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Joel Stein

Publications and source records attributed to Joel Stein.

At least 19 recordsLinked to original sources

Differential transcriptional response to nonassociative and associative components of classical fear conditioning in the amygdala and hippocampus.

Classical fear conditioning requires the recognition of conditioned stimuli (CS) and the association of the CS with an aversive stimulus. We used Affymetrix oligonucleotide microarrays to characterize changes in gene expression compared to naive mice in both the amygdala and the hippocampus 30 min after classical fear conditioning and 30 min after exposure to the CS in the absence of an aversive stimulus. We found that in the hippocampus, levels of gene regulation induced by classical fear conditioning were not significantly greater than those induced by CS alone, whereas in the amygdala, classical fear conditioning did induce significantly greater levels of gene regulation compared to the CS. Computational studies suggest that transcriptional changes in the hippocampus and amygdala are mediated by large and overlapping but distinct combinations of molecular events. Our results demonstrate that an increase in gene regulation in the amygdala was partially correlated to associative learning and partially correlated to nonassociative components of the task, while gene regulation in the hippocampus was correlated to nonassociative components of classical fear conditioning, including configural learning.

Amygdala↗

Noise-enhanced balance control in patients with diabetes and patients with stroke.

OBJECTIVE: Somatosensory function declines with diabetic neuropathy and often with stroke, resulting in diminished motor performance. Recently, it has been shown that input noise can enhance human sensorimotor function. The goal of this study was to investigate whether subsensory mechanical noise applied to the soles of the feet via vibrating insoles can be used to improve quiet-standing balance control in 15 patients with diabetic neuropathy and 15 patients with stroke. Sway data of 12 healthy elderly subjects from a previous study on vibrating insoles were added for comparison. METHODS: Five traditional sway parameters and three sway parameters from random-walk analysis were computed for each trial (no noise or noise). RESULTS: Application of noise resulted in a statistically significant reduction in each of the eight sway parameters in the subjects with diabetic neuropathy, the subjects with stroke, and the elderly subjects. We also found that higher levels of baseline postural sway in sensory-impaired individuals was correlated with greater improvements in balance control with input noise. INTERPRETATION: This work indicates that noise-based devices could ameliorate diabetic and stroke impairments in balance control.

Adult↗

Determination of the minimal clinically important difference in the FIM instrument in patients with stroke.

OBJECTIVE: To define the minimal clinically important difference (MCID) for the FIM instrument in patients poststroke. DESIGN: Prospective case series discharged over a 9-month period. SETTING: Long-term acute care hospital. PARTICIPANTS: Patients with stroke (N=113). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Admission, discharge, and change scores were calculated for the total FIM, motor FIM, and cognitive FIM. Assessments of clinical change were rated at discharge on a 15-point (-7 to +7) Likert scale by attending physicians, with MCID defined at a cutoff score of 3. The FIM change scores associated with MCID were identified from receiver operating characteristic curves. Bayesian analysis was used to determine the probability of individual patients achieving MCID. RESULTS: FIM change scores associated with MCID were 22, 17, and 3 for the total FIM, motor FIM, and cognitive FIM, respectively. The accuracy of the MCID was greater when subjects were categorized based on admission FIM scores than when considering the sample as a whole. Larger FIM change scores were related to MCID in subjects with lower admission FIM scores. CONCLUSIONS: These findings will assist in the interpretation of FIM change scores relative to physicians' assessments of important clinical change.

Activities of Daily Living↗

Near-infrared spectroscopy and imaging for investigating stroke rehabilitation: test-retest reliability and review of the literature.

