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Objective: To evaluate the association between functional measures at admission to acute inpatient rehabilitation (AIR) and health-related quality of life (HRQOL) scores at 3 months after ischemic stroke., Design: Consecutive patients with ischemic stroke admitted to AIR were consented to a prospective registry., Setting: Large academic referral inpatient rehabilitation hospital., Participants: Patients (N=113) with ischemic stroke (mean age 70.6 ± 14.5y; 54.0% male; 56.6% white) were included in the analysis., Interventions: Not applicable., Main Outcome Measures: Admission FIM and Berg Balance Scores (BBS) were abstracted when available. The Neuro-Quality of Life questionnaire was used to assess 3-month HRQOL in 4 domains: upper extremity (UE), lower extremity (LE), executive functions (EF), and general concerns (GC). Associations of FIM and BBS scores with impaired HRQOL at 3 months were evaluated., Results: The median time from stroke onset to admission FIM and BBS was 6.4 (interquartile range [IQR] 4.2-11.3) and 8.9 (IQR 5.8-14.4) days, respectively. A 5-point increase in admission FIM score decreased the likelihood of impairment in HRQOL at 3 months by 25% for GC (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.61-0.93, P=.01), 31% for EF (OR 0.69, 95% CI 0.56-0.85, P=.001), 16% for UE function (OR 0.84, 95% CI 0.73-0.96, P=.01), and 21% for LE function (OR 0.79, 95% CI 0.67-0.93 P=.004). A 5-point increase in admission BBS decreased the likelihood of impairment in HRQOL domains at 3 months by 15% for UE function (OR 0.85, 95% CI 0.75-0.98, P=.02) and 25% for LE function (OR 0.75, 95% CI 0.64-0.89, P=.001)., Conclusions: Admission FIM and BBS were strongly associated with 3-month HRQOL associated across multiple domains following stroke. These findings indicate that HRQOL can be predicted earlier in a patient's course during AIR., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine agreement between patient and proxy responses on the Quality of Life in Neurological Disorders (Neuro-QoL) instruments after stroke., Design: Cross-sectional observational substudy of the longitudinal, multisite, multicondition Neuro-QoL validation study., Setting: In-person, interview-guided, patient-reported outcomes., Participants: Convenience sample of dyads (N=86) of community-dwelling persons with stroke and their proxy respondents., Interventions: Not applicable., Main Outcome Measures: Dyads concurrently completed short forms of 8 or 9 items for the 13 Neuro-QoL adult domains using the patient-proxy perspective. Agreement was examined at the scale-level with difference scores, intraclass correlation coefficients (ICCs), effect size statistics, and Bland-Altman plots, and at the item-level with kappa coefficients., Results: We found no mean differences between patients and proxies on the Applied Cognition-General Concerns, Depression, Satisfaction With Social Roles and Activities, Stigma, and Upper Extremity Function (Fine Motor, activities of daily living) short forms. Patients rated themselves more favorably on the Applied Cognition-Executive Function, Ability to Participate in Social Roles and Activities, Lower Extremity Function (Mobility), Positive Affect and Well-Being, Anxiety, Emotional and Behavioral Dyscontrol, and Fatigue short forms. The largest mean patient-proxy difference observed was 3 T-score points on the Lower Extremity Function (Mobility). ICCs ranged from .34 to .59. However, limits of agreement showed dyad differences exceeding ±20 T-score points, and item-level agreement ranged from not significant to weighted kappa=.34., Conclusions: Proxy responses on Neuro-QoL short forms can complement responses of moderate- to high-functioning community-dwelling persons with stroke and augment group-level analyses, but do not substitute for individual patient ratings. Validation is needed for other stroke populations., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the relationship between poststroke shoulder pain, upper-limb motor impairment, activity limitation, and pain-related quality of life (QOL)., Design: Cross-sectional, secondary analysis of baseline data from a multisite clinical trial., Setting: Outpatient rehabilitation clinics of 7 academic medical centers., Participants: Volunteer sample of 61 chronic stroke survivors with poststroke shoulder pain and glenohumeral subluxation., Interventions: Not applicable., Main Outcome Measures: We measured poststroke shoulder pain with the Brief Pain Inventory question 12 (BPI 12), a self-reported 11-point numeric rating scale (NRS) that assesses "worst pain" in the last 7 days. Motor impairment was measured with the Fugl-Meyer Assessment (FMA). Activity limitation was measured with the Arm Motor Ability Test (AMAT) and the FIM instrument. Pain-related QOL was measured with BPI question 23, a self-reported 11-point NRS that assesses pain interference with general activity, mood, walking ability, normal work, interpersonal relationships, sleep, and enjoyment of life., Results: Stepwise regression analyses indicated that poststroke shoulder pain is associated with the BPI 23, but not with the FMA, FIM, or AMAT scores., Conclusions: Poststroke shoulder pain is associated with reduced QOL, but not with motor impairment or activity limitation.

