Attivita' fisica adattata nella riabilitazione post-ictus: Risultati al follow-up di 12 mesi

L’ictus è un importante problema di salute pubblica, è causa di morte e disabilità nella popolazione anziana. La necessità di strategie di prevenzione secondaria e terziaria per migliorare il funzionamento post-ictus e prevenire o ritardare altre condizioni disabilitanti, ha portato l’Italia a sviluppare un intervento di Attività Fisica Adattata (AFA) per l’ictus, che permettesse di migliorare gli esiti della riabilitazione. Obiettivo dello studio è di valutare se l’AFA unita all’Educazione Terapeutica (ET), rispetto al trattamento riabilitativo standard, migliora il funzionamento e la qualità di vita in pazienti con ictus. Studio clinico non randomizzato, in cui sono stati valutati 229 pazienti in riabilitazione post-ictus, 126 nel gruppo sperimentale (AFA+ET) e 103 nel gruppo di controllo. I pazienti sono stati valutati al baseline, a 4 e a 12 mesi di follow-up. Le misure di esito sono il cambiamento a 4 mesi di follow-up (che corrisponde a 2 mesi post-intervento nel gruppo sperimentale) di: distanza percorsa, Berg Balance Scale, Short Physical Performance Battery, e Motricity Index. Le variabili misurate a 4 e a 12 mesi di follow-up sono: Barthel Index, Geriatric Depression Scale, SF-12 e Caregiver Strain Index. La distanza percorsa, la performance fisica, l’equilibrio e il punteggio della componente fisica della qualità di vita sono migliorate a 4 mesi nel gruppo AFA+ET e rimasti stabili nel gruppo di controllo. A 12 mesi di follow-up, il gruppo AFA+ET ottiene un cambiamento maggiore, rispetto al gruppo di controllo, nell’abilità di svolgimento delle attività giornaliere e nella qualità di vita. Infine il gruppo AFA+ET riporta, nell’ultimo anno, un minor numero di fratture e minor ricorso a visite riabilitative rispetto al gruppo di controllo. I risultati confermano che l’AFA+ET è efficace nel migliorare le condizioni cliniche di pazienti con ictus e che gli effetti, soprattutto sulla riabilitazione fisica, sono mantenuti anche a lungo termine.

Measurement of Training Intensity and Work During Submaximal Isokinetic Progressive Resistance Training Protocols

Physical exercise programmes are routinely prescribed in clinical practice to treat impairments, improve activity and participation in daily life because of their known physiological, health and psychological benefits (RCP, 2009). Progressive resistance exercise is a type of exercise prescribed specifically to improve skeletal muscle strength (Latham et al., 2004). The effectiveness of progressive resistance exercise varies considerably between studies and populations. This thesis focuses on how training parameters influence the delivery of progressive resistance exercise. In order to appropriately evaluate the influence of training parameters, this thesis argues the need to record training performance and the total work completed by participants as prescribed by training protocols. In the first study, participants were taken through a series of protocols differentiated by the intensity and volume of training. Training intensity was defined as a proportion of the mean peak torque achieved during maximal voluntary contractions and was set at 80% and 40% respectively of the MVC mean peak torque. Training volume was defined as the total external work achieved over the training period. Measures of training performance were developed to accurately report the intensity, repetitions and work completed during the training period. A second study evaluated training performance of the training protocols over repeated sessions. These protocols were then applied to 3 stroke survivors. Study 1 found sedentary participants could achieve a differentiated training intensity. Participants completing the high and low intensity protocols trained at 80% and 40% respectively of the MVC mean peak torque. The total work achieved in the high intensity low repetition protocol was lower than the total work achieved in the low intensity high repetition protocol. With repeated practice, study 2 found participants were able to improve in their ability to perform manoeuvres as shown by a reduction in the variation of the mean training intensity achieving total work as specified by the protocol to a lower margin of error. When these protocols were applied to 3 stroke survivors, they were able to achieve the specified training intensity but they were not able to achieve the total work as expected for the protocol. This is likely to be due to an inability in achieving a consistent force throughout the contraction. These results demonstrate evaluation of training characteristics and support the need to record and report training performance characteristics during progressive resistance exercise, including the total work achieved, in order to elucidate the influence of training parameters on progressive resistance exercise. The lack of accurate training performance may partly explain the inconsistencies between studies on optimal training parameters for progressive resistance exercise.

