Rasch analysis of a new stroke-specific outcome scale: the Stroke Impact Scale

Patient-Reported Variables Affecting Self-Perceived Overall Recovery Among People With Subacute Stroke

IMPORTANCE

Patients' perception of overall recovery is a critical outcome for stroke rehabilitation. However, the perception of overall recovery cannot be obtained using multidimensional measures, because satisfaction in most domains of life does not guarantee satisfaction in overall recovery. A single overall recovery score seems a straightforward measure. However, the clinical implications of overall scores are restricted, because factors affecting patients' overall recovery are unclear, which can be prioritized to optimize the effectiveness of rehabilitation.

OBJECTIVE

To examine patient-reported variables affecting overall recovery scores in patients with differing stroke severity.

DESIGN

The 59 items of the Stroke Impact Scale 3.0 were selected using regression analysis with a forward selection to explain the overall recovery score (0% = no recovery; 100% = full recovery). Stroke severity was determined with the National Institutes of Health Stroke Scale.

SETTING

Hospitals.

PARTICIPANTS

Data of 950 patients collected 90 days after stroke.

RESULTS

The models explained about 55% of the variance of the overall recovery scores with five to nine variables, but merely 16% of the variance was explained for patients with moderate stroke. As stroke severity increased, the number of identified variables decreased. Most identified variables were related to social participation and self-care activities (e.g., ability to help others, control the bowels, and dress the torso). Differences in the remaining variables depended on stroke severity.

CONCLUSIONS AND RELEVANCE

Patients' priorities differ depending on stroke severity. The identified variables may be set as treatment goals to optimize patients' self-perceived overall recovery. Plain-Language Summary: How patients perceive their overall recovery after a stroke is a critical outcome for their stroke rehabilitation. This study demonstrated that patients with different stroke severity may have different priorities that influence their self-perceived levels of overall recovery. The variables identified in this study may help occupational therapy practitioners identify meaningful goals to optimize patients' self-perceived overall recovery.

Evidence of aberrant anti-epstein-barr virus antibody response, though no viral reactivation, in people with post-stroke fatigue

BACKGROUND

Fatigue is a common complication of stroke that has a significant impact on quality of life. The biological mechanisms that underly post-stroke fatigue are currently unclear, however, reactivation of latent viruses and their impact on systemic immune function have been increasingly reported in other conditions where fatigue is a predominant symptom. Epstein-Barr virus (EBV) in particular has been associated with fatigue, including in long-COVID and myalgic encephalomyelitis/chronic fatigue syndrome, but has not yet been explored within the context of stroke.

AIMS

We performed an exploratory analysis to determine if there is evidence of a relationship between EBV reactivation and post-stroke fatigue.

METHODS

In a chronic ischemic stroke cohort (> 5 months post-stroke), we assayed circulating EBV by qPCR and measured the titres of anti-EBV antibodies by ELISA in patients with high fatigue (FACIT-F < 40) and low fatigue (FACIT-F > 41). Statistical analysis between two-groups were performed by t-test when normally distributed according to the Shapiro-Wilk test, by Mann-Whitney test when the data was not normally distributed, and by Fisher's exact test for categorical data.

RESULTS

We observed a similar incidence of viral reactivation between people with low versus high levels of post-stroke fatigue (5 of 22 participants (24%) versus 6 of 22 participants (27%)). Although the amount of circulating EBV was similar, we observed an altered circulating anti-EBV antibody profile in participants with high fatigue, with reduced IgM against the Viral Capsid Antigen (2.244 ± 0.926 vs. 3.334 ± 2.68; P = 0.031). Total IgM levels were not different between groups indicating this effect was specific to anti-EBV antibodies (3.23 × 105 ± 4.44 × 104 high fatigue versus 4.60 × 105 ± 9.28 × 104 low fatigue; P = 0.288).

CONCLUSIONS

These data indicate that EBV is not more prone to reactivation during chronic stroke recovery in those with post-stroke fatigue. However, the dysregulated antibody response to EBV may be suggestive of viral reactivation at an earlier stage after stroke.

Effectiveness of mixed reality-based rehabilitation on hands and fingers by individual finger-movement tracking in patients with stroke

BACKGROUND

Mixed reality (MR) is helpful in hand training for patients with stroke, allowing them to fully submerge in a virtual space while interacting with real objects. The recognition of individual finger movements is required for MR rehabilitation. This study aimed to assess the effectiveness of updated MR-board 2, adding finger training for patients with stroke.

METHODS

Twenty-one participants with hemiplegic stroke (10 with left hemiplegia and 11 with right hemiplegia; nine female patients; 56.7 ± 14.2 years of age; and onset of stroke 32.7 ± 34.8 months) participated in this study. MR-board 2 comprised a board plate, a depth camera, plastic-shaped objects, a monitor, a palm-worn camera, and seven gamified training programs. All participants performed 20 self-training sessions involving 30-min training using MR-board 2. The outcome measurements for upper extremity function were the Fugl-Meyer assessment (FMA) upper extremity score, repeated number of finger flexion and extension (Repeat-FE), the thumb opposition test (TOT), Box and Block Test score (BBT), Wolf Motor Function Test score (WMFT), and Stroke Impact Scale (SIS). One-way repeated measures analysis of variance and the post hoc test were applied for the measurements. MR-board 2 recorded the fingers' active range of motion (AROM) and Dunnett's test was used for pairwise comparisons.

RESULTS

Except for the FMA-proximal score (p = 0.617) and TOT (p = 0.005), other FMA scores, BBT score, Repeat-FE, WMFT score, and SIS stroke recovery improved significantly (p < 0.001) during MR-board 2 training and were maintained until follow-up. All AROM values of the finger joints changed significantly during training (p < 0.001).

CONCLUSIONS

MR-board 2 self-training, which includes natural interactions between humans and computers using a tangible user interface and real-time tracking of the fingers, improved upper limb function across impairment, activity, and participation. MR-board 2 could be used as a self-training tool for patients with stroke, improving their quality of life.

TRIAL REGISTRATION NUMBER

This study was registered with the Clinical Research Information Service (CRIS: KCT0004167).

Strengthening oropharyngeal muscles as an approach to treat post-stroke obstructive sleep apnea: A feasibility randomised controlled trial

This study aimed to determine the feasibility of a randomised controlled trial (RCT) evaluating oropharyngeal exercise (OPE) intervention as an alternative therapy for obstructive sleep apnea (OSA) in patients with stroke or transient ischaemic attack (TIA). Despite the high prevalence of OSA in this population, the standard therapy, continuous positive airway pressure (CPAP), is often poorly tolerated. Thirty stroke/TIA patients with OSA unable to tolerate CPAP were randomly assigned to an oropharyngeal exercise or sham exercise protocol. They performed exercises for 6 weeks, 5 days per week, 30 minutes twice per day. Feasibility was ascertained by the proportion of enrolled patients who completed more than 80% of the OPE regimen. Isometric tongue pressures, apnea-hypopnea index (AHI), oxygen desaturation index (ODI), daytime sleepiness, and quality of life (QOL) outcomes were collected at baseline, post-training (6-week follow-up), and retention (10-week follow-up) to document preliminary efficacy. Adherence to study exercises was excellent, with 83% of participants completing more than 80% of the exercises. The isometric tongue pressures were observed to improve in the oropharyngeal exercise group (compared with the sham group), along with a decrease in OSA severity (measured by the AHI and ODI), reduced daytime sleepiness, and enhanced quality of life outcomes following the exercise programme. Only the effects on posterior isometric tongue pressure and daytime sleepiness remained significantly different between groups at the retention session. In conclusion, an RCT evaluating the efficacy of oropharyngeal exercises on post-stroke/TIA OSA is feasible and our preliminary results suggest a clinically meaningful effect.

Developing and Validating the Preschool Nutrition Education Practices Survey

OBJECTIVE

Validate the Preschool Nutrition Education Practices Survey.

DESIGN

Iterative approach combining design-based research and Standards for Educational and Psychological Testing.

SETTING

Los Angeles, CA and Philadelphia, PA Early Care and Education (ECE) classrooms.

PARTICIPANTS

Expert panel members (n = 7); ECE teachers: interviews (n = 8), pilot survey (n = 31), and final survey (n = 136).

VARIABLES MEASURED

Early care and education nutrition education practices used in the classroom either during class time or mealtime.

ANALYSIS

Qualitative content analysis was implemented for content, response process, and consequences of testing validity evidence. Rasch rating scale analysis was conducted for the response process and internal structure validity and reliability evidence.

RESULTS

Qualitative field-testing produced strong content, response process, and consequences of testing validity evidence to inform survey modifications. Quantitative field-testing generated a psychometrically sound, well-targeted 12-item survey on a 4-point frequency scale with excellent item and person reliability (0.97 and 0.93 respectively) and separation (5.36 and 3.77 respectively); good Rasch Principal Components Analysis findings (60.3%); and productive item fit statistics (0.50-1.50 logits).

CONCLUSIONS AND IMPLICATIONS

Robust validity (content, response process, consequences of testing, internal structure) and reliability evidence were demonstrated for using the Preschool Nutrition Education Practices Survey to assess ECE teachers' use of nutrition education practices. Future research is needed to examine its relationship to other variables, such as nutrition teaching efficacy, and to determine its ability to detect change in ECE nutrition education practices over time and across groups.

Allied rehabilitation using caregiver-mediated exercises combined with telerehabilitation for stroke (ARMed4Stroke): A randomised controlled trial

OBJECTIVE

To assess the added value of caregiver-mediated exercises combined with telerehabilitation in addition to usual care compared to usual care alone on the self-reported mobility outcome after subacute stroke.

DESIGN

Multicentre, observer-blinded, parallel randomised controlled trial. An off-site researcher allocated treatments using minimisation.

SETTING

Four rehabilitation centres in the Netherlands.

PARTICIPANTS

Forty-one patient-caregiver dyads within 3 months poststroke.

INTERVENTION

Eight-week blended care program with caregiver-mediated mobility exercises for 2.5 h per week supported by telerehabilitation and four face-to-face sessions in addition to usual care.

MAIN MEASURES

Self-reported mobility domain of the Stroke Impact Scale postintervention. Secondary outcomes were functional outcome, dyads' psychosocial wellbeing, care transition to the community postintervention and after 6 months.

