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Objective Sleep Measures in Inpatients With Subacute Stroke Associated With Levels and Improvements in Activities of Daily Living

  • Author Footnotes
    ∗ Huang and Lai contributed equally to this work.
    Ren-Jing Huang
    Footnotes
    ∗ Huang and Lai contributed equally to this work.
    Affiliations
    Department of Medical Image and Radiological Sciences, Chung Shan Medical University, Taichung, Taiwan

    Sleep Medicine Center, Chung Shan Medical University Hospital, Taichung, Taiwan
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  • Author Footnotes
    ∗ Huang and Lai contributed equally to this work.
    Ching-Hsiang Lai
    Footnotes
    ∗ Huang and Lai contributed equally to this work.
    Affiliations
    Sleep Medicine Center, Chung Shan Medical University Hospital, Taichung, Taiwan

    Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan
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  • Shin-Da Lee
    Affiliations
    Department of Occupational Therapy, Asia University, Taichung, Taiwan

    Department of Physical Therapy, Graduate Institute of Rehabilitation Science, China Medical University, Taichung, Taiwan

    School of Rehabilitation Science, Shanghai University of TCM, Shanghai, China
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  • Fang-Yu Pai
    Affiliations
    Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan
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  • Shen-Wen Chang
    Affiliations
    Sleep Medicine Center, Chung Shan Medical University Hospital, Taichung, Taiwan
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  • Ai-Hui Chung
    Affiliations
    Sleep Medicine Center, Chung Shan Medical University Hospital, Taichung, Taiwan
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  • Yi-Fang Chang
    Affiliations
    Department of Physical Medicine and Rehabilitation, Chung Shan Medical University Hospital, Taichung, Taiwan
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  • Hua Ting
    Correspondence
    Corresponding author Hua Ting, MD, Institute of Medicine, Chung Shan Medical University Hospital, 110, Sec. 1, Jianguo N. Rd, Taichung, 40201, Taiwan.
    Affiliations
    Sleep Medicine Center, Chung Shan Medical University Hospital, Taichung, Taiwan

    Department of Physical Medicine and Rehabilitation, Chung Shan Medical University Hospital, Taichung, Taiwan

    Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
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  • Author Footnotes
    ∗ Huang and Lai contributed equally to this work.
Published:January 12, 2018DOI:https://doi.org/10.1016/j.apmr.2017.12.016

      Abstract

      Objective

      To investigate whether objective polysomnographic measures of prevalent sleep problems such as sleep-disordered-breathing (SDB) and insomnia are associated with activities of daily living levels in inpatients at rehabilitation units.

      Design

      Retrospective and observational study.

      Setting

      Single rehabilitation center.

      Participants

      Inpatients with subacute stroke (N=123) (61.6±13.1 years; 23.8±3.4 kg/m2; 33% women; 90.5±36.7 days post-stroke) underwent a 1-night polysomnographic study and a 1-month inpatient rehabilitation program.

      Main outcome measures

      Admission and discharge Barthel Index (BI) scores and its change scores.

      Results

      One hundred three (92%) patients had moderate-to-severe SDB (46.7±25.1 events/h in the apnea-hypopnea index), and 24 (19.5%) patients had acceptable continuous positive airway pressure adherence. Diverse values were found for total sleep time (259±71 min), sleep efficiency (69.5%±19.3%), sleep latency (24.3±30.9 min), and wakefulness after sleep onset (93.1±74.2 min). Admission BI scores and the BI change scores were 33.8±23.2 and 10.1±9.2, respectively. The National Institutes of Health Stroke Scale (NIHSS, 10.2±5.6), available in 57 (46%) patients, was negatively associated with admission levels and gains in BI change scores (P<.001, =0.002, respectively) in a univariate analysis. In regression models with backward selection, excluding NIHSS score, both age (P=.025) and wakefulness after sleep onset (P<.001) were negatively associated (adjusted R2=0.260) with admission BI scores. Comorbidity of hypertension; sleep latency percentage of stage 1, non–rapid eye movement sleep; and desaturation events ≥4% (P<.001, 0.001, 0.021, and 0.043, respectively; adjusted R2=0.252) were negatively associated with BI score gains.

      Conclusions

      Based on objective sleep measures, insomnia rather than SDB in inpatients with subacute stroke was associated negatively with admission levels of activity of daily living and its improvement after a 1-month rehabilitation course.

