Transcript Fast and Furious

Christina Kwasnica, MD
Medical Director,
Neurorehabilitation
Barrow Neurological
Institute
Lisa A. Lombard, MD
Medical Director,
Rehabilitation Hospital
of Indiana
Assistant Professor
Indiana University
School of Medicine
 Dr. Kwasnica: Ipsen
Speaker’s Board
 Dr. Lombard: none
 To
identify and review the most clinically
significant articles in CNS rehabilitation
from 7/1/2014 through 6/30/2015
 Each
presenter selected 13-15 articles of
interest from a selection of journals
 The preliminary lists were exchanged
and a final list of 10 articles were
narrowed down in areas of Spinal Cord
Injury, Traumatic Brain Injury, Stroke and
other neurologic conditions
 American
Journal of Neuroradiology
 American Journal of Sports Medicine
 Annals of Emergency Medicine
 Archives of Neurology
 Brain
 Brain
Injury
 International Journal of Stroke: Official
Journal of the International Stroke Society
 Journal of the American Heart
Association
 JAMA
 Journal of Neuroengineering and
Rehabilitation
 Journal
of Neurology
 Journal of Neurology, Neurosurgery,
and Psychiatry
 The Journal of Neuroscience: The
official journal of the Society for
Neuroscience
 Journal of Neurotrauma
 The Journal of Spinal Cord Medicine
 Neuropharmacology
 Neuropsychological
Rehabilitation
 NEJM
 PMR: the
journal of injury, function and
rehabilitation
 Spinal Cord
 Stroke: a journal of cerebral circulation
Divergent long-term consequences
of chronic treatment with
haloperidol, risperidone, and
bromocriptine on traumatic brain
injury-induced cognitive deficits
 Many TBI
patients receive antipsychotic
drugs (APDs) for treatment of agitation
and aggression
 Typical APDs, like haloperidol, can cause
extrapyramidal symptoms
 Atypical APDs have reduced
extrapyramidal symptoms but long-term
affects on TBI are not clear
 Haloperidol
has shown to delay motor
recovery after brain injury both with
acute or chronic treatment
 Both haloperidol and risperidone have
been to shown to delay motor and
cognitive recovery in rats with TBI
• Deficits noted to be present at least 3 days after
discontinuation of treatment
 Purpose: to
assess the long term
persistence of negative effects of APDs
after chronic administration
 Methods:
• 60 male adult rats used
• 40 underwent controlled cortical impact injury
(CCI), 20 sham procedures
 Treatment
• 10 CCI rats per group, 5 sham, treated with 19
days of clinically significant doses of
 Haldoperidol 0.5 mg/kg
 Risperidone 0.45 mg/kg
 Bromocriptine 5.0 mg/kg
 Vehicle
 Motor
performance was tested by beam
balance and beam walking tasks
• Tested at baseline on day of surgery, and then 3
trials per day on PO days 1-5 then days 48 and
108
 Cognitive
function was tested with a
Morris Water maze task
• Spatial learning began PO day 14 with 4 daily
trials for 5 consecutive days, then days 48 and
108
 After
PO day 109, cortical lesion volume
was measured
 One TBI+Vehicle rat was eliminated due
to inability to view the MWM platform,
suggestive of visual deficits
 Results: Beam
balance
• All TBI groups
were impaired but
no significant
differences were
noted on any time
point
 Results: Beam
walking
• Single day analysis
indicated worsening
deficit in the
haloperidol group
on day 5 compared
to bromocriptine
and vehicle, but not
overall on all days
 Results: Morris Water Maze
• All TBI groups were impaired compared to sham
• The haloperidol and risperidone groups were
significantly impaired in comparison to the
vehicle groups
• On day 48 haloperidol and risperidone groups
continued to be more significantly impaired
• On day 108, the deficits with the haloperidol
group persisted
• The bromocriptine group was significantly faster
than the haloperidol group
 Results: Lesion
volume
• Significantly
smaller in the
bromocriptine
group
 Summary
• Minimal group differences seen in motor recovery
(beam balance and walk)
• Spatial learning was significantly impaired in the
haldoperidol and risperidone both during the
treatment phase and 1 month afterwards
 Depression of learning continued in haloperidol group at 3
months
• Bromocriptine treatment resulted in reduced cortical
volume loss and improved cognitive recovery in
comparison with APD treatment and vehicle
 Why
is this important to physiatrists?
