The Anti-gravity (AG) treadmill is a new modality, initially used by athletes and astronauts allowing precise unweighting up to 80% of body weight. Patients are enclosed in a cockpit which unweights by filling with air, allowing patients to be safely progressed at higher speed and longer durations than the conventional treadmill. Only a few case studies report outcomes of stroke patients using this system. Methods: We trialled the AG system on 9 (5 men, 4 women) community dwelling, chronic stroke patients between 6/2014 and 8/2014 as part of an outpatient physical therapy (PT) program. 7/9 patients received AG treatment following conventional treadmill training, while 2 began new PT treatments with the AG system. Endurance was measured with the standardized 6 minute walk test before initiation and after completion of AG system treatments. Various other PT and stroke outcomes were measured. Results: 8 ischemic and 1 hemorrhage stroke patients with average age 63 (49-79); average NIHSS of 7.9 (range 3-15) and Modified Rankin Scores of 4 for 5 patients and 3 for 4 were treated an average of 21.4(range 11-86) months post stroke. Patients received an average of 5 sessions (2-8) over an average of 2.8 weeks ((1-4). Blood Pressures monitored pre and post each treatment were stable. No adverse complications or pain occurred. All patients reported subjectively experiencing improvement in gait quality with AG system use. 89% (8/9) patients had improved 6" walk test scores following AG treatments. 7/9 patients had received conventional treadmill training during skilled PT prior to initiation of AG treatments. In the 1 month prior to AG treatment, 3/7 of these patients had worsening of 6" walk scores; 2/7 improved, and 2/7 had no change. Of the 7/9 patients receiving AG treatment following usual treadmill training, 6/7 had improved 6" walk scores (range 2-17%). 6 minute walk scores improved by 81% and 1% in 2 patients initiating AG training without preceding treadmill training. All patients had improved walking duration and speed on AG compared to traditional treadmill. Conclusions: AG treadmill treatment was reported to be positive and led to improved walking and endurance compared to conventional treadmill training in this pilot group of chronic community dwelling stroke patients.
Background: Patients beginning an outpatient rehabilitation program often do not understand medications, good blood pressure (BP) control, and monitoring and recording of BPs Methods: An educational curriculum based on AHA guidelines and AHA Life’s Simple 7’s program was designed to improve patient understanding of medications, cardiovascular risk factors, and BP monitoring. Results: 51 consecutive patients, (27 men, 24 women, ages 41-90) with admit NIHSS 0-16 treated from 12/2011 to 7/2013 had an average of 9.6(0-21) NP visits with calls to MD about BP meds in 16%. On rehab admit, 6 patient/caregivers reported AHA recommendations for normal BP, and 7 patients/caregivers checked and recorded BPs. After NP sessions, 71%(36/51) patients checked and recorded BPs independently, 29% with assist. 46 patients received an average of 16.5 PT sessions, with BPs taken pre, during, and after exercise. Among 647 pre-exercise BPs, 37% were in AHA normal range(<120/80). 32% in mild (121-139/81-90), 28 % moderate (140-159/91-99), and 6% severe (>160/100). BPs measured during the first 75% of PT sessions were compared to BPs during the last 25%. 63% of patients had fewer moderate-severe range BPs and more normal-mild range. 14% had no change in mild-normal range BPs. 20% had some worsening of BP control. On admission, 6/51 (12%) patients could describe the name, purpose, dosage, schedule of all their medications, 16(31%) could describe partially, and 29(57%) gave no information about meds; 76%(16 aphasic) relied on caregivers for medication administration. After NP education, 31% of dependent patients became independent with med administration; 47% (6 aphasic) administered meds independently. 27(53%) (11 aphasic) remained dependant on caregivers. SIS Stroke Recovery Scale Domain scores increased an average of 41%(-50 to 167%) with 23/24 reporting improvement. 6” walk scores improved an average of 55%. Conclusions: Community dwelling stroke patients often cannot translate previously provided medication, CV risk factor, BP instructions into practical use. Patients receiving NP education as part of an outpatient rehab program showed improved independence with medication administration, blood pressure self monitoring, blood pressure control and rehab outcomes.
Background: Despite the availability of community based outpatient rehabilitation programs in the U.S., few use standardized measure sets and assessments, and outcomes studies are sparse. There is especially a knowledge gap regarding outcomes of participating chronic stroke patients (rehabilitation begins more than 6 months post stroke). Methods: Prospective observational study of stroke patients treated between 12/2011-1/2015 in an interdisciplinary outpatient rehabilitation program that addresses health literacy, risk factors, physical, psychosocial, cognitive, communicative and vocational issues. Patients were classified as chronic if admitted to the program >6 months and sub-acute if admitted <6 months post stroke. Results: Among 96 consecutive patients, 71 were sub-acute (72% ischemic, 28% hemorrhages) and 25 chronic (68% ischemic, 32% hemorrhages) who were admitted to the program an average 18.5 months post stroke (range 6-121 months). Chronic vs subacute stroke patients were 64% vs 59% male, with no difference in age (mean 66, range 27-90 years vs 65, range 18-90 years), but with greater stroke severity (chronic mean NIHSS score 8.32, range 2-15 vs subacute NIHSS of 5.2, range 0-16). On admission, chronic vs subacute patients were 44% vs 34% aphasic and 96% vs 86% needed assistance with activities of daily living (chronic with modified Rankin Scale [mRS] of 3=28% and 4=68% vs subacute mRS of 3=65% and 4=21%). The percent change in outcomes from baseline to program discharge for subacute and chronic stroke patients is presented in the Table. Conclusions: Although age, sex and stroke types were similar in both groups, chronic patients were more severely impaired than subacute patients but achieved greater improvement in activities of daily living, recovery, walking speed, balance, and risk factor knowledge. These findings demonstrate that outpatient rehabilitation programs can aid in stroke recovery independent of time since stroke onset.
Background: Return to Employment and driving are goals for many stroke survivors. Little is known about the frequency and characteristics of patients returning to work. Methods: Prospective observational study of stroke patients treated between 12/2011-1/2015 in an interdisciplinary outpatient rehabilitation program that addresses physical, psychosocial, cognitive, communicative, risk factors, driving, and vocational issues. Results: Of 96 consecutive patients, 48% were working prior to their stroke. 44% (70% men, 30% women) of those working prior to their stroke returned to work upon program completion. On admit, these returning workers had an average age of 56 years, average NIHSS score of 3.4(range 0-9), 40% were aphasic, 65% needed assistance with ADL's(55% with {mRS} of 3 and 10% with {mRS} of 4). 15 of these suffered ischemic strokes( 4 Left, 4 Right, 3 Bi-lateral hemisphere, 4 posterior circulation), and 5 had hemorrhages. All patients working prior to their stroke were also driving, and 15% of these were driving on admit. 90% of those who returned to work also returned to driving. In those returning to work, Stroke Impact Scale(SIS) scores improved an average of: mood 12%, ADL’s 15%, participation 24%, and stroke recovery domain 16%. These patients received an average of 21 physical therapy visits, with 6 minute walk and Berg Balance scores improving an average of 112% and 11% respectively. Multiple other demographic, risk factor, and outcome measures are collected. An additional 9% of patients were work capable on discharge. In comparison, 19 of those not returning to work had ischemic strokes, 7 had hemorrhages. This group had average age 57, average NIHSS score 6.8(range2-16), 42% aphasic, 89% needed assistance with ADL’s (58% with {mRS} of 3 and 31% with {mRS} of 4), and 28% returned to driving. Average length of stay was 4 (range 0.25-12) and 6 months(range 2-12) in those returning and not returning to work respectively. Conclusions: These findings demonstrate that outpatient rehab programs can promote stroke recovery, return to work and driving. Further collection of characteristics and rehabilitation outcomes of patients returning to work can help direct rehabilitation efforts for patients with return to work goals.
Background: Return to work is a motivating goal for many stroke survivors. Little is known about the cost, length of treatment, and characteristics of patients returning to work. Methods: Prospective observational study of stroke patients treated between 12/2014-6/2016 in an interdisciplinary outpatient rehabilitation program addressing physical, psychosocial, cognitive, communicative, driving, and vocational issues. The estimated average cost of treatment was calculated from reimbursement amounts received for skilled PT, OT, ST, and Nurse Practitioner services, including services received after patients returned to work. Results: Of 96 consecutive patients, 48% were working prior to their stroke. Of these, 9% of patients were work capable and 44% returned to work (n=20) by rehabilitation discharge (mean program length was 8 months, maximum of 34 months). Returning workers were 70% men, mean age of 56 years, 75% ischemic strokes (4 Left, 4 Right, 3 Bi-lateral hemisphere, 4 posterior circulation), and on program admit had an average NIHSS score of 3.4 (range 0-9), 40% were aphasic, 65% needed ADL assistance (55% mRS=3, 10% mRS=4). All patients working prior to their stroke were also driving and 90% of those who returned to work also returned to driving. All patients demonstrated improvements in multiple standardized rehab outcome measures. Mean treatment cost for patients who returned to work was $17,730 (60% had costs less than $7,500; 25% had costs from $7,501-$21,000; 15% had costs from $50,000-$92,000). Services continued for 75% of patients after returning to work for an average of 3.7 months(included in mean program length of 8 months). Almost half of these patients (47%) were aphasic. Mean treatment cost for patients not returning to work was $22,561, with mean program length of 6.5 months. Conclusions: These findings demonstrate that interdisciplinary, outpatient rehabilitation programs can promote successful return to work at a reasonable cost, with 60% of patients who returned to work costing less than $7500. Aphasic patients needed longer treatment, but were able to successfully return to work. Additional outcomes research is needed to understand mechanisms supporting stroke patients’ return to work and other patient-centered goals.
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