      Keywords

      List of abbreviations:

      ADL (activities of daily living), AHI (apnea-hypopnea index), AI (arousal index), BI (Barthel Index), CPAP (continuous positive airway pressure), LACI (lacunar circulation infarct), NIHSS (National Institutes of Health Stroke Scale), PACI (partial anterior circulation infarcts), POCI (posterior circulation infarcts), PSG (polysomnography), Sao2 (oxygen saturation), SDB (sleep-disordered breathing), TACI (total anterior circulation infarcts)
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      References

        • Go A.S.
        • Mozaffarian D.
        • Roger V.L.
        • et al.
        Executive summary: heart disease and stroke statistics—2013 update: a report from the American Heart Association.
        Circulation. 2013; 127: 143-152
        • Veerbeek J.M.
        • Kwakkel G.
        • van Wegen E.E.
        • Ket J.C.
        • Heymans M.W.
        Early prediction of outcome of activities of daily living after stroke: a systematic review.
        Stroke. 2011; 42: 1482-1488
        • Spira A.P.
        • Stone K.L.
        • Rebok G.W.
        • et al.
        Sleep-disordered breathing and functional decline in older women.
        J Am Geriatr Soc. 2014; 62: 2040-2046
        • Frohnhofen H.
        • Heuer H.C.
        • Kanzia A.
        • Firat A.
        Influence of type of treatment for sleep apnea on activities of daily living in a sample of elderly patients with severe sleep apnea.
        J Physiol Pharmacol. 2009; 60: 51-55
        • Frohnhofen H.
        • Heuer H.C.
        • Pfundner N.
        • Orth G.
        Cyclical nocturnal oxygen desaturation and impact on activities of daily living in elderly patients.
        J Physiol Pharmacol. 2007; 58: 185-191
        • Brimah P.
        • Oulds F.
        • Olafiranye O.
        • et al.
        Sleep duration and reported functional capacity among black and white US adults.
        J Clin Sleep Med. 2013; 9: 605-609
        • Faubel R.
        • Lopez-Garcia E.
        • Guallar-Castillon P.
        • et al.
        Sleep duration and health-related quality of life among older adults: a population-based cohort in Spain.
        Sleep. 2009; 32: 1059-1068
        • Yaggi H.K.
        • Concato J.
        • Kernan W.N.
        • Lichtman J.H.
        • Brass L.M.
        • Mohsenin V.
        Obstructive sleep apnea as a risk factor for stroke and death.
        N Engl J Med. 2005; 353: 2034-2041
        • Becker H.F.
        • Jerrentrup A.
        • Ploch T.
        • et al.
        Effect of nasal continuous positive airway pressure treatment on blood pressure in patients with obstructive sleep apnea.
        Circulation. 2003; 107: 68-73
        • Kernan W.N.
        • Ovbiagele B.
        • Black H.R.
        • et al.
        Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2014; 45: 2160-2236
        • Palomaki H.
        • Berg A.
        • Meririnne E.
        • Kaste M.
        • et al.
        Complaints of poststroke insomnia and its treatment with mianserin.
        Cerebrovasc Dis. 2003; 15: 56-62
        • Park J.Y.
        • Chun M.H.
        • Kang S.H.
        • Lee J.A.
        • Kim B.R.
        • Shin M.J.
        Functional outcome in poststroke patients with or without fatigue.
        Am J Phys Med Rehabil. 2009; 88: 554-558
        • Lerdal A.
        • Bakken L.N.
        • Rasmussen E.F.
        • et al.
        Physical impairment, depressive symptoms and pre-stroke fatigue are related to fatigue in the acute phase after stroke.
        Disabil Rehabil. 2011; 33: 334-342
        • Charles M.S.
        • Zhang J.H.
        Sleep a therapeutic target for stroke?.
        Exp Neurol. 2012; 234: 1-4
        • Littner M.
        • Hirshkowitz M.
        • Kramer M.
        • et al.
        Practice parameters for using polysomnography to evaluate insomnia: an update.
        Sleep. 2003; 26: 754-760
        • Vgontzas A.N.
        • Fernandez-Mendoza J.
        • Liao D.
        • Bixler E.O.
        Insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder.
        Sleep Med Rev. 2013; 17: 241-254
        • Vgontzas A.N.
        • Bixler E.O.
        • Lin H.M.
        • et al.
        Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: clinical implications.
        J Clin Endocrinol Metab. 2001; 86: 3787-3794
        • Vgontzas A.N.
        • Liao D.
        • Bixler E.O.
        • Chrousos G.P.
        • Vela-Bueno A.
        Insomnia with objective short sleep duration is associated with a high risk for hypertension.
        Sleep. 2009; 32: 491-497
        • Edinger J.D.
        • Means M.K.
        • Krystal A.D.
        Does physiological hyperarousal enhance error rates among insomnia sufferers?.
        Sleep. 2013; 36: 1179-1186
        • Brooks D.
        • Davis L.
        • Vujovic-Zotovic N.
        • et al.
        Sleep-disordered breathing in patients enrolled in an inpatient stroke rehabilitation program.
        Arch Phys Med Rehabil. 2010; 91: 659-662
        • Sangha H.
        • Lipson D.
        • Foley N.
        • et al.
        A comparison of the Barthel Index and the Functional Independence Measure as outcome measures in stroke rehabilitation: patterns of disability scale usage in clinical trials.
        Int J Rehabil Res. 2005; 28: 135-139
