Stroke-related Disabilities Research Articles

Neuropsychiatric sequelae of stroke.

Stroke survivors are often affected by psychological distress and neuropsychiatric disturbances. About one-third of stroke survivors experience depression, anxiety or apathy, which are the most common neuropsychiatric sequelae of stroke. Neuropsychiatric sequelae are disabling, and can have a negative influence on recovery, reduce quality of life and lead to exhaustion of the caregiver. Despite the availability of screening instruments and effective treatments, neuropsychiatric disturbances attributed to stroke are currently underdiagnosed and undertreated. Stroke severity, stroke-related disabilities, cerebral small vessel disease, previous psychiatric disease, poor coping strategies and unfavourable psychosocial environment influence the presence and severity of the psychiatric sequelae of stroke. Although consistent associations between psychiatric disturbances and specific stroke locations have yet to be confirmed, functional MRI studies are beginning to unveil the anatomical networks that are disrupted in stroke-associated psychiatric disorders. Evidence regarding biochemical and genetic biomarkers for stroke-associated psychiatric disorders is still limited, and better understanding of the biological determinants and pathophysiology of these disorders is needed. Investigation into the management of these conditions must be continued, and should include pilot studies to assess the benefits of innovative behavioural interventions and large-scale cooperative randomized controlled pharmacological trials of drugs that are safe to use in patients with stroke.

An Occupational Therapy intervention for residents with stroke-related disabilities in UK Care Homes (OTCH): cluster randomised controlled trial with economic evaluation.

Care home residents with stroke-related disabilities have significant activity limitations. Phase II trial results suggested a potential benefit of occupational therapy (OT) in maintaining residents' capacity to engage in functional activity. To evaluate the clinical effectiveness and cost-effectiveness of a targeted course of OT in maintaining functional activity and reducing further health risks from inactivity for UK care home residents living with stroke-related disabilities. Pragmatic, parallel-group, cluster randomised controlled trial with economic evaluation. Cluster randomisation occurred at the care-home level. Homes were stratified according to trial administrative centre and type of care provided (nursing or residential), and they were randomised 1 : 1 to either the intervention or the control arm. The setting was 228 care homes which were local to 11 trial administrative centres across England and Wales. Care home residents with a history of stroke or transient ischaemic attack, including residents with communication and cognitive impairments, not receiving end-of-life care. Personalised 3-month course of OT delivered by qualified therapists. Care workers participated in training workshops to support personal activities of daily living. The control condition consisted of usual care for residents. Outcome data were collected by a blinded assessor. The primary outcome at the participant level was the Barthel Index of Activities of Daily Living (BI) score at 3 months. The secondary outcomes included BI scores at 6 and 12 months post randomisation, and the Rivermead Mobility Index, Geriatric Depression Scale-15 and European Quality of Life-5 Dimensions, three levels, questionnaire scores at all time points. Economic evaluation examined the incremental cost per quality-adjusted life-year (QALY) gain. Costs were estimated from the perspective of the NHS and Personal Social Services. Overall, 568 residents from 114 care homes were allocated to the intervention arm and 474 residents from another 114 care homes were allocated to the control arm, giving a total of 1042 participants. Randomisation occurred between May 2010 and March 2012. The mean age of participants was 82.9 years, and 665 (64%) were female. No adverse events attributable to the intervention were recorded. Of the 1042 participants, 870 (83%) were included in the analysis of the primary outcome (intervention, n = 479; control, n = 391). The primary outcome showed no significant differences between groups. The adjusted mean difference in the BI score between groups was 0.19 points higher in the intervention arm [95% confidence interval (CI) -0.33 to 0.70, p = 0.48; adjusted intracluster correlation coefficient 0.09]. Secondary outcome measures showed no significant differences at all time points. Mean incremental cost of the Occupational Therapy intervention for residents with stroke living in UK Care Homes intervention was £438.78 (95% CI -£3360.89 to £1238.46) and the incremental QALY gain was 0.009 (95% CI -0.030 to 0.048). A large proportion of participants with very severe activity-based limitations and cognitive impairment may have limited capacity to engage in therapy. A 3-month individualised course of OT showed no benefit in maintaining functional activity in an older care home population with stroke-related disabilities. There is an urgent need to reduce health-related complications caused by inactivity and to provide an enabling built environment within care homes. Current Controlled Trials ISRCTN00757750. This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 15. See the Health Technology Assessment programme website for further project information.