OBJECTIVES: To review the use of near-infrared spectroscopy (NIRS) in stroke rehabilitation and to evaluate NIRS test-retest reliability within-session on a motor control task commonly used in neuroimaging of stroke recovery. DESIGN: Cohort study. SETTING: Hospital-based research laboratory. PARTICIPANTS: Nineteen healthy control subjects (age range, 22-55y). INTERVENTIONS: Subjects performed 2 experimental runs of a finger-opposition task in a block-design paradigm (finger opposition alternated with a fixation rest period) while undergoing multichannel NIRS and physiologic monitoring. MAIN OUTCOME MEASURE: Reliability coefficients (Pearson r) for oxyhemoglobin (O(2)Hb) and deoxyhemoglobin (HHb) correlated amplitude modulations across measurement channels during individual blocks and block averages. RESULTS: Correlations between single blocks (ie, 16-s slices of data) exhibited a correlation intercept of .33+/-.09 for O(2)Hb. This value was minimally decreased by increasing lag between compared blocks (slope, -.012; P=.019) but was substantially enhanced by averaging across blocks (within-run slope, .11; between-run slope, .044). Correlations using 64 seconds of data reached 0.6. Results for HHb were virtually identical. CONCLUSIONS: NIRS modulations were repeatable even when comparing very short segments of data. When averaging longer data segments, the test-retest correspondences compared favorably to neuroimaging using other modalities. This suggests that NIRS is a reliable tool for longitudinal stroke rehabilitation and recovery studies.

Adult↗

Failure to achieve assent in a communicative patient: what are the caregiver's obligations?

Disclosure of facts related to an individual's health care, including level and location of care, are central to the fulfillment of informed consent. When an individual is unable to provide informed consent because they lack the decision-making capacity to process the information and/or they have been deemed legally incompetent, the health care team should obtain assent from the individual whenever possible. Questions remain as to how to proceed when assent cannot be gained and the decision involved causes a level of distress for the individual that is difficult to resolve. A focus on maintaining hope and support with a clear transition and follow-up plan are important variables to consider for an ethical, caring response.

Aged↗

Is informed consent a "yes or no" response? Enhancing the shared decision-making process for persons with aphasia.

Respect for patient autonomy and the need to have a comprehensive discussion of the risks and benefits of a medical intervention are two important issues involved in the process of obtaining informed consent. In dealing with individuals with aphasia, there may be particular challenges in balancing these two ethical imperatives. Although decision-making capacity may be preserved with aphasia, the patients' ability to fully participate in a dialogue regarding a proposed medical intervention is frequently impaired. We propose a process of enhancing informed consent for persons with aphasia while continuing to respect and enhance patient autonomy and the exercise of decision making for these patients. The use of a patient-selected "helper" during the informed consent process can improve the quality of the informed consent, while reserving final decision-making authority for the patient.

Aphasia↗

Predictors of survival after severe dysphagic stroke.

BACKGROUND AND PURPOSE: Dysphagia is estimated to occur in up to 50% of the stroke neurorehabilitation population. Those patients with severe neurogenic oropharyngeal dysphagia (NOD) may receive feeding gastrostomy tubes (FGT) if noninvasive therapies prove ineffective in eliminating aspiration or sustaining adequate nutritional intake. Our aim was to quantify the recovery of swallowing function, and to identify variables predictive of survival after dysphagic stroke requiring FGT placement. METHODS: We identified consecutive stroke patients with severe dysphagic stroke requiring FGT placement admitted to a rehabilitation hospital between May 1998 and October 2001. The medical records were reviewed, and demographic, clinical, videofluoroscopic (VSS) and neuroimaging information were abstracted. A follow-up telephone interview was performed to determine whether the FGT was still in use, had been removed,or if the patient had died. State death certificate records were reviewed to ascertain date of death for subjects who had expired by the time of follow-up. Univariate and multivariate analyses were performed. RESULTS: 11.6 % (77/664) of stroke patients admitted during the study period had severe dysphagic stroke with FGT insertion. Follow-up was available for 66 (85.7 %) of these individuals at a mean of two years after acute stroke. On follow-up 64% (42/66) of the patients were alive and 45 % had had the FGT removed and resumed oral diets. On univariate analysis patients who were alive at the time of follow-up had received FGT feeding for a shorter period of time (p < 0.0003), showed no signs of aspiration on the Clinical Assessment of Feeding & Swallowing (CAFS,p < 0.020) and on the Videofluoroscopic Swallowing Study (VSS, 0.001), had a better discharge FIM-Score (Functional Independence Measure) for eating (p < 0.0002) and cognitive function (p < 0.002) as well as better discharge FCM-Score (Functional Communication Measure) for swallowing (p < 0.0001). On multivariate analysis we developed a model consisting of FGT removal at discharge from the rehabilitation hospital (p < 0.011) and non-aspiration during VSS (p < 0.040) that was significantly associated with longer survival time during follow-up. CONCLUSIONS: Severe dysphagia requiring FGT is common in patients with stroke referred for neurorehabilitation. Patients who had a FGT in place at the time of discharge from the stroke rehabilitation unit or aspirated during VSS were substantially more likely to have died by the time of follow-up compared to those who had had the FGT removed and had no signs of aspiration on VSS. However functional outcome measurements (FIM, FCM) including the cognitive function (attention, concentration etc.) could play an important role for prediction of swallowing regeneration and survival in neurorehabilitation. These findings may have practical utility in guiding physicians and speech language pathologists when advising patients and families about prognosis in stroke survivors with severe dysphagia.

