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Biomedical subjects

M Limburg

Publications and source records attributed to M Limburg.

At least 55 records · Page 3Linked to original sources
PubMed1997

[Structured care for stroke patients: stroke units and transmural stroke services].

Following the successful introduction of Coronary Care Units for patients after a myocardial infarction, Stroke Units were designed where the specialized care for patients who had suffered a stroke might be concentrated. A meta-analysis in 1993 indicated that patients indeed benefited from treatment in such a unit. Stroke is the third cause of death in the Netherlands, with a prevalence in people aged 55 and more of 3.5% in men and of 1.9% in women. A Stroke Unit is part of a hospital; a Transmural Stroke Service in which neurologists and general practitioners participate, may deliver the appropriate care in the appropriate setting: patients may quickly be admitted to the hospital, an outpatient clinic can limit unnecessary hospitalization, and the general practitioner supervises chronic home treatment. The possibilities are there, now they have to be implemented.

Aged↗
PubMed1997

[Treatment of stroke in Europe: the Helsingborg Declaration].

Late in 1995, the Helsingborg Declaration was adopted, a European consensus text on the basic elements for policy in, and objectives of treatment of strokes. This declaration was prompted by the fact that the differences in incidence in different European countries, and the changes of the incidence in the course of the years suggest a great importance of environmental factors that can be influenced. The organizers of this consensus meeting might have enhanced the value of the document by more exactly indicating the (scientific) strength of the argumentation for each recommendation. Nevertheless, many of the recommendations are based on solid evidence. A plea is made to structure stroke care, measure the quality of care, facilitate early diagnosis and therapy after stroke, improve the possibilities for rehabilitation, and apply appropriate secondary prevention.

Acute Disease↗
PubMed1997

Length of hospital stay and discharge delays in stroke patients.

BACKGROUND AND PURPOSE: In The Netherlands, many stroke patients stay in the hospital for some time merely waiting for discharge placement. This indicates an inefficient use of hospital resources, as well as a possible deficiency in the quality of care, because hospitals are not adequately equipped to care for these patients. In this study, we tried to quantify this "waiting problem." METHODS: Six hospitals and 29 neurologists participated in this prospective study. The neurologists were asked during weekly interviews to specify for 154 patients the reason for retention in the hospital on a day-to-day basis. The reasons were noted on a list specified by the authors in advance. RESULTS: The mean length of hospital stay was 28 days. On average, there were "hard" medical reasons for 15 days (54%) and "soft" medical reasons for 3 days (10%), whereas the remaining 10 days (36%) were explained by nonmedical reasons (most frequently, waiting for placement in a nursing home). CONCLUSIONS: The length of hospital stay for stroke patients in The Netherlands can be reduced considerably without compromising the quality of care. This might be realized by increasing the capacity of long-term care facilities, improving the efficiency of the discharge procedures, or creating "stroke services."

Adult↗
PubMed1997

A stroke-adapted 30-item version of the Sickness Impact Profile to assess quality of life (SA-SIP30).

BACKGROUND AND PURPOSE: In view of the growing therapeutic options in stroke, measurement of quality of life has become increasingly relevant as an outcome parameters. The Sickness Impact Profile (SIP) is one of the most widely used measures to assess quality of life. To overcome the major disadvantage of the SIP, its length, we constructed a short stroke adapted 30-item SIP version (SA-SIP30). METHODS: Data on the original SIP version were collected for 319 communicative patients at 6 months after stroke. The 12 subscales and the 136 items of the original SIP were reduced to 8 subscales with 30 items in a three step procedure, on the basis of relevancy and homogeneity. Reliability of the SA-SIP30 was evaluated by means of an analysis of homogeneity (Cronbach's alpha coefficient). Different types of validity were assessed: construct, clinical, and external validities. RESULTS: Homogeneity of the SA-SIP30 was demonstrated by a high Cronbach's alpha (0.85). Principal component analyses revealed the same two dimensions as in the original SIP (a physical and a psychosocial dimension). The SA-SIP30 could explain 91% of the variation in scores of the original SIP in the same cohort of patients, and 89% in a different cohort. Furthermore, the SA-SIP30 was related to other functional health measures similar to how the original SIP was. We could demonstrate that the SA-SIP30 was able to distinguish patients with lacunar infarctions from patients with cortical or subcortical lesions. CONCLUSIONS: We conclude that the SA-SIP30 is a feasible and clinimetrically sound measure to assess quality of life after stroke.

