Stroke is a disease that leads to long-term disability, with about 80% of stroke patients having upper extremity paresis just after stroke and more than 40% in the chronic phase. The functional ...prognosis of the paretic upper extremity is dependent on its severity, and for severe paresis, it is difficult to obtain the function for practical use of daily living. Therefore, symptomatic approaches such as effective utilization of residual functions and compensation by the unaffected side, including dominant hand exchange training, self-help devices, and environment setting after accepting the state of paresis, are adopted in the conventional rehabilitation adjuvant approaches for paretic upper extremity. Neurorehabilitation techniques have been developed to modulate cortical excitability and improve paretic upper extremity function. The main concept of the newly developed neurorehabilitation techniques is task-oriented training and dose dependent plasticity. Constraint-induced movement therapy is an intensive training of the paretic upper extremity in which patients use their paretic upper extremity with their unaffected hand constrained and overcome learned non-use. Neuromuscular electrical stimulation is usually performed along with other rehabilitation approaches. Stimulation of the target nerve assists the movement of the paretic upper extremity and reduces the difficulty of the task. Non-invasive brain stimulation, such as repetitive transcranial magnetic stimulation and transcranial direct current stimulation, could temporarily modulate cortical excitability by preconditioning before rehabilitation and is usually performed before conventional rehabilitation. Robotics is used to assist the patient’s performance like a neuromuscular electrical stimulation. These new rehabilitation techniques are combined and used as a hybrid rehabilitation therapy. The tailor-made neurorehabilitation approaches adjusted to the paresis and needs of individual patients are needed for functional recovery.
Stepwise linear regression (SLR) is the most common approach to predicting activities of daily living at discharge with the Functional Independence Measure (FIM) in stroke patients, but noisy ...nonlinear clinical data decrease the predictive accuracies of SLR. Machine learning is gaining attention in the medical field for such nonlinear data. Previous studies reported that machine learning models, regression tree (RT), ensemble learning (EL), artificial neural networks (ANNs), support vector regression (SVR), and Gaussian process regression (GPR), are robust to such data and increase predictive accuracies. This study aimed to compare the predictive accuracies of SLR and these machine learning models for FIM scores in stroke patients.
Subacute stroke patients (N = 1,046) who underwent inpatient rehabilitation participated in this study. Only patients' background characteristics and FIM scores at admission were used to build each predictive model of SLR, RT, EL, ANN, SVR, and GPR with 10-fold cross-validation. The coefficient of determination (R2) and root mean square error (RMSE) values were compared between the actual and predicted discharge FIM scores and FIM gain.
Machine learning models (R2 of RT = 0.75, EL = 0.78, ANN = 0.81, SVR = 0.80, GPR = 0.81) outperformed SLR (0.70) to predict discharge FIM motor scores. The predictive accuracies of machine learning methods for FIM total gain (R2 of RT = 0.48, EL = 0.51, ANN = 0.50, SVR = 0.51, GPR = 0.54) were also better than of SLR (0.22).
This study suggested that the machine learning models outperformed SLR for predicting FIM prognosis. The machine learning models used only patients' background characteristics and FIM scores at admission and more accurately predicted FIM gain than previous studies. ANN, SVR, and GPR outperformed RT and EL. GPR could have the best predictive accuracy for FIM prognosis.
Post-stroke disability affects patients' lifestyles after discharge, and it is essential to predict functional recovery early in hospitalization to allow time for appropriate decisions. Previous ...studies reported important clinical indicators, but only a few clinical indicators were analyzed due to insufficient numbers of cases. Although review articles can exhaustively identify many prognostic factors, it remains impossible to compare the contribution of each predictor. This study aimed to determine which clinical indicators contribute more to predicting the functional independence measure (FIM) at discharge by comparing standardized coefficients. In this study, 980 participants were enrolled to build predictive models with 32 clinical indicators, including the stroke impairment assessment set (SIAS). Trunk function had the most significant standardized coefficient of 0.221. The predictive models also identified easy FIM sub-items, SIAS, and grip strength on the unaffected side as having positive standardized coefficients. As for the predictive accuracy of this model, R
was 0.741. This is the first report that included FIM sub-items separately in post-stroke predictive models with other clinical indicators. Trunk function and easy FIM sub-items were included in the predictive model with larger positive standardized coefficients. This predictive model may predict prognosis with high accuracy, fewer clinical indicators, and less effort to predict.
To investigate the cognitive function and its relation to the home discharge of patients following subacute stroke.
