Activities, participation and satisfaction one-year post stroke

Fear of falling in people with chronic stroke

OBJECTIVE

We assessed the prevalence of fear of falling (FoF) in a sample of people with chronic stroke and compared multiple variables (balance, anxiety, depression, activity and participation, and stroke severity) in people with and without FoF.

METHOD

This study was a secondary analysis of data collected from a cross-sectional study of mobility after stroke in 77 participants with chronic stroke (>6 mo poststroke).

RESULTS

Of the 77 participants, 51 (66%) reported experiencing FoF. People with FoF had significantly decreased balance (p<.001) and activity and participation (p=.006) and significantly increased anxiety (p=.007). People with FoF also had significantly worse stroke severity (p=.001).

CONCLUSION

FoF is a prevalent concern in the chronic stroke population. The presence of FoF was associated with a variety of negative consequences. Occupational therapy practitioners should address FoF to help clients manage FoF and possibly improve recovery.

An exploratory analysis of the self-reported goals of individuals with chronic upper-extremity paresis following stroke

PURPOSE

To classify the self-identified goals of individuals post-stroke with chronic upper extremity (UE) paresis, and determine if age, UE functional capacity and pre-stroke hand dominance influence overall goal selection.

METHOD

Sixty-five subjects participated. Using the Canadian Occupational Performance Measure (COPM) to establish treatment goals, the top five goals were categorized using the Occupational Therapy Practice Framework into five categories: activities of daily living (ADLs), instrumental activities of daily living (IADLs), leisure, work and general UE movement. A Chi-square analysis determined if age, UE functional capacity (measured by the Action Research Arm Test) and UE hand dominance influenced individual goal selection.

RESULTS

The majority of goals were in the ADL (37%) and IADL (40%) categories. A small percentage (12%) was related to general UE movement. Individuals with moderate UE functional capacity identified more ADL goals than those with higher UE functional capacity. There was not a difference between age and UE dominance across all five goal areas.

CONCLUSIONS

Individuals with chronic UE paresis had specific goals that were not influenced by age or hand dominance, but partially influenced by severity. General UE movement goals were identified less than goals related to specific activities.

IMPLICATIONS FOR REHABILITATION

Considering the specificity of individual goals following stroke, it is recommended that clinicians regularly utilize a goal setting tool to help establish client goals. It is recommended that clinicians further inquire about general goals in order to link upper extremity deficits to functional activity limitations. Age, upper extremity functional capacity and hand dominance have little influence on the rehabilitation goals for individuals with chronic paresis after stroke.

Self-Care Self-Efficacy Correlates with Independence in Basic Activities of Daily Living in Individuals with Chronic Stroke

BACKGROUND

(1) To characterize the self-care self-efficacy (SCSE) of community dwelling individuals with chronic stroke and (2) to determine the contribution of SCSE to the independence in basic and instrumental activities of daily living (BADL and IADL) and the participation of individuals with chronic stroke. SCSE is the confidence in one's own ability to perform self-care activities.

METHODS

This cross-sectional study included fifty community-dwelling individuals mean (SD) age 59.8 (9.3) years, mean (SD) 3.1 (1.7) years post-stroke who were able to walk at least 10 meters. SCSE was assessed using the Stroke Self-Efficacy Questionnaire (SSEQ), BADL was assessed by the Functional Independence Measure (FIM) (interview), the IADL questionnaire assessed IADL and the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) assessed participation. Correlation and regression analyses were performed after controlling for grip strength, executive functions and gait speed, factors known to influence independence in daily living.

RESULTS

The mean SCSE level was moderate-high (70%). Significant moderate correlations were found between SCSE to independence in BADL (r = .596, P < .001), IADL (r = .567, P < .001) and participation (r = .340, P < .005). SCSE of our cohort explained 7.4% of the variance of the individual's independence in BADL after controlling for executive functions and gait speed, but did not contribute to their independence in IADL and participation.

CONCLUSIONS

Higher SCSE of individuals with chronic stroke contributes to more independence in BADL. Additional questionnaires regarding self efficacy for IADL should be developed and investigated.

Video-games used in a group setting is feasible and effective to improve indicators of physical activity in individuals with chronic stroke: a randomized controlled trial

OBJECTIVES

To investigate the feasibility of using video-games in a group setting and to compare the effectiveness of video-games as a group intervention to a traditional group intervention for improving physical activity in individuals with chronic stroke.

DESIGN

A single-blind randomized controlled trial with evaluations pre and post a 3-month intervention, and at 3-month follow-up. Compliance (session attendance), satisfaction and adverse effects were feasibility measures. Grip strength and gait speed were measures of physical activity. Hip accelerometers quantified steps/day and the Action Research Arm Test assessed the functional ability of the upper extremity.

RESULTS

Forty-seven community-dwelling individuals with chronic stroke (29-78 years) were randomly allocated to receive video-game (N=24) or traditional therapy (N=23) in a group setting. There was high treatment compliance for both interventions (video-games-78%, traditional therapy-66%), but satisfaction was rated higher for the video-game (93%) than the traditional therapy (71%) (χ(2)=4.98, P=0.026). Adverse effects were not reported in either group. Significant improvements were demonstrated in both groups for gait speed (F=3.9, P=0.02), grip strength of the weaker (F=6.67, P=0.002) and stronger hands (F=7.5, P=0.001). Daily steps and functional ability of the weaker hand did not increase in either group.

CONCLUSIONS

Using video-games in a small group setting is feasible, safe and satisfying. Video-games improve indicators of physical activity of individuals with chronic stroke.