The patient-provider relationship and antenatal care uptake at two referral hospitals in Malawi: A qualitative study

Background In post-stroke patients, impairment of quality of life (QOL) has been associated with functional impairment, age, anxiety, depression, and fatigue. Good social support, higher education, and better socioeconomic status are associated with better QOL among stroke survivors. In Africa, studies from Nigeria and Tanzania have reported on post-stroke QOL. Background Approximately 90% of Malawian women attend antenatal care at least once during their pregnancies; however, most mothers first present during months five and six and do not adhere to the World Health Organization’s recommended four visits. The objective of this study was to explore the role the patient-provider relationship has on antenatal care uptake. Methods A qualitative study, consisting of interviews with 20 urban pregnant mothers and eight health workers, was conducted from September to December 2014. Two large tertiary care hospitals in the Central and Southern regions of Malawi were selected as study sites. Results Several factors influenced antenatal care attendance. Significant barriers reported included the patient-provider relationship, clinic wait times, family and friend support, distance from home to the clinic, transportation, cost, and number of visits. The patient-provider relationship appears to have a large impact on antenatal clinic participation. Mothers indicated that health workers often mistreat or demean them during visits. Additionally, health workers revealed that, due to staff shortages, patients often do not receive the care they deserve. Conclusions The results of this study suggest that, in addition to other factors, healthcare provider attitudes influence antenatal clinic attendance. Improving the patient-provider relationship may increase antenatal clinic attendance and decrease pregnancy complications during pregnancy. Professional development opportunities and quality improvement programmes are would help improve patient care and health outcomes while the continued staff shortages in the country are addressed.

Television viewing time and 13-year mortality in adults with cardiovascular disease: data from the Australian Diabetes, Obesity and Lifestyle Study (AusDiab)

BACKGROUND: In the general population, excessive sedentary behaviour is associated with increased all-cause mortality. Few studies have examined this relationship in people with cardiovascular disease (CVD). Using a sample of people with CVD who were excluded from an analysis of the Australian Diabetes, Obesity and Lifestyle (AusDiab) study, we examined the relationship between sedentary behaviour and 13-year all-cause mortality.

METHODS: In the original AusDiab study, television viewing time was used as a marker of sedentary behaviour in 609 adults (≥45 years of age) with CVD. During 6,291 person-years of follow-up (median follow-up 13 years), there were 294 deaths (48% of sample). Using the time scale of attained age, the Cox proportional hazards model predicting all-cause mortality adjusted for sex, self-rated general health, leisure-time physical activity, smoking status, education, household income, body mass index, lipid levels, blood pressure, and diabetes mellitus was used.

RESULTS: Compared with a TV viewing time of <2hours per day, the fully adjusted hazard ratios for all-cause mortality were 1.18 (95% CI, 0.88 to 1.57) for ≥2 to <4hours per day and 1.52 (95% CI, 1.09 to 2.13) for >4hours per day.

CONCLUSIONS: Sedentary behaviour was associated with increased risk of all-cause mortality in people with CVD, independent of physical activity and other confounders. In addition to the promotion of regular physical activity, cardiac rehabilitation efforts which also focus on reducing sedentary behaviour may be beneficial.

