Clinical Performance Measures for Stroke Rehabilitation: Performance Measures From the American Heart Association/American Stroke Association.

The American Heart Association/American Stroke Association released the adult stroke rehabilitation and recovery guidelines in 2016. A working group of stroke rehabilitation experts reviewed these guidelines and identified a subset of recommendations that were deemed suitable for creating performance measures. These 13 performance measures are reported here and contain inclusion and exclusion criteria to allow calculation of rates of compliance in a variety of settings ranging from acute hospital care to postacute care and care in the home and outpatient setting.

Transcranial magnetic stimulation as an investigative tool for motor dysfunction and recovery in stroke: an overview for neurorehabilitation clinicians.

RATIONALE: An improved understanding of motor dysfunction and recovery after stroke has important clinical implications that may lead to the design of more effective rehabilitation strategies for patients with hemiparesis. SCOPE: Transcranial magnetic stimulation (TMS) is a safe and painless tool that has been used in conjunction with other existing diagnostic tools to investigate motor pathophysiology in stroke patients. Since TMS emerged more than two decades ago, its application in clinical and basic neuroscience has expanded worldwide. TMS can quantify the corticomotor excitability properties of clinically affected and unaffected muscles and can probe local cortical networks as well as remote but functionally related areas. This provides novel insight into the physiology of neural circuits underlying motor dysfunction and brain reorganization during the motor recovery process. This important tool needs to be used with caution by clinical investigators, its limitations need to be understood, and the results should to be interpreted along with clinical evaluation in this patient population. SUMMARY: In this review, we provide an overview of the rationale, implementation, and limitations of TMS to study stroke motor physiology. This knowledge may be useful to guide future rehabilitation treatments by assessing and promoting functional plasticity.

Computerized adaptive testing for follow-up after discharge from inpatient rehabilitation: II. Participation outcomes.

OBJECTIVES: To measure participation outcomes with a computerized adaptive test (CAT) and compare CAT and traditional fixed-length surveys in terms of score agreement, respondent burden, discriminant validity, and responsiveness. DESIGN: Longitudinal, prospective cohort study of patients interviewed approximately 2 weeks after discharge from inpatient rehabilitation and 3 months later. SETTING: Follow-up interviews conducted in patient's home setting. PARTICIPANTS: Adults (N=94) with diagnoses of neurologic, orthopedic, or medically complex conditions. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participation domains of mobility, domestic life, and community, social, & civic life, measured using a CAT version of the Participation Measure for Postacute Care (PM-PAC-CAT) and a 53-item fixed-length survey (PM-PAC-53). RESULTS: The PM-PAC-CAT showed substantial agreement with PM-PAC-53 scores (intraclass correlation coefficient, model 3,1, .71-.81). On average, the PM-PAC-CAT was completed in 42% of the time and with only 48% of the items as compared with the PM-PAC-53. Both formats discriminated across functional severity groups. The PM-PAC-CAT had modest reductions in sensitivity and responsiveness to patient-reported change over a 3-month interval as compared with the PM-PAC-53. CONCLUSIONS: Although continued evaluation is warranted, accurate estimates of participation status and responsiveness to change for group-level analyses can be obtained from CAT administrations, with a sizeable reduction in respondent burden.

Enabling Stroke Rehabilitation in Home and Community Settings: A Wearable Sensor-Based Approach for Upper-Limb Motor Training.

High-dosage motor practice can significantly contribute to achieving functional recovery after a stroke. Performing rehabilitation exercises at home and using, or attempting to use, the stroke-affected upper limb during Activities of Daily Living (ADL) are effective ways to achieve high-dosage motor practice in stroke survivors. This paper presents a novel technological approach that enables 1) detecting goal-directed upper limb movements during the performance of ADL, so that timely feedback can be provided to encourage the use of the affected limb, and 2) assessing the quality of motor performance during in-home rehabilitation exercises so that appropriate feedback can be generated to promote high-quality exercise. The results herein presented show that it is possible to detect 1) goal-directed movements during the performance of ADL with a [Formula: see text]-statistic of 87.0% and 2) poorly performed movements in selected rehabilitation exercises with an [Formula: see text]-score of 84.3%, thus enabling the generation of appropriate feedback. In a survey to gather preliminary data concerning the clinical adequacy of the proposed approach, 91.7% of occupational therapists demonstrated willingness to use it in their practice, and 88.2% of stroke survivors indicated that they would use it if recommended by their therapist.

Comparison of clinical characteristics and functional outcomes of ischemic stroke in different vascular territories.

