post-CVA Patients Research Articles

Assessment of diabetes as a risk factor for neurogenic dysphagia confirmed by FEES examination in post-CVA patients

IntroductionDiabetes mellitus (DM) is an independent factor for the occurrence of neurogenic dysphagia following an acute cerebrovascular accident in the form of a stroke. This study assesses the role of DM as a risk factor for post-stroke dysphagia (PSD), confirmed by the fiberoptic endoscopic examination of swallowing (FEES) with particular emphasis on silent aspiration (SA) as a high risk factor of aspiration pneumonia (AP).AimThe aim of the study is to assess the role of DM as a risk factor for PSD.Material and methodsStatistical analysis was performed on the cohort of 81 post-cerebrovascular-accident patients hospitalized in the neurological rehabilitation department. DM was diagnosed in more than one third of the cohort (35.8%). After the FEES examination, which was assessed in the penetration–aspiration scale (PAS), an analysis of DM incidence was performed in patients with diagnosed pharyngeal dysphagia of moderate degree (PAS 3–6) and severe degree (PAS 7–8).Results and discussionThe incidence of DM in patients with moderate dysphagia was lower than in the cohort. The incidence of DM in patients with severe dysphagia (aspiration) was comparable to the percentage in the cohort. Although diabetes was twice as frequent among patients with aspiration than among those with mild dysphagia (24% vs. 12%), the odds ratio (OR) of the diabetes incidence in these groups was not statistically significant.ConclusionsAlthough DM is an independent factor for PSD occurrence after cerebrovascular accident in the form of a stroke and a potential factor for lower cranial nerve neuropathy, no correlation between DM and PSD was found.

Evaluation of Language in Post-CVA Patients: A Clinicophonological Study

Evaluation of Language in Post-CVA Patients: A Clinicophonological Study

Efeitos do uso do Kinesio® Taping na marcha de indivíduos pós-acidente vascular encefálico: uma revisão sistemática com metanálise

RESUMO O Kinesio® Taping (KT) vem sendo utilizado na reabilitação de pacientes pós-acidente vascular encefálico (AVE) e vários estudos recentes têm investigado seus efeitos na marcha destes indivíduos, reportando resultados promissores. Investigou-se, por meio de uma revisão sistemática da literatura, os efeitos do uso do KT na marcha de indivíduos pós-AVE. As buscas foram realizadas nas bases de dados MEDLINE, CINAHL, SPORTDiscus, Web of Science, LILACS e PEDro, sem restrição de data ou idioma de publicação. Os artigos foram selecionados de forma independente por dois avaliadores e discordâncias foram resolvidas por um terceiro. A qualidade metodológica foi avaliada de acordo com a escala PEDro. Quando possível, as medidas de desfecho foram analisadas utilizando o programa Comprehensive Meta-Analysis, Versão 3.0. Foram incluídos quinze estudos de qualidade metodológica baixa a moderada (média de 4,7). Para velocidade de marcha, foram incluídos na metanálise sete estudos de qualidade metodológica baixa a moderada que, sob o modelo de efeitos fixos, encontrou que o KT aumentou significativamente a velocidade de marcha dos indivíduos pós-AVE em 0,05 m/s (95% IC 0,002 a 0,100; I2 = 0%; p<0.05). No entanto, para o comprimento do passo, mobilidade funcional e equilíbrio não houve diferença significativa (p>0,05). Esta revisão sistemática da literatura demonstrou que ainda não existem evidências sobre o uso do KT na reabilitação de pacientes pós-AVE com o objetivo de melhorar a marcha. Embora a velocidade de marcha, segundo a metanálise, tenha apresentado um ganho estatisticamente significativo, seu valor não pode ser considerado clinicamente relevante para os pacientes.

Abstract P261: The Effectiveness of the “InSTROKEtional” Module in Increasing the Level of Knowledge of Primary Caregivers of Postcerebrovascular Accident Patients for Home Care Management