Ischemic Stroke in Young Adults

Stroke is the second leading cause of death and the leading cause of disability worldwide. Of all strokes, up to 80% to 85% are ischemic, and of these, less than 10% occur in young individuals. Stroke in young adults—most often defined as stroke occurring under the age of 45 or 50—can be particularly devastating due to long expected life-span ahead and marked socio-economic consequences. Current basic knowledge on ischemic stroke in this age group originates mostly from rather small and imprecise patient series. Regarding emergency treatment, systematic data on use of intravenous thrombolysis are absent. For this Thesis project, we collected detailed clinical and radiological data on all consecutive patients aged 15 to 49 with first-ever ischemic stroke between 1994 and 2007 treated at the Helsinki University Central Hospital. The aims of the study were to define demographic characteristics, risk factors, imaging features, etiology, and long-term mortality and its predictors in this patient population. We additionally sought to investigate, whether intravenous thrombolysis is safe and beneficial for the treatment of acute ischemic stroke in the young. Of our 1008 patients, most were males (ratio 1.7:1), who clearly outnumbered females after the age of 44, but females were preponderant among those aged <30. Occurrence increased exponentially. The most frequent risk factors were dyslipidemia (60%), smoking (44%), and hypertension (39%). Risk factors accumulated in males and along aging. Cardioembolism (20%) and cervicocerebral artery dissection (15%) were the most frequent etiologic subgroups, followed by small-vessel disease (14%), and large-artery atherosclerosis (8%). A total of 33% had undetermined etiology. Left hemisphere strokes were more common in general. Posterior circulation infarcts were more common among those aged <45. Multiple brain infarcts were present in 23% of our patients, 13% had silent infarcts, and 5% had leukoaraiosis. Of those with silent brain infarcts, majority (54%) had only a single lesion, and most of the silent strokes were located in basal ganglia (39%) and subcortical regions (21%). In a logistic regression analysis, type 1 diabetes mellitus in particular predicted the presence of both silent brain infarcts (odds ratio 5.78, 95% confidence interval 2.37-14.10) and leukoaraiosis (9.75; 3.39-28.04). We identified 48 young patients with hemispheric ischemic stroke treated with intravenous tissue plasminogen activator, alteplase. For comparisons, we searched 96 untreated control patients matched by age, gender, and admission stroke severity, as well as 96 alteplase-treated older controls aged 50 to 79 matched by gender and stroke severity. Alteplase-treated young patients recovered more often completely (27% versus 10%, P=0.010) or had only mild residual symptoms (40% versus 22%, P=0.025) compared to age-matched controls. None of the alteplase-treated young patients had symptomatic intracerebral hemorrhage or died within 3-month follow-up. Overall long-term mortality was low in our patient population. Cumulative mortality risks were 2.7% (95% confidence interval 1.5-3.9%) at 1 month, 4.7% (3.1-6.3%) at 1 year, and 10.7% (9.9-11.5%) at 5 years. Among the 30-day survivors who died during the 5-year follow-up, more than half died due to vascular causes. Malignancy, heart failure, heavy drinking, preceding infection, type 1 diabetes, increasing age, and large-artery atherosclerosis causing the index stroke independently predicted 5-year mortality when adjusted for age, gender, relevant risk factors, stroke severity, and etiologic subtype. In sum, young adults with ischemic stroke have distinct demographic patterns and they frequently harbor traditional vascular risk factors. Etiology in the young is extremely diverse, but in as many as one-third the exact cause remains unknown. Silent brain infarcts and leukoaraiosis are not uncommon brain imaging findings in these patients and should not be overlooked due to their potential prognostic relevance. Outcomes in young adults with hemispheric ischemic stroke can safely be improved with intravenous thrombolysis. Furthermore, despite their overall low risk of death after ischemic stroke, several easily recognizable factors—of which most are modifiable—predict higher mortality in the long term in young adults.