The reliability and validity of the Complex Task Performance Assessment: A performance-based assessment of executive function

The objective of this study was to evaluate the inter-rater reliability, test-retest reliability, concurrent validity, and discriminant validity of the Complex Task Performance Assessment (CTPA): an ecologically valid performance-based assessment of executive function. Community control participants (n = 20) and individuals with mild stroke (n = 14) participated in this study. All participants completed the CTPA and a battery of cognitive assessments at initial testing. The control participants completed the CTPA at two different times one week apart. The intra-class correlation coefficient (ICC) for inter-rater reliability for the total score on the CTPA was .991. The ICCs for all of the sub-scores of the CTPA were also high (.889-.977). The CTPA total score was significantly correlated to Condition 4 of the DKEFS Color-Word Interference Test (p = -.425), and the Wechsler Test of Adult Reading (p  = -.493). Finally, there were significant differences between control subjects and individuals with mild stroke on the total score of the CTPA (p = .007) and all sub-scores except interpretation failures and total items incorrect. These results are also consistent with other current executive function performance-based assessments and indicate that the CTPA is a reliable and valid performance-based measure of executive function.

Development and evaluation of tools and an intervention to improve patient- and carer-centred outcomes in Longer-Term Stroke care and exploration of adjustment post stroke: the LoTS care research programme

Background

Evidence-based care pathways are required to support stroke patients and their carers in the longer term.

Aims

The twofold aim of this programme of four interlinking projects was to enhance the care of stroke survivors and their carers in the first year after stroke and gain insights into the process of adjustment.

Methods and results

We updated and further refined a purposely developed system of care (project 1) predicated on a patient-centred structured assessment designed to address areas of importance to patients and carers. The structured assessment is linked to evidence-based treatment algorithms, which we updated using a structured protocol: reviewing available guidelines, Cochrane reviews and randomised trials. A pragmatic cluster randomised controlled trial evaluation of the clinical effectiveness and cost-effectiveness of this system of care was undertaken in 29 community-based UK stroke care co-ordinator services (project 2). In total, 15 services provided the system of care and 14 continued with usual practice. The primary objective was to determine whether the intervention improved patient psychological outcomes (General Health Questionnaire-12) at 6 months; secondary objectives included functional outcomes for patients, outcomes for carers and cost-effectiveness, as measured through self-completed postal questionnaires at 6 and 12 months. A total of 800 patients and 208 carers were recruited; numbers of participants and their baseline characteristics were well balanced between intervention and control services. There was no evidence of statistically significant differences in primary or secondary end points or adverse events between the two groups, nor evidence of cost-effectiveness. Intervention compliance was high, indicating that this is an appropriate approach to implement evidence into clinical practice. A 22-item Longer-term Unmet Needs after Stroke (LUNS) questionnaire was developed and robustly tested (project 3). A pack including the LUNS questionnaire and outcome assessments of mood and social activity was posted to participants 3 or 6 months after stroke to assess acceptability and validity. The LUNS questionnaire was re-sent 1 week after return of the first pack to assess test–retest reliability. In total, 850 patients were recruited and the acceptability, validity and test–retest reliability of the LUNS questionnaire as a screening tool for post-stroke unmet need were confirmed. This tool is now available for clinical use. An in-depth qualitative investigation was undertaken with 22 patients (and carers) at least 1 year after stroke (project 4) to gain further insights into the experience of adjustment. This included initial semistructured interviews, limited observations and solicited diaries with a follow-up interview 3–4 months after the initial interview and highlighted a range of different trajectories for post-stroke recovery.

Conclusions

The programme has been completed as planned, including one of the largest ever stroke rehabilitation trials. This work highlights that successfully addressing the needs of a heterogeneous post-stroke population remains problematic. Future work could explore stratifying patients and targeting services towards patients (and carers) with specific needs, leading to a more specialised bespoke service. The newly developed LUNS questionnaire and the qualitative work will help inform such services.

Trial registration

Current Controlled Trials ISRCTN67932305.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme. The Bradford Teaching Hospitals NHS Foundation Trust received additional funding for project 2 in the submitted work from the Stroke Association, reference number TSA 2006/15. The initial development work for the LUNS tool and the Longer-Term Stroke care (LoTS care) trial carried out before the start of the programme grant was funded by the Stroke Association, reference number TSADRC 2006/01.

Effect of remote sensory noise on hand function post stroke

Hand motor impairment persists after stroke. Sensory inputs may facilitate recovery of motor function. This pilot study tested the effectiveness of tactile sensory noise in improving hand motor function in chronic stroke survivors with tactile sensory deficits, using a repeated measures design. Sensory noise in the form of subthreshold, white noise, mechanical vibration was applied to the wrist skin during motor tasks. Hand dexterity assessed by the Nine Hole Peg Test and the Box and Block Test and pinch strength significantly improved when the sensory noise was turned on compared with when it was turned off in chronic stroke survivors. The subthreshold sensory noise to the wrist appears to induce improvements in hand motor function possibly via neuronal connections in the sensoriomotor cortex. The approach of applying concomitant, unperceivable mechanical vibration to the wrist during hand motor tasks is easily adoptable for clinic use as well as unsupervised home use. This pilot study suggests a potential for a wristband-type assistive device to complement hand rehabilitation for stroke survivors with sensorimotor deficit.

Depression in older adults: screening and referral

Depression is related to disability and affects rehabilitation participation, outcomes, and compliance with treatment. Improving older adult depression detection and referral requires knowledge, skills, supportive organizational policies, and access to mental health experts. This review provides a selected overview of evidence-based approaches for screening of suspected cases of depression in older adults by physical therapists and other non-mental health professionals and discusses procedures to refer suspected cases to primary care providers and/or mental health specialists for evaluation, including resources and a tool to assist in communicating depression-related information to the primary care provider or mental health specialist. We hope that this review will promote the incorporation of evidence-based screening and referral of suspected cases of depression in older adults into routine practice.

