Stroke-related Disability Research Articles

Development and evaluation of a Smartphone-enabled, caregiver-supported educational intervention for management of physical disabilities following stroke in India: protocol for a formative research study

The incidence and prevalence of stroke in India has reached epidemic proportions. The growing magnitude of disability in patients with stroke in India poses a major public health challenge. Given...

Abstract W MP97: Post-discharge Pneumonia And Urinary Tract Infection After Hospitalization For Ischemic And Hemorrhagic Strokes

Background and purpose: Stroke related disability is a risk factor for infectious complications and the risk persists even after discharge from the hospital. Therefore, we studied the incidence and predictors of pneumonia and urinary tract infection (UTI) up to 1 year after hospitalization for ischemic stroke, spontaneous intracerebral hemorrhage (ICH) and non-traumatic subarachnoid hemorrhage (SAH). Methods: We analyzed all adult cases treated in acute care hospitals and emergency departments in California state between 2005 and 2011 using state inpatient and emergency databases of Healthcare Cost and Utilization Project. Patients with principle diagnosis of ischemic stroke (ICD-9 codes 433.x1, 434.x1, 436), ICH (431) and SAH (430) surviving up to discharge were followed up for development of first episode of pneumonia and UTI at 30-days, 90-days and 1-year intervals. Index cases were limited to 2005-2010 to ensure at least 1 year of follow up. Negative binomial regression was used to obtain predictors of post-discharge pneumonia or UTI. Results: Among 168,194 ischemic strokes, 26,502 ICH and 10,659 SAH cases, 5.7%, 7.3% and 4.9% developed pneumonia, and 8.6%, 11.5% and 8.8% developed UTI within 90-days after discharge respectively. The incidence rate of pneumonia during first 30 days was 38.8 per 100 person years which decreased to 14.8 per 100 person years between 31-90 days. The rate decreased further during 91-365 days to 7.3 per 100 person years. The rates of pneumonia among ICH and SAH and of UTI among different stroke types showed similar trend with higher risk during immediate post-discharge period. Factors independently associated with post-discharge infections were older age, female sex, non-white race, hypertension, diabetes, congestive heart failure, dementia, liver disease, anemia, atrial fibrillation, mechanical ventilation, gastrostomy and longer length of index admission. Conclusions: Risk of infectious complications is highest after ICH among different stroke types. The risk is highest during immediate post-discharge period but remains higher than general hospital population at least up to 1 year.

Abstract T P82: The Role of the A2B Receptor in a Mouse Model Of Stroke

Introduction: Every 40 seconds someone in the United States has a stroke, and we currently spend $73.3 billion on stroke-related disability. A2B receptor agonists are strongly protective against ischemia in many organ systems including liver, lung, and kidney. Very little work has been carried out to uncover the role, if any, for A2B in brain ischemia. The objective of this study was to elucidate the role of the A2B receptor through the use of the middle cerebral artery occlusion mouse model (MCAO), the A2B receptor antagonist PSB1115, and A2B KO animals. Hypothesis: We hypothesized that the A2B receptor antagonist PSB1115 would be detrimental in stroke. Methods: Transient focal ischemia was induced for 60 min of middle cerebral artery occlusion (MCAo) using the intraluminal filament model in male C57Bl/6 wild-type and A2B KO mice. PSB1115 at a dose of 5mg/kg and a vehicle of DMSO in saline were blinded and animals were randomized to treatment. Drug was delivered to C57BL/6 mice immediately post-reperfusion in the 60 minute MCAO model. Mice were sacrificed after 24 or 72 hours and infarct volume was measured using 2,3,5-triphenyltetrazolium chloride (TTC). Infarct volumes were compared between drug and vehicle groups and WT and A2B KO mice. Statistical analysis was performed using Student’s t-test with P<0.05 considered significant. Results: Analysis of histological damage 24 hours after MCAo revealed that the A2B antagonist PSB1115 decreased infarct size from 49±8.0% (n=7) to 37±4.3% (n=10;p<0.005). Similarly, we observed that the same dose of PSB1115 provided prolonged protection (analyzed 72 hours after MCAo), infarct volume decreased from 44±6.4% (n=7) in vehicle treated animals to 22±2.9% (n=4;p<0.05) in PSB115 treated animals. To extend this remarkable observation, we took advantage of A2B KO mice. We observed that A2B KO mice had significantly smaller infarct size at 24h compared to WT littermates, reducing from 55±6.4% (n=4) in WT mice to 19±4.3% (n=6;p<0.05) in A2B KO mice. Conclusion: Contrary to our hypothesis and its role in other organ systems, blocking or genetic deletion (KO mice) of the A2B receptor conveys protection following experimental stroke.