This retrospective cohort study included 1,229 convalescent patients experiencing ...their first subacute stroke. We determined discharge destination and demographic and clinical information. We recorded the following measurement scores: Mini-Mental State Examination (MMSE) score, Stroke Impairment Assessment Set score, grip strength, and Functional Independence Measure (FIM). We performed a multivariable logistic regression analysis with the forced-entry method to identify factors related to home discharge.
Of the 1,229 participants (mean age: 68.7 ± 13.5 years), 501 (40.8%), 735 (59.8%), and 1,011 (82.3%) were female, had cerebral infarction, and were home discharged, respectively. Multivariable logistic regression analysis revealed that age (odds ratio OR, 0.93; 95% confidence interval CI, 0.91 - 0.96; P < 0.001), duration from stroke onset to admission (OR, 0.98; 95% CI, 0.96 - 0.99; P = 0.003), living situation (OR, 4.40; 95% CI, 2.69 - 7.20; P < 0.001), MMSE score at admission (OR, 1.05; 95% CI, 1.00 - 1.09; P = 0.035), FIM motor score at admission (OR, 1.04; 95% CI, 1.01 - 1.06; P = 0.001), and FIM cognitive score at admission (OR, 1.08; 95% CI, 1.04 - 1.13; P < 0.001) were significantly associated with home discharge.
MMSE at admission is significantly associated with home discharge in patients with subacute stroke.
Objective: To investigate the long-term cumulative risk and factors associated with fall-related fractures in stroke survivors discharged from convalescent rehabilitation wards.Design: Retrospective ...cohort study.Participants: A total of 786 stroke survivors discharged from a rehabilitation hospital.Methods: Data regarding fall-related fractures posthospital discharge were collected using self-reported questionnaires. The Kaplan–Meier method was used to calculate the cumulative incidence of fall-related fractures, and risk factors were analysed using Cox proportional hazard regression analysis.Results: Of 1,861 consecutive stroke survivors who had been discharged from hospital, 786 (42.2%) provided information concerning fall-related fractures. Duration from time of discharge to time of collection of questionnaires ranged from 1 to 6 years (mean 38.0 months). The cumulative incidence of fall-related fractures at 1-, 2-, 3-, 4-, and 5-years post-discharge was 4.2%, 7.9%, 10.8%, 12.5% and 13.7%, respectively. Cox proportional hazard regression analysis indicated that female sex (hazard ratio (HR) 1.69) and moderate lower limb paresis (HR 3.08) were significant risk factors.Conclusion: The cumulative risk of fall-related fractures in stroke survivors post-discharge from a rehabilitation hospital was notably high. Intensive preventive intervention should be considered for female stroke survivors with moderate lower limb paresis.
LAY ABSTRACTThis study aimed to investigate the risk of fall-related fractures and associated factors in stroke survivors who had been discharged from rehabilitation wards. A questionnaire was sent by post to 1,861 post-discharge stroke survivors to investigate their experiences of fall-related fractures, to which 786 stroke survivors responded. The incidence of fall-related fractures at 1, 2, 3, 4, and 5 years post-discharge was 4.2%, 7.9%, 10.8%, 12.5% and 13.7%, respectively. The presence of moderate lower limb paresis and female sex were associated with 3.08- and 1.69-times higher risk of developing a fall-related fracture, respectively. Intensive preventive intervention should be considered for female stroke survivors with moderate lower limb paresis following discharge from rehabilitation wards.
Background and purpose:
Trunk function plays a key role in performing activities of daily living (ADL) including locomotion and sitting. Sitting and ADL should be performed as early as possible ...especially during the acute phase of stroke rehabilitation. Therefore, this study aimed to assess trunk function among patients with acute stroke using the Trunk Impairment Scale (TIS) and to predict its functional outcomes.
Methods:
Overall, 67 patients with acute stroke (i.e., within 2 days of occurrence of the stroke) were included. The following clinical assessment items were obtained within 48 h after stroke onset and on the day before discharge from the hospital. Trunk function was examined using TIS and Trunk Control Test (TCT). The motor function of the upper and lower extremities was assessed using the stroke impairment assessment set motor (SIAS-M) score, and ADL was assessed using functional independence measure motor (FIM-M) items.
Results:
Multiple regression analysis was performed using the stepwise regression method, using the total FIM-M score following discharge as the dependent variable and age, TIS, TCT, SIAS-M, and FIM-M within 48 h after stroke onset as the independent variables. Age, TIS, and FIM-M within 48 h after stroke onset were selected as the input variables and showed a high-adjusted determination coefficient (R
2
= 0.79;
P
< 0.001).