Perceived participation after stroke: the influence of activity retention, reintegration, and perceived recovery

OBJECTIVE

We sought to determine the extent to which perceptions of participation in everyday occupations were affected in a sample of people with predominantly mild stroke. Demographic variables, stroke severity, community integration, participation in everyday occupations, and perceptions of recovery were examined as potential contributors to their perceptions of participation.

METHOD

We conducted a cross-sectional study with 116 people with mild to moderate first stroke assessed approximately 6 mo after stroke.

RESULTS

Perceptions of participation assessed using the Stroke Impact Scale varied (range = 19-100), with a mean score of 82. Regression analyses revealed three factors that contributed to perceptions of participation: retention of previous activities, reintegration in home and community, and perception of stroke recovery.

CONCLUSION

Although the majority of participants reported a high level of perceived participation, more than a third failed to report successful participation.

Impact of first-ever mild stroke on participation at 3 and 6 month post-event: the TABASCO study

PURPOSE

This study focused on the relationships between cognition, participation and quality of life (QoL) among first-ever mild ischemic stroke patients 3 months post-event. We hypothesized that significant correlations exist between cognition, executive functions (EF), QoL and participation; and that EF and QoL will significantly contribute to participation beyond demographics and stroke severity at 3 and from 3 to 6 months post-stroke.

METHODS

A prospective cohort study, recruiting consecutive first-ever stroke patients from a large tertiary hospital. The inclusion criteria were first event, mild stroke (NIHSS ≤ 5), and no previous significant neurological or cognitive impairment. In addition to assessment every 6 month at the hospital, an assessment battery was administered at home 3 months post-stroke.

RESULTS

Participants showed mild to moderate difficulties in cognition and participation (n = 249). Low to moderate correlations were found between cognition and EF with participation (-0.380, p < 0.05; r = 0.460, p < 0.001, respectively); and cognition with QoL (r = 0.421, p < 0.001). EF and QoL contributed significantly to participation at 3 months (R(2) = 0.961) and in addition education at 6 months (R(2) = 0.701).

CONCLUSIONS

Participants after mild ischemic stroke experienced cognitive and EF difficulties that affect their participation and QoL. Further studies are needed of mild stroke survivors to enhance our understanding of the variables that affect participation.

IMPLICATIONS FOR REHABILITATION

The findings of the current study have significant implications for the participation of people after mild stroke in the community. Health care systems in general and rehabilitation programs, in particular, do not consider that these clients need rehabilitation as most of them perform basic daily functions independently. Thus, although cognitive and EF deficits are found in people following even mild stroke, but are not externally apparent, these impairments are mostly neglected by the health care system. Mild stroke has long-term effects in most cases and effect family members as well. The implications of the study's results, as well as those of other studies, emphasize the necessity of follow-up and rehabilitation efforts at home and in the community. These efforts should focus on re-enabling the individual to participate in previous activities as much as possible and on providing support for family members. The strength of this study lies in the large number of participants who were evaluated at home in their natural environments. Studies of this kind are rarely performed in the participants' real-life settings, thus the current study provides an important perspective on the participation of this population in the community.

Caregiver-Mediated Intervention Can Improve Physical Functional Recovery of Patients With Chronic Stroke

Background and Purpose. Patients with chronic stroke may benefit from continuing rehabilitation training after hospital discharge. This study examined whether caregiver-mediated, home-based intervention (CHI) could improve physical functioning and social participation in these patients. Methods. A single-blind, randomized, controlled 12-week trial conducted with 51 patients from 3 hospitals in Taiwan who had chronic stroke (>6 months; Brunnstrom recovery stages III-V). Patients and their caregivers in the intervention arm (n = 25) were given weekly personalized CHI trainings designed by a physical therapist. Patients in the control arm (n = 26) received visits from the therapist without intervention. All were evaluated for physical recovery through the Stroke Impact Scale, Berg Balance Scale, 10-Meter Walk Test, 6-Minute Walk Test, and Barthel Index at baseline and endpoint. Caregivers were evaluated with the Caregiver Burden Scale. Results were analyzed through Mann-Whitney U test. Results. CHI significantly improved scores of the Stroke Impact Scale: strength (control vs intervention, respectively: 1.4 vs 15.5; P = .002), mobility (–0.5 vs 13.7; P < .001), composite physical (–0.7 vs 11.2; P < .001), and general recovery domain (0.2 vs 17.4; P < .001). CHI also significantly improved free-walking velocity (–1.4 vs 7.5 cm/s; P = .006), 6-minute walk distance (–10.5 vs 15.8 m; P = .003), Berg Balance Scale score (–0.8 vs 4.5; P = .006), and Barthel Index score (0.6 vs 7.2; P = .008). CHI did not significantly increase caregiver burden at endpoint. Conclusion. CHI can improve physical functional recovery and, possibly, social participation in patients with chronic stroke.

Associations between quality of life and socioeconomic factors, functional impairments and dissatisfaction with received information and home-care services among survivors living at home two years after stroke onset

Background

Quality of life (QoL) assessment is important when monitoring over time the recovery of stroke-survivors living at home. This study explores the associations between QoL and socioeconomic factors, functional impairments and self-reported dissatisfaction with received information and home-care services among survivors two years after stroke onset. This problem remains partially addressed though optimal information and services may improve survivors’ QoL.

Methods

Stroke-survivors admitted to all hospitals in Luxembourg 18 months or more previously were identified using the only care-expenditure-reimbursement national system database. The clinical diagnosis was confirmed. Ninety four patients aged 65 years and living at home were interviewed to gather socioeconomic characteristics, functional impairments, dissatisfaction with information and home-care services, and QoL (using the Newcastle Stroke-Specific QoL, newsqol) assessing 11 domains. Data were analyzed using multiple linear regression models.