Mobile clinical teams for stroke and neurological handicaps in the community: A pilot project in the Île-de-France area

In December 2013 the Regional Health Agency in Île-de-France (Paris city and surrounding districts) started an experimental project of mobile clinical teams for post-acute care and rehabilitation of serious neurological conditions such as stroke. This pilot project was organized in 8 departments. The goal was to coordinate health and social services in order to facilitate home transitions and home living maintenance for persons with disabilities, while enhancing persons’ independence. In this communication, we compare the organizations of these teams: their part-time team members as specialists in geriatrics or Physical Medicine and Rehabilitation, social workers, occupational therapists and secretaries; their intervention types and places (in acute or post-acute care, or in the community); the methods of referral to the teams; the tools used for evaluation, functioning and communication. Since one year, monthly global meetings of the teams have led to an harmonization of these tools and to a useful sharing of experiences. As most teams have been fully functional since September 2014, a synthesis of 6 months of activity can be drawn. The number of patients managed by each team was between 9 and 40. Main reasons for referral to the teams were assistance in the transition from hospital to home, help in home living maintenance, functional evaluations, and administrative assistance. The teams performed between 3 and 32 home visits. Through this first experiment, the added value of these mobile teams was highlighted. The multidisciplinary analysis of individual situations, which combines a functional approach to a social support, gives a comprehensive insight into the neurological handicap and its challenges at home and in the community. The acquired knowledge enables the teams to improve the management of recent stroke in preparing home transitions and to take into account the complexity of stroke-related disabilities at all ages. The limits of the interventions of these teams are related to the large geographical territories which need to be addressed, to the incomplete knowledge of care and residential possibilities, and sometimes to an under-evaluation of the medical work time required.

An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): cluster randomised controlled trial

Objective To evaluate the clinical efficacy of an established programme of occupational therapy in maintaining functional activity and reducing further health risks from inactivity in care home residents living with...

Electroacupuncture and Transcranial Direct Current Stimulation: Simultaneous Treatment for Patients with Chronic Poststroke Symptoms

Abstract Background: As the population ages, more individuals present with stroke-related impairments and disabilities. One area of research interest is a family of proteins called neurotrophins, which induce the survival, development, and function of neurons. Two current treatment modalities that utilize the release of neurotrophic factors are transcranial direct current stimulation (tDCS) and electroacupuncture (EA). Cases: Two individuals (patients A and B) with chronic poststroke symptoms were treated simultaneously with tDCS and EA. The patients received tDCS, anodal stimulation at C4-Fp1, according to the EEG 10/20 system, and EA, points at specific locations along the neglected limb simultaneously for 20 minutes. Each patient was then given a postacupuncture massage of the neglected limb and an exercise program. Treatments consisted of four weekly treatments for 5 weeks, for a total of twenty visits. Outcome measurements were range of motion, Jammar grip strength, and video golf swing. Results: Pat...

Post‐stroke depression and apathy: Interactions between functional recovery, lesion location, and emotional response

Depression and apathy are often observed after stroke and are often confused with one another. In the present review, we argue that the current concept of 'post-stroke depression' (PSD) in fact consists of two core symptoms or syndromes: (i) affective (depressive) PSD; and (ii) apathetic PSD. We argue that these two core symptoms are each associated with a different underlying neuroanatomical mechanism, a pattern that influences functional recovery. Post-stroke disabilities can provoke several distinct emotional responses, some of which are associated with severe depression. We examined one of these emotional responses previously, namely 'insistence on recovery', which was believed to be a negative indicator of functional improvement in disabled stroke patients. However, an appropriate level of insistence on recovery may, in fact, be associated with reduced depression and apathy, resulting in enhanced recovery from stroke-related disabilities. Improvements in physical disabilities (trunk stability or activities of daily living, such as walking) also reduce depression and apathy. Therefore, the experience of PSD/apathy may be intertwined with various initial emotional responses and improvements in physical functioning. Effective treatment of PSD/apathy requires a multidisciplinary approach, such that neuroanatomical/neurobiological, emotional, and physical (rehabilitation) domains are all addressed.

