Control of lead and trail limbs during obstacle crossing following stroke

Background and Purpose. Obstacle crossing is compromised following stroke. The purpose of this study was to quantify modifications during obstacle clearance following stroke.

Subjects. Twelve subjects with stroke and 12 subjects without stroke participated in the study.

Methods. Kinematic variables were measured while participants crossed a 4-cm-high obstacle. Subjects with stroke walked at a self-selected speed; subjects without stroke walked at a comparable speed and at a self-selected speed.

Results. Several modifications were observed following stroke with both groups walking at self-selected speeds. The affected lead limb was positioned closer to the obstacle before crossing. Affected trail-limb clearance over the obstacle was reduced. Both affected and unaffected lead and trail limbs landed closer to the obstacle after clearance. Swing time was increased in the affected lead limb after obstacle clearance. Fewer modifications were detected at matched walking speed; the trail limb still landed closer to the obstacle.

Discussion and Conclusion. Modifications during obstacle crossing following stroke may be partly related to walking speed. The findings raise issues of safety because people with stroke demonstrated reduced clearance of a 4-cm obstacle and limb placement closer to the obstacle after clearance.

Predicting the grade of disability 1 year after stroke following rehabilitation

The purpose of this study was to identify predictors of grades of disability at least 1 year after stroke rehabilitation therapy. We recruited stroke patients from the inpatient rehabilitation department of a university hospital. The degree of disability was graded using the disability evaluation at least 1 year after stroke onset. Functional ability was evaluated using the Functional Independence Measure instrument on admission, on discharge from the inpatient rehabilitation program, and at the 6-month follow-up visit after discharge. Major sociodemographic, medical, and rehabilitative factors were also collected during the hospitalization period. Of the 109 patients surveyed, 64 (58.7%) had severe or very severe grades of disability. The correlates of severe or very severe disability in logistic regression analyses were bilaterally affected (odds ratio, OR, 10.8), impaired orientation (OR, 3.6), and poorer functional ability at discharge (OR, 7.6). Based on the significant predictors identified, the logistic regression model correctly classified severe or very severe disability in 68.0% of subjects. The higher frequency of severe or very severe disability in this study may have been due to the relatively more severely affected stroke patient population in the inpatient rehabilitation service and the use of unique disability evaluation criteria. These results may provide information useful in planning continuous rehabilitation care and setting relevant socio-welfare policies for stroke victims.

Thromboyytic therapy for acute ischaemic stroke : successful implementation in an Australian tertiary hospital

Background: The use of tissue-type plasminogen activator (t-PA) in ischaemic stroke outside of experienced stroke centres remains controversial. The aim of this study was to present the initial experience with t-PA in patients with ischaemic stroke at an institution with no prior experience in i.v. stroke thrombolysis and to compare results to published reports.

Methods: Prospective audit of 888 patients with consecutive stroke and transient ischaemic attack admitted to a 426-bed tertiary referral hospital from March 2003 to October 2005. Main outcome measures were treatment rate, exclusion criteria, protocol violations, intracerebral haemorrhage, disability (modified Rankin scale) and mortality at 3 months.

Results: Over the study period, 72 patients received t-PA (11% of ischaemic strokes). The main reason for exclusion was presentation beyond 3 h of onset (44%); if all eligible patients had arrived within 3 h, treatment rate was estimated at 32.5%. Protocol violations occurred in 15 (21%) patients. There were seven (10%) asymptomatic intracerebral haemorrhage and one (1%) non-fatal symptomatic intracerebral haemorrhage. At 3 months, 37% had achieved excellent recovery (modified Rankin scale 0–1) and seven (10%) had died. The delivery and outcomes associated with the use of t-PA were comparable to the results of the National Institute of Neurological Disorders and Stroke trial and meta-analysis of open-labelled studies.

Conclusion: With appropriate infrastructure and protocols, previously inexperienced tertiary referral centres can replicate the experience and outcome measures reported by clinical trials of t-PA in patients with stroke.

The health loss from ischemic stroke and intracerebral hemorrhage : evidence from the North East Melbourne Stroke Incidence Study (NEMESIS)

Background People suffering different types of stroke have differing demographic characteristics and survival. However, current estimates of disease burden are based on the same underlying assumptions irrespective of stroke type. We hypothesized that average Quality Adjusted Life Years (QALYs) lost from stroke would be different for ischemic stroke and intracerebral hemorrhage (ICH).

Methods We used 1 and 5-year data collected from patients with first-ever stroke participating in the North East Melbourne Stroke Incidence Study (NEMESIS). We calculated case fatality rates, health-adjusted life expectancy, and quality-of-life (QoL) weights specific to each age and gender category. Lifetime 'health loss' for first-ever ischemic stroke and ICH surviving 28-days for the 2004 Australian population cohort was then estimated. Multivariable uncertainty analyses and sensitivity analyses (SA) were used to assess the impact of varying input parameters e.g. case fatality and QoL weights.

