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VA Telerehab Program Improves Post-Stroke Functioning

by U.S. Medicine

October 11, 2012

Participating in a home telerehabilitation program improves lower-body physical functioning after a stroke, as well as increasing the likelihood of maintaining a regular fitness routine, enhancing money-management skills and improving the capability to prepare meals and take care of personal needs such as bathing, according to a recent study.1

The program, called STeleR, was developed by Neale Chumbler PhD, a research scientist with the Center of Excellence on Implementing Evidence-Based Practice at the Richard Roudebush VAMC, Indianapolis. A report on its effectiveness was published in the August issue of the journal Stroke.

“We know that post-stroke rehab is critically important,” Chumbler said. “But for many veterans and others who experience a stroke, participating in supervised rehab can be difficult because they live far from a rehab facility. Even if distance isn’t an impediment, getting someone to provide transportation may not be easy. Providing rehab in the home is costly, and the availability of qualified physical or occupational therapists may be limited, particularly in rural areas.

“We found that stroke survivors will participate in and can benefit from a telehealth system that enables therapists to deliver and monitor rehab in the patient’s home from a remote location.”

The 52 veterans in the multi-site study — predominantly male, ethnically diverse and averaging 67 years old — received care from VA medical centers in Atlanta, Durham, NC, and Tampa, FL. The study participants, who had suffered an ischemic or hemorrhagic stroke within the previous two years and were community-based, were randomized to either usual care or stroke telerehab (STeleR). All received routine VA care.

Those in the intervention group received three hourlong visits where researchers used a camcorder to record physical and functional performance, discussed the home environment with the stroke survivor and installed an in-home messaging device. Over a three-month period, the device was monitored weekly by a teletherapist, who also participated in bi-weekly calls with patients.

The authors noted that, while most of the gains in physical functioning and other improvements occurred during the initial three months of the study, most also were maintained during the subsequent three months during which no STeleR services were provided.

“STeleR has potential to be a useful supplement to traditional post-stroke rehabilitation, given the limited resources available for in-home rehabilitation for stroke survivors,” Chumbler said. “STeleR or a similar telehealth program could be an important way to overcome access barriers and may be particularly useful for reaching vulnerable patient groups, such as individuals from a lower socioeconomic status and those who live in a rural area.”

Another recent study found that, in general, rural VA patients were less likely to receive post-acute stroke rehabilitant therapy than those who live in urban areas.2

That retrospective study, conducted by the Rehabilitation Outcomes Research Center at the North Florida/South Georgia Veterans Health System in Gainesville, FL, looked at all VA stroke inpatients in 2001 and 2002 to determine rehab therapy received within 12 months after their hospitalization for stroke.

It determined that, among the 8,296 stroke patients, the rural and/or isolated/highly rural patients were significantly more likely to be older, white, married, living further from the VA hospitals, not hospitalized for stroke directly from home and not intubated, compared with their urban counterpoints.

Researchers also determined that, compared with the rural patients, the odds of receiving rehabilitation therapy were slightly greater for urban patients but much less likely for the highly rural patients.

1. Chumbler NR, Quigley P, Li X, Morey M, Rose D, Sanford J, Griffiths P, Hoenig
H. Effects of telerehabilitation on physical function and disability for stroke
patients: a randomized, controlled trial. Stroke. 2012 Aug;43(8):2168-74. Epub

2. Jia H, Cowper DC, Tang Y, Litt E, Wilson L. Postacute stroke rehabilitation utilization: are there differences between rural-urban patients and taxonomies? J Rural Health. 2012 Jun;28(3):242-7. doi: 10.1111/j.1748-0361.2011.00397.x. Epub 2011 Oct 21. PubMed PMID: 22757948.

Aspirin May Not Protect Against Blood Clots in Diabetics

Popping an aspirin every day may not be as protective against blood clots for patients with type 2 diabetes, according to a study out of the Stratton VAMC in Albany.1

The study was presented this past summer at The Endocrine Society’s 94th Annual Meeting in Houston. It involved 142 male patients with type 2 diabetes, averaging 48-years-old at Overton Brooks VAMC in Shreveport, LA, between 2006 and 2009.