Predictors of psychological health in spouses of persons affected by stroke

To identify predictors of psychological health and examine if these predictors change over time in spouses of stroke patients during the first year after stroke. A second aim was to identify gender differences in psychological health among the spouses. The impact of burden in long-term caregivers may result in psychological consequences for the spouse. The rehabilitation process for the patient can be negatively affected by a stressed caregiver and result in long-term hospitalization. To identify spouses at risk for physical and psychological distress is, therefore, essential to support those in need. Longitudinal, comparative study. One hundred spouses of stroke patients were assessed at baseline, as well as after six and 12 months, regarding psychological health, well-being, own illness, need of assistance from general practitioner and/or district nurse, social network and knowledge about stroke. Stepwise multiple regression analyses were conducted for baseline, six- and 12-month assessments, respectively, with psychological health as the dependent variable. General well-being and presence of illness in spouse were the most prominent predictors of psychological health, throughout the first year. Enhancing psychological health and preventing medical problems in the caregiver are essential considerations to enable patients with stroke-related disabilities to continue to live at home. Evaluating the situation for spouses of stroke patients is an important component when planning for the future care of the patient.

Physical activity and nutritional behaviors of women with physical disabilities: Physical, psychological, social, and environmental influences

We examined predictors of 2 important health behaviors, namely, physical activity and nutritional behaviors, in a sample of community-living women with physical disabilities (N = 386). We conducted a cross-sectional survey with regression analysis. Our regression model accounted for 33.5% of the variance in physical activity. Women with joint problems or multiple sclerosis tended to engage in less physical activity than those with stroke-related disabilities. Those who had lived with their disability longer and those experiencing greater pain tended to report less physical activity. Consistent with the literature, women with greater self-efficacy for physical activity tended to engage in more physical activity. The regression model for nutritional behaviors accounted for 37.9% of the variance. Women with better mobility, greater self-efficacy for nutrition, and more vitality had better nutritional behaviors while those who needed assistance with activities of daily living, had lower social functioning scores, and were engaged in more productive activities reported poorer nutritional behaviors. Our findings highlight the importance of self-efficacy for improving health behaviors. Further research is needed to develop a new paradigm for the measurement of health behaviors, one that focuses on individual improvement rather than comparison to a norm, and health promoting interventions that are responsive to the needs and life circumstances of women with physical disabilities.

Treatment innovation in behavioral rehabilitation of stroke: Removing limits on recovery

Of the 5.4 million people in the United States who have had a stroke, half may have related motor and cognitive disabilities. Nearly one-quarter of stroke survivors need physical assistance in everyday life, and cognitive symptoms may have an equal or greater impact on function compared with physical limitations [1-3]. These numbers are frightening when we realize that health outcome studies in stroke may underrepresent the magnitude of the problem. Persons with disabilities who enter supervised or chronic-care settings may not be included in databases or research studies, and stroke survivors with cognitive disabilities may also fail to participate in research because of behavioral abnormalities, such as abnormal arousal and motivation, communication disorders, or the inability to coordinate activities and comply with study protocols. Although meticulous poststroke medical care is reducing stroke-related mortality in the United States, the number of survivors living with stroke-related disabilities may significantly increase as a result [4]. Thus, rehabilitation scientists are challenged to develop better and more effective treatments for cognitive and motor dysfunction so that people may return to satisfying life activities. Neuroscience researchers routinely suggest that investigation of the mechanisms of stroke-related cognitive and motor deficits will inspire new treatments. However, basic research in poststroke deficits may only describe the correlates of disability rather than the degree of disability and may include subjects with subtle signs who would not ordinarily meet the clinical criteria for treatment. Thus, we as clinicians may have difficulty generalizing and applying the results of basic science experiments to the treatment of patient groups in a valid fashion. Most clinical researchers are aware of this limitation and regard mechanistic studies as a first step toward the development of treatment-valid research. How to move from basic discovery toward large-scale, systematic clinical studies is not always as clear to the rehabilitation community [5]. That within-subject, exploratory, and experimental designs advance research questions and bridge the gap to randomized group studies may not be acknowledged. Scientists may criticize early phase clinical trial studies because they do not use randomized controls or meta-analysis, which are characteristic of phase III studies. However, the methodology of phase III research is neither appropriate nor desirable when a research question is innovative, being refined, and being explored for its feasibility and optimal setting. An unfortunate truth is that even after quality randomized clinical trials of a treatment are available and the benefits indicated, problems occur when practitioners apply them to the treatment of individual patients. As practitioners apply a developed treatment, they may discover that the results do not generalize or do not apply to certain patients. Systematic investigation of these particular patients will give rise to data-refining clinically valid practice [6-7]. Such patients may belong to groups who were excluded or underrepresented in the formal trial but are frequently encountered in the aged population, such as patients with multiple chronic medical problems. Other understudied groups include women; members of ethnic, racial, and cultural minorities; rural dwellers; and the poor. Averaged results from patients with diverse presentations of a clinical disorder in a large-scale clinical trial also may not represent the treatment-response spectrum. Patients with some theoretically defined subtypes of a clinical disorder may benefit, while others may experience adverse effects. Unless appropriate secondary analyses are performed, this disparity in response may go undetected and the trial reported as lacking any treatment benefit [8-9]. Such reexamination of gold standard results is desirable and, indeed, inevitable, as paradigm shifts in the field of cognitive rehabilitation help us redefine the brain-behavior mechanisms of the disorders that we treat. …