• Continues to demonstrate the importance of
avoiding typical and some atypical APDs
• Treatment in acute care with APDs may result in
slowed recovery in rehabilitation
 More involvement in acute care consultation may
result in avoiding use of these medications
• Dopaminergic medications can be helpful in
recovery of TBIs
A randomized trial of functional
electrical stimulation for
walking in incomplete spinal
cord injury: Effects on walking
competency
 Largest
amount of recovery from SCI has
been noted to occur in the first 6 months
after SCI
 Rate plateaus at 12-18 months
 Investigations into modalities for
improving function in chronic incomplete
SCI
• Body weight support treadmill training (BWSTT)
has shown to improve gait and balance in
incomplete SCI
 Functional
electrical stimulation (FES)
has been shown to improve voluntary
walking function in incomplete SCI
 Suggested that it enhances the spinal and
supraspinal neuroplasticity
 Majority of research has been on foot
drop
 Previous
pilot study found a multichannel
FES setup can mimic a natural gait cycle
over ground
 Study purpose to use the multichannel
FES in larger population as locomotion
therapy
 Assess if FES ambulation would reduce
the secondary health complications in
chronic SCI
• Spasticity, muscle atrophy, bone loss
 Design: parallel
group randomized
controlled trial
 Subjects: Traumatic incomplete (AIS C or D)
SCI C2-T12, at least 18 months after injury
• Either not walking at baseline or walking with AD at
a rate less than 0.5 m/s
 Both
control and intervention groups
received the same volume of therapies
• 45 minute sessions, 3 days per week for 16 weeks
 Control
group: Individually tailored
exercise program
• 20-25 minutes of resistance training (hand
weights, cables, Uppertone training system)
• 20-25 minutes of aerobic training (arm cycling,
leg cycling, walking in parallel bars or treadmill)
• Exercise was performed on a moderate pace
 Borg rating 3-5
 Intervention
group: FES training
• 4 channel FES: B quadraceps, hamstrings,
dorsiflexors and plantarflexors – pushbutton
system to initiate the leg movement
• Ambulated on body supported treadmill and
harness system
• Initially therapists controlled the pushbutton
system, as the training progressed, the subject
took control
 Intervention
group: FES training
• Minimal weight on the harness was used to
facilitate walking
• Speed was chosen to attain natural walking and
which the subject could tolerate
• Manual assist with leg movement was performed
by therapists when needed
• Subjects would have 4-5 minute bouts of walking
alternating with resting intervals
 Outcome
measures:
• Gait
 6 minute walk test
 10 meter walk test
 Assistive device score
 Walking mobility score
• Balance and mobility
 Timed up and go
 Outcome
measures:
• Functional measures:
 Spinal cord independence measure
 FIM locomotor score
• Spasticity
 Modified Ashworth
 Pendulum test
 FES
group SCIM mobility subscore was
improved compared with the exercise
group
 All other measures did not show
significant improvement over the
exercise group
 Both
interventions resulted in
improvements
• 2 minute walking distances
• 4 minute walking distances
• 6 minute walking distance
• Timed up and go
 Improvements
persisted over time
 Persons
with chronic incomplete SCI
have potential to improve long after
injury
 Emphases the need for continued
rehabilitation in this population
 Authors suggest larger more
homogenous population in future studies
 Why
is this important to physiatrists?