Aged↗

Acupuncture for upper-extremity rehabilitation in chronic stroke: a randomized sham-controlled study.

OBJECTIVE: To compare the effects of traditional Chinese acupuncture with sham acupuncture on upper-extremity (UE) function and quality of life (QOL) in patients with chronic hemiparesis from stroke. DESIGN: A prospective, sham-controlled, randomized controlled trial (RCT). SETTING: Patients recruited through a hospital stroke rehabilitation program. PARTICIPANTS: Thirty-three subjects who incurred a stroke 0.8 to 24 years previously and had moderate to severe UE functional impairment. INTERVENTIONS: Active acupuncture tailored to traditional Chinese medicine diagnoses, including electroacupuncture, or sham acupuncture. Up to 20 treatment sessions (mean, 16.9) over a mean of 10.5 weeks. MAIN OUTCOME MEASURES: UE motor function, spasticity, grip strength, range of motion (ROM), activities of daily living, QOL, and mood. All outcomes were measured at baseline and after treatment. RESULTS: Intention-to-treat (ITT) analyses found no statistically significant differences in outcomes between active and sham acupuncture groups. Analyses of protocol-compliant subjects revealed significant improvement in wrist spasticity (P<.01) and both wrist (P<.01) and shoulder (P<.01) ROM in the active acupuncture group, and improvement trends in UE motor function (P=.09) and digit ROM (P=.06). CONCLUSIONS: Based on ITT analyses, we conclude that acupuncture does not improve UE function or QOL in patients with chronic stroke symptoms. However, gains in UE function observed in protocol-compliant subjects suggest traditional Chinese acupuncture may help patients with chronic stroke symptoms. These results must be interpreted cautiously because of small sample sizes and multiple, unadjusted, post hoc comparisons. A larger, more definitive RCT using a similar design is feasible and warranted.

Activities of Daily Living↗

Clinical characteristics and rehabilitation outcomes of patients with posterior cerebral artery stroke.

