Predictors of long-term participation after stroke

Person and Environment Factors Supporting Self-Care Performance and Social Participation After Mild Stroke

Mild stroke survivors seldom receive occupational therapy services as their deficits are assumed to be minor enough to not affect their daily occupations. Yet many mild stroke survivors report deficits in self-care performance and social participation. This study investigates person and environment factors influencing self-care performance and social participation among mild stroke survivors, using the Person-Environment-Occupation-Performance (PEOP) model. A retrospective cohort analysis of 736 mild stroke survivors was conducted using electronic health records. Person factors included demographic characteristics and clinical characteristics, and environment factors included the Social Vulnerability Index. The analysis included logistic regression. Approximately, 10% of patients reported deficits in self-care or social participation. Disability level was the only person factor associated with self-care performance. Person factors affecting social participation included mobility and unemployment. Socioeconomic status was associated with both occupation measures. Occupational therapy practitioners must address the person and environment factors affecting mild stroke survivors' self-care performance and social participation.

Trajectories of fatigue and related outcomes following mild acquired brain injury: a multivariate latent class growth analysis

OBJECTIVE

Fatigue is a common symptom following acquired brain injury although the severity and course differs for many individuals. This longitudinal study aimed to identify latent trajectory classes of fatigue and associated outcomes following mild brain injury.

METHODS

204 adults with mild traumatic brain injury (159; 78%) or minor stroke (45; 22%) were assessed 4 times over 1 year. Subjective measures of fatigue, anxiety, depression, cognitive complaints and societal participation were collected. Multivariate Latent Class Growth Analysis identified classes of participants with similar longitudinal patterns. Demographic and injury characteristics were used to predict class membership.

RESULTS

Analysis revealed four classes. Class 1 (53%) had mild, decreasing fatigue with no other problems. Class 2 (29%) experienced high persistent fatigue, moderate cognitive complaints and societal participation problems. Class 3 (11%) had high persistent fatigue with anxiety, depression, cognitive complaints and participation problems. Class 4 (7%) experienced decreasing fatigue with anxiety and depression but no cognitive or participation problems. Women and older individuals were more likely to be in class 2.

CONCLUSION

Half the participants had a favourable outcome while the remaining classes were characterised by persistent fatigue with cognitive complaints (class 2), decreasing fatigue with mood problems (class 4) or fatigue with both cognitive and mood problems (class 3). Fatigue treatment should target combinations of problems in such individual trajectories after mild brain injury.

An evaluation of 3D printable elastics for post stroke dynamic hand bracing: a pilot study

The rise of 3D printing allows unprecedented customization of rehabilitation devices, and with an ever-expanding library of 3D printable (3DP) materials, the spectrum of attenable rehabilitation devices is likewise expanding. The current pilot study explores feasibility of using 3DP elastic materials to create dynamic hand orthoses for stroke survivors. A dynamic orthosis featuring a replaceable finger component was fabricated using 3DP elastic materials. Duplicates of the finger component were printed using different materials ranging from low stiffness (low elastic modulus) to relatively high stiffness (high elastic modulus). Five stroke survivors with predominantly moderate hand impairment were recruited to evaluate usability and impact of orthoses on upper extremity function and biomechanics. No significant differences in usability were found between 3D-printed orthoses and a commercial orthosis. Increases in stiffness of the 3DP material reduced pincer force (p = .0041) and the BBT score (p = .043). In comparison, the commercial orthosis did not reduce pincer force but may reduce BBT score to a degree that is clinically significant (p = .0002). While preliminary, these findings suggest that a dynamic orthosis is a feasible clinical application of 3DP elastic materials, and future study is warranted.

Participation and Its Association With Health Among Community-Dwelling Adults With Chronic Stroke

IMPORTANCE

Little is known about the severity of participation restrictions among people living in the community with chronic stroke. Even less is known about the association between participation and health in this population.

OBJECTIVE

To describe participation among people with chronic stroke and examine the association between participation and physical and mental health.

DESIGN

Secondary analysis of baseline data from an intervention study.

SETTING

The parent multisite intervention study was conducted in the community, and assessments were administered in participants' homes.

PARTICIPANTS

Thirty-one community-dwelling adults with chronic stroke.

OUTCOMES AND MEASURES

Participation was measured with the Activity Card Sort (percentage of prestroke activities retained) and the Enfranchisement Scale of the Community Participation Indicators. Health was measured with the PROMIS®-29 Physical Health and Mental Health subscales. We calculated descriptive statistics for participation measures and Spearman's ρ correlations between participation and health outcomes.

RESULTS

Participation scores were poor on all measures of participation. Most striking, 94.9% of participants retained less than 80% of their prestroke activities. All measures of participation were modestly correlated with physical health (ρ = .28-.46) and were moderately correlated with mental health (ρ = .42-.63).

CONCLUSIONS AND RELEVANCE

Participation restrictions are prevalent among adults with chronic stroke, with potential implications for mental health. Stronger community-based rehabilitation and support services to enhance participation of this high-risk population are warranted. What This Article Adds: This report highlights the severity of participation restrictions among people with chronic stroke. Moreover, this report shows that people with stroke feel a lack of inclusion in the community and that participation is associated with mental and physical health.