• Importance of continuing rehabilitation long
after incomplete SCI to improve function
• Does not necessarily require specialized
equipment
Liu N, Cadilhac DA, Andrew NE, Zeng L, Li Z, Li J, Li Y, Yu X, Mi B,
Li Z, Xu H, Chen Y, Wang J, Yao W, Li K, Yan F, Wang J. Stroke 2014;
45:3502-3507
 >30%
of strokes in China are ICH
 Associated with poorer functional
outcome and higher fatality than
ischemic stroke
 Recent research has shown early
rehabilitation in strokes may be
beneficial
• Improved motor recovery, reduced disability,
improved quality of life
• Studies limited to only small numbers of ICH
 ICH
strokes will have different acute care
management than ischemic
• More stringent blood pressure management,
may result in reluctance to rehabilitate early
• General consensus of delayed mobilization in
ICH despite no research to support it
 Study
aim: Compare very early
rehabilitation (VER – within 48 hours of
ICH) with standard care
 Hypothesis: VER will result in lowered
mortality, morbidity, and improved
quality of life at 3 and 6 months after
stroke
 Design: prospective, multicenter,
randomized controlled study
 2 parallel groups
 Eligibility:
• Patients presenting <48 hours after first ICH
• No contraindications to early mobilization
• Fugl-Meyer score between 27-90
 Exclusion
criteria:
• Very mild deficits
• Severe aphasia or cognitive deficits
• Other medical conditions such as severe CHF, LE
disorders that limit mobility
• Those unable to provide consent
 In
China, families are educated to
provide the rehabilitation care for both
exercise, ADLs, functional training
 Subjects were randomized to one of 2
interventions:
• Standard care: rehabilitation started 1 week after
stroke
• VER: rehabilitation started within 48 hours of
stroke
 Outcome
measures:
• Primary: mortality at 6 months after stroke
• Secondary: Questionnaires at 3 and 6 months,
which included:
 Short Form-36 (SF-36) – health related QOL measure
 Modified Barthel Index – functional measure for ADLS
 Zung Self-rated Anxiety Scale
 Recurrent stroke
 Needed
>170 patients to power the study
properly
 No
significant demographic differences
between the groups
 Average hospital stay 10 days less in VER
group (24 vs 34 days, p<0.001)
 Reports of experiencing adverse events
in the 6 months after stroke was
significantly higher in the standard
treatment group (83 % vs 31 %, p<0.001)
 Patients
in standard treatment we much
less likely to be alive at 6 months
 No
significant differences were seen in
short term improvements (0-3 months)
 Significant improvements seen for VER
group over standard care at 6 months in
• Physical component summary score
• Mental component summary score
• Self rating anxiety scale
 Results
summary - VER group
• Shorter acute care LOS
• At 6 months:
 More likely to be alive
 Greater improved QOL
 Independence in ADLs
 Improved mental health
 Results
similar to other studies on early
mobilization after stroke
 Possibility that families in VER group
were less likely to view the patient in a
dependent role and encouraged more
functional independence
 Why
is this important to physiatrists?
