The Impact of Mild Stroke on Meaningful Activity and Life Satisfaction

Exploring changing needs following minor stroke

Medical advances have led to many of the severe consequences of stroke being averted. Consequently, more people are being discharged from hospital following treatment for what is classed as minor stroke. The needs of people with minor stroke have received little research attention. The aim of the current study was to conduct an exploratory prospective needs analysis to document the unmet health, rehabilitation and psychosocial needs of a recently hospitalised minor stroke cohort approximately 2 weeks (T1) and 2 months (T2) post-hospital discharge. An exploratory cohort design was used to explore the unmet health, service and social needs of 20 patients with minor stroke. Participants completed questionnaires (Survey of Unmet Needs and Service Use, Mayo-Portland Adaptability Inventory-4, Exeter Identity Transition Scales, RAND 36-Item Health Survey 1.0) at T1 and T2. Nine participants reported unmet needs at T1 and seven participants reported unmet needs at T2. Between T1 and T2, there was a significant improvement in perceived role limitations due to physical health. Participation in society was significantly better at T2. In conclusion, patients with minor stroke report health, service and social needs that are unmet by existing services. This patient cohort urgently requires co-ordinated services to detect and manage these unmet needs.

Disrupted biographies: making sense of minor stroke after hospital discharge

PURPOSE

To explore how people with minor stroke make sense of the stroke in the first weeks following hospital discharge to home.

MATERIALS AND METHODS

A qualitative descriptive approach using semi-structured interviews with 17 participants with minor stroke at approximately 2 weeks post-hospital discharge was used to explore their experiences of the early stage of recovery. Interview transcripts were analysed using qualitative content analysis.

RESULTS

Three main themes were derived from the analysis 1) Reconciling personal reactions, 2) Emotional introspection after the stroke, and 3) Navigating the social side of stroke.

CONCLUSIONS

Although participants had different experiences of minor stroke, there were common elements. The first weeks post-hospital discharge were a time of questioning and reconciling the stroke for many participants. Adjusting to post-stroke impairments and the impact of these on social participation was also prominent. There is a critical need for education about what to expect prior to discharge from hospital with minor stroke and a designated discharge pathway to avoid the development of secondary post-stroke issues in the community.IMPLICATIONS FOR REHABILITATIONPeople with minor stroke may experience ongoing post-stroke disabilities following discharge home.The transition period is characterised by questioning and reconciling what has happened by people with minor stroke.Information about what to expect prior to discharge from hospital for people with minor stroke and their families is essential.There is a critical need for a designated discharge pathway with follow up for people with minor stroke and their families.

Occupational engagement following mild stroke in the Australian context using the occupational gaps questionnaire

BACKGROUND

There is a need for research to identify the impact of mild stroke on occupational engagement. The Occupational Gaps Questionnaire (OGQ) measures the difference between a person's actual and preferred occupational engagement.

AIMS/OBJECTIVES

This study aimed to test the feasibility of the English version of the OGQ, and describe occupational gaps of people with mild stroke.

MATERIAL AND METHODS

A mixed methods, cross-sectional study involving 10 people with mild stroke at 1 and/or 9 months after stroke. Quantitative data were summarised descriptively and thematic analysis explored qualitative responses.

RESULTS

Participants reported a mean of 6.7 (SD 5.1) gaps at 1-month and 3.00 (SD 2.1) gaps at 9-months. Outdoor activities, work, sports, and light home and heavy-duty maintenance were identified as gaps at both time-points. Two themes emerged from the qualitative analysis: Drivers of occupation and Occupations can be challenged or enabled. An additional finding in terms of feasibility was drawn from qualitative data: Feasibility of Conducting the OGQ with people with mild stroke.

CONCLUSIONS AND SIGNIFICANCE

The English version of the OGQ was found to be a feasible instrument for identifying occupational gaps following mild stroke and may be suitable to support research and clinical practice with this population.

The relationship between social cognition and participation in the long term after stroke

Social cognitive impairments may play a role in participation restrictions after stroke. Understanding their relationship could inform treatment approaches to improve participation. We investigated the relationship between social cognition and participation in the long term after stroke. Of 395 patients participating in a large prospective cohort study, cross-sectional data were available at 3-4 years post-stroke of 118 patients on tests for emotion recognition, theory of mind, empathy, and behaviour regulation. Participation was assessed with the Utrecht Scale for Evaluation of Rehabilitation - Participation (USER-P). Bivariate and multivariate regression analysis were used to examine the relationship between social cognitive domains and participation. The majority suffered from minor stroke (83.1% scored NIHSS 0-4). Only behaviour regulation was related to participation restrictions in bivariate analysis, but social cognitive impairments did not predict participation restrictions in multivariate regression in this group. To conclude, in a sample of minor stroke patients with mild impairments in theory of mind, emotion recognition and behavioural control, there were no associations with restrictions in participation. Research should examine whether a relationship is present in patients with more severe stroke. In addition, measuring social aspects of participation is necessary to further unravel this relationship, to determine treatment targets for improving participation.

TIA and minor stroke: a qualitative study of long-term impact and experiences of follow-up care

Background

Transient ischaemic attack (TIA) and minor stroke are often considered transient events; however, many patients experience residual problems and reduced quality of life. Current follow-up healthcare focuses on stroke prevention and care for other long-term problems is not routinely provided.

We aimed to explore patient and healthcare provider (HCP) experiences of residual problems post-TIA/minor stroke, the impact of TIA/minor stroke on patients’ lives, and current follow-up care and sources of support.

Methods

This qualitative study recruited participants from three TIA clinics, seven general practices and one community care trust in the West Midlands, England. Semi-structured interviews were conducted with 12 TIA/minor stroke patients and 24 HCPs from primary, secondary and community care. Data was analysed using framework analysis.

Results

A diverse range of residual problems were reported post-TIA/minor stroke, including psychological, cognitive and physical impairments. Consultants and general practitioners generally lacked awareness of these long-term problems; however, there was better recognition among nurses and allied HCPs. Residual problems significantly affected patients’ lives, including return to work, social activities, and relationships with family and friends. Follow-up care was variable and medically focused. While HCPs prioritised medical investigations and stroke prevention medication, patients emphasised the importance of understanding their diagnosis, individualised support regarding stroke risk, and addressing residual problems.

Conclusion

HCPs could better communicate information about TIA/minor stroke diagnosis and secondary stroke prevention using lay language, and improve their identification of and response to important residual impairments affecting patients.