Abstract T P259: Study of Factors Contributing to Reduce Cost in an Innovative Post-Stroke Program

Background and Purpose: Stroke is the 4 th leading cause of death in the United States. Stroke-related medical costs and disability in the US cost approximately $73.7 billion in 2010 and is projected to cost $185 billion by 2030. Decreasing costs of care among post-stroke patients requires a combination of follow-up care and monitoring and targeted risk factor reduction. Ochsner Neuroscience Institute (ONI) has implemented a Comprehensive Stroke Care Model designed to increase quality and decrease costs of stroke across the continuum from symptom onset through 12 months post-discharge. This Model combines evidence-based, streamlined in-hospital care with monthly post-discharge follow-up and education in the home for patients and caregivers. Innovative technology that connects patients and caregivers with ONI stroke and internal medicine providers to address issues real-time during outpatient visits. This research will describe this innovative Stroke Care Model, including its impact on mortality, length of stay, stroke reoccurrence rate, and cost of care. Methods: This research will include patients seen as part of this Model from 1/3/2013-7/31/2014. Stroke Central, the in-hospital component, coordinated patients who presented at Ochsner’s Emergency Department via transfer, EMS, or personal transportation (n=1,711). Stroke Mobile, the outpatient component, includes a subsample of patients and their caregivers who were discharged with a stroke diagnosis and who reside in St. Tammany and Jefferson Parishes in Louisiana (n=288). Results: Stroke Mobile includes patients discharged from Ochsner’s Stroke Program with a final diagnosis of stroke who reside in St. Tammany or Jefferson Parishes in Louisiana from 2013-2014 (n=288 as of 7/31/2014). Patients that participated in stroke mobile reported a stroke reoccurrence rate 40% lower than patients not participating in stroke mobile. Conclusions: These results suggest a significant cost reduction in post stroke care through personalized patient visits that resulted in reduced readmissions rates, reduced stroke reoccurrence rates, and decreased clinic visits.

Evaluation of differences in brain neurophysiology and morphometry associated with hand function in individuals with chronic stroke.

Rehabilitation interventions need to be optimized to maximize therapeutic effects and minimize stroke-related disability. However, a comprehensive understanding of the neural substrates underlying recovery is lacking. The purpose of this study was to investigate relationships between brain anatomy, physiology and hand motor function in individuals with chronic stroke. Transcranial magnetic stimulation (TMS) and magnetic resonance imaging (MRI) approaches were used to evaluate cortical excitability and brain structural morphometry in individuals with chronic stroke. Hemispheric differences and relationships between these measures and hand dexterity were evaluated. Hemispheric differences were observed for TMS and MRI measures. Bilateral hand dexterity correlated with TMS resting motor threshold and precentral gyral thickness. Transcallosal inhibition across hemispheres was positively associated with midcallosal white matter volume. Regression modeling results demonstrated that combining TMS and MRI measures predicted unique amounts of variance in hand dexterity. RESULTS confirm and extend findings showing differences in brain structure and function after stroke. RESULTS suggested a structure-function relationship underlying interhemispheric connectivity in chronic stroke. The utility of combined TMS and MRI measures to predict motor function can be used in future investigations to aid identifying optimal biomarkers of stroke recovery to predict response to rehabilitation to maximize treatment outcomes.

