[129] N-ACETYLASPARTATE: A PREDICTOR OF OUTCOME IN NEUROREHABILITATION
Steven H. Graham, MD, PhD; Lydia Bayne, MD; Lalith
Talagala, PhD
Neurology Service, University Drive VA Medical Center,
Pittsburgh, PA 15240; Department of Neurology, University of
Pittsburgh 15261; email: sgra+@pitt.edu
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(Project #B785-RA)
PURPOSE--Little is known about the mechanisms of recovery after coma. Accordingly, it is difficult to predict outcomes and advise families with any degree of certainty, particularly in patients with traumatic brain injury. Consequently, significant resources are expended in attempts to rehabilitate patients with head injury, even when there may be little chance for recovery for some. Thus, a better understanding of the reversible and irreversible changes that occur during coma would be of great benefit to guide rehabilitation of head-injured patients and, perhaps, provide insight into potential therapies.
A large part of the uncertainty regarding the potential for recovery after traumatic coma may be due to the insensitivity of conventional imaging techniques in detecting neuronal loss. MRI and CT are primarily measures of brain water. Although neurons constitute about 30-35 percent of the volume of brain, selective neuronal loss is poorly visualized on MRI and CT. Conventional scans reveal structural lesions such as contusions and hematomas in many cases, but many patients have diffuse head injuries without such mass lesions. The pathology in these cases reveals diffuse axonal injury due to shear injury and/or diffuse neuronal cell body loss due to hypoxia. Macroscopic evidence of axonal injury may be detected by MRI, but MRI does not reveal the full extent of these changes, nor is it definitive in predicting outcome.
N-acetylaspartate (NAA) has been shown to be produced only by neurons and not by glia or other non-neuronal elements of mature brain. The distribution of NAA may be determined noninvasively by magnetic resonance spectroscopy (MRS). Therefore, MRS may be used to regionally estimate the population of viable neurons in the brain.
It is hypothesized that MRS imaging of total brain NAA of head-injured patients at the time of entry into neurorehabilitation predicts functional and neurobehavioral outcome after 1 year.
Our specific objectives are: 1) to determine whether MRS measurements of total brain NAA of head-injured patients at the time of entry into neurorehabilitation predicts functional and neurobehavioral performance at 1 year after entry into rehabilitation; 2) to determine whether gray or white matter NAA predicts outcome more accurately than total brain NAA; and 3) to determine whether changes occur to NAA during recovery and whether such changes correlate with degree of improvement.
METHODOLOGY--Measurements of NAA will be obtained by MRS of all patients entering rehabilitation after coma due to closed head injury. MRS will determine both gray and white matter NAA in the cortex. The functional independence measure (FIM) 1 year after entry into rehabilitation will be used as the primary outcome measure. Neurobehavioral dysfunction will be measured by a battery of neuropsychological tests sensitive to the executive, organizational, attentional, and memory deficits prevalent in head injury. In half of the patients studied, a second MRS will be performed at this time.
PROGRESS--Previous work in animals has shown than NAA measured by MRS is decreased in some diseases where neurons are selectively injured, such as hypoxic-ischemic encephalopathy and status epilepticus. Human studies demonstrate that NAA is decreased in other diseases where neurons are lost, such as Alzheimer's disease, epilepsy, and stroke.
RESULTS--Quantitative MRS measurements have been completed on 36 head trauma patients and age-matched controls. NAA is significantly decreased in frontal gray matter: controls demonstrated 8.35±0.0 millimolar (mM) vs. 6.16±0.40 mM for the patients, but decreases in NAA did not reach significant levels in frontal white matter or midbrain. The functional independence measure and neuropsychological outcome data on these patients are being collected 1 year after entry into rehabilitation. It has been impractical to study a number of patients eligible for the study due to motion artifacts or contraindications to MR.
[130] AUDITORY EVOKED RESPONSES, SEVERITY, AND PROGNOSIS IN APHASIA: A PILOT STUDY
Robert T. Wertz, PhD; Linda L. Auther, PhD; James W.