RESULTS

Forty-one dyads (21 intervention, 20 control) were randomised, and 37 (N = 18; N = 19) were analysed following intention-to-treat. The Stroke Impact Scale mobility was not significantly different between groups postintervention (B 0.8, 95% CI -6.8-8.5, p = 0.826). The secondary outcomes, namely, (a) caregivers' quality of life postintervention (p = 0.013), (b) caregivers' symptoms of depression postintervention (p = 0.025), and (c) independence in leisurely activities at 6 months (p = 0.024), showed significant benefits in favour of caregiver-mediated exercises with telerehabilitation. A significant difference favouring controls was found in self-reported muscle strength at 6 months (p = 0.002).

CONCLUSIONS

Caregiver-mediated exercises combined with telerehabilitation yielded no differential effect on our primary outcome self-reported mobility. Although the trial is underpowered, current findings are in line with previous trials. Future studies should further explore beneficial effects of caregiver involvement in stroke rehabilitation targeting psychosocial wellbeing.

Task-Oriented Training by a Personalized Electromyography-Driven Soft Robotic Hand in Chronic Stroke: A Randomized Controlled Trial

BACKGROUND

Intensive task-oriented training has shown promise in enhancing distal motor function among patients with chronic stroke. A personalized electromyography (EMG)-driven soft robotic hand was developed to assist task-oriented object-manipulation training effectively. Objective. To compare the effectiveness of task-oriented training using the EMG-driven soft robotic hand.

METHODS

A single-blinded, randomized controlled trial was conducted with 34 chronic stroke survivors. The subjects were randomly assigned to the Hand Task (HT) group (n = 17) or the control (CON) group (n = 17). The HT group received 45 minutes of task-oriented training by manipulating small objects with the robotic hand for 20 sessions, while the CON group received 45 minutes of hand-functional exercises without objects using the same robot. Fugl-Meyer assessment (FMA-UE), Action Research Arm Test (ARAT), Modified Ashworth Score (MAS), Box and Block test (BBT), Maximum Grip Strength, and active range of motion (AROM) of fingers were assessed at baseline, after intervention, and 3 months follow-up. The muscle co-contraction index (CI) was analyzed to evaluate the session-by-session variation of upper limb EMG patterns.

RESULTS

The HT group showed more significant improvement in FMA-UE (wrist/hand, shoulder/elbow) compared to the CON group (P < .05). At 3-month follow-up, the HT group demonstrated significant improvements in FMA-UE, ARAT, BBT, MAS (finger), and AROMs (P < .05). The HT group exhibited a more significant decrease in muscle co-contractions compared to the CON group (P < .05).

CONCLUSIONS

EMG-driven task-oriented training with the personalized soft robotic hand was a practical approach to improving motor function and muscle coordination.

CLINICAL TRIAL REGISTRY NAME

Soft Robotic Hand System for Stroke Rehabilitation.

CLINICAL TRIAL REGISTRATION-URL

https://clinicaltrials.gov/.

UNIQUE IDENTIFIER

NCT03286309.

Safety & efficacy of a robotic hip exoskeleton on outpatient stroke rehabilitation

OBJECTIVE

The objective of this study was to analyze the safety and efficacy of using a robotic hip exoskeleton designed by Samsung Electronics Co., Ltd., Korea, called the Gait Enhancing and Motivating System-Hip (GEMS-H), in assistance mode only with the poststroke population in an outpatient-rehabilitation setting.

METHODS

Forty-one participants with an average age of 60 and average stroke latency of 6.5 years completed this prospective, single arm, interventional, longitudinal study during the COVID-19 pandemic. Significant modifications to the traditional outpatient clinical environment were made to adhere to organizational physical distancing policies as well as guidelines from the Centers for Disease Control. All participants received gait training with the GEMS-H in assistance mode for 18 training sessions over the course of 6-8 weeks. Performance-based and self-reported clinical outcomes were assessed at four time points: baseline, midpoint (after 9 training sessions), post (after 18 training sessions), and 1-month follow up. Daily step count was also collected throughout the duration of the study using an ankle-worn actigraphy device. Additionally, corticomotor excitability was measured at baseline and post for 4 bilateral lower limb muscles using transcranial magnetic stimulation.

RESULTS

By the end of the training program, the primary outcome, walking speed, improved by 0.13 m/s (p < 0.001). Secondary outcomes of walking endurance, balance, and functional gait also improved as measured by the 6-Minute Walk Test (47 m, p < 0.001), Berg Balance Scale (2.93 points, p < 0.001), and Functional Gait Assessment (1.80 points, p < 0.001). Daily step count significantly improved with and average increase of 1,750 steps per day (p < 0.001). There was a 35% increase in detectable lower limb motor evoked potentials and a significant decrease in the active motor threshold in the medial gastrocnemius (-5.7, p < 0.05) after training with the device.

CONCLUSIONS

Gait training with the GEMS-H exoskeleton showed significant improvements in walking speed, walking endurance, and balance in persons with chronic stroke. Day-to-day activity also improved as evidenced by increased daily step count. Additionally, corticomotor excitability changes suggest that training with this device may help correct interhemispheric imbalance typically seen after stroke.

TRIAL REGISTRATION

This study is registered with ClinicalTrials.gov (NCT04285060).

Electroencephalogram Alpha Oscillations in Stroke Recovery: Insights into Neural Mechanisms from Combined Transcranial Direct Current Stimulation and Mirror Therapy in Relation to Activities of Daily Life

The goal of stroke rehabilitation is to establish a robust protocol for patients to live independently in community. Firstly, we examined the impact of 3 hybridized transcranial direct current stimulation (tDCS)-mirror therapy interventions on activities of daily life (ADL) in stroke patients. Secondly, we explored the underlying therapeutic mechanisms with theory-driven electroencephalography (EEG) indexes in the alpha band. This was achieved by identifying the unique contributions of alpha power in motor production to ADL in relation to the premotor cortex (PMC), primary cortex (M1), and Sham tDCS with mirror therapy. The results showed that, although post-intervention ADL improvement was comparable among the three tDCS groups, one of the EEG indexes differentiated the interventions. Neural-behavioral correlation analyses revealed that different types of ADL improvements consistently corresponded with alpha power in the temporal lobe exclusively in the PMC tDCS group (all rs > 0.39). By contrast, alterations in alpha power in the central-frontal region were found to vary, with ADL primarily in the M1 tDCS group (r = -0.6 or 0.7), with the benefit depending on the complexity of the ADL. In conclusion, this research suggested two potential therapeutic mechanisms and demonstrated the additive benefits of introducing theory-driven neural indexes in explaining ADL.

Examining Sex Differences in Relationships Between Subjective and Objective Measures of Upper Extremity Motor Impairment in a Sample of Stroke Survivors

BACKGROUND AND PURPOSE

Rehabilitation professionals use subjective and objective outcome measures to assess stroke-related impact and impairment. Understanding if subjective and objective findings correlate among stroke survivors, especially if these associations differ between females and males, can inform care decisions.

METHODS

A retrospective cross-sectional design was used, with data selected from subacute to chronic stroke survivors on age, time since stroke, the hand domain from the Stroke Impact Scale version 3.0 (SIS-H), and the Fugl-Meyer Upper Extremity (FMUE) Assessment. Group differences were assessed for all outcomes based on sex and time poststroke. Separate correlations for females and males were performed between the subjective (SIS-H) and objective measures (FMUE) of upper limb function and impairment.

RESULTS

Data from 148 participants (44 females) were included in this study. SIS-H was significantly correlated with FMUE in both females and males ( P s ≤ 0.001). No significant differences were found between the groups' mean SIS-H or FMUE scores based on sex or time poststroke.

DISCUSSION AND CONCLUSIONS

Subjective and objective measures of physical functioning were correlated in both females and males. Although we found no sex differences in our primary outcomes, the sample size of females was disproportionately lower than the males. This is consistent with an ongoing problem in the stroke recovery research field, where females are often underrepresented and understudied, and where females who experience higher levels of impairment are less likely to participate in research.

Comparing the EQ-5D-5L and stroke impact scale 2.0 in stroke patients: an analysis of measurement properties

BACKGROUND

Stroke has evolved to become a chronic disease and a major public health challenge. To adequately capture the full disease burden of stroke patients, the assessment of health-related quality of life (HRQoL) and thus the performance of respective measures is increasingly relevant. The aim of this analysis was to compare the measurement properties of two self-report instruments, the EQ-5D-5L and the Stroke Impact Scale 2.0.

METHODS

The data used for the analysis was derived from a quasi-experimental case management study for mildly to moderately affected incident stroke and transient ischemic attack (TIA) patients aged ≥ 18 in Germany. Data was collected patient-individually at 3, 6 and 12 months after initial stroke. The EQ-5D-5L and SIS 2.0 were compared in terms of feasibility, ceiling and floor effects, responsiveness and known-groups validity (Kruskal-Wallis H and Wilcoxon rank-sum test).

RESULTS

A response for all three follow-ups is available for n = 855 patients. The feasibility of the EQ-5D-5L is determined as good (completion rate: 96.4-96.6%, ≥ one item missing: 3.2 - 3.3%), whereas the SIS 2.0 is moderately feasible (overall completion rate: 44.9-46.1%, ≥ one item missing in domains: 4.7 - 28.7%). The SIS 2.0 shows substantial ceiling effects in comparable domains (physical function: 10.4 - 13%, others: 3.5-31.3%) which are mainly larger than ceiling effects in the EQ-5D-5L index (17.1-21.5%). In terms of responsiveness, the EQ-5D-5L shows small to moderate change while the SIS 2.0 presents with moderate to large responsiveness. The EQ-5D-5L index, mobility, usual activities and Visual Analogue Scale show known-groups validity (p < 0.05). Content-related domains of the SIS 2.0 show known-groups validity as well (p < 0.05). However, it is compromised in the emotion domain in both measures (p > 0.05).

CONCLUSIONS

The EQ-5D-5L seems to be slightly more suitable for this cohort. Nonetheless, the results of both measures indicate limited suitability for TIA patients. Large-scale studies concerning responsiveness and known-groups validity are encouraged.

TRIAL REGISTRATION

The study was registered in the German Clinical Trials Register, retrospective registration on 21.09.2022.

REGISTRATION ID

DRKS00030297.

The Combined Effect of Robot-assisted Therapy and Activities of Daily Living Training on Upper Limb Recovery in Persons With Subacute Stroke: A Randomized Controlled Trial

OBJECTIVES

To evaluate the effectiveness of robot-assisted therapy (RAT) followed by activities of daily living (ADL) training in comparison with conventional rehabilitation therapy (CRT) and ADL training in individuals with subacute stroke.