Results

About 50% of survivors had low education and lower income. Functional impairments were common: sensory (45%), motor (35%), memory (32%), language (31%), and vision (20%). Survivors with education (<12th grade) or lower income had low values for most newsqol domains (sex-age-adjusted regression coefficient saRC, i.e. mean difference, between -23 and -8). Patients who were working had better values for pain, mental feelings and sleep domains than did retired people (saRC between -3.9 and 4.2). Various functional impairments were associated with markedly low values of nearly all domains (saRC between -33.5 and -7.5) and motor, language, memory and sensory impairments had the highest impact. The survivors’ perceived QoL was markedly low, especially for the domains of interpersonal relationship, sleep, cognition, mental feelings, and pain. Various QoL domains were strongly related to dissatisfaction with information about stroke and its consequences/changes over time, accuracy of information obtained, help received, coordination between services, and the possibility of receiving help when necessary (saRC reaching -30).

Conclusions

Stroke-survivors had major alterations in QoL that reflected depressive symptoms, which should be appropriately treated. These findings may help with the development of public policies aiming at improving QoL among stroke survivors. The newsqol could be used routinely to measure the recovery of survivors over time and their needs in terms of information, help and care services.

A follow-up study on the relationship among participation, activity and motor function in survivors of stroke following constraint-induced therapy

PURPOSE

The aim of this follow-up study was to examine the relationships among motor function, activity and participation following constraint-induced therapy (CIT).

METHODS

In this correlational study, 12 individuals who had previously participated in CIT completed the Fugl Meyer Assessment for the Upper Extremity and Wolf Motor Function Test (motor assessments), the Motor Activity Log (activity measure) and the Daily Experiences of Pleasure, Productivity and Restoration Profile (participation measure). Motor and activity changes over time were assessed using repeated measures ANOVA and Friedman's tests. Spearman's correlations were used to examine the associations between the participation measure and motor and activity measures were analyzed using Spearman's correlations.

RESULTS

No statistically significant correlations were found among motor and activity scores and the amount of time spent in activity categories (e.g. self-care, leisure). Yet, moderate to strong correlations were found between motor assessments and time spent with others versus alone.

CONCLUSION

The lack of significant correlations between motor, activity and participation measures challenges assumptions that improved motor abilities will translate to greater participation. Correlations found between motor and activity measures and the context of participation suggests participation post-stroke is complex, and survivors of stroke may benefit from rehabilitation practices that encompass more than motor therapy.

Mild impairment of cognition impacts on activity participation after stroke in a community-dwelling Australian cohort

Ongoing disability following stroke can severely impact activity participation and quality of life. The authors investigated the association between cognition and mood and activity participation in 30 survivors of stroke living in the community, using quantitative assessment tools. Non-parametric correlation analyses quantified the presence and strength of association between variables. Differences for those with cognitive impairment or with depressive symptoms were investigated. Survivors of stroke with cognitive impairment of even mild severity had significantly reduced participation in all activity domains. Significant differences in activity participation were not found with mood, although relatively few were identified as being depressed. The findings suggest that mild cognitive impairment after stroke is associated with participation limitations that are important for occupational therapists to consider when planning intervention.

Activity engagement of aging retirees in South Korea

[Purpose] The purpose of this study was to analyze the activity engagement of the retiree population in South Korea. [Methods] The Korean-Activity Card Sort (K-ACS) was used to collect research data. A One-way ANOVA and post-hoc comparisons showed significant group effects among three age groups. The independent t-tests was used to analyze the differences in mean retained level of activity (MRA) between men and women. [Results] The one-way ANOVA showed statistically significant differences in MRA among different age groups. Scheffé’s test revealed a statistically significant decrease in MRA in Group A, aged more than 75 years, as compared to the other two age groups. When participants were divided by gender, MRA of instrumental activities showed a statistically significant difference between the 65–74 years group and the 55–65 years group, but no difference in females of the leisure activities among the age groups. The independent t-tests demonstrated significant gender differences in MRA of activity of the 55–64 years group. [Conclusion] These findings suggest that health professionals should monitor the changes in retained level of activity after age 75, to maintain their engagement, and the importance of age-, gender- and activity-specific analyses in order to identifying patterns of activity engagement.

Corticospinal excitability as a predictor of functional gains at the affected upper limb following robotic training in chronic stroke survivors

BACKGROUND

Robotic training can help improve function of a paretic limb following a stroke, but individuals respond differently to the training. A predictor of functional gains might improve the ability to select those individuals more likely to benefit from robot-based therapy. Studies evaluating predictors of functional improvement after a robotic training are scarce. One study has found that white matter tract integrity predicts functional gains following a robotic training of the hand and wrist. Objective. To determine the predictive ability of behavioral and brain measures in order to improve selection of individuals for robotic training.

METHODS

Twenty subjects with chronic stroke participated in an 8-week course of robotic exoskeletal training for the arm. Before training, a clinical evaluation, functional magnetic resonance imaging (fMRI), diffusion tensor imaging, and transcranial magnetic stimulation (TMS) were each measured as predictors. Final functional gain was defined as change in the Box and Block Test (BBT). Measures significant in bivariate analysis were fed into a multivariate linear regression model.

RESULTS

Training was associated with an average gain of 6 ± 5 blocks on the BBT (P < .0001). Bivariate analysis revealed that lower baseline motor-evoked potential (MEP) amplitude on TMS, and lower laterality M1 index on fMRI each significantly correlated with greater BBT change. In the multivariate linear regression analysis, baseline MEP magnitude was the only measure that remained significant.

CONCLUSION

Subjects with lower baseline MEP magnitude benefited the most from robotic training of the affected arm. These subjects might have reserve remaining for the training to boost corticospinal excitability, translating into functional gains.

Poststroke shoulder pain and its association with upper extremity sensorimotor function, daily hand activities, perceived participation, and life satisfaction

OBJECTIVE

To assess the differences in upper extremity sensorimotor function, daily hand activities, and perceived participation and life satisfaction between individuals with and without poststroke shoulder pain (PSSP), and to determine how PSSP is associated with these variables.

