Creating a Canadian stroke system.
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Aged↗
Biomedical subjects
R W Teasell
Publications and source records attributed to R W Teasell.
Physical and functional correlations of ankle-foot orthosis use in the rehabilitation of stroke patients.
OBJECTIVE: To examine factors associated with the use of ankle-foot orthoses (AFOs) in stroke patients undergoing rehabilitation. DESIGN: Retrospective cohort study of the frequency of AFO use. SETTING: Inpatient rehabilitation unit. PARTICIPANTS: Consecutive stroke patients (n = 423) admitted to an inpatient rehabilitation unit over a 10-year period. INTERVENTION: Discharge with AFO. MAIN OUTCOME MEASURES: Functional outcome measurement scores of patients who were and who were not prescribed an AFO were examined. The groups were compared by using admission and discharge Chedoke-McMaster Stroke Impairment Inventory (CM; each measure analyzed separately), FIMtrade mark instrument (walking, stairs, overall measures), and Berg Balance Scale scores. RESULTS: Ninety-three of the 423 patients (22%) were discharged with an AFO. Overall, they scored consistently lower than patients who were discharged without an AFO. Statistically significant differences (p <.001) were noted between AFO users and nonusers in admission and discharge scores in the arm, hand, leg, and foot components of the CM and the FIM stairs and walking component scores. Average admission and discharge Berg scores differed between the 2 groups (p =.005, p =.013, respectively). Overall FIM scores were also significantly different both at admission and discharge (p <.001, p =.025, respectively). CONCLUSION: Use of AFOs at discharge was associated with significantly lower admission and discharge CM scores of the arm, hand, leg, and foot; FIM walking and stairs scores; total FIM scores; and Berg Balance Scale scores.
Activities of Daily Living↗
Pathophysiology of chronic pain disorders.
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Animals↗
Employment-related factors in chronic pain and chronic pain disability.
BACKGROUND: Disability is a multifactorial phenomenon. Social scientists suggest that nonclinical factors, including age, education, and job status, correlate with disability. OBJECTIVE: Do employment-related factors predict chronic pain and/or chronic pain disability? METHODOLOGY: The literature search identified 15 observational studies to provide the evidence about this question. RESULTS: Review topics included job satisfaction, type of work, modified work and work autonomy, other employment-related factors, and socioeconomic status. Most subjects in the studies had low back pain. The studies used return to work as an outcome predicting chronic pain disability. CONCLUSIONS: Lack of modified work and lack of work autonomy predicted chronic pain disability (level 2). There was limited evidence (level 3) that lack of job satisfaction, perception of difficult job conditions and demands, heavy physical demands of the job, private rather than public employment, and lower socioeconomic group predict chronic pain disability. The number of years employed varied as a predictor in different studies (level 4b).
Chronic Disease↗
Compensation and chronic pain.
BACKGROUND: The literature contains many different viewpoints on the impact of compensation on recovery from chronic pain. OBJECTIVE: What is the role of compensation in chronic pain and/or chronic pain disability? METHODOLOGY: The literature search identified 11 observational studies to provide evidence about this question. RESULTS: There is a paucity of high-quality data on the subject of the impact of compensation on chronic pain. This subject was reviewed under the headings of (1) injury claim rate and duration; (2) recovery; and (3) rehabilitation treatment programs. The studies were of subjects with musculoskeletal pain, mainly low back pain. CONCLUSIONS: Filing a compensation claim for costs, retaining a lawyer, or higher pain intensities were limited predictors of longer claims (level 3). As the ratio of compensation to preinjury wage increases, there is moderate evidence (level 2) that the duration of the claim increases and that disability is more likely. Compensation status, particularly combined with higher pain intensities, is associated with poorer prognosis after rehabilitation treatment programs (level 3).
Chronic Disease↗
Effect of eliminating compensation for pain and suffering on the outcome of insurance claims.
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Accidents, Traffic↗
Social issues in the rehabilitation of younger stroke patients.