Conclusion:
TIS is a reliable method for evaluating trunk control function and is an early predictor of ADL among patients with acute stroke.
In post-stroke hemiparesis patients, the skeletal muscle mass decrease rapidly with the histological degradation. We investigated the effect of nutritional supplementation with whey protein and ...vitamin D on the muscle mass and muscle quality, in post-stroke convalescent rehabilitation patients in a randomized, single-blinded, placebo-controlled trial. Fifty patients were randomly assigned to two groups; HP group received supplemental jelly (100 kcal; whey protein 10 g; vitamin D 20 μg) twice a day throughout up to 16-week period, the control group received placebo jelly. Cross-sectional area (CSA) of thigh muscle, skeletal muscle index (SMI), muscle strength, activity of daily living (ADL), and some nutritional indicators in blood were measured. Although no significant difference was observed in CSA and SMI between the groups, fat infiltration into the thighs muscle was singnificantly lower in the HP group. There were no significant difference in muscle strength and ADL between the groups. Blood urea nitrogen and serum 25(OH)D at endpoint were significantly higher in the HP group but physiological normal ranges. Supplementation with whey protein and vitamin D in post-stroke patients led to suppression of fat infiltration into the muscle. Long-term follow-up studies are needed to verify whether this nutritional intervention provides substantial benefits for the prognosis of stroke survivors.
To elucidate the characteristics of subacute stroke survivors with post-stroke cognitive impairment, and examine the factors associated with cognitive recovery.
Retrospective cohort study.
A total of ...218 consecutive stroke survivors, who were admitted to a rehabilitation hospital between April 2014 and March 2015, were included.
The prevalence of post-stroke cognitive impairment, defined as having a Mini-Mental State Examination (MMSE) score < 24 was investigated. Among those with post-stroke cognitive impairment, the characteristics of patients with clinically significant improvement in MMSE scores (change ≥ 4) were explored. Univariable and multivariable regression analyses were performed to examine the relationship between Functional Independence Measure (FIM) items and improvement in post-stroke cognitive impairment.
Post-stroke cognitive impairment occurred in 47.7% of participants. The mean improvement in their MMSE scores was 3.43. Participants who showed improvement had significantly higher FIM scores at discharge than those who did not show improvement. Regarding FIM items, eating (odds ratio 1.3; 95% confidence interval 1.0-1.7; p = 0.041) and social interaction (odds ratio 1.5, 95% CI 1.1-2.1, p = 0.010) were associated with cognitive improvement.
Approximately half of subacute stroke survivors have post-stroke cognitive impairment. Eating and social interaction are significantly associated with cognitive improvement.
•The relation of spinal reflexes with leg motor function was tested in sub-acute and chronic stroke.•Severe spasticity is linked to heteronymous facilitation and disynaptic reciprocal inhibition in ...sub-acute stroke patients.•Spinal reflexes are potential biomarkers for spasticity and motor function.
To assess the relationship between spinal reflexes and motor function in sub-acute (SAS) and chronic stroke (CS) patients.
Twelve SAS and 16 CS patients underwent electrophysiological assessment of heteronymous facilitation (HF), heteronymous inhibition (HI), disynaptic reciprocal inhibition (DRI), and D1 inhibition (D1). The Fugl-Meyer Assessment Lower Extremity (FMA-LE) and modified Ashworth scale (MAS) were assessed. The relationship between spinal reflexes and motor function was examined in a cross-sectional manner. SAS patients were also longitudinally evaluated before and after intensive rehabilitation for approximately 2 months.
SAS patients with triceps surae muscle spasticity (MAS ≥ 1) showed higher HF values (p = 0.03) than those without spasticity. SAS patients with quadriceps muscle spasticity showed higher HF values (p < 0.01); patients with hamstring muscle spasticity showed higher DRI value (disinhibition) (p < 0.01) than those without spasticity. CS patients showed no significant correlation between spinal reflexes and motor function. The longitudinal study revealed a significant correlation between increase in D1 inhibition and FMA-LE improvement in SAS patients (r = 0.69).
The association between impaired spinal reflexes varies with the stage of stroke; HF and DRI may be spasticity indicators in SAS patients.
Spinal reflexes as potential biomarkers may facilitate tailor-made rehabilitation of stroke patients.
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