Cerebrovascular Accident (CVA) is a major cause of disability which afflicts a great number of Filipinos yearly. Disability often leads to inability to perform activities of daily living resulting to the need for caregivers for assistance. However, not all caregivers are knowledgeable enough about CVA. As nurses, providing care includes educating the client and caregiver about CVA and its management. Therefore, in order to facilitate effective home care management, informational materials must be provided to ensure quality care. This led to the development of the “InSTROKEtional” module to increase the level of knowledge of caregivers on CVA and its management. The study utilized a quasi-experimental quantitative research that followed pretest-posttest design. The design was used to evaluate the effectiveness of the “InSTROKEtional” module in increasing the level of knowledge of primary caregivers of post-CVA patients. A non-probability, convenience sampling design was used to gather participants consisting of fifteen (15) caregivers of post-CVA patients from hospitals in the Philippines. The caregivers were subjected to a pretest to measure their level of knowledge prior to the implementation of the “InSTROKEtional” module. After a five day interval, the participants were given a posttest to determine the change in their level of knowledge about CVA. The mean scores of the pretest taken by the caregivers was 11.87 while the mean score for the posttest was 16.73. The results showed that the module was effective in providing the caregivers additional information about CVA. Therefore, the “InSTROKEtional” module is an effective intervention in increasing the level of knowledge of primary caregivers of post-CVA clients as seen by the significant difference between the pretest and posttest scores.

Comparison of psychological symptoms in post-cryptogenic cerebral-vascular accident (CVA) and/or transient ischemic attack (TIA) patients who have undergone foramen ovale closure, and in post-CVA patients

The patent foramen ovale (PFO) is a controversial risk factor for CVA or TIA. In our center, adult PFO patients diagnosed with post cryptogenic CVA/TIA undergo trans-catheter closure of the PFO to decrease the risk of recurrent stroke. The aim of the study was to compare levels of functioning, depression and anxiety in post PFO closure patients following cryptogenic CVA/TIA and in other patients post CVA/TIA without PFO. Eighty-nine patients who had undergone trans-catheter PFO closure and 56 non-PFO post-CVA patients completed demographic, functioning, anxiety and depression questionnaires. Additional medical data were recorded from the medical files. Patients who had undergone trans-catheter PFO closure post CVA or TIA reported better level of functioning and substantially lower levels of depression and anxiety. The 70% of depression and 55% of anxiety variances were explained by female gender, older age, lower education, lower functioning level and additional health problems. Functioning level was the strongest contributor to the explained variance of psychological symptoms. We conclude that patients who have undergone trans-catheter PFO closure following cryptogenic CVA/TIA, which may prevent stroke recurrence, show good functioning and low levels of psychological symptoms. The procedure helps to keep these patients in a good physical and psychological health.

Effect of Age, Sex, and Timing on Correction of Spastic Equinovarus following Cerebrovascular Accident

Spastic equinovarus (SEV) is the most common leg deformity after cerebrovascular accident (CVA). This study reviewed functional outcomes after surgical correction of SEV in a cohort of hemiplegic, post-CVA patients. Sixty-four consecutive post-CVA SEV patients who underwent surgical correction from January 2003 to January 2006 were included. Data parameters included age, sex, duration since CVA, preoperative orthotic and ambulatory requirements, and Viosca ambulation scores. There were 45 females and 19 males. Average age was 54 (range, 24 to 74) years. Average duration from CVA to surgery was 66 (range, 17 to 523) months. Mean followup was 50.1 (range, 12 to 168) weeks. Final outcomes included status of correction, bracing needs, use of assistive devices, and Viosca score. Univariate and multivariate statistical analyses were performed to determine if age, sex, and time from CVA to surgery affected outcome. All feet were corrected to plantigrade position. Of the 48 patients who used orthoses preoperatively, 27 (56%) continued use while 11 (44%) were brace-free postoperatively. Of the 23 patients that used an ambulatory assistive device preoperatively, 12 (52%) continued use and 11 (47.8%) were free of assistive devices postoperatively. Median Viosca score improved from two (Independent Household Ambulation) to three (Independent Neighborhood Ambulation) (p < 0.001). There was no statistical association between age, sex, CVA chronicity and outcome parameters. These results indicate that surgical correction of SEV is effective in post-CVA patients. Patients demonstrated improvement in ambulation score regardless of age, sex, or duration from CVA to surgery.