DESIGN

A cross-sectional study of a convenience sample.

PARTICIPANTS

Forty-nine community-dwelling individuals (mean ± standard deviation [SD] age, 64 ± 9 years), 24 with PSSP and 25 without (non-PSSP) were assessed, in mean ± SD 15 ± 8 months after stroke.

METHODS

Upper extremity sensorimotor function was assessed, and daily hand activities, perceived participation, and life satisfaction were reported. Demographics were described, and shoulder pain characteristics were recorded in the PSSP group. Between-group differences and regression analyses were conducted.

RESULTS

The PSSP group had significantly decreased passive shoulder abduction (P = .001) and upper extremity motor function (P = .03) in comparison with the non-PSSP group, but there were no significant differences between the groups in daily hand activities, perceived participation, or life satisfaction. In the multivariate analyses, PSSP (odds ratio [OR] 4.42 [95% confidence interval (CI), 1.21-16.24]; P = .03) and proprioception (OR 10.28 [95% CI, 1.1-96.01]; P = .04) were associated with upper extremity motor function, whereas perceived participation was associated with life satisfaction (OR 1.08 [95% CI, 1.03-1.13]; P = .002). Passive shoulder abduction, resistance to passive movements, and proprioception explained 45% of variance of daily hand activities, whereas daily hand activities, vocational situation, and gender explained 40% of variance of perceived participation.

CONCLUSIONS

This cross-sectional study indicated that there is an association between PSSP and upper extremity motor function, whereas the association between PSSP, daily hand activities, perceived participation, and life satisfaction is less clear. PSSP is commonly described as a severely disabling condition, but our results imply that, in individuals with mild-to-moderate upper extremity paresis, it may not have a great impact on their life situation.

Understanding stroke survivorship: expanding the concept of poststroke disability

BACKGROUND AND PURPOSE

Limitations in essential daily activities are common among older adults after stroke, but little is known about restrictions in their ability to participate in valued social activities. We sought to broaden our understanding of disability after stroke by characterizing poststroke participation restrictions and investigating the extent to which they are accounted for by differences in physical and cognitive capacity, aphasia/dysarthria, depressive, and anxiety symptoms.

METHODS

Data from the 2011 National Health and Aging Trends Study (NHATS) were used to identify 892 self-reported stroke survivors aged≥65 years. One-to-one propensity matching was performed on demographics and comorbidities to create a matched sample. Participation restrictions were defined as reductions/absence in social activities valued by respondents because of their health or functioning. Physical and cognitive capacity, depressive and anxiety symptoms were measured by validated scales and aphasia/dysarthria by a single question. Comparisons using survey-weighted χ2 tests and logistic regression were made.

RESULTS

Stroke survivors had more participation restrictions (32.8% versus 23.5%; odds ratio, 1.59; 95% confidence interval, 1.28-1.95; P<0.01) than controls. Differences between stroke survivors and controls in any participation restriction and several components (attending religious service, clubs/classes, and going out for enjoyment) were eliminated after adjusting for physical capacity. Depressive and anxiety symptoms and aphasia/dysarthria were independent predictors of participation restrictions.

CONCLUSIONS

Stroke survivors have more participation restrictions than can be accounted for by sociodemographic profiles and comorbidity burden. Future work aimed at improving physical capacity, reducing depressive and anxiety symptoms, and improving aphasia/dysarthria has potential to enhance participation.

STroke imAging pRevention and Treatment (START): A Longitudinal Stroke Cohort Study: Clinical Trials Protocol

Rationale

Stroke and poststroke depression are common and have a profound and ongoing impact on an individual's quality of life. However, reliable biological correlates of poststroke depression and functional outcome have not been well established in humans.

Aims

Our aim is to identify biological factors, molecular and imaging, associated with poststroke depression and recovery that may be used to guide more targeted interventions.

Design

In a longitudinal cohort study of 200 stroke survivors, the START – STroke imAging pRevention and Treatment cohort, we will examine the relationship between gene expression, regulator proteins, depression, and functional outcome. Stroke survivors will be investigated at baseline, 24 h, three-days, three-months, and 12 months poststroke for blood-based biological associates and at days 3–7, three-months, and 12 months for depression and functional outcomes. A sub-group ( n = 100), the PrePARE: Prediction and Prevention to Achieve optimal Recovery Endpoints after stroke cohort, will also be investigated for functional and structural changes in putative depression-related brain networks and for additional cognition and activity participation outcomes. Stroke severity, diet, and lifestyle factors that may influence depression will be monitored. The impact of depression on stroke outcomes and participation in previous life activities will be quantified.

Study Outcomes

Clinical significance lies in the identification of biological factors associated with functional outcome to guide prevention and inform personalized and targeted treatments. Evidence of associations between depression, gene expression and regulator proteins, functional and structural brain changes, lifestyle and functional outcome will provide new insights for mechanism-based models of poststroke depression.

Construct validity of the functionally simulated technology task: an exploratory study

This study explored the construct validity of the Functional Simulated Technology Task (FSTT), online bill-pay version. The FSTT was administered to matched groups: persons with cognitive impairment and persons with no known cognitive impairment, established through the Montreal Cognitive Assessment (MoCA). Results indicated significance for construct validity by discriminating between the two groups. Results also indicated a good to excellent positive relationship between scores on the MoCA and the FSTT score areas of Outcome, Quality, Process, and Independence. The findings support the use of the FSTT to measure executive function using a simulated online bill-pay task.

Quality of life amongst young adults with stroke living in Kenya

BACKGROUND

The world has been experiencing an increase of stroke among young adults. Occurrence of stroke in young adults dramatically affects the quality of life of the individuals.

