Carotid doppler study compared with carotid angiography in patients with symptomatic carotid artery stenosis

Abstracts would complicate scoring by trial investigators and would affect interrater reliability in stroke trials. Purpose: To determine how many stroke patients fit the clinical patterns described in the MRS. Methods: Data from 100 consecutive stroke patients discharged from a rehabilitation service were prospectively collected; 97 patients were included. We used the Functional Independence Measure (FIM) to rate patients on each function explicitly described in the MRS. Using a computerized algorithm, we determined how many patients matched the functional categories described by the MRS. Patients were also given a discharge MRS score by their attending neurologist. Results: Only 27 patients could be classified into an MRS category using the FIM item algorithm. Of the 91 patients scored by the neurologist as Rankin levels 2 through 4, 69 could not be classified in any Rankin level using FIM data. Conclusions: Our data suggests that most moderately disabled stroke patients do not fit any of the clinical descriptions included in the MRS. Since patients who are moderately affected are most likely to be recruited into trials and may potentially benefit most from interventions, it is essential that measures used to evaluate this population be effective. Further modifications of the MRS or use of alternative disability measures may be desirable in future stroke trials.

Incorporation of an Attention-Based Model of Hemispatial Neglect in Cognitive Rehabilitation of CVA. Judith Hutchinson and April Wood (St. David's Rehabilitation Centel, Austin, TX) Patients with focal right-hemisphere CVA typically demonstrate relatively intact linguistic performance and verbal IQ, an appearance of unimpaired cognition, and apparent potential for good outcome based on these cognitive factors. In fact, however, right-hemisphere patients tend to have poor outcomes, particularly in terms of safety and independence, due to the prevalence of significant impairments in attention and the presence of hemispatial neglect. The presence and severity of hemi-spatial neglect is highly correlated with the rehabilitation success and ultimate independence level of CVA patients. Experimental data, neuroanatomical evidence, and clinical correlations have led to proposal of an attention-based model of the neglect syndrome. This model in turn suggests a treatment approach focused on rehabilitation of underlying attention deficits, environmental modification to maximize attention, and utilization of compensatory strategies compatible with the underlying attention deficit. This presentation summarizes the foundations of the attention-based model of neglect, discussed appropriate assessment of attention and neglect, and presents recommendations for attention-based neglect treatment.

145 Clinical Test of Robot-aided Stroke Rehabilitation. Hermano Krebs and Neville Hogan (Massachusetts hlstitute of Technology, Cambridge, MA) Mindy Aisen and Bruce Volpe (The Burke Institute for Medical Research, White Plains, NY) We are investigating the application of robot technology to assist in stroke rehabilitation. A pilot clinical trial was conducted at the Burke Rehabilitation Hospital both to evaluate the safety, acceptability, and effectiveness of robot-aided neurorehabilitation and to further our understanding of the process of post-traumatic recovery of sensory-motor function. The study used a novel robot designed for clinical neurological applications. It is capable of stable and compliant operation in close contact with disabled patients and can move, guide or perturb the movement of a patient's upper limb while measuring limb motions and other mechanical quantities. The clinical trial involved 20 patients recruited from the same hospital ward, and assigned to the same team of rehabilitation professionals. Half were enrolled in a robotaided therapy group and the other half in a control group. Both groups received conventional therapy, but the experimental group received an additional 5 h per week of robot-aided therapy consisting of peripheral manipulation of the impaired limb correlated with audio-visual stimuli. All the patients received a standardized clinical assessment and a robot-aided evaluation. No adverse events occurred in an estimated 500 hours of operation in close contact with patients. A questionnaire administered by the therapists showed that robotassisted therapy was well accepted. In this limited pool of patients, robot-assisted therapy did influence recovery of selected patients. Kinematic analysis of post-traumatic sensory-motor behavior suggested that the movements were accomplished using a sequence of segments, each with a bell-shaped velocity profile. As recovery progressed, these segments appeared more overlapped and blended, resembling the motion of unimpaired subject. These preliminary results suggest that robotics and automation technology may be a promising new tool for neurological diagnostic and rehabilitation.