Hall, III, PhD
Audiology and Speech Pathology Service, VA Medical
Center, Nashville, TN 37212; Division of Hearing and Speech
Sciences, Vanderbilt University School of Medicine,
Nashville, TN 37212; email: wertz.robert@forum.va.gov
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(Pilot Project #C1761-PA)
PURPOSE--This pilot study is designed to determine the relationship among auditory evoked responses (AERs), severity, and prognosis for improvement in aphasia. We asked two primary research questions: do AERs to verbal stimuli predict severity of aphasia, and do AERs to verbal stimuli predict improvement in aphasia?
METHODOLOGY--A battery of AER tasks is administered to samples of young, nonimpaired adults; to aphasic patients representing three levels of severity (mild, moderate, and severe); and to a sample of nonimpaired adults matched for age, education, and gender with the aphasic sample. The AER battery comprises phonologic, semantic, and syntactic stimuli. AER responses of interest are the mismatched negativity (MMN) and P 300 to phonologic stimuli, N 400 to semantic stimuli, and P 600 to syntactic stimuli. In addition, the aphasic and matched nonimpaired samples receive a battery of language measures. Aphasic patients are evaluated with the AER and language measures at entry and again after 20 treatment sessions. The matched nonimpaired subjects are evaluated at entry and again after 1 to 2 months. Analyses include analysis of variance to compare language performance and AERs between and among the aphasic severity groups and the matched nonimpaired group. Correlations are used to determine whether AERs predict severity in the aphasic subjects. Additionally, multiple regression analysis is used to determine whether the AER measures predict improvement in aphasia after 20 treatment sessions.
PROGRESS--All AER stimuli and tasks have been developed and standardized with a sample of young, nonimpaired adults. Aphasic subjects and matched, nonimpaired subjects are being evaluated and reevaluated with the AER and language measures to determine the relationship between AERs and severity of aphasia and the ability of AERs to predict improvement in aphasia.
PRELIMINARY RESULTS--All young, nonimpaired subjects show MMN responses to phonologic stimuli and N 400 responses to semantic stimuli. Eighty percent of the young, nonimpaired subjects show P 300 responses to phonologic stimuli, and 60 percent show P 600 responses to syntactic stimuli. In the aphasic subjects evaluated to date, all show MMN responses to phonologic stimuli regardless of their severity of aphasia. However, the presence of P 300 responses to phonologic stimuli, N 400 responses to semantic stimuli, and P 600 responses to syntactic stimuli appears to be related with the severity of aphasia.
FUTURE PLANS--We continue to recruit, evaluate, and reevaluate aphasic subjects and matched, nonimpaired control subjects to obtain a sufficient sample size for conducting multiple regression analysis to determine the prognostic precision of the AER in predicting improvement in aphasia.
[131] PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION EFFECTS UPON MAXIMAL ISOMETRIC STRENGTH AND ENDURANCE
David A. Gabriel, PhD; Jeffrey R. Basford, MD, PhD;
Kai-Nan An, PhD
Department of Orthopedics and Department of Physical
Medicine, Mayo Clinic and Mayo Foundation, Rochester,
Minnesota 55901; email: dgabriel@mayo.edu
Sponsor: The MayoClinic/Mayo Foundation, Rochester, MN 55905
PURPOSE--This study compared the efficacy of increasing muscular strength through motor learning versus proprioceptive mechanisms. The research question being addressed was: should agonist-antagonist coordination be considered an important factor in neuromuscular reeducation? Maximal isometric elbow extension strength and endurance were tested under a measurement schedule previously demonstrated to result in rapid strength and endurance gains through motor learning. Agonist and antagonist muscular strength and endurance were tested in an experimental group (N=13) on the same day using a proprioceptive neuromuscular facilitation (PNF) technique termed the reversal of antagonists. Testing the agonist and antagonist in successive combination on the same day may counterbalance the development of agonist-antagonist coordination and interfere with extension strength gains. However, it is equally possible that this technique may result in facilitation of extension strength. A control group (N=13) was used to verify that the measurement schedule did indeed result in rapid strength and endurance gains. Testing the extensors alone may allow for the development of some type of efficiency in the firing patterns between flexor and extensor muscle groups. This hypothesis provides for the development of strength through enhanced coordination, or skill, between agonist and antagonist muscle groups.