OBJECTIVES

To investigate the quality of life amongst young adults who experienced a stroke living in Kenya.

METHODS

A cross-sectional study was carried out on a conveniently selected sample of 161 young adults with stroke drawn from three tertiary hospitals in Kenya. The Short-Form 36-item second version (SF-36v2) was used to collect the data. Descriptive and association statistical analysis using Mann-Whitney U, and Kruskal Wallis tests were calculated on the data using SPSS.

RESULTS

In relation to a total score of 100, when expressed as a percentage the mean quality of life scores, ranged from 30% to 48% for each of the SF-36v2 domains. The results showed that males scored higher than females in all the domains except in physical functioning and that the scores decline with advance in age in most domains.

CONCLUSION

The quality of life scores for this group were low meaning that that they were experiencing more challenges with physical functioning, psychological and emotional functioning and fulfilling previous roles.

Employment status, social function decline and caregiver burden among stroke survivors. A South Indian study

Stroke leaves at least 60% of the survivors with moderate to severe disability limiting their employment status and social functioning leading to high levels of caregiver burden.

AIM

We sought to study the employment status and level of change of social functioning of stroke survivors and their principal caregiver and correlate it with severity of stroke, functional disability, and anxiety and depression scores.

METHODS

One hundred and fifty stroke survivors and principal caregivers (3 months-2 years post-stroke) were recruited for the study. The employment status pre- and post-stroke was assessed. The social function of the patient and caregiver was analyzed using a 6 item social function scale developed for the study, encompassing culturally relevant questions. A 20 point scale adapted from Burden assessment schedule was used to assess the caregiver burden.

RESULTS

Mean age of the study group was 54.37±12.072 (range 22-75 years), with 116 males and 34 females. Spouse was the principal caregiver for 142/150 patients (94.6%). In the stroke survivors, compared to the pre-stroke employment status of 62.7%, only 20.7% were employed post-stroke with half having change of job. But the employment status of caregiver was not reduced post-stroke (34.7% vs 33.3%). Employment loss in stroke survivors had a statistically significant association with severity of functional disability, male gender and presence of limb weakness (p values 0.037, 0.0001 and 0.043 respectively). There was an overall decline in social functions among the 6 parameters assessed in both the stroke survivors and caregivers. Of the caregiver burden, financial burden was more among female and older caregivers. The functional status and motor weakness of the stroke survivors did not tend to worsen the overall caregiver burden.

CONCLUSIONS

Loss of occupation among stroke survivors is high. The decline in social function among stroke survivors and caregivers was significant. Even though functional disability contributed to employment loss and social function decline among stroke survivors, it did not have a significant impact on caregiver burden.

Validation of the Longer-term Unmet Needs after Stroke (LUNS) monitoring tool: a multicentre study

Objective:

To evaluate the acceptability, test–retest reliability and validity of the Longer-term Unmet Needs after Stroke monitoring tool.

Design:

A questionnaire pack was posted to stroke survivors living at home three or six months after stroke. A second pack was sent two weeks after receipt of the completed first pack.

Setting:

Stroke survivors living at home across England.

Subjects:

Stroke survivors were recruited from 40 hospitals across England, in two phases. The first with an optimal cohort of patients, the second to capture a broader post-stroke population, including those with communication and/or cognitive difficulties. Patients were excluded if they required palliative care or if permanent discharge to a nursing or residential home was planned.

Main measures:

The questionnaire pack included the Longer-term Unmet Needs after Stroke tool, General Health Questionnaire-12, Frenchay Activities Index, and Short Form-12.

Results:

Interim analysis of phase 1 data ( n = 350) indicated that the tool was sufficiently robust to progress to phase 2 ( n = 500). Results are reported on the combined study population. Of 850 patients recruited, 199 (23%) had communication and/or cognitive difficulties. The median age was 73 years (range 28–98). Questionnaire pack return rate was 69%. For the new tool, there was 3.5% missing data and test–retest reliability was moderate to good (percentage item agreement 78–99%, kappa statistic 0.45–0.67). Identification of an unmet need was consistently associated with poorer outcomes on concurrent measures.

Conclusions:

The Longer-term Unmet Needs after Stroke tool is acceptable, reliable, can be self-completed, and used to identify longer-term unmet needs after stroke.

Determinants of change in stroke-specific quality of life after distributed constraint-induced therapy

OBJECTIVE

We identified the predictive factors of change in quality of life (QOL) after a distributed form of constraint-induced therapy (dCIT) among stroke survivors.

METHOD

Seventy-four participants were treated with dCIT. We identified eight potential determinants of change: age, gender, side of lesion, time since stroke, cognitive status, motor impairment of the upper extremity, activities of daily living (ADLs), and instrumental ADLs (IADLs). The Stroke-Specific Quality of Life Scale (SS-QOL) was used to assess QOL.

RESULTS

Right-sided lesion and onset >17 mo earlier determined greater improvement in the SS-QOL Energy domain. Onset >10 mo earlier, poorer IADL performance, and age >68 yr predicted improvement in the Family Role, Mobility, and Mood domains, respectively.

CONCLUSION

Side of lesion, time since stroke, IADL performance, and age were the most important determinants of QOL in patients receiving stroke motor rehabilitation.

Participation in the chronic phase of stroke

BACKGROUND

Participation is a multidimensional concept, consisting of an objective and a subjective dimension. Many studies have focused on determinants of only 1 dimension of participation post stroke.

OBJECTIVE

To describe participation (both objective and subjective) and to determine how physical and cognitive independence and subjective complaints (pain, fatigue, and mood) influence participation in community-dwelling stroke survivors in the Netherlands.

METHODS

The Utrecht Scale for Evaluation of Rehabilitation (USER) measures physical and cognitive independence and subjective complaints. USER-Participation measures 3 dimensions of participation: frequency (objective perspective), restrictions (subjective perspective), and satisfaction (subjective perspective). Spearman correlations and backward linear regression analyses were used to analyze associations between the 3 USER-Participation scores with demographics, stroke characteristics, physical and cognitive independence, and subjective complaints.