Self-Reported Reasons for Activity Limitations According to Age and Sex in Community-Dwelling Stroke Survivors

We examined self-reported reasons for activity limitations among Korean community-dwelling stroke survivors, focusing on age and sex differences. Data from 1547 stroke survivors who participated in the Korean National Health and Nutrition Examination Survey were analysed. The study outcomes were the self-reported reasons for activity limitations, encompassing general medical factors and stroke-related problems. These reasons were compared by age (<65 vs. ≥65 years) and sex using a complex-sample chi-square test. Stroke survivors reported different musculoskeletal, medical, and neurological problems as reasons for activity limitations, which differed by age and sex. Older stroke survivors reported more problems related to dementia, memory loss, auditory problems, back or neck problems, arthritis, or leg pain than younger survivors. Women reported more psychiatric problems, headaches or dizziness, back or neck problems, arthritis, gastrointestinal problems, and dental or oral problems than men. Older and female stroke survivors reported a higher mean number of reasons for activity limitations compared to younger and male survivors. Thus, a tailored approach considering age and sex is necessary to help stroke survivors with activity limitations in the Korean community. This study highlights the importance of considering demographic factors when designing interventions to improve their quality of life.

What does feeling younger or older than one's chronological age mean to men and women? Qualitative and quantitative findings from the PROTECT study

OBJECTIVE

We explored which factors are associated with subjective age (SA), i.e. feeling younger, the same as, or older than one's chronological age, and whether these factors differ between men and women and between two age sub-groups.

DESIGN

Cross-sectional study using qualitative and quantitative data for 1457 individuals (mean age= 67.2 years).

MAIN OUTCOME MEASURES

Participants reported how old they feel they are and provided comments in relation to their SA judgments.

RESULTS

By using content analysis participants' comments were assigned to 13 categories, grouped into three higher-order categories (antecedents of age-related thoughts, mental processes, and issues when measuring subjective age). SA may result from the interaction between factors that increase or decrease age-related thoughts and mental processes that individuals use to interpret age-related changes. Chi-squared tests show that individuals reporting an older SA are more likely to experience significant negative changes and to engage in negative age-related thoughts than individuals reporting an age-congruent SA or a younger SA. Women experience a more negative SA and more age-salient events than men.

CONCLUSION

Individuals reporting an older SA may benefit from interventions promoting adaptation to negative age-related changes. There is the need to eradicate negative societal views of older women.

Factors associated with mental health service access among Australian community-dwelling survivors of stroke

PURPOSE

To describe types of mental health treatment accessed by community-based stroke survivors and factors associated with access.

METHODS

A sub-group of registrants from the Australian Stroke Clinical Registry completed a supplementary survey 2.5 years post-stroke. Self-reported information about depression/anxiety and treatment access were collected. Demographic and clinical data were obtained through linkages with registry and government data. Staged multivariable logistic regression was conducted to examine factors associated with treatment access.

RESULTS

Among 623 registrants surveyed (37% female, median age 69 years), 26% self-reported a medical diagnosis of depression/anxiety at 2.5 years post-stroke. Of these, only 30% reported having accessed mental health services, mostly through government-funded Medicare schemes. Younger age (odds ratio (OR) 0.95, 95% CI 0.93, 0.98), history of mental health treatment (OR 3.38, 95% CI 1.35, 8.48), feeling socially isolated (OR 2.32, 95% CI 1.16, 4.66), self-reported medical diagnosis of depression/anxiety (OR 4.85, 95% CI 2.32, 10.14), and government-subsidised team care plan arrangement (OR 4.05, 95% CI 1.96, 8.37) were associated with receiving treatment.

CONCLUSIONS

Many stroke survivors have untreated depression/anxiety. Primary care practitioners should be supported in undertaking effective detection and management. Older and newly diagnosed individuals should be educated about depression/anxiety and available supports.Implications for rehabilitationPrimary care providers play a pivotal role in the pathway to mental health care, and therefore should always screen for depression/anxiety and provide comprehensive assessment and referral to specialist services where necessary.Targeted psychoeducation should be provided to survivors of stroke who are older and newly diagnosed with depression/anxiety, to increase awareness about mood problems following stroke.Primary care providers should collaborate with other health professionals (e.g., through coordinating a team care arrangement plan), to address patients' multiple and complex rehabilitation needs.Rehabilitation professionals should remain informed about current evidence-based treatments for post-stroke depression/anxiety and pathways that enable their patients to access these services.

Perceived participation and autonomy structural relationships among related factors in patients with stroke and hypertension in China: A ISM model approach

Aims

To explore the structural relationship between perceived participation and autonomy among older adults with stroke and hypertension in home and community-based services (HCBSs) in the eastern coastal region of China.

Design

An explorative cross-sectional study.

Methods

From July to September 2021, a total of 714 respondents were reported to have stroke and hypertension, and their information was used in the analysis of this study. A multiple linear regression analysis was used to explore the factors influencing factors older adults' perceived participation and autonomy. Using the ISM model, we analyzed the factors affecting social participation in patients with stroke and hypertension and explained the logical relationships and hierarchy among the factors.

Results

The mean score of perceived participation was 58.34 ± 27.57. Age, marital status, health insurance, living status, number of children, chronic diseases, sleep time, frequency of outings, and health utility value were significant factors affecting perceived participation and autonomy with stroke and hypertension patients. Among them, health insurance is the direct factor on the surface, age, number of children, chronic diseases, sleep time, frequency of outings, and health utility value are the intermediate indirect factors, and marital status and living status are the deep-rooted factors.

Conclusion

By the study that the hierarchical structure provides a visualization