OBJECTIVES: To describe the demographics, clinical profile, and functional outcomes in posterior cerebral artery (PCA) stroke and to identify factors associated with functional change during rehabilitation and discharge disposition. DESIGN: Retrospective study of patients with PCA stroke admitted to a rehabilitation hospital over an 8-year period. SETTING: Free-standing urban rehabilitation hospital in the United States. PARTICIPANTS: Eighty-nine consecutive patients with PCA stroke (48 men, 41 women; mean age, 71.5y) met inclusion criteria. INTERVENTION: Inpatient multidisciplinary comprehensive rehabilitation program. MAIN OUTCOME MEASURES: Demographic, clinical, and discharge disposition information were collected. Functional status was measured using the FIM instrument, recorded at admission and discharge. The main outcome measures were the discharge total FIM score, the change in total FIM score (DeltaFIM), and the discharge disposition. Multiple and logistic regression analyses were performed to identify factors associated with the main outcome measures. RESULTS: The most common impairments were motor paresis (65%), followed by visual field defects (54%) and confusion or agitation (43%). The mean discharge total FIM score +/- standard deviation was 88.3+/-28.2. The mean DeltaFIM was 23.3+/-16.4. Fifty-five (62%) patients were discharged home. On multiple regression analysis, higher admission total FIM score, longer length of stay (LOS), and a rehabilitation stay free of interruptions were associated with higher discharge total FIM score and greater DeltaFIM. Absence of diabetes mellitus and younger age were also associated with higher discharge total FIM scores, and male sex had greater DeltaFIM. On logistic regression analysis, younger patients, higher discharge FIM scores, presence of a caregiver, and the nonnecessity for 24-hour support were associated with a discharge to home. CONCLUSIONS: Motor, visual, and cognitive impairments are common in PCA stroke, and good functional gains are achievable after comprehensive rehabilitation. Higher admission FIM scores, longer LOS, and younger and male patients were associated with better functional outcomes. Most patients were discharged home, particularly those with caregivers and those for whom 24-hour support was not required. Further research should aim at the development of functional outcome measures of greater breadth and sensitivity to visual and cognitive deficits and should compare PCA stroke outcomes with outcomes of strokes in other vascular territories.

Aged↗

High-intensity resistance training improves muscle strength, self-reported function, and disability in long-term stroke survivors.

BACKGROUND AND PURPOSE: To evaluate the efficacy of supervised high-intensity progressive resistance training (PRT) on lower extremity strength, function, and disability in older, long-term stroke survivors. METHODS: Forty-two volunteers aged 50 years and above, 6 months to 6 years after a single mild to moderate stroke, were randomized into either a control group of upper extremity stretching or a PRT group that received a 12-week supervised high-intensity resistance training program consisting of bilateral leg press (LP), unilateral paretic and nonparetic knee extension (KE), ankle dorsiflexion (DF), and plantarflexion (PF) exercises. Functional performance was assessed using the 6-minute walk, stair-climb time, repeated chair-rise time, and habitual and maximal gait velocities. Self-reported changes in function and disability were evaluated using the Late Life Function and Disability Instrument (LLFDI). RESULTS: Single-repetition maximum strength significantly improved in the PRT group for LP (16.2%), paretic KE (31.4%), and nonparetic KE (38.2%) with no change in the control group. Paretic ankle DF (66.7% versus -24.0%), paretic ankle PF (35.5% versus -20.3%), and nonparetic ankle PF (14.7% versus -13.8%) significantly improved in the PRT group compared with the control. The PRT group showed significant improvement in self-reported function and disability with no change in the control. There was no significant difference between groups for any performance-based measure of function. CONCLUSIONS: High-intensity PRT improves both paretic and nonparetic lower extremity strength after stroke, and results in reductions in functional limitations and disability.

Aged↗

Robotic therapy for chronic motor impairments after stroke: Follow-up results.

OBJECTIVES: To study the effects of robotic rehabilitation in persons with chronic motor impairments after stroke and to examine whether improvements in motor abilities were sustained 4 months after the end of therapy. DESIGN: Pretest-posttest design. SETTING: Rehabilitation hospital, outpatient care. PARTICIPANTS: Volunteer sample of 42 persons with persistent hemiparesis from a single, unilateral stroke within the past 1 to 5 years. INTERVENTION: Robotic therapy for the paretic upper limb consisted of either sensorimotor active-assistive exercise, or progressive-resistive training during repetitive, planar reaching tasks, 3 times a week for 6 weeks. MAIN OUTCOME MEASURES: Modified Ashworth Scale, Fugl-Meyer Assessment (FMA), Motor Status Scale (MSS) score, and Medical Research Council motor power score. RESULTS: No significant differences were found among pretreatment clinical evaluations. Statistically significant gains from admission to discharge and from admission to follow-up (P<.05) were found on the FMA, MSS score for shoulder and elbow, and motor power score. CONCLUSIONS: Short-term, goal-directed robotic therapy can significantly improve motor abilities of the exercised limb segments in persons with chronic stroke that are sustained 4 months after discharge. This suggests that motor recovery can be enhanced by repetitive exercise training more than 1 year after stroke.