• Continues to support early mobilization in acute
stroke patients, no matter what the type of stroke
• Early consultation with physiatry allows for
advocating aggressive treatment and better
outcomes
Tiftik T, Gökkaya NKO, Malas FÜ, Tunç H, Yalçin
S, Erden R, Akkus S. Spinal Cord 2015;53:467470
 Persons
with SCI experience a decrease
in lung volume due to decreased chest
wall and lung compliance, weakness in
abdominal muscles, rib cage stiffness
 Results in ineffective cough and inability
to completely clear mucous
 Cervical SCI may result in increased
secretions, bronchospasms and
pulmonary edema
 Pulmonary
issues one of the most
common causes of morbidity and
mortality
 Locomotor training (LT) has been shown
to improve cardiopulmonary function,
body composition and quality of life
 Limited
research on locomotor training
on pulmonary function
 Small studies found reduced ventilatory
demand and improved locomotorrespiratory coupling during walking
 Study
aim
• To compare the effects of LT and standard
rehabilitation with rehabilitation only on
pulmonary function in SCI patients
 Participants: 52
patients (40 male)
admitted to an inpatient rehabilitation
program
 Exclusion:
• Brain injury
• Joint limitations
• Severe spasticity (Ashworth grades 3 and 4)
 Prospective
design
• LT group (19 men and 7 women)
• Control (21 men and 5 women)
 Group
A: received both the conventional
rehabilitation program and LT
 Group B: conventional rehabilitation
program only
 Conventional
rehabilitation consisted of
ROM and stretching exercises, balance
endurance, gait training with orthoses,
occupational therapy
 LT consisted of Body Weight Supported
Treadmill Training (BWSTT) three 30
minute sessions per week for 4 weeks
• Speed as low as 1 km/hr increased up to 1.5
km/hr as tolerated by the subject
 Resting
pulmonary function was assessed
before and after the rehabilitation
program
•
•
•
•
•
•
•
Forced vital capacity (FVC)
Forced expiratory volume in 1 second (FEV1)
Forced expiratory flow rate 25-50 % (FEF 25-75)
Peak expiratory flow rate (PEF)
Vital capacity (VC)
Ratio of FEV1 to FVC
Maximum voluntary ventilation (MVV)
 Statistically
significant improvements in
VC and FVC in LT group for all injury
levels and severities
 FVC, FEV1, FEF 25-75, VC increased
significantly in LT group and no
improvement in control group
 Mechanism
of improvement not clear
• LT may enhance corticospinal connectivity to LE
muscles in incomplete SCI
• Volitional effort may improve diaphragm and
abdominal muscle activation by postural
changes
• LT providing increased proprioceptive input to
the spinal cord
 Why
is this important for physiatrists?
• Engaging patients in locomotor therapies may
result in improved pulmonary function
• May result in fewer respiratory complications
Skolnick BE, Maas AI, Narayan RK, van der Hoop RG, MacAllister
T, Ward JD, Nelson NR, Stocchetti N. NEJM 2015 371(26);24672476
Wright DW, Yeatts SD, Silbergleit R, Palesch YY, Hertzberg VS,
Frankel M, Goldstein FC, Caveney AF, Howlett-Smith H,
Bengelink EM, Manley GT, Merck LH, Janis LS, Barsan WG. NEJM
2014 371(26):2457-2466
 The
secondary injury cascade offers an
opportunity to intervene and reduce cell
death and tissue damage
 Progesterone has been shown to have
neuroprotective properties
• Inhibition of inflammatory cytokines
• Prevention of excitotoxicity
• Reduction of apoptosis
• Reduction of vasogenic edema
 20
research groups working in 4 species
and 22 different models have shown the
neuroprotective effect of progesterone
 Two
phase 2 randomized controlled
clinical trials with progesterone showed
clinical benefit
• PROTECT I trial – 100 acute TBI, GCS 4-12
 Progesterone resulted in reduction in mortality
(13.0% vs 30.4%)
• Chinese trial 159 patients with GCS < or =8
 Reduced mortality
 Phase
3 trials:
• Study of a Neuroprotective Agent, Progesterone,
in Severe Traumatic Brain Injury (SYNAPSE)
• Progesterone for the Treatment of Traumatic
Brain Injury (PROTECT III)
 Multinational
prospective double-blind
parallel group trial
 July 2010-September 2013
 Recruited from level 1 trauma centers
 21 countries
 Total of 10,519 patients 16-70 years old
were screened
 Inclusion
•
•
•
•
•
•
criteria:
GCS 8 or less post-resuscitation
Marshall classification score of II or higher
At least one reactive pupil
Body weight 45-135 kg
Initiation of treatment within 8 hours
Clinical indication for monitoring intracranial
pressure
 Exclusion
