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ABSTRACT: Obtaining comprehensive health outcomes and health services utilization data on stroke patients has been difficult. This research grew out of a memorandum of understanding between the NIH and the ISS (its Italian equivalent) to foster collaborative research on rehabilitation.
The purpose of this study was to pilot a methodology using administrative data to monitor and improve health outcomes for stroke survivors in Tuscany.
This study used qualitative and quantitative methods to study health resources available to and utilized by stroke survivors during the first 12 months post-stroke in two Italian health authorities (AUSL10 and 11). Mortality rates were used as an outcome measure.
Number of inpatient days, number of prescriptions, and prescription costs were significantly higher for patients in AUSL 10 compared to AUSL 11. There was no significant difference between mortality rates.
Using administrative data to monitor process and outcomes for chronic stroke has the potential to save money and improve outcomes. However, measures of functional impairment and more sensitive outcome measures than mortality are important. Additional recommendations for enhanced data collection and reporting are discussed.
Disability and Health Journal 10/2010; 3(4):271-81. · 0.98 Impact Factor
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ABSTRACT: Abstract
Background
Hemiparesis after stroke often leads to impaired ankle motor control that impacts gait function. In recent studies, robotic devices have been developed to address this impairment. While capable of imparting forces to assist during training and gait, these devices add mass to the paretic leg which might encumber patients' gait pattern. The purpose of this study was to assess the effects of the added mass of one of these robots, the MIT's Anklebot, while unpowered, on gait of chronic stroke survivors during overground and treadmill walking.
Methods
Nine chronic stroke survivors walked overground and on a treadmill with and without the anklebot mounted on the paretic leg. Gait parameters, interlimb symmetry, and joint kinematics were collected for the four conditions. Repeated-measures analysis of variance (ANOVA) tests were conducted to examine for possible differences across four conditions for the paretic and nonparetic leg.
Results
The added inertia and friction of the unpowered anklebot had no statistically significant effect on spatio-temporal parameters of gait, including paretic and nonparetic step time and stance percentage, in both overground and treadmill conditions. Noteworthy, interlimb symmetry as characterized by relative stance duration was greater on the treadmill than overground regardless of loading conditions. The presence of the unpowered robot loading reduced the nonparetic knee peak flexion on the treadmill and paretic peak dorsiflexion overground (p < 0.05).
Conclusions
Our results suggest that for these subjects the added inertia and friction of this backdriveable robot did not significantly alter their gait pattern.
Journal of NeuroEngineering and Rehabilitation (JNER). 01/2010;
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ABSTRACT: To determine whether Adaptive Physical Activity (APA-stroke), a community-based exercise program for participants with hemiparetic stroke, improves function in the community.
Nonrandomized controlled study in Tuscany, Italy, of participants with mild to moderate hemiparesis at least 9 months after stroke. Forty-nine participants in a geographic health authority (Empoli) were offered APA-stroke (40 completed the study). Forty-four control participants in neighboring health authorities (Florence and Pisa) received usual care (38 completed the study). The APA intervention was a community-based progressive group exercise regimen that included walking, strength, and balance training for 1 hour, thrice a week, in local gyms, supervised by gym instructors. No serious adverse clinical events occurred during the exercise intervention. Outcome measures included the following: 6-month change in gait velocity (6-Minute Timed Walk), Short Physical Performance Battery (SPPB), Berg Balance Scale, Stroke Impact Scale (SIS), Barthel Index, Hamilton Rating Scale for Depression, and Index of Caregivers Strain.
After 6 months, the intervention group improved whereas controls declined in gait velocity, balance, SPPB, and SIS social participation domains. These between-group comparisons were statistically significant at P<.00015. Individuals with depressive symptoms at baseline improved whereas controls were unchanged (P<.003). Oral glucose tolerance tests were performed on a subset of participants in the intervention group. For these individuals, insulin secretion declined 29% after 6 months (P=.01).
APA-stroke appears to be safe, feasible, and efficacious in a community setting.
Neurorehabilitation and neural repair 04/2009; 23(7):726-34. · 4.49 Impact Factor
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ABSTRACT: A plateau in recovery within the first few months of rehabilitative therapy was assumed to be the norm in stroke survivors. Recent studies in our laboratory examined the effect of 6 months of treadmill exercise training in chronically disabled stroke survivors. Treadmill exercise improves fitness and walking ability in patients when initiated 6 months or more following their index stroke. Functional imaging studies show that such exercise also induces subcortical reorganization in these patients. Future investigations will explore the relationship between these functional and structural effects and characterize the therapeutic mechanisms of post-stroke rehabilitation. Nonetheless, treadmill exercise appears to have motor, cardiac, and daily functional benefits in stroke survivors.
