American Stroke Association Late-Breaking Science News Report

  • High-intensity, repetitive rehabilitation exercises, whether assisted by a robot or human, can improve movement in a stroke patient’s paralyzed arm, even years after the disabling event.
  • The finding challenges the notion that little rehabilitation can occur a year after stroke.
  • Intense training could potentially improve leg paralysis or cognitive problems long after a stroke, researchers said.

High-intensity, repetitive rehabilitation exercises can help stroke survivors significantly improve functioning in their paralyzed arm and in their quality of life — even years after their disabling event, according to late-breaking science results presented at the American Stroke Association’s International Stroke Conference 2010.

Survivors who had 12 weeks of either robot- or human-assisted therapy showed clinically significant improved arm function (3-point improvement on the Fugl-Meyer Scale compared to usual care) and better quality of life (6-point improvement on the Stroke Impact Scale) six months later compared to survivors who had no additional therapy.

“Even very chronic stroke patients can achieve meaningful recovery,” said Albert C. Lo, M.D., Ph.D., the study’s lead author and a neurologist at the Veterans Affairs (VA) Medical Center and Assistant Professor of Neurology at Brown University in Providence, R.I. “These findings offer a potential new therapy for stroke survivors, suggesting that high-intensity therapy can result in modest but significant improvement in motor functioning, performance and quality of life.”

The findings are particularly important because “there is still a widely held belief among physicians that very little recovery can occur beyond the first six or 12 months after a stroke,” Lo said.

In the study, researchers examined whether robot-assisted therapy, compared to a group receiving therapy based on conventional techniques and another receiving usual care, could reduce arm paralysis years after stroke.

Researchers recruited 127 VA patients (96 percent males; average age 65) whose paralyzing stroke had occurred an average of 56 months before enrollment.

“They had severe paralysis, and 33 percent had suffered multiple strokes,” Lo said.

Patients were randomly assigned to one of three groups: robot-assisted therapy (49), human-assisted intensive-comparative therapy (50) and usual care (28). Both the robot and intensive-comparative groups were asked to attend one-hour therapy sessions three times a week for 12 weeks. They did the same number of similar arm exercises, and for the same lengths of time. One group worked with a human therapist and one worked with a robot along with a therapist. The usual care group received no extra therapy.

Of the 127 patients, 111 (87 percent) completed the study. They were tested at the beginning of the trial and at six, 12, 24 and 36 weeks, using three scales for arm function. One measured the disabled arm’s basic motor function. Another tested a patient’s ability to do simple tasks, such as fold a towel. The third used the patients’ own views on how paralyzed arm function affected their daily activities and quality of life.

The study showed:
– At 12 weeks — the end of therapy — none of the groups showed significant improvement in motor function.
– At 36 weeks, robot-assisted therapy proved significantly superior to usual care in improving arm function (3 point improvement on the Fugl-Meyer scale). Intensive-comparative therapy showed similar improvements, without statistical differences compared to robot-assisted therapy.
– The patients receiving robot-assisted therapy also reported significant improvements in quality of life compared to usual care (6 points on the Stroke Impact Scale).

“These findings offer hope for all with chronic stroke impairment,” Lo said. “Intensive, repetitive therapy could potentially benefit legs and cognitive function as well as arms.”

Each year, about 795,000 Americans suffer a stroke, according to the American Heart Association/American Stroke Association. Of the 6.4 million U.S. stroke survivors alive today, as many as 15 percent to 30 percent are considered “permanently disabled.”

Co-authors are Peter Guarino, Ph.D.; Hermano I. Krebs, Ph.D.; Bruce T. Volpe, M.D.; Christopher T. Bever, Jr., M.D.; Pamela W. Duncan, Ph.D.; Robert J. Ringer, PharmD.; Todd H. Wagner, Ph.D.; Lorie G. Richards, Ph.D.; Dawn M. Bravata, M.D.; Jodie K. Haselkorn, M.D.; George F. Wittenberg, M.D., Ph.D.; Daniel G. Federman, M.D.; Barbara H. Corn, Ph.D.; Alysia D. Maffucci, J.D. ; Stephen E. Nadeau, M.D.; Susan S. Conroy, D.Sci.; Janet W. Powell, Ph.D.; Grant D. Huang, Ph.D.; and Peter Peduzzi, Ph.D.

Author disclosures are on the abstract.