Non-breathing-related sleep disorders following stroke

IntroductionIt has been shown that sleep-related breathing disorders, especially sleep apnoea, are very common in patients who have had a stroke, and that they also reduce the potential for neurological recovery. Nevertheless, other sleep disorders caused by stroke (excessive daytime sleepiness, insomnia, sleep-related movement disorders) can also cause or increase stroke-related disability, and this fact is less commonly known. DevelopmentStudies with polysomnography have shown many abnormalities in sleep architecture during the acute phase of stroke; these abnormalities have a negative impact on the patient's quality of life although they tend to improve with time. This also happens with other sleep disorders occurring as the result of a stroke (insomnia, narcolepsy, restless legs syndrome, periodic limb movement disorder and REM sleep behaviour disorder), which are nevertheless potentially treatable. In this article, we briefly review the physiopathology and epidemiology of the disorders listed above in order to raise awareness about the importance of these disorders and the effects they elicit in stroke patients. ConclusionsSleep disorders that are not breathing-related have scarcely been studied in stroke patients despite the fact that almost all such disorders may present as a result of a cerebrovascular event.

Assimilation of Web-Based Urgent Stroke Evaluation: A Qualitative Study of Two Networks

BackgroundStroke is a leading cause of death and serious, long-term disability across the world. Urgent stroke care treatment is time-sensitive and requires a stroke-trained neurologist for clinical diagnosis. Rural areas, where neurologists and stroke specialists are lacking, have a high incidence of stroke-related death and disability. By virtually connecting emergency department physicians in rural hospitals to regional medical centers for consultations, specialized Web-based stroke evaluation systems (telestroke) have helped address the challenge of urgent stroke care in underserved communities. However, many rural hospitals that have deployed telestroke have not fully assimilated this technology.ObjectiveThe objective of this study was to explore potential sources of variations in the utilization of a Web-based telestroke system for urgent stroke evaluation and propose a telestroke assimilation model to improve stroke care performance.MethodsAn exploratory, qualitative case study of two telestroke networks, each comprising an academic stroke center (hub) and connected rural hospitals (spokes), was conducted. Data were collected from 50 semistructured interviews with 40 stakeholders, telestroke usage logs from 32 spokes, site visits, published papers, and reports.ResultsThe two networks used identical technology (called Remote Evaluation of Acute isCHemic stroke, REACH) and were of similar size and complexity, but showed large variations in telestroke assimilation across spokes. Several observed hub- and spoke-related characteristics can explain these variations. The hub-related characteristics included telestroke institutionalization into stroke care, resources for the telestroke program, ongoing support for stroke readiness of spokes, telestroke performance monitoring, and continuous telestroke process improvement. The spoke-related characteristics included managerial telestroke championship, stroke center certification, dedicated telestroke coordinator, stroke committee of key stakeholders, local neurological expertise, and continuous telestroke process improvement.ConclusionsRural hospitals can improve their stroke readiness with use of telestroke systems. However, they need to integrate the technology into their stroke delivery processes. A telestroke assimilation model may improve stroke care performance.

An Update on Surgical and Medical Management Strategies for Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) accounts for ∼ 10 to 15% of all strokes and is one of the major causes of stroke-related death and disability. After the initial hemorrhage, further bleeding and edema contribute to secondary damage and worsened outcomes. As such, goals of previous and ongoing trials are to prevent continued bleeding, as well as mitigate the impact of cerebral edema. Although no trials have shown a definite functional outcome benefit with a given intervention, much progress has been made recently. This review focuses on recent developments that inform the acute management of ICH.

Blood pressure control and primary prevention of stroke: summary of the recent clinical trial data and meta-analyses.