Cleveland Clinic Journal of Medicine 04/2008; 75 Suppl 2:S83-6. · 3.77 Impact Factor
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ABSTRACT: Reorganization in central motor networks occurs during early recovery from hemiparetic stroke. In chronic stroke survivors, specific rehabilitation therapy can improve upper extremity function.
To test the hypothesis that in patients who have chronic motor impairment following stroke, specific rehabilitation therapy that improves arm function is associated with reorganization of cortical networks.
A randomized controlled clinical trial conducted in a US ambulatory rehabilitation program with 21 patients (median [IQR], 50.3 [34.8-77.3] months after unilateral stroke). Data were collected between 2001 and 2004.
Patients were randomly assigned to bilateral arm training with rhythmic auditory cueing (BATRAC) (n = 9) or standardized dose-matched therapeutic exercises (DMTE) (n = 12). Both were conducted for 1 hour, 3 times a week, for 6 weeks.
Within 2 weeks before and after the intervention, brain activation during elbow movement assessed by functional magnetic resonance imaging (fMRI) and functional outcome assessed using arm function scores.
Patients in the BATRAC group but not in the DMTE group increased hemispheric activation during paretic arm movement (P = .03). Changes in activation were observed in the contralesional cerebrum and ipsilesional cerebellum (P = .009). BATRAC was associated with significant increases in activation in precentral (P<.001) and postcentral gyri (P = .03) and the cerebellum (P<.001), although 3 BATRAC patients showed no fMRI changes. Considering all patients, there were no differences in functional outcome between groups. When only BATRAC patients with fMRI response were included (n = 6), BATRAC improved arm function more than DMTE did (P = .02).
These preliminary findings suggest that BATRAC induces reorganization in contralesional motor networks and provide biological plausibility for repetitive bilateral training as a potential therapy for upper extremity rehabilitation in hemiparetic stroke.
JAMA The Journal of the American Medical Association 11/2004; 292(15):1853-61. · 30.03 Impact Factor
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ABSTRACT: Peripheral arterial disease (PAD) is associated with comorbid atherosclerosis of the coronary and carotid arteries and is a significant risk factor for stroke. However, cognitive function in PAD patients before clinically evident stroke remains poorly characterized. Here we hypothesized that, on neuropsychological testing, PAD patients would perform more poorly than healthy control subjects, and persons with mild cardiovascular disease (essential hypertension), but better than stroke patients, thus reflecting a continuum of cognitive impairment associated with increased severity of vascular disease.
The cognitive performance of 38 PAD patients (mean ankle-brachial index=0.67, Fontaine Class II) was contrasted with that of 23 healthy normotensive controls, 20 essential hypertensives, and 26 anterior ischemic stroke patients on twelve neuropsychological tests.
PAD patients performed significantly more poorly than hypertensives and normotensives, but better than stroke patients, on seven tests of nonverbal memory, concentration, executive function, perceptuo-motor speed, and manual dexterity. Hypertensives displayed poorer performance than normotensives on tests of nonverbal memory and manual dexterity. These findings were independent of age, education, and depression scores. Higher diastolic blood pressure and plasma glucose levels predicted poorer performance of select cognitive tests by PAD patients. Eight to 67% of PAD patients displayed impaired performance (< 5(th) percentile of normotensive controls) on the seven aforementioned cognitive tests.
PAD patients exhibit diminished performance across a variety of domains of cognitive function. Findings also suggest a continuum of cognitive impairment associated with increasingly severe manifestations of cardiovascular disease, thus emphasizing the need for enhanced preventative measures to avert functional declines.
Psychosomatic Medicine 65(5):757-63. · 3.97 Impact Factor
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Margaret A Finley,
Susan E Fasoli,
Laura Dipietro,
Jill Ohlhoff,
Leah Macclellan,
Christine Meister,
Jill Whitall, Richard Macko,
Christopher T Bever,
Hermano I Krebs,
Neville Hogan
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ABSTRACT: Chronic motor deficits in the upper limb (UL) are a major contributor to disability following stroke. This study investigated the effect of short-duration robot-assisted therapy on motor impairment, as measured by clinical scales and robot-derived performance measures in patients with chronic, severe UL impairments after stroke. As part of a larger study, 15 individuals with chronic, severe UL paresis (Fugl-Meyer < 15) after stroke (minimum 6 mo postonset) performed 18 sessions of robot-assisted UL rehabilitation that consisted of goal-directed planar reaching tasks over a period of 3 weeks. Outcome measures included the Fugl-Meyer Assessment, the Motor Power Assessment, the Wolf Motor Function Test, the Stroke Impact Scale, and five robot-derived measures that reflect motor control (aiming error, mean speed, peak speed, mean:peak speed ratio, and movement duration). Robot-assisted training produced statistically significant improvements from baseline to posttreatment in the Fugl-Meyer and Motor Power Assessment scores and the quality of motion (quantified by a reduction in aiming error and movement duration with an increase in mean speed and mean:peak speed ratio). Our findings indicate that robot-assisted UL rehabilitation can reduce UL impairment and improve motor control in patients with severe UL paresis from chronic stroke.