Adult↗

Comparison of two techniques of robot-aided upper limb exercise training after stroke.

OBJECTIVE: This study examined whether incorporating progressive resistive training into robot-aided exercise training provides incremental benefits over active-assisted robot-aided exercise for the upper limb after stroke. DESIGN: A total of 47 individuals at least 1 yr poststroke were enrolled in this 6-wk training protocol. Paretic upper limb motor abilities were evaluated using clinical measures and a robot-based assessment to determine eligibility for robot-aided progressive resistive training at study entry. Subjects capable of participating in resistance training were randomized to receive either active-assisted robot-aided exercises or robot-aided progressive resistance training. Subjects who were incapable of participating in resistance training underwent active-assisted robotic therapy and were again screened for eligibility after 3 wks of robotic therapy. Those subjects capable of participating in resistance training at 3 wks were then randomized to receive either robot-aided resistance training or to continue with robot-aided active-assisted training. RESULTS: One subject withdrew due to unrelated medical issues, and data for the remaining 46 subjects were analyzed. Subjects in all groups showed improvement in measures of motor control (mean increase in Fugl-Meyer of 3.3; 95% confidence interval, 2.2-4.4) and maximal force (mean increase in maximal force of 3.5 N, P = 0.027) over the course of robot-aided exercise training. No differences in outcome measures were observed between the resistance training groups and the matched active-assisted training groups. Subjects' ability to perform the robotic task at the time of group assignment predicted the magnitude of the gain in motor control. CONCLUSION: The incorporation of robot-aided progressive resistance exercises into a program of robot-aided exercise did not favorably or negatively affect the gains in motor control or strength associated with this training, though interpretation of these results is limited by sample size. Individuals with better motor control at baseline experienced greater increases in motor control with robotic training.

Adult↗

Submovements grow larger, fewer, and more blended during stroke recovery.

Submovements are hypothesized building blocks of human movement, discrete ballistic movements of which more complex movements are composed. Using a novel algorithm, submovements were extracted from the point-to-point movements of 41 persons recovering from stroke. Analysis of the extracted submovements showed that, over the course of therapy, patients' submovements tended to increase in peak speed and duration. The number of submovements employed to produce a given movement decreased. The time between the peaks of adjacent submovements decreased for inpatients (those less than 1 month post-stroke), but not for outpatients (those greater than 12 months post-stroke) as a group. Submovements became more overlapped for all patients, but more markedly for inpatients. The strength and consistency with which it quantified patients' recovery indicates that analysis of submovement overlap might be a useful tool for measuring learning or other changes in motor behavior in future human movement studies.

Adult↗

Motor recovery strategies after stroke.

Impaired motor function after stroke is a major cause of disability in young stroke survivors. The plasticity of the adult human brain provides opportunities to enhance traditional rehabilitation programs for these individuals. Younger stroke patients appear to have a greater ability to recover from stroke and are likely to benefit substantially from treatments that facilitate plasticity-mediated recovery. The use of new exercise treatments, such as constraint-induced movement therapy, robot-aided rehabilitation, and partial body weight supported treadmill training are being studied intensively and are likely to ultimately be incorporated into standard poststroke rehabilitation. Medications to enhance recovery, growth factors, and stem cells will also be components of rehabilitation for the young stroke survivor in the foreseeable future.

Adolescent↗

Rushing to judgment.

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Drug and Narcotic Control↗