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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

A variety of mechanisms may cause intravascular coagulation. Fibrinolysis is nearly always secondary to the initial clotting. In the acute form, ICF is characterized by depletion of platelets and several coagulation factors together with active fibrinolysis. There is a decrease in Factors V and VIII because they are sensitive to coagulation. The stable coagulation factors may be decreased as well because after activation they are removed from the circulation by the liver and reticuloendothelial system. Severe bleeding is the usual accompaniment of the acute syndrome, which may also occur in cancer and infection of all types. The acute syndrome may also occur in prolonged, extensive operations, after transfusion of incompatible blood, heat stroke, acute injury, certain snake bites, and with the administration of certain drugs. The chronic syndrome of intravascular coagulation is much more common and is associated with many diseases, including collagen diseases or immune diseases and malignancy. Many patients with chronic intravascular coagulation have normal or even increased levels of coagulation factors, and these patients have no unusual bleeding. The diagnosis depends on the demonstration of circulating complex of "soluble" fibrin revealed by the ethanol gel and protamine sulfate gelation tests. The secondary fibrinolysis results in elevation of FSP. Many laboratories are investigating the use of other procedures in the diagnosis of intravascular coagulation, including fibrinopeptides A and B, the VIII:C VIIIR:AG ratio, antithrombin III, PF 4, beta-thromboglobulin, D dimer, urinary FSP, and fibrinogen chromatography.
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PMID:The clinical pathology of intravascular coagulation. 642 Dec 71

A literature review on the subject of rehabilitation of stroke patients is presented based on WHOs classification system ICF. Studies are presented regarding body function, activity, participation and environment, since the consequences of a stroke for the person effects different areas, indicating a need for rehabilitative efforts. Evidence based medicine has been used when available.
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PMID:[There is evidence for good effect of rehabilitation after stroke. A literature review based on WHO's classification system ICF]. 1471 10

Lesion-induced cortical hyperexcitability has been demonstrated in animal models of cerebral ischemia and after human stroke. We used transcranial magnetic stimulation to investigate motor cortex excitability in ten patients who suffered short transient ischemic attacks (TIAs; i.e. duration <60 min) in the week before examination. Intracortical inhibition (ICI) and facilitation (ICF) were assessed using paired-pulse stimulation. Single-pulse stimulation was applied to investigate cortical silent period and transcallosal inhibition. The side affected by the TIA was compared to the normal side of each patient. We found ICI significantly reduced, and a trend towards enhanced ICF on the affected side. All other parameters remained normal. Motor cortex disinhibition may occur after short TIAs in spite of morphologically intact brain tissue. Possibly, these functional changes correlate to the protective neurometabolic mechanisms elicited by short episodes of focal ischemia in animal models and in man.
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PMID:Long-lasting motor cortex disinhibition after short transient ischemic attacks (TIAs) in humans. 1513 83

Today, thanks to intensive care treatment and modern diagnostic tools, increasingly more patients with severe brain and spinal cord lesions, mainly secondary to accidents, stroke, tumours, and congenital malformations survive the acute impact on the central nervous system (CNS). Complicated operative procedures and concomitant complication may also lead to severe impairment of the sensory motor and cognitive behavioural functioning as it can be described according to the WHO-ICF criteria. New developments of functional neurorehabilitation in neurosurgery can significantly improve patients' quality of life (QoL) in terms of both brain and body functioning and certain health-related components of well-being (such as social activities and leisure). Rehabilitation starts with assessment of the functional impairment and the underlying pathophysiology by using all modern diagnostic tools. Our concept of postoperative neurorehabilitation is exemplarily demonstrated in one patient who suffered from acute postoperative locked-in syndrome. Surgical decompression and fusion were required for post traumatic and recurrent congenital craniovertebral instability at C0-C1. Subsequent functional neurorehabilitation is based on careful planning in accordance with our concept of a holistic Spectrum of functional early Neurorehabilitation.
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PMID:Functional neurorehabilitation in locked-in syndrome following C0-C1 decompression. 1598 50

