Pharmacotherapy for Depression Posttraumatic Brain Injury: A Meta-analysis.

OBJECTIVE: To examine the effectiveness of pharmacotherapy for the treatment of depression following traumatic brain injury (TBI). DESIGN: Systematic review and meta-analysis. Multiple electronic databases were searched to identify relevant studies examining effectiveness of pharmacotherapy for depression post-TBI. Clinical trials evaluating the use of pharmacotherapy in individuals with depression at baseline and using standardized assessments of depression were included. Data abstracted included sample size, antidepressant used, treatment timing/duration, method of assessment, and results pertaining to impact of treatment. Study quality was assessed using a modified Jadad scale. RESULTS: Nine studies met criteria for inclusion. Pooled analyses based on reported means (standard deviations) from repeated assessments of depression showed that, over time, antidepressant treatment was associated with a significant effect in favor of treatment (Hedges g = 1.169; 95% confidence interval, 0.849-1.489; P < .001). Similarly, when limited to placebo-controlled trials, treatment was associated with a significant reduction in symptoms (standardized mean difference = 0.84; 95% confidence interval, 0.314-1.366; P = .002). CONCLUSION: Pharmacotherapy after TBI may be associated with a reduction in depressive symptomatology. Given limitations within the available literature, further well-powered, placebo-controlled trials should be conducted to confirm the effectiveness of antidepressant therapy in this population.

A systematic review and meta-analysis examining pneumonia-associated mortality in dementia.

BACKGROUND: Although it is generally accepted that deaths associated with pneumonia are more common in patients with dementia, no comprehensive reviews on the subject have previously been published. SUMMARY: Relevant studies were identified through a literature search of the PubMed, EMBASE, Scopus, and ISI Web of Science databases for publications up to August 2013. Studies were included if (1) a group of adult subjects with dementia and a (comparison) group composed of subjects without dementia were included, (2) the cause(s) of death was/were reported, and (3) pneumonia was identified as one of the possible causes of death. The occurrence of death due to pneumonia associated with dementia was expressed as an odds ratio (OR) with 95% confidence interval (CI). Thirteen studies were included. The odds of death resulting from pneumonia were significantly increased for persons with any form of dementia compared with those without dementia (OR = 2.22, 95% CI 1.44-3.42, p < 0.001). In a subgroup analysis, using the results from 8 studies that restricted inclusion to persons with Alzheimer's disease, the odds of death resulting from pneumonia were also significantly higher (OR = 1.70, 95% CI 1.12-2.58, p = 0.013). Key Messages: The odds of pneumonia-associated mortality were increased more than 2-fold for patients with dementia.

Prevention of poststroke depression: does prophylactic pharmacotherapy work?

BACKGROUND: Given the negative influence of poststroke depression (PSD) on functional recovery, cognition, social participation, quality of life, and risk for mortality, the early initiation of antidepressant therapy to prevent its development has been investigated; however, individual studies have offered conflicting evidence. The present systematic review and meta-analysis examined available evidence from published randomized controlled trials (RCTs) evaluating the effectiveness of pharmacotherapy for the prevention of PSD to provide updated pooled analyses. METHODS: Literature searches of 6 databases were performed for the years 1990 to 2011. RCTs meeting study inclusion criteria were evaluated for methodologic quality. Data extracted included the antidepressant therapy used, treatment timing and duration, method(s) of assessment, and study results pertaining to the onset of PSD. Pooled analyses were conducted. RESULTS: Eight RCTs were identified for inclusion. Pooled analyses demonstrated reduced odds for the development of PSD associated with pharmacologic treatment (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.22-0.53; P<.001), a treatment duration of 1 year (OR 0.31; 95% CI 0.18-0.56; P<.001), and the use of a selective serotonin reuptake inhibitor (OR 0.37; 95% CI 0.22-0.61; P<.001). CONCLUSIONS: The early initiation of antidepressant therapy, in nondepressed stroke patients, may reduce the odds for development of PSD. Optimum timing and duration for treatment and the identification of the most appropriate recipients for a program of indicated prevention require additional examination.

Community integration following TBI: an examination of community integration measures within the ICF framework.