Aged↗
PubMed1997

Risk factors for falls of hospitalized stroke patients.

BACKGROUND AND PURPOSE: Patients with stroke are at a high risk for falling. We assessed the fall incidence and risk factors for patients hospitalized as the result of an acute stroke. METHODS: We studied a cohort of 720 stroke patients from 23 hospitals in The Netherlands. The data were abstracted from the medical and nursing records. RESULTS: We studied 346 women and 374 men with a median age of 75 years; 77% of the patients had had a cerebral infarct, 17% had had a hemorrhage, and 6% had had an undefined stroke. We recorded 104 patients (14%) who fell at least once; there were a total of 173 falls. The incidence of falls was 8.9/1000 patients per day. The daily incidence was 6.2/1000 patients for first falls and 17.9/1000 patients for second falls. Heart disease (relative risk [RR], 1.6; 95% confidence interval [CI], 1.0 to 2.4), mental decline (RR, 1.6; 95% CI, 1.0 to 2.4), and urinary incontinence (RR, 2.3; 95% CI, 1.3 to 4.1) were incremental risk factors for first falls, whereas the use of major psychotropic drugs lowered the fall risk (RR, 0.5; 95% CI, 0.3 to 0.8). The fall RR for patients with one previous fall was 2.2 (95% CI, 1.5 to 3.2), adjusted for the other risk factors. Most falls occurred during the day. Approximately 25% of the falls caused slight-to-severe injury, whereas three falls (2%) led to hip fractures. CONCLUSIONS: Stroke patients have at risk of falling. The identification of patients at risk may be a first step toward the implementation of fall-prevention measures for these patients.

Accidental Falls↗
PubMed1997

Assessing quality of life after stroke. The value and limitations of proxy ratings.

BACKGROUND AND PURPOSE: Because many stroke survivors have cognitive and communication disorders, self-reported information on a patient's quality of life (QL) cannot always be obtained. Proxy ratings may be used to prevent exclusion of this highly relevant subgroup of patients from QL studies. The purpose of this study was to evaluate both the value and possible limitations of such proxy ratings. METHODS: The patient sample was composed of 437 patients who had suffered a stroke 6 months earlier. QL was assessed by means of the Sickness Impact Profile (SIP). For 108 patients who were not communicative because of cognitive or linguistic deficits, proxy ratings on the SIP were provided by the patients' significant others. For 228 of the 329 communicative patients, both self-reported and proxy SIP ratings were obtained. RESULTS: When mean SIP scores for patients with both self-reported and proxy-derived data available were compared, the proxy mean scores were generally in close agreement with those of the patients. However, systematic differences were noted for several SIP scales, with proxies rating patients as having more QL impairments than the patients themselves. Intraclass correlations were moderate to high for most SIP subscales (average intraclass correlation coefficient [ICC] = .63), the physical (ICC = .85) and psychosocial dimensions (ICC = .61), and the total SIP score (ICC = .77). The proxy SIP scores were sensitive to differences in patients' functional health, which supports the validity of these ratings. For all patients combined, more QL impairments were found for patients with supratentorial cortical or subcortical infarctions and hemorrhages than for patients with lacunar infarctions and infratentorial strokes. Although proxy respondents were more frequently needed for patients with the first two types of stroke, we found no evidence of biased results as a consequence of an unbalanced use of proxy respondents across the different types of stroke. CONCLUSIONS: These results suggest that the benefits of using proxy ratings for noncommunicative patients outweigh their limitations. The findings stress the need for inclusion of this important subgroup of patients in QL studies. Their significant others are able to provide useful information on these patients' QL.

Adolescent↗
PubMed1997

Some patients with intracranial aneurysms have a reduced type III/type I collagen ratio. A case-control study.

