Impact of stroke-associated infection on long-term survival: a cohort study.

BACKGROUND AND OBJECTIVE: The effects of stroke-associated infection (SAI) on long-term survival are unclear. We performed a prospective evaluation to explore risk factors of SAI, and compared survival status over the 3 years following stroke onset between those who experienced SAI and those who did not. METHODS: Consecutive patients with acute stroke admitted to a stroke unit between April 2005 and December 2006 were invited to participate. We prospectively collected data on demographics, pathological and clinical stroke subtype, stroke severity, and neurological and functional consequences, and abstracted additional data on occurrence and timing of SAI in hospital from medical notes. Survival status 3 years after stroke onset was obtained. RESULTS: We recruited 413 acute stroke patients, 161 (39%) experienced SAI. After excluding patients with infection at onset, patients with intracerebral haemorrhage (p=0.014), dysphagia (p=0.003) and urinary incontinence/catheterisation (p=0.000) were at higher risk of infection after controlling for case mix. The risk of death in hospital was greater following an SAI (HR 3.56; 95% CI 1.94 to 6.53; p=0.000), as was risk of death calculated over the whole 3-year follow-up period among those acquiring SAI within 2 weeks of onset (HR 1.66; 95% CI 1.14 to 2.40; p=0.031). CONCLUSIONS: SAIs have long-lasting effects on patient survival. This serves to emphasise the importance of immediate access to organised stroke unit care for people with acute stroke, with active physiological monitoring and protocols for early detection and treatment of SAIs.

Strategies used by people with Parkinson's disease who report difficulty turning.

PURPOSE: Difficulty turning (DT) is common in Parkinson's disease (PD). We set out to answer the questions: (1) do people who do and do not report DT differ in postural stability, heel strike, the use of support and step count when performing functional turns during everyday tasks, (2) is the structured observation of functional tasks an ecologically valid way of assessing an individual's ability to turn and (3) does a history of DT predict freezing and/or falls. METHOD: At home, 75 people (median age 75 years; PD duration 7 years) answered questions about DT, freezing and falls and completed a standard 180 degrees turn test and an everyday task necessitating spontaneous turns, later rated from video by blinded assessors. RESULTS: Forty-two people reported DT, of whom 86% reported frequent freezing and/or falls. Twenty-six people with DT and 15 without completed the functional task. Greater proportions of the former appeared Unstable (12 vs 1; P = 0.014), lacked Heel Strike (25 vs 9; P = 0.006) and Used Support (7 vs 0; P = 0.035): the former took more Turning Steps (medians 6 vs 4; P = 0.001). The 95% limits of agreement between step counts (functional vs standard turns) ran from -6.3 to 3.6 steps. Of 49 people with a history of freezing and/or falls, 36 (73%) reported frequent DT. CONCLUSIONS: People who report DT turn differently to those who report no problems. Standard turn tests poorly reflect step count during real-life turning, whereas unobtrusive structured observation reveals the turning strategies people use, so can guide rehabilitation. Reported DT is a sensitive indicator of freezing and/or falling, both indicators for physiotherapy.

Stepping onto a single step: a kinematic study.

BACKGROUND AND PURPOSE: To describe the timings and ranges of linear displacements of the pelvis and feet occurring in a healthy older population when stepping up onto a step, and to describe variations noted in a small sample of subjects with hemiplegia. METHOD: An observational case series study design was used and the study took place in a gait laboratory in a general hospital. A convenience sample of 54 healthy volunteers (mean age 57.6 years, range 40-90 years; 26 males, 28 females) and six subjects with chronic hemiplegia (mean age 61.7 years, range 47-70 years; five males, one female) was recruited. Participants stepped up onto an 18 cm step. The following outcome measures were made: kinematic measures of stepping up cycle time; pelvic lateral displacement; width of foot base; and height of heel clearance by use of CODA (a three-dimensional movement analysis system). RESULTS: The mean (standard deviation, SD) stepping up cycle of healthy subjects was 1.68 seconds (+/- 0.22 seconds). The total range of pelvic lateral displacement during one stepping up cycle was 70 mm. Pelvic lateral displacement was asymmetrical, being significantly greater towards the initial weightbearing leg (p<0.0001). Older subjects (aged 60+ years) had less heel clearance (p<0.03) than younger subjects (aged <60 years). Stepping up performance by subjects with hemiplegia showed wide inter-subject variability, and was observed to be as much as three times slower to use as much as four times the range of pelvic lateral displacement and twice the foot base, and to be asymmetrical in timing of the stepping up cycle. CONCLUSIONS: This kinematic study describes a healthy stepping up pattern not previously reported. Age and hemiplegia influenced the amount and speed of movement adopted during the task. Information about the movement strategies used by the elderly and those with hemiplegia should guide physiotherapists in their management of physical function.

Kinematic analysis of head, trunk, and pelvis movement when people early after stroke reach sideways.

BACKGROUND: Sideways reaching with the unaffected arm while seated is a component of everyday activities and can be a challenging task early after stroke. Kinematic analysis of a lateral reach task may provide potential rehabilitation strategies. OBJECTIVE: The authors examined the difference between people with stroke and healthy controls in the movement sequence of head, trunk, and pelvis, as well as the difference in angle at maximum reach and peak velocity for each body segment during reach and return. METHODS: Twenty-four people within 12 weeks of a stroke and 20 healthy subjects performed a standardized lateral reach. Using CODAmotion, movement sequence was determined and angles and peak velocities were calculated. RESULTS: When reaching, people with stroke moved their pelvis first, followed by the trunk and head, whereas healthy controls started with their head and then moved their trunk and pelvis. Patients achieved significantly smaller angles at maximum reach compared with healthy subjects for all body segments and lower peak velocities during the reach (for head, trunk, and pelvis) and the return (for head and trunk). CONCLUSIONS: Lateral reaching to the unaffected side early after stroke revealed a different pattern than normal and patients reached less far and moved at a slower speed. Specific training strategies to improve reaching are needed.

Impaired bed mobility and disordered sleep in Parkinson's disease.

The contribution of impaired mobility to disordered sleep in Parkinson's disease (PD) remains uncertain. We evaluated the sleep of 38 people with PD and observed their turning strategies. Most reported difficulty maintaining sleep and difficulty turning. Those who hip-hitched rated themselves more disabled and those who sat up had more severe PD than those who used support. Using multiple strategies was associated with sleep disturbance. As the ability to turn deteriorates, we recommend patients identify the single strategy least disruptive to sleep. Research must address whether improving mobility improves sleep quality.