Can overestimation of walking ability increase the risk of falls in people in the subacute stage after stroke on their return home?

PURPOSE: Falls are common in patients who have had a stroke who return home after neurorehabilitation. Some studies have found that walking speed inversely correlates with the risk of falls. SCOPE: This study examined whether comparison between comfortable self-selected walking speed and maximum maintainable speed is informative with regard to the risk of falls in patients with stroke. METHODS: A prospective cohort study was performed with 75 ambulant stroke patients. At discharge, the Barthel Index score and performance at the 10-m and 6-min walking tests were assessed. Number of falls was recorded by telephone interview every two months for one year. Regression analysis was performed to identify factors that were related to the risk of falls. RESULTS: Using forward multiple linear regression, only the ratio between walking speeds on the 6-min and 10-m tests was linked to the number of falls in the year after discharge (R=-0.451, p<0.001, OR=0.046). Patients who chose a walking speed for short distances that was not maintainable long term fell more frequently. CONCLUSIONS: A discrepancy between short and long-term walking speed can help in identifying subjects in the subacute stage after stroke with an increased risk of suffering a fall.

Seven capital devices for the future of stroke rehabilitation.

Stroke is the leading cause of long-term disability for adults in industrialized societies. Rehabilitation's efforts are tended to avoid long-term impairments, but, actually, the rehabilitative outcomes are still poor. Novel tools based on new technologies have been developed to improve the motor recovery. In this paper, we have taken into account seven promising technologies that can improve rehabilitation of patients with stroke in the early future: (1) robotic devices for lower and upper limb recovery, (2) brain computer interfaces, (3) noninvasive brain stimulators, (4) neuroprostheses, (5) wearable devices for quantitative human movement analysis, (6) virtual reality, and (7) tablet-pc used for neurorehabilitation.

Walking training with foot drop stimulator controlled by a tilt sensor to improve walking outcomes: a randomized controlled pilot study in patients with stroke in subacute phase.

Foot drop is a quite common problem in nervous system disorders. Neuromuscular electrical stimulation (NMES) has showed to be an alternative approach to correct foot drop improving walking ability in patients with stroke. In this study, twenty patients with stroke in subacute phase were enrolled and randomly divided in two groups: one group performing the NMES (i.e. Walkaide Group, WG) and the Control Group (CG) performing conventional neuromotor rehabilitation. Both groups underwent the same amount of treatment time. Significant improvements of walking speed were recorded for WG (168 ± 39%) than for CG (129 ± 29%, P = 0.032) as well as in terms of locomotion (Functional Ambulation Classification score: P = 0.023). In terms of mobility and force, ameliorations were recorded, even if not significant (Rivermead Mobility Index: P = 0.057; Manual Muscle Test: P = 0.059). Similar changes between groups were observed for independence in activities of daily living, neurological assessments, and spasticity reduction. These results highlight the potential efficacy for patients affected by a droop foot of a walking training performed with a neurostimulator in subacute phase.

Effects of walking endurance reduction on gait stability in patients with stroke.

Control of gait is usually altered following stroke, and it may be further compromised by overexertion and fatigue. This study aims to quantitatively assess patients' gait stability during six-minute walking, measuring upper body accelerations of twenty patients with stroke (64 ± 13 years old) and ten age-matched healthy subjects (63 ± 10 years old). Healthy subjects showed a steady gait in terms of speed and accelerations over the six minutes. Conversely, the patients unable to complete the test (n = 8) progressively reduced their walking speed (-22 ± 11%, confidence interval CI(95%): -13, -29%, P = 0.046). Patients able to complete the test (n = 12) did not vary their walking speed over time (P = 0.493). However, this ability was not supported by an adequate capacity to maintain their gait stability, as shown by a progressive increase of their upper body accelerations (+5 ± 11%, CI(95%): -1; +12%, P = 0.010). Walking endurance and gait stability should be both quantitatively assessed and carefully improved during the rehabilitation of patients with stroke.