DESIGN

A single-blind, 2-arm, parallel-group, open-level, randomized controlled trial.

SETTING

A tertiary care teaching hospital in India.

PARTICIPANTS

Forty-four persons (n=44) with first-ever stroke (in subacute stage) were enrolled from August 2021 to July 2023.

INTERVENTION

Participants in the RAT group (n=22) received RAT for 30 minutes, followed by ADL training for 30 minutes. In contrast, participants in the CRT group (n=22) received CRT (30 minutes) followed by ADL training (30 minutes). Both groups received allocated interventions for 15 days over 3 weeks (5 days/week, 3 weeks).

MAIN OUTCOME MEASURES

Primary outcome: Motor domain score of the Fugl-Meyer Assessment scale for upper extremity (FMA-UE).

SECONDARY OUTCOMES

the other domains scores of FMA-UE (UL -sensation, -joint motions, -joint pain); Modified Ashworth Scale (MAS) (spasticity); hand-function (HF) and ADL-domain scores of the stroke impact scale (SIS); WHOQQL-BREF questionnaires (QOL). Participants were assessed at enrolment and follow-up at 3, 6, and 12 weeks.

RESULTS

Persons who received RAT and ADL training reported significant improvement (P<.05) in UL motor function (mean difference [MD]=3.54;(95% confidence interval [CI]: 1.28 to 5.79]), UL passive joint motions (MD=2.54; [95% CI: 1.56 to 3.52]), SIS-HF (MD=6.37;[95% CI: 4.75 to 7.99]), SIS-ADL (MD=7.13 [95% CI: 3.52 to 8.74]), and in all domains of WHOQOL-BREF (except environmental domain) compared with persons who received CRT and ADL training at 12 weeks.

CONCLUSIONS

The findings indicate that RAT followed by ADL training is more effective than CRT followed by ADL training in motor improvement, SIS-HF, SIS-ADL, and QOL at 12 weeks.

Development of a Self-Report Measure of Prediction in Daily Life: The Prediction-Related Experiences Questionnaire

PURPOSE

Predictions are complex, multisensory, and dynamic processes involving real-time adjustments based on environmental inputs. Disruptions to prediction abilities have been proposed to underlie characteristics associated with autism. While there is substantial empirical literature related to prediction, the field lacks a self-assessment measure of prediction skills related to daily tasks. Such a measure would be useful to better understand the nature of day-to-day prediction-related activities and characterize these abilities in individuals who struggle with prediction.

METHODS

An interdisciplinary mixed-methods approach was utilized to develop and validate a self-report questionnaire of prediction skills for adults, the Prediction-Related Experiences Questionnaire (PRE-Q). Two rounds of online field testing were completed in samples of autistic and neurotypical (NT) adults. Qualitative feedback from a subset of these participants regarding question content and quality was integrated and Rasch modeling of the item responses was applied.

RESULTS

The final PRE-Q includes 19 items across 3 domains (Sensory, Motor, Social), with evidence supporting the validity of the measure's 4-point response categories, internal structure, and relationship to other outcome measures associated with prediction. Consistent with models of prediction challenges in autism, autistic participants indicated more prediction-related difficulties than the NT group.

CONCLUSIONS

This study provides evidence for the validity of a novel self-report questionnaire designed to measure the day-to-day prediction skills of autistic and non-autistic adults. Future research should focus on characterizing the relationship between the PRE-Q and lab-based measures of prediction, and understanding how the PRE-Q may be used to identify potential areas for clinical supports for individuals with prediction-related challenges.

Impact of long-term white matter hyperintensity changes on mobility and dexterity

White matter hyperintensities (WMH), a common feature of cerebral small vessel disease, are related to worse clinical outcomes after stroke. We assessed the impact of white matter hyperintensity changes over 1 year after minor stroke on change in mobility and dexterity, including differences between the dominant and non-dominant hands and objective in-person assessment versus patient-reported experience. We recruited participants with lacunar or minor cortical ischaemic stroke, performed medical and cognitive assessments and brain MRI at presentation and at 1 year. At both time points, we used the timed-up and go test and the 9-hole peg test to assess mobility and dexterity. At 1 year, participants completed the Stroke Impact Scale. We ran two linear mixed models to assess change in timed-up and go and 9-hole peg test, adjusted for age, sex, stroke severity (National Institutes of Health Stroke Scale), dependency (modified Rankin Score), vascular risk factor score, white matter hyperintensity volume (as % intracranial volume) and additionally for 9-hole peg test: Montreal cognitive assessment, hand (dominant/non-dominant), National Adult Reading Test (premorbid IQ), index lesion side. We performed ordinal logistic regression, corrected for age and sex, to assess relations between timed-up and go and Stroke Impact Scale mobility, and 9-hole peg test and Stroke Impact Scale hand function. We included 229 participants, mean age 65.9 (standard deviation = 11.13); 66% male. 215/229 attended 1-year follow-up. Over 1 year, timed-up and go time increased with aging (standardized β [standardized 95% Confidence Interval]: 0.124[0.011, 0.238]), increasing National Institutes of Health Stroke Scale (0.106[0.032, 0.180]), increasing modified Rankin Score (0.152[0.073, 0.231]) and increasing white matter hyperintensity volume (0.176[0.061, 0.291]). Men were faster than women (-0.306[0.011, 0.238]). Over 1 year, slower 9-hole peg test was related to use of non-dominant hand (0.290[0.155, 0.424]), aging (0.102[0.012, 0.192]), male sex (0.182[0.008, 0.356]), increasing National Institutes of Health Stroke Scale (0.160 [0.094, 0.226]), increasing modified Rankin Score (0.100[0.032, 0.169]), decreasing Montreal cognitive assessment score (-0.090[-0.167, -0.014]) and increasing white matter hyperintensity volume (0.104[0.015, 0.193]). One year post-stroke, Stroke Impact Scale mobility worsened per second increase on timed-up and go, odds ratio 0.67 [95% confidence interval 0.60, 0.75]. Stroke Impact Scale hand function worsened per second increase on the 9-hole peg test for the dominant hand (odds ratio 0.79 [0.71, 0.86]) and for the non-dominant hand (odds ratio 0.88 [0.83, 0.93]). Decline in mobility and dexterity is associated with white matter hyperintensity volume increase, independently of stroke severity. Mobility and dexterity declined more gradually for stable and regressing white matter hyperintensity volume. Dominant and non-dominant hands might be affected differently. In-person measures of dexterity and mobility are associated with self-reported experience 1-year post-stroke.

Occupational balance and stroke impact among community-dwelling stroke survivors 65 years or older: a cross-sectional study

INTRODUCTION

Occupational balance has been investigated in different populations but less in stroke survivors. Previous studies have focussed on occupational balance among stroke survivors of working age (15-64 years of age), showing they did not perceive they had occupational balance. There is, therefore, a lack of knowledge of how older stroke survivors perceive their occupational balance. The aims of this study were to describe occupational balance in community-dwelling stroke survivors 65 years or older and to investigate if there were any associations between their perceived stroke impact and occupational balance.

METHODS

A cross-sectional study was performed with 58 stroke survivors, with a median age of 75 years at stroke onset and a median time since stroke onset of 11 months. The participants were recruited from a local stroke register and answered questionnaires on occupational balance and stroke impact. Data were analysed with descriptive statistics, correlations and logistic regression.

RESULTS

The participants had a median score of 29 (min 12 to max 33), indicating a very high occupational balance, a low stroke impact, and a good recovery (median 82.5; min 0 to max 100). An association between participation and occupational balance (OR 1.13; 95% CI 1.04-1.23) was found.

CONCLUSION

The stroke survivors perceived a low stroke impact and a high occupational balance. It is possible that older community-dwelling stroke survivors, of whom many have retired, juggle less occupations leaving them with more time to engage in those occupations they want to, leading to a better occupational balance.

Self-perceived upper extremity motor function predicts health-related quality of life in chronic stroke survivors

PURPOSE

To examine whether the Upper Extremity Functional Index (UEFI) score independently contributes to the Stroke Impact Scale (SIS) score and quantified its relative contribution to SIS scores in chronic stroke survivors.

MATERIALS AND METHODS

A cross-sectional study in a university-based rehabilitation centre with people with chronic stroke (N = 95) aged ≥ 50 years. The outcome measures included paretic hand grip strength, Fugl-Meyer Upper Extremity Assessment (FMA-UE), Wolf Motor Function Test (WMFT), UEFI, and SIS.

RESULTS

Correlation analysis revealed that paretic hand grip strength, FMA-UE, UEFI, and WMFT scores exhibited a significant moderate positive correlation with SIS scores (r = 0.544-0.687, p < 0.001). The results of a regression model indicated that after adjustment for demographic factors and stroke-related impairments, the UEFI scores remained independently associated with SIS scores, accounting for 18.8% of the variance. The entire model explained 60.3% of the variance in SIS scores.

CONCLUSIONS

Self-perceived UE motor function is a crucial component to be included in rehabilitation programmes aimed at enhancing quality of life and participation among chronic stroke survivors.

Estimating the minimal clinically important difference of upper extremity outcome measures in chronic stroke patients with moderate to severe impairment: a cross-sectional study

BACKGROUND

Approximately 70% of chronic stroke patients experience upper extremity (UE) functional impairments, and UE outcome measures are often used as quality-of-life indicators.

OBJECTIVE

The purpose of this study was to estimate minimal clinically important difference (MCID) values for UE outcome measures in chronic stroke patients with moderate to severe UE hemiplegia.

METHODS

This study was a cross-sectional study, conducted as a secondary analysis of data from the ReoGo-J study, a multicenter, prospective, randomized, parallel-group trial of robot-assisted self-training for UE hemiplegia in chronic stroke. The patients were randomized to 1 of 3 treatment groups. Treatment was provided 3 times a week for 10 weeks, and UE outcome measures were evaluated before and after treatment. The anchor-based method was used to estimate MCID values for UE outcome measures, with Stroke Impact Scale (SIS) subscales as anchors. MCID values were estimated by identifying cutoff values in a receiver operating characteristic (ROC) curve.

RESULTS

Between-group comparisons of UE outcome measures, based on the clinically important difference (CID) values of SIS subscales, revealed significant differences in both the Amount of Use (AOU) and Quality of Movement (QOM) components of the Motor Activity Log (MAL)-14. The estimated MCID values were 0.89 for the AOU component and 0.77 for the QOM component.