“This result adds to our understanding of the prevalence of this problem, which varies considerably among studies,” said lead author Subhashini Yaturu MD, section chief of the endocrinology and metabolism Department at the Stratton VAMC, Albany, NY. “The standard baby aspirin may not be adequate for subjects with diabetes for cardiovascular protection.”

While low doses of aspirin are considered routine treatment for prevention of dangerous blood clots and is recommended for patients with diabetes and other high-risk medical conditions, some patients are resistant to aspirin’s anti-clotting effects. By testing urine samples, this resistance can be identified by measuring the level of a particular chemical called 11-dehydro-thromboxane beta-2, or 11DhTx2, which is formed during the clotting process.

In this clinical study, researchers found 53% study participants with type 2 diabetes were aspirin-resistant. They also found that longer duration of diabetes led to greater 11DhTx2 levels and increased urinary levels of microalbumin, an indicator of early kidney disease. Concentrations of 11DhTx2 were not associated with insulin levels, insulin resistance or certain markers of inflammation, however.

Interestingly, patients with relatively higher blood-pressure readings and a greater waist circumference had lower 11DhTx2 measurements compared with other patients, Yaturu pointed out.

“These results provide new information about the factors associated with aspirin resistance,” Yaturu said. “This may help doctors identify people who are likely to be aspirin-resistant, so that higher doses or different drugs can be prescribed to prevent blood clots. Further studies are required to clarify the appropriate dose of aspirin and or other therapies for subjects with diabetes to prevent clots.”

1. Yaturu, S, Dier, E, Mousa, S, et al. “Aspirin Resistance in Young Men With Type 2 Diabetes” The Endocrine Society, Houston June 23-26

VA Telerehab Program Improves Post-Stroke Functioning

Combining Natural Agent With Rehab Helps Stroke Victims

A neurovascular protective agent found naturally in the body combined with physical activity improved recovery from stroke in a rat model, according to research from the Medical University of South Carolina and the Ralph H. Johnson VAMC, both in Charleston.

The animal study, published recently in the journal Restorative Neurology and Neuroscience, found that a therapy combining exercise with the neurovascular protective agent S-nitrosoglutathione (GSNO), which has no known side effects or toxicity.1

“In our study, GSNO or motor exercise provided neuroprotection, reduced neuronal cell death, maintained tissue structure and aided functional recovery by stimulating the expression of neuronal repair mediators,” said lead investigator Avtar K. Singh MD. “GSNO in combination with exercise accelerated the rate and enhanced the degree of recovery.”

While stroke’s acute phase is associated with cell death and secondary injury, the chronic phase is characterized by insufficient neurorepair mechanisms, according to the study. It pointed out that monotherapies fail because of ineffectiveness of drugs in the chronic phase and that rehabilitation, used to improve neurofunction in the chronic phase, is effective but slow and limited.

The goal of the research was to find a therapy to ameliorate the injury in both phases, including a combination of rehabilitation and an agent that provides both neuroprotection and repair.

Singh and her colleagues induced stroke in rats, which were then assigned to one of five treatment groups:

  • The first group received no treatment;
  • the second group was treated with exercise, i.e., running at a constant speed for 20 minutes a day;
  • the third group was treated with GSNO;
  • the fourth group received both exercise and GSNO treatment; and
  • the fifth group received a sham treatment.

Animals in each group were evaluated for neurological function, motor behavior and locomotor function before and after the procedure. In addition, the size of the infarct was measured and, at 7 and 14 days after stroke was induced, brain-tissue samples were removed and tested.

Researchers found that administration of GSNO not only reduced brain injury but also improved neurological scores. While exercise alone began too late to reduce infarct volume, it improved neurobehavioral functions. Adding GSNO created a synergistic effect, providing greater functional improvement than either GSNO or exercise alone, the authors said.

“GSNO is an attractive candidate to be investigated in humans for neurorepair and rehabilitation following stroke,” Singh said.

Back to October Articles

  1. Sakakima H, Khan M, Dhammu TS, Shunmugavel A, Yoshida Y, Singh I, Singh AK. Stimulation of functional recovery via the mechanisms of neurorepair by S-nitrosoglutathione and motor exercise in a rat model of transient cerebral ischemia and reperfusion. Restor Neurol Neurosci. 2012 Jun 20. [Epub ahead of print] PubMed PMID: 22717646.

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