A Novel Robot-Aided Upper Limb Rehabilitation Training System Based on Multimodal Feedback

During robot-aided rehabilitation exercises, monotonous, and repetitive actions can, to the subject, feel tedious and tiring, so improving the subject's motivation and active participation in the training is very important. A novel robot-aided upper limb rehabilitation training system, based on multimodal feedback, is proposed in this investigation. To increase the subject's interest and participation, a friendly graphical user interface and diversiform game-based rehabilitation training tasks incorporating multimodal feedback are designed, to provide the subject with colorful and engaging motor training. During this training, appropriate visual, auditory, and tactile feedback is employed to improve the subject's motivation via multi-sensory incentives relevant to the training performance. This approach is similar to methods applied by physiotherapists to keep the subject focused on motor training tasks. The experimental results verify the effectiveness of the designed multimodal feedback strategy in promoting the subject's participation and motivation.

Places visited for activities outside the home after stroke: Relationship with the severity of disability

Introduction

Knowledge about the places people visit or do not visit after stroke is lacking. The aim of this study was to describe and compare the places visited for activities outside the home of people with stroke of working age and to explore the influence of the severity of disability, fatigue, driving a car and sociodemographic characteristics on the total number of places visited for activities outside the home.

Methods

An exploratory cross-sectional study was conducted and 63 people with stroke were interviewed with instruments that covered places outside the home, severity of disability and fatigue. Data were analysed using non-parametric tests, analysis of variance and the general linear model.

Results

Significant difference in the total number of places visited for activities outside the home were found between all three groups of severity of disability. The good recovery group visited eight places to a significantly higher extent than those with severe/moderate disability. The severity of disability and driving a car were the only aspects that significantly influenced the total number of places visited.

Conclusions

Places for activities outside the home people with stroke visit and changes therein can add valuable knowledge about participation that can be used in the design of rehabilitation.

Predictors of quality of life 1 year after minor stroke or TIA: a prospective single-centre cohort study

OBJECTIVES

In patients after a transient ischaemic attack (TIA) or minor stroke, dysfunction is often underestimated by clinical measures due to invisible symptoms, including cognitive and emotional problems. Many of these patients need stroke care programme, but others do not. In this study, we aim to identify potential predictors of quality of life (QoL) in patients with TIA or minor stroke 1 year poststroke to be able to select which of these patients will need aftercare.

DESIGN

Prospective observational cohort study.

SETTING

Single-centre hospital in the Netherlands.

PARTICIPANTS

120 patients, diagnosed with TIA or minor stroke and discharged without rehabilitation treatment, completed the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

QoL (RAND-36), anxiety and depressive symptoms (Hospital Anxiety and Depression scale), the degree of disability or functional dependence after stroke (modified Rankin Scale (mRS)) and symptoms of anxiety and depression specific to stroke (SSADQ) were assessed at baseline (2-6 weeks poststroke) and compared with follow-up at 1 year poststroke.

RESULTS

Depression (B=-1.35, p<0.001) and anxiety (B=-0.57, p=0.041) at baseline predicted a worse mental component of QoL after 1 year. Depression (B=-1.100, p<0.001) at baseline, but also age (B=-0.261, p=0.002) and female sex (B=4.101, p=0.034) predicted a worse physical component of QoL after 1 year.

CONCLUSION

With the identification of these predictors, we might be able to select more efficiently and timely the patients with TIA or minor stroke who need stroke aftercare.

Participation in Younger and Older Adults Post-stroke: Frequency, Importance, and Desirability of Engagement in Activities

Purpose: To characterize and compare frequency and subjective dimensions of post-stroke participation in younger (<65) and older adults (>age 65), in social, productivity and leisure activities, 6 months post-inpatient rehabilitation. Secondary aims included exploration of demographic and clinical factors influencing desire for increased participation and comparison of two measures of participation. Methods: A prospective cohort study of people with stroke (n = 99) who were identified during their inpatient rehabilitation stay and followed-up 6 months post-discharge with telephone interviews using two self-report participation measures. The Stroke Impact Participation subscale (SIS-P) measured the frequency of perceived limitations in social, leisure, productive activities and extent of stroke recovery. The Community Participation Indicators (CPI) examined activity frequency, importance, and desire for increased activity engagement. Descriptive statistics were used to summarize demographic variables and characterize SIS-P and CPI items. Differences between age groups on individual items were examined. Associations between measures and demographic variables were explored. Results: Both groups reported a wide variation in participation restrictions that was not associated with stroke severity and weakly associated with discharge functional status (rho = 0.20-0.35). There were no significant differences between age groups in CPI frequency (for 18/19 items), or the SIS-P. However, there was a trend toward more participation restrictions on the SIS-P among those <65 (p = 0.07). Younger adults (n = 46; median age = 53) were significantly more likely to indicate that they were not doing selected activities enough on the CPI, compared with older adults (n = 56; median age = 76). While age and ethnicity were independently associated with some activities, it was not associated with other activities. The CPI and SIS-P were moderately related at a correlation of rho = 0.54, p < 0.001. Conclusion: The CPI demonstrated value and utility in examining subjective perspectives of activity importance and desire for change for people who are 6 months post-stroke. Although the CPI and SIS-P are moderately related, subjective appraisal of participation in selected individual activities (CPI) better distinguished between age groups and provided unique and distinct information from the SIS-P.

Participation and autonomy five years after stroke: A longitudinal observational study

OBJECTIVE

Stroke is the second most common cause of disability in the world. The purpose of this study was to evaluate the participation and autonomy of persons with stroke, five years after a stroke, and to explore potential associations between factors and perceived restrictions in participation and autonomy.

METHODS

This five-year follow-up survey study included individuals diagnosed with a first-time stroke during 2009-2010, in Gothenburg. The survey included the Impact of Participation and Autonomy-questionnaire (IPA-E), which comprised five domains: Autonomy Indoor, Family Role, Autonomy Outdoor, Work & Education, and Social Life & Relationships. Logistic regression analyses were used to analyze factors associated with participation restrictions.

RESULTS

At 5 years after a stroke, 457 patients were alive; of these, 281 responded to the follow-up survey. Participation restrictions were most pronounced in the IPA-E domains of Autonomy Outdoors, Work/Education, and Social Life and Relationships. In contrast, restrictions were less pronounced in the IPA-E domains of Autonomy Indoors and Family Role. Severe stroke, older age, and female sex predicted participation restrictions at five years after a stroke. Participation restrictions were partly explained by feelings of depression at five years after stroke. Problems associated with participation restrictions were most frequently observed in the areas of mobility, leisure, and help/support from other people.

CONCLUSION

This study showed that participation and autonomy were restricted among persons with stroke at five years after the stroke. The domains perceived as most restricted were those that required high levels of physical, social, and cognitive abilities.

