Author Identifier

Jessica Nolan

https://orcid.org/0000-0001-5802-2120

Date of Award

2023

Document Type

Thesis - ECU Access Only

Publisher

Edith Cowan University

Degree Name

Doctor of Philosophy

School

School of Medical and Health Sciences

First Supervisor

Barbara Singer

Second Supervisor

Erin Godecke

Third Supervisor

Angela Jacques

Abstract

Background:

Post-stroke lateropulsion is prevalent. A person with lateropulsion actively pushes their body across the midline toward their more affected side and/or actively resists weight shift toward the less affected side.

Aims:

The objectives of this thesis were to; investigate outcomes associated with post-stroke lateropulsion; understand short- and long-term rehabilitation needs of affected people; and provide recommendations for rehabilitation best-practice.

This thesis aimed to:

  • Determine the association of lateropulsion severity (Four Point Pusher Score: 4PPS), with functional change (Functional Independence Measure: FIM) and length of stay (LOS) in inpatient rehabilitation;
  • Investigate accuracy of the Australian National Sub-Acute and Non-Acute Patient Classification (AN-SNAP) funding model to predict LOS for people with post-stroke lateropulsion;
  • Explore associations between 4PPS, mobility status, adverse event occurrence, and FIM at three, six, nine and twelve months post-stroke;
  • Explore associations between lateropulsion presence and aspects of stroke pathology, derived from neuroimaging data; and
  • Develop international consensus on lateropulsion terminology, best-practice rehabilitation, and future research priorities.

Methods:

This research comprised three sections:

Section 1. Retrospective outcome data (4PPS, FIM, and LOS) for 1,087 participants admitted to a stroke rehabilitation unit (SRU) were analysed. Individual comparisons were made between AN-SNAP-predicted and actual LOS.

Section 2. The prospective longitudinal cohort study included 144 consecutive SRU admissions. Acute stroke imaging results were coded based on consensus from two neuroradiologists. Lateropulsion severity, FIM, mobility status, and adverse event occurrence were recorded at SRU admission, discharge and three, six, nine and twelve months post-stroke and tested for association with lateropulsion resolution.

Section 3. A Delphi Panel Process addressed lateropulsion terminology, best-practice rehabilitation, and research priorities. The process included four survey rounds. Round One consisted of 13 open questions. Subsequent rounds ascertained levels of agreement with statements derived from Round One.

Results:

Section 1. Complete lateropulsion resolution was recorded in 69.4% of those admitted with mild lateropulsion, 49.3% of those with moderate lateropulsion, and 18.8% of those with severe lateropulsion. Average FIM change was lower in those admitted with severe lateropulsion than those without lateropulsion (p < 0.001). Higher admission 4PPS was associated with reduced FIM efficiency (p < 0.001), longer LOS (p < 0.001), and reduced likelihood of discharge home (p < 0.001). Reported LOS exceeding AN-SNAP-predicted LOS was associated with greater admission lateropulsion severity. Greater FIM improvement was associated with reported LOS exceeding AN-SNAP-predicted LOS (p < 0.001).

Section 2. Eighty-two participants (56.9%) had lateropulsion on admission. Stroke lesion volume was not associated with lateropulsion presence or resolution. Haemorrhagic stroke was associated with lateropulsion presence (p=0.002) and long-term persistence (p=0.015). Odds of resolved lateropulsion increased longitudinally from discharge for people who participated in rehabilitation-focused physiotherapy (p < 0.001).

Section 3. Twenty international experts completed four rounds of the process. There was ‘some agreement’ (50%) that ‘lateropulsion’ was the recommended term to describe the condition. Consensus ( ≥ 75% agreement) was achieved regarding 119 rehabilitation recommendations.

Conclusions:

Given a sufficient duration of skilled rehabilitation, people with post-stroke lateropulsion can achieve meaningful short- and long-term improvements. The consensus-based recommendations provide guidance in selecting rehabilitation approaches that will likely facilitate the best possible outcomes in people with post-stroke lateropulsion.

DOI

10.25958/smv6-k102

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