        • Bakken L.N.
        • Kim H.S.
        • Finset A.
        • Lerdal A.
        Stroke patients' functions in personal activities of daily living in relation to sleep and socio-demographic and clinical variables in the acute phase after first-time stroke and at six months of follow-up.
        J Clin Nurs. 2012; 21: 1886-1895
        • Duncan P.W.
        • Jorgensen H.S.
        • Wade D.T.
        Outcome measures in acute stroke trials: a systematic review and some recommendations to improve practice.
        Stroke. 2000; 31: 1429-1438
        • Granger C.V.
        • Albrecht G.L.
        • Hamilton B.B.
        Outcome of comprehensive medical rehabilitation: measurement by PULSES profile and the Barthel Index.
        Arch Phys Med Rehabil. 1979; 60: 145-154
        • Adams Jr., H.P.
        • Leclerc J.R.
        • Bluhmki E.
        • Clarke W.
        • Hansen M.D.
        • Hacke W.
        Measuring outcomes as a function of baseline severity of ischemic stroke.
        Cerebrovasc Dis. 2004; 18: 124-129
        • Bamford J.
        • Sandercock P.
        • Dennis M.
        • Burn J.
        • Warlow C.
        Classification and natural history of clinically identifiable subtypes of cerebral infarction.
        Lancet. 1991; 337: 1521-1526
        • Yan-fang S.
        • Yu-ping W.
        Sleep-disordered breathing: impact on functional outcome of ischemic stroke patients.
        Sleep Med. 2009; 10: 717-719
        • Cherkassky T.
        • Oksenberg A.
        • Froom P.
        • Ring H.
        Sleep-related breathing disorders and rehabilitation outcome of stroke patients: a prospective study.
        Am J Phys Med Rehabil. 2003; 82: 452-455
        • Marquez-Romero J.M.
        • Morales-Ramirez M.
        • Arauz A.
        Non-breathing-related sleep disorders following stroke.
        Neurologia. 2014; 29: 511-516
        • Vock J.
        • Achermann P.
        • Bischof M.
        • et al.
        Evolution of sleep and sleep EEG after hemispheric stroke.
        J Sleep Res. 2002; 11: 331-338
        • Carmichael S.T.
        • Chesselet M.F.
        Synchronous neuronal activity is a signal for axonal sprouting after cortical lesions in the adult.
        J Neurosci. 2002; 22: 6062-6070
        • Arzt M.
        • Young T.
        • Peppard P.E.
        • et al.
        Dissociation of obstructive sleep apnea from hypersomnolence and obesity in patients with stroke.
        Stroke. 2010; 41: e129-e134
        • Edinger J.D.
        • Means M.K.
        • Carney C.E.
        • Krystal A.D.
        Psychomotor performance deficits and their relation to prior nights' sleep among individuals with primary insomnia.
        Sleep. 2008; 31: 599-607
        • Fernandez-Mendoza J.
        • Vgontzas A.N.
        • Bixler E.O.
        • et al.
        Clinical and polysomnographic predictors of the natural history of poor sleep in the general population.
        Sleep. 2012; 35: 689-697
        • Vgontzas A.N.
        • Tsigos C.
        • Bixler E.O.
        • et al.
        Chronic insomnia and activity of the stress system: a preliminary study.
        J Psychosom Res. 1998; 45: 21-31
        • Song J.
        • Kim E.
        • Kim C.H.
        • Song H.T.
        • Lee J.E.
        The role of orexin in post-stroke inflammation, cognitive decline, and depression.
        Mol Brain. 2015; 11: 16
        • Fiorina P.
        • Lattuada G.
        • Silvestrini C.
        • Ponari O.
        • Dall'Aglio P.
        Disruption of nocturnal melatonin rhythm and immunological involvement in ischaemic stroke patients.
        Scand J Immunol. 1999; 50: 228-231
        • Lai T.W.
        • Zhang S.
        • Wang Y.T.
        Excitotoxicity and stroke: identifying novel targets for neuroprotection.
        Prog Neurobiol. 2014; 115: 157-188
        • Wang W.
        • Pan Y.
        • Li Q.
        • Wang L.
        Orexin: a potential role in the process of obstructive sleep apnea.
        Peptides. 2013; 42: 48-54
        • Xie L.
        • Kang H.
        • Xu Q.
        • et al.
        Sleep drives metabolite clearance from the adult brain.
        Science. 2013; 342: 373-377
        • Cosin C.
        • Sibon I.
        • Poli M.
        • et al.
        Circadian sleep/wake rhythm abnormalities as a risk factor of a poststroke apathy.
        Int J Stroke. 2015; 10: 710-715
        • Kim C.R.
        • Chun M.H.
        • Han E.Y.
        Effects of hypnotics on sleep patterns and functional recovery of patients with subacute stroke.
        Am J Phys Med Rehabil. 2010; 89: 315-322

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      • Correction
        Archives of Physical Medicine and RehabilitationVol. 99Issue 8
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          In the article by Huang et al, Objective sleep measures in inpatients with subacute stroke associated with levels and improvements in activities of daily living, published in Archives of Physical Medicine and Rehabilitation 2018; 99: 699-706 ( https://doi.org/10.1016/j.apmr.2017.12.016 ), we failed to note that the authors Ren-Jing Huang PhD, Ching-Hsiang Lai PhD, and Shin-Da Lee PhD all contributed equally to this study. We apologize for this error.
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