BACKGROUND AND PURPOSE: We aim to compare demographics and functional outcomes of patients with stroke in a variety of vascular territories who underwent inpatient rehabilitation. Such comparative data are important in functional prognostication, rehabilitation, and healthcare planning, but literature is scarce and isolated. METHODS: Using data collected prospectively over a 9-year period, we studied 2213 individuals who sustained first-ever ischemic strokes and were admitted to an inpatient stroke rehabilitation program. Strokes were divided into anterior cerebral artery, middle cerebral artery (MCA), posterior cerebral artery, brain stem, cerebellar, small-vessel strokes, and strokes occurring in more than one vascular territory. The main functional outcome measure was the Functional Independence Measure (FIM). Repeated-measures analysis of covariance with post hoc analyses was used to compare functional outcomes of the stroke groups. RESULTS: The most common stroke groups were MCA stroke (50.8%) and small-vessel stroke (12.8%). After adjustments for age, gender, risk factors, and admission year, the stroke groups can be arranged from most to least severe disability on admission: strokes in more than one vascular territory, MCA, anterior cerebral artery, posterior cerebral artery, brain stem, cerebellar, and small-vessel strokes. The sequence was similar on discharge, except cerebellar strokes had the least disability rather than small-vessel strokes. Hemispheric (more than one vascular territory, MCA, anterior cerebral artery, posterior cerebral artery) strokes collectively have significantly lower admission and discharge total and cognitive FIM scores compared with the other stroke groups. MCA stroke had the lowest FIM efficiency and cerebellar stroke the highest. Regardless, patients with stroke made significant (P<0.001) and approximately equal (P=0.535) functional gains in all groups. Higher admission motor and cognitive FIM scores, longer rehabilitation stay, younger patients, lower number of medical complications, and a year of admission after 2000 were associated with higher discharge total FIM scores on multiple regression analysis. CONCLUSIONS: Patients with stroke made significant functional gains and should be offered rehabilitation regardless of stroke vascular territory. The initial functional status at admission, rather than the stroke subgroup, better predicts discharge functional outcomes postrehabilitation.

Communication among levels of care for stroke patients.

Stroke patients in the United States frequently progress through several different locations of care and groups of providers during the course of their recovery. Consistently effective communication from one level of care and one set of providers to the next is a basic expectation, but one that is often not fully met. New concepts and promising technologies offer opportunities to improve hand-off processes at all levels.

Age and functional outcome after stroke.

The effect of age on functional outcome after stroke remains uncertain. Many studies have found that younger patients do better than older patients, whereas others have found minimal or no effect of age on rehabilitation outcomes. We examined the effect of advancing age on FIM trade mark gain, length of stay, length of stay efficiency, and home discharge in 979 stroke rehabilitation patients at a long-term acute care rehabilitation hospital. We found a strong relationship of increasing age to poorer outcome in all measures for patients with admission FIM (AFIM) score <40, a variable relationship in those with AFIM 40-80, and no relationship of age to the outcome measures in patients with AFIM >80.

Computer adaptive testing: a strategy for monitoring stroke rehabilitation across settings.

Current functional assessment instruments in stroke rehabilitation are often setting-specific and lack precision, breadth, and/or feasibility. Computer adaptive testing (CAT) offers a promising potential solution by providing a quick, yet precise, measure of function that can be used across a broad range of patient abilities and in multiple settings. CAT technology yields a precise score by selecting very few relevant items from a large and diverse item pool based on each individual's responses. We demonstrate the potential usefulness of a CAT assessment model with a cross-sectional sample of persons with stroke from multiple rehabilitation settings.

Determination of the minimal clinically important difference in the FIM instrument in patients with stroke.

OBJECTIVE: To define the minimal clinically important difference (MCID) for the FIM instrument in patients poststroke. DESIGN: Prospective case series discharged over a 9-month period. SETTING: Long-term acute care hospital. PARTICIPANTS: Patients with stroke (N=113). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Admission, discharge, and change scores were calculated for the total FIM, motor FIM, and cognitive FIM. Assessments of clinical change were rated at discharge on a 15-point (-7 to +7) Likert scale by attending physicians, with MCID defined at a cutoff score of 3. The FIM change scores associated with MCID were identified from receiver operating characteristic curves. Bayesian analysis was used to determine the probability of individual patients achieving MCID. RESULTS: FIM change scores associated with MCID were 22, 17, and 3 for the total FIM, motor FIM, and cognitive FIM, respectively. The accuracy of the MCID was greater when subjects were categorized based on admission FIM scores than when considering the sample as a whole. Larger FIM change scores were related to MCID in subjects with lower admission FIM scores. CONCLUSIONS: These findings will assist in the interpretation of FIM change scores relative to physicians' assessments of important clinical change.

Computerized adaptive testing for follow-up after discharge from inpatient rehabilitation: I. Activity outcomes.