criteria:
• GCS 3 with B fixed dilated pupils
• Life expectancy of <24 hours
• Prolonged or uncorrectable hypoxemia
•
•
•
•
(<60mmHg arterial)
Hypotension at time of randomization (SBP <90)
SCI
Isolated EDH
Pregnancy
 Subjects
were randomized using a web
based system, 1:1 in treatment or
placebo group
 Infusion started with a loading dose of
0.71 mg/kg for 1 hr and then a
continuous infusion of 0.5 mg/kg/hr for
119 hours
 During
the first 6 days ABG, ICP, CPP,
therapeutic intensity levels monitored
 Lab assessments on days 6 and 15
 CT scan on day 6
 Monitored for neurologic worsening
daily through day 15
 Follow up visits per planned for day 90
and day 180 after injury
 Primary
outcome: GOS at 6 months
 Secondary outcomes:
•
•
•
•
•
•
•
•
GOS at 3 months
Mortality at 1 and 6 months
GOS-E score
Changes in ICP
CPP
Therapeutic intensity level
Changes in CT findings
SF 36 at 3 and 6 months
 Total
of 1195 patients
• Progesterone 591, placebo 588
 96
% were followed for 6 months or died
 GOS
score at 6 months did not differ
between the groups (Odds ratio 0.96)
 Favorable outcome in 50.4 % in
progesterone group and 50.5 % in
placebo
 Vegetative state or death: 22.2 % in
progesterone group and 22.3 % in
placebo
 Secondary
outcomes: No differences
noted in any measure
 Double
blind, placebo controlled clinical
trial
 49 trauma centers in the US
 Primary outcome at 6 months with GOS-E
 Secondary outcomes: DRS, adverse
events
 Inclusion
criteria:
• Severe, moderate-severe or moderate TBI
• Blunt mechanism
• GCS 4-12
• Treatment initiated within 4 hours of surgery
 Exclusion
criteria:
• Nonsurvivable injury, B fixed dilated pupils, CPR
required, hypotension, hypoxemia, pregnancy
 Intervention: infusion
of progesterone or
placebo
• 1 hour loading dose, 71 hours of maintenance
infusion, 24 h infusion taper
 17,681
persons screened
 882 patients enrolled
• Most were moderate-severe
 Trial
stopped after 2nd interim analysis
due to futility
• Favorable outcomes in 51.0 % of progesterone
and 55.5 % of placebo group
• No difference in 6 month mortality
 Why
another failure of a multicenter TBI
trial?
• Variability and complexity of TBI
• Insensitivity of outcome measurement
• Difficulty in classifying TBI
• Difficulty in translating experimental data to TBI
in humans
 Why
is this important to physiatrists?
• Be aware of the successes and failures of trials in
acute rehabilitation
Mucha, A, Collins, MW, Elbin, RJ, et al. Am J
Sports Med. 2014 October;42(10): 2479-2486.
Vestibular complaints and impairments are
documented after concussion
Vestibulospinal vs. vestibulo-ocular
Vestibular impairments generally assessed using
assessment of the vestibulospinal system
BESS, SOT


Provide initial data for internal consistency for a brief
clinical screening tool of vestibular and ocular motor
impairments
Examine the predictive validity of discriminating
concussed athletes from controls
9
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9
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100 consecutive patients with diagnosed with sportrelated concussion- 64 met enrollment criteria as well
as 78 healthy controls
MeasuresVOMS
PCSS
Evaluated differences between patient and control
groups using Mann-Whitney U test and Chi square test
Used Cronbach analysis to examine internal
consistency of the VOMS
Logistic regression analysis to examine predictive
validity of the VOMS to discriminate between
concussed patients and controls
Internal consistency of the VOMS total symptom score
and the NPC distance is high
VOR item associated with highest percentage of
symptom provocation
Mean NPC distance significantly greater in concussed
group compared with controls
Best subset of independent predictors of concussions
is VMS and convergence distance
VOMS has good internal consistency and basic
validity with PCSS
Each of the VOMS item was positively correlated with
total PCSS score at a moderate level- but may not
measure the same thing- NPC distance correlated at a
lower level
Common concussion assessment tools (SAC, BESS,
SCAT-3) do not include measures of vestibular or
ocular motor function
May be a portion of side line and first clinic evaluation
for athletes with concussion
NPC distance may explain common symptoms such as
difficulty reading, difficulty in focusing and blurred
vision
English, C, Bernhardt, J, Crotty, M, Esterman, A, Segal,
L, and Hillier, S. I Jnl Stroke Vol 10, June 2015, 594-602.