We used two complementary methods to investigate cortical reorganization in chronic stroke patients during treatment with a defined motor rehabilitation program. BOLD ("blood oxygenation level dependent") sensitive functional magnetic resonance imaging (fMRI) and intracortical inhibition (ICI) and facilitation (ICF) measured with transcranial magnetic stimulation (TMS) via paired pulse stimulation were used to investigate cortical reorganization before and after "constraint-induced movement therapy" (CI). The motor hand function improved in all subjects after CI. BOLD signal intensity changes within affected primary sensorimotor cortex (SMC) before and after CI showed a close correlation with ICI (r = 0.93) and ICF (r = 0.76) difference before and after therapy. Difference in number of voxels and ICI difference before and after CI also showed a close correlation (r = 0.92) in the affected SMC over the time period of training. A single subject analysis revealed that patients with intact hand area of M1 ("the hand knob") and its descending motor fibers (these patients revealed normal motor evoked potentials [MEP] from the affected hand) showed decreasing ipsilesional SMC activation which was paralleled by an increase in intracortical excitability. This pattern putatively reflects increasing synaptic efficiency. When M1 or its descending pyramidal tract was lesioned (MEP from the affected hand was pathologic) ipsilesional SMC activation increased, accompanied by decreased intracortical excitability. We suggest that an increase in synaptic efficiency is not possible here, which leads to reorganization with extension, shift and recruitment of additional cortical areas of the sensorimotor network. The inverse dynamic process between both complementary methods (activation in fMRI and intracortical excitability determined by TMS) over the time period of CI illustrates the value of combining methods for understanding brain reorganization.
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PMID:Two different reorganization patterns after rehabilitative therapy: an exploratory study with fMRI and TMS. 1651 99

It has been shown on hand muscles in normal subjects that paired associative stimulation (PAS) combining peripheral nerve stimulation and transcranial magnetic stimulation (TMS) induces lasting changes in cortical motor excitability (Stefan et al., Brain 123 (Pt3):572-584, 2000). Because the motor recovery of distal upper limb and particularly wrist extension in post-stroke patients is one of the major rehabilitation challenge, we investigate here the effect of one session of paired associative stimulation on the excitability of the corticospinal projection to extensor carpi radialis (ECR) muscle (motor evoked potential size) before and after PAS in 17 healthy subjects and in two patients 5 months after stroke. The time course, the topographical specificity, changes in rest motor threshold (RMT), short intracortical inhibition and intracortical facilitation (SICI and ICF), the respective role of cutaneous and muscular afferents and the effect of a prolonged peripheral stimulation alone were also studied in normal subjects. Using a protocol derived from that of Ridding et al. J Physiol 537:623-631 (2001), PAS was able to induce lasting changes in the excitability of corticospinal projection to wrist muscles in healthy subjects and in the two post-stroke patients studied. Electrophysiological features of these plastic changes were similar to those previously observed in hand muscles: rapid evolution, 30-60 min duration, reversibility, relative topographical specificity and associative dependence suggesting an LTP-like mechanism. A contribution of cutaneous afferents in inducing PAS effects was also demonstrated. The decrease in ECR RMT after PAS observed in patients and in healthy subjects was an unexpected result because it has not been previously reported in the hand muscles of healthy subjects. However, it has been observed in dystonic patients (Quartarone et al., Brain 126:2586-2596, 2003). This suggests that other mechanisms like changes in membrane excitability could be involved in ECR facilitation after PAS. Further studies performed on patients using daily repeated PAS protocols and showing a functional improvement in hand motor function will be necessary to confirm that this technique could be relevant in motor rehabilitation, at least for some selected patients.
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PMID:Induction of cortical plastic changes in wrist muscles by paired associative stimulation in healthy subjects and post-stroke patients. 1726 41