Funding was provided by VA Cooperative Studies Program and VA Rehabilitation and Research Development Service.

Source: American Heart Association


Is the person exposing you to radiation qualified?

Every day in the United States, tens of thousands of patients are exposed to ionizing radiation through radiation therapy, CT scans, x rays, mammograms, and other medical imaging and therapeutic procedures. Patients need to have confidence that the technologists caring for them have the credentials and qualifications to safely administer radiation, and that the equipment they are using is properly calibrated and maintained to deliver radiation safely and within the proper dose parameters.

These imaging procedures are key to making correct diagnoses of injuries and disease processes. Radiation therapy procedures are an important weapon in treating cancer. But, along with its life-saving capacity, ionizing radiation can cause harm to patients when used improperly. Too much radiation and the patient may suffer debilitating injury or death, as today’s testimony before the U.S. House of Representatives’ Energy and Commerce Committee’s Subcommittee on Health has documented.

Responsibility for assuring balance between the amount of radiation used and the costs and benefits of its use lies with the physicians, the radiation oncologists, the equipment manufacturers, the radiation physicists, and the technologists who interact directly with the patients and who operate the equipment that delivers the radiation. Being fully qualified to perform their role in this team of professionals requires that the individuals have been appropriately educated in the fundamental concepts of radiation — including its biological effects — and how to achieve positive benefits and avoid or mitigate negative effects.

“For technologists, that means a formal educational program that covers both the underlying concepts of radiation physics and its application for medical uses,” according to Michael DelVecchio, B.S., R.T.(R)(ARRT), president of the American Registry of Radiologic Technologists. “This includes both classroom work and hands-on education in clinical settings.”

Completion of the educational program is followed by application for certification by a national organization specializing in medical imaging and/or radiation therapy, according to DelVecchio. Certification organizations evaluate the applicant’s education (including successful completion of specified clinical competencies), compliance with ethics standards related to patient care, and passing a comprehensive examination that covers both principles of radiation and application to imaging or therapy.

“Initial certification alone, however, is not sufficient for assuring ongoing qualifications,” DelVecchio notes. Although the concepts of radiation learned in the educational program may remain relevant for decades, the technology of how it is used changes rapidly. “This means that technologists must continue to update their qualifications on an ongoing basis,” he adds. Continuing education relevant to their practice is an essential requirement for technologists and is a requirement for maintaining the registration of certification.

“While no medical error is acceptable,” DelVecchio asserts, “they do occur. They can result from lack of knowledge and education in some cases. But errors may also result from behavior that lacks the appropriate ethical grounding, which is also essential to assuring ongoing qualifications. Measured by an appropriate standard of ethics, individuals can demonstrate that they have internalized a set of guidelines that reflect the best interests of the patient.”

Answering the question – Is the person exposing you to radiation qualified? — is a matter of both initial and ongoing evaluation and monitoring of qualifications. Certification programs such as those administered by the American Registry of Radiologic Technologists are important elements in providing the quality of care that all patients and their loved ones should expect.

Source: American Registry of Radiologic Technologists


Only 11 Percent Receive Any Treatment

DRUGS, ALCOHOL IMPLICATED IN 78 PERCENT OF VIOLENT CRIMES, 83 PERCENT OF PROPERTY CRIMES, 77 PERCENT OF WEAPON, PUBLIC ORDER, OTHER CRIMES

Of the 2.3 million inmates crowding our nation’s prisons and jails, 1.5 million meet the DSM IV medical criteria for substance abuse or addiction, and another 458,000, while not meeting the strict DSM IV criteria, had histories of substance abuse; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or drug law violation; or shared some combination of these characteristics, according to Behind Bars II: Substance Abuse and America’s Prison Population. Combined these two groups constitute 85 percent of the U.S. prison population.

The new 144-page report released today by The National Center on Addiction and Substance Abuse (CASA) at Columbia University also reveals that alcohol and other drugs are significant factors in all crime. In 2006, alcohol and other drugs were involved in these inmate offenses:

– 78 percent of violent crimes;
– 83 percent of property crimes; and
– 77 percent of public order, immigration or weapon offenses; and probation/parole violations.

The CASA report found that only 11 percent of all inmates with substance abuse and addiction disorders receive any treatment during their incarceration. The report found that if all inmates who needed treatment and aftercare received such services, the nation would break even in a year if just over 10 percent remained substance and crime free and employed. Thereafter, for each inmate who remained sober, employed and crime free the nation would reap an economic benefit of $90,953 per year.