RESULTS

Of the 111 participants, 48.5% returned to work post stroke, but mostly for only 1 to 16 hours a week. Experienced participation restrictions were most prevalent in physical exercise, chores in/around the house, housekeeping, and outdoor activities. On average, participants were relatively satisfied with their participation, but dissatisfaction occurred in cognition, activities outdoors, and work/housekeeping. Regression analysis revealed that objective participation was determined by physical and cognitive independence, age, and education, whereas subjective participation was determined by physical and cognitive independence, fatigue, and mood.

CONCLUSIONS

Most participants experienced participation problems, despite relatively good physical recovery. In addition to physical and cognitive factors, subjective complaints of persons with stroke should be addressed in the rehabilitation program.

Development of a poststroke checklist to standardize follow-up care for stroke survivors

BACKGROUND

Long-term care for stroke survivors is fragmented and lacks an evidence-based, easy-to-use tool to identify persistent long-term problems among stroke survivors and streamline referral for treatment. We sought to develop a poststroke checklist (PSC) to help health care professionals identify poststroke problems amenable to treatment and subsequent referral.

METHODS

An instrument development team, supported by measurement experts, international stroke experts, and poststroke care stakeholders, was created to develop a long-term PSC. A list of long-term poststroke problem areas was generated by an international, multidisciplinary group of stroke experts, the Global Stroke Community Advisory Panel. Using Delphi methods, a consensus was reached on which problem areas on the list were most important and relevant to include in a PSC. The instrument development team concurrently created the actual checklist, which provided example language about how to ask about poststroke problem areas and linked patient responses to a specific referral process.

RESULTS

Eleven long-term poststroke problem areas were rated highly and consistently among stroke experts participating in the Delphi process (n = 12): secondary prevention, activities of daily living, mobility, spasticity, pain, incontinence, communication, mood, cognition, life after stroke, and relationship with caregiver. These problem areas were included in the long-term PSC.

CONCLUSIONS

The PSC was developed to be a brief and easy-to-use tool, intended to facilitate a standardized approach for health care providers to identify long-term problems in stroke survivors and to facilitate appropriate referrals for treatment.

The effects of a rhythm and music-based therapy program and therapeutic riding in late recovery phase following stroke: a study protocol for a three-armed randomized controlled trial

BACKGROUND

Stroke represents one of the most costly and long-term disabling conditions in adulthood worldwide and there is a need to determine the effectiveness of rehabilitation programs in the late phase after stroke. Limited scientific support exists for training incorporating rhythm and music as well as therapeutic riding and well-designed trials to determine the effectiveness of these treatment modalities are warranted.

METHODS/DESIGN

A single blinded three-armed randomized controlled trial is described with the aim to evaluate whether it is possible to improve the overall health status and functioning of individuals in the late phase of stroke (1-5 years after stroke) through a rhythm and music-based therapy program or therapeutic riding. About 120 individuals will be consecutively and randomly allocated to one of three groups: (T1) rhythm and music-based therapy program; (T2) therapeutic riding; or (T3) control group receiving the T1 training program a year later. Evaluation is conducted prior to and after the 12-week long intervention as well as three and six months later. The evaluation comprises a comprehensive functional and cognitive assessment (both qualitative and quantitative), and questionnaires. Based on the International classification of functioning, disability, and health (ICF), the outcome measures are classified into six comprehensive domains, with participation as the primary outcome measure assessed by the Stroke Impact Scale (SIS, version 2.0.). The secondary outcome measures are grouped within the following domains: body function, activity, environmental factors and personal factors. Life satisfaction and health related quality of life constitute an additional domain.

CURRENT STATUS

A total of 84 participants were randomised and have completed the intervention. Recruitment proceeds and follow-up is on-going, trial results are expected in early 2014.

DISCUSSION

This study will ascertain whether any of the two intervention programs can improve overall health status and functioning in the late phase of stroke. A positive outcome would increase the scientific basis for the use of such interventions in the late phase after stroke.

TRIAL REGISTRATION

Clinical Trials.gov Identifier: NCT01372059.

Measuring participation after stroke: a review of frequently used tools

OBJECTIVE

To identify and critique the measures currently used to assess participation in clinical stroke studies.

DATA SOURCES

Relevant articles published between January 2001 and April 2012 identified through Medline, CINAHL, and ProQuest Central databases.

STUDY SELECTION

Published articles involving poststroke assessment of participation. Case studies, cohort studies, and randomized controlled trials were included.

DATA EXTRACTION

The most frequently used measures were identified and the psychometric properties evaluated. Three raters independently evaluated each measure relative to the first and second coding levels of the International Classification of Functioning, Disability and Health (ICF) Activities and Participation domain categories.

DATA SYNTHESIS

Thirty-six measures were identified. The Stroke Impact Scale (SIS), London Handicap Scale, Assessment of Life Habits (LIFE-H), Frenchay Activities Index, and Activity Card Sort (ACS) were used most frequently. No single measure met criteria across all psychometric indices, and not one covered all 9 of the ICF Activities and Participation domains. The SIS, LIFE-H, and ACS covered the widest range. The domains covered most frequently were Community, Social and Civic Life, Domestic Life, and Mobility. Learning and Applying Knowledge, General Tasks and Demands, and Communication were the domains less frequently covered.

CONCLUSIONS

This review identified and evaluated the most frequently used participation measures in clinical stroke studies. The SIS, LIFE-H, and ACS covered the ICF Activities and Participation domain categories most comprehensively. However, none of the measures covered all the ICF Activities and Participation domain categories. The information provided in this systematic review can be used to guide the selection of participation measures to meet specific clinical and research purposes.