METHODOLOGY--There were 4 test days with a 2-week interval between each day. The control group performed five baseline maximal isometric elbow extension strength trials; each contraction was 2 s in duration with a 24-s intertial rest period. After a 5-min rest, subjects then performed a 30-trial fatigue protocol. The maximal isometric elbow extension endurance trials were limited to 2 s with 6 s between each trial. The experimental group performed five baseline reversals of antagonists, which consisted of a 2-s maximal isometric elbow flexion immediately followed by a 2-s maximal isometric elbow extension; a 22-s rest period was allowed between each trial. After a 5-min rest, subjects then performed a 30-trial fatigue protocol with a 4-s rest period between each trial.
Subjects were seated at a table designed to isolate the elbow extensors in an isometric contraction, and forces and moments were measured in six degress-of-freedom. We measured elbow extension moment, and root-mean-square amplitude of electromyographic (EMG) activity, mean power frequency (MPF), and median power frequency (MF) obtained from surface recordings of the biceps brachii long head, brachioradialis, triceps brachii long head, and triceps brachii lateral head. These measures were analyzed using a split-plot factorial analysis of variance with one between-block treatment, groups, and two within-block treatments corresponding to days and trials. An orthogonal polynomial breakdown for means across days and trials was used to further assess the experimental affects.
PROGRESS--Data reduction and analysis has been completed for baseline strength. Both groups exhibited a quadratic increase (P<0.05) in baseline maximal isometric elbow extension strength. Strength increased (P<0.05) between test days 1, 2, and 3 then plateaued between test days 3 and 4. Based on the strength data alone, both methods of training resulted in a rapid increase in strength.
[132] PREVENTION OF THROMBOEMBOLISM IN STROKE REHABILITATION PATIENTS
David Green, MD, PhD
Rehabilitation Institute of Chicago, Chicago, IL
60611
Sponsor: Department of Education, National Institute on Disability and Rehabilitation Research, Washington, DC 22202
PURPOSE--Deep vein thrombosis and pulmonary embolism are important causes of morbidity and mortality in patients who have survived a recent stroke. Complicating the efforts of rehabilitation is a vulnerability to thromboembolism, which has been shown to affect 60-75 percent of elderly stroke patients. This is a study to compare two methods of thromboprophylaxis, calf compression boots (CC) and low molecular weight heparin (LMWH), to see which is most safe and effective.
METHODOLOGY--The end points will be to determine efficacy as the presence or absence of thrombus, as defined by venous flow studies, venography, positive V/Q scan or pulmonary angiography. Also, to determine the safety by the presence or absence of bleeding, either intracranial (positive CT scan or MRI), or elsewhere (decline in hematocrit of >5 percent, hemoglobin >2g).
PROGRESS--To date, 53 subjects have entered the study and 42 have had venograms, of which 39 were negative and 3 were positive. Two of the positive venograms were in the LMWH group and one was in the CC group. One subject in the LMWH group has had bleeding. These numbers are still too small for statistical analysis, and recruitment is ongoing. The goal is still to recruit a total of 100 subjects.
Of the 11 subjects in whom venograms were not performed, 6 were dropouts and 5 could not have venography because of technical reasons. Of the six dropouts, four left because of patient or family withdrawals, one had a leg infection which precluded performance of the test, and one had gastrointestinal bleeding.
[133] THE EFFECTIVENESS OF A TELEPHONE SUPPORT GROUP FOR STROKE CAREGIVERS
Robert Hartke, PhD; Rosemarie King, PhD
Rehabilitation Institute of Chicago, Chicago, IL
60611
Sponsor: Department of Education, National Institute on Disability and Rehabilitation Research, Washington, DC 22202
PURPOSE--The study explores the effectiveness of a unique intervention for the stress of older spousal caregivers of stroke survivors.