Emergency Response Teams Share Strategies: Human and rat brains reorganize similarly after stroke

The human brain behaves like a close-knit community. When natural disaster destroys a few houses, friends across town as well as those next door lend a hand. Similarly, in a stroke-damaged human brain, the uninjured hemisphere tries to help, and later the neighborhood around the hardest hit region recovers enough to pitch in as well. Now, researchers have used functional magnetic resonance imaging (fMRI)--the same technique that uncovered this behavior in human brains--to show that rats' brains reorganize similarly after stroke. Functional magnetic resonance imaging of rat brains after stroke offers a new experimental model for studying how the brain repairs itself and for evaluating therapies. Dijkhuizen and colleagues induced a stroke in rats by tying off an artery in the right side of the animals' brains; as a result, the left side of the body became temporarily clumsy. They then exploited fMRI to assess how the brains changed as the rats' disabled left limbs recovered. This technique measures blood flow, a reflection of metabolic activity; fMRI generates information about which regions of the brain respond when the subject performs a task. While the animals slept inside the fMRI machine, the researchers gently shocked the rats' left paws to simulate the task of tapping fingers. Three days after the stroke, the brains of sham-operated rats responded on the side opposite the injured limb, but the damaged rats' brains lit up on the unharmed left side. After 14 days, when the animals had regained some control over their left paws, the brightness of the unaffected hemisphere dwindled; the edges of the lesion, however, glowed for the first time. Functional magnetic resonance imaging provides a noninvasive way to pinpoint sites of physiological change that occur during recovery from a stroke. Because rat and human brains appear to share healing strategies, researchers are optimistic that the new system will provide an experimental model in which to study stroke and its potential treatments. They hope to develop new approaches, because the two therapies currently available are not always effective: Clot-busting drugs work only if used in the first few hours after the mishap, and physical therapy doesn't succeed in all patients. For the approximately 4 million Americans who live with stroke-related disabilities, innovative therapies offer hope of regaining control over their bodies and minds--and toward that end, neighborly rats might now lend a paw. --Katharine Miller R. M. Dijkhuizen, J. Ren, J. B. Mandeville, O. Wu, F. M. Ozdag, M. A. Moskowitz, B. R. Rosen, S. P. Finklestein, Functional magnetic resonance imaging of reorganization in rat brain after stroke. Proc. Natl. Acad. Sci. U.S.A. 98 , 12766-12771 (2001). [Abstract] [Full Text]

Stroke rehabilitation: assessing stroke survivors' long-term learning needs.

What are the long-term learning needs of stroke survivors who must adapt to living with stroke-related disabilities? A broad-based educational needs assessment was conducted to find answers to this question and to gain insight into the concerns and challenges facing stroke survivors who have returned to living in the community. Stroke survivors, family members, and rehabilitation healthcare professionals were surveyed; positive responses strongly indicated that there was interest in learning more about the selected topics. Although there was congruence across all groups, healthcare professionals indicated that they felt more strongly than either patients or patients' family members that stroke survivors need to learn more about the facts and statistics of strokes. Stroke survivors and family members indicated a stronger interest in learning about complementary therapies such as massage, acupuncture, and the role of food and vitamins. Time since stroke was an influencing factor for both stroke survivors and family members in their responses to how strongly they wanted to learn about various topics. The findings from this needs assessment formed the basis for an educational course that uses a holistic approach to address the physical, emotional, social, economic, and spiritual aspects of adapting to living with stroke-related disabilities.