Peer support interventions for individuals with acquired brain injury, cerebral palsy, and spina bifida: a systematic review

Background

Neurological disorders may negatively impact community integration and/or quality of life. Peer support has emerged as a potential strategy to enhance patients’ efficacy in managing their own health. This review examines the key characteristics and impact of peer support interventions for adults with acquired brain injury, cerebral palsy, and spina bifida on community integration and quality of life.

Methods

Eligible studies reported on peer support interventions for adults (16 years of age or older) with acquired brain injury, cerebral palsy, or spina bifida. Only randomized controlled trials published in English in the last 10 years were included. MEDLINE, EMBASE, PsycINFO, and CINAHL were used to conduct the literature search. Two reviewers independently screened studies, abstracted data, and evaluated the risk of bias (for individual study elements and overall) using the Cochrane Risk of Bias Tool.

Results

The systematic review included 6 trials reporting on acquired brain injury only. Of these studies, 4 reported on stroke and 2 reported on traumatic brain injury. Two studies found significant improvements in quality of life following peer support. No studies reported significant results on community integration. Considerable heterogeneity existed in the key characteristics of interventions.

Conclusions

There are a limited number of studies on the impact of peer support interventions for adults with acquired brain injury, cerebral palsy, or spina bifida on community integration and quality of life. Standardization of key intervention characteristics may aid the global adoption of peer support as a formalized, evidence-based practice.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4110-5) contains supplementary material, which is available to authorized users.

Enriching Communicative Environments: Leveraging Advances in Neuroplasticity for Improving Outcomes in Neurogenic Communication Disorders

Purpose Research manipulating the complexity of housing environments for healthy and brain-damaged animals has offered strong, well-replicated evidence for the positive impacts in animal models of enriched environments on neuroplasticity and behavioral outcomes across the lifespan. This article reviews foundational work on environmental enrichment from the animal literature and considers how it relates to a line of research examining rich communicative environments among adults with aphasia, amnesia, and related cognitive-communication disorders. Method Drawing on the authors' own research and the broader literature, this article first presents a critical review of environmental complexity from the animal literature. Building on that animal research, the second section begins by defining rich communicative environments for humans (highlighting the combined effects of complexity, voluntariness, and experiential quality). It then introduces key frameworks for analyzing and designing rich communicative environments: distributed communication and functional systems along with sociocultural theories of learning and development in humans that support them. The final section provides an overview of Hengst's and Duff's basic and translational research, which has been designed to exploit the insights of sociocultural theories and research on environmental complexity. In particular, this research has aimed to enrich communicative interactions in clinical settings, to trace specific communicative resources that characterize such interactions, and to marshal rich communicative environments for therapeutic goals for individuals with aphasia and amnesia. Conclusions This article concludes by arguing that enriching and optimizing environments and experiences offers a very promising approach to rehabilitation efforts designed to enhance the reorganization of cognitive-communicative abilities after brain injury. Such interventions would require clinicians to use the principles outlined here to enrich communicative environments and to target distributed communication in functional systems (not the isolated language of individuals).

Classification of Mild Stroke: A Mapping Review

Persons with mild stroke experience motor and cognitive impairments that negatively affect their health and quality of life. To address these deficits, it is essential for clinicians and researchers to precisely identify mild stroke survivors. Despite the fact that half of all strokes are categorized as mild, no standards exist on what constitutes a "mild" stroke. The purpose of this study is to summarize the current classification of mild stroke using a mapping review approach. Strategies to categorize "mild stroke" severity were explored in 188 papers indexed in the PubMed database. The results indicate that there was substantial variability in the procedures and scoring criteria used to determine mild stroke. To identify persons with mild stroke, researchers have largely applied assessment instruments developed to inform acute stroke care (eg, National Institutes of Health Stroke Scale, Modified Rankin Scale, Barthel Index). Unfortunately, these approaches demonstrate floor effects and fail to detect the long-term disabling impairments that often limit the outcomes of mild stroke survivors. Additional research is warranted to suggest an evidence-based mild stroke categorization strategy that enhances diagnosis, treatment, and referral decisions to the benefit of mild stroke survivors.

Motivators and barriers to using information and communication technology in everyday life following stroke: a qualitative and video observation study

Purpose: Information and communication technology devices have become a ubiquitous part of everyday life and a primary means of communication. The aim of this study was to describe the experience of information and communication technology and to explore the barriers and motivators to its use following stroke.Materials and methods: This observational study used semi-structured individual interviews and video observation of information and communication technology device use with six people, four men, and two women age 60-82 years with upper limb disability following stroke. They were analyzed using thematic analysis.Results: Three themes were identified that relate to barriers: (i) Sensory and motor impairments; (ii) Limited vision and impaired speech; and (iii) Device-specific limitations. Six themes were identified as motivators: (i) Connect with others; (ii) Provide safety; (iii) Facilitate reintegration; (iv) Reinforce technology adoption; (v) Leisure activities; and (vi) Contribute to the rehabilitation process.Conclusion: All participants used some form of information and communication technology daily to promote safety, enable daily activities, and social interaction, and to a lesser extent engage in leisure and rehabilitation activities. Barriers to information and communication technology use were primarily related to stroke related impairments and device-specific requirements, which limited use, particularly of smartphones. These barriers should be addressed to facilitate the use of information and communication technology devices.Implications for rehabilitationThis research suggests that;People with stroke are highly motivated to use information and communication technology devices in daily activitiesStroke-specific and age-related impairments limit the use and functionality of information and communication technology devices for people with strokeInformation and communication technology devices do not appear to be promoted or used in the rehabilitation or as assistive technologies.

Cognitive deficits in acute mild ischemic stroke and TIA and effects of rt-PA

Introduction

It is unknown if treatment with rt-PA in mild acute ischemic stroke (MIS) is associated with improvement in long term cognition.

Methods

Forty-five patients with suspected acute mild stroke or transient ischemic attacks with NIHSS ≤6 were enrolled in a prospective cohort. Cognitive testing was performed within 24 h of symptom onset. Follow-up assessment was performed at Day 90 on 25 patients. Prestroke baseline cognition was based on age, years of education (YrE), history of cognitive impairment, and the Fazekas score.

Results

Eighty-five percent patients with suspected MIS or TIA showed cognitive abnormalities within 24 h of onset. There was no significant difference in age, sex, Fazekas score, or YrE between rt-PA versus No-rt-PA groups (N = 8 vs. 17).Two sample t-test for change in performance in the WMS-III sub-tests (follow-up - baseline) ± SD, indicated a difference between rt-PA 0.74 ± 0.77 and no-rt-PA groups -0.02 ± 0.83 (P = 0.044). Logistic regression for predicting normal status using the mental control subtest, at follow-up showed an OR 8.96, CI 0.98-82.12 (P = 0.05) favoring the rt-PA group. Improvement in Mental Control at 90 days occurred in patients with low white matter disease compared to high white matter disease, 0.60 ± 0.46 (P = 0.048). A statistical trend was observed and suggested an improvement on SDMT and Trail Making tests, 1.43 ± 0.8 (P = 0.077).

