To evaluate the effect of constraint-induced movement therapy in adult stroke patients and to examine the impact of time since stroke and various treatment modalities.
PubMed, EMBASE, Cochrane and ...PEDro trial registers were searched for clinical trials published before November 2012.
Randomized or quasi-randomized controlled trials of constraint-induced movement therapy lasting 2-7 h/day for 8-28 days were included.
Measurements were classified into the following categories: arm motor function, arm motor activity, activities of daily living, and participation. A pooled standardized mean difference (SMD) was calculated for each category. Moderators were: trial quality, behavioural techniques, amount of training, time since stroke, shaping, and the nature of the control group.
Of 3842 records initially screened 23 trials were included. A small post-treatment effect was found on arm motor function (SMD 0.28, 95% confidence interval (CI) 0.11-0.44). Meanwhile, a moderate effect on arm motor activity was found post-treatment (SMD 0.51, 95% CI 0.30-0.73) and at 3-6 months follow-up (SMD 0.41, 95% CI 0.08-0.74).
Constraint-induced movement therapy can improve arm motor function and improve arm motor activities and may have a lasting effect on arm motor activity.
To investigate how physical activity changes over the first 6 months after stroke, and how activity is related to function.
A longitudinal study with an initial assessment within 14 days after stroke ...(in hospital) and follow-up assessments 1, 3 and 6 months later (in-patient rehabilitation or at home).
Patients with acute stroke.
An accelerometer with a switch tilt was used to measure activity over a period of 24 h on each occasion. The Barthel Index (BI) and Berg Balance Scale (BBS) were applied as functional measures.
A total of 28 out of 44 recruited patients were included in the analysis (15 men (53.6%), mean age 79 years). The median time in the upright position increased from 92 min at baseline to 144 min 6 months later. A generalized least-square regression models showed that time in the upright position increased by 2.0 min for every day from baseline to 1 month later (p = 0.003). A single point increase on the BBS was associated with an extra 4.3 min in the upright position (p < 0.001), while a single point increase on the BI was associated with an extra 2.1 min in the upright position (p < 0.001).
Activity levels are very low during the first 6 months after stroke. However, time in the upright position was found to increase as function improved.
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Background. The aims of the study were (i) to examine which antithrombotic therapy patients with known atrial fibrillation use at the point of time when they suffer an ischaemic stroke, (ii) to ...evaluate the effects of optimal antithrombotic treatment on outcome and severity of the stroke.
Methods. Patients with known atrial fibrillation before onset of acute ischaemic stroke, and age >60 years were included. Antithrombotic therapy on admission was classified into four groups: no antithrombotic therapy, aspirin, sub‐optimal anticoagulation (warfarin and international normalized ratio, INR < 2.0) and optimal anticoagulation (warfarin and INR ≥ 2.0). Primary outcome: modified Rankin Scale (mRS) 5 or 6 at day 7 poststroke. Secondary outcomes: (i) death or discharge to a nursing home, (ii) death, (iii) stroke severity on admission assessed by Scandinavian Stroke Scale.
Results. A total of 394 patients were included. On admission 109 (28%) patients used no antithrombotic therapy, 169 (43%) aspirin, 52 (13%) warfarin and had an INR < 2.0, and 64 (16%) used warfarin and had an INR ≥ 2.0. The proportion of patients with an mRS 5 or 6 and the corresponding odds ratios were: in the warfarin group with INR < 2.0, 16 (31%), OR 3.1 (CI: 1.2–8.0), (P = 0.019), in the group with no antithrombotic therapy 29 (27%), 2.5 (1.1–5.9), (P = 0.034), and in the aspirin group 41(24%), 2.2 (1.0–5.1) (P = 0.054), compared with the warfarin group with INR ≥ 2.0, where eight (13%) patients had a poor outcome. A significantly higher proportion of patients died or were discharged to a nursing home in the warfarin group with an INR < 2.0 (P = 0.014), in the aspirin group (P = 0.018) and in the no‐treatment group (P = 0.035), compared with the warfarin group with an INR ≥ 2.0. No significant differences were found regarding death alone and stroke severity on admission.
Discussion. Few patients with known atrial fibrillation who suffer an ischaemic stroke receive optimal antithrombotic therapy prior to the onset of stroke. Optimal anticoagulation does not only reduce the risk of ischaemic stroke, but also appears to reduce death and severe dependency as well as the need for nursing home care, if an ischaemic stroke occurs.