Exploring the use of ''Protocollo di Minima per l'ictus - PMIC'': preliminary data in two Italian rehabilitation units.

AIM: This study was designed associated to evaluate applicability of ''Protocollo di Minima per l'ictus PMIC'' in Italian rehabilitative units, and to collect preliminary data METHODS: The authors evaluated, by means of PMIC, stroke patients admitted to rehabilitative unit of both IRCCS Santa Lucia Foundation, Rome and Sant'Agostino Estense New Civil Hospital, Baggiovara, Modena for sequelae of their first-ever event. Multiple regression analyses (backward selection) were then performed to identify variables with discharge functional status (Barthel Index [BI] and Functional Ambulation Category [FAC] score) and rehabilitation effectiveness (on BI and FAC), and logistic regression to quantify the probability of reaching a discharge BI score > or = 70 and FAC score > or = 4. RESULTS: Sample included 94 patients with recent stroke (onset-admission interval 12.68+/-16.09 days). Mean time of evaluation for each case was 16.15+/-1.43 minutes. Increasing age, sex, degree of basal impairment and disability confirmed to be reliable prognostic factors. CONCLUSION: Recording data of patients admitted to rehabilitative hospital according to PMIC, is easy, quick and enough exhaustive.

Poststroke depression and its role in rehabilitation of inpatients.

OBJECTIVES: To identify the prevalence of poststroke depression (PSD) in a population of patients admitted for rehabilitation of neurologic sequelae of their first stroke, to recognize reliable prognostic factors associated with the occurrence of PSD, and to evaluate the impact of PSD on the results of rehabilitation treatment. METHODS: In a prospective study of 470 of 508 consecutive patients admitted to a rehabilitation hospital for sequelae of their first stroke, the relation between 23 independent variables and the development of depression was assessed by using a logistic regression analysis (forward stepwise). In addition, the impact of PSD on basal disability and on rehabilitation results was assessed by multiple measures (length of stay, efficiency, effectiveness, and percent of low responders on activities of daily living [ADL] and mobility). RESULTS: PSD occurred in 129 patients (27.4%). Being female and having more than 8 years of schooling were associated with a higher probability of developing depression (odds ratio [OR] = 1.94, 95% confidence interval [CI] = 1.27-2.96, and OR = 1.61, 95% CI = 1.04-2.48, respectively). No association was found with site or side of cerebral lesion. In a logistic model, depression was a significant independent predictor (OR = 1.99, 95% CI = 1.14-3.46) of low response on ADL in spite of treatment. CONCLUSIONS: PSD occurs especially in female patients and in patients with a high level of education and, even if treated, may affect rehabilitation results. No association was found between brain lesion location and PSD.

Prognostic factors in rehabilitation of above knee amputees for vascular diseases.

PURPOSE: This study was undertaken to predict rehabilitation potential and prognostic factors of patients undergoing above knee amputation for vascular diseases. METHOD: In a prospective study on 144 patients consecutively admitted to our rehabilitation unit for above knee amputation, multiple regression analyses were used to assess the relationship between nine independent variables and a battery of outcome measures: the Rivermead Mobility Index (RMI) and Barthel Index (BI) effectiveness on discharge, length of hospital stay. Two multiple logistic regressions were performed, using as dependent variable the occurrence of good or partial autonomy in mobility, quantified as RMI scores. RESULTS: Advanced age was the most powerful prognostic factor influencing effectiveness expressed as both mobility (RMI) and BI. Patients aged < 65 years had a greater probability (odds ratio 2.92) of good autonomy in mobility than older patients. The absence of vascular impairment of the residual limb and timely admission to the rehabilitation hospital correlated positively with effectiveness of mobility. CONCLUSIONS: These findings indicate that relevant prognostic factors can be identified at the beginning of rehabilitation treatment.

Functional outcome in stroke inpatient rehabilitation: predicting no, low and high response patients.