Stroke is the second most common cause of death worldwide and of adult disability, but in the near future the global burden of cerebrovascular diseases will rise due to ageing and adverse lifestyle changes in populations worldwide. The risk of stroke increases at blood pressure levels above 115/75 mm Hg and high blood pressure (BP) is the most important modifiable risk factor for stroke, associated with 54 % episodes of stroke worldwide. There is strong evidence from clinical trials that antihypertensive therapy reduces substantially the risk of any type of stroke, as well as stroke-related death and disability. The risk attributed to BP is associated not only with absolute values but also with certain parameters describing BP diurnal pattern as well as short-term and long-term variability. Many studies reported that certain features of BP like nocturnal hypertension, morning surge or increased variability predict an increased stroke risk. However, there is no accepted effective modality for correction of these disturbances (chronotherapy, certain classes of antihypertensive drugs). In the elderly, who are mostly affected by stroke, the primary prevention guidelines recommend treatment with diuretics and calcium channel blockers to lower blood pressure to the standard level.

Trastornos del sueño no respiratorios en relación con ictus

IntroductionIt has been shown that sleep-related breathing disorders, especially sleep apnea, are very common in patients who have had a stroke, and that they also reduce the potential for neurological recovery. Nevertheless, other sleep disorders caused by stroke (excessive daytime sleepiness, insomnia, sleep related movement disorders) can also cause or increase stroke-related disability, and this fact is less commonly known. DevelopmentStudies with polysomnography have shown many abnormalities in sleep architecture during the acute phase of stroke; these abnormalities have a negative impact on the patient's quality of life although they tend to improve with time. This also happens with other sleep disorders occurring as the result of a stroke (insomnia, narcolepsy, restless legs syndrome, periodic limb movement disorder and REM sleep behavior disorder), which are nevertheless potentially treatable. In this article, we briefly review the physiopathology and epidemiology of the disorders listed above in order to raise awareness about the importance of these disorders and the effects they elicit in stroke patients. ConclusionsSleep disorders that are not breathing-related have scarcely been studied in stroke patients despite the fact that almost all such disorders may present as a result of a cerebrovascular event.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Abstract WP383: An Economic Model of Improved Acute Stroke Care in the Management of Acute Ischemic Stroke From A State Medicaid Perspective

Background: Stroke is a leading cause of long-term disability in the United States. Approximately one in four stroke survivors is admitted to a nursing home, accounting for a significant portion of Medicaid spending on stroke. Objective: To assess the impact of increasing access to primary stroke centers (PSCs) and implementing an emergency medical services (EMS) system on disability and Medicaid spending on nursing homes for ten geographically representative states. Methods: An economic model was developed to estimate potential reductions in stroke-related disability and corresponding reductions in Medicaid spending on nursing homes among Medicaid enrollees with acute ischemic stroke (AIS), due to improved stroke care infrastructure. The model assessed the increased use of intravenous (IV) thrombolysis as a result of a higher proportion of AIS treated in PSCs, or as a result of integrating an EMS system with PSCs. Based on published literature, more patients received IV thrombolysis in PSCs vs. non-PSCs (6.5 vs. 0.9%) and PSCs with an EMS routing protocol vs local services (10.5 vs. 2.5%). State-specific model inputs included the incidence of first-ever AIS in Medicaid enrollees, nursing home costs, and Medicaid spending on stroke-related care. Results: A 20% absolute increase in the proportion of AIS patients treated at PSCs will lead to 111 to 2004 more patients receiving IV thrombolysis; 9 to 160 fewer patients with disability; and a reduction in Medicaid nursing home spending of $299,442 to $5.6 million per year across the ten states analyzed (Table). The integration of an EMS system with PSCs will lead to 791 to 14,314 more patients receiving IV thrombolysis; 63 to 1145 fewer patients with disability; and a reduction in Medicaid nursing home spending of $2.1 to $40.0 million per year across the ten states (Table). Conclusions: States may achieve substantial savings through legislative policies that improve PSC access and integration of an EMS system with PSCs.

