Six-month outcomes and patterns of recovery for people with lateropulsion following stroke.

PURPOSE: This study investigated the (1) six-month outcomes of individuals with lateropulsion; (2) the relationship between baseline measures (from in-patient hospitalisation) and six-month functional abilities; and (3) recovery patterns for lateropulsion in stroke survivors. MATERIALS AND METHODS: Forty-one individuals with lateropulsion participated in this study. Measures of lateropulsion, postural function, and weight-bearing asymmetry in standing were taken initially and fortnightly over eight weeks. Functional independence and walking abilities were assessed at six months post-stroke. RESULTS: Compared to individuals with moderate to severe lateropulsion, those with mild lateropulsion achieved higher levels of functional outcome at six months. However, there were a wide range of scores. Baseline lateropulsion severity explained 26% of the variation in functional outcome. A stronger correlation with functional outcome was observed for lateropulsion (-0.526) than function independence at baseline (0.384). For the task of standing with arm support, patterns of asymmetry were divergent at baseline, favouring either the paretic or non-paretic leg. Over the eight-week period, asymmetry moved towards the non-paretic leg and lateropulsion reduced consistently. CONCLUSIONS: Individuals with lateropulsion can recover from lateropulsion and make meaningful functional gains, including some individuals with more severe lateropulsion. Lateropulsion severity is a key indicator of functional outcome post-stroke.IMPLICATIONS FOR REHABILITATIONIndividuals with lateropulsion can make significant gains in terms of mobility and functional abilities by six months post-stroke, learning to compensate for their verticality impairment in standing by loading their non-paretic leg.It is important that stroke survivors with lateropulsion, including those with moderate and severe lateropulsion, are provided with adequate rehabilitation to optimise their longer-term mobility and functional abilities.Routine screening of acute stroke survivors for lateropulsion is recommended, given lateropulsion may negatively impact longer-term functional outcomes in stroke survivors.Therapists should carefully analyse the weight-bearing pattern which an individual with lateropulsion adopts in standing and subsequently tailor treatment to target this.

Clinical practice recommendations for management of lateropulsion after stroke determined by a Delphi expert panel.

OBJECTIVE: People exhibiting post-stroke lateropulsion actively push their body across the midline to the more affected side and/or resist weight shift toward the less affected side. Despite its prevalence and associated negative rehabilitation outcomes, no clinical practice guidelines exist for the rehabilitation of post-stroke lateropulsion. We aimed to develop consensus-based clinical practice recommendations for managing post-stroke lateropulsion using an international expert panel. DESIGN: This Delphi panel process conformed with Guidance on Conducting and Reporting Delphi Studies recommendations. PARTICIPANTS: Panel members had demonstrated clinical and/or scientific background in the rehabilitation of people with post-stroke lateropulsion. MAIN MEASURES: The process consisted of four electronic survey rounds. Round One consisted of 13 open questions. Subsequent rounds ascertained levels of agreement with statements derived from Round One. Consensus was defined a priori as ≥75% agreement (agree or strongly agree), or ≥70% agreement after excluding 'unsure' responses. RESULTS: Twenty participants completed all four rounds. Consensus was achieved regarding a total of 119 recommendations for rehabilitation approaches and considerations for rehabilitation delivery, positioning, managing fear of falling and fatigue, optimal therapy dose, and discharge planning. Statements for which 'some agreement' (50%-74% agreement) was achieved and those for which recommendations remain to be clarified were recorded. CONCLUSIONS: These recommendations build on existing evidence to guide the selection of interventions for post-stroke lateropulsion. Future research is required to elaborate specific rehabilitation strategies, consider the impact of additional cognitive and perceptual impairments, describe positioning options, and detail optimal therapy dose for people with lateropulsion.

Post-stroke lateropulsion terminology: pushing for agreement amongst experts.

Post-stroke lateropulsion is prevalent. The global inconsistency in terminology used to describe the condition presents obstacles in accurately comparing research results, reaching consensus on use of measurement tools, agreeing upon a consistent approach to rehabilitation, and translating research to clinical practice. Commencing in 2021, 20 international experts undertook a Delphi Process that aimed to compile clinical practice recommendations for the rehabilitation of lateropulsion. As a part of the process, the panel agreed to aim to reach consensus regarding terminology used to describe the condition. Improved understanding of the condition could lead to improved management, which will enhance patient outcomes after stroke and increase efficiency of healthcare resource utilisation. While consensus was not reached, the panel achieved some agreement that 'lateropulsion' is the preferred term to describe the phenomenon of 'active pushing of the body across the midline toward the more affected side, and / or actively resisting weight shift toward the less affected side'. This group recommends that 'lateropulsion' is used in future research and in clinical practice.

Standing weight-bearing asymmetry in adults with lateropulsion following stroke.