Results Paired QoL data at 1 and 5 years were available for 237 NEMESIS participants. Extrapolating NEMESIS rates, 31,539 first-ever strokes were expected for Australia in 2004. Average discounted (3%) QALYs lost per first-ever stroke were estimated to be 5.09 (SD 0.20; SA 5.49) for ischemic stroke (n = 27,660) and 6.17 (SD 0.26; SA 6.45) for ICH (n = 4,291; p < 0.001). QALYs lost also differed according to gender for both subtypes (ischemic stroke: males 4.69 SD 0.38, females 5.51 SD 0.46; ICH: males 5.82 SD 0.67, females 6.50 SD 0.40).

Discussion People with ICH incurred greater loss of health over a lifetime than people with ischemic stroke. This is explained by greater stroke related case fatality at a younger age, but longer life expectancy with disability after the first 12 months for people with ICH. Thus, studies of disease burden in stroke should account for these differences between subtype and gender. Otherwise, in countries where ICH is more common, health loss for stroke may be underestimated. Similar to other studies of this type, the generalisability of the results may be limited. Sensitivity and uncertainty analyses were used to provide a plausible range of variation for Australia. In countries with demographic and life expectancy characteristics comparable to Australia, our QoL weights may be reasonably applicable.

Efeitos imediatos da eletroestimulação nervosa transcutânea e crioterapia na espasticidade e na atividade eletromiográfica de sujeitos hemiparéticos

Cerebrovascular accident (CVA) is a term used to characterize an ischemic or hemorrhagic vascular injury, which has got as main clinic manifestations, the motor and reflex function disturbance. In the first stage there is flaccidity and loss of voluntary movements that afterwards is substituted by mass patterns and spasticity. The spasticity brings with itself functional deficits and can generate negative impacts in various motor patterns. The aim of this research was to investigate the hyperreflexia and identify the immediate effects of transcutaneous nervous stimulation (TENS) and cryotherapy in the spasticity and electromyographic activity of hemiparetic subjects. The study is characterized as an almost experimental type, in which were selected, to compose the sample, 16 patients of both sex with CVA sequel. These individuals were evaluated by collecting the amplitude peak to peak and H reflex latency, Motor response (M response) in solear muscle and the electromyography (EMG) of the injured and healthy legs anterior tibial muscles. In the injured limb the evaluations occurred in different days for cryotherapy, TENS and control, in two moments, before and after the interventions. The healthy limb was evaluated one single time to serve as baseline, for comparison with the injured limb. It was used an statistic analysis, the t paired student test to identify the H reflex differences, latency and EMG of the injured and healthy limbs and to compare the results before and after the recourses application. The ANOVA for related samples was used to identify the differences among the recourses used. It was attributed for the statistic tests a significance level of 5%. The amplitude peak to peak of normalized maximum H reflex through the maximum motor response (Hmax/Mmax), showed itself significantly increased in the injured limb (p=0.0245). The H reflex latency was presented reduced in the injured limb (p=0, 0375). The electromyographic activity was showed decreased in the injured limb (p< 0.0001). After the TENS there was a Hmáx/Mmáx ratio decrease (0.60±0.16 versus 0.49.±0.18; P = 0.0006). Nonetheless, Just after the cryotherapy application there was an increase of Hmáx/Mmáx ratio (0.58 ± 0,15 to 0.77 ± 0.13, P=0,0007) and increase of signal latency (30.41 ± 1.87 versus 33.24 ± 2.19; P=0.0001). The electromyographic activity wasn t altered significantly by any resource. It was met statistic significant differences when the Hmáx/Mmáx P<0.0001) ratio and H reflex latency (P<0.0001) were compared between the post TENS, cryotherapy and control. One can conclude that the TENS can be used to spasticity immediate reduction, and that the cryotherapy can increase the hyperreflexia state in spastic patients. Nonetheless, the spasticity decrease or increase didn t provoke lectromyographic activity change in the muscle that is opponent to the spastic one

Características sociodemográficas, hábitos de sono, estado cognitivo e funcional após acidente vascular cerebral

