Ward

Summary Background The predictors for failure of home discharge after post-acute inpatient stroke rehabilitation need investigation. Methods With this retrospective case-control study conducted in a stroke rehabilitation unit in one tertiary hospital, data of 297 eligible stroke patients regarding patient demographics, family information, disease and function were collected. The primary outcome was failure of home discharge. Results One hundred and eighteen of 297 stroke patients (mean age 63 years, 37% women) failed to discharge home, including 109 admitted to rehabilitation hospitals and 9 to long-term care facilities. An inverse trend existed between numbers of daughters and the risk of failure of home discharge: having three or more daughters significantly lowers the risks for poor discharge destination (adjusted odds ratio, 0.23, 95% confidence interval, 0.07–0.72; test for trend, p = 0.002). Conclusion Having more daughters independently predicts home discharge after post-acute inpatient stroke rehabilitation.

Where to now? AVERT answered an important question, but raised many more.

A Very Early Rehabilitation Trial (AVERT) was a Phase 3 randomized trial with over 2100 subjects post stroke that had unexpected results with better outcomes for usual care than those receiving very early mobilization. This review of published stroke clinical practice guidelines highlights that recommendations for mobilization have changed after publication of AVERT but also that developers have struggled to provide recommendations for appropriate dose, duration and intensity of mobilization in the acute post stroke period with available analyses from AVERT and other literature. This review highlights the priority research questions about early rehabilitation post stroke that need to be addressed through future large scale randomized controlled trials.

Dukungan keluarga dan kualitas hidup bagi penderita stroke pada fase pasca akut di Kabupaten Wonogiri

Family support and quality of life for stroke patients in the post-acute phase of WonogiriPurposeThis research aimed to determine the relationship of family support such as emotional, information, instrumental and reward with the quality of stroke patients in the post-acute phase in Wonogiri.MethodsA cross-sectional study was conducted involving interviews and the use of medical record data of 161 post-acute stroke patients in Wonogiri.ResultsThis study showed that there was a significant correlation of information support (p= 0.000), and awareness support (p=0.000) with the quality of life of post-acute stroke patients. ConclusionThe study confirms the importance of family support in terms of information support and awards support to the quality of life of patients with post-acute stroke.

Accelerometer-Determined Physical Activity and All-Cause Mortality in a National Prospective Cohort Study of Adults Post-Acute Stroke.

No epidemiological study has examined the association of objectively measured physical activity with all-cause mortality among adults who have had a stroke, which was the purpose of this study. Prospective. National Health and Nutrition Examination Survey 2003 to 2006. One hundred eighty-four patients with stroke. Physical activity assessed via accelerometry (ActiGraph 7164), with stroke assessed via self-report of physician diagnosis. Mortality was assessed via linkage with the National Death Index, with follow-up through 2011. Cox proportional hazard model. The median follow-up period was 71.96 months, with 13 241 person-months; 53 deaths occurred during this follow-up period. After adjustments, for every 60 min/d increase in total physical activity, adults who have had a stroke had a 28% (hazard ratio = 0.72; 95% confidence interval: 0.59-0.88) reduced risk of all-cause mortality. Physical activity among stroke survivors is inversely associated with all-cause mortality.