PURPOSE: The objectives of the present study are (1) to examine whether the content of existing community integration measures used following traumatic brain injury (TBI) is represented in the International Classification of Functioning, Disability and Health (ICF) and (2) to determine if the ICF provides a reasonable framework within which such measurement tools may be compared. METHOD: Five commonly-used assessment instruments were selected for inclusion. Independent raters mapped identified measurement concepts to the ICF using established linking rules. RESULTS: One hundred and eighty-five concepts were identified from 85 items in five scales. Of these more than 75% could be linked to the ICF. The majority of linked concepts were assigned to 64 categories within the activities and participation component of the ICF; however, the focus of assessment within each instrument varied considerably. CONCLUSION: Through a standardized process of item mapping to the ICF, one may examine operationalizations of community integration. This may help inform selection of a method of assessment appropriate to both the subject population and clinical or research purpose. However, this process allows comparison of only the objective content of measurement tools. Subjective evaluations may also be necessary to provide comprehensive assessment of community integration.

Which reported estimate of the prevalence of malnutrition after stroke is valid?

BACKGROUND AND PURPOSE: The reported prevalence of malnutrition after stroke varies widely, whereas it remains unclear which of the estimates is most accurate. The aim of this review was to explore possible sources of this heterogeneity among studies and to evaluate whether the nutritional assessment techniques used were valid. METHODS: A literature search was conducted to identify all studies in which the nutritional state of patients was assessed after inpatient admission for stroke. The percentages of patients identified as malnourished in each study and method of nutritional assessment are reported. For the purposes of this study, an assessment technique was considered valid if at least one form of validity had been demonstrated previously through psychometric evaluation. RESULTS: Eighteen studies meeting inclusion criteria were identified. The reported frequency of malnutrition ranged from 6.1% to 62%. Seventeen different methods of nutritional assessment were used. Four trials used previously validated assessment methods: Subjective Global Assessment, "an informal assessment," and Mini Nutritional Assessment. The nutritional assessment methods used in the remaining studies used had not been validated previously. CONCLUSIONS: The use of a wide assortment of nutritional assessment tools, many of which have not been validated, may have contributed to the wide range of estimates of malnutrition. If so, this underscores the need for valid and reliable assessment tools to further our understanding of the relationship between stroke and nutritional status.

A blueprint for transforming stroke rehabilitation care in Canada: the case for change.

Stroke is a major source of disability in Canada and other developed countries, which carries with it a high toll in terms of personal suffering for the stroke survivor and their family in addition to the associated economic costs. Despite the impressive body of evidence describing effective and feasible stroke rehabilitation practices, stroke survivors, their families, and health professionals currently do not benefit from a rehabilitation system that is well organized and evidence based. Using the principles of best evidence, we make the case for needed changes to the current system based on 5 processes of care known to be important in the pursuit of optimal outcomes: (1) admission to specialized stroke rehabilitation units, (2) early admission to stroke rehabilitation units, (3) intensive stroke rehabilitation therapies, (4) task-specific rehabilitation therapies, and (5) well-resourced outpatient programs. Implementation of these strategies will be expected to result in improved functional gain, fewer complications, decreased mortality, and reduced need for institutionalization. In addition to providing improved care for both the stroke survivor and their family, evidence-based stroke rehabilitation care is more efficient and may reduce costs. Our experience in Canada suggests that instituting these 5 measures alone will result in significant improvements to the health care system.

Health-related quality of life after stroke: what are we measuring?

As there is no single, accepted definition of health-related quality of life (HRQOL), it is assumed to be a broad, multidimensional construct referring to those aspects of people's lives that reasonably relate to their health. Although many scales are used to assess HRQOL, the operationalization of this construct within each tool is unclear. To clarify what each tool is measuring, this study reviewed eight scales commonly used to evaluate HRQOL after stroke. Two reviewers classified scale items from five generic and three stroke-specific scales within an established framework with nine dimensions; physical functioning, symptoms, global judgments of health, psychological well-being, social well-being, cognitive functioning, role activities, personal constructs, and satisfaction with care. All scales reviewed provide multidimensional assessment, but vary in number and combination of dimensions. All include assessment of physical functioning and most incorporate concepts, such as psychological well-being, social well-being, and role activities. One generic (Sickness Impact Profile) and two stroke-specific scales (Stroke Impact Scale and Stroke-Specific Quality of Life Scale) seemed most comprehensive. Evaluated against a common framework of dimensions, scales commonly used in the assessment of HRQOL after stroke provide varying multidimensional assessments of aspects of life function related to health. Whether any of these assessments are sufficient to describe HRQOL in its entirety is unclear.

Assessment of participation outcomes in randomized controlled trials of stroke rehabilitation interventions.