OBJECTIVES: To study social factors and outcomes in stroke rehabilitation patients under the age of 50. STUDY DESIGN: Retrospective chart review examining (1) martial status and employment status on admission and at 3 months post discharge, (2) discharge destination, (3) the presence of absence of children under the age of 16, and (4) psychosocial difficulties as recorded by staff during hospitalization. SUBJECTS AND SETTING: Eighty-three consecutive stroke patients under the age of 50 admitted to a Canadian tertiary-care hospital rehabilitation unit. MAIN OUTCOME MEASURES: Discharge destination and primary caregiver at discharge, and return to work and marital separation 3 months after rehabilitation discharge. RESULTS: Of the 55 patients with spouses, 8 (14.5%) separated within 3 months of hospital discharge. Fifteen of the 83 patients (18.1%) were not able to return to their premorbid place of residence; 4 (4.8%) required institutionalization. Of the 64 patients employed outside the home or studying at the time of their stroke, only 13 (20.3%) were able to return to work within 3 months of their discharge to home. Only 9.4% of those working full-time were able to return to full-time employment. CONCLUSIONS: Rehabilitation of young stroke patients is associated with a variety of social problems, including marital breakup, child care responsibilities, and return to employment, which are uniquely important in this age group.
Adolescent↗
Trauma and fibromyalgia: is there an association and what does it mean?
OBJECTIVES: The primary objective is to review current research with respect to the role of trauma in fibromyalgia (FM). A secondary objective is to hypothesize which steps need to be taken, first to determine whether such an association truly exists, and second to clarify what such an association might mean. METHODS: An extensive literature review was undertaken, including Medline from 1979 to the present. RESULTS: The strongest evidence supporting an association between trauma and FM is a recently published Israeli study in which adults with neck injuries had greater than a 10-fold increased risk of developing FM within 1 year of their injury, compared with adults with lower extremity fractures (P= .001). Several other studies provide a hypothetical construct for such an association. These include studies on (1) postinjury sleep abnormalities; (2) local injury sites as a source of chronic distant regional pain; and (3) the concept of neuroplasticity. There are, however, several primary arguments against such an association: (1) FM may not be a distinct clinical entity; (2) FM may be a psychological, rather than physical, disease; (3) the evidence supporting any association is limited and not definitive; (4) the Israeli study, itself, has some methodological limitations; and (5) other factors may be more important than the injurious event in determining chronic symptoms after an acute injury. CONCLUSIONS: Although there is some evidence supporting an association between trauma and FM, the evidence is not definitive. Further prospective studies are needed to confirm this association and to identify whether trauma has a causal role.
Adult↗
Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury.
Spinal cord injury (SCI) with resultant quadriplegia or high paraplegia is associated with significant dysfunction of the sympathetic nervous system. This alteration of sympathetic nervous system activity occurs as a consequence of loss of supraspinal control of the sympathetic nervous system and is further complicated by at least three subsequent phenomena that occur below the level of SCI: reduced overall sympathetic activity, morphologic changes in sympathetic preganglionic neurons, and peripheral alpha-adrenoceptor hyperresponsiveness. Reduced sympathetic activity below the level of SCI appears to result in orthostatic hypotension, low resting blood pressure, loss of diurnal fluctuation of blood pressure, reflex bradycardia, and, rarely, cardiac arrest. Peripheral alpha-adrenoceptor hyperresponsiveness likely accounts for some, if not the majority, of the excessive pressor response in autonomic dysreflexia and may also contribute to decreased blood flow in the peripheral microcirculation, potentially increasing susceptibility to pressure sores. What has yet to be established is whether this alpha-adrenoceptor hyperresponsiveness is a consequence of receptor hypersensitivity or a failure of presynaptic reuptake of noradrenaline at the receptor level. Better understanding of the pathophysiology of sympathetic nervous system dysfunction after high-level SCI should allow development of more effective measures to manage clinical complications.
Autonomic Dysreflexia↗
Frequency of videofluoroscopic modified barium swallow studies and pneumonia in stroke rehabilitation patients: a comparative study.
OBJECTIVE: To study the association between the frequency of videofluoroscopic modified barium swallow (VMBS) studies and the incidence of pneumonia in stroke rehabilitation patients. DESIGN: Retrospective comparative study. SUBJECTS AND SETTING: Five hundred sixty-three consecutive stroke patients admitted to one hospital rehabilitation unit in London, Ontario, Canada were compared with 461 consecutive stroke patients admitted to another hospital rehabilitation unit in the same city. INTERVENTIONS: The number of initial and total VMBS studies and the timing from stroke onset to initial VMBS studies. MAIN OUTCOME MEASURE: Incidence of pneumonia. RESULTS: At the first hospital, 146 patients (25.9%) had 232 total VMBS studies performed, whereas at the second hospital 57 patients (12.4%) had 73 total studies (p<.001). For the first 15 days there was no significant difference in the number of initial VMBS studies performed (8.2% vs. 9.2%). There was a marked difference in the number of initial VMBS studies performed after 15 days (17.2% vs. 2.0%, p<.0001). The difference between the hospitals in the number of VMBS studies in patients with brain stem strokes was not statistically significant, but for patients with hemispheric stroke, the difference was statistically significant. Pneumonia developed in 12 patients at the first hospital (2.1%) and 10 patients at the second hospital (2.2%), a difference that was not significant. CONCLUSIONS: The more frequent use of VMBS beyond 15 days after stroke was not associated with a change in the incidence of pneumonia among hemispheric stroke rehabilitation patients, assuming the two units were otherwise similar.