A reduced production of type III collagen has been reported in previous studies to be associated with intracranial aneurysms. The purpose of this prospective case-control study was to assess the possible role of a reduced type III collagen production as a risk factor for having an intracranial aneurysm. The study group consisted of 41 consecutively admitted patients with intracranial aneurysms. Intracranial aneurysms were demonstrated by intraarterial digital subtraction cerebral angiography or during operation. The control group consisted of 41 healthy volunteers matched for age and sex. Fibroblasts were cultured from skin biopsies from patients and control subjects, and the type III/type I collagen ratios were determined. The type III/type I collagen ratios in the controls ranged from 5.5 to 19.8%, with a median ratio of 10%, and none had a ratio below 5.5%. The type III/type I collagen ratios in patients ranged from 1.1 to 25.1%, with a median ratio of 10.5%, and eight patients (19.5%) had a low (< 5.5%) ratio (p = 0.005, Fisher's exact test). Our findings support the hypothesis that a reduced production of type III collagen may contribute to the formation of intracranial aneurysms in some patients.

Adult↗
PubMed1997

Impairment of cerebrovascular reactivity in long-term type 1 diabetes.

The early preclinical detection of cerebrovascular complications in individuals with diabetes is one of the goals of care described in the St. Vincent Declaration. In accordance with this goal, the aim of the present work was to investigate whether altered cerebral microvascular function in patients suffering from type 1 diabetes can be detected with a transcranial Doppler probe after the administration of acetazolamide. A total of 72 type 1 diabetic patients and 40 healthy control subjects entered the study. Patients were divided into two groups: those with long-term diabetes (disease duration of >10 years, n = 37) and those with short-term diabetes (disease duration of < or =10 years, n = 35). Mean blood-flow velocity in the middle cerebral artery (MCAV) was measured at rest and at 5, 10, 15, and 20 min after intravenous administration of 1 g acetazolamide with a transcranial Doppler probe and expressed as the percentage change from the pretest measurement. The percentage increase in MCAV (cerebrovascular reactivity) was calculated at each time point and compared between the groups. Cerebrovascular reserve capacity (CRC), expressed as the maximal percentage increase of the MCAV, was compared between the groups. Additionally, a reproducibility study of CRC was performed in 10 patients, using intraclass correlations. Cerebrovascular reactivity in the long-term diabetes group was lower (means +/- SD: 5 min, 23.4 +/- 15.4%; 10 min, 28.8 +/- 17.0%; 15 min, 30.0 +/- 15.6%; 20 min, 24.2 +/- 17.8%) than that of the control subjects (5 min, 43.5 +/- 23.9%; 10 min, 55.3 +/- 24.0%; 15 min, 56.7 +/- 23.8%; 20 min, 54.8 +/- 25.9%) and the short-term diabetic patients (5 min, 43.6 +/- 25.9%; 10 min, 52.2 +/- 27.7%; 15 min, 55.3 +/- 32.2%; 20 min, 45.8 +/- 35.8%). CRC was lower in the long-term diabetes group than in the control group or the short-term diabetes group. Impairment of cerebrovascular reactivity was associated with retino- and nephropathy and increased levels of fibrinogen. In contrast, CRC was independent from actual glucose, insulin, glycosylated hemoglobin, von Willebrand factor antigen, and alpha-2 macroglobulin levels. Transcranial Doppler measurements of the changes in MCAV after stimulation with acetazolamide can detect altered cerebral microvascular function in patients with diabetes. Cerebrovascular reactivity and reserve capacity are reduced in patients with long-term diabetes. Further prospective studies should delineate the clinical significance of our results.

Acetazolamide↗
PubMed1996

[Cerebrovascular reactivity in insulin dependent diabetes mellitus studied by an acetazolamide test].

The aim of this study was to investigate, whether the cerebrovascular reactivity (CR) was altered in diabetes mellitus and to evaluate the influence of diabetes's duration on cerebrovascular reactivity. Transcranial Doppler-Acetazolamide tests were performed on 20 insulin-dependent diabetics and in 19 controls. Patients were divided into two groups, each group consisted of 10 patients: diabetics with > 10 years disease duration and with < 10 years diseases duration. Middle cerebral artery mean velocities were measured at rest and after i.v. administration of Ig Acetazolamide (AZ). There were no differences in the absolute velocities between controls and diabetics. The percentual increase of the mean velocity after AZ was slower and less intensive in longterm diabetics (means +/- SE: 5 min: 19.4 +/- 2.8%, 10 min: 28 +/- 3.6%, 15 min: 25.7 +/- 3.8%, 20 min: 23.9 +/- 4.3%), than that in controls (5 min: 32.3 +/- 4.3% -p < 0.05-, 10 min: 45.1 +/- 4.9% -p < 0.05-, 15 min: 47.5 +/- 4.3% -p < 0.01-, 20 min: 46.5 +/- 4.7% -p < 0.01) as well as in diabetics with < 10 years disease duration (5 min.: 39.5 +/- 7% -p < 0.05-, 10 min.: 49.2 +/- 6.5% -p < 0.05-, 15 min.: 53.9 +/- 8.6% -p < 0.01-, 20 min: 32.9 +/- 5.9% -n.s.). The cerebrovascular reactivity is impaired in diabetics after long duration of the disease. The altered cerebrovascular reactivity might be caused by angiopathy of the cerebral arterioles.