In recent years, the importance of understanding the impact of interventions on an individual's ability to participate in social roles after a stroke event has gained much attention. Comprehensive assessment of treatment effectiveness should include a broader range of outcomes, including social participation. This study attempted to determine the degree to which the assessment of social participation has been included in randomized controlled trials of stroke rehabilitation. An extensive literature search was used to identify all randomized controlled trials from 1968 to 2005. Assessment scales used to evaluate study outcomes were recorded and classified based on the International Classification of Functioning Disability and Health (ICF) framework. Studies citing assessment of more than one ICF component were identified. In total, 1447 outcomes were assessed using 489 measurement scales and were cited in 491 identified trials. Both number of studies and assessment of participation outcomes increased over time. Participation assessments accounted for less than 6% of all measurement citations. Around 56.8% of studies reported multicomponent assessment. Of these, 25% included assessment at the level of ICF Participation. In conclusion, the vast body of work within the areas of impairment and function is a cornerstone for rehabilitation. This is certainly reflected in the recorded measurement citations. Despite increasing awareness and a significant increase in participation assessment, relatively few studies include assessment at this level, thereby limiting our understanding with regard to the impact of rehabilitation interventions on more complex areas of social participation.

Estimates of quality and reliability with the physiotherapy evidence-based database scale to assess the methodology of randomized controlled trials of pharmacological and nonpharmacological interventions.

BACKGROUND AND PURPOSE: Systematic reviews and meta-analyses often include an evaluation of the methodological quality of the individual studies that have been included, and are usually conducted by at least 2 individuals. The objective of this study was to assess the methodological quality and reliability of a series of randomized controlled trials (RCTs) of both pharmacological and nonpharmacological interventions by use of the 10-item Physiotherapy Evidence-Based Database (PEDro) Scale. METHODS: Two abstractors independently reviewed 81 RCTs assessing a variety of interventions. The Cohen kappa statistic and the intraclass correlation coefficient (ICC) were used to assess agreement between abstractors. RESULTS: The average total PEDro scores were 5.94 (SD=1.43) for all studies combined, 6.88 (SD=1.2) for pharmacological studies, and 5.29 (SD=1.26) for nonpharmacological studies. The median score for pharmacological studies was significantly higher than that for nonpharmacological studies (7 versus 5). Pair-wise kappa scores ranged from a low of .452 for concealed allocation among drug trials to perfect agreement (1.00) for randomization and reporting of results from between-group comparisons. The ICCs associated with the cumulative PEDro score were .91 (95% confidence interval [CI]=.83-.94) for all studies, .89 (95% CI=.78-.95) for pharmacological studies, and .91 (95% CI=.84-.952) for nonpharmacological studies. DISCUSSION AND CONCLUSION: The methodological quality for pharmacological interventions was significantly higher than that for nonpharmacological interventions. There was good agreement between raters at an individual item level and in total PEDro scores. A lack of reporting clarity, poor organization of the report, or the failure to include salient details contributed to less-than-perfect agreement between raters.

The PEDro scale provides a more comprehensive measure of methodological quality than the Jadad scale in stroke rehabilitation literature.

OBJECTIVE: To systematically compare the PEDro scale and the Jadad scale when applied to the stroke rehabilitation literature. STUDY DESIGN AND SETTING: A literature search of multiple databases was used to identify all trials from 1968 through 2002. Each article was reviewed and assigned quality scores according to PEDro and Jadad criteria. Quality scores for both scales were compared using descriptive statistics. The correlation between the scales was estimated using the Pearson product moment correlation coefficient. RESULTS: 272 randomized controlled trials were retrieved and subjected to quality scoring to both the PEDro scale and the Jadad scale. Mean scores (with standard deviation) for the PEDro and Jadad scales were 5.78 (1.4) and 2.46 (1.1), respectively. The Pearson coefficient determined the PEDro and Jadad scales to be significantly correlated (r = .59, P < .01). Although significant, the correlation was not deemed to be very strong. When applied to physical or rehabilitation therapy studies only, the scales were slightly less correlated (r = .49, P < .01) than among drug-based studies (r = .52, P < .01). CONCLUSION: In the stroke rehabilitation literature, where double-blinding studies are often not possible due to the nature of the interventions, breaking down the levels of blinding and accounting for concealed allocation, intention-to-treat, and attrition is important. Accordingly, the PEDro scale provides a more comprehensive measure of methodological quality of the stroke literature.