METHODOLOGY--One hundred thirty-six caregivers of spouses with stroke, 60 yrs and older, are randomly assigned to a treatment or control group. The treatment group participates in an 8-week educational/support group professionally led by telephone conference calls. They are assessed upon recruitment, after the group intervention, and at 6 months. The control group receives written material on caregiver stress and is assessed upon recruitment and after 6 months. At the end of their control group commitment, they are entered into the treatment group, participate in a support group, and are followed for an additional 6 months. The study hypotheses are that the treatment group shows less depression, loneliness, burden, increased health behaviors, and increased competence. The research protocol has also been revised to make the control group into a "wait list" control. In this design, control subjects go on to participate in the treatment group after completing the control condition.
PROGRESS--Seventy-six subjects have been recruited and 64 have remained in the study, resulting in a 19 percent attrition rate. The major reasons for subject drop out have been: too busy, death of spouse, and unable to contact in 6-month follow-up. Of the 64 subjects, 30 were assigned to the treatment group and 34 to the control group. A total of seven support groups have been conducted and 44 subjects have completed the study.
Of 76 subjects fully assessed and entered into the study database, the average age is 69.6 yrs. Seventy-six percent of the sample are women and 72 percent are white. They have been married on average for 41.2 yrs to the stroke survivor (range: 4-64 yrs.) and have an average of 14.3 yrs of education (range: 8-20 yrs); 21 percent of them work full or part-time. Seventy-nine percent rate their health to be good or excellent. Their median time caregiving is 2.0 years with a (range: 1 mo-27 yrs). Sixty-one percent provide up to 15 hrs of care per day; 37 percent report receiving paid outside assistance.
At the first assessment, the caregivers indicated on average that their spouses require supervision with functional activities, although the range of functional limitations reported is quite wide. Twenty percent rate their spouses as severely impaired as measured by the Functional Independence Measure. Thirty-two percent scored above the usual cutoff of 16 indicating significant number of depressive symptoms. On the UCLA Loneliness Scale, the mean score was 17.4 which is close to a community average. Thirty-nine percent had an above average score indicating greater loneliness.
RESULTS--Limited analyses have now been conducted on small subsets. A sample of 30 caregivers was analyzed for their most pressing problems. Social isolation, worry and over protectiveness, finances, and frustration with various caring tasks are frequent problems. Health, conflicts with others, and loss of companionship with their spouse are also frequently mentioned. The most frequently identified problems are not necessarily the most stressful ones. There are a few types of problems that caregivers rate as more stressful but do not feel confident to handle, including spousal noncompliance, interpersonal conflicts with others, specific stroke impairments, and future health uncertainty. These tend to be complicated problems without easy solution.
[134] EFFECTS OF AEROBIC EXERCISE ON YOUNG PERSONS POST-STROKE
Michele Averbuch, PT; Jim Hibler, PT
Rehabilitation Institute of Chicago, Chicago, IL
60611
Sponsor: Department of Education, National Institute on Disability and Rehabilitation Research, Washington, DC 22202
PURPOSE--Young stroke survivors participated in an aerobic fitness program to determine the effects of aerobic exercise on fitness levels, ambulatory speed, and life satisfaction. A pre-post design was used to allow each subject to act as his/her own control.
METHODOLOGY--The first 10-week session was the initial control period. Subjects were instructed to maintain the same activity level. The aerobic walking program was introduced at the onset of the second 10-week period. Subjects ambulated three times per week for a minimum of 20 minutes at their target heart rate with a warm-up and cool-down phase included in each session. Blood pressure and heart rate were taken at the beginning and completion of each exercise session to ensure a return to baseline measures. Heart rate and rating of perceived exertion were used to monitor subjects during baseline. An educational component was provided on a weekly basis; topics discussed were relevant to stroke rehabilitation and exercise. The final 10 weeks served as the second control period. During this interval, subjects were encouraged to continue with independent exercise as performed during the previous structured walking program. Local health clubs were visited by the authors to form a liaison between community-based facilities and any interested participants, and to ensure that the specific needs of stroke survivors would be sufficiently addressed. Community reentry is an important facet that was promoted through an ongoing emphasis on safe, independent exercise for the participants throughout the study.
