Synergistic effects of aerobic exercise and cognitive training on cognition, physiological markers, daily function, and quality of life in stroke survivors with cognitive decline: study protocol for a randomized controlled trial.

BACKGROUND: Aerobic exercise and cognitive training have been effective in improving cognitive functions; however, whether the combination of these two can further enhance cognition and clinical outcomes in stroke survivors with cognitive decline remains unknown. This study aimed to determine the treatment effects of a sequential combination of aerobic exercise and cognitive training on cognitive function and clinical outcomes. METHODS/DESIGN: Stroke survivors (n = 75) with cognitive decline will be recruited and randomly assigned to cognitive training, aerobic exercise, and sequential combination of aerobic exercise and cognitive training groups. All participants will receive training for 60 minutes per day, 3 days per week for 12 weeks. The aerobic exercise group will receive stationary bicycle training, the cognitive training group will receive cognitive-based training, and the sequential group will first receive 30 minutes of aerobic exercise, followed by 30 minutes of cognitive training. The outcome measures involve cognitive functions, physiological biomarkers, daily function and quality of life, physical functions, and social participation. Participants will be assessed before and immediately after the interventions, and 6 months after the interventions. Repeated measures of analysis of variance will be used to evaluate the changes in outcome measures at the three assessments. DISCUSSION: This trial aims to explore the benefits of innovative intervention approaches to improve the cognitive function, physiological markers, daily function, and quality of life in stroke survivors with cognitive decline. The findings will provide evidence to advance post-stroke cognitive rehabilitation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02550990 . Registered on 6 September 2015.

Favorable circulatory system outcomes as adjuvant traditional Chinese medicine (TCM) treatment for cerebrovascular diseases in Taiwan.

BACKGROUND: This study searches the National Health Insurance Research Database (NHIRD) used in a previous project, aiming for reconstructing possible cerebrovascular disease-related groups (DRG),and estimating the costs between cerebrovascular disease and related diseases. METHODS AND MATERIALS: We conducted a nationwide retrospective cohort study in stroke inpatients, we examined the overall costs in 3 municipalities in Taiwan, by evaluating the possible costs of the expecting diagnosis related group (DRG) by using the international classification of diseases version-9 (ICD-9) system, and the overall analysis of the re-admission population that received traditional Chinese medicine (TCM) treatment and those who did not. RESULTS: The trend demonstrated that the non-participant costs were consistent with the ICD-9 categories (430 to 437) because similarities existed between years 2006 to 2007. Among the TCM patients, a wide variation and additional costs were found compared to non-TCM patients during these 2 years. The average re-admission duration was significantly shorter for TCM patients, especially those initially diagnosed with ICD 434 during the first admission. In addition, TCM patients demonstrated more severe general symptoms, which incurred high conventional treatment costs, and could result in re-admission for numerous reasons. However, in Disease 7 of ICD-9 category, representing the circulatory system was most prevalent in non-TCM inpatients, which was the leading cause of re-admission. CONCLUSION: We concluded that favorable circulatory system outcomes were in adjuvant TCM treatment inpatients, there were less re-admission for circulatory system events and a two-third reduction of re-admission within ICD-9 code 430 to 437, compared to non-TCM ones. However, there were shorter re-admission duration other than circulatory system events by means of unfavorable baseline condition.

Readmission, mortality, and first-year medical costs after stroke.

BACKGROUND: Stroke is the leading cause of adult disability and mortality in Taiwan, resulting in a tremendous burden on the healthcare system. The purpose of this study was to characterize disease burden by evaluating readmissions, mortality, and medical cost during the first year after acute stroke under the National Health Insurance (NHI) program. METHODS: This retrospective cohort study extracted information about patients hospitalized with acute stroke from claims data of 200,000 randomly sampled NHI enrollees in Taiwan, with a 1-year follow-up duration. The incidence of the first-year adverse events (AEs) indicated by readmissions or mortality, and the amount of the first-year medical cost (FYMC) were assessed with predictive factors explored. Additionally, we also estimated the cost per life and life-year saved. RESULTS: There were 2368 first-ever stroke patients in our study, including those with subarachnoid hemorrhage (SAH) 3.3%, intracerebral hemorrhage (ICH) 17.9%, ischemic stroke (IS) 49.8%, and transient ischemic attack/other ill-defined cerebrovascular diseases (TIA/unspecified) 29.0%; each stroke type was identified with an all-cause AE of 59.0%, 63.0%, 48.6%, and 46.8%, respectively. Readmissions were mainly because of acute recurrent stroke or the late effects of previous stroke, respiratory disease/infections, heart/circulatory disease, and diseases of the digestive system. Advanced age, hemorrhagic stroke type, respiratory distress/infections, and greater comorbidities were predictive of increased AE risk. Admission to neurology/rehabilitation wards, undertaking neurosurgery, or use of inpatient/outpatient rehabilitation was less likely to incur AEs. Initial hospitalization, readmission, and ambulatory care constituted 44%, 29%, and 27%, respectively, of FYMC with the initial length of stay being the most reliable predictor. The FYMCs were NT $217,959, $246,358, $168,003, and $122,084 for SAH, ICH, IS, and TIA/unspecified, respectively. The cost per life saved were estimated to be NT $435,919, $384,028, $196,281, and $138,888, whereas cost per life-year saved were estimated to be NT$43,926, $48,019, $97,830, and $188,770 for SAH, ICH, IS, and TIA/unspecified, respectively. CONCLUSION: Half of the patients encountered readmission or death during the first year after stroke. Patients with advanced age, more complications, or comorbidities during initial stay tended to be highly vulnerable to AE occurrence, whereas TIA/unspecified stroke carried no less risk for AEs. FYMC or estimated cost per life saved for IS or TIA/unspecified was lower relative to SAH or ICH; however, their estimated cost per life-year saved became higher because of reduced life expectancy.