Objective: To determine the effectiveness of anticoagulant and antiplatelet agents in preventing venous thromboembolism (VTE) during stroke rehabilitation., Design: Historical cohort study., Setting: Acute inpatient rehabilitation hospital., Participants: Consecutive patients (N=1506) with ischemic and hemorrhagic stroke admitted for rehabilitation., Interventions: Documented use of anticoagulants (warfarin or anticoagulant doses of heparin), heparin in prophylactic doses, and antiplatelet agents., Main Outcome Measure: Occurrence of deep vein thrombosis detected by ultrasound or venography or pulmonary embolism detected by ventilation perfusion scan, spiral computed tomography, or pulmonary angiography., Results: Fifty-eight VTE events occurred (3.9% incidence or 1.36 events per 1000 patient days), with higher risk in patients with severe stroke. Only therapeutic anticoagulation had a statistically significant protective effect for VTE risk in univariate analysis (odds ratio [OR]=.44; 95% confidence interval [CI],.20-.98). After adjusting for multiple medication use and other factors, including age, stroke onset to admission interval, length of rehabilitation stay, cause of stroke, and admission National Institutes of Health Stroke Scale score, therapeutic anticoagulation gave strong protection against VTE (OR=.37; 95% CI,.15-.88), followed by heparin (OR=.48; 95% CI,.23-.98) but not by antiplatelet agents (OR=.79; 95% CI,.40-1.57). No medications were associated with significant bleeding complications., Conclusions: Use of therapeutic anticoagulants or prophylactic heparin prevented VTE in stroke patients during inpatient rehabilitation.

Objective: To assess the effectiveness of intramuscular neuromuscular electric stimulation (NMES) in reducing poststroke shoulder pain., Design: Multicenter, single-blinded, randomized clinical trial., Setting: Ambulatory centers of 7 academic rehabilitation centers in the United States., Participants: Volunteer sample of 61 chronic stroke survivors with shoulder pain and subluxation., Intervention: Treatment subjects received intramuscular NMES to the supraspinatus, posterior deltoid, middle deltoid, and trapezius for 6 hours a day for 6 weeks. Control subjects were treated with a cuff-type sling for 6 weeks. Main outcome measure Brief Pain Inventory question 12 (BPI 12), an 11-point numeric rating scale administered in a blinded manner at the end of treatment, and at 3 and 6 months posttreatment., Results: The NMES group exhibited significantly higher proportions of success based on the 3-point or more reduction in BPI 12 success criterion at the end of treatment (65.6% vs 24.1%, P<.01), at 3 months (59.4% vs 20.7%, P<.01), and at 6 months (59.4% vs 27.6%, P<.05). By using the most stringent "no pain" criterion, the NMES group also exhibited significantly higher proportions of success at the end of treatment (34.4% vs 3.4%, P<.01), at 3 months (34.4% vs 0.0%, P<.001), and at 6 months (34.4% vs 10.3%, P<.05)., Conclusions: Intramuscular NMES reduces poststroke shoulder pain among those with shoulder subluxation and the effect is maintained for at least 6 months posttreatment.

Objective: To evaluate relationships between unilateral spatial neglect and both overall and cognitive-communicative functional outcomes in patients with right hemisphere stroke., Design: Assessment of overall and cognitive-communicative function was conducted on admission to acute rehabilitation, at discharge, and at 3-month follow-up., Setting: Urban, acute inpatient rehabilitation facility., Patients: Fifty-two consecutive admissions of adult right-handed patients with a single, right hemispheric stroke, confirmed by computed tomography scan., Main Outcome Measures: The FIM instrument and reading comprehension and written expression items of the Rehabilitation Institute of Chicago Functional Assessment Scale(R)., Results: Patients made significant functional gains between admission and discharge, and between discharge and follow-up on the FIM. Severity of neglect was correlated with total, motor, and cognitive FIM scores at admission, discharge, and follow-up. Subjects with neglect had significantly more days from onset to admission and a longer length of rehabilitation stay than subjects without neglect. FIM outcomes were significantly different for subject groups with more severe neglect. Both the presence of neglect and its severity were significantly related to functional outcomes for reading and writing., Conclusions: Patients with neglect show reduced overall and cognitive-communicative functional performance and outcome than patients without neglect. Further studies are needed to explore causal relationships between these factors.

This self-directed learning module highlights new advances in the understanding of co-morbid conditions and medical complications of stroke. It is part of the chapter on stroke rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers co-morbid conditions of stroke patients, including cardiovascular disease, diabetes, and sleep apnea. It reviews recent information on complications of stroke, including deep venous thrombosis, dysphagia and aspiration, hospital-acquired infections, depression, falls, spasticity, shoulder pain, and seizures. Treatment advances in diabetes, depression, and spasticity are highlighted. Recent information is presented regarding exercise guidelines for the stroke patient with cardiovascular disease, the relationship between stroke and sleep apnea, prophylaxis of deep venous thrombosis, the changing spectrum of hospital-acquired infections, malnutrition in stroke patients, the problem of falls during rehabilitation, the evaluation and management of poststroke shoulder pain, and the risk of seizures after stroke.