OBJECTIVE: To examine score agreement, precision, validity, efficiency, and responsiveness of a computerized adaptive testing (CAT) version of the Activity Measure for Post-Acute Care (AM-PAC-CAT) in a prospective, 3-month follow-up sample of inpatient rehabilitation patients recently discharged home. DESIGN: Longitudinal, prospective 1-group cohort study of patients followed approximately 2 weeks after hospital discharge and then 3 months after the initial home visit. SETTING: Follow-up visits conducted in patients' home setting. PARTICIPANTS: Ninety-four adults who were recently discharged from inpatient rehabilitation, with diagnoses of neurologic, orthopedic, and medically complex conditions. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Summary scores from AM-PAC-CAT, including 3 activity domains of movement and physical, personal care and instrumental, and applied cognition were compared with scores from a traditional fixed-length version of the AM-PAC with 66 items (AM-PAC-66). RESULTS: AM-PAC-CAT scores were in good agreement (intraclass correlation coefficient model 3,1 range, .77-.86) with scores from the AM-PAC-66. On average, the CAT programs required 43% of the time and 33% of the items compared with the AM-PAC-66. Both formats discriminated across functional severity groups. The standardized response mean (SRM) was greater for the movement and physical fixed form than the CAT; the effect size and SRM of the 2 other AM-PAC domains showed similar sensitivity between CAT and fixed formats. Using patients' own report as an anchor-based measure of change, the CAT and fixed length formats were comparable in responsiveness to patient-reported change over a 3-month interval. CONCLUSIONS: Accurate estimates for functional activity group-level changes can be obtained from CAT administrations, with a considerable reduction in administration time.

Clinical characteristics and rehabilitation outcomes of patients with posterior cerebral artery stroke.

OBJECTIVES: To describe the demographics, clinical profile, and functional outcomes in posterior cerebral artery (PCA) stroke and to identify factors associated with functional change during rehabilitation and discharge disposition. DESIGN: Retrospective study of patients with PCA stroke admitted to a rehabilitation hospital over an 8-year period. SETTING: Free-standing urban rehabilitation hospital in the United States. PARTICIPANTS: Eighty-nine consecutive patients with PCA stroke (48 men, 41 women; mean age, 71.5y) met inclusion criteria. INTERVENTION: Inpatient multidisciplinary comprehensive rehabilitation program. MAIN OUTCOME MEASURES: Demographic, clinical, and discharge disposition information were collected. Functional status was measured using the FIM instrument, recorded at admission and discharge. The main outcome measures were the discharge total FIM score, the change in total FIM score (DeltaFIM), and the discharge disposition. Multiple and logistic regression analyses were performed to identify factors associated with the main outcome measures. RESULTS: The most common impairments were motor paresis (65%), followed by visual field defects (54%) and confusion or agitation (43%). The mean discharge total FIM score +/- standard deviation was 88.3+/-28.2. The mean DeltaFIM was 23.3+/-16.4. Fifty-five (62%) patients were discharged home. On multiple regression analysis, higher admission total FIM score, longer length of stay (LOS), and a rehabilitation stay free of interruptions were associated with higher discharge total FIM score and greater DeltaFIM. Absence of diabetes mellitus and younger age were also associated with higher discharge total FIM scores, and male sex had greater DeltaFIM. On logistic regression analysis, younger patients, higher discharge FIM scores, presence of a caregiver, and the nonnecessity for 24-hour support were associated with a discharge to home. CONCLUSIONS: Motor, visual, and cognitive impairments are common in PCA stroke, and good functional gains are achievable after comprehensive rehabilitation. Higher admission FIM scores, longer LOS, and younger and male patients were associated with better functional outcomes. Most patients were discharged home, particularly those with caregivers and those for whom 24-hour support was not required. Further research should aim at the development of functional outcome measures of greater breadth and sensitivity to visual and cognitive deficits and should compare PCA stroke outcomes with outcomes of strokes in other vascular territories.

Vocational outcome after stroke.

This article reviews the literature on vocational outcome after stroke and discusses reasons for the minimal use of vocational outcome measures in stroke rehabilitation research. A vocational function measurement tool is proposed. The vocational rehabilitation process and experience of the Young Stroke Program at New England Rehabilitation Hospital are described, and determinants of success or failure in vocational rehabilitation after stroke as described in the medical literature are reviewed. The impact of the Americans with Disabilities Act of 1990 and of changes in health care funding on vocational outcomes after stroke are discussed.

Treatment of upper limb deep vein thrombosis with low molecular weight heparin.

Upper limb deep vein thrombosis has been an under-recognized disease; however, physicians' awareness of it as a cause of arm pain and edema is increasing. Previously thought of as benign, upper limb deep vein thrombosis has been shown in recent studies to pose a significant risk for pulmonary embolus and death. The need for treatment is now recognized; however, effective treatments for upper limb deep vein thrombosis have not been fully defined. Anticoagulation with oral agents is known to be successful in preventing complications and recurrence. This report presents the first case of upper limb deep vein thrombosis successfully treated with only low molecular weight heparin.

Upper-extremity deep vein thrombosis and paralysis: a case report.

Upper-extremity deep venous thrombosis (DVT) has been understudied in the rehabilitation population. Patients undergoing rehabilitation often have many risk factors that predispose them to DVT. It is important to recognize upper-extremity DVT, because recent studies have shown it to pose a significant risk for pulmonary embolus and death. This is the first reported association of an upper-extremity DVT with paralysis.