CONCLUSIONS

The estimated MCID values for the MAL-14 not only add information regarding the clinical characteristics of the MAL-14 but also facilitate interpretations of changing scores in chronic stroke patients with moderate to severe UE hemiplegia undergoing rehabilitation therapy.

STUDY REGISTRATION

https://www.umin.ac.jp/ctr/index.htm (UMIN000022509; 1 July 2016).

Indirect causal path from motor function to quality of life through daily use of the affected arm poststroke after task-specific training: a longitudinal mediation analysis

PURPOSE

Task-specific training generally targets motor function, with the ultimate goal of improving quality of life (QoL). This study aimed to determine whether motor function indirectly affects QoL through daily use of the affected arm and activities of daily living (ADL) in patients with chronic stroke.

METHODS

This was a retrospective cohort study of 155 patients who received training for 90-120 min/session, 3-5 sessions/week, for 4-6 weeks. The training involved specific mirror or robot-assisted therapy, followed by functional task practice for 15-30 min in each session. Patients were assessed before and after the intervention.

RESULTS

At both pre-test and post-test, significant indirect effects of motor function on QoL through daily use of the affect arm and ADL were observed (β = 0.087-0.124). When the change scores of the measures between the pre-test and post-test were used, significant mediating effects of daily arm use on the relationship between motor function and QoL were identified (β = 0.094-0.103).

CONCLUSIONS

Enhanced motor function after intervention may lead to an increase in arm use for daily activities and subsequently result in an improvement in QoL. These results highlight the critical role of daily arm use in task-specific training aimed at improving QoL.

Translation and pilot validation of the Moroccan version of Stroke Impact Scale (SIS) 3.0

INTRODUCTION

The Stroke Impact Scale 3.0 appears to be a promising measure of health-related quality of life for stroke patients. However, the lack of a cross-cultural adaptation in Arabic dialect may limit its use in the Moroccan context. The objective of this study was to carry out a transcultural adaptation and pilote validation of the Stroke Impact Scale 3.0 in Moroccan Arabic dialect, commonly called « Darija ».

PATIENTS AND METHODS

A cross-sectional design was used for this study. The cross-cultural adaptation of the SIS 3.0 scale into Moroccan Darija was carried out following the guidelines proposed by Beaton et al (2000). Ceiling and floor effects were calculated for all scales. The internal consistency of multi-item scales was assessed using Cronbach's α coefficient. Convergent and divergent validity were evaluated using the Multi-Trait Multi-Method Correlation Matrix method.

RESULTS

A total of 102 patients, with a mean age of 49 ± 12.9 years, participated in the study. The results revealed that the dimensions of the translated scale had no floor effect and no ceiling effect. The internal consistency of SIS 3.0 (Cronbach's alpha) was calculated, and all dimensions had good reliability, above the threshold of 0.70 (between 0.705 and 0.945). The results showed that the dimensions and their own items had correlation coefficients greater than 0.4, with good convergent and divergent validity.

CONCLUSION

The darija version appears to be culturally acceptable with good psychometric properties and can be used to measure the quality of life of stroke survivors in Morocco.

Stroke disease-specific quality of life trajectories and their associations with caregivers' anxiety, depression, and burden in stroke population: a longitudinal, multicentre study

AIMS

The aims of this study were to: (i) test if there are clusters of stroke survivors who experience distinct trajectories of quality of life (QOL) from hospital rehabilitation discharge to 12-month follow-up; (ii) test if any sociodemographic or clinical variables predict this class membership; and (iii) examine the associations between the clusters of stroke survivors' and their caregivers' trajectories of anxiety, depression, and burden over time.

METHODS AND RESULTS

A total of 415 stroke survivors and their caregivers were recruited in Italy for this 1-year, longitudinal, multicentre prospective study, filling out a survey at five time points. We found two distinct trajectories of change in stroke survivors' psychological QOL (i.e. Memory, Communication, Emotion, and Participation). The first trajectory (86% of the survivors) included those who started with greater levels of QOL and improved slightly to markedly in all psychological domains, while the second trajectory (14% of the survivors) comprised those who started with lower overall levels of psychological QOL and experienced a worsening or no changes at all in these dimensions up to 12-month follow-up. Very few clinical and sociodemographic variables at baseline predicted class membership. Finally, caregivers of those patients who experienced no change or a worsening in psychological QOL reported greater distress and burden over time.

CONCLUSION

Our results highlight the need for more tailored interventions to improve patients' psychological QOL and consequently their caregivers' well-being. This requires a shift from a stroke survivor-centred approach to a stroke survivor- and caregiver-centred one.

Investigating the Telerehabilitation With Aims to Improve Lower Extremity Recovery Poststroke Program: A Feasibility Study

OBJECTIVE

The purpose of this study was to examine the feasibility of a progressive virtual exercise and self-management intervention, the TeleRehabilitation with Aims to Improve Lower extremity recovery poststroke program (TRAIL), in individuals with stroke.

METHODS

A single group pre-post study design was used. Thirty-two participants were recruited who were aged 19 years or older, had a stroke within 18 months of the beginning of the study, had hemiparesis of the lower extremity, and were able to tolerate 50 minutes of activity. Participants completed TRAIL, a synchronous exercise and self-management program delivered via videoconferencing. Participants received 8 telerehabilitation sessions over 4 weeks that were 60 to 90 minutes, with a trained physical therapist in a ≤2 to 1 participant-to-therapist ratio. Feasibility indicators in the areas of process (recruitment and retention rates, perceived satisfaction), resources (treatment fidelity and adherence, participant and assessor burden, therapist burden), management (equipment, processing time), and scientific indicators (safety, treatment response, treatment effect) were collected throughout the study using a priori criteria for success. The treatment effect was examined on the Timed "Up & Go" test, the virtual Fugl-Meyer Lower Extremity Assessment, the 30-Second Sit-to-Stand Test, the Functional Reach, the Tandem Stand, the Activities-Specific Balance Confidence Scale, the Stroke Impact Scale, and the Goal Attainment Scale.

RESULTS

Forty-seven individuals were screened, of which 32 (78% male; median age of 64.5 years) were included for the study from 5 sites across Canada. Nine feasibility indicators met our study-specific threshold criteria for success: retention rate (0 dropouts), perceived satisfaction, treatment fidelity, adherence, therapist burden, equipment, and safety. In terms of treatment response and effect, improvements were observed in Timed "Up & Go" test (Cohen d = 0.57); Fugl-Meyer Lower Extremity Assessment (d = 0.76); 30-Second Sit-to-Stand Test (d = 0.89); and Goal Attainment Scale (d = 0.95).

CONCLUSION

The delivery of TRAIL, a lower extremity stroke rehabilitation program using videoconferencing technology, is feasible and appears to have positive influences on mobility, lower extremity impairment, strength, and goal attainment.

IMPACT

Community-based telerehabilitation programs, such as TRAIL, could extend the continuum of care during the transition back to community postdischarge or during global disruptions, such as Coronavirus Disease 2019 (COVID-19). Delivery of synchronous lower extremity rehabilitation via videoconferencing to community-dwelling stroke survivors is feasible.

Inclusion of People With Aphasia in Stroke Trials: A Systematic Search and Review

BACKGROUND

Although people with aphasia (PwA) represent 30% of stroke survivors, they are frequently excluded from stroke research, or their inclusion is unclear. Such practice significantly limits the generalizability of stroke research, increases the need to duplicate research in aphasia-specific populations, and raises important ethical and human rights issues.

OBJECTIVE

To detail the extent and nature of inclusion of PwA in contemporary stroke randomized controlled trials (RCTs).

METHODS

We conducted a systematic search to identify completed stroke RCTs and RCT protocols published in 2019. Web of Science was searched using terms "stroke" and "randomized controlled trial". These articles were reviewed by extracting rates of PwA inclusion/exclusion, whether "aphasia" or related terms were referred to in the article or supplemental files, eligibility criteria, consent procedures, adaptations made to support the inclusion of PwA, and attrition rates of PwA. Data were summarized, and descriptive statistics applied when appropriate.

RESULTS

271 studies comprising 215 completed RCTs and 56 protocols were included. 36.2% of included studies referred to aphasia/dysphasia. Of completed RCTs, only 6.5% explicitly included PwA, 4.7% explicitly excluded PwA, and inclusion was unclear in the remaining 88.8%. Among RCT protocols, 28.6% of studies intended inclusion, 10.7% intended excluding PwA, and in 60.7%, inclusion was unclear. In 45.8% of included studies, sub-groups of PwA were excluded, either explicitly (ie, particular types/severities of aphasia, eg, global aphasia) or implicitly, by way of ambiguous eligibility criteria which could potentially relate to a sub-group of PwA. Little rationale for exclusion was provided. 71.2% of completed RCTs did not report any adaptations that could support the inclusion of PwA, and minimal information was provided about consent procedures. Where it could be determined, attrition of PwA averaged 10% (range 0%-20%).

CONCLUSION

This paper details the extent of inclusion of PwA in stroke research and highlights opportunities for improvement.

Validation of the Machine Learning-Based Stroke Impact Scale With a Cross-Cultural Sample

IMPORTANCE

The machine learning-based Stroke Impact Scale (ML-SIS) is an efficient short-form measure that uses 28 items to provide domain scores comparable to those of the original 59-item Stroke Impact Scale-Third Edition (SIS 3.0). However, its utility is largely unknown because it has not been cross-validated with an independent sample.

OBJECTIVE

To examine the ML-SIS's comparability and test-retest reliability with that of the original SIS 3.0 in an independent sample of people with stroke.

DESIGN

Comparability was examined with the coefficient of determination (R2), mean absolute error, and root-mean-square error (RMSE). Test-retest reliability was examined using the intraclass correlation coefficient (ICC).

SETTING

Five hospitals in Taiwan.

PARTICIPANTS

Data of 263 persons with stroke were extracted from a previous study; 144 completed repeated assessments after a 2-wk interval.

RESULTS

High R2 (.87-.95) and low mean absolute error or RMSE (about 2.4 and 3.3) of the domain scores, except for the Emotion scores (R2 = .08), supported the comparability of the two measures. Similar ICC values (.39-.87 vs. .46-.87) were found between the two measures, suggesting that the ML-SIS is as reliable as the SIS 3.0.