A rehabilitation program for patients recovering from severe stroke.

OBJECTIVE: The purpose of this study was to describe the outcomes of patients with a severe stroke admitted to a specialized "slow stream" rehabilitation program and to develop a model to predict discharge destination. METHODS: Chart review of 196 consecutive non-ambulatory ("lower-band") stroke patients admitted between 1996-2001, to a specialized in-patient rehabilitation unit designed to accommodate the needs of patients with profound disabilities, and who were considered inappropriate for conventional inpatient rehabilitation programs. Special features of this program included the availability of an independent living unit, therapies tailored to individual tolerance and the opportunity to remain on the unit for an extended period until such time that the patients' rehabilitation potential had been maximized. RESULTS: Patients were admitted to the unit after a median of 49 days following stroke onset. Their median admission and discharge functional independence measure (FIM) scores were 46 and 70, respectively. The improvement in ability to perform self-care tasks was statistically significant (Z= -11.18, p<0.0001). By discharge, 54 patients (28%) were able to ambulate independently (with or without an assistive device), while 142 patients (72%) remained wheelchair dependent. Eighty-five patients (43%) returned to their own home upon rehabilitation discharge, while the remainder were admitted to nursing homes or hospitals closer to the patients' home. Admission FIM score, age, no previous history of stroke and male sex were the variables found to most strongly predict discharge home. CONCLUSIONS: Patients with severe strokes who received individualized care on a highly specialized stroke rehabilitation unit achieved impressive functional outcomes despite a lag of seven weeks post stroke before rehabilitation was initiated. Many patients were no longer wheelchair dependent and almost half returned home. Active rehabilitation should not be limited to "middle-band" stroke patients.

Recovery from stroke: differences between subtypes.

The objective of this study was to compare the differences in patterns of recovery and incidence of medical complications in hemorrhagic and ischemic stroke patients admitted for rehabilitation, using a retrospective case series design. It was set in three tertiary care facilities in London, Ontario, Canada. Eight-hundred-and-nineteen consecutive patients, admitted from 1997 to 2001 for rehabilitation following cerebrovascular event, were reviewed. The main outcome measures were: age, length of hospital stay, time to admission, medical complications, ambulation status and functional independence measure scores on both admission and discharge. The results showed that 110 patients had strokes that were hemorrhagic, while 709 were ischemic. The hemorrhagic stroke patients were younger (66 vs. 70 years, P=0.001) and were admitted later post stroke onset (30 vs. 18 days, P<0.0001). They had a higher incidence of pneumonia (6.4 vs. 2.7%, P=0.04), pulmonary emboli (3.6 vs. 0.07%, P=0.006) and wheelchair ambulation on admission (53 vs. 41%, P=0.026). There was no significant difference in incidence of seizures or wheelchair ambulation on discharge, length of rehabilitation stay or Functional Independence Measure scores on both admission and discharge. In conclusion, hemorrhagic stroke patients took longer than ischemic stroke patients to enter into rehabilitation, and were more inclined to experience ambulatory impairments and develop medical complications.

Measuring longitudinally the metabolic demands of stroke patients: resting energy expenditure is not elevated.

BACKGROUND AND PURPOSE: Little is known of the acute, subacute, and longer-term energy demands of stroke, information essential to appropriate clinical and nutritional management. The goals of this study were to (1) determine the resting energy expenditure (REE) of stroke patients from stroke onset to 3 months, (2) examine relations between stroke size, type, location, severity, and REE, and (3) evaluate whether estimation of REE from the Harris-Benedict equation (HB) requires the addition of a "stress factor" to capture the possible additional REE imposed by stroke. METHODS: The REE of new stroke patients was measured prospectively at hospital admission and on days 7, 11, 14, 21, and 90 by indirect calorimetry. Stroke patients' REEs (Kcal/d) over time and REEs as a percentage of HB were compared with control subjects' single measurements. RESULTS: Mean REE and %HB of stroke patients ranged from 1521+/-290 to 1663+/-268 Kcal/d and from 107+/-14.9 to 114+/-12.9 %HB, respectively. Mean measurements of control subjects were 1665+/-265 Kcal/d and 112.9+/-11.4 %HB (NS). REE was not associated with stroke characteristics (NS). Changes in REE measured longitudinally were not clinically meaningful (4 to 62 Kcal/d) though statistically significant (P=0.004). CONCLUSIONS: The REEs of stroke patients and controls were both approximately 10% higher than those predicted by HB. No hypermetabolic response pattern of energy expenditure was evident after stroke. REE did not vary with stroke characteristics, although confirmation with larger subgroups is required.