Satisfaction with rehabilitation in relation to self-perceived quality of life and function among patients with stroke - a 12 month follow-up

BACKGROUND AND PURPOSE

Stroke causes complex disability and function, and perceived quality of life has been shown to correlate with satisfaction with care as well as with life in general among stroke patients. The aim of this study was to study the relation of satisfaction with how rehabilitation was provided with self-perceived quality of life, self-perceived function and rehabilitation received, 12 months after the incidence.

METHOD

The subjects were assessed 12 months after the onset of stroke. The Barthel index was used to measure function, and the EuroQol-5D to measure quality of life. To measure satisfaction with how rehabilitation was provided, a questionnaire from the Swedish Stroke Register was used.

RESULTS

Two hundred and eighty-three patients participated in the follow-up, 137 women and 146 men, aged between 42 and 95 years (mean age 75.2, SD 11.8). For the majority of patients rehabilitation was initiated at in-hospital care (directly after onset). One hundred and sixty-eight patients considered that rehabilitation was well provided for. Sixty-six regarded that the rehabilitation was only partly provided for and 35 that it was not provided for at all. High value on Barthel Index was associated with satisfaction with how rehabilitation was provided for (OR 2.81). Also, rehabilitation on three or more levels was negatively associated with satisfaction with rehabilitation provision (OR 0.24) and so was being male (OR 0.49).

CONCLUSION

In this study, patients with higher values on Barthel Index were more satisfied with how rehabilitation was provided for. However, male patients and patients who received rehabilitation on three or more levels of care were less satisfied. Given the assumption that patients with more severe dysfunction after stroke are being rehabilitated on more levels, this might imply that it is not the amount of rehabilitation that gives satisfaction but the patients self-perceived function after rehabilitation.

Participation After Stroke: Do We Understand All the Components and Relationships As Categorised in the ICF?

Although advances in stroke care have been shown to improve functional outcomes and survival, evidence suggests that stroke survivors continue to report restricted participation and dissatisfaction with life after returning home. There remains a need to identify ways to improve participation after stroke, considering the person within their context. The International Classification of Functioning, Disability and Health (ICF) provides a valuable framework that can be useful for categorising key components associated with participation. The two parts of the ICF — (a) Functioning and Disability and (b) Contextual Factors — encourage consideration of the functions/body structures, activity and participation, and personal and environmental factors, respectively. Previous research has identified links between body functions, structures and activity, with increasing attention being given to the ways in which these link with participation. Although some of the components influencing participation poststroke are well defined, there is a need to further develop our understanding of how personal and environmental factors may affect participation. In this article, stroke literature is categorised using the ICF and a range of personal and environmental factors are investigated as potential contributors to levels of participation poststroke. This article concludes that research investigating contextual factors and their interactions with participation is warranted.

Activity Participation Differences Between Younger and Older Individuals with Stroke

The purpose of this study was to describe differences in activity participation between younger and older individuals with stroke to inform transition after stroke. This was a cross-sectional study with individuals six-months poststroke (n = 177). All individuals completed an outcomes assessment battery that included the Stroke Impact Scale, the Reintegration to Normal Living Index and the Activity Card Sort. The sample was divided into two groups: (1) Young — those under the age of 65 (n = 89); and (2) Old — those 65 or older (n = 88). Analysis was completed to examine differences between the groups on the primary outcome measures of the study and to look at differences between the groups on individual questions/items on the specific measures. The results of this study demonstrate: (1) significant differences in both the quantity and nature of activity participation prior to and after stroke between younger and older stroke survivors and (2) total scores and measures of central tendency do not necessarily provide therapists with the information they need to guide treatment. Rehabilitation professionals should focus on providing clients with the tools they will need to be successful in transitioning back to home and community environments once rehabilitation has ended.

[Acupuncture treatment programs for post-stroke motor rehabilitation in community hospitals: study protocol of a multicenter, randomized, controlled trial]

BACKGROUND

Stroke is responsible for increasingly high rates of mortality and disability worldwide. Approximately two million people suffer from stroke for the first time in China each year. The high incidence (50%) of post-stroke disability brings a heavy burden to patients and their caregivers. Acupuncture has been widely used in the communities for post-stroke rehabilitation in China. The objective of this trial is to apply our acupuncture research achievement to treatment and evaluation of post-stroke hemiplegic patients in community.

METHODS AND DESIGN

A multicenter, randomized, controlled trial will be performed in Longhua Hospital and a number of community health service centers in Shanghai. A total of 124 patients (estimated sample size) with post-stroke hemiplegia will be randomly divided into an acupuncture group and a control group. The patients undergoing randomization should be stratified according to National Institutes of Health Stroke Scale score at baseline. Within the acupuncture group, different acupuncture protocols are administered to patients with flaccid paralysis or spastic paralysis based on the Ashworth Scale. Patients in the acupuncture group will also be treated with comprehensive rehabilitation therapy. The control group will be treated with comprehensive rehabilitation therapy only. The primary outcome measures are the Simplified Fugl-Meyer Motor Scale, the Modified Barthel Index, and the Burden of Stroke Scale. Secondary outcome measures are the modified Rankin Scale, the modified Ashworth Scale and the Stroke Scale of Traditional Chinese Medicine. Outcome measures will be performed after 4 and 8 weeks of treatment. The patients will be followed up after 6 months.

DISCUSSION

The results of this study are expected to demonstrate that our standardized acupuncture protocol for treating and evaluating post-stroke hemiplegic patients will improve motor function and lessen the burden of post-stroke patients within the communities. This will provide the evidence to support successful translation of acupuncture therapy for post-stroke hemiplegic patients in community hospital use.

TRIAL REGISTRATION

This trial was registered in Chinese Clinical Trial Registry with the registration number ChiCTR-TRC-11001347.