Aged↗
Antidepressants in rehabilitation.
Antidepressant medications have a variety of uses in addition to the treatment of depression. This article focuses on the two most widely used categories of antidepressants, tricyclic antidepressants (TCAs) and the newer selective serotonin reuptake inhibitors (SSRIs), and highlights their use in post-stroke depression and chronic pain.
Antidepressive Agents↗
Chronic whiplash re-revisited.
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Anesthesia, Spinal↗
Functional restoration. Returning patients with chronic low back pain to work--revolution or fad?
STUDY DESIGN: A review was performed to assess the basis for functional restoration programs in returning patients with chronic low back pain to work. OBJECTIVE: To review and assess the effectiveness of functional restoration programs in the treatment of chronic low back pain. SUMMARY OF BACKGROUND DATA: Functional restoration programs generally use an aggressive program of physical exercises and psychosocial support with the focus on improving function despite the pain. METHODS: A review was conducted of significant papers presenting results of large clinical trials that used functional restoration programs. RESULTS: Several influential studies have reported statistically significant improvement in return-to-work rates of treated patients. The comparison groups consisted of treatment failures and/or patients refused entry to the programs because of insurers refusal to pay. Selection bias, incomplete follow-up, and inappropriate allocation of compared patients cast doubt on the effectiveness of these functional restoration programs. The only published prospective randomized clinical trial failed to demonstrate the efficacy of a functional restoration program. CONCLUSIONS: Further clinical trials based on sound methodology are needed.
Disability Evaluation↗
The effect of litigation status on adjustment to whiplash injury.
STUDY DESIGN: This retrospective study examined the effect of civil litigation on reports of pain and disability in chronic pain patients who sustained whiplash injuries after a motor vehicle accident. OBJECTIVES: To examine the effect of litigation on adjustment to chronic pain. SUMMARY OF BACKGROUND DATA: A common methodologic weakness with many studies in this area is the composition of the nonlitigant group, which often includes individuals who have completed litigation as well as those who opted not to litigate. This introduces a confound in that litigant and nonlitigant groups differ not only with respect to litigation status but with respect to any factors that predispose one to litigate. METHODS: Questionnaire data were obtained from 41 patients (current litigants) in the process of litigation and 21 patients (postlitigants) who had completed litigation. Subjects completed self-report measures assessing demographic characteristics, psychological distress, sleep disturbance, employment status, and various pain indices. RESULTS: There were no significant group differences in demographic characteristics, employment status, or psychological distress. Litigants, however, reported more pain than did postlitigants. Group differences in pain reports remained statistically significant even after controlling for length of time since accident and initial severity of the injuries. CONCLUSIONS: That litigation status did not predict employment status suggests that secondary gain does not figure prominently in influencing the functionality of these patients. The rather robust effect of litigation status on pain reports is discussed with respect to the potential mediational role of the stress of litigation.
Adaptation, Psychological↗
Pneumonia associated with aspiration following stroke.
OBJECTIVE: To determine the association between demonstrated aspiration and pneumonia in stroke patients. METHODS: Chart review of 441 consecutive stroke patients admitted to a stroke rehabilitation unit within 4 months of their stroke over an 8-year period. Videofluoroscopic modified barium swallow (VMBS) was performed on all patients suspected of aspirating. In all patients, the presence or absence of pneumonia was noted. RESULTS: Eighty-four of the 441 (19.0%) stroke patients transferred for rehabilitation demonstrated aspiration of thin liquids on VMBS. Twelve of the 441 (2.7%) developed pneumonia while in hospital, either in the acute or rehabilitation phases. The incidence of pneumonia among proven aspirators on VMBS was 10 of 84 (11.9%) patients. Two of the 357 (0.6%) patients who were presumed nonaspirators developed pneumonia. Brain stem and right hemispheric stroke patients had a higher incidence of pneumonia. CONCLUSIONS: Pneumonia is an uncommon complication of stroke. However, approximately 12% of stroke rehabilitation patients diagnosed as aspirators on VMBS developed pneumonia, a 20-fold increase over presumed nonaspirators. VMBS is a potentially valuable tool in determining those patients at risk of aspiration pneumonia.