Acetazolamide↗
PubMed1996

Feasibility of cognitive screening of patients with ischaemic stroke using the CAMCOG. A hospital-based study.

Brief screening tests would be convenient for the measurement of cognitive impairment in stroke patients. In these patients aphasia can interfere with test procedures. To evaluate the feasibility of examining cognitive functions in stroke patients we examined 129 patients with an ischaemic stroke using the CAMCOG, a standardised neuropsychological screening test, after an interval of at least 3 months. Most patients (88%) were able to complete the CAMCOG. Patients with severe aphasia were significantly more likely to have an abnormal CAMCOG score than patients without aphasia [relative risk (RR) 4.0, 95% confidence interval (CI) 2.8-5.8]. The group of patients with moderate aphasia was not at higher risk of having an abnormal CAMCOG score than patients without aphasia (RR 1.4, 95% CI 0.6-2.8). Looking for other factors that might correlate with the scores, logistic regression analysis revealed age as the only significant factor for the prediction of the CAMCOG score (odds ratio 4.0, 95% CI 1.2-13.2). We concluded that the CAMCOG can conveniently be used for screening cognitive functions in patients with cerebral infarcts, even if there is moderate aphasia.

Aphasia↗
PubMed1996

The role of cognitive impairment in the quality of life after ischaemic stroke.

Many patient- and disease-related factors influence the quality of life (QL) after stroke. Few studies address the direct relation between cognition and quality of life. The objective of this study was to investigate the role of cognitive impairment in the QL of patients after stroke. We evaluated several variables including age, degree of paralysis, cognitive deficits and volume of infarcts, in 129 patients (64 men, 65 women; mean age 63.2, SD 14.6 years), who had been hospitalized a mean of 2.3 (range 0.25-4) years previously with ischaemic stroke. Cognitive function was assessed with the CAMCOG and QL with a visual analogue scale (VAS). Ninety-seven patients (75%) of our sample completed all the tests. Univariate analysis showed that substantial infarct volume, aphasia, impaired motor function, disability relating to activities of daily life, disturbed global functional health and impaired cognitive function were significantly associated with poorer QL. Age, sex and education of the patient, co-morbidity and location of the infarcts were not related to QL. Linear regression analysis revealed that disturbed global functional health, larger volume of infarcts and severity of aphasia were significant independent explanatory factors for poorer QL (adjusted R2 = 22%). In conclusion, we did not find a significant impact of cognitive impairment on the patients' QL. However, this conclusion is restricted to a relatively well group of stroke survivors.

Aged↗
PubMed1996

Patients' satisfaction with care after stroke: relation with characteristics of patients and care.

OBJECTIVES: To evaluate stroke patients' satisfaction with care received and to identify characteristics of patients and care which are associated with patients' dissatisfaction. DESIGN: Cross sectional study. SETTING: Sample of patients who participated in a multicentre study on quality of care in 23 hospitals in the Netherlands. PATIENTS: 327 non-institutionalised patients who had been in hospital six months before because of stroke. MAIN MEASURES: Data were collected on (a) characteristics of patients: socio-demographic status, cognitive function (mini mental state examination), disability (Barthel index), handicap (Rankin scale), emotional distress (emotional behavior subscale of the sickness impact profile) and health perception; (b) characteristics of care: use of various types of formal care after stroke, unmet care demands perceived by patients, unmet care demands confirmed by their general practitioners, continuity of care, and secondary prevention, and (c) patients' satisfaction with care received. RESULTS: 40% of the study sample were dissatisfied with at least one type of care received. Multivariate analyses showed that unmet care demands perceived by patients (odds ratio (OR) 3.2, 95% confidence interval (95% CI) 1.8-5.7) and emotional distress (OR 1.8, 95% CI 1.1-3.0) were the main variable associated with dissatisfaction. CONCLUSIONS: Patients' satisfaction was primarily associated with emotional distress and unmet care demands perceived by patients. No association was found between patients' satisfaction on the one hand and continuity of care or secondary prevention on the other; two care characteristics that are broadly accepted by professional care givers as important indicators of quality of long term care after stroke. IMPLICATIONS: In view of these findings discussion should take place about the relative weight that should be given to patients' satisfaction as an indicator of quality of care, compared with other quality indicators such as continuity of care and technical competence. More research is needed to find which dimensions of quality care are considered the most important by stroke patients and professional care givers.