Cost-effectiveness analysis of stroke management under a universal health insurance system.

OBJECTIVE: Cost-effectiveness analysis (CEA) of stroke management was evaluated in three care models: Neurology/Rehabilitation wards (NW), Neurosurgery wards (NS), and General/miscellaneous wards (GW) under a universal health insurance system. METHODS: From 1997 to 2002, subjects with first-ever acute stroke were sampled from claims data of a nationally representative cohort in Taiwan, categorized as hemorrhage stroke (HS) including subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH); or, ischemic stroke (IS), including cerebral infarction (CI), transient ischemic attack/ unspecified stroke (TIA/unspecified); with mild-moderate and severe severity. All-cause readmissions or mortality (AE) and direct medical cost during first-year (FYMC) after stroke were explored. CEA was performed by incremental cost-effectiveness ratios. RESULTS: 2368 first-ever stroke subjects including SAH 3.3%, ICH 17.9%, CI 49.8%, and TIA/unspecified 29.0% were identified with AE 59.0%, 63.0%, 48.6%, 46.8%, respectively. There were 50.8%, 13.5%, 35.6% of stroke patients served by NW, NS and GW with AE 44.9%, 60.6%, 56.0%, and medical costs of US$ 5,031, US$ 8,235, US$ 4,350, respectively. NW was cost-effective for both mild-moderate and severe IS. NS was the dominant care model in mild-moderate HS, while NW appeared to be a cost-minimization model for severe HS. CONCLUSIONS: TIA/unspecified stroke carried substantial risk of AE. NS performed better in serving mild-moderate HS, whereas NW was the optimal care model in management of IS.

Mental health of parents having children with physical disabilities.

BACKGROUND: Parents of children with disabilities play an essential role in the successful rehabilitation of their children. However, the high level of care required may affect the mental health of the parents and consequently contribute to an unfavorable rehabilitation outcome in their children. The aims of this study are to investigate the mental health of parents of children with physical disabilities and to elucidate the factors affecting parental mental health. METHOD: This was a cross-sectional study. Ninety-one parents of children with physical disabilities who visited the outpatient rehabilitation clinics of a tertiary hospital were invited to join the study. Data from the parents and children were recorded during face-to-face interviews. Parental- perceived stress was assessed using the simplified Parenting Stress Index (PSI/SF). Parental mental health was evaluated as the main outcome measure using the 12-item version of the Chinese Health Questionnaire (CHQ-12). RESULTS: Forty parents (44%) were categorized as psychiatric cases on the CHQ. Child-related factors that negatively affected parental mental health were poor walking ability (p < 0.05), dependency on others to perform activities of daily life (ADL) (p < 0.01), and younger age (p < 0.05). Parent-related factors that negatively affected parental mental health were low income (p < 0.05), no religious beliefs (p < 0.01), high level of parental distress (p < 0.01), parent-child dysfunctional interaction (p < 0.01), and having difficult child (p < 0.05). The most significant predictor of overall parental mental health in multivariate analysis was found to be parental distress. CONCLUSIONS: Parents of children with physical disabilities were at risk of poor mental health. Perceived parental distress is the most important factor affecting parental mental health. Strategies to reduce parental stress should be developed to prevent deterioration of parental mental health.

Regional survey of assistive devices use by children with physical disabilities in southern Taiwan.

BACKGROUND: Despite increasing use of assistive devices (ADs) by physically disabled (PD) children, the use rate, number, effects and related services have seldom been studied. Understanding AD utilization is helpful in improving the related services. This study describes the usage of ADs by children with physical disabilities (PDs). METHODS: This regional survey enrolled children with PDs. The children's parents or primary caregivers filled out structured questionnaires regarding the children's use of and need for ADs, the benefits and problems associated with the ADs and related services. RESULTS: In total, 224 ADs were used by 124 children (1.79 ADs per child). The most commonly used ADs were orthoses (n = 77, 62.10%), mobility aids (n = 51, 41.13%), and aids for therapy and training (n = 21, 16.94%). The degree of disability, age, gender, diagnosis and rehabilitation training location were not associated with the number of ADs used. Most children (n = 103, 83.06%) benefited from ADs, and 93 (75%) children had been evaluated prior to buying ADs. Eighty three (66.94%) parents paid for the Ads, and 108 (87.10%) parents acquired information from rehabilitation professionals. Forty one (40.20%) parents were satisfied with the services of local suppliers; 119 (95.97%) parents had applied to their local government for financial support; 82 (68.91%) parents were not satisfied with the application procedures or the amount of support they received. CONCLUSION: Although parents of PD children favored the usage of ADs, they needed additional information. We suggest that policies and strategies are needed to reduce barriers to ADs utilization, enhance insurance coverage and improve ease of using the services.

Fitting a bilateral transhumeral amputee with utensil prostheses and their functional assessment 10 years later: a case report.

Traumatic transhumeral amputations resulting from electric burn injury are uncommon and present a significant rehabilitation challenge. Compensating for loss of fine, coordinated function of the upper extremities with prostheses is difficult medically, technologically, psychologically, and socially. We followed up a patient with traumatic bilateral transhumeral amputation who was fitted with specially designed bilateral low-temperature utensil prostheses for 10 years. A bilateral utensil prosthesis consists of 2 thermoplastic sockets, an elastic harness, 2 utensil holders, and several different utensils. The characteristics of utensil prostheses are low cost, quick fabrication, and responsiveness to a patient's needs. Ten years after the patient's first prosthesis fitting, he still used these specially designed prostheses. By using these devices and his feet, the patient has regained independence in most activities of daily living and gained a new working skill.