Monitoring the implementation of the State-Regional Council agreement 03/02/2005 as to the management of acute stroke events: a comparison of the Italian regional legislations

Access to effective acute stroke services is a crucial factor to reduce stroke-related death and disability, but is limited in different parts of Italy. Our study addresses this inequality across the Italian regions by examining the regional legislations issued to adopt and implement the State-Regional Council agreement 03/02/2005 as to the acute stroke management. All decrees and resolutions as to acute stroke were collected from each region and examined by the means of a check list including quantitative and qualitative characteristics, selected in accordance with the recommendations from the State-Regional Council document. Each completed check list was then sent to each regional reference person, who filled in the section on the implementation of the indications and compliance, with the collaboration of stroke specialists if necessary. The study was carried out from November 2009 to September 2010. The documents and information were collected from 19 regions. Our survey revealed disparities both in terms of number of decrees and resolutions and of topics covered by the regional legislations about stroke care. Most legislations lacked practical and economical details. This feedback from national and regional stroke regulations revealed a need of more concrete indications. Involvement of various stakeholders (legislators, consumers, providers) might possibly ensure that policies are actually adopted, implemented and maintained. Although considerable challenges are present to the development of standard and optimal stroke care more widely across Italian regions, the potential gains from such developments are substantial.

Concerns about medications mediate the association of posttraumatic stress disorder with adherence to medication in stroke survivors

Post-traumatic stress disorder (PTSD) can be a consequence of acute medical events and has been associated with non-adherence to medications. We tested whether increased concerns about medications could explain the association between PTSD and non-adherence to medication in stroke survivors. We surveyed 535 participants aged 40 years or older who had at least one stroke or transient ischaemic attack in the previous 5 years. We assessed PTSD using the PTSD checklist-specific for stroke, medication adherence with the Morisky Medication Adherence Questionnaire, and beliefs about medications with the Beliefs about Medicines Questionnaire. We used logistic regression to test whether concerns about medications mediated the association between stroke-induced PTSD and non-adherence to medication. Covariates for adjusted analyses included age, sex, race, comorbid medical conditions, stroke-related disability, years since last stroke/TIA, and depression. Symptoms of PTSD were correlated with greater concerns about medications (r = 0.45; p < .001), and both were associated with medication non-adherence. Adjustment for concerns about medications attenuated the relationship between PTSD and non-adherence to medication, from an odds ratio [OR] of 1.04 (95% confidence interval [CI], 1.01-1.06; OR, 1.63 per 1 SD) to an OR of 1.02 (95% CI, 1.00-1.05; OR, 1.32 per 1 SD), and increased concerns about medications remained associated with increased odds of non-adherence to medication (OR, 1.17; 95% CI, 1.10-1.25; OR, 1.72 per 1 SD) in this fully adjusted model. A bootstrap mediation test suggested that the indirect effect was statistically significant and explained 38% of the association of PTSD to medication non-adherence, and the direct effect of PTSD symptoms on medication non-adherence was no longer significant. Increased concerns about medications explain a significant proportion of the association between PTSD symptoms and non-adherence to medication in stroke survivors.

National Utilization Patterns of Warfarin Use in Older Patients with Atrial Fibrillation: A Population-Based Study of Medicare Part D Beneficiaries

