Vascular risk factor control and adherence to secondary preventive medication after ischaemic stroke.

BACKGROUND: Studies regarding adequacy of secondary stroke prevention are limited. We report medication adherence, risk factor control and factors influencing vascular risk profile following ischaemic stroke. METHODS: A total of 664 home-dwelling participants in the Norwegian Cognitive Impairment After Stroke study, a multicenter observational study, were evaluated 3 and 18 months poststroke. We assessed medication adherence by self-reporting (4-item Morisky Medication Adherence Scale) and medication persistence (defined as continuation of medication(s) prescribed at discharge), achievement of guideline-defined targets of blood pressure (BP) (<140/90 mmHg), low-density lipoprotein cholesterol (LDL-C) (<2.0 mmol L-1 ) and haemoglobin A1c (HbA1c) (≤53 mmol mol-1 ) and determinants of risk factor control. RESULTS: At discharge, 97% were prescribed antithrombotics, 88% lipid-lowering drugs, 68% antihypertensives and 12% antidiabetic drugs. Persistence of users declined to 99%, 88%, 93% and 95%, respectively, at 18 months. After 3 and 18 months, 80% and 73% reported high adherence. After 3 and 18 months, 40.7% and 47.0% gained BP control, 48.4% and 44.6% achieved LDL-C control, and 69.2% and 69.5% of diabetic patients achieved HbA1c control. Advanced age was associated with increased LDL-C control (OR 1.03, 95% CI 1.01 to 1.06) and reduced BP control (OR 0.98, 0.96 to 0.99). Women had poorer LDL-C control (OR 0.60, 0.37 to 0.98). Polypharmacy was associated with increased LDL-C control (OR 1.29, 1.18 to 1.41) and reduced HbA1c control (OR 0.76, 0.60 to 0.98). CONCLUSION: Risk factor control is suboptimal despite high medication persistence and adherence. Improved understanding of this complex clinical setting is needed for optimization of secondary preventive strategies.

Short- and long-term outcome of constraint-induced movement therapy after stroke: a randomized controlled feasibility trial.

OBJECTIVE: Constraint-induced movement therapy (CIMT) is a method to improve motor function in the upper extremity following stroke. The aim of this trial was to determine the effect and feasibility of CIMT compared with traditional rehabilitation in short and long term. DESIGN: A randomized controlled trial. SETTING: An inpatient rehabilitation clinic. SUBJECTS: Thirty patients with unilateral hand impairment after stroke. INTERVENTION: Six hours arm therapy for 10 consecutive weekdays, while using a restraining mitten on the unaffected hand. MAIN MEASURES: The patients were assessed at baseline, post-treatment and at six-month follow-up using the Wolf Motor Function Test as primary outcome measure and the Motor Activity Log, Functional Independence Measure and Stroke Impact Scale as secondary measurements. RESULTS: The CIMT group (n=18) showed a statistically significant shorter performance time (4.76 seconds versus 7.61 seconds, P= 0.030) and greater functional ability (3.85 versus 3.47, P= 0.037) than the control group (n=12) on the Wolf Motor Function Test at post-treatment assessment. There was a non-significant trend toward greater amount of use (2.47 versus 1.97, P= 0.097) and better quality of movement (2.45 versus 2.12, P=0.105) in the CIMT group according to the Motor Activity Log. No such differences were seen on Functional Independence Measure at the same time. At six-month follow-up the CIMT group maintained their improvement, but as the control group improved even more, there were no significant differences between the groups on any measurements. CONCLUSIONS: CIMT seems to be an effective and feasible method to improve motor function in the short term, but no long-term effect was found.

Evaluation of an extended stroke unit service with early supported discharge for patients living in a rural community. A randomized controlled trial.

OBJECTIVE: To evaluate the effect of an extended stroke unit service (extended service), with early supported discharge and co-ordination of further rehabilitation in co-operation with the primary health care system in three rural municipalities. DESIGN: A randomized controlled trial comparing extended service with ordinary stroke unit service (ordinary service). SUBJECTS: Sixty-two eligible patients with acute stroke living in the rural municipalities of Malvik, Melhus and Klaebu. MAIN MEASURES: The primary outcome was the proportion of patients who were independent according to Modified Rankin Scale (mRS) (independence = mRS < or = 2) 52 weeks after onset of stroke. Secondary outcomes were mRS at 6 and 26 weeks and Barthel Index (BI), Nottingham Health Profile (NHP) and Caregiver Strain Index (CSI) at 6, 26 and 52 weeks. Mortality and length of stay were registered during the 52 weeks. RESULTS: Twelve patients (39%) in the extended service group versus 16 patients (52%) in the ordinary service group were independent according to mRS at 52 weeks (p = 0.444). The odds ratio for independence (extended service versus ordinary service) was 0.33 (95% confidence interval (CI) 0.088-1.234). According to outcome by secondary measures there were no significant differences except less social isolation on NHP in the extended service group at 26 weeks (p = 0.046). There were no significant differences in length of stay. CONCLUSION: An extended stroke unit service with early supported discharge seems to have no positive effect on functional outcome for patients living in rural communities, but might give a trend toward better quality of life. There were no significant differences in length of stay.