“States complain mightily about their rising prison costs; yet they continue to hemorrhage public funds that could be saved if they provided treatment to inmates with alcohol and other drug problems and stepped up use of drug courts and prosecutorial drug treatment alternative programs,” said Susan E. Foster, CASA’s Vice President and Director of Policy Research and Analysis.

Joseph A. Califano, Jr., CASA’s Chairman and President and former U.S. Secretary of Health, Education, and Welfare, called the nation’s current prison policies, “Inane and inhuman. Between 1996 and 2006, the U.S. population grew by 12 percent. Over that same period, the number of adults incarcerated grew by 33 percent to 2.3 million inmates and the number of inmates who either met the DSM IV medical criteria for alcohol or other drug abuse and addiction or were otherwise substance involved shot up by 43 percent to 1.9 million inmates. The tragedy is that we know how to sharply reduce the costs of incarceration and the crimes committed by substance-involved offenders.”

The report also noted that in 2005, federal, state and local governments spent $74 billion on incarceration, court proceedings, probation and parole for substance-involved adult and juvenile offenders and less than one percent of that amount — $632 million — on prevention and treatment for them. (1)

Twelve years ago, CASA released Behind Bars: Substance Abuse and America’s Prison Population. CASA prepared this report to see if any progress had been made in reducing the number of substance-involved offenders behind bars and to examine and identify promising practices for cost-effective investments. To conduct this study, CASA researchers analyzed data on inmates from 11 federal sources, reviewed more than 650 articles and other publications, examined best practices in prevention and treatment for substance-involved offenders, reviewed accreditation standards and analyzed costs and benefits of treatment.

“Despite increased recognition of the problem and its potential solutions, we have made no progress in reducing the number of substance-involved inmates crowding our prisons and jails. The United States has less than five percent of the world’s population and we consume two-thirds of the world’s illegal drugs and incarcerate almost a quarter of the world’s prisoners, more than eight of ten of whom have some substance involvement,” said Califano.

The CASA report also found that compared to non-substance involved inmates, substance-involved inmates are not only likelier to be re-incarcerated, begin their criminal careers at an early age, and have more contacts with the criminal justice system, but they are also:

– Four times likelier to receive income through illegal activity;
– Twice as likely to have had at least one parent who abused alcohol or other drugs when they were children;
– 41 percent likelier to have some family criminal history;
– 29 percent less likely to have completed at least high school; and
– 20 percent likelier to be unemployed a month before incarceration.

Other Key Findings
– In 2006, an estimated one million substance-involved inmates were parents to more than 2.2 million minor children. Three quarters of these children were age 12 or younger.
– Alcohol is implicated in the incarceration of more than half of all inmates in America; illicit drugs are implicated in three quarters of incarcerations.
– Contrary to public perception, only two percent of all inmates are incarcerated for marijuana possession as their controlling or only offense.

A Call for Action

To reduce the number of substance-involved inmates crowding our prisons, improve the health of inmates and reduce crime, the CASA report offers specific recommendations in its call for action by the nation’s criminal justice systems and federal, state, and local governments including these:

– Use trained health care professionals to screen, assess and treat substance-involved offenders and provide care for co-occurring physical and mental health problems.
– Provide comprehensive pre-release planning and aftercare to continue treatment services for inmates with substance use disorders.
– Require addiction treatment for inmates to be medically managed.
– Expand the use of treatment-based alternatives to jail and prison.
– Require accreditation for prison- and jail-based treatment programs and providers.

“This report lays out the steps we need to take to address the treatment needs of offenders while holding them accountable for their crimes,” noted Foster. “We do not as a nation refuse to provide treatment for other chronic ailments like heart disease or diabetes. We should do so for addictive disorders, especially when the added benefits of treatment for offenders include significant reductions in crime and its costs to society.”

CASA is the only national organization that brings together under one roof all the professional disciplines needed to study and combat all types of substance abuse as they affect all aspects of society.

CASA and its staff of some 60 professionals has issued 71 reports and white papers, published three books, conducted demonstration programs focused on children, families and schools at 241 sites in 94 cities and counties in 35 states plus Washington, D.C. and two Native American reservations, held 19 conferences attended by professionals and others from 49 states and several foreign countries, and has been evaluating the effectiveness of drug and alcohol treatment and prevention in a variety of programs and drug courts. CASA is the creator of the nationwide initiative Family Day — A Day to Eat Dinner With Your ChildrenTM — the fourth Monday in September — the 27th in 2010 — that promotes parental engagement as a simple and effective way to reduce children’s risk of smoking, drinking and using illegal drugs.