Music Therapy in Mobility Training With the Elderly: A Review of Current Research

It has been our clinical observation for several years that music therapy techniques, which were initially designed to address socioemotional needs, elicited motor responses in neurologically impaired clients not readily accessible to other forms of therapy. Over the past 8 years we have conducted a series of experiments to better understand the role of music therapy in motor rehabilitation. Our research is concentrated on auditory rhythm as a sensory stimulus to facilitate gait and arm movement patterns in patients with a variety of movement disorders. Our studies have focused primarily on mechanisms in rhythm perception and rhythm production in order to be able to assess the effect of auditory rhythm on the organization and guidance of movement. We believe that among all musical elements utilized in music therapy and motor rehabilitation, rhythm has the most promising cognitive and physiological attributes and can influence motor control substantially. For example, auditory rhythm may be a useful stimulus because of the speed and high resolution in time and synchronization processing in the auditory system and also the existence of auditory-motor arousal circuitry at the reticulo-spinal level. Conceptually our work has been based on an oscillator-entrainment model in which the perception of rhythmic stimuli in the auditory system entrains movement frequency and stability in neural motor networks. In order to evaluate the effect of rhythm on motor facilitation, we first studied the effect of rhythmic cuing on stride and muscle activation patterns through use of electromyography (EMG) in the gait of normal individuals (Thaut, Mclntosh, Rice, & Prassas, 1992a). © 1999 Springer Publishing Company We found improvement in stride parameters, especially symmetry, and EMG patterns, particularly the amplitude variability in muscle contractions across the stride cycle. Similar results were seen when we applied rhythmic cues to individual patients with stroke, cerebellar, and transverse myelitis (Thaut, Mclntosh, Prassas, & Rice, 1992b). Based on these encouraging observations we began to study rhythmic auditory stimulation (RAS) as a potential therapeutic measure in neurologic rehabilitation. Since then, we have conducted 3 studies on persons with stroke, 3 on persons with Parkinson's Disease (PD), 1 study on persons with traumatic brain injury (TBI), and 1 on persons with Huntington's Disease (HD). Studies with PD patients and cerebral palsy children are currently under way. RAS IN MOBILITY AND ARM TRAINING FOR POST CVA PATIENTS We first explored the immediate effect of rhythm on gait ability in stroke patients. In a rehabilitation study with 10 hemispheric stroke patients who were post-CVAfrom 4 weeks to 24 months, we matched the beat frequency of musical 'on'-beats to the step rate of the patients (Thaut, Mclntosh, Rice, & Prassas, 1993). Five of the subjects had either thrombotic or hemorrhagic lesions affecting the right cerebral hemisphere, and five had lesions affecting the left cerebral hemisphere, typically in a middle cerebral artery distribution. Patients walked for six meters at free speed to determine their baseline walking ability. During the second walk RAS was matched to their baseline step rate (cadence) to determine if immediate entrainment effects would occur without interference from practice. The same trial was repeated three times with each trial spaced a week apart. Results from this study showed that most patients were clearly able to synchronize their step times to the rhythm. In the course of synchronizing their gait movements to the rhythm, stride time symmetry, as well as stride length symmetry improved significantly, as did weight bearing time on the paretic side (p

Reassessing the Role of Urodynamics after Cerebrovascular Accident

Background and Purpose: To determine whether there is a gender difference in the need for urodynamics in the evaluation of urinary incontinence after cerebrovascular accident (CVA). Materials and Methods: We studied 72 consecutive post-CVA patients with new onset urinary incontinence documented by the patients or the persons who looked after them. Patients were evaluated between 4 and 6 weeks after their CVA and all had negative urine cultures and a postvoid residual urine determination. Exclusion criteria included narrow angle glaucoma, postvoid residual urine greater than 100 cm³ and radiographic evidence for a brainstem infarct. This left 30 male (mean age 65) and 30 female (mean age 67) patients evaluable. Patients were empirically started on anticholinergic medications and timed voids for 4 weeks after which cytoscopy and cystometry were performed. Results: 28/30 females (93%) reported subjective improvement in their continence with conservative measures. 1 (3%) was found to have a urethral diverticulum, and 1 (3%) had uninhibited detrusor contractions that did not improve with medications. In the male group, 20/30 (67%) reported subjective improvement, 5 (17%) developed elevated postvoid residual urine volumes, 3 (10%) were diagnosed with urethral strictures, 1 (3%) had a bladder neck contracture, and 1 (3%) had transitional cell carcinoma in situ in the bladder. Conclusion: In the patient with new onset urinary incontinence in the initial period after CVA, an empiric trial of anticholinergic medications and timed voiding may be warranted in a select population of female patients without urodynamic testing or cystoscopy. This conservative approach may not be appropriate in males because of their increased likelihood of having secondary urologic conditions.