Submaximal treadmill tests were performed at the onset of participation in the study, after the first control period, after the completion of the aerobic walking program, and at the end of the second control session (0 wks, 10 wks, 20 wks, and 30 wks).
PROGRESS--Ten subjects were able to finish the entire protocol. The 10 included 7 men and 3 women, ranging in age from 29 to 62 years (mean=49). Due to the length of the study (30 weeks), a number of subjects had to discontinue participation because of schedule conflicts, including return to work or school, or transportation difficulties. The initial stress test using the treadmill produced abnormal results in several cases, necessitating a return to their primary physician for further evaluation and exclusion from data collection. The stress tests themselves proved difficult with some subjects due to gait deviations and fear while using the treadmill.
RESULTS--Eight of the 10 subjects demonstrated improvement in life satisfaction as measured by the Quality of Life Index (QLI). A program written by Ferrans and Powers was used to calculate an overall QLI score from the surveys administered to the subjects at the completion of each 10 week period. A maximum score for the QLI is 30, and a change of 2 points is considered clinically significant. The changes in QLI between pre-test and post-test 1, and between the post-test 1 and post-test 2 were not found to be significant. The change in score between the pre-test and post-test 2, however, was determined to be statistically significant at a t value of 3.98.
[135] A CONTROLLED STUDY OF THE EFFECTS OF EMG FEEDBACK AND ELECTRICAL STIMULATION ON MOTOR RECOVERY IN ACUTE STROKE PATIENTS
John McGuire, MD
Rehabilitation Institute of Chicago, Chicago, IL
60611
Sponsor: Department of Education, National Institute on Disability and Rehabilitation Research, Washington, DC 22202
PURPOSE--Despite conventional rehabilitation efforts, loss of upper extremity control continues to be one of the main limiting factors determining functional independence in stroke survivors. The restoration of motor control relies on the convergence of at least three types of physiologic information: central representations of motor output encoding the goal of movement, afferent input to provide the means to monitor movement progress, and relevant data from motor memory.
METHODOLOGY--The main objective of this project is to investigate in a controlled manner whether more normal muscle synergistic relations can be encouraged in acute stroke patients by using either EMG feedback, functional electrical stimulation, or a combination of these therapeutic interventions. Subject recruitment and testing are underway.
PROGRESS--Currently 26 stroke patients with low motor function have been randomized, 20 of whom have completed 18-20 treatment sessions. Seven patients have completed the 1-year follow-up. Pre- and postevaluation data are being analyzed.
[136] REDUCING MOTOR DISABILITY IN HEMIPARETIC STROKE BY MANIPULATION OF SENSORY INPUT FROM THE PARETIC UPPER LIMB: A QUANTITATIVE EVALUATION
Jules Dewald, PT, PhD; Joseph Given, PhD
Rehabilitation Institute of Chicago, Chicago, IL
60611
Sponsor: Department of Education, National Institute on Disability and Rehabilitation Research, Washington, DC 22202
PURPOSE--The disability of the upper limb after a hemiparetic stroke is often perceived as one of the most frustrating experiences by stroke survivors. There are well defined reasons for the disproportionate impact of cerebral stroke in upper limb function, such as the greater relative area of cortex devoted to upper limb control, coupled with the fact that arm motions play a major role in both activities of daily living and in the workplace. A large number of neurotherapeutic techniques claim that the effect of their respective interventions creates the best results. However, because of the absence of quantitative measures to evaluate the effect of these therapeutic interventions on limb motor behavior, little progress has been made toward the determination of the optimum intervention protocols for impaired limb motion. The broad objective of our research is to quantify how sensory input can reduce disturbed muscle synergic relations and/or spasticity and thereby improve function of the impaired limb.
METHODOLOGY--The investigation of the effect of sensory manipulations with topical drugs has been initiated with a mixture of Lidocaine and Prilocaine (EMLA) on normal control subjects to determine the analgesic effect on various cutaneous afferent types. Subsequently, we plan to investigate the effect of EMLA on abnormal torque synergies using the new synergy quantification approach discussed above.