The Journal of Rehabilitation Research and Development 42(5):683-92. · 1.78 Impact Factor
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ABSTRACT: Demonstrating the treatment fidelity of an intervention is a key methodological requirement of any trial testing the impact of the intervention.
The purpose of this report was to serve as a model for evaluating treatment fidelity in stroke exercise intervention studies and to provide evidence for treatment fidelity in the Exercise Training for Hemiparetic Stroke Intervention Development Study.
Treatment fidelity was evaluated based on study design, training of interventionists, and delivery and receipt of the intervention.
There were some concerns about design fidelity as the control group and intervention group traveled to the study location together and received different exercise programs in the same facility. With regard to training of interventionists, observations were utilized to help maintain adherence to the protocol. There was strong support for the delivery and receipt of the intervention with participants exposed to the anticipated number of exercise sessions. As per study protocol, there was evidence that progress toward the proposed physical activity goal was made. Treatment fidelity findings are reported using cumulative data rather than at points throughout the study. Thus the findings may be conservative with regard adherence, for example, to time spent in exercise.
In addition to assurance of true testing of the intervention in this study, treatment fidelity of this work provides a useful model for replication and critically important information to better understand the type, dose, and length of exposure to exercise interventions that is needed to optimize stroke recovery.
Topics in Stroke Rehabilitation 18 Suppl 1:611-9. · 0.95 Impact Factor
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ABSTRACT: Context
Reorganization in central motor networks occurs during early recovery
from hemiparetic stroke. In chronic stroke survivors, specific rehabilitation
therapy can improve upper extremity function.Objective
To test the hypothesis that in patients who have chronic motor impairment
following stroke, specific rehabilitation therapy that improves arm function
is associated with reorganization of cortical networks.Design, Setting, and Patients
A randomized controlled clinical trial conducted in a US ambulatory
rehabilitation program with 21 patients (median [IQR], 50.3 [34.8-77.3] months
after unilateral stroke). Data were collected between 2001 and 2004.Interventions
Patients were randomly assigned to bilateral arm training with rhythmic
auditory cueing (BATRAC) (n = 9) or standardized dose-matched therapeutic
exercises (DMTE) (n = 12). Both were conducted for 1 hour, 3 times
a week, for 6 weeks.Main Outcome Measures
Within 2 weeks before and after the intervention, brain activation during
elbow movement assessed by functional magnetic resonance imaging (fMRI) and
functional outcome assessed using arm function scores.Results
Patients in the BATRAC group but not in the DMTE group increased hemispheric
activation during paretic arm movement (P = .03).
Changes in activation were observed in the contralesional cerebrum and ipsilesional
cerebellum (P = .009). BATRAC was associated
with significant increases in activation in precentral (P<.001) and postcentral gyri (P = .03)
and the cerebellum (P<.001), although 3 BATRAC
patients showed no fMRI changes. Considering all patients, there were no differences
in functional outcome between groups. When only BATRAC patients with fMRI
response were included (n = 6), BATRAC improved arm function more
than DMTE did (P = .02).Conclusions
These preliminary findings suggest that BATRAC induces reorganization
in contralesional motor networks and provide biological plausibility for repetitive
bilateral training as a potential therapy for upper extremity rehabilitation
in hemiparetic stroke.
Figures in this Article
Hemiparesis represents the dominant functionally limiting symptom in
80% of patients with acute stroke.1 Within
2 to 5 months after a stroke, patients recover a variable degree of function,
depending on the magnitude of the initial deficit.1 Several
studies have demonstrated that recovery is associated with reorganization
of central nervous system networks.2- 3 Functional
brain imaging of paretic movement during the recovery period has shown recruitment
of cortex immediately adjacent to the stroke cavity along with intact cortical
areas within the lesioned and in the uninjured contralesional hemisphere.4- 5 The pattern of recruitment depends
on the severity of impairment,6 lesion location,7 and time since stroke.8 The
factors that initiate and maintain cortical reorganization are not known.
Imaging data suggest that circuitry in motor cortices on both sides of the
brain is modified during recovery.2
Even with traditional rehabilitation therapy, 50% to 95% of stroke survivors
remain impaired.9- 11 For
some patients, recently developed repetitive active training therapies provide
additional benefit.12 Bilateral arm training
with rhythmic auditory cueing (BATRAC), a rehabilitation therapy based on
the concept that bilateral movement permits interhemispheric facilitation
of the limbs,13 is one such intervention. We
previously showed that BATRAC improves arm function in chronic stroke survivors
with fixed upper extremity deficits.14
We hypothesized that BATRAC may be associated with reorganization of
brain regions involved in motor control.
JAMA The Journal of the American Medical Association 292(15):1853-1861. · 30.03 Impact Factor