The aims of this study were: (1) to identify reliable prognostic factors for detecting subgroups of no, low and high response in consecutive patients admitted for rehabilitation of first stroke sequelae, and (2) to quantify the relative risk of poor or excellent prognosis on both Activities of Daily Living (ADL) and mobility for each significant variable. We prospectively studied 440 of 475 patients. From a group of 32 independent variables, those significantly associated with no, low and high effectiveness on both ADL and mobility were selected by means of multiple regression; then, the relative risk was calculated for each variable that significantly entered the multiple regressions. Patients with severe impairment or with global aphasia showed a relative risk of no response 4-6 times higher than that of other patients. An interval before rehabilitation longer than 2 months was associated with an increasing risk of no response. Elderly patients had a significantly higher relative risk of low response both on ADL and mobility. The presence of hemineglect and depression was associated with an increasing risk of low response on ADL but not on mobility. The absence of hemineglect and a short interval are prerequisites for an excellent functional prognosis on both ADL and mobility. A minor impairment, employed status, the absence of global aphasia and age < or = 65 years increased the risk of high response. At the beginning of treatment, clear prognostic factors for the detection of subgroups with poor or excellent rehabilitation prognosis can be identified.

Changes in functional outcome in inpatient stroke rehabilitation resulting from new health policy regulations in Italy.

This study was designed to assess whether enforcement of new health policy regulations in Italy limiting fully paid hospital stay to 60 days has actually caused a decrease in rehabilitation outcomes of stroke patients. Final sample included 370 out of 398 consecutive patients hospitalized between 1993 and 1996 for first stroke sequelae. Rehabilitation results were compared between subgroups of patients admitted before and after new Italian regulations. Length of stay was significantly (p < 0.001) shorter in 1996 than in previous years. However, between 1993 and 1996 a significant (p < 0.05) decrease in effectiveness on mobility and a significant (p < 0.05) increase in "low responders" on both daily living activities and mobility was observed. Moreover, in 1995-96 the precocious discharge of patients compromised stabilization of recovery with subsequent functional worsening. After discharge, outpatient rehabilitation treatment was able to conserve achieved mobility status, but not functional status on daily living activities. We suggest revising the present regulation for medical rehabilitation services to one based on FRGs (functional related groups), so that the appropriate treatment can be carried out for each patient.

Post-stroke rehabilitation: an economic or medical priority? Current issues and prospects in light of new legislative regulations.

The aim of this study was to evaluate: 1) whether the reduction in duration of in-patient rehabilitation imposed by the Italian Ministry of Health's circular of 29/6/95 has been accompanied by a decline in the results achieved; and 2) whether the system of basing payments on diagnosis related group (DRG) criteria is capable of correctly evaluating differences in post-stroke clinical pictures. The study involved 461 of 497 patients consecutively admitted between 1991 and 1996 for rehabilitation after a first stroke. The average duration of hospitalisation for the period 1995-1996 was significantly shorter (p<0.001) than that of the previous years; at the same time, there was a significant increase (p<0.05) in the number of poor responders in both neurological and functional (mobility) terms. Furthermore, the early discharge after 60 days of the 1995-1996 patients compromised the stabilisation of recovery and led to a subsequent functional decline. It is therefore hoped that the current regulations will be revised and that payments based on a functional related group (FRG) criterion will be introduced.

Poststroke late seizures and their role in rehabilitation of inpatients.