For neurorehabilitation to advance from art to science, it must become evidence-based. Historically, there has been a dearth of evidence from which to construct rehabilitation interventions that are properly framed, accurately targeted, and credibly measured. In many instances, evidence of treatment response has not been sufficiently robust to demonstrate a change in function that is clinically, statistically, and economically important. Research evidence of activity-dependent central nervous system (CNS) plasticity and the requisite motor learning principles can be used to construct an efficacious motor recovery intervention. Brain plasticity after stroke refers to the regeneration of brain neuronal structures and/or reorganization of the function of neurons. Not only can CNS structure and function change in response to injury, but also, the changes may be modified by "activity". For gait training or upper limb functional training for stroke survivors, the "activity" is motor behavior, including coordination and strengthening exercise and functional training that comprise motor learning. Critical principles of motor learning required for CNS activity-dependent plasticity include: close-to-normal movements, muscle activation driving practice of movement; focused attention, repetition of desired movements, and training specificity. The ultimate goal of rehabilitation is to restore function so that a satisfying quality of life can be experienced. Accurate measurement of dysfunction and its underlying impairments are critical to the development of accurately targeted interventions that are sufficiently robust to produce gains, not only in function, but also in quality of life. The Classification of Functioning, Disability, and Health Model (ICF) model of disablement, put forth by the World Health Organization, can provide not only some guidance in measurement level selection, but also can serve as a guide to incorporate function and quality of life enhancement as the ultimate goals of rehabilitation interventions. Based on the evidence and principles of activity-dependent plasticity and motor learning, we developed gait training and upper limb functional training protocols. Guided by the ICF model, we selected and developed measures with characteristics rendering them most likely to capture change in the targeted aspects of intervention, as well as measures having membership not only in the impairment, but also in the functional or life role participation levels contained in the ICF model. We measured response to innovative gait training using a knee flexion coordination measure, coefficient of coordination consistency (ACC) of relative hip/knee (H/K) movement across multiple steps (H/K ACC), and milestones of participation in life role activities. We measured response to upper limb functional training according to measures designed to quantify functional gains in response to treatment targeted at wrist/hand or shoulder elbow training (Arm Motor Ability Test for wrist/hand (AMAT W/H) or shoulder/elbow (AMAT S/E)). We found that there was a statistically significant advantage for adding FES-IM gait training to an otherwise comparable and comprehensive gait training, according to the following measures: H/K ACC, the measure of consistently executed hip/knee coordination during walking; a specific measure of isolated joint knee flexion coordination; and a measure of multiple coordinated gait components. Further, enhanced gains in gait component coordination were robust enough to result in achievement of milestones in participation in life role activities. In the upper limb functional training study, we found that robotics + motor learning (ROB ML; shoulder/elbow robotics practice plus motor learning) produced a statistically significant gain in AMAT S/E; whereas functional electrical stimulation + motor learning (FES ML) did not. We found that FES ML (wrist/hand FES plus motor learning) produced a statistically significant gain in AMAT W/H; whereas ROB ML did not. These results together, support the phenomenon of training specificity in that the most practiced joint movements improved in comparison to joint movements that were practiced at a lesser intensity and frequency. Both ROB ML and FES ML protocols addressed an array of impairments thought to underlie dysfunction. If we are willing to adhere to the ICF model, we accept the challenge that the goal of rehabilitation is life role participation, with functional improvement as in important intermediary step. The ICF model suggests that we intervene at multiple lower levels (e.g., pathology and impairment) in order to improve the higher levels of function and life role participation. The ICF model also suggests that we measure at each level. Not only can we then understand response to treatment at each level, but also, we can begin to understand relationships between levels (e.g., impairment and function). With the ICF model proffering the challenge of restoring life role participation, it then becomes important to design and test interventions that result in impairment gains sufficiently robust to be reflected in functional activities and further, in life role participation. Fortunately, CNS plasticity and associated motor learning principles can serve well as the basis for generating such interventions. These principles were useful in generating both efficacious gait training and efficacious upper limb functional training interventions. These principles led to the use of therapeutic agents (FES and robotics) so that close-to-normal movements could be practiced. These principles supported the use of specific therapeutic agents (BWSTT, FES, and robotics) so that sufficient movement repetition could be provided. These principles also supported incorporation of functional task practice and the demand of attention to task practice within the intervention. The ICF model provided the challenge to restore function and life role participation. The means to that end was provided by principles of CNS plasticity and motor learning.
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PMID:Construction of efficacious gait and upper limb functional interventions based on brain plasticity evidence and model-based measures for stroke patients. 1816 18