ABSTRACT Introduction: The cerebrovascular accident (CVA) is an important cause of neurological impairment. Few data about the factors associated with morbidity of cerebrovascular accident are found in Brazil. Objectives: Evaluate sociodemographic characteristics, sleep habits, cognitive and functional status of patients with cerebrovascular accident. Methods: The patients evaluated through questionnaire Step 1 to survey the sociodemographic characteristics and Modified Rankin Scale for functional assessment. The neurological degree was evaluated by the National Institutes of Health Stroke Scale (NIHSS), the sleep Habits questionnaire for sleep and cognitive status by the Mini-Examination of the Mental State (MEMS). The data were analyzed using the chi-square test to determine differences in proportions of variables and linear regression analysis. Results: 305 patients were evaluated and the larger number of subjects was between 50 and 69 years (40%), most patients had no formal education (40.3%) and had ischemic type of cerebrovascular accident (72.5%). In the analysis of the functionality it was found that most patients had moderate impairment (55.1%). The results of the sleep habits showed that 63,6% of patients had one more person in the bedroom,12,3% complained about too much noise in the 11 room and 35% of too much light. From these patients 5,8% were smokers, 7,8% and 70,1% drank coffee drinkers, 28,6% had difficulty in initiate to sleep and woke up 37,6% in the middle of the night. Were showed complaints about nightmares (11%), feeling of suffocation (37,7%) and 35% felt very sleepy during the day. In addition, 95% were unemployed, 80,5% did not perform physical activities and 95,4% did not perform mental activities. The cognitive screening conducted a determined association of cognitive status with age and education level and neurological status. Conclusion: The study showed a high frequency of cases of cerebrovascular accident with functional dependence in a moderate degree, identified that many patients do not follow hygienic measures of sleep and found that the assessment of cognitive deficits must take into consideration the age, educational level and degree of neurological patients. We suggest the need for programs of assistance to victims of cerebrovascular accident patients, with a multidimensional approach including the rehabilitation team, the role of sleep medicine and Neuropsychology, so that patients have access to a more appropriate functional rehabilitation, develop a lifestyle that ensures a good sleep quality and are evaluated and rehabilitated with regard to cognitive impairment

Vivenciando a sobrecarga ao vir-a-ser um cuidador familiar de pessoa com acidente vascular cerebral (AVC): análise do conhecimento

Trata-se de trabalho do tipo bibliográfico com a finalidade de fazer uma análise temática da produção do conhecimento em periódicos, acerca da sobrecarga em cuidadores familiares de pessoas com Acidente Vascular Cerebral (AVC). O corpus de análise reuniu artigos localizados nas décadas de 80 e 90, a partir das bases de dados Medline, Lilacs e Cinahl. A análise de conteúdo foi o referencial metodológico que permitiu organizar todo o conhecimento, em um corpo de categorias e subcategorias, denominadas: Categoria 1 - As seqüelas do AVC gerando sobrecarga; Categoria 2 - Aspectos gerando sobrecarga, congregando as subcategorias: o isolamento social, as mudanças e as insatisfações conjugais, as dificuldades financeiras e os déficits na saúde física e no autocuidado do cuidador; Categoria 3 - Outras análises relacionadas à sobrecarga em cuidadores familiares.

Interação cuidador familiar-pessoa com AVC: autonomia compartilhada

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Between freedom and reclusion: Social support as a quality-of-life component in the family caregiver-dependent person binomial

This is a qualitative study which uses Grounded Theory as its methodological framework and Symbolic Interactionism as a theoretical base to understand the experience of family caregivers for Cerebrovascular Accident (CVA) patients with regard to social support during their rehabilitation process at home. The components (themes and categories) of the phenomenon assuming home care and specifically the themes assuming care with support and assuming care without support were inter-related for the purpose of comparison and analysis, in order to apprehend how the interaction between them occurred, It was observed that, in addition to the recovery of the patient's autonomy, social support is one of the intervenient components in the quality of life for the family caregiver-disabled person binomial, particularly with respect to the caregiver's freedom to resume his/her life plan.

O papel do enfermeiro como educador junto a cuidadores familiares de pessoas com AVC.

This article was written based on bibliographical research aiming at making a thematic analysis of the production of knowledge in newspapers and magazines about the nurse's role as an educator toward people who care for BVA (brain vascular accident) patients. The analysis gathered articles published in the 80's and 90's, from the Medline, Lilacs and Cinahl databases. Content analysis was the methodological background that allowed the organization of knowledge in two categories: educational intervention in the acute stage and the post-discharge support.