CONCLUSIONS AND RELEVANCE

The ML-SIS provides scores mostly identical to those of the original measure, with similar test-retest reliability, except for the Emotion domain. Thus, it is a promising alternative that can be used to lessen the burden of routine assessments and provide scores comparable to those of the original SIS 3.0. Plain-Language Summary: The machine learning-based Stroke Impact Scale (ML-SIS) is as reliable as the original Stroke Impact Scale-Third Edition, except for the Emotion domain. Thus, the ML-SIS can be used to improve the efficiency of clinical assessments and also relieve the burden on people with stroke who are completing the assessments.

The feasibility of the adapted H-GRASP program for perceived and actual daily-life upper limb activity in the chronic phase post-stroke

(Purpose: Assessing feasibility and initial impact of the Home-Graded Repetitive Arm Supplementary Program combined with in-home accelerometer-based feedback (AH-GRASP) on perceived and actual daily-life upper limb (UL) activity in stroke survivors during the chronic phase with good UL motor function but low perceived daily-life activity. Material and methods: A 4-week intervention program (4 contact hours, 48 h self-practice) encompassing task-oriented training, behavioral techniques, phone-based support, monitoring, and weekly feedback sessions using wrist-worn accelerometery was implemented using a pre-post double baseline repeated measures design. Feasibility, clinical assessments, patient-reported outcomes, and accelerometer data were investigated. Results: Of the 34 individuals approached, nineteen were included (recruitment rate 56%). Two dropped out, one due to increased UL pain (retention rate 89%). Seven (41%) achieved the prescribed exercise target (120 min/day, six days/week). Positive patient experiences and improvements in UL capacity, self-efficacy, and contribution of the affected UL to overall activity (p < 0.05, small to large effect sizes) were observed. Additionally, seven participants (41%) surpassed the minimal clinically important difference in perceived UL activity.Conclusions: A home-based UL exercise program with accelerometer-based feedback holds promise for enhancing perceived and actual daily-life UL activity for our subgroup of chronic stroke survivors.

Benefits of Robot-Assisted Upper-Limb Rehabilitation from the Subacute Stage after a Stroke of Varying Severity: A Multicenter Randomized Controlled Trial

BACKGROUND

The aim of this study was to compare the clinical effectiveness of robot-assisted therapy with that of conventional occupational therapy according to the onset and severity of stroke.

METHODS

In this multicenter randomized controlled trial, stroke patients were randomized (1:1) to receive robot-assisted therapy or conventional occupational therapy. The robot-assisted training group received 30 min of robot-assisted therapy twice and 30 min of conventional occupational therapy daily, while the conventional therapy group received 90 min of occupational therapy. Therapy was conducted 5 days/week for 4 weeks. The primary outcome was the Wolf Motor Function Test (WMFT) score after 4 and 8 weeks of therapy.

RESULTS

Overall, 113 and 115 patients received robot-assisted and conventional therapy, respectively. The WMFT score after robot-assisted therapy was not significantly better than that after conventional therapy, but there were significant improvements in the Motricity Index (trunk) and the Fugl-Meyer Assessment. After robot-assisted therapy, wrist strength significantly improved in the subacute or moderate-severity group of stroke patients.

CONCLUSIONS

Robot-assisted therapy improved the upper-limb functions and activities of daily living (ADL) performance as much as conventional occupational therapy. In particular, it showed signs of more therapeutic effectiveness in the subacute stage or moderate-severity group.

Quality of Life in Patients with Excellent 3-Month Clinical Outcome after First-Ever Ischemic Stroke: A Time to Redefine Excellent Outcome?

INTRODUCTION

Ischemic stroke (IS) may have impact on long-term health-related quality of life (HRQoL) even in the patients with good clinical outcome, and tools mostly used for the assessment of outcome may underestimate or not reflect all relevant sequels after IS. We aimed to analyze HRQoL in the patients with excellent outcome after IS.

METHODS

We analyzed consecutive IS patients enrolled in the prospective FRAILTY study (ClinicalTrials.gov: NCT04839887) with excellent 3-month clinical outcome (score 0-1 in modified Rankin Scale [mRS]). Stroke Impact Scale (SIS) version 3.0 and Hospital Anxiety and Depression Scale (HADS) were used for the HRQoL, anxiety, and depression assessments, and subgroup comparisons were performed according to NIHSS score (0, ≥1), age (50<, ≥50 years), and sex.

RESULTS

In total, 158 patients (55.7% men, mean age 60.3 ± 13.4 years) were analyzed, and 72.2% of them had score 0 in mRS. The overall lowest median scores were found in the SIS domain "emotion," "strength," and "participation." Patients with NIHSS ≥1 had lower scores in all SIS domains except "emotions" and "mobility." Patients ≥50 years had lower score in "mobility" (p = 0.004) and females in domain of "social participation" (p = 0.044). No differences were found among all subgroups in HADS anxiety and depression. Age, NIHSS score, and depression were found negative predictors for the physical domains of HRQoL.

DISCUSSION/CONCLUSIONS

Despite excellent 3-month clinical outcome after IS, patients had affected substantially their HRQoL, especially those with NIHSS ≥1. Patients ≥50 years had more affected "mobility" and females "social participation."

Quality of life in elderly patients with Neuro-co-Cardiological Diseases: Rasch analysis and confirmatory factor analysis of WHOQOL-BREF and SF-36 instruments

PURPOSE

The quality of life (QOL) in elderly patients with neuro-co-cardiological diseases multimorbidity (NCCD) exhibits distinct features, but there is a scarcity of research in this specialized area. This study seeks to comprehensively assess the QOL of elderly patients with NCCD, employing both the WHOQOL-BREF and SF-36 instruments, while concurrently evaluating the validity and reliability of these two measurement scales.

METHODS

The study participants were derived from the Elderly Individuals with Neuro-co-Cardiological Diseases Registered Cohort Study (EINCCDRCS). WHOQOL-BREF and SF-36 were used for QOL assessment. Rasch analysis, and Confirmatory Factor Analysis were conducted. Internal consistency, ceiling, and floor effects were also analyzed.

RESULTS

202 patients from the EINCCDRCS were included in the study. Both scales showed good reliability and validity. SF-36 demonstrated better distribution and targeting compared to WHOQOL-BREF. Some items exhibited potential bias in specific patient groups. However, the 'Role limitations due to emotional problems' component showed suboptimal performance in certain assessments, suggesting its consideration for removal in practical use. Differential item functioning was observed in patients with anxiety, depression, and cognitive impairment, highlighting the impact of these conditions on the QOL of elderly NCCD patients.

CONCLUSIONS

Both WHOQOL-BREF and SF-36 are effective instruments for assessing QOL in elderly NCCD patients, showing good reliability and validity for both scales. SF-36 generally outperforms WHOQOL-BREF overall. Patients diagnosed with anxiety and depression, as well as cognitive impairment, exhibited differences in QOL assessment. Further attention to these findings can improve QOL assessment and care for this population.

Stroke survivors' long-term participation in paid employment

BACKGROUND

Knowledge on long-term participation is scarce for patients with paid employment at the time of stroke.

OBJECTIVE

Describe the characteristics and the course of participation (paid employment and overall participation) in patients who did and did not remain in paid employment.

METHODS

Patients with paid employment at the time of stroke completed questions on work up to 30 months after starting rehabilitation, and the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P, Frequency, Restrictions and Satisfaction scales) up to 24 months. Baseline characteristics of patients with and without paid employment at 30 months were compared using Fisher's Exact Tests and Mann-Whitney U Tests. USER-P scores over time were analysed using Linear Mixed Models.

RESULTS

Of the 170 included patients (median age 54.2 interquartile range 11.2 years; 40% women) 50.6% reported paid employment at 30 months. Those returning to work reported at baseline more working hours, better quality of life and communication, were more often self-employed and in an office job. The USER-P scores did not change statistically significantly over time.

CONCLUSION

About half of the stroke patients remained in paid employment. Optimizing interventions for returning to work and achieving meaningful participation outside of employment seem desirable.

Validity and reliability of selective control of upper extremity scale (SCUES) in patients with chronic stroke

PURPOSE

The aim of this study is to investigate the validity and reliability of the Selective Control of Upper Extremity Scale (SCUES) in patients with stroke.

MATERIALS AND METHODS

Forty-two patients with stroke aged 18-75 years, were included in the study. Patients were video-recorded while SCUES was administered. The videos were scored to determine the intrarater and inter-rater reliability. Fugl Meyer Assessment of Upper Extremity (FMA-UE), Box and Block test (BBT) and Brunnstrom Stages of Motor Recovery were measured to evaluate validity of SCUES. Spearman correlation analysis was used to assess the validity of SCUES. Intraclass correlation coefficient (ICC), Kappa (κ) and weighted Kappa (κw) were calculated to determine intrarater and inter-rater reliability.

RESULTS

There were significant positive high correlations between SCUES and FMA-UE and BBT and Brunnstrom upper extremity proximal and distal values (rho = 0.944, p = 0.01; rho = 0,875, p = 0.01; rho = 0.84, p = 0.01, rho = 0.82, p = 0.01; respectively) showing validity of SCUES. The ICC value of inter-rater reliability of SCUES was 0,99 (%95 CI: 0,989-0,997, p = 0,001) showing excellent reliability. κ and κ w values for inter-rater and intrarater reliability of individual SCUES items were above 0.7 indicating excellent reliability. ICC of SCUES and FMA-UE indicated excellent intrarater reliability (ICC = 0,99; %95 CI: 0,989-0,997, p = 0,001; ICC = 0.943; %95 CI: 0.9-0.97, p = 0,0001, consecutively).

CONCLUSIONS

SCUES showed similar validity and reliability with FMA-UE and SCUES can be used in the evaluation of upper extremity selective motor control in patients with stroke.

Correlation between kinetic and kinematic measures, clinical tests and subjective self-evaluation questionnaires of the affected upper limb in people after stroke

Introduction

Assessment of stroke recovery should include multiple sources of information in order to obtain a complete understanding of the individual's rehabilitation progress. Self-evaluation questionnaires' scores do not always correspond to the scores of commonly used clinical evaluation tools. The purpose of this study was to assess the relationship between self-evaluation questionnaires, clinical tests, and kinematic and kinetic analyses of the affected upper limb after stroke, and to determine the correlation between these measures and self-reported general function 2-4 years after the stroke.