Conclusion

Suspected MIS and TIA patients have cognitive impairment within 24 h of onset. rt-PA administration might be associated with improvement on some cognitive tests at 90 days.

Activities of daily living and life satisfaction of persons with stroke after rehabilitation in China: a longitudinal descriptive study

OBJECTIVES

The information regarding to the long-term outcome of stroke after rehabilitation is limited in China. The aims were to investigate activities of daily living (ADLs) and life satisfaction after stroke in China within 3 years after rehabilitation, and to explore the possible predictors of life satisfaction.

METHODS

A longitudinal descriptive study was conducted to evaluate ADLs and life satisfaction of persons with stroke. Participants completed Life Satisfaction Checklist-11 (LiSat-11), and Barthel Index (BI) at discharge, 6, 12 months, and 3 years after discharge.

RESULTS

A total of 69 participants were followed at discharge, and 32 of them finished 3 years' follow-up. BI increased significantly within 3 years compared with that at discharge (p < 0.01). Total score and all items of LiSat-11 indicated low satisfaction and was maintained relatively stable within 3 years except for a decreased satisfaction in "sexual life" (p < 0.05). Life satisfaction at 12 months was predicted by stroke severity, marital status, and return to work (R² = 0.38) and life satisfaction at 3 years was predicted by disability (R² = 0.27). Age was found as a predictor for items "Vocation" and "Leisure" (R² = 0.26 and 0.31, respectively).

CONCLUSIONS

Functional independence in ADLs increased within 3 years after discharge from rehabilitation, while life satisfaction was reported low and constant. Life satisfaction was predicted by severity of stroke, marital status, and return back to work at 1 year post discharge and by disability at 3 years post discharge.

From Hospital to Home to Participation: A Position Paper on Transition Planning Poststroke

Based on a review of the evidence, members of the American Congress of Rehabilitation Medicine Stroke Group's Movement Interventions Task Force offer these 5 recommendations to help improve transitions of care for patients and their caregivers: (1) improving communication processes; (2) using transition specialists; (3) implementing a patient-centered discharge checklist; (4) using standardized outcome measures; and (5) establishing partnerships with community wellness programs. Because of changes in health care policy, there are incentives to improve transitions during stroke rehabilitation. Although transition management programs often include multidisciplinary teams, medication management, caregiver education, and follow-up care management, there is a lack of a comprehensive and standardized approach to implement transition management protocols during poststroke rehabilitation. This article uses the Transitions of Care (TOC) model to conceptualize how to facilitate a comprehensive patient-centered hand off at discharge to maximize patient functioning and health. Specifically, this article reviews current guidelines and provides an evidence summary of several commonly cited approaches (Early Supported Discharge, planned predischarge home visits, discharge checklists) to manage TOC, followed by a description of documented barriers to effective transitions. Patient-centered and standardized transition management may improve community integration, activities of daily living performance, and quality of life for stroke survivors while also decreasing hospital readmission rates during the transition from hospital to home to community.

Emotional and social characteristics of stroke patients with low verbal memory

BACKGROUND

Cognitive deficits, especially problems with memory observed after stroke often coexist with patients' experience of difficulties in everyday life situations.

AIMS

The purposes of the study were to explore the relationships between verbal memory, emotional functioning and social competence in stroke patients, and to examine the emotional and social condition of stroke patients with low verbal memory.

METHODS

Ninety-five participants were assessed with the Rey Auditory Verbal Learning Test, the Neuropsychology Behavior and Affect Profile, and the Social Competency Questionnaire. The participants' relatives (N = 95) also took part in the study evaluating patients' emotional and social functioning.

RESULTS

Stroke patients with low verbal memory had higher scores in depression, indifference, and inappropriateness than the patients with normal memory. They also obtained higher scores in the self-reported intimacy and lower scores in objectively assessed social exposition than controls.

DISCUSSION

It is worth considering patients' relationships with relatives that evolve after stroke, especially when the patients experience cognitive difficulties in gaining new information. Collecting verbal information seems to be important for the feeling of effectiveness in some dimensions of elders' social functioning.

CONCLUSIONS

Because the social engagement may be treated as protective factor in the course of recovery we would recommend that during rehabilitation more attention should be paid to emotional and social functioning of stroke patients with low verbal memory.

Course of Social Participation in the First 2 Years After Stroke and Its Associations With Demographic and Stroke-Related Factors

Background. Many persons with stroke experience physical, cognitive, and emotional problems that contribute to restrictions in social participation. There is, however, a lack of knowledge on the long-term course of participation over time post-stroke. Objective. To describe the time course of participation up to 2 years post-stroke and to identify which demographic and stroke-related factors are associated with this time course. Methods. This was a multicenter, prospective cohort study following 390 persons with stroke from hospital admission up to 2 years (at 2, 6, 12, and 24 months). Multilevel modeling with linear and quadratic time effects was used to examine the course of the frequency of vocational and social/leisure activities, experienced restrictions, and satisfaction with participation. Results. The frequency of vocational activities increased up to 1 year post-stroke and leveled off thereafter. Older and lower-educated persons showed less favorable courses of participation than younger and higher-educated persons, respectively. The frequency of social/leisure activities decreased post-stroke. Participation restrictions declined up to 1 year post-stroke and leveled off thereafter. Persons dependent in activities of daily living (ADL) kept experiencing more restrictions throughout time than independent persons. Satisfaction with participation increased slightly over time. Conclusions. Changes in participation occurred mostly in the first year post-stroke. Particularly older and lower-educated persons, and those dependent in ADL showed less favorable courses of participation up to 2 years post-stroke. Clinicians can apply these findings in identifying persons most at risk of long-term unfavorable participation outcome and, thus, target rehabilitation programs accordingly.

Construct validity of the NIH Toolbox Cognition Battery in individuals with stroke

OBJECTIVE

The National Institutes of Health (NIH) Toolbox (NIHTB) for the Assessment of Behavior and Neurological Function Cognition Battery (NIHTB-CB) provides a brief assessment (approximately 30 min) of key components of cognition. This article examines construct validity to support the clinical utility of the NIHTB-CB in individuals with stroke.