An alternate way to determine the relation between sensory input and disturbed muscle synergic relations in hemiparetic stroke has been obtained by studying flexion withdrawal reflexes following stroke. Flexion withdrawal reflexes were compared in the impaired and unimpaired upper extremities of eight hemiparetic stroke subjects. Six nonimpaired subjects served as the control group. The effects of mildly noxious electrical stimuli delivered to the index finger were studied using EMGs from 12 arm muscles along with elbow and shoulder torques measured at the wrist with a 6 degree of freedom load cell. A quantitative analysis of torque and EMG responses was performed.
PROGRESS--We have studied the effects of electrical stimulation of the skin on upper extremity spasticity in nine hemiparetic stroke subjects. In seven subjects, we observed a significant reduction in ensemble mean peak flexor torque while significant reductions of mean peak extensor torque were observed in four of the five subjects with consistent extensor reflex responses. In the other two subjects, one exhibited significant increases in mean peak torque for both extensors and flexors while the other showed a corresponding increase in mean flexor peak torque with reductions in mean extensor peak torque. In five subjects we were able to evaluate changes in stretch reflex threshold angle and reflex gain. Analysis of reflex stiffness identified no significant differences in stiffness for either elbow extensors or flexors. In contrast, we observed significant shifts in angular threshold angles such that greater angular stretches were required to elicit the stretch reflex after cutaneous electrical stimulation. In all subjects, angular shifts of the extensors, when present, resulted in later onsets of the stretch reflex. Angular shifts in the flexors followed the same trend for four of the five subjects.
We have gathered data on the effect of sensory manipulation on arm movements, mostly additional control data from normal and hemiparetic stroke subjects. We have been studying movement trajectories during supported and unsupported ballistic planar arm movements in stroke.
RESULTS--In general our preliminary movement results seem to suggest that during supported planar arm motions, abnormal torque synergies play no significant role. However, spasticity may play a role depending on the target matching direction and movement velocity. Weakness appears to play no role in movement trajectory formation. In the case of unsupported planar arm motions, abnormal trajectories are observed in directions which require torque elbow/shoulder combinations away from abnormal torque synergies as measured during static conditions. These results indicate that interventions which reduce spasticity and/or abnormal torques synergies may result in improved functional usage of the impaired upper limb in stroke.
[137] COURSE OF RECOVERY OF COGNITIVE-COMMUNICATIVE PROBLEMS IN RIGHT BRAIN DAMAGED INDIVIDUALS
Leora R. Cherney, PhD; Anita S. Halper, MA
Rehabilitation Institute of Chicago, Chicago, IL
60611
Sponsor: Department of Education, National Institute on Disability and Rehabilitation Research, Washington, DC 22202
PURPOSE--Historically, it was assumed that only left hemisphere (LH) damage resulted in language deficits while right hemisphere (RH) damage had no important effect on communication. However, recent evidence suggests that the RH makes an important contribution to language processing, and it is now widely acknowledged that RH stroke also results in impairments in communication. RH communication impairments are believed to result from underlying deficits in attention, memory, and perception. However, the precise relationship between communication impairment and deficits in these cognitive processes is not well understood. Appropriate rehabilitation interventions cannot be designed until a better understanding of the relationship between communication and these cognitive processes emerges. There is also very little information regarding the course of recovery of cognitive-communicative problems in patients with RH damage.
METHODOLOGY--Increased knowledge about the rate, amount, and patterns of recovery of communication problems in RH stroke patients is needed to facilitate the selection of more effective rehabilitation interventions.
PROGRESS--Subject recruitment has been progressing slowly but steadily. The charts of all consecutive admissions to RIC with unilateral RH stroke are reviewed weekly. During this period of time, 17 new subjects have been recruited and have participated in the initial evaluation session, bringing the total number of participants to 38. Seven of these subjects have been followed longitudinally over an 18-month period and have now completed their 4 test sessions; 8 subjects have been tested 3 times and 13 subjects have been tested twice. Most of the repeated evaluations have been conducted in the current reporting period.
RESULTS--Data analysis is underway. All cognitive tests have been scored and the discourse of all subjects has been transcribed. Preliminary analyses have focused on 1) changes in unilateral visual neglect over time, 2) the relationship between unilateral visual neglect and production of informational content in a story retelling task, and 3) performance trends on word list recall and recognition both in the acute stage and longitudinally over time.