Acute Disease↗
Prolonged length of stay and reduced functional improvement rate in malnourished stroke rehabilitation patients.
OBJECTIVE: To determine associations between the nutritional status of inpatient rehabilitation (rehab) unit stroke patients and (1) length of stay (LOS) and (2) functional outcome using Modified Barthel Index (MBI). Secondary objective-to determine whether hypoalbuminemia was equally related to outcome measures. A priori hypothesis-LOS and MRI are adversely related to malnutrition. DESIGN: inception cohort study. SETTING: Tertiary care center. PATIENTS: 49 consecutive "middle-band" patients (4 declined). MAIN OUTCOME MEASURES: LOS and MRI at admission (T1), 1 month (T2), and discharge (T3). RESULTS: LOS was significantly related to overall malnutrition, T1 and T2MBI scores, T1 dysphagia, T1 enteral feeding (all p<.01), T1 malnutrition, peripheral vascular disease (negative relationship), and diabetes mellitus history (all p<.05). In analysis of covariance, adjusting for T1 MBI, overall rehab malnutrition was related to LOS (p=.011). Other covariates were not significant. T1 malnutrition was related to lower T2 MBI scores(p=.038). Lower T1 MBI scores was related to T2 malnutrition (p=.032). Diabetics (p=.005) and right hemispheric lesion patients(p=.015) had lower T1 MBI scores. Hypoalbuminemia was unrelated to LOS and MBI scores. Although malnourished and adequately nourished functionally dependent patients improved equally in MBI scores by discharge, prolonged LOS in the malnourished lowered their functional improvement rate ([T3 MBI - T1 MBI]/LOS) (p=.047). CONCLUSIONS: Malnutrition was the most potentially modifiable variable relating to LOS and functional outcome. Close attention to nutrition status may help to optimize stroke patients' rehab potential and use of health care resources.
Activities of Daily Living↗
Autonomic dysreflexia in tetraplegic patients: evidence for alpha-adrenoceptor hyper-responsiveness.
A controlled study of acute pharmacological intervention was designed to determine whether decreased sympathetic nerve activity in tetraplegic patients results in increased responsiveness of alpha-adrenoceptors which might contribute to vascular hyperreactivity and the clinical scenario of autonomic dysreflexia. The study took place in a university teaching hospital and included six male tetraplegic patients and six age-matched normal male controls. All tetraplegics were 5 months or longer post-traumatic spinal cord injury and all had experienced symptoms of autonomic dysreflexia on at least one occasion. The dorsal foot vein diameter was recorded with a tonometer during local infusions of noradrenaline 0.125-256 ng/min given through a short intravenous needle. In tetraplegic patients, there was a significant shift to the left of the dose-response curve indicating increased venous responsiveness to noradrenaline. The concentration of noradrenaline required to cause a 50% reduction of the resting vein diameter was decreased in tetraplegics (1.6 ng/min, geometric mean) compared to normal controls (10.9 ng/min, p < 0.02). alpha-Adrenoceptor responsiveness in dorsal foot veins is increased in patients with tetraplegia. Hypersensitivity of vascular alpha-adrenoceptors may contribute to autonomic dysreflexia in patients with high spinal cord injury.
Adult↗
Malnutrition in stroke patients on the rehabilitation service and at follow-up: prevalence and predictors.
This prospective study presents the prevalence and risk factors of malnutrition in 49 consecutive stroke patients on the rehabilitation (Rehab) service and at 2- to 4-month follow-up. Malnutrition was diagnosed using biochemical and anthropometric data. Stroke patients, on admission to Rehab, have a very high prevalence of malnutrition. Malnutrition, 49% on admission, declined to 34%, 22%, and 19% at 1 month, 2 months, and follow-up, respectively. Dysphagia, 47% on admission, was associated with malnutrition (p = .032) and significantly declined over time. Using logistic regression, predictors of malnutrition on admission involved acute service tube feedings (p = .002) and histories of diabetes (p = .027) and prior stroke (p = .013). Tube feedings, associated with malnutrition on admission (p = .043), were more prevalent in brain stem lesion patients. Patients tube fed > or = 1 month during rehabilitation or at home were not malnourished. Malnutrition was associated with advanced (> 70 years) age at 1 month (p = .002) and weight loss (p = .011) and lack of community care (p = .006) at follow-up. Early and ongoing detection and treatment of malnutrition are recommended during rehabilitation of stroke patients both on the service and at follow-up.
Adult↗