RESEARCH METHOD

A total of 131 individuals with stroke (n = 71 mild stroke; n = 60 moderate/severe stroke) completed the NIHTB-CB. Univariate analyses were conducted to examine the cognitive profiles of the two different stroke groups (mild vs. moderate/severe stroke) on NIHTB-CB measures and composite scores. Pearson correlations were conducted between NIHTB-CB and established measures to examine convergent and discriminant validity. Effect sizes and clinical impairment rates for the different NIHTB-CB measures and composite scores were also examined.

RESULTS

Participants experiencing moderate to severe stroke had poorer performance than did individuals with mild stroke on several of the NIHTB cognition measures. Evidence of convergent validity was provided by moderate to strong correlations between the NIHTB measures and the corresponding standard neuropsychological test (Pearson rs ranged from 0.31 to 0.88; median = .60). Evidence of discriminant validity was provided by smaller correlations between different cognitive domains than correlations of measures within the same domain. Effect sizes for composite and subtest scores regarding stroke severity were generally moderate-to-large. In addition, 42% of the sample were exhibiting mild cognitive impairment (i.e., ≥2 low scores on fluid tests).

CONCLUSIONS

Findings provide support for the construct validity of the NIHTB-CB in individuals with stroke. (PsycINFO Database Record

Effects of Somatosensory Impairment on Participation After Stroke

OBJECTIVE

Our objective was to determine the effect of loss of body sensation on activity participation in stroke survivors.

METHOD

Participants (N = 268) were assessed at hospital admission for somatosensory and motor impairment using the National Institutes of Health Stroke Scale. Participation was assessed using the Activity Card Sort (ACS) in the postacute phase. Between-group differences in activity participation were analyzed for participants with and without somatosensory impairment and with or without paresis.

RESULTS

Somatosensory impairment was experienced in 33.6% of the sample and paresis in 42.9%. ACS profiles were obtained at a median of 222 days poststroke. Somatosensory loss alone (z = 1.96, p = .048) and paresis in upper and lower limbs without sensory loss (z = 4.62, p < .001) influenced activity participation.

CONCLUSION

Somatosensory impairment is associated with reduced activity participation; however, paresis of upper and lower limbs can mask the contribution of sensory loss.

Validity of the PROMIS-10 Global Health assessed by telephone and on paper in minor stroke and transient ischaemic attack in the Netherlands

OBJECTIVES

Dysfunction after transient ischaemic attack (TIA) and minor stroke is often underestimated by clinical measures. Patient-reported outcome measures used in value-based healthcare may help in detecting these problems. The Patient-Reported Outcomes Measurement Information System 10-Question Short Form (PROMIS-10 Global Health) is a concise patient-centred outcome measuring tool proposed for assessing health status in patients who had stroke. This study aims to address the validity of the Dutch PROMIS-10 in patients who had stroke in the Netherlands and also aims to compare telephone versus on-paper assessment.

DESIGN

Observational cohort study.

SETTING

Single-centre hospital in the Netherlands.

PARTICIPANTS

75 patients who were diagnosed with TIA or minor stroke and discharged without rehabilitation treatment 1 year ago (between December 2014 and January 2016) completed the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

PROMIS-10 physical (PH) and mental health (MH) scores assessed 1 year poststroke on paper (n=37) and by telephone (n=38) was compared with RAND-36 physical and mental component scores assessed on paper.

RESULTS

PROMIS-10 and RAND-36 correlated significantly in PH, r=0.81 (95% CI 0.69 to 0.88), and MH, r=0.76 (95% CI 0.64 to 0.85). Paper-and-pencil assessed correlations were r=0.87 and 0.79 for PH and MH, respectively. Telephone assessed correlations were r=0.76 and 0.73 for PH and MH, respectively. Internal consistency analysis indicated high reliabilities for both health components of the PROMIS-10, all Cronbach's α>0.70.

CONCLUSIONS

The Dutch PROMIS-10 was found to strongly correlate with the RAND-36. Paper-and-pencil assessment was found to have a higher correlation than telephone assessment. This study provides support for the use of the Dutch PROMIS-10 in assessing health status in patients after TIA and minor stroke.

Client Perceptions of Task-Oriented Training at Home: “I Forgot I Was Sick”

Task-oriented training is a contemporary intervention based on behavioral neuroscience and recent models of motor learning. It can logically be guided by the theory of occupational adaptation. This report presents the perceptions of four participants who underwent task-oriented training at home (TOTE Home) for upper extremity hemiparesis following a stroke. Guided by principles of motor learning and the theory of occupational adaptation, a directed content analysis was used with field notes recorded during the TOTE Home. Three themes emerged: salience of the activity within context, desire for mastery by creating the just right challenge, and adapted self-perception of abilities. While motor learning principles informed the method of task practice and feedback, it was the person’s desire to perform meaningful, relevant activities that drove the adaptive process. This study provided insight in the perceptions and experiences of participants undergoing TOTE Home.

Thoughts About the Negative Results of Clinical Trials in Rehabilitation Medicine

The last decade has witnessed an increase in the number of moderate to large-scale nonpharmacologic stroke recovery trials. While a majority, having tested the superiority of a particular evidence-based intervention, returned negative findings, the rehabilitation research community has gained an important perspective for future efforts. We offer our interpretation first, on why most of the past decade’s trials failed in the sense of not supporting the primary superiority hypothesis, and, second, we provide our perspective on how to solve this problem and thereby inform the next generation of neurorehabilitation clinical trials. The first large-scale randomized controlled trial (RCT) ever conducted in neurorehabilitation was the Extremity Constraint Induced Movement Therapy Evaluation (EXCITE) trial. The majority of stroke recovery trials that followed were based on a prevailing, but as yet immature science of brain-behavior mechanisms for recovery and limited practical know-how about how to select the most meaningful outcomes. The research community had been seduced by a set of preclinical studies, ignited by the 1990’s revolution in neuroscience and an oversimplified premise that high doses of task-oriented training was the most important ingredient to foster recovery. Here, we highlight recent qualitative and quantitative evidence, both mechanistic and theory-driven, that integrates crucial social and personal factors to inform a more mature science better suited for the next generation of recovery-supportive rehabilitation clinical trials.

Establishing research priorities relating to the long-term impact of TIA and minor stroke through stakeholder-centred consensus

PLAIN ENGLISH SUMMARY

What is the problem and why is this important? Mini-strokes are similar to full strokes, but symptoms last less than 24 h. Many people (up to 70%) have long-term problems after a mini-stroke, such as anxiety; depression; problems with brain functioning (like memory loss); and fatigue (feeling tired). However, the current healthcare pathway only focuses on preventing another stroke and care for other long-term problems is not routinely given. Without proper treatment, people with long-term problems after a mini-stroke could have worse quality of life and may find it difficult to return to work and their social activities. What is the aim of the research? We wanted to understand the research priorities of patients, health care professionals and key stakeholders relating to the long-term impact of mini-stroke. How did we address the problem? We invited patients, clinicians, researchers and other stakeholders to attend a meeting. At the meeting people discussed the issues relating to the long-term impact of mini-stroke and came to an agreement on their research priorities. There were three stages: (1) people wrote down their individual research suggestions; (2) in smaller groups people came to an agreement on what their top research questions were; and (3) the whole group agreed final research priorities. What did we find? Eleven people attended who were representatives for patients, GPs, stroke consultants, stroke nurses, psychologists, the Stroke Association (charity) and stroke researchers, The group agreed on eleven research questions which they felt were the most important to improve health and well-being for people who have had a mini-stroke.The eleven research questions encompass a range of categories, including: understanding the existing care patients receive (according to diagnosis and geographical location); exploring what optimal care post-TIA/minor stroke should comprise (identifying and treating impairments, information giving and support groups) and how that care should be delivered (clinical setting and follow-up pathway); impact on family members; and education/training for health care professionals.

ABSTRACT

Background Clinical management after transient ischaemic attack (TIA) and minor stroke focuses on stroke prevention. However, evidence demonstrates that many patients experience ongoing residual impairments. Residual impairments post-TIA and minor stroke may affect patients' quality of life and return to work or social activities. Research priorities of patients, health care professionals and key stakeholders relating to the long-term impact of TIA and minor stroke are unknown.Methods Our objective was to establish the top shared research priorities relating to the long-term impact of TIA and minor stroke through stakeholder-centred consensus. A one-day priority setting consensus meeting took place with representatives from different stakeholder groups in October 2016 (Birmingham, UK). Nominal group technique was used to establish research priorities. This involved three stages: (i) gathering research priorities from individual stakeholders; (ii) interim prioritisation in three subgroups; and (iii) final priority setting.Results The priority setting consensus meeting was attended by 11 stakeholders. The individual stakeholders identified 34 different research priorities. During the interim prioritisation exercise, the three subgroups generated 24 unique research priorities which were discussed as a whole group. Following the final consensus discussion, 11 shared research priorities were unanimously agreed.The 11 research questions encompass a range of categories, including: understanding the existing care patients receive (according to diagnosis and geographical location); exploring what optimal care post-TIA/minor stroke should comprise (identifying and treating impairments, information giving and support groups) and how that care should be delivered (clinical setting and follow-up pathway); impact on family members; and education/training for health care professionals.Conclusions Eleven different research priorities were established through stakeholder-centred consensus. These research questions could usefully inform the research agenda and policy decisions for TIA and minor stroke. Inclusion of stakeholders in setting research priorities is important to increase the relevance of research and reduce research waste.

Return to work predictors of stroke survivors and their spousal caregivers

BACKGROUND

Return to work is an issue of concern for stroke survivors and their spouses. Ramifications may include loss of income and self-efficacy.

OBJECTIVE

This study describes the return to work patterns of stroke survivors and their spousal caregivers post stroke.

METHODS

One hundred fifty-nine dyads were examined for their return to work patterns at baseline (post hospital discharge) and then at 3 month intervals for one year. Relationships were determined between work and gender, age, ethnicity, education, type of insurance, type of stroke, location of stroke, motor and cognitive functional status, depression, mutuality, and life satisfaction.

RESULTS

Low levels of return to work by stroke survivors (7.5%) and a small decrease in the amount of working caregivers (from 45.3% to 40.35%) were found one year post baseline. Variables that predicted return to work changed over the five data points except for younger age for the caregiver, which was consistently significant across all data points. Three case scenarios representative of working patterns are offered.

CONCLUSIONS

Further research is needed regarding the return to work needs of stroke survivors and their spousal caregivers, particularly what role the occupational therapist may play in facilitating that process.

Impact of disease duration on functional status of patients with spinocerebellar ataxia type 2

OBJECTIVE

To correlate disease duration in spinocerebellar ataxia type 2 (SCA2) with disease severity, balance and functionality.

METHOD

Sixteen SCA2 patients were analyzed for: disease duration, disease severity (SARA score), balance (Berg balance scale score) and functionality (FIM and Lawton scores).

RESULTS

Greater severity was correlated with worse functionality (Lawton: r = -0.0561, FIM: r = -0.6402) and balance (r = -0.7188). Longer disease duration was correlated with greater severity (p = 0.0002) and reduced functionality (FIM: p = 0.005; Lawton: p = 0.0402) and balance (p = 0.0036). A year increase in disease duration corresponded to a 0.8-point increase on the SARA scale, a 1.38-point decrease in FIM score, a 2.30-point decrease on the Berg balance scale and a 0.45-point decrease on the Lawton scale.

CONCLUSION

Longer disease duration in this series of SCA2 patients was correlated with greater disease severity, worse balance and greater functional dependency.

The ATTEND trial: An alternative explanation with implications for future recovery and rehabilitation clinical trials

Over the past decade, ATTEND is one of only a handful of moderate to large-scale nonpharmacologic stroke recovery trials with a focus on rehabilitation. While unique in some respects, its test of superiority for the experimental intervention returned negative/neutral results, with no differences in outcome between the experimental intervention and an appropriate control group – a result not uncommon to the majority of moderate to large stroke rehabilitation intervention trials (i.e. six out of eight conducted in the past decade). The authors offer a number of potential explanations for the negative outcome, all of which have merit. We choose not to dwell on these possibilities, but rather offer a radically different explanation, one which has implications for future rehabilitation clinical trials. Our premise is that the process of neurorehabilitation is complex and multifaceted, but most importantly, for success, it requires a genuine collaboration between the patient and the clinician or caregiver to effect optimal recovery. This collaborative relationship must be defined by the unique perspective of each patient. By doing so, we acknowledge the importance of the individual patient’s values, goals, perspectives, and capacity. Rehabilitation scientists can design what arguably is a scientifically sound intervention that is evidence-based and even with preliminary data supporting its efficacy, but if the patient does not value the target outcome, does not fully engage in the therapy, or does not expect the intervention to succeed, the likelihood of success is poor. We offer this opinion, not to be critical, but to suggest a paradigm shift in the way in which we conduct stroke recovery and rehabilitation trials.

Racial Differences in Neurocognitive Outcomes Post-Stroke: The Impact of Healthcare Variables

OBJECTIVES

The present study examined differences in neurocognitive outcomes among non-Hispanic Black and White stroke survivors using the NIH Toolbox-Cognition Battery (NIHTB-CB), and investigated the roles of healthcare variables in explaining racial differences in neurocognitive outcomes post-stroke.

METHODS

One-hundred seventy adults (91 Black; 79 White), who participated in a multisite study were included (age: M=56.4; SD=12.6; education: M=13.7; SD=2.5; 50% male; years post-stroke: 1-18; stroke type: 72% ischemic, 28% hemorrhagic). Neurocognitive function was assessed with the NIHTB-CB, using demographically corrected norms. Participants completed measures of socio-demographic characteristics, health literacy, and healthcare use and access. Stroke severity was assessed with the Modified Rankin Scale.

RESULTS

An independent samples t test indicated Blacks showed more neurocognitive impairment (NIHTB-CB Fluid Composite T-score: M=37.63; SD=11.67) than Whites (Fluid T-score: M=42.59, SD=11.54; p=.006). This difference remained significant after adjusting for reading level (NIHTB-CB Oral Reading), and when stratified by stroke severity. Blacks also scored lower on health literacy, reported differences in insurance type, and reported decreased confidence in the doctors treating them. Multivariable models adjusting for reading level and injury severity showed that health literacy and insurance type were statistically significant predictors of the Fluid cognitive composite (p<.001 and p=.02, respectively) and significantly mediated racial differences on neurocognitive impairment.

CONCLUSIONS

We replicated prior work showing that Blacks are at increased risk for poorer neurocognitive outcomes post-stroke than Whites. Health literacy and insurance type might be important modifiable factors influencing these differences. (JINS, 2017, 23, 640-652).

Post-acute hospital healthcare services for people with mild stroke: a scoping review

BACKGROUND

People with mild stroke comprise a significant proportion of the overall stroke population. Previously this population has been viewed as having limited impairments, receiving minimal services following hospital discharge. Recent findings demonstrate that the implications of mild stroke are more significant than originally comprehended, warranting further services.

OBJECTIVES

To identify the evidence-base regarding services for people with mild stroke, post-acute hospital discharge, that target secondary prevention and/or changes following stroke.

METHODS

Scoping review utilizing the five-stage framework proposed by Arksey and O'Malley, with revisions by Levac, Colquhuon, and O'Brien. Framework stages included: identification of a research question and relevant studies, study selection, charting of data, and collating, summarizing, and reporting. A critical appraisal using the Downs and Black Checklist was added to determine methodological quality of studies. The search strategy used six databases: Pubmed, Embase, PsycINFO, CINAHL, OTseeker, and Scopus, alongside a hand-search. Three researchers were involved in article selection and two in critical appraisal.

RESULTS

Twelve articles met inclusion criteria from 589 identified. A number of study methodologies were used to assess services, with varying methodological qualities. Studies were located within two major regions in the world. Five main approaches to service provision were identified: telehealth, exercise and education, Comprehensive Cardiac Rehabilitation, one-off visits and care-plan development, and community group programs. The majority of programs focused on secondary prevention and were aimed at an impairment level, with a mix of findings observed.

CONCLUSION

Further development and assessment of services is warranted. Incorporation of the entire transition period, and research that is mild stroke and location-specific is advised. Attention to maximizing participation in daily life, secondary prevention, emotional well-being, and careful reporting is needed.

Functional Test of the Hemiparetic Upper Extremity: A Rasch Analysis With Theoretical Implications

OBJECTIVE

To investigate the measurement properties of the Functional Test of the Hemiparetic Upper Extremity (FTHUE) and examine how its score may or may not inform design of a rehabilitation program.

DESIGN

The FTHUE was recently used in the Interdisciplinary Comprehensive Arm Rehabilitation Evaluation randomized controlled trial. This circumstance provided the opportunity to examine the psychometric properties of the FTHUE as it pertains to contemporary poststroke rehabilitation and recovery models.

SETTING

Outpatient rehabilitation clinic.

PARTICIPANTS

Participants (N=109; mean age, 61.2±13.5y; mean days poststroke, 46±20.3) with resultant hemiparesis in the upper extremity.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Dimensionality was examined with confirmatory factor analysis (CFA), and person and item measures were derived with Rasch item response analysis. Therapists' notes were also reviewed.

RESULTS

The CFA results support unidimensionality, and 16 of 17 items fit the Rasch model. The Rasch person separation (2.17) and item separation (4.50) indices, ability strata (3.22), person reliability (.82), and item reliability (.95) indicate good measurement properties. Item difficulties ranked from -6.46 to 3.43 logits; however, there was a substantial ceiling effect of person measures. Post hoc examination of therapists' written observations indicated that the scoring criteria are not sensitive to the movement strategy used for task completion.

CONCLUSIONS

The FTHUE's item difficulty hierarchy indicated that scores adequately distinguished the ability to perform simple versus complex motor movements of functional tasks. However, the FTHUE scoring method did not allow inclusion of the type of movement strategy used to accomplish task items. Therefore, we suggest modifications to the FTHUE that would allow it to be used for collaborative treatment planning and align well with more contemporary perspectives on treatment theory.

Stroke survivors' levels of community reintegration, quality of life, satisfaction with the physiotherapy services and the level of caregiver strain at community health centres within the Johannesburg area

Background

Stroke survivors are discharged home before they are functionally independent and return home with activity limitations that would not be manageable without a caregiver.

Aim

To determine stroke survivors’ levels of community reintegration, quality of life (QOL), satisfaction with the physiotherapy services and the level of caregiver strain at community health centres within the Johannesburg area.

Method

This was a cross-sectional study using the following outcome measures: Maleka Stroke Community Reintegration Measure, Stroke-specific quality of life scale, Caregiver strain index and Physical therapy patient satisfaction questionnaire.

Results

A total of 108 stroke survivors and 45 caregivers participated in this study. The average age of the stroke survivors was 54 years (standard deviation = 12.73) and 58% (n = 62) had moderate to full community reintegration. They were happy with physiotherapy services but not with parking availability and cost of services. The QOL was poor with the lowest scores for energy and highest scores for vision and language domains. Twenty five (55%) caregivers were strained. A positive correlation was found between community reintegration and satisfaction with services (r = 0.27, p < 0.0001) and QOL (r = 0.51, p < 0.0001). A negative correlation was found between community reintegration and caregiver strain (r = -0.37, p < 0.0001).

Conclusion

Most stroke survivors are reintegrated into their communities except in the areas of work and education and have poor QOL and most of their caregivers are strained; however, they are satisfied with physiotherapy services.

Utility of Items of Baseline National Institutes of Health Stroke Scale as Predictors of Functional Outcomes at Three Months after Mild Ischemic Stroke

BACKGROUND

Predicting outcomes of acute stroke patients initially presenting with mild neurologic deficits is crucial in decision making regarding thrombolytic therapy. We examined the utility of individual National Institutes of Health Stroke Scale (NIHSS) score items or clusters of items as predictors of functional outcomes at 3 months after mild stroke.

METHODS

Using a multicenter stroke registry database, we identified patients with acute ischemic stroke who presented within 4.5 hours of symptom onset and had baseline NIHSS scores less than or equal to 5. Functional outcomes at 3 months were dichotomized as favorable (modified RankinScale [mRS] score 0 or 1) or unfavorable (mRS 2-6). Individual NIHSS items, clusters of items, and the total score were tested for their ability to predict outcomes in multivariable models. Area under the receiver operating characteristic curve (AUC) was used to assess model performance.

RESULTS

Of the 2209 patients who met eligibility criteria, 588 (26.6%) exhibited unfavorable functional outcomes at 3 months. Of the 15 items of the NIHSS, all except item 8 (sensory) and item 11 (extinction) were significantly associated with unfavorable functional outcomes in bivariate analysis (P's < .05). Among the multivariable models, the model with the total NIHSS score exhibited an AUC similar to that of the model with all NIHSS items in predicting functional outcomes (.758 [95% confidence interval .739-.775] versus .759 [.740-.776]; P = .75 for pairwise comparison).

CONCLUSIONS

Simply using the total NIHSS score was as effective as using all individual items in predicting outcomes of mild stroke patients.

Life satisfaction in persons with severe stroke - A longitudinal report from the Sunnaas International Network (SIN) stroke study

Introduction

The overall aim of the present study was to explore perceived life satisfaction in persons with stroke, from admission to specialised rehabilitation until follow up 1 year post-discharge. The secondary aim was to evaluate possible external and internal explanatory factors for perceived life satisfaction.

Patients and methods

A prospective, descriptive study of specialised rehabilitation of persons with stroke. Persons with a primary diagnosis of stroke were enrolled in the study.

Results

Overall, total score on LiSat-11 showed that life was perceived as satisfying by 11% on admission, 21% at discharge, 25% at 6 and 31% at 12 months after discharge from rehabilitation, reported by 230 participating persons with stroke. Repeated measurement indicated significant differences of total life satisfaction between clinics, also when controlled for disability and severity. The items "sexual life," "health," and "vocational life"/"financial" were most dissatisfying at the various reported time points. The linear regression analysis revealed an equal amount of internal and external explanatory factors at the different time points, explaining between 16% and 41% of the variations.

Discussion and conclusion

The perceived life satisfaction was reported as low/dissatisfying at the four stated time points in all the participating clinics. Four items were especially vulnerable post-stroke: vocational situation, sexual life, physical health and mental health. Both internal and external factors contributed to life satisfaction, such as gender, severity of stroke, marital status, country, models of rehabilitation, occupational status, length of stay (LOS), number of therapies and hours in therapy. However, there were significant differences between clinics, indicating that unidentified factors may also influence life satisfaction.

The effect of self-management education following mild stroke: an exploratory randomized controlled trial

BACKGROUND

Mild stroke comprises 53% of stroke hospital admissions; however, the majority of those with mild stroke patients receive little support to address chronic symptoms following stroke.

OBJECTIVES

To evaluate the feasibility and preliminary effect of the Chronic Disease Self-Management Program (CDSMP) for use with individuals immediately post mild-stroke.

METHODS

Single-blind, exploratory, randomized controlled trial with participants who sustained a mild stroke (NIHSS <6). Participants were randomized to either receive the CDSMP intervention or to an inactive control group. Primary outcomes were self-reported health and self-efficacy and were obtained at baseline, post-intervention (treatment group only), and at six months post-baseline. Wilcoxon Signed Rank Tests were used to compare change score differences for all participants and effect size was computed using effect size r for non-parametric data.

RESULTS

There were no differences between groups in demographics or baseline data with the exception of how participants felt they are able to manage their health in general (p = 0.05). At follow-up, effect sizes ranged from 0 to 0.35 (no effect to medium effect); however, while the treatment group reported improvements in several areas of health at follow-up, the results are not compelling when compared to the control group over the same time period.

CONCLUSIONS

The results did not identify a positive effect that would support the use of the CDSMP with individual's post-mild stroke; however, the generalizability of these results is limited secondary to several limitations in this exploratory study.

Robot-assisted and conventional therapies produce distinct rehabilitative trends in stroke survivors

Background

Comparing the efficacy of alternative therapeutic strategies for the rehabilitation of motor function in chronically impaired individuals is often inconclusive. For example, a recent randomized clinical trial (RCT) compared robot-assisted vs. conventional therapy in 77 patients who had had chronic motor impairment after a cerebrovascular accident. While patients assigned to robotic therapy had greater improvements in the primary outcome measure (change in score on the upper extremity section of the Fugl-Meyer assessment), the absolute difference between therapies was small, which left the clinical relevance in question.

Methods

Here we revisit that study to test whether the multidimensional rehabilitative response of these patients can better distinguish between treatment outcomes. We used principal components analysis to find the correlation of changes across seven outcome measures between the start and end of 8 weeks of therapy. Permutation tests verified the robustness of the principal components found.

Results

Each therapy in fact produces different rehabilitative trends of recovery across the clinical, functional, and quality of life domains. A rehabilitative trend is a principal component that quantifies the correlations among changes in outcomes with each therapy.

Conclusions

These findings challenge the traditional emphasis of RCTs on using a single primary outcome measure to compare rehabilitative responses that are naturally multidimensional. This alternative approach to, and interpretation of, the results of RCTs may will lead to more effective therapies targeted for the multidimensional mechanisms of recovery.

Trial registration

ClinicalTrials.gov number NCT00719433. Registered July 17, 2008.

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-016-0199-5) contains supplementary material, which is available to authorized users.

Cognitive Assessment Trends in Home Health Care for Adults With Mild Stroke

OBJECTIVE

This article describes current trends in cognitive assessment use for adults with mild stroke by home health practitioners in the United States.

METHOD

Participants were 56 home health occupational therapists and occupational therapy assistants. A self-administered survey about use of cognitive assessment tools in home health care and influences on their use was conducted.

RESULTS

Ninety-six percent of participants assessed cognition in adults with mild stroke. Nonstandardized assessments were the most widely used method for evaluating cognition in the home health setting. Influences such as specialized training in specific assessments, confidence, and productivity requirements may have affected the practitioners' cognitive assessment decisions in home health care.

CONCLUSION

Although cognitive assessments are widely used in home health care, occupational therapy practitioners are selecting nonstandardized assessments most frequently to assess cognition.