Carotid Doppler Study Compared With Carotid Angiography in Patients With Symptomatic Carotid Artery Stenosis. Srinivas Koneru (VA Medical Centre, WilkesBarre, PA) Duplex ultrasonography is frequently used for noninvasive screening for extra cranial occlusive disease. In this study the duplex ultrasound examination is compared with conventional angiographic findings in 51 patients who had both these studies. Methods: Men presenting with symptoms consistent with TIA, transient monocular blindness, small strokes

146 underwent rigorous screening. Of the total patients who had carotid doppler studies, we took the patients who had carotid artery stenosis and subsequently underwent for carotid angiography. A comparison is made in each stenosis range between the local determination of angiogram and the duplex scan for all patients. Discussion: Traditionally noninvasive measurements of extra cranial stenosis have been compared with conventional cerebral angiography. The accuracy of duple study may be affected by several factors, including plaque asymmetry, low velocities, patient motion, extension of lesion and experience of sonographer. Whereas variations in the interpretation for determining stenosis have occurred between readers with conventional angiography. At present duplex ultrasonography remains the most practical noninvasive test for atheromatous cervical stenosis and recent advances in sonographic technology, e.g. color-coded doppler, may further improve duplex ultrasound accuracy. However, duplex ultrasonography alone may not be valid method on which to base clinical decisions regarding patients with carotid artery atherosclerotic disease.

Transdisciplinary Treatment in Acute Stroke Rehabilitation. Kevin Pallone, Renee Hinson, and Allan Ribbler (Holy Cross Hospital, Fort Lauderdale, FL) It is accepted that acute stroke rehabilitation requires a team approach. That the team includes specialists from rehabilitation medicine, physical, occupational and speech therapy, psychology and neuropsychology, rehabilitation nursing and social work is also agreed upon. However, the nature of team interaction is less constant as one observes various rehabilitation settings. The continuum ranges from discipline/program centered multidisciplinary teams with minimal crossing of disciplinary boundaries to interdisciplinary teams with somewhat more sharing of treatment goals, to patient-focused transdisciplinary teams with shared goals and liberal crossing of disciplinary boundaries. The current paper presents the process of moving from a more traditional treatment model to a patient-centered transdisciplinary model. The rationale for using this model is present and emphasizes patient involvement in treatment and goal-setting (Haig, A.J., 1994, Archives of P. M. & R.), focus on functional goals, increasing team cohesiveness and interprofessional relations (Strasser, D.C., 1994, Archives of P. M. & R.) and the value of consistency across treatment sessions which is so important for physically and cognitively impaired persons. Cases are presented to represent both traditional and transdisciplinary models.

Time From Stroke Onset to Arrival in the Hospital. Jeffery L. Saver, Askiel Bruno, Edward Feldmann, Richard

Abstracts B. Libman, Mark Hansen, Karla Grimsman, Harold P. Adams Jr., and the TOAST investigators, a Multicenter Clinical Trial To enhance public stroke awareness, the factors associated with delayed arrival in the hospital after onset of symptoms need to be identified and studied. Methods: We analyzed data on 591 patients enrolled in a multicenter acute ischemic stroke treatment trial TOAST, whose stroke occurred during wakefulness. Results: Mean time from stroke onset to arrival in the hospital for strokes occurring between midnight and 6:00 AM was 6.2 hours, between 6:01 AM and noon was 5.0 hours, between 12:01 PM and 6:00 PM was 6.5 hours, and between 6:01 PM and midnight was 7.7 hours (P = 0.02); for white patients was 6.6 hours and for non-white patients was 5.6 hours (P = 0.02); for patients with TIA history was 5.1 hours and without TIA history was 6.4 hours (P = 0.02); for patients with admission NIH stroke score <:6 was 7.1 hours and with a score of >6 was 5.6 hours (P <: 0.001). Age, gender, history of stroke, cardioembolic vs. non-cardioembolic stroke, side of brain involved, or the geographic location of a hospital did not significantly affect the time to arrival. Conclusion: Factors associated with a significantly longer time from stroke onset to arrival in the hospital include stroke occurrence between 6:01 PM and midnight, white race, absence of TIA history, and a mild initial neurologic deficit.

A Transdisciplinary Approach to Improving Urinary Incontinence in Long-Term Care Settings. Leigh Ann Black (NovaCare) Current statistics estimate the economic impact of incontinence to be greater than 10 billion dollars annually and that greater than 50% of all long-term care placements can be attributed to incontinence. When stroke patients experience complications related to urinary incontinence, slower recovery and an increased burden of care can result. This paper presents a transdisciplinary incontinence program that enhances functional independence and integrates skilled physical therapy interventions with nursing management techniques. The program uses noninvasive technology, such as pelvic floor musculature retraining, as well as physical agent modalities to reduce urinary incontinence in the long-term care environment. Using case studies, four classifications of urinary incontinence and relevant treatment options for each will be discussed. Strategies for collaboration with nursing personnel to ensure carryover and patient compliance will be presented. Learning Objectives At the end of this session participants will be able to: Discuss the goals and benefits of a transdisciplinary