With regard to neglect, results indicate that there is a relationship between production of meaningful content and performance on a test of unilateral visual neglect. Furthermore, subjects with persistent neglect (over a period of at least 1 year) produced less meaningful content than subjects with a transient neglect (i.e., no neglect evident at 6 months post-onset). These findings are consistent with the objectives of the study.
With regard to word list recall and recognition, results indicate that poor performance is associated with difficulties in the encoding process rather than in the retrieval process; therefore, individuals in a rehabilitation program would benefit from practice, repetition of important information, and the imposition of a strategy that facilitates encoding. The precise relationship between performance on this task and production of meaningful discourse is yet to be examined.
[138] COMORBIDITIES AND COMPLICATIONS IN STROKE: INCIDENCE, RISK FACTORS, AND EFFECTS ON OUTCOMES
Elliot Roth, MD; Allen Heinemann, PhD
Rehabilitation Institute of Chicago, Chicago, IL
60611
Sponsor: Department of Education, National Institute on Disability and Rehabilitation Research, Washington, DC 22202
PURPOSE--Individuals who sustain a stroke may be as disabled by the consequences of associated medical conditions as by the stroke itself.
METHODOLOGY--This study is designed to investigate clearly and systematically the incidence, risk factors, and impact on rehabilitation outcomes of pre-existing conditions and medical complications of stroke.
PROGRESS--Data have been collected on all 980 new patients admitted to the inpatient stroke rehabilitation service from December 1993 through May 1996. Demographic, stroke, medical comorbidity, and other information has been collected on 809 patients and entered into the database. Laboratory results and data on secondary complications have been reviewed for 697 of those patients. Impairment disability measures have also been collected on these same 697 patients.
RESULTS--The most common pre-existing complications found in our stroke population are hypertension, a history of smoking, and diabetes. Other pre-existing complications of clinical significance include coronary artery disease, myocardial infarction, and congestive heart failure. The most frequent complications developed during the acute hospitalization are urinary tract infection, pneumonia, and hypertension. The most common complications developed during acute inpatient rehabilitation include urinary tract infection, joint and soft tissue pain, electrolyte abnormalities, and depression. It is significant that 23 percent of stroke survivors seen for acute inpatient rehabilitation did not develop any complications.
Information from routine laboratory tests also has been collected. Almost one-third of patients have low serum albumin on admission to rehabilitation and 19 percent have low levels of hemoglobin.
We have investigated the usefulness of the Charleston Comorbidity Index in predicting functional outcomes and resource utilization. While preliminary data analysis indicates that this particular severity of illness index may not be very useful in the stroke population, further data analysis is ongoing.
[139] INFLUENCES OF CANE LENGTH ON THE STABILITY OF STROKE PATIENTS
Chun-Liang Lu, MD; Bing Yu, PhD; Jeffrey R. Basford, MD;
Marjorie E. Johnson, MS, PT; Kai-Nan An, PhD;
Orthopedic Biomechanics Laboratory, Mayo Clinic and Mayo
Foundation, Rochester, MN 55905; email: an@mayo.edu
Sponsor: National Institutes of Health, Bethesda, MD 20892; Mayo Foundation, Rochester, MN 55905
PURPOSE--One of the common problems for stroke patients is falling. Using canes can help stroke patients to improve their stability and reduce the risk of falling. In the selection of an appropriate cane for a stroke patient, cane length is an important consideration. There are significant discrepancies between cane lengths prescribed using different methods for determining appropriate cane length. The purposes of this study were to investigate the influence of cane length on the standing and walking stability of stroke patients and determine the appropriate lengths for individual patients.
METHODOLOGY--Ten male stroke patients with hemiplegia due to cerebrovascular accidents were recruited as volunteer subjects for the study. The mean age of these patients was 59 years with a standard deviation of 7 years. The mean following-up time since the onset of symptoms was 49 months (4 to 126 months). Each subject was using a cane for ambulation in his daily activities. Two different cane lengths based on the measurements of the distance from distal wrist crease to the ground (WC cane), and the distance from greater trochanter to ground (GT cane) were given to each patient. The elbow flexion angle corresponding to each cane length was also recorded for each patient. Three force plates were used to collect the path of the center of pressure (COP) for each patient in standing and walking. The maximum sways, the total travel distances, and the mean travel speeds of the COP were determined and used as stability measures for each patient in standing and walking with and without canes. Analyses of variance with repeated measures were conducted to compare these parameters between WC and GT canes. Regression analysis was conducted to determine the effects of elbow flexion angle on these parameters.
RESULTS--It was found that the total travel distance and the mean travel speed of the COP in the medial-lateral direction were significantly lower when standing with a cane than when standing without one. It was also found the values of these parameters and the maximum sways of the COP in both anterior-posterior and medial-lateral directions were significantly lower when standing with the WC cane than when standing with the GT cane. No significant difference was found in the maximum medial-lateral sway, the total travel distance, and the mean travel speed of the COP in walking. These results suggested that the standing stability of stroke patients was improved by using canes, especially by using WC cane, although no significant influence of using canes was detected for the walking stability.
Significant correlations were found between the maximum sways of the COP in standing tests and the elbow flexion angle when the elbow flexion angle was less than 40°. This relationship indicated that the greater the elbow flexion angle, the lower the maximum sways of the COP. There were still large variations in the maximum sways of the COP when the elbow flexion angle was greater than 40°. These results suggested that (a) the elbow flexion angle for cane prescription should be no less than 40°; and (b) the elbow flexion angle was not a reliable parameter for determining appropriate cane length when it was greater than 40°.
No significant difference was found in any of the selected stability measures for walking with different canes.
Based on these results, it is recommended that the WC canes be used for stroke patients. However, the cane length may need to be adjusted to have an elbow flexion angle greater than 40°.
[140] A DISABILITY-ORIENTED EPIDEMIOLOGICAL STUDY ON THE LONG-TERM SEQUELAE OF TRAUMATIC BRAIN INJURY
H.G.G. Van Balen, Drs; Theo Mulder, PhD
Department of Research and Development, and Nijmegen
centre of Motor behaviour and Cognition, Sint
Maartenskliniek, Hengstdal 3, 6522 JV Nijmegen,
Netherlands.
Sponsor: Stichting Fonds Johannastichting, Arnhem, and Sint Maartenskliniek, Nijmegen, Netherlands
PURPOSE--We seek to determine the differences in long-term consequences between a selected group of traumatic brain injured (TBI) patients, those belonging to a support organization, and an unselected "epidemiological" group.
METHODOLOGY--We surveyed a randomly selected retrospective sample from a Nijmegen hospital discharge list and members of a support group from across The Netherlands, taking a random sample of all patients living in the Nijmegen area discharged with a diagnosis of TBI aged 15-30 years at the time of injury, and selection from total membership of support group of persons who had suffered a TBI at the same age and who did not live in Nijmegen.
Initial contact was made by letter; all interviews were undertaken at home. We employed the Sickness Impact Profile, the Wimbledon Self-Report Scale, the Employability Rating Scale, and the Barthel ADL index to elucidate residual problems.
PROGRESS--Of the 124 hospital patients identified, 61 were randomly selected for study, and 51 participated. Of the 500 support group members listed, 22 fulfilled the criteria. The hospital group contained fewer men (55 percent vs 73 percent) and the hospital patients had less severe brain injuries (55 percent vs 0 percent coma under 24 hours), more were at work (71 percent vs 10 percent), fewer were in long-term care, and most were or could live independently. Nonetheless 34 (67 percent) of the hospital sample suffered cognitive, behavioral, or "situational" disabilities, whereas only 10 percent received any rehabilitation services at all after the acute-care period.
RESULTS--Members of a support organization are not representative of all TBI patients. Their views on services and service development should be interpreted in this light, in particular with respect to patients with less visible or less pronounced disabilities. In addition, service development should be based both on disease and disability-oriented data.
FUTURE PLANS--We plan to develop, introduce, and administer more comprehensive cognitive rehabilitation programs.
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