Cerebrovascular Disorders↗
PubMed1996

Is Marfan syndrome associated with symptomatic intracranial aneurysms?

BACKGROUND AND PURPOSE: Marfan syndrome is a heritable disorder of connective tissue caused by a deficiency of the glycoprotein fibrillin. In several publications and neurological textbooks, a relationship between Marfan syndrome and intracranial aneurysms has been assumed. METHODS: The records of 135 patients classified as having Marfan syndrome who visited the Amsterdam Marfan clinic or were admitted to the departments of neurology and neurosurgery and the records of all patients with a subarachnoid hemorrhage or intracranial aneurysm who visited or were admitted to the departments of neurology and neurosurgery between January 1, 1982, and January 1, 1994, were retrieved. The literature was reviewed regarding Marfan syndrome and intracranial aneurysms. RESULTS: No patient visiting the Marfan clinic had a symptomatic intracranial aneurysm. No patient with Marfan syndrome had been admitted with a ruptured intracranial aneurysm at the departments of neurology or neurosurgery in this period, while during that period 826 patients with symptomatic intracranial aneurysms had been admitted. During follow-up of 129 of the 135 patients with Marfan syndrome (2850 retrospective patient observation years and 581 prospective patient observation years), none presented a symptomatic intracranial aneurysm. The suggested relationship between Marfan syndrome and intracranial aneurysms is based mainly on 10 case reports. However, the diagnosis of Marfan syndrome is doubtful in several of these reports. Several large studies of patients with Marfan syndrome did not mention a ruptured intracranial aneurysm as a clinical manifestation. CONCLUSIONS: We conclude that there is insufficient evidence to presume a relationship between symptomatic intracranial aneurysms and Marfan syndrome on the basis of currently available data.

Adolescent↗
PubMed1996

Computed tomographic brain scans and antiplatelet therapy after stroke: a study of the quality of care in Dutch hospitals.

BACKGROUND AND PURPOSE: We sought to develop a measure ("quality weight" that indicates the severity of a deviation from optimal care with respect to secondary prevention with antiplatelet treatment after stroke. We also sought to estimate the effects that efforts to improve the quality of secondary prevention may have on health outcome and healthcare costs in the Netherlands. METHODS: First, we developed quality weights with decision analysis techniques. These quality weights express the excess risk of vascular events in the first 2 years after stroke compared with the optimal strategy (CT brain scan in all patients and aspirin in case of cerebral infarction). Second, these weights were applied in a follow-up study of 738 stroke patients older than 45 years. The number of stroke patients admitted to a hospital in 1991 in the Netherlands was used to estimate nationwide effects. We used data from 23 neurological departments and from the Information Center for Health Care in the Netherlands. RESULTS: The 2-year excess risk of fatal and nonfatal vascular events caused by omitting CT brain scan and giving aspirin to all patients is rather small (on average, 0.6%). The 2-year excess risk caused by not giving aspirin to a patient with cerebral infarction is much higher (4.1%). The follow-up study indicated that only 6% of the admitted patients had not been evaluated with a CT brain scan and that 14% of the patients with cerebral infarction proven by CT scan did not get antiplatelet treatment at discharge. Efforts to improve the quality of secondary prevention after stroke may prevent 74 vascular events annually in the Netherlands at an expense of 6200 Dutch guilders per prevented event (1 Dutch guilder=0.53 US dollar, 1991). CONCLUSIONS: Efforts to improve the quality of secondary prevention with antiplatelet treatment might reduce the number of new vascular events within the first 2 years after stoke by approximately 3%. The total costs related to the extra diagnostic and therapeutic activities are approximately 0.2% of the total annual hospital costs for acute stroke patients in teh Netherlands (250 million Dutch guilders).