Methods

Twenty-six subjects recovering from stroke were included in the study. Spearman's correlation coefficient was used to measure the correlation between Stroke Impact Scale (SIS), Motor activity Log (MAL), Fugl-Meyer Assessment (FMA) and Action Reach Arm Test (ARAT) scores, and kinematic and kinetic analyses. A logistic regression was used to assess the extent to which these measures may predict the participants' functional self-reported status 2-4 years post stroke.

Results

Sections regarding hand function, hand force and general ADL of the self-evaluation questionnaires correlated with kinematic variables. However, only questionnaires that focus on hand function correlated with clinical tests. Mean and maximal hand velocity had the strongest correlations with self-evaluation questionnaires and with the clinical tests, more than other kinematic variables. Self-evaluation questionnaires and clinical tests were found to be correlated with hand kinetic metrics force-to-time ratio and number of force peaks. SIS hand force domain, mean velocity and maximal velocity predicted self-reported general function 2-4 years after the stroke.

Conclusion

Self-evaluation questionnaires should be considered for wider use in the clinical evaluation of a patient's stroke recovery, since they add important information on the individual's functional status, which is not reflected in the clinical tests.

The caregiver burden of informal caregivers for stroke patients with and without dysphagia: A multi-center, cross-sectional study in Türkiye

Objectives

The aim of this study was to investigate the caregiver burden (CB) of informal caregivers for stroke survivors with and without dysphagia and to assess the relationship between the CB levels of informal caregivers for stroke survivors with dysphagia, patients' swallowing-related quality of life (QoL), and patients' stroke-specific QoL.

Patients and methods

This multi-center, prospective, cross-sectional study included a total of 120 stroke patients (76 males, 44 females; mean age: 61.1±12.3 years; range, 19 to 86 years) between October 2019 and 2020. Of the patients, 57 had dysphagia and 63 had no dysphagia. The Functional Oral Intake Scale (FOIS) was used to classify the degree of functional dietary limitation caused by each patient's swallowing impairment. Patients and caregivers completed the Eating Assessment Tool (EAT-10), Swallowing Quality of Life (SWQoL) questionnaire, Stroke Impact Scale (SIS), and the Zarit Caregiver Burden Interview (ZBI).

Results

The CB levels were higher in those caring for stroke patients with dysphagia than in those caring for stroke patients without dysphagia. Caregiver burden was found to be associated with patients' swallowing-related QoL and stroke-related QoL. Significant predictors of high CB scores (F=2.55, R2=0.59; p=0.007) were being an employed caregiver (B=17.48, p=0.003), being a caregiver with high school (B=-19.6, p=0.03), and secondary school (B=-16.28, p=0.02) educational status, being son, daughter (B=30.63, p=0.007) or other relative of the patient (B=20.06, p=0.01), lower FOIS stage (B=-3.14, p=0.011), lower SWQoL (B=0.52, p=0.009) and lower SIS (B=-0.37, p=0.04) scores.

Conclusion

Caregivers of stroke patients with dysphagia suffer from a higher CB than those without dysphagia. In stroke patients with dysphagia, swallowing-related QoL is associated with the QoL levels of stroke patients and the CB levels of their caregivers. Employment status, educational status of caregiver, caregiver's relativity to the patient, FOIS stage, swallowing and stroke related QoL of the patients are factors related to burden levels of caregivers of stroke patients with dysphagia. These results may help health professionals to understand dysphagia as an essential source of CB and consider it, while planning treatments.

Associations between participation and personal factors in community-dwelling adults post-stroke

PURPOSE

To examine associations between post-stroke participation and personal factors, including demographic characteristics, self- and threat appraisals, and personality variables.

METHODS

An exploratory cross-sectional study with purpose-designed survey was completed online or via mail. The survey was comprised of demographic and health-related questions and multiple questionnaires, including the Stroke Impact Scale Version 3.0 (SISv3) (participation/perceived recovery), Community Integration Questionnaire (CIQ) (participation), Head Injury Semantic Differential III (pre- vs post-stroke self-concept/self-discrepancy), Appraisal of Threat and Avoidance Questionnaire (threat appraisal), Life Orientation Test - Revised (optimism) and Relationships Questionnaire (adult attachment style) that measured variables of interest. Sixty-two participants, aged 24-96 years who had experienced a stroke (one or multiple events) and had returned to community living, completed the survey. Associations were examined using correlations, and univariate and multiple linear regression analyses.

RESULTS

Regression analysis showed that greater participation, measured using the CIQ, was associated with younger age, female gender, lower self-discrepancy and higher perceived recovery, explaining 69% of the variability in CIQ participation. Further, greater participation on the SISv3 was associated with lower self-discrepancy and higher perceived recovery, explaining 64% of the variability in SISv3 participation.

CONCLUSIONS

Results indicate that personal factors, particularly self-appraisals like self-concept/self-discrepancy, in combination with perceived recovery may be important in explaining a large portion of variance in post-stroke participation. Specifically, findings highlight the interrelatedness of self-concept change, perceived recovery and post-stroke participation. Further longitudinal research is needed to clarify the directionality of these associations throughout the hospital-to-home transition.

Results of a 12-Month Randomized Controlled Trial Testing the Efficacy of the Diabetes Prevention Program Group Lifestyle Balance (DPP-GLB) for People Post Stroke (GLB-CVA)

BACKGROUND

Experience of stroke is associated with an increased risk for diabetes and metabolic syndrome, yet few interventions exist that have been tailored to the population's unique needs.

PURPOSE

To examine adherence and efficacy of the Diabetes Prevention Program Group Lifestyle Balance program (DPP-GLB) modified for individuals post stroke (GLB-CVA) using a randomized controlled trial.

METHODS

Adults (18-85 years of age), >12 months post stroke, and body mass index ≥25 kg/m2 were included in this study. Sixty-five individuals were assigned to either the GLB-CVA intervention or a 6-month wait-list control. Participants completed the 12-month GLB-CVA intervention, with attendance and assessment of weight, anthropometric, biomarker, functional, and patient reported outcome data collected at baseline, 3, 6, and 12 months.

RESULTS

High attendance (90%) and dietary and activity tracking (71%) suggest high adherence to the 12-month GLB-CVA. Six-month randomized controlled trial data indicate significant weight loss (p = .005) in the GLB-CVA group (7.4 ± 13.6 lbs, 3.65%) compared with the wait-list control (0.1 ± 10.1 lbs, 0%), and improvements in arm circumference (p = .04), high-density lipoprotein (HDL) cholesterol (p = .028), 8-year diabetes risk (p = .011), and pain interference (p < .001). Combined 12-month data showed participants lost 10.1 ± 16.8 lbs (4.88%) and improved waist circumference (p = .001), HbA1c (3.6%), diastolic blood pressure (p < .001), pain (p = .001), social participation (p = .025), and eating practices (p = .01) and habits (p < .001).

CONCLUSIONS

Engagement in the GLB-CVA can result in weight loss and improved health for individuals who are overweight or obese following stroke. Future efforts should examine effectiveness in real-world settings and focus on knowledge translation efforts.

Contralaterally controlled functional electrical stimulation video game therapy for hand rehabilitation after stroke: a randomized controlled trial

PURPOSE

To estimate the effect of integrating custom-designed hand therapy video games (HTVG) with contralaterally controlled functional electrical stimulation (CCFES) therapy.

METHODS

Fifty-two stroke survivors with chronic (>6 months) upper limb hemiplegia were randomized to 12 weeks of CCFES or CCFES + HTVG. Treatment involved self-administration of technology-mediated therapy at home plus therapist-administered CCFES-assisted task practice in the lab. Pre- and post-treatment assessments were made of hand dexterity, upper limb impairment and activity limitation, and cognitive function.

RESULTS

No significant between-group differences were found on any outcome measure, and the average magnitudes of improvement within both groups were small. The incidence of technical problems with study devices at home was greater for the CCFES + HTVG group. This negatively affected adherence and may partially explain the absence of effect of HTVG. At end-of-treatment, large majorities of both treatment groups had positive perceptions of treatment efficacy and expressed enthusiasm for the treatments.

CONCLUSION

This study makes an important contribution to the research literature on the importance of environmental factors, concomitant impairments, and technology simplification when designing technology-based therapies intended to be self-administered at home. This study failed to show any added benefit of HTVG to CCFES therapy.Clinicaltrials.gov (NCT03058796).

Validation of two short forms of Stroke Impact Scale: unidimensionality and reliability

PURPOSE

We examined the unidimensionality and Rasch reliability of both Jenkinson's and MacIsaac's eight-item short versions of the Stroke Impact Scale (SF-SIS), a questionnaire for assessing overall health-related quality of life (HRQOL).

METHODS

This study was a secondary data analysis in which 263 persons with stroke completed the SIS. The 263 persons, on average, had age of 60 years, mild stroke, and moderate disability of self-care. The unidimensionality of both versions was validated via testing of model fitting and principal component analysis (PCA) of residuals using the Rasch analysis to determine the Rasch reliability and measures.

RESULTS

The eight items in both SF-SIS versions met the criteria of infit and outfit MNSQ (<1.4 and >0.6), indicating good data-model fit. The PCA showed that no dominant factors existed in the residuals of the items. The person reliability of Jenkinson's and MacIsaac's SF-SIS versions was 0.80 and 0.79, respectively. The Rasch measures (i.e., person measure in logits) ranged from -1.06 to 1.87 in Jenkinson's SF-SIS and -0.82 to 1.88 in MacIsaac's version.

CONCLUSIONS

The unidimensionality of both versions was supported. The Rasch measures of both appear valid for representing overall HRQOL levels. Both versions also showed acceptable reliability for research purposes.Implications for rehabilitationThe unidimensionality was justified for both versions (Jenkinson's and MacIsaac's eight-item short-versions of Stroke Impact Scale).The Rasch scores of both versions appear valid for representing overall health-related quality of life.Both versions showed acceptable reliability for research purposes, but not sufficiently reliable for clinical use.