PURPOSE: This study was designed to (a) identify the prevalence of poststroke late seizures in a population of patients admitted to rehabilitation of neurologic sequelae of their first stroke, (b) recognize reliable prognostic factors associated with the occurrence of poststroke late seizures, and (c) evaluate the impact of seizures on the results of rehabilitation treatment. METHODS: In a prospective study of 306 consecutive patients admitted to a rehabilitation hospital for sequelae of their first stroke, we assessed the relation among 15 independent variables and the development of seizures by using multiple regression analysis (forward stepwise). In addition, we evaluated the impact of occurrence of poststroke seizures on both efficiency and effectiveness of rehabilitation and length of stay. RESULTS: Poststroke late seizures occurred in 46 (15.03%) patients, with a mean interval from stroke of 101.98 +/- 37.96 days. In multiple regression analysis, putaminal and lobar hemorrhages showed a significant positive association with the development of seizures (p < 0.005), whereas high scores on the Canadian Neurological Scale (CNS) (indicating less severe strokes) and increasing age were negatively associated (p < 0.01 and p < 0.05, respectively). Patients with putaminal and lobar hemorrhages and patients with severe stroke (CNS score at admission, <7) were at significantly greater relative risk of seizures [relative risk (RR) = 1.99, 95% confidence interval (CI), 1.11-1.39; RR = 3.00, CI, 1.06-1.13; and RR = 2.41, CI, 1.01-1.27, respectively). No significant association was found between poststroke seizures and results of rehabilitation. CONCLUSIONS: Poststroke late seizures occurred mainly in patients with putaminal and lobar hemorrhagic strokes but, if treated, did not affect rehabilitation therapy.

Predicting stroke inpatient rehabilitation outcome: the prominent role of neuropsychological disorders.

This study was designed to determine the role of demographic, medical and cognitive factors in the results of rehabilitation in first stroke patients. In a prospective study on 273 consecutive patients admitted to a rehabilitation hospital for sequelae of first stroke, we used multiple regressions to assess the relationship between 11 independent variables and a battery of outcome measures: mortality, length of hospital stay, Barthel Index (BI) and Rivermead Mobility Index (RMI) scores at discharge and their effectiveness. Severity of stroke at admission and hemineglect were the strongest prognostic factors. In a logistic model, cognitive impairment was a significant independent predictor (OR = 4.10) also after adjusting for age and severity of stroke. Patients with hemineglect had a significantly higher relative risk of poor autonomy [RR = 7.30, 95% confidence interval (CI) 4.04-13.18] and impaired mobility (RR = 9.25, CI 4.63-18.45). Global aphasic patients had similar risks for both autonomy (RR = 4.51, CI 2.74-7.41) and mobility (RR = 4.71, CI 2.79-7.97). This study underlines the crucial role of cognitive disorders as predictors of poor functional outcome in stroke survivors and confirms the need for early neuropsychological screening.

Rehabilitation and Parkinson's disease.

In this study we evaluated the efficacy of physical therapy together with drug therapy in a group of parkinsonian patients, compared with a group of patients treated using drug therapy only. The physical therapy program lasted four months and included passive and active mobilization exercises, adopted for postural control and equilibrium, walking and prevention of contractures and ankylosis. The assessment was accomplished by means of clinical rating scales and motor performance tests. Patients treated by means of physiotherapy showed an improvement at the end of the study in both clinical scales and motor performance tests. This improvement was noted in both patients with less severe and more severe symptoms as well as in those with shorter and longer disease duration. It is not easy to assess the role played by physical therapy due to the difficulty of an objective evaluation; our results, however, show an improvement in the functional performance of patients and suggest the usefulness of physical therapy associated with drug therapy in a comprehensive treatment for Parkinson's disease.

Cardiovascular reflexes and autonomic dysfunction in Parkinson's disease.

Cardiovascular reflexes were analysed in a group of 20 patients suffering from Parkinson's disease and in 12 age-matched healthy subjects, in order to ascertain the incidence and degree of autonomic dysfunction. The following were measured: heart rate variation during normal breathing, postural change (30/15 ratio) and during the Valsalva manoeuvre: blood pressure variation after standing. These measurements were taken at least 12 h after therapy had been withdrawn and were repeated after therapy had been resumed. Significant changes in the different heart rate variation indices were found in the parkinsonian patients which correlated with the duration and severity of the extrapyramidal symptomatology. After standing the patients showed a significant drop in blood pressure, when compared respectively with their base values and with the response in controls. Anticholinergic drugs had no significant effect on the heart rate variation indices, whereas antiparkinsonian therapy seems to have contributed to the drop in blood pressure after standing.