We have previously shown that treatment in our combined acute and rehabilitation Stroke Unit improves outcome during the first year after onset of stroke compared with stroke patients treated in ...general wards. The aim of the present trial was to examine the long-term effects of the stroke unit care.
In a randomized controlled trial, 110 patients with symptoms and signs of an acute stroke were allocated to the Stroke Unit and 110 to general wards. No significant differences existed in baseline characteristics between the two groups. The outcome after 5 years was measured by the proportion of patients at home, the proportion of patients in an institution, the mortality, and the functional state assessed by Barthel Index.
After 5 years, 38 (34.5%) of the patients randomized to the Stroke Unit and 20 (18.2%) of the patients randomized to the general wards were at home (P = .006). Sixty-five (59.1%) of the patients from the Stroke Unit and 78 (70.9%) of the patients from the general wards were dead (P = .041), while 7 (6.4%) and 12 (10.9%), respectively, were in an institution (e.g., nursing home) (P = NS). Functional state was significantly better for patients treated in the Stroke Unit.
For the first time it is shown that stroke unit care improves long-term survival and functional state and increases the proportion of patients able to live at home 5 years after the stroke. Combined acute and rehabilitation stroke units appear to be an effective way of organizing treatment for acute stroke patients.
We have previously shown that treatment of acute stroke patients in our stroke unit (SU) compared with treatment in general ward (GWs) improves short- and long-term survival and functional outcome ...and increases the possibility of earlier discharge to home. The aim of the present study was to identify the differences in treatment between the SU and the GW and to assess which aspects of the SU care which were most responsible for the better outcome.
Of the 220 patients included in our trial, only 206 were actually treated (SU, 102 patients; GW, 104 patients). For these patients, we identified the differences in the treatment and the consequences of the treatment. We analyzed the factors that we were able to measure and their association with the outcome, discharge to home within 6 weeks.
Characteristic features in our SU were teamwork, staff education, functional training, and integrated physiotherapy and nursing. Other treatment factors significantly different in the SU from the GW were shorter time to start of the systematic mobilization/training and increased use of oxygen, heparin, intravenous saline solutions, and antipyretics. Consequences of the treatment seem to be less variation in diastolic and systolic blood pressure (BP), avoiding the lowest diastolic BP, and lowering the levels of glucose and temperature in the SU group compared with the GW group. Univariate analyses showed that all these factors except the level of glucose were significantly associated with discharge to home within 6 weeks. In the final multivariate Cox regression model, shorter time to start of the mobilization/training and stabilized diastolic BP were independent factors significantly associated with discharge to home within 6 weeks.
Shorter time to start of mobilization/training was the most important factor associated with discharge to home, followed by stabilized diastolic BP, indicating that these factors probably were important in the SU treatment. The effects of characteristic features of an SU, such as a specially trained staff, teamwork, and involvement of relatives, were not possible to measure. Such factors might be more important than those actually measured.
We have previously shown that treatment in our combined acute and rehabilitation stroke unit (SU) improves the outcome during the first 5 years after onset of stroke compared with that for stroke ...patients treated in general wards (GW). The aim of the present trial was to examine the effects of SU care after 10 years of follow-up.
In a randomized controlled trial, 110 patients with symptoms and signs of an acute stroke were allocated to the SU and 110 to GW. No significant differences existed in baseline characteristics between the groups. The outcome after 10 years was measured by the proportion of patients at home, the proportion of patients in an institution, the mortality, and the functional state as assessed by the Barthel Index, in which a Barthel Index score of >/=60 was classified as independent or partly independent and a score of >/=95 was classified as independent.
After 10 years, 21 (19.1%) of the patients randomized to the SU and 9 (8.2%) of the patients randomized to the GW were at home (P=0.0184). Eighty-three (75.5%) of the patients from the SU and 96 (87.3%) of the patients from the GW were dead (P=0.0082), and 6 (5.4%) and 5 (4.5%), respectively, were in an institution (eg, nursing home; NS). Twenty-two (20.0%) of the SU patients and 9 (8. 2%) of the GW patients had a Barthel Index score of >/=60 (P=0.0118), and 14 (12.7%) and 6 (5.4%), respectively, had a score of >/=95 (P=0.0606).