Machine learning models of plasma proteomic data predict mood in chronic stroke and tie it to aberrant peripheral immune responses

Post-stroke depression is common, long-lasting and associated with severe morbidity and death, but mechanisms are not well-understood. We used a broad proteomics panel and developed a machine learning algorithm to determine whether plasma protein data can predict mood in people with chronic stroke, and to identify proteins and pathways associated with mood. We used Olink to measure 1,196 plasma proteins in 85 participants aged 25 and older who were between 5 months and 9 years after ischemic stroke. Mood was assessed with the Stroke Impact Scale mood questionnaire (SIS3). Machine learning multivariable regression models were constructed to estimate SIS3 using proteomics data, age, and time since stroke. We also dichotomized participants into better mood (SIS3 > 63) or worse mood (SIS3 ≤ 63) and analyzed candidate proteins. Machine learning models verified that there is indeed a relationship between plasma proteomic data and mood in chronic stroke, with the most accurate prediction of mood occurring when we add age and time since stroke. At the individual protein level, no single protein or set of proteins predicts mood. But by using univariate analyses of the proteins most highly associated with mood we produced a model of chronic post-stroke depression. We utilized the fact that this list contained many proteins that are also implicated in major depression. Also, over 80% of immune proteins that correlate with mood were higher with worse mood, implicating a broadly overactive immune system in chronic post-stroke depression. Finally, we used a comprehensive literature review of major depression and acute post-stroke depression. We propose that in chronic post-stroke depression there is over-activation of the immune response that then triggers changes in serotonin activity and neuronal plasticity leading to depressed mood.

Investigating the quality of life for children with autism spectrum disorder scale using Rasch methodology

Our purpose in this study was to provide additional psychometric evidence of the Quality of Life for Children with Autism Spectrum Disorder (QOLASD-C) scale. We used Rasch modeling to investigate the QOLASD-C functioning, the characteristics of the items comprising the scale, and the item functioning across subgroups of children with ASD based on gender and race/ethnicity. Results showed that QOLASD-C was unidimensional, met the local independence assumption, and measured quality of life (QOL). The items showed excellent fit to the model and good discriminating ability between low and high QOL. Most items showed a moderate difficulty level. No differential item functioning was observed based on children's gender and race/ethnicity. Implications for research and practice are discussed.

Study protocol for a randomized, controlled, multicentre, pragmatic trial with Rehabkompassen®-a digital structured follow-up tool for facilitating patient-tailored rehabilitation in persons after stroke

BACKGROUND

Stroke is a leading cause of disability among adults worldwide. A timely structured follow-up tool to identify patients' rehabilitation needs and develop patient-tailored rehabilitation regimens to decrease disability is largely lacking in current stroke care. The overall purpose of this study is to evaluate the effectiveness of a novel digital follow-up tool, Rehabkompassen®, among persons discharged from acute care settings after a stroke.

METHODS

This multicentre, parallel, open-label, two-arm pragmatic randomized controlled trial with an allocation ratio of 1:1 will be conducted in Sweden. A total of 1106 adult stroke patients will have follow-up visits in usual care settings at 3 and 12 months after stroke onset. At the 3-month follow-up, participants will have a usual outpatient visit without (control group, n = 553) or with (intervention group, n = 553) the Rehabkompassen® tool. All participants will receive the intervention at the 12-month follow-up visit. Feedback from the end-users (patient and health care practitioners) will be collected after the visits. The primary outcomes will be the patients' independence and social participation at the 12-month visits. Secondary outcomes will include end-users' satisfaction, barriers and facilitators for adopting the instrument, other stroke impacts, health-related quality of life and the cost-effectiveness of the instrument, calculated by incremental cost per quality-adjusted life year (QALY).

DISCUSSION

The outcomes of this trial will inform clinical practice and health care policy on the role of the Rehabkompassen® digital follow-up tool in the post-acute continuum of care after stroke.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04915027. Registered on 4 June 2021. ISRCTN registry ISRCTN63166587. Registered on 21 August 2023.

Validation of the Greek version of the contact lens dry eye questionnaire-8 (CLDEQ-8)

PURPOSE

Contact lens discomfort (CLD) has been cited as one of the prime reasons for discontinuing contact lens wear. The CLDEQ-8 was created in 2008 to reflect status of and change in overall opinion of soft contact lenses. The purpose of this study is to examine the validity and reliability of a Greek version of the Contact Lens Dry Eye Questionnaire-8 (CLDEQ-8), using Rasch statistical analysis.

METHODS

This an observational prospective study of 150 consecutive patients who received soft contact lenses and were followed through with a single follow-up appointment up to a year following their initial one. The patients filled in the Greek versions of the CLDEQ-8, the Ocular Surface Disease Index (OSDI) and a self-report item on their experience of contact lens use. The CLDEQ-8 was analyzed with Rasch analytic methodology.

RESULTS

The original scoring system of the CLDEQ-8 had to be altered regarding the response categories collapsing in fewer options in items b, 2b, 3b and item 5 of the original scale. The revised scoring system proved more psychometrically valid and the CLDEQ-8 had good measurement precision, category threshold order, targeting and differential item functioning for gender. Two alternative result indexes are proposed, a symptom intensity index and a symptom frequency index to address dimensionality issues that are evident with the items relating to symptom intensity versus the rest. Results from the CLDEQ-8 correlated with the OSDI total score and the self-reported experience of contact lens use.

CONCLUSIONS

The Greek version of the CLDEQ-8 is a psychometrically valid and reliable assessment tool for contact lens discomfort in Greek-speaking populations.

Semi-automated Rasch analysis with differential item functioning

Rasch analysis is a procedure to develop and validate instruments that aim to measure a person's traits. However, manual Rasch analysis is a complex and time-consuming task, even more so when the possibility of differential item functioning (DIF) is taken into consideration. Furthermore, manual Rasch analysis by construction relies on a modeler's subjective choices. As an alternative approach, we introduce a semi-automated procedure that is based on the optimization of a new criterion, called in-plus-out-of-questionnaire log likelihood with differential item functioning (IPOQ-LL-DIF), which extends our previous criterion. We illustrate our procedure on artificially generated data as well as on several real-world datasets containing potential DIF items. On these real-world datasets, our procedure found instruments with similar clinimetric properties as those suggested by experts through manual analyses.

The Critical Period After Stroke Study (CPASS) Upper Extremity Treatment Protocol

Objective

To present the development of a novel upper extremity (UE) treatment and assess how it was delivered in the Critical Periods After Stroke Study (CPASS), a phase II randomized controlled trial (RCT).

Design

Secondary analysis of data from the RCT.

Setting

Inpatient and outpatient settings the first year after stroke.

Participants

Of the 72 participants enrolled in CPASS (N=72), 53 were in the study groups eligible to receive the treatment initiated at ≤30 days (acute), 2-3 months (subacute), or ≥6 months (chronic) poststroke. Individuals were 65.1±10.5 years of age, 55% were women, and had mild to moderate UE motor capacity (Action Research Arm Test=17.2±14.3) at baseline.

Intervention

The additional 20 hours of treatment began using the Activity Card Sort (ACS), a standardized assessment of activities and participation after stroke, to identify UE treatment goals selected by the participants that were meaningful to them. Treatment activities were broken down into smaller components from a standardized protocol and process that operationalized the treatments essential elements.

Main Outcome Measures

Feasibility of performing the treatment in a variety of clinical settings in an RCT and contextual factors that influenced adherence.

Results

A total of 49/53 participants fully adhered to the CPASS treatment. The duration and location of the treatment sessions and the UE activities practiced during therapy are presented for the total sample (n=49) and per study group as an assessment of feasibility and the contextual factors that influenced adherence.

Conclusions

The CPASS treatment and therapy goals were explicitly based on the meaningful activities identified by the participants using the ACS as a treatment planning tool. This approach provided flexibility to customize UE motor therapy without sacrificing standardization or quantification of the data regardless of the location and UE impairments of participants within the first year poststroke.

The Effect of Botulinum Toxin Type A Injection in the Rectus Femoris in Stroke Patients Walking With a Stiff Knee Gait: A Randomized Controlled Trial

BACKGROUND

Over activity of the rectus femoris is often cited as a main cause for stiff knee gait (SKG). Botulinum toxin (BoNT) can be used to reduce this over activity. Inconsistent results for the effect of BoNT injections were found in literature which can possibly be explained by the study design as these were uncontrolled or non-randomized studies.

OBJECTIVE

To conduct a randomized controlled trial (RCT) to investigate the effect of botulinum toxin type A (BoNT-A) injections in the rectus femoris on gait kinematics and functional outcome in adult stroke patients.

METHODS

Twenty-six participants were included in this triple-blind cross-over RCT. The intervention consisted of an injection with BoNT-A. Placebo is an injection with saline. Besides knee and hip kinematics, functional outcomes were measured.

RESULTS

Comparison of the effect of BoNT-A injection to placebo injection showed a significant increase in peak knee flexion and knee range of motion of 6.7° and 4.8° respectively. There was no difference in hip kinematics. In functional outcomes, only the 6 Minute Walking Test showed a significant increase of 18.3 m.

CONCLUSIONS

BoNT-A injections in the rectus femoris is a valuable treatment option for stroke patients walking with a SKG to improve knee kinematics. To study the effect on functional outcome more research is necessary with different functional outcome measures that can capture the effect in kinematics. It is important to use kinematic measurements to demonstrate effects in quality of movement that are not captured by commonly used functional outcome measurements post stroke.Clinical Trial Registration: https://trialsearch.who.int/Trial2.aspx?TrialID=NTR2169.

Ecologically valid virtual reality-based technologies for assessment and rehabilitation of acquired brain injury: a systematic review

Purpose

A systematic review was conducted to examine the state of the literature regarding using ecologically valid virtual environments and related technologies to assess and rehabilitate people with Acquired Brain Injury (ABI).

Materials and methods

A literature search was performed following the PRISMA guidelines using PubMed, Web of Science, ACM and IEEE databases. The focus was on assessment and intervention studies using ecologically valid virtual environments (VE). All studies were included if they involved individuals with ABI and simulated environments of the real world or Activities of Daily Living (ADL).

Results

Seventy out of 363 studies were included in this review and grouped and analyzed according to the nature of its simulation, prefacing a total of 12 kitchens, 11 supermarkets, 10 shopping malls, 16 streets, 11 cities, and 10 other everyday life scenarios. These VE were mostly presented on computer screens, HMD's and laptops and patients interacted with them primarily via mouse, keyboard, and joystick. Twenty-five out of 70 studies had a non-experimental design.

Conclusion

Evidence about the clinical impact of ecologically valid VE is still modest, and further research with more extensive samples is needed. It is important to standardize neuropsychological and motor outcome measures to strengthen conclusions between studies.

Systematic review registration

identifier CRD42022301560, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=301560.