The efficacy of stroke rehabilitation: a qualitative review.

A systematic review of randomized controlled trials published from 1970-2002 was conducted to assess whether specialized inpatient stroke rehabilitation is associated with improved outcomes compared to conventional care. Twelve studies involving 2,813 patients were included for detailed review. The methodological quality of the studies was assessed using the PEDro Scale. The outcomes of death, functional outcome, length of hospital stay, and rates of institutionalization were compared between the intervention and control group(s). Improved functional outcomes and reduced length of hospital stays were reported among patients receiving specialized rehabilitation in the majority of studies (7/12 and 5/8, respectively), while no differences in mortality or institutionalization were reported between the groups.

Early supported discharge in stroke rehabilitation.

A systematic review of the randomized controlled trials published from 1970-2002 was conducted to assess the effectiveness of early supported discharge programs in the context of stroke rehabilitation. Ten studies, including 1,286 patients, were selected for detailed review. The methodological quality of the studies was assessed using the PEDro Scale. The outcome assessed included functional outcomes, cost analysis, and length of hospital stay. Although the majority of studies reported no statistically significant differences in functional outcomes between the two groups, there was a reduction in hospital stays for patients receiving home-based therapy. These results suggest that patients with milder strokes who receive home-based therapies have similar functional outcomes to patients who receive traditional inpatient rehabilitation.

Gait retraining post stroke.

A major component of stroke rehabilitation focuses on gait restoration. The purpose of this review is to examine the efficacy of a variety of gait retraining techniques currently in clinical use, including strength training, functional electrical stimulation, treadmill training, partial body-weight support, EMG biofeedback, and splinting of the lower extremity. Forty-eight studies evaluating six gait enhancement techniques were reviewed. There is either strong or moderate evidence to support the use of strength training, EMG/biofeedback, and functional electrical stimulation as an adjunctive therapy in gait training, and there is either limited or conflicting evidence to support the use of ankle-foot orthosis, treadmill training, and partial body-weight support.

Rehabilitation of aphasia: more is better.

Although the most effective means of treating aphasia post stroke has not been determined, several areas of aphasia therapy have proven to be more effective than others. A recent study had determined that intense aphasia therapy over a short period of time has greater impact on recovery than less intense therapy over a longer period of time. Building upon the idea that more is better, this article examines other spects of aphasia therapy that may be combined to facilitate recovery.

Community reintegration after stroke.

A systematic review of the literature from 1970-2002 was conducted to highlight the issues facing stroke survivors and their families upon integration into the community. Areas of interests were social support, caregiver burden and depression, family interactions, family education intervention, social and leisure activities post stroke, and leisure therapy. Four studies were selected for detailed reviews of the effectiveness of social support, 10 studies for family education intervention, and 3 studies for leisure therapy post stroke. There was evidence that improved social support as an intervention improves outcomes and that an active educational-counseling approach has a positive impact on family functioning post stroke. However, consensus regarding leisure therapy was not achieved. This article also stresses the impact of caring for a stroke survivor and the effect it has on family functioning and caregiver burden.

Stroke Rehabilitation Evidence-Based Review: methodology.

The Stroke Rehabilitation Evidence-Based Review was intended to be an up-to-date review of all therapies associated with stroke rehabilitation including both therapeutic interventions and medications. This section describes the literature search strategy, the data abstraction process, and the scale used to evaluate the methodological quality of randomized controlled trials included in the review and the system upon which the levels of evidence were based.

Quality of the stroke rehabilitation research.

The Stroke Rehabilitation Evidence-Based Review revealed a wide range of quality scores across primary studies. The aim of this section is to determine what differences there are across studies and to provide a detailed examination of methodological issues in the stroke rehabilitation literature. Methodology of each article was assessed using the Physiotherapy Evidence Database (PEDro) quality scale. Mean PEDro scores and percentage of studies meeting individual PEDro criteria were determined for all studies, for therapy-based studies only, and for drug-based studies only. It was noted that the stroke rehabilitation literature lacked rigor in the area of concealed allocation, blinding of the assessor, and intention-to-treat analysis. Investigation of the methodological quality of stroke rehabilitation literature emphasizes the need for improved treatment protocols, taking into account previous deficits, during research.