Aged↗
PubMed1995

Costs of medical care after first-ever stroke in The Netherlands.

BACKGROUND AND PURPOSE: Stroke causes high morbidity and mortality. The aging of the population further increases the demands on healthcare costs. METHODS: We estimated the lifetime direct costs of care of first-ever stroke patients in the Netherlands in 1991 using epidemiological data from national and international studies. In addition, we examined the effect of an aging population on future healthcare costs. RESULTS: The lifetime costs for 24,007 first-ever stroke patients are estimated to be 1870 million Dutch guilders (Dfl) (1 Dfl = 0.53 US dollar, 1991). Per-person costs are higher for women (83,000 Dfl) than for men (71,000 Dfl). The major cost component of first-year costs is hospital costs (45%), while nursing home costs dominate lifetime costs (50%). An increase of the elderly population older than 65 years of 27% between 1991 and 2010 might lead to a parallel increase of total costs of 30%, or 1.5% per year. CONCLUSIONS: Long-term care rather than acute care dominates the lifetime costs for stroke patients now and in the future.

Aged↗
PubMed1995

The clinical meaning of Rankin 'handicap' grades after stroke.

BACKGROUND AND PURPOSE: The Rankin Scale is a frequently used handicap index in stroke outcome research. However, relatively little is known about its validity. The purpose of this study was to investigate the clinical meaning of Rankin grades by identifying the functional health aspects that contribute to Rankin scores. METHODS: We studied 438 patients 6 months after stroke. Data were collected on the following functional health indicators: alertness, communication, independence, disability in activities of daily living, mobility, instrumental disability, social interaction, and recreation. Disability in activities of daily living was assessed with the Barthel Index, whereas the other indicators were measured with subscales of the Sickness Impact Profile. The association between functional health and Rankin Scale was expressed in terms of relative frequencies and Somers' D statistic. Linear regression analysis (after ordinal transformation) was used to identify the significant health factors that explain Rankin scores. RESULTS: Mobility, disability in daily and instrumental activities, and living arrangements showed a stronger association with Rankin scores (Somers' D range, 0.60 to 0.74) than cognitive and social functioning (Somers' D range, 0.34 to 0.47). Disability in activities of daily living turned out to be the most important explanatory factor of Rankin scores (R2 = 67%). CONCLUSIONS: The Rankin Scale is not a pure handicap measure but should be viewed as a global functional health index with a strong accent on physical disability. The index is useful as a simple and time-efficient outcome measure in largescale multicenter trials. It is argued that at present there is no clear need to assess handicap as the primary outcome in medically oriented stroke intervention studies.

Aged↗
PubMed1995

Quality of life after stroke. Impact of stroke type and lesion location.

BACKGROUND AND PURPOSE: Little attention has been focused on the relationship between neurological lesions and quality of life (QL) in stroke research. The purpose of this study was to analyze the impact of stroke types and lesion locations on QL. METHODS: The study sample was composed of 441 stroke patients. Lesion locations and stroke types were divided into 194 left-sided and 173 right-sided lesions, 61 infratentorial strokes (55 infarctions and 6 hemorrhages), and 335 supratentorial strokes (204 [sub]cortical infarctions, 82 lacunar infarctions, and 49 hemorrhages). Six months after stroke, QL was assessed with the Sickness Impact Profile. Age-adjusted QL scores were expressed in standard scores. RESULTS: Although patients with left-sided lesions had more speech pathology (P < .001), there was slightly more QL deterioration in patients with right-sided lesions. Patients with infratentorial strokes reported better overall functioning than patients with supratentorial strokes (P = .02). Patients with lacunar infarction had less dysfunction compared to patients with (sub)cortical lesions (P < .001). There was no difference in QL between supratentorial (sub)cortical infarcts and hemorrhages. Lesion locations and stroke types did not affect patients' emotional distress. Severely impaired QL patterns were related significantly to older age (P < .001), comorbidity (P = .02), stroke severity (P < .001), and supratentorial lesions (P = .02). CONCLUSIONS: There is only a weak relationship between lesion laterality and QL. Survivors of hemorrhagic strokes do not evidence more QL impairment than survivors of ischemic strokes. Stroke per se is not unequivocally followed by emotional discomfort. In addition to stroke type, patient and clinical characteristics are also important in explaining impaired QL patterns.

Activities of Daily Living↗