49. Breathing assessment and treatment in post-CVA and neurological patients: a clinical approach

49. Breathing assessment and treatment in post-CVA and neurological patients: a clinical approach

Depression in Post-CVA Patients Residing in Long Term Care Facilities

The purpose of this study was to identify and describe depression of non-aphasic post-CVA patients in long term care facilities. The "Beck Depression Inventory" was used to collect data on the mood level of 52 subjects in seven nursing homes. Information was gathered about their functional level in activities of daily living and use of leisure time. The results of this study indicate that more than one-third of the subjects were depressed. Depressed patients spent their time differently from non-depressed patients. No relationship was found between depression and (1) the time elapsed since the CVA, (2) the affected body side, (3) gender, (4) functional level in self-care activities or (5) social functioning. Recommendations for treatment are included.

Hotter monitoring in the evaluation and rehabilitation of post-cerebrovascular accident patients

Coronary artery disease, overt or silent, is frequently present in patients who have suffered a cerebrovascular accident (CVA). Rehabilitation therapy of CVA patients is based mostly on physical activity, which may be limited by fear of overloading the cardiovascular system. Therefore, assessment of the severity of coronary heart disease in CVA patients is of utmost importance. In this study we assessed the usefulness of 24-hour electrocardiographic Holter monitoring in the evaluation of post-CVA patients during daily activities and rehabilitation. Of the 43 post-CVA patients, 24 (55.8%) revealed pathological changes on Holter monitoring and 17 (71%) had a history of coronary artery disease prior to CVA. Holter monitoring revealed mainly ventricular and atrial arrhythmias and in three patients detected transient ischaemic episodes. Only six patients (14%) showed aggravation of arrhythmia during rehabilitation therapy, without aggravation of ST-T changes. The mean maximum heart rate during regular daily activities was 104 +/- 20 beats/min, which was significantly higher than the mean maximum heart rate during physical therapy (100 +/- 18 beats/min; p less than 0.01) and during occupational therapy (87 +/- 18 beats/min; p less than 0.001). These findings indicate that more vigorous physical and occupational therapy can be prescribed to these patients. The performance of Holter monitoring in post-CVA patients is a valuable substitute to exercise testing, and is useful for cardiovascular evaluation during daily activities and rehabilitation therapy.

Depression in Post-CVA Patients Residing in Long Term Care Facilities

The purpose of this study was to identify and describe depression of non-aphasic post-CVA patients in long term care facilities. The Beck Depression Inventory was used to collect data on the mood level of 52 subjects in seven nursing homes. Information was gathered about their functional level in activities of daily living and use of leisure time. The results of this study indicate that more than one-third of the subjects were depressed. Depressed patients spent their time differently from non-depressed patients. No relationship was found between depression and (1) the time elapsed since the CVA, (2) the affected body side, (3) gender, (4) functional level in self-care activities or (5) social functioning. Recommendations for treatment are included.

Identification of Visual Scanning Deficits in Adults After Cerebrovascular Accident

Visual scanning deficits can result in the inefficient acquisition of information about one's environment. For adults who have had cerebrovascular accidents (CVAs), such deficits can interfere with the independent performance of many daily activities. The present study examined five tests designed to measure visual scanning deficits in post-CVA adults. Subjects with right and left hemisphere lesions were matched with control subjects by age and sex, and their performances on the tests were compared. The difference between the matched groups was statistically significant for all tests, with the hemiplegic subjects achieving lower scores than their normal counterparts. Deficits in visual scanning speed, identification of visual stimuli in the hemifield on the involved side, use of a systematic scanning pattern, and the ability to reproduce accurate visual designs were identified in the hemiplegic group. Statistically significant correlations were obtained on test-retest and interrater data, which indicates that the tests are reliable measures. The results of this study show that visual scanning deficits are present in post-CVA patients and can be measured with simple clinical evaluations. The presence of scanning deficits may significantly interfere with performance on tests measuring higher level visual-perceptual skills such as visual closure, figure-ground perception, and visual memory. An accurate assessment of visual-perceptual skills cannot be made without prior evaluation of such basic oculomotor functions as scanning. This approach is consistent with the developmental framework applied to most areas of treatment with brain-injured adults but is one that traditionally has not been applied in the evaluation of visual-perceptual skills.