Although warfarin therapy reduces stroke incidence in patients with atrial fibrillation (AF), the rate of warfarin use in this population remains low. In 2008, the Medicare Part D program was expanded to pay for medications for Medicare enrollees. To examine rates and predictors of warfarin use in Medicare Part D beneficiaries with AF. This population-based retrospective cohort study used claims data from 41,447 Medicare beneficiaries aged 66 and older with at least 2 AF diagnoses in 2007 and at least 1 diagnosis in 2008. All subjects had continuous Medicare Part D prescription coverage in 2008. Statistical analysis using χ(2) was used to examine differences in warfarin use by patient characteristics (age, ethnicity, sex, Medicaid eligibility, comorbidities, contraindications to warfarin, and whether they visited a cardiologist or a primary care physician [PCP]), CHADS(2) score (congestive heart failure, hypertension, age, diabetes, and stroke or transient ischemic attack; higher scores indicate higher risks of stroke), and geographic regions. Using hierarchical generalized linear models restricted to subjects without warfarin contraindications (n = 34,947), we examined the effect of patient characteristics and geographic regions on warfarin use. The overall warfarin use rate was 66.8%. The warfarin use rates varied between hospital referral regions, with highest rates in the Midwestern states and lowest rates in the South. The regional variation persisted even after adjustment for patient characteristics. Multivariable analysis showed that the odds of being on warfarin decreased significantly with age and increasing comorbidity, in blacks, and among those with low income. Seeing a cardiologist (OR 1.10; 95% CI 1.05-1.16), having a PCP (OR 1.23; 95% CI 1.17-1.29), and CHADS(2) score of 2 or greater (OR 1.09; 95% CI 1.01-1.17) were associated with increased odds of warfarin use. Warfarin use rates vary by patient characteristics and region, with higher rates among residents of the Midwest and among patients seen by cardiologists and PCPs. Preventing stroke-related disability in AF requires implementation of evidence-based initiatives to increase warfarin use.

New modalities of brain stimulation for stroke rehabilitation

Stroke is a leading cause of disability, and the number of stroke survivors continues to rise. Traditional neurorehabilitation strategies aimed at restoring function to weakened limbs provide only modest benefit. New brain stimulation techniques designed to augment traditional neurorehabilitation hold promise for reducing the burden of stroke-related disability. Investigators discovered that repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), and epidural cortical stimulation (ECS) can enhance neural plasticity in the motor cortex post-stroke. Improved outcomes may be obtained with activity-dependent stimulation, in which brain stimulation is contingent on neural or muscular activity during normal behavior. We review the evidence for improved motor function in stroke patients treated with rTMS, tDCS, and ECS and discuss the mediating physiological mechanisms. We compare these techniques to activity-dependent stimulation, discuss the advantages of this newer strategy for stroke rehabilitation, and suggest future applications for activity-dependent brain stimulation.

Characteristics and early and long-term outcome in patients with acute ischemic stroke and low ejection fraction

We assessed the clinical characteristics of patients with acute ischemic stroke (AIS) with left ventricular ejection fraction (EF) ≤ 35% and investigated the association of low EF with early and long-term outcome. A total of 2439 patients of the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) were selected. Demographics, risk factors, pre-stroke treatment, and clinical, radiological and metabolic variables in patients with and without low EF were compared. Functional independence (modified Rankin Score ≤ 2) and mortality were recorded 1 week up to 12 months from admission. Low EF patients (n=119) were more commonly men, older, had higher rates of coronary artery disease and atrial fibrillation (AF), and more frequent pretreatment with anticoagulants, antiplatelets and antihypertensive agents. On admission, they presented with higher stroke severity and had lower values of systolic blood pressure, higher heart rate, and worse estimated glomerular filtration rate. Stroke-related disability and death rates were higher in low EF patients during follow-up (19.5% vs. 7.8% at 1 week, and 36.1% vs. 16.5% at 12 months). Increasing age, stroke severity, and AF were independent predictors of one-year mortality in these patients while prior use of statins had a favorable effect on early mortality. AIS in patients with low EF is associated with older age, cardiac comorbidities, and more severe clinical presentation. Low EF can identify a subset of AIS patients at high risk of early and long-term functional disability and mortality.