For the first time it has been shown that SU care improves survival and functional state and increases the proportion of patients able to live at home 10 years after their stroke. Treatment in combined acute and rehabilitation SU seems to have important long-term effects on outcome for stroke patients.
Objective: Constraint-induced movement therapy (CIMT) is a method to improve motor function in the upper extremity following stroke. The aim of this trial was to determine the effect and feasibility ...of CIMT compared with traditional rehabilitation in short and long term.
Design: A randomized controlled trial.
Setting: An inpatient rehabilitation clinic.
Subjects: Thirty patients with unilateral hand impairment after stroke.
Intervention: Six hours arm therapy for 10 consecutive weekdays, while
using a restraining mitten on the unaffected hand.
Main measures: The patients were assessed at baseline, post-treatment and at six-month follow-up using the Wolf Motor Function Test as primary outcome measure and the Motor Activity Log, Functional Independence Measure and Stroke Impact Scale as secondary measurements.
Results: The CIMT group (n=18) showed a statistically significant shorter performance time (4.76 seconds versus 7.61 seconds, P= 0.030) and greater functional ability (3.85 versus 3.47, P= 0.037) than the control group (n=12) on the Wolf Motor Function Test at post-treatment assessment. There was a non-significant trend toward greater amount of use (2.47 versus 1.97, P= 0.097) and better quality of movement (2.45 versus 2.12, P=0.105) in the CIMT group according to the Motor Activity Log. No such differences were seen on Functional Independence Measure at the same time. At six-month follow-up the CIMT group maintained their improvement, but as the control group improved even more, there were no significant differences between the groups on any measurements.
Conclusions: CIMT seems to be an effective and feasible method to improve motor function in the short term, but no long-term effect was found.
Objective: To evaluate the effect of an extended stroke unit service (extended service), with early supported discharge and co-ordination of further rehabilitation in co-operation with the primary ...health care system in three rural municipalities.
Design: A randomized controlled trial comparing extended service with ordinary stroke unit service (ordinary service).
Subjects: Sixty-two eligible patients with acute stroke living in the rural municipalities of Malvik, Melhus and Klñ bu.
Main measures: The primary outcome was the proportion of patients who were independent according to Modified Rankin Scale (mRS) (independence = mRS < 2) 52 weeks after onset of stroke. Secondary outcomes were mRS at 6 and 26 weeks and Barthel Index (BI), Nottingham Health Profile (NHP) and Caregiver Strain Index (CSI) at 6, 26 and 52 weeks. Mortality and length of stay were registered during the 52 weeks.
Results: Twelve patients (39%) in the extended service group versus 16 patients (52%) in the ordinary service group were independent according to mRS at 52 weeks (p= 0.444). The odds ratio for independence (extended service versus ordinary service) was 0.33 (95% confidence interval (CI) 0.088 –1.234). According to outcome by secondary measures there were no significant differences except less social isolation on NHP in the extended service group at 26 weeks (p= 0.046). There were no significant differences in length of stay.
Conclusion: An extended stroke unit service with early supported discharge seems to have no positive effect on functional outcome for patients living in rural communities, but might give a trend toward better quality of life. There were no significant differences in length of stay.
There is limited information on reliable and valid measures of physical activity in older people with impaired function.
This study was conducted to compare the accuracy of single-axis accelerometers ...in recognizing postures and transitions and step counting with the accuracy of video recordings in people with stroke (n=14), older inpatients (n=14), people with hip fracture (n=8), and a reference group of 10 adults who were healthy.
This was a cross-sectional study, evaluating the concurrent validity of small body-worn accelerometers against video observations as the criterion measure.
Activity data were collected from 3 sensors (activPAL) attached to the thighs and the sternum and from registration of the same activities from video recordings. Participants performed a test protocol of in-bed, transfer, and walking activities.
The sensor system was highly accurate in classifying lying, sitting, and standing positions (100%) and in recognizing transitions from lying to sitting positions and from sitting to standing positions (100%). Placement of a sensor on the nonaffected leg resulted in less underestimation of step counts than placement on the affected leg. Still, the sensor system underestimated step counts during walking, especially at slow walking speeds (≤0.47 m/s) (limits of agreement=-2.01 to 16.54, absolute percent error=40.31).
The study was performed in a controlled setting and not during the natural performance of activities.
The activPAL sensor system provides valid measures of postures and transitions in older people with impaired walking ability. Step counting needs to be improved for the sensor system to be acceptable for this population, especially at slow walking speeds.
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