Differences in Responses to Exercise by Post-CVA and Normal Subjects

Electromyography and electrogoniometry were used to compare the output of the flexor digitorum profundus, flexor digitorum superficialis, and extensor digitorum of 10 post-CVA subjects and 10 normal subjects during and following resisted and unresisted slow and rapid hand exercises The purpose of this study was to determine differences in motor unit recruitment and ability to extend the fingers between normal and post-CVA subjects following stereotyped exercises. The results indicated that normal and post-CVA subjects differed in percent of motor unit recruitment during exercise, but not all differences were statistically significant. In general, post-CVA subjects recruited a lower percentage of maximum voluntary contraction than normal subjects during rapid or resisted exercise and a higher percentage during slow, unresisted exercise. The most common patterns of muscle contraction were reciprocal and independent for both groups Post-CVA subjects required a significantly longer time than did normal subjects to do grasp exercises as well as resisted and rapid extension exercises. Both before and after the exercises, normal subjects showed significantly more range of motion for extension than did post-CVA subjects. Neither impairment of the ability to recruit motor units or activate and relax muscles nor hyperactive stretch reflexes seem to be more conclusively supported as a major deficit for post-CVA subjects. Further study is required. The results suggested that therapists should not base treatment of post-CVA patients on data derived from normal subjects.

The Effects of Exercise on Finger Extension of CVA Patients

The choice of activity to improve finger extension of post-CVA patients is based on untested assumptions and hypotheses. In this study, using electromyography of the extrinsic finger muscles and electrogoniometry of wrist and finger joints, the effects of five types of exercise on the finger extension of post-CVA patients were documented. Results indicated that resisted and rapid exercises recruited high percentages of output of all three muscles. Slow, unresisted extension exercises preferentially recruited the extensor digitorum. No exercise caused significant immediate changes in range of motion (ROM), flexor/extensor balance, time required to open the hand, or level of activity of the extensor digitorum during opening of the hand. Resisted grasp did not limit the patients' ability to extend the fingers. Variability in percent of motor output among the subjects of this study indicates the need to monitor each patient during therapy.

Strokes

Stroke is a cause of chronic disability and mortality throughout the United States. Knowing that the means of modifying the course of events once the stroke occurs still remains elusive, it becomes obvious that something needs to be done before. Therefore, emphasis should be placed on recognizing signs and symptoms of impending strokes. Thorough health histories need to be taken; include in them questions that will identify those with an increased risk, such as patients with a history of cerebrovascular disease, diabetes, and hypertension. In the review of systems include questions of intermittent signs of paresthesia, weakness, and aphasia, all of which could help recognize individuals who have experienced transient focal ischemic attacks or lacunar strokes. If necessary, do not hesitate to refer patients with questionable signs and symptoms who are not already under medical care. Taking vital signs of every patient in your office at each appointment will uncover any hypertensive patients, who should be referred to a physician for evaluation and management. It will also be helpful in monitoring the effectiveness of treatment of those already being treated. Be sure to contact post-CVA patients’ physicians on their condition before beginning any treatment. There may be impairments, whether mental or physical, that can make a considerable difference in your treatment. Also discuss with the physicians any possible changes in medication that you are considering. Prevention will be your biggest asset in limiting complications of the stroke-prone and post-CVA patients, but be prepared for the exception.

A Survey of Post-Apoplectic Home Patients in Tamagawa District of Tokyo

Actual recovery states of 160 cases with histories of CVA were investigated on home visits by public health nurses in Tamagawa district of Tokyo.The results were as follows;1) 59.3% of the cases were independants, 21.9% were partially dependants and 18.8% were completely dependants. The rate of return to job was 26.7%.2) Numbers of completely dependants according to the lapse of time after the stroke was as follows; those number decreased remarkably one year after the stroke, but thereafter 1.0-1.3% of the cases were present per year stationally to ten years after the stroke. 11.9% of the cases still remained as completely dependant over one year after the stroke.3) The ratio of male to female was 5:3 and the restoration of ADL showed no marke'd difference between them.4) From this survey, factors pointed out as impedimental to restoration of ADL of post-CVA patients were right-side hemiplegia, incontinentia urinae et albi, decubiti, lack of motivation, moderate mental impairments and speech disturbances. Concomitant visual disturbance, tremor, convulsive seizure and involuntary movements were also noted as impedimental.5) In living circumstances, incomplete heating using “Kotatsu” “Hibachi” or “Anka” in the winter and living rooms lack of sun shine through the seasons were noted as impedimental factors also.6) Therapeutic exercises were experienced by only 11.9% of the cases and braces were used by only 1.3% of the cases.