Training dual-task walking in community-dwelling adults within 1 year of stroke: a protocol for a single-blind randomized controlled trial

BackgroundCommunity ambulation is a highly complex skill requiring the ability to adapt to increased environmental complexity and perform multiple tasks simultaneously. After stroke, individuals demonstrate a diminished ability to perform dual-tasks. Current evidence suggests that conventional rehabilitation does not adequately address gait-related dual-task impairments after stroke, which may be contributing to low levels of participation and physical inactivity in community-dwelling stroke survivors. The objective of this study is to investigate the efficacy of dual-task gait training in community-dwelling adults within 1 year of stroke. Specifically, we will compare the effects of dual-task gait training and single-task gait training on cognitive-motor interference during walking at preferred speed and at fastest comfortable speed (Aim 1), locomotor control during obstacle negotiation (Aim 2), and spontaneous physical activity (Aim 3).Methods/DesignThis single-blind randomized controlled trial will involve 44 individuals within 12 months of stroke. Following baseline evaluation, participants will be randomly allocated to single- or dual-task gait training. Both groups will receive 12, 30-minute sessions provided one-on-one over 4–6 weeks in an outpatient therapy setting. Single-task gait training involves practice of gait activities incorporating motor relearning principles. Dual-task gait training involves an identical gait training protocol; the critical difference being that the dual-task gait training group will practice the gait activities while simultaneously performing a cognitive task for 75% of the repetitions. Blinded assessors will measure outcomes at baseline, post-intervention, and 6 months after completion of the intervention. The primary outcome measure will be dual-task effects on gait speed and cognition during unobstructed walking. Secondary outcomes include spatiotemporal and kinetic gait parameters during unobstructed single- and dual-task walking at preferred and fastest comfortable walking speeds, gait parameters during high and low obstacle crossing, spontaneous physical activity, executive function, lower extremity motor function, Timed Up and Go, balance self-efficacy, number of falls, and stroke-related disability. Hypotheses for each aim will be tested using an intention-to-treat analysis with repeated measures ANOVA design.DiscussionThis trial will provide evidence to help clinicians make decisions about the types of activities to include in rehabilitation to improve dual-task walking after stroke.Trial registrationClinicalTrials.gov NCT01568957

Stroke rehabilitation: recent advances and future therapies

Despite advances in the acute management of stroke, a large proportion of stroke patients are left with significant impairments. Over the coming decades the prevalence of stroke-related disability is expected to increase worldwide and this will impact greatly on families, healthcare systems and economies. Effective neuro-rehabilitation is a key factor in reducing disability after stroke. In this review, we discuss the effects of stroke, principles of stroke rehabilitative care and predictors of recovery. We also discuss novel therapies in stroke rehabilitation, including non-invasive brain stimulation, robotics and pharmacological augmentation. Many trials are currently underway, which, in time, may impact on future rehabilitative practice.

Returning to Paid Employment after Stroke: The Psychosocial Outcomes In StrokE (POISE) Cohort Study

ObjectivesTo determine which early modifiable factors are associated with younger stroke survivors' ability to return to paid work in a cohort study with 12-months of follow-up conducted in 20 stroke units in the Stroke Services NSW clinical network.ParticipantsWere aged >17 and <65 years, recent (within 28 days) stroke, able to speak English sufficiently to respond to study questions, and able to provide written informed consent. Participants with language or cognitive impairment were eligible to participate if their proxy provided consent and completed assessments on the participants' behalf. The main outcome measure was return to paid work during the 12 months following stroke.ResultsOf 441 consented participants (average age 52 years, 68% male, 83% with ischemic stroke), 218 were in paid full-time and 53 in paid part-time work immediately before their stroke, of whom 202 (75%) returned to paid part- or full-time work within 12 months. Being male, female without a prior activity restricting illness, younger, independent in activities of daily living (ADL) at 28 days after stroke, and having private health insurance was associated with return to paid work, following adjustment for other illnesses and a history of depression before stroke (C statistic 0·81). Work stress and post stroke depression showed no such independent association.ConclusionsGiven that independence in ADL is the strongest predictor of return to paid work within 12 months of stroke, these data reinforce the importance of reducing stroke-related disability and increasing independence for younger stroke survivors.Trial RegistrationAustralian New Zealand Clinical Trials Registry ANZCTRN 12608000459325