PERFECT Stroke : PERFormance, Effectiveness, and Costs of treatment episodes in Stroke

Stroke is a major cause of death and disability, incurs significant costs to healthcare systems, and inflicts severe burden to the whole society. Stroke care in Finland has been described in several population-based studies between 1967 and 1998, but not since. In the PERFECT Stroke study presented here, a system for monitoring the Performance, Effectiveness, and Costs of Treatment episodes in Stroke was developed in Finland. Existing nationwide administrative registries were linked at individual patient level with personal identification numbers to depict whole episodes of care, from acute stroke, through rehabilitation, until the patients went home, were admitted to permanent institutional care, or died. For comparisons in time and between providers, patient case-mix was adjusted for. The PERFECT Stroke database includes 104 899 first-ever stroke patients over the years 1999 to 2008, of whom 79% had ischemic stroke (IS), 14% intracerebral hemorrhage (ICH), and 7% subarachnoid hemorrhage (SAH). A 18% decrease in the age and sex adjusted incidence of stroke was observed over the study period, 1.8% improvement annually. All-cause 1-year case-fatality rate improved from 28.6% to 24.6%, or 0.5% annually. The expected median lifetime after stroke increased by 2 years for IS patients, to 7 years and 7 months, and by 1 year for ICH patients, to 4 years 5 months. No change could be seen in median SAH patient survival, >10 years. Stroke prevalence was 82 000, 1.5% of total population of Finland, in 2008. Modern stroke center care was shown to be associated with a decrease in both death and risk of institutional care of stroke patients. Number needed to treat to prevent these poor outcomes at one year from stroke was 32 (95% confidence intervals 26 to 42). Despite improvements over the study period, more than a third of Finnish stroke patients did not have access to stroke center care. The mean first-year healthcare cost of a stroke patient was ~20 000 , and among survivors ~10 000 annually thereafter. Only part of this cost was incurred by stroke, as the same patients cost ~5000 over the year prior to stroke. Total lifetime costs after first-ever stroke were ~85 000 . A total of 1.1 Billion , 7% of all healthcare expenditure, is used in the treatment of stroke patients annually. Despite a rapidly aging population, the number of new stroke patients is decreasing, and the patients are more likely to survive. This is explained in part by stroke center care, which is effective, and should be made available for all stroke patients. It is possible, in a suitable setting with high-quality administrative registries and a common identifier, to avoid the huge workload and associated costs of setting up a conventional stroke registry, and still acquire a fairly comprehensive dataset on stroke care and outcome.

Mixed methods feasibility study for a trial of blood pressure telemonitoring for people who have had stroke/transient ischaemic attack (TIA).

Background Good blood pressure (BP) control reduces the risk of recurrence of stroke/transient ischaemic attack (TIA). Although there is strong evidence that BP telemonitoring helps achieve good control, none of the major trials have considered the effectiveness in stroke/TIA survivors. We therefore conducted a feasibility study for a trial of BP telemonitoring for stroke/ TIA survivors with uncontrolled BP in primary care. Method Phase 1 was a pilot trial involving 55 patients stratified by stroke/TIA randomised 3:1 to BP telemonitoring for 6 months or usual care. Phase 2 was a qualitative evaluation and comprised semi-structured interviews with 16 trial participants who received telemonitoring and 3 focus groups with 23 members of stroke support groups and 7 carers. Results Overall, 125 patients (60 stroke patients, 65 TIA patients) were approached and 55 (44%) patients were randomised including 27 stroke patients and 28 TIA patients. Fifty-two participants (95%) attended the 6-month follow-up appointment, but one declined the second daytime ambulatory blood pressure monitoring (ABPM) measurement resulting in a 93% completion rate for ABPM − the proposed primary outcome measure for a full trial. Adherence to telemonitoring was good; of the 40 participants who were telemonitoring, 38 continued to provide readings throughout the 6 months. There was a mean reduction of 10.1 mmHg in systolic ABPM in the telemonitoring group compared with 3.8 mmHg in the control group, which suggested the potential for a substantial effect from telemonitoring. Our qualitative analysis found that many stroke patients were concerned about their BP and telemonitoring increased their engagement, was easy, convenient and reassuring Conclusions A full-scale trial is feasible, likely to recruit well and have good rates of compliance and follow-up.

Exploring health care providers' perceptions of the needs of stroke carers: informing development of an optimal health program.

Health care provider experiences of the carer have been researched, but little is written about how these can inform development of support programs.

Quality of life in survivors after cervical artery dissection

BACKGROUND AND PURPOSE: Little data exists about longterm outcome, quality of life (QOL) and its predictors after spontaneous cervical artery dissections (sCAD). METHODS: Clinical and radiological data of 114 patients with sCAD were collected prospectively. Six patients died within 3 months, the remaining 108 were contacted after a mean of 1498 days (range: 379-3455), 99 survivors (92 %) replied. QOL, assessed with the stroke-specific QOL scale (SSQOL), and functional abilities, measured with modified Rankin Scale (mRS) were compared, and predictors of QOL were analyzed. Subgroup analyses were performed for patients with ischemic stroke, those with isolated local symptoms or transient ischemic symptoms and those without significant disabilities (mRS 0-1) at follow-up. RESULTS: Seventy-one of 99 patients (72 %) had no significant disability, but only 53 (54 %) reported a good QOL (SS-QOL > or = 4). Compared to the self-rated premorbid QOL of all patients, SS-QOL was impaired after sCAD (p < 0.001); impairment of QOL was observed in patients with ischemic stroke (p < 0.001), in patients with isolated local or transient ischemic symptoms (p < 0.038) and those without significant disabilities at follow-up (p = 0.013). Nevertheless, low mRS was associated with better overall QOL (Kendall's tau > 0.5). High National Institute of Health Stroke Scale score on admission and higher age were independent predictors of impaired QOL (p < 0.05). CONCLUSION: QOL is impaired in almost half of long-term survivors after sCAD, even in patients with local or transient symptoms or without functional disability. Impairment of QOL is a surprisingly frequent long-term sequela after sCAD and deserves attention as an outcome measure in these patients.

Long-term outcome after arterial ischemic stroke in children and young adults.

OBJECTIVE To compare long-term outcome of children and young adults with arterial ischemic stroke (AIS) from 2 large registries. METHODS Prospective cohort study comparing functional and psychosocial long-term outcome (≥2 years after AIS) in patients who had AIS during childhood (1 month-16 years) or young adulthood (16.1-45 years) between January 2000 and December 2008, who consented to follow-up. Data of children were collected prospectively in the Swiss Neuropediatric Stroke Registry, young adults in the Bernese stroke database. RESULTS Follow-up information was available in 95/116 children and 154/187 young adults. Median follow-up of survivors was 6.9 years (interquartile range 4.7-9.4) and did not differ between the groups (p = 0.122). Long-term functional outcome was similar (p = 0.896): 53 (56%) children and 84 (55%) young adults had a favorable outcome (modified Rankin Scale 0-1). Mortality in children was 14% (13/95) and in young adults 7% (11/154) (p = 0.121) and recurrence rate did not differ (p = 0.759). Overall psychosocial impairment and quality of life did not differ, except for more behavioral problems among children (13% vs 5%, p = 0.040) and more frequent reports of an impact of AIS on everyday life among adults (27% vs 64%, p < 0.001). In a multivariate regression analysis, low Pediatric NIH Stroke Scale/NIH Stroke Scale score was the most important predictor of favorable outcome (p < 0.001). CONCLUSION There were no major differences in long-term outcome after AIS in children and young adults for mortality, disability, quality of life, psychological, or social variables.

Caregiver burden, time spent caring and health status in the first 12 months following stroke

Objective: To quantify time caring, burden and health status in carers of stroke patients after discharge from rehabilitation; to identify the potentially modifiable sociodemographic and clinical characteristics associated with these outcomes. Methods: Patients and carers prospectively interviewed 6 (n = 71) and 12 (n = 57) months after discharge. Relationships of carer and patient variables with burden, health status and time analysed by Gaussian and Poisson regression. Results: Carers showed considerable burden at 6 and 12 months. Carers spent 4.6 and 3.6 hours per day assisting patients with daily activities at 6 and 12 months, respectively. Improved patient motor and cognitive function were associated with reductions of up to 20 minutes per day in time spent in daily activities. Better patient mental health and cognitive function were associated with better carer mental health. Conclusions: Potentially modifiable factors such as these may be able to be targeted by caregiver training, support and education programmes and outpatient therapy for patients.