Long-Term Functional Recovery After First Ischemic Stroke The Northern Manhattan Study

Neurological Institute, 710 W 168th Street, Box 206, New York, NY 10032.
Stroke (Impact Factor: 5.72). 07/2009; 40(8):2805-11. DOI: 10.1161/STROKEAHA.109.549576
Source: PubMed


Several factors predict functional status after stroke, but most studies have included hospitalized patients with limited follow-up. We hypothesized that patients with ischemic stroke experience functional decline over 5 years independent of recurrent stroke and other risk factors.
In the population-based Northern Manhattan Study, patients > or =40 years of age with incident ischemic stroke were prospectively followed using the Barthel Index at 6 months and annually to 5 years. Baseline stroke severity was categorized as mild (National Institutes of Health Stroke Scale <6), moderate (6 to 13), and severe (> or =14). Follow-up was censored at death, recurrent stroke, or myocardial infarction. Generalized Estimating Equations provided ORs and 95% CIs for predictors of favorable (Barthel Index > or =95) versus unfavorable (Barthel Index <95) functional status after adjusting for demographic and medical risk factors.
Of 525 patients, mean age was 68.6+/-12.4 years, 45.5% were male, 54.7% Hispanic, 54.7% had Medicaid/no insurance, and 35.1% had moderate stroke. The proportion with Barthel Index > or =95 declined over time (OR, 0.91; 95% CI, 0.84 to 0.99). Changes in Barthel Index by insurance status were confirmed by a significant interaction term (beta for interaction=-0.167, P=0.034); those with Medicaid/no insurance declined (OR, 0.84; P=0.003), whereas those with Medicare/private insurance did not (OR, 0.99; P=0.92).
The proportion of patients with functional independence after stroke declines annually for up to 5 years, and these effects are greatest for those with Medicaid or no health insurance. This decline is independent of age, stroke severity, and other predictors of functional decline and occurs even among those without recurrent stroke or myocardial infarction.

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Available from: Tatjana Rundek, Jan 26, 2015
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    • "Literature has demonstrated that, as a stroke enters its chronic or long term post-insult phase, there is increased risk of future stroke and functional decline reported at 5.0% and 9.0% respectively [2,3]. These risks occur even among survivors who have achieved full recovery following rehabilitation. "
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    ABSTRACT: The importance of long term rehabilitation for people with stroke is increasingly evident, yet it is not known whether such services can be materialised in countries with limited community resources. In this study, we explored the perception of rehabilitation professionals and people with stroke towards long term stroke rehabilitation services and potential approaches to enable provision of these services. Views from providers and users are important in ensuring whatever strategies developed for long term stroke rehabilitations are feasible and acceptable. Focus group discussions were conducted involving 15 rehabilitation professionals and eight long term stroke survivors. All recorded conversations were transcribed verbatim and analysed using the principles of qualitative research. Both groups agreed that people with stroke may benefit from more rehabilitation compared to the amount of rehabilitation services presently provided. Views regarding the unavailability of long term rehabilitation services due to multi-factorial barriers were recognised. The groups also highlighted the urgent need for the establishment of community-based stroke rehabilitation centres. Family-assisted home therapy was viewed as a potential approach to continued rehabilitation for long term stroke survivors, given careful planning to overcome several family-related issues. Barriers to the provision of long term stroke rehabilitation services are multi-factorial. Establishment of community-based stroke rehabilitation centres and training family members to conduct home-based therapy are two potential strategies to enable the continuation of rehabilitation for long term stroke survivors.
    BMC Health Services Research 03/2014; 14(1):118. DOI:10.1186/1472-6963-14-118 · 1.71 Impact Factor
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    • "Current guidelines offer no specific recommendations on the need of thrombolysis in stroke patients with mild or rapidly improving symptoms [1], [2]. However, this issue is of great clinical interest as up to half of ischemic stroke patients manifest mild or rapidly improving symptoms at clinical onset [3], [4], and around 30% of these patients are not treated with thrombolytic agents on the assumption that they may achieve an excellent recovery spontaneously [5]–[7]. However, according to some reports [5], [6], [8]–[11], up to one third of these patients fail to recover as much as it was anticipated by the responsible physician, and persist having symptoms as the result from a delayed growth of the infarction. "
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    ABSTRACT: In up to one third of patients with mild stroke suitable to receive systemic thrombolysis the treatment is not administered because the treating physicians estimate a good spontaneous recovery. However, it is not settled whether the fate of these patients is equivalent to those who are thrombolysed. We analyzed 203 consecutive patients (134 men and 69 women, mean age 69±14 years) without premorbid disability and a NIHSS score ≤5 at admission [median 3 (IQR 2-4)]. Intravenous thrombolysis was administered within 4.5 hours from stroke onset (n = 119), or it was withheld (n = 84) whenever the treating physician predicted a spontaneous recovery. The baseline risk factors, clinical course, infarction volume, bleeding complications, and functional outcome at 3 months were analyzed and declared to a Web-based registry which was accessible to the local Health Authorities. Expectedly, not thrombolysed patients had the mildest strokes at admission [median 2 (IQR 1-3.75)]. At day 2 to 5, the infarct volume on DWI-MRI was similar in both groups. There were no symptomatic cerebral bleedings in the study. An ordinal regression model adjusted for baseline stroke severity showed that thrombolysis was associated with a greater proportion of patients who shifted down on the modified Rankin Scale score at 3 months (OR 2.66; 95% CI 1.49-4.74, p = 0.001). Intravenous thrombolysis seems to be safe in patients with mild stroke and may be associated with improved outcome compared with untreated patients. These results support the evaluation of the efficacy of intravenous thrombolysis in mild stroke patients in randomized clinical trials.
    PLoS ONE 03/2013; 8(3):e59420. DOI:10.1371/journal.pone.0059420 · 3.23 Impact Factor
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    • "There is considerable evidence that early and continued intervention following ABI is likely to enhance the recovery process and minimize functional disability [2], [3]. Post-discharge care is often not comprehensive, integrated, nor well-coordinated [4] and there is growing evidence that the long term management of people who have had an ABI will improve with a more organized, multidisciplinary approach to post-acute rehabilitation [5], [6]. There is no doubt that healthcare systems around the world are having greater and greater difficulty in responding to the challenges presented by increased longevity and costly resources [7] [8]. "
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    ABSTRACT: The goal was to evaluate the clinical effectiveness of a quasi-home-based tele-motion-rehabilitation (TMR) program, using the Gertner System, in improving functional ability of the weak upper extremity post-stroke. Eighteen adults with stroke were randomized into two groups; a quasi-home-based TMR program and a self-training upper extremity home exercise group. No between groups differences were found. Within group differences were found in the impairment level for both groups but in the participation level only in the research group. The results point to the potential of using the TMR system to improve the functional use of the upper extremity post-stroke.
    Virtual Rehabilitation (ICVR), 2013 International Conference on; 01/2013
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