This self-directed learning module highlights new advances in the treatment of patients after stroke by means of a case study format. It is part of the chapter on stroke rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses both medical and rehabilitation issues that arise in the care of persons with strokes involving the right and left middle cerebral arteries and the vertebral artery. Cases were chosen to cover problems seen in both older and younger persons. Management of common sequelae that are typical of these stroke syndromes and identification of common co-morbidities are included.

Objective: To identify predictors of rehabilitation hospital resource utilization for patients with stroke, using demographic, medical, and functional information available on admission., Design: Statistical analysis of data prospectively collected from stroke rehabilitation patients., Setting: Large, urban, academic freestanding rehabilitation facility., Participants: A total of 945 stroke patients consecutively admitted for acute inpatient rehabilitation., Main Outcome Measures: Resource utilization was measured by rehabilitation length of stay (LOS) and mean hospital charge per day (CPD)., Methods: Independent variables were organized into categories derived from four consecutive phases of clinical assessment: (1) patient referral information, (2) acute hospital record review and patient history, (3) physical examination, and (4) functional assessment. Predictors for LOS and CPD were identified separately using four stepwise multiple linear regression analyses starting with variables from the first category and adding new category data for each subsequent analysis., Results: Severe neurologic impairment, as measured by Rasch-converted NIH stroke scale and lower Rasch-converted motor measure of the Functional Independence Measure (FIM) instrument predicted longer LOS (F2,824 = 231.9, p < .001). Lower Rasch-converted motor FIM instrument measure, tracheostomy, feeding tube, and a history of pneumonia, coronary artery disease, or renal failure predicted higher CPD (F6,820 = 90.2, p < .001)., Conclusion: Stroke rehabilitation LOS and CPD are predicted by different factors. Severe impairment and motor disability are the main predictors of longer LOS; motor disability and medical comorbidities predict higher CPD. These findings will help clinicians anticipate resource needs of stroke rehabilitation patients using medical history, physical examination, and functional assessment.

Objectives: To describe the association between impairment and disability during stroke rehabilitation and to examine the effects of rehabilitation by studying the degree of disability reduction experienced by stroke patients who did not have significant reductions in impairment levels., Design: Statistical analysis of items from a database of prospectively collected information on stroke patients admitted for rehabilitation., Setting: Large urban academic freestanding rehabilitation facility., Participants: Four hundred two patients consecutively admitted for comprehensive acute stroke inpatient rehabilitation., Main Outcome Measures: The National Institutes of Health Stroke Scale (NIHSS) was used to measure impairment and the Functional Independence Measure (FIM) was used to measure disability. Motor and cognitive subscales of the FIM instrument were evaluated. Raw NIHSS and FIM scores were converted to linear measures using Rasch analysis., Methods: Relationships were studied between converted NIHSS and the two FIM subscales for admission, discharge, and change scores using linear regression analysis. In a second analysis, two groups of patients were identified; the 342 patients who experienced no substantial reduction of impairment comprised the "no impairment reduction (NIR) group," and the 60 patients who had a significant reduction of impairment level comprised the "impairment reduction (IR) group." Multivariate analysis of variance was used to determine and compare the amount of change in motor and cognitive FIM measures over time for each of the two groups., Results: NIHSS correlated significantly with motor and cognitive FIM subscores for admission, discharge, and change measures; R2 values ranged between .02 and .36. Both the NIR group and the IR group experienced significant decreases in disability during rehabilitation. The differences in discharge FIM measures between the two groups were relatively small., Conclusions: Although stroke-related impairment and disability are significantly correlated with each other, reduced impairment level alone does not fully explain the reduced disability that occurs during rehabilitation. Even patients without substantial impairment reduction demonstrate disability reduction during rehabilitation, suggesting that rehabilitation has an independent role in improving function beyond that explained by neurologic recovery alone.

Diabetes mellitus is an independent risk factor for stroke, and the incidence of diabetes in patients presenting with stroke is 16% to 20%. Administration of insulin is an important activity of daily living that should be addressed in hemiplegic patients with diabetes. Presented here is a table-top clamp that can be used with an insulin pen allowing independent insulin dosing and subcutaneous administration with one hand. The clamp is built on a wood block base that is mounted to a smooth table surface by suction cups. Construction of the device is simple, inexpensive, and can be incorporated as a therapeutic project for the patient during the rehabilitation stay. A diabetic patient with a left hemiplegia is presented who demonstrated independence with the device prior to her discharge home.