The WHODAS II (World Health Organization Disability Assessment Schedule II) is a questionnaire derived from the ICF classification system (International Classification of Functioning, Disability and Health) for the evaluation of disabilities and handicaps. Data on its validity and reliability with respect to the consequences of stroke are largely lacking. The present study aimed at measurements of reliability of the WHODAS II in its application to stroke patients and their closest others. Eighty-four patient-relative pairs were assessed six months after stroke with the self- and observer-rating versions. From the patients' and relatives' judgements, Cronbach's alpha was computed as measurement of internal consistency, intra-class correlation coefficients as measurements of the inter-rater reliability of subscales and total scores, and Spearman's rho (rho) for the inter-rater reliability for single items. In addition, the inter-rater correspondence was calculated as the percentage of responses. The internal consistency was found to be good to excellent (alpha=0.81-0.99) both for patients' and relatives' judgements. Inter-rater reliabilities ranged from satisfactory for the subscale Understanding and Communication to excellent for the total score (ICC 0.64-0.94). However, the inter-rater reliability of the items as well as their percental correspondence was hardly satisfactory, with few exceptions in the realms of Life Activities and Self-Care (rho=0.24-0.90 and percental correspondence 29.6%-75.7%). Our results demonstrate that the WHODAS II is a reliable instrument for the assessment of stroke patients, both as a self- and an observer-rating questionnaire. Whereas the correspondence between patient and relative may be disparate with respect to single items - especially those not directly observable -, subscale and total scores seem to allow predictions based on observer judgements. The assessment of stroke patients' disabilities and handicaps through relatives' judgements with the WHODAS II scales is reliable.
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PMID:[Use of the WHODAS II with stroke patients and their relatives: reliability and inter-rater-reliability]. 1824 69

The purpose of this study was to identify factors that facilitated or acted as a barrier to return to work (RTW) for stroke survivors. We applied 3 approaches to identify the factors. First, we conducted qualitative interviews with 10 stroke survivors about their RTW experience post stroke. Second, we surveyed 21 vocational specialists about barriers and facilitators of RTW based on their clinical practice. Last, we interviewed 7 employers who had experience in interviewing individuals with disabilities or had the authority to make hiring decisions. Descriptions of barriers and facilitators to RTW from these 3 perspectives were illustrated. Identified components were mapped based on the ICF framework. From stroke survivors' perspectives, factors affecting employment after stroke include neurological (motor, cognition, communication), social, personal, and environmental factors. Vocational specialists described similar barriers and facilitators of RTW as the stroke survivors but emphasized personal factors such as flexibility and being realistic in vocational goals. The employers explained that the candidate's disability plays no role in the hiring process and indicated that all applicants must meet the essential job requirements. Some employers described the benefits of having the support of vocational rehabilitation staff and being able to interact with the vocational rehabilitation specialists during the hiring process. The interaction allows the employer to gather initial information (consented to by the job applicant) about the applicants from the vocational rehabilitation service and to be educated about any specific needs related to the applicant's medical issues.
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PMID:Barriers and facilitators of return to work for individuals with strokes: perspectives of the stroke survivor, vocational specialist, and employer. 2191 97

In the context of developing and testing a procedure for "Outcome-oriented payment for rehabilitation after stroke", we found that the instruments commonly used to measure the outcomes of rehabilitation after stroke (e. g., Barthel-Index or FIM) were not meeting the special requirements of the new payment system. Therefore the "Scores of Independence for Neurologic and Geriatric Rehabilitation" (SINGER) was developed as a new assessment instrument. This instrument is based on the ICF and measures 20 aspects of "independence in activities of daily living". The characteristic feature of the SINGER is, above all, the way all items are graded in 6 steps: the gradation does not refer to the degree of disability but to the kind and amount of help required for the respective activity, i. e.: 0 = totally dependent on professional help; 1 = professional contact help needed; 2 = contact help by (instructed) lay persons sufficient; 3 = preparation or supervision by lay persons still needed; 4 = independent with assistive device or still slow; 5 = independent without assistive device. For experienced personnel in neurologic rehabilitation, these gradations are "intuitively plausible". A manual moreover describes each grade in detail for each item so that the instrument can be used in rehabilitation facilities without extensive training. The SINGER has been tested and validated in a pilot study (n = 100) and in 2 subsequent studies with large case numbers in neurologic rehabilitation (n = 1058 and n = 700 patients after stroke in all categories of severity). Factor analyses showed that the instrument contains 2 dimensions which can be interpreted as "physical activities" and "activities of communication and cognition". Each of these 2 dimensions can be split into 2 sub-dimensions that can be assigned to the tasks of therapeutical professions in care/Occupational Therapy, physiotherapy, logopedics, and neuro- psychology. The test criteria of reliability, sensitivity, convergent validity, floor and ceiling effects as well as sensitivity to change show good to very good results. Particular emphasis can be given to the high degree of interrater reliability and the wide range of possible applications in clinical practice as well as in research. A limitation of the instrument to be taken into account is the fact that the SINGER has not yet been tested and validated in geriatric rehabilitation facilities.
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PMID:["Scores of Independence for Neurologic and Geriatric Rehabilitation (SINGER)" - development and validation of a new assessment instrument]. 2247 80


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