Feasibility of a Virtual-Reality-Enabled At-Home Telerehabilitation Program for Stroke Survivors: A Case Study

Stroke rehabilitation is a lengthy procedure that is necessary for stroke recovery. However, stroke rehabilitation may not be readily available for patients who live rurally due to barriers such as transportation and expenses. This shortage in wearable technology, in turn, causes health disparity among the rural population, which was exacerbated by the COVID-19 pandemic restrictions. Telerehabilitation (TR) is a potential solution for stroke rehabilitation in rural areas. This one-case study aimed to examine the feasibility and safety of a technology-enabled at-home TR program for stroke survivors living in a rural area in Canada. A VR setup was installed successfully in the home of our participant. A tablet was also supplied for the TR program. Each program consisted of 24 sessions to be completed over a 12-week period. Our participant was assessed on day one using the Fugl-Meyer assessment, the Modified Ashworth Scale, the 10 m walk test, and the Mini-Mental State Exam. Three questionnaires were also completed, including the Motor Activity Log (MAL), the Stroke Index Scale (SIS), and the Treatment Self-Regulation Questionnaire. These assessments were completed thrice, on day 1, at week 6, and at week 12. The participant found the tablet and its accompanying exercises easy to use, with a few limitations. The participant found the VR system more challenging to manage independently as a lack of comfortability, the visual contrast during the first trials, and certain technical aspects of the technology created several functional barriers. Although some limitations with the technology were noted, this case study indicates that telerehabilitation is feasible under certain circumstances when used in conjunction with traditional rehabilitation services.

TeleRehabilitation with Aims to Improve Lower extremity recovery in community-dwelling individuals who have had a stroke: protocol for a multisite, parallel group, assessor-blinded, randomised attention-controlled trial

INTRODUCTION

Telerehabilitation is an accessible service delivery model that may support innovative lower extremity rehabilitation programmes that extend the stroke recovery continuum into the community. Unfortunately, there is limited evidence on the provision of exercises for lower extremity recovery after stroke delivered using telerehabilitation. In response, we developed the TeleRehabilitation with Aims to Improve Lower extremity recovery poststroke (TRAIL) programme, a 4-week progressive exercise and self-management intervention delivered synchronously using video-conferencing technology. Our primary hypothesis is that individual within 1-year poststroke who participate in TRAIL will experience significantly greater improvements in functional mobility than individuals in an attention-controlled education programme (EDUCATION).

METHODS AND ANALYSIS

In this multisite, parallel group, assessor-blinded randomised attention-controlled trial, 96 community-living stroke survivors within 1-year poststroke will be recruited from five sites (Vancouver, Winnipeg, Toronto, London and Halifax, Canada) from the CanStroke Recovery Trials Platform which is a network of Canadian hospital sites that are affiliated with academic institutions to facilitate participant recruitment and quality trial practices. Participants will be randomised on a 1:1 basis to TRAIL or EDUCATION. Participants randomised to TRAIL will receive eight telerehabilitation sessions where they will perform exercises and receive self-management support to improve lower extremity recovery from a TRAIL physical therapist. The primary outcome will be measured using the Timed Up and Go. Secondary outcomes include lower extremity muscle strength, functional balance, motor impairment, balance self-efficacy, health-related quality of life and health service use for our economic evaluation. Measurements will be taken at baseline, immediately after the intervention, 3-month and 6-month postintervention.

ETHICS AND DISSEMINATION

Ethics approval for this research has been obtained by all participating sites. All study participants will provide their informed consent prior to enrolling them in the study. Findings from this trial will be disseminated in peer-reviewed journals and presentations at international scientific meetings.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, NCT04908241.

Psychometric properties of the caregiving difficulty scale in mothers of children with cerebral palsy

BACKGROUND

The Caregiving Difficulty Scale is used to measure the burden of caregiving experienced by mothers of children with cerebral palsy. This study aimed to identify the psychometric properties of the Caregiving Difficulty Scale using the Rasch model.

METHODS

Data collected from 206 mothers of children with cerebral palsy were analyzed. Unidimensionality, difficulty of item, rating scale appropriateness, and reliability using the separation index of the Caregiving Difficulty Scale were verified. Unidimensionality of all 25 items was identified through the item fit.

RESULTS

Our analysis of item difficulty indicated that person ability and item difficulty are expressed as a similar logit extend. The use of the 5-point rating scale appeared to be appropriate. Outcome analysis revealed that the reliability was high based on the person and that the item separation level was acceptable.

CONCLUSIONS

This study showed that the Caregiving Difficulty Scale could be a valuable tool for evaluating the caregiving burden in mothers of children with cerebral palsy.

Struck by stroke - experiences of living with stroke in a rural area in Uganda

BACKGROUND

The global burden of stroke is increasing and persons with low socioeconomic status are among those worst affected. In Uganda, stroke is estimated to be the sixth highest ranking cause of death. The Ugandan healthcare system is reported to be inequitable, where poorer populations often live in rural areas with long distances to health care. Stroke rehabilitation is often scarce, with less financial and human resources. The aim of this study was to explore and describe the consequences of stroke in daily activities in everyday life for people in a rural part of Masaka in Uganda.

METHODS

Qualitative study design. Fourteen persons who had had stroke and were living in their home environment were interviewed about their experiences of having a stroke and managing their lives after the stroke incident. The interviews were analysed using thematic analysis. In addition, sociodemographic data and level of independence (Barthel Index and Stroke Impact Scale 3.0) was collected to describe participant characteristics.

RESULTS

Most of the participants had major consequences of stroke and described that they were dependent on support for managing their daily activities. Five themes were identified in the analysis: (1) Accepting and adapting to new ways of managing everyday life, (2) Changing roles and hierarchical positions, (3) Depending on caregiver support, (4) Interrupted care due to economic constraints, (5) Stroke leading to losses and losses leading to stroke.

CONCLUSIONS

The consequences of stroke on the persons' daily lives clearly reached beyond the person with stroke, affecting the whole family and their proximate social networks. These consequences included increased burdens on caregivers and a worsened economic situation for all persons affected. Therefore, interventions for stroke management should preferably not only target the individual affected by stroke, but also support the caregivers in the caring and rehabilitation process. Home rehabilitation approaches with a focus on improving health literacy are suggested.

Measurement Property Evaluation of the Arabic Version of the Patient-Specific Functional Scale for Patients with Stroke

Neurological disorders refer to disorders that occur due to disease or damage to the nervous system. Stroke is one of the most common neurological disorders in which individuals commonly present with motor and sensory deficits, leading to the limitations on the activities of daily life. Outcome measures are used to assess and monitor patients' condition change. The patient-specific functional scale (PSFS) is an outcome measure used to assess changes in performance levels in participants with a functional disability during daily activities. This study aimed to assess the reliability and validity of the Arabic version of the patient-specific functional scale (PSFS-Ar) in individuals with stroke. A longitudinal cohort study was used to examine the reliability and validity of the PSFS-Ar in patients with stroke. All participants completed the PSFS-Ar in addition to other outcome measures. Fifty-five individuals participated (fifty male, five female). The PSFS-Ar showed excellent test-retest reliability, with ICC2,1 = 0.96, p < 0.001. The SEM and MDC95 of the PSFS-Ar were 0.37 and 1.03, respectively. No floor and ceiling effect was observed in this study. Additionally, the construct validity of the PSFS-Ar showed 100% satisfaction with the pre-defined hypotheses. Since the number of female participants was very small in this study, the findings were established for male individuals with stroke. This study showed that the PSFS-Ar is a reliable and valid outcome measure for male individuals with stroke.

Supporting stroke survivors to meet their personal rehabilitation needs in community-based arm rehabilitation: development of initial programme theories to explore what may work for whom, how and under what circumstances

Objective

This study explored what worked for whom, how and under what circumstances in a community-based augmented arm rehabilitation programme that was designed to enable stroke survivors to meet their personal rehabilitation needs.

Design

A mixed methods realist-informed study of data from a randomised controlled feasibility trial, comparing augmented arm rehabilitation after stroke with usual care. The analysis was designed to develop initial programme theories and refine these through triangulation of qualitative and quantitative trial data. Participants with a confirmed stroke diagnosis and stroke-related arm impairment were recruited from five health boards in Scotland. Only data from participants in the augmented group were analysed. The augmented intervention comprised evidence-based arm rehabilitation (27 additional hours over 6 weeks) including self-managed practice, and focused on individual rehabilitation needs identified through the Canadian Occupational Performance Measure (COPM). The COPM indicated to which extent rehabilitation needs were met following the intervention, the Action Research Arm Test provided data on changes in arm function, and qualitative interviews provided information about the context and potential mechanisms of action.

Findings

Seventeen stroke survivors (11 males, age range 40-84 years, NIHSS median (IQR) 6 (8)) were included. Median (IQR) COPM Performance and Satisfaction scores (min.1-max.10) improved from pre-intervention 2 (5) to post-intervention 5 (7). Findings suggested that meeting rehabilitation needs was facilitated by strengthening participants' sense of intrinsic motivation (through grounding exercises in everyday activities linked to valued life roles, and enabling them to overcome barriers to self-managed practice), and via therapeutic relationships (through trust and expertise, shared decision-making, encouragement and emotional support). Collectively, these mechanisms enabled stroke survivors to build confidence and gain mastery experience necessary to engage in new self-managed practice routines.

Conclusion

This realist-informed study enabled the development of initial programme theories to explain how and in what circumstances the augmented arm rehabilitation intervention may have enabled participants to meet their personal rehabilitation needs. Encouraging participants' sense of intrinsic motivation and building therapeutic relationships appeared instrumental. These initial programme theories require further testing, refinement, and integration with the wider literature.

Will Your Next Therapist Be a Robot?-A Review of the Advancements in Robotic Upper Extremity Rehabilitation

Several recent studies have indicated that upper extremity injuries are classified as a top common workplace injury. Therefore, upper extremity rehabilitation has become a leading research area in the last few decades. However, this high number of upper extremity injuries is viewed as a challenging problem due to the insufficient number of physiotherapists. With the recent advancements in technology, robots have been widely involved in upper extremity rehabilitation exercises. Although robotic technology and its involvement in the rehabilitation field are rapidly evolving, the literature lacks a recent review that addresses the updates in the robotic upper extremity rehabilitation field. Thus, this paper presents a comprehensive review of state-of-the-art robotic upper extremity rehabilitation solutions, with a detailed classification of various rehabilitative robots. The paper also reports some experimental robotic trials and their outcomes in clinics.