The most recent CASA book, How To Raise a Drug Free Kid: The Straight Dope for Parents by Joseph A. Califano, Jr., a practical, user friendly book of advice and information for parents, is widely available in paperback and book events can be arranged for parents. For more information visit www.casacolumbia.org.

*The National Center on Addiction and Substance Abuse at Columbia University is neither affiliated with, nor sponsored by, the National Court Appointed Special Advocate Association (also known as “CASA”) or any of its member organizations, or any other organizations with the name of “CASA”.

(1) From CASA’s 2009 Shoveling Up II: The Impact of Substance Abuse on Federal, State and Local Budgets report.

Source: The National Center on Addiction and Substance Abuse (CASA) at Columbia University


Findings released today and detailed in the analysis Low Consumption and Higher Medicare Cost: Consumption Clusters in a Medicare Fee-for-Service Population, examine how individuals utilize benefits and services under the Medicare program. The research suggests that beneficiaries with chronic diseases who consume the least of their Medicare benefits and services (referred to as “low consumers”) and potentially under manage their disease may experience an acute event that requires costly emergency room visits and hospitalizations.

The research, spearheaded by the National Minority Quality Forum (The Forum), analyzed Medicare data over a six-year period. The Forum found that Medicare beneficiaries may be clustered into five consumption groups (crisis consumers, heavy consumers, moderate consumers, light consumers and low consumers) based on how much Medicare reimburses for services provided to beneficiaries in any year. The two most-costly clusters are crisis consumers and heavy consumers — representing only 11 percent of Medicare beneficiaries, but 65 percent of all costs. These are dynamic clusters as consumption patterns among beneficiaries can significantly vary from one year to the next. Beneficiaries who are low consumers one year may become heavy consumers the next sparked by a critical and often costly health event. There is ample evidence that in the immediate future, significant increases in reimbursements may be anticipated for those beneficiaries with diabetes who rank among the lowest consumers of benefits. It is likely that similar patterns exist for those with other chronic diseases.

“The findings paint a new picture of the Medicare beneficiary living with a chronic disease and how that individual utilizes the program,” said Gary Puckrein, PhD., Founding Partner of the Diabetes Care Project and President and CEO of the National Minority Quality Forum. “If we can identify these patients, who are under-managing their chronic condition putting them at high-risk for disease complications, we can intervene to help these individuals manage their disease more effectively, and, ultimately, reduce overall health care costs.” One out of every four Medicare dollars is spent on beneficiaries with diabetes, with a high percentage attributed to tertiary illness caused by unmanaged or under-managed diabetes.

“We know that diabetes and other chronic conditions disproportionately affect the elderly, and with an aging population and a rapid influx of Baby Boomers entering the Medicare program, we need to better understand the barriers associated with managing their chronic diseases,” said James R. Gavin III, MD, PhD, CEO and Chief Medical Officer, Healing Our Village and Chairman Emeritus, National Diabetes Education Program. “If we can better understand our Medicare patients, we can help them achieve better health outcomes.”

The Diabetes Care Project (DCP), founded by The Forum, Roche Diagnostics and in partnership with the American Association of Diabetes Educators (AADE) and Healthways, Inc., is a new coalition of patient advocates and health partners who are committed to dramatically reducing acute events that are a consequence of diabetic complications through early interventions and improved chronic-care management (www.diabetescareproject.org). In 2010, the DCP plans to undertake a series of projects that will help better understand the low consuming diabetic, and their impact on the health care system. The purpose of these initiatives is to offer guidance as to how policies, regulations, targeted interventions, education, and personalized diabetes care management plans may help improve patient outcomes and lower costs for the entire health system.

Diabetes is a growing public health epidemic affecting over 23 million Americans. According to the Centers for Disease Control and Prevention, type 2 diabetes, fueled by rising rates of obesity, accounts for nearly 90-95 percent of all people with diabetes and disproportionately affects minority and aging populations in the U.S. (nearly 20 percent of Medicare beneficiaries have diabetes). The U.S. spends approximately $174 billion in annual total costs for diagnosed diabetes with $166 billion in direct medical costs.

Source: Diabetes Care Project


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