BACKGROUND: Weight-bearing asymmetry biasing the non-paretic leg is common following stroke. However, little is known as to how lateropulsion impacts on the weight-bearing patterns adopted in standing by individuals following stroke. RESEARCH QUESTIONS: (1) Are there differences in weight-bearing asymmetry patterns observed in standing in people with lateropulsion relative to healthy controls; (2) What is the relationship between weight-bearing asymmetry and clinical measures of lateropulsion and postural function; and (3) Are measures of weight-bearing asymmetry reliable between test occasions. METHODS: Thirty-three individuals with lateropulsion and 35 healthy controls participated in this study. For the participants with lateropulsion, weight-bearing asymmetry during standing tasks (measured using two Wii Balance Boards) and clinical measures of lateropulsion (Burke Lateropulsion Scale) and postural function (Postural Assessment Scale for Stroke) were assessed initially and fortnightly over eight weeks. RESULTS: Individuals with lateropulsion displayed marked weight-bearing asymmetry in standing compared to healthy controls. This asymmetry was predominantly towards their non-paretic leg when standing unsupported, and mixed presentation of weight-bearing asymmetry directions when standing with arm support. No significant correlations were observed between directional weight-bearing asymmetry and the Burke Lateropulsion Scale. A moderate correlation was found between absolute weight-bearing asymmetry for the stand with arm support task and the Postural Assessment Scale for Stroke (r = -0.608). The weight-bearing asymmetry variables for the standing with arm support task were found to be highly reliable between test occasions (ICC 0.915-0.972) and the standard error of measurement was 8.2%-9.3% body weight. SIGNIFICANCE: Individuals with lateropulsion following stroke demonstrate marked and varied patterns of asymmetry in standing. Weight-bearing asymmetry when standing with arm support may be an appropriate outcome measure for use with patients with lower functional abilities, including those with lateropulsion.

Rasch analysis of the Burke Lateropulsion Scale (BLS).

BACKGROUND: Lateropulsion is a common problem following stroke. Whilst the Burke Lateropulsion Scale (BLS) is recommended in the literature as the outcome measure of choice for measuring lateropulsion, the internal validity of the BLS has not been investigated. OBJECTIVES: To evaluate the internal validity of the BLS for use in evaluating the effectiveness of therapies aimed at reducing lateropulsion. METHODS: Rasch analysis procedures were undertaken including assessment of overall model fit, item, and person fit, threshold ordering, differential item functioning, internal consistency, targeting, and dimensionality. RESULTS: Data from 132 participants were utilized to perform Rasch analysis of the BLS. In this preliminary study, overall model fit and individual item and person fit were found to be good using fit residual statistics and chi-square probability values. The BLS was found to be unidimensional and have good internal consistency (Person Separation Index 0.867). Thresholds for four of the five items were found to be only marginally disordered and were subsequently not modified. Non-uniform differential item functioning was detected for age for the transfers item; however, this item did not display item misfit and was therefore not removed. CONCLUSIONS: This study identified good psychometric properties of the BLS using Rasch analysis and supports the use of the BLS as a measure of lateropulsion following stroke. Further use of Rasch analysis on the BLS using a larger sample is recommended to confirm these preliminary findings and allow transformation into an interval-level scale.

Comprehensive clinical sitting balance measures for individuals following stroke: a systematic review on the methodological quality.

PURPOSE: The aim of this systematic review was to examine the psychometric properties of published clinical sitting measurement scales containing dynamic tasks in individuals following stroke. METHOD: Databases, including Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, EMBASE, Cochrane, PubMed and Allied and Complementary Medicine Database (AMED) were searched from inception to December 2015. The search strategy included terms relating to sitting, balance and postural control. Two reviewers independently selected and extracted data from the identified articles and assessed the methodological quality of the papers using the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist. RESULTS: Fourteen clinical sitting measurement scales (39 papers) containing dynamic tasks met the inclusion criteria and various measurement properties were evaluated. The methodological quality of the majority of the included studies was rated as poor to fair using the COSMIN checklist, with common limitations including small sample size and inappropriate use of statistical methods. CONCLUSIONS: This review was unable to identify measures with sufficient psychometric properties to enable recommendation as preferred tools. However, measures were identified that warrant further specific psychometric investigations to fulfil requirements for a high quality measure. Implications for Rehabilitation Fourteen clinical sitting balance scales containing dynamic tasks are available to measure sitting balance with individuals following stroke. No single scale has sufficient psychometric properties to enable recommendation as a preferred tool for measuring sitting balance with stroke survivors. Use of a balance scale or dedicated sitting balance measure containing static and dynamic sitting items should be utilised to monitor progress for individuals following stroke with more severe deficits.

Venlafaxine in treatment-resistant obsessive-compulsive disorder.

BACKGROUND: While selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment of obsessive-compulsive disorder (OCD), approximately 40% of patients fail to respond to SSRIs. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI) that might be effective in the treatment of OCD, even among those who have failed previous SSRI trials. METHOD: Thirty-nine patients who met DSM-IV criteria for OCD, including 29 who were resistant to prior SRI treatment trials, were treated with venlafaxine in an open, naturalistic fashion. Improvement was assessed using the Clinical Global Impressions-Improvement scale. RESULTS: Of 39 patients treated with venlafaxine, 27 (69.2%) were rated as sustained treatment responders. Of the 29 patients who did not respond to 1 or more previous SRI trials, 22 (75.9%) were rated as having sustained response to treatment. Mean dose of venlafaxine was 232.2 mg/day (range, 37.5-375 mg/day), and it was generally well tolerated. CONCLUSION: Venlafaxine may be beneficial to individuals with OCD, including those who have not responded to prior SSRI trials. However, these findings must be interpreted with caution, as the study is limited by its open, retrospective nature and its inclusion of patients with comorbid diagnoses and patients on concomitant medications. Prospective, controlled trials with a more homogeneous patient population are needed to replicate these preliminary findings.