Risk factors for vascular dementia in elderly psychiatric outpatients with preserved cognitive functions

The aim of the study was to assess risk factors for vascular dementia (VaD) in elderly psychiatric outpatients without dementia, and to determine to what extent clinical interventions targeted such risk factors. Out of 250 clinical charts, 78 were selected of patients over 60 years old, who showed no signs of dementia. Information was obtained regarding demographics, clinical conditions (diagnosis according to ICD-10), complementary investigation, cognitive functions (via CAMCOG), neuroimaging, and the presence of risk factors for VaD. Depression was the most prevalent psychiatric disorder (74%). A great majority of the patients (86%) had at least one risk factor for VaD. One-third of the sample showed three or more risk factors for VaD. The clinical conditions related to risk factors for VaD were hypertension (48.7%), heart disease (30.8%), hypercholesterolemia (25.6%), diabetes mellitus (23.1%), stroke (12.8%), tryglyceride (12.8%), and obesity (5.1%). In terms of lifestyle, smoking (19.2%), alcohol abuse (16.7%), and sedentarism (14.1%) were other risk factors found. Definite risk factors for VaD were found in 83.3% of the patients. Previous interventions targeting risk factors were found in only 20% of the cases. The high rates of risk factors for VaD identified in this sample suggest that psychiatrists should be more attentive to these factors for the prevention of VaD. © 2007 Elsevier B.V. All rights reserved.

Risk-assessment algorithm and recommendations for venous thromboembolism prophylaxis in medical patients

The risk for venous thromboembolism (VTE) in medical patients is high, but risk assessment is rarely performed because there is not yet a good method to identify candidates for prophylaxis. Purpose: To perform a systematic review about VTE risk factors (RFs) in hospitalized medical patients and generate recommendations (RECs) for prophylaxis that can be implemented into practice. Data sources: A multidisciplinary group of experts from 12 Brazilian Medical Societies searched MEDLINE, Cochrane, and LILACS. Study selection: Two experts independently classified the evidence for each RF by its scientific quality in a standardized manner. A risk-assessment algorithm was created based on the results of the review. Data synthesis: Several VTE RFs have enough evidence to support RECs for prophylaxis in hospitalized medical patients (eg, increasing age, heart failure, and stroke). Other factors are considered adjuncts of risk (eg, varices, obesity, and infections). According to the algorithm, hospitalized medical patients ≥40 years-old with decreased mobility, and ≥1 RFs should receive chemoprophylaxis with heparin, provided they don't have contraindications. High prophylactic doses of unfractionated heparin or low-molecular-weight-heparin must be administered and maintained for 6-14 days. Conclusions: A multidisciplinary group generated evidence-based RECs and an easy-to-use algorithm to facilitate VTE prophylaxis in medical patients. © 2007 Rocha et al, publisher and licensee Dove Medical Press Ltd.

Análise cinemática da marcha em indivíduos com Acidente Vascular Encefálico

Introduction. Gait becomes the individual independence for their daily activities. The functional deficit caused by central lesion as stroke, makes difficult this motor independence, mainly the locomotion. Objective. Analyze the kinematics gait in stroke patients. Method. It was included 8 patients with clinical diagnosis of stroke, 4 with hemiparesia on the right and 4 on the left. It was analyzed gait spatial-temporal parameters as: length, duration and average speed of the step, using the register in videotape and the software of image 6.3 Dvideow Barros. Results. All patients presented alterations in the kinematics standards of the gait, with lesser duration and length of step, and greater speed than normal subjects. Conclusion. The motor disorder caused by the central lesions produces alterations in the kinematics standards of the gait, in order to adapt the neuro-sensorial sequels, the demands of the task and the way where they live.

Highlights from the I international symposium of thrombosis and anticoagulation in internal medicine, October 23-25, 2008, Sao Paulo, Brazil

The importance of thrombosis and anticoagulation in clinical practice is rooted firmly in several fundamental constructs that can be applied both broadly and globally. Awareness and the appropriate use of anticoagulant therapy remain the keys to prevention and treatment. However, to assure maximal efficacy and safety, the clinician must, according to the available evidence, choose the right drug, at the right dose, for the right patient, under the right indication, and for the right duration of time. The first International Symposium of Thrombosis and Anticoagulation in Internal Medicine was a scientific program developed by clinicians for clinicians. The primary objective of the meeting was to educate, motivate and inspire internists, cardiologists and hematologists by convening national and international visionaries, thought-leaders and dedicated clinician-scientists in Sao Paulo, Brazil. This article is a focused summary of the symposium proceedings. © Springer Science+Business Media, LLC 2009.

Equilíbrio em indivíduos com acidente vascular encefálico: Clínica Escola de Fisioterapia da Uniararas

Objective. To describe balance of stroke patients in the UNIA-RARAS Physical Therapy clinic school evaluating the correlation with age and time of lesion. Method. It was an observational study with 22 subjects, both genders, with diagnosis of stroke, ages ranged from 23 to 86 years old. The subjects were submitted to balance evaluation with Berg's Scale of Functional Balance (BSFB), Brazilian version, composed by fourteen tasks. Results. Stroke patients had an average punctuation of 37 points, showing a high risk of falls. There was no significant correlation between the patient's age and time of lesion with BSFB punctuation. Conclusion. This study showed that stroke patients present high risks of falls, independently of age and time of lesion.