Providing therapy in group circuit classes will lead to
improved walking ability when compared with usual
care (5 days a week)
Providing seven day a week therapy will lead to
improved walking ability when compared with usual
care
Providing group circuit classes will be superior to
seven day a week therapy
Participants with stroke admitted to inpatient
rehabilitation with moderate disability (FIM 40-80)
From rehab admission to randomization received
usual care
After randomization received the allocated model of
therapy delivery until discharge



Usual care included 5 day a week therapy with a
combination of individual and groups (not to exceed
4 times a week)
Seven day week therapy- Received therapy on
Saturday and Sunday but otherwise same as usual
care.
Circuit class therapy- Up for 3 hours a day with two 90
minute sessions
• Ratio of 1 staff to 3 participants
• Task specific activities focused on repetition
107
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Six minute walk test
Walking speed over 5 meters in beginning of walk test
Degree of independence in walking (FAC)
Degree of independence in ADLs (FIM)
Wolf Motor Function test
Self reported physical function
Length of hospital stay
Health related quality of life
Resource utilization
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At 4 weeks, no significant differences between groups
in 6 minute walk test, walking speed, independence in
walking, arm function or quality of life
Length of stay did not differ significantly between
groups though participants in 7 day arm had a mean
2.9 days shorter length of stay and participants in the
circuit class arm had a mean 9.2 days shorter length of
stay
Participants in all three groups walked significantly
further on the six minute walk test.
Despite the substantial increase in therapy time (extra
22 hours over 4 weeks for circuit class group) there
was no difference in walking ability, arm function or
ADLs
Content of therapy sessions (videotape analysis was
done) may be as important as amount of practice
Challenge of the semi-supervised nature of circuit
class group and influence in activities given to
patients that can be done safely
Need to look at cost-effectiveness of therapy delivery
models and potential that more doesn’t always mean
better outcomes
Role of therapy delivery methods in length of stay
(median vs. mean LOS, FIM efficiency)
Abo, M, Kakuda, W, Momosaki, R et al Intl J
Stroke Vol. 9, July 2014, 607-612.
To compare the clinical efficacy of low-frequency
repetitive transcranial magnetic stimulation with
intensive occupational therapy (NEURO) with
constraint-induced movement therapy
Recruited 66 post-stroke patients with upper limb
hemiparesis greater than 1 year after stroke
Baseline measures of the Fugl-Meyer Assessment and
Wolf-Motor Function test done
Random allocation to NEURO group (22 sessions of 20
minutes LF rTMS, 60 minute one to one training and 60
minutes self training) or CIMT group (11 sessions of 6
hour constraint induced movement therapy with
supervisors
Length of intervention 15 days
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rTMS at the site of largest motor evoked potential in
FDI
OT to start within 10 minutes of application of rTMS
One on one training with OT consisting of shaping
and repetitive task techniques
Self exercise done in another room without
supervision with written instructions
115
Required to wear instrumental mitt on less impaired
upper limb only during CIMT
Self exercise was not encouraged
All CIMT done in one on one face to face manner
The Fugl Meyer score and the FAS of the WMFT
increased significantly in both groups
The WMFT log performance time significantly
decreased in both groups
There was a significantly larger increase in the
FAS of the WMFT in the NEURO group compared
with the CIMT
No significant difference between groups on the
WMFT LOG score which measures distal arm
movement
There were significant differences in the FMA
(measures whole arm) and FAS (measures
proximal arm) suggesting NEURO is superior to
CIMT
Did not postulate mechanism of motor recovery or
use functional neuroimaging
Another short duration (15 day) high intensity therapy
intervention for hemiparesis after stroke
Unclear the functional significance of the statistically
significant difference on the FAS (because both groups
had an improvement)
Ripley, DL, Morey, CE, Gerber, D, et al. Brain
Injury Vol 28; August 2014, 1514-1522.
To determine if atomoxetine would improve attention
impairment in chronic TBI patients
Double blind placebo control cross over trial with
placebo run in
55 participants with moderate to severe TBI as
measured by GCS with post-traumatic amnesia greater
than 24 hours or radiographic evidence of intracranial
injury
Injury greater than 12 months earlier
Subjects randomized into 2 groups- drug first group
and placebo first group



Atomoxetine 40 mg taken twice a day at 7 am and 12
noon
Randomization occurred after 2 week placebo run in
with repeat baseline assessment at day 14
Assessments repeated at Day 28, Day 42 and Day 56.
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Brain Inj, 2014;28(12) 1514-1522
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Cognitive Drug Research (CDR) Computerized
Cognitive Assessment system
CDR Continuity of Attention, Quality of Episodic
Memory and Speed of Memory factors were analyzed
separately
Stroop Color and Word Test
Adult ADHD Self-report Scale
Neurobehavioral Functioning Inventory
Trends to improvement in performance in all
measures indicating a successful placebo run in
No significant treatment effect of atomoxetine vs.
placebo
Post-hoc analysis of neuropathology unable to be
completed due to preponderance of individuals with
multifocal injury
Atomoxetine well tolerated- only side effects greater
than placebo was dry mouth and insomnia
No significant effect of atomoxetine either objectively
or even subjectively on self report questionnaires
Variation in neuropathology may affect efficacy of the
intervention- multifocal nature may disrupt the
physiological pathway of action which is the
noradrenergic pathway from the locus coeruleus to the
prefrontal cortex
Classification system focused on neuroanatomy rather
than GCS may allow for discrimination of patients to
focus on pharmacologically more appropriate
treatments
Question the use of this medication even though it is
well tolerated
Need to discriminate the difference between ADHD
and TBI to other practitioners, payors
Bettger, JP, McCoy, L, Smith, EE et al
JAHA 2015;4: 1-11.
To examine the trends in discharge to post acute care
(PAC) in stroke patients after the implementation of
the prospective payment system for acute and PAC
Retrospective analysis of clinical registry data for
patients treated at Get With The Guidelines- Stroke
participating hospitals
Enrolled consecutive admissions with acute ischemic
stroke and hemorrhagic stroke
Excluded those with TIA and discharge destinations
other than IRF, SNF, home with HH or home without
services
Discharge destination based on billing codes- 01
(home without services, 06 (home with HH), 62 (IRF),
03 (SNF)
Patient sociodemographics and clinical characteristics
NIHSS
Inability to ambulate on Day 2
Failed dysphagia screen



Compared patient and hospital characteristics for
stroke patients discharged to IRF, SNF, HH and home
without services using Pearson chi-square tests and
chi-square rank-based group means depending on the
variables
Fit a logistic regression model to assess specific
association of stroke severity and insurance type with
disposition
Also analyzed trends for each discharge group from
year to year and in younger and older population
(above and below 65 years of age)
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Unadjusted analyses of change in discharge to PAC
over 8 years showed a slight increase in discharge to
PAC- greatest increase for IRF, decrease for discharge
to SNF
Discharge to PAC increased over time for all ranges of
stroke severity
Strongest patient predictor of discharge to PAC was
not ambulating on second day of hospital stay
Medicare patients were more likely to be discharged
to PAC than no insurance or private insurance
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Medicare’s introduction of PPS was originally
associated with reduced utilization from 1998-2002.
The IRF 75% rule favored stroke patients and was
being newly enforced
May explain the increase in discharges to IRF in
patients 65 and older during this time period
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Further reinforces the important indicators for post
acute care we use in consultation- ambulatory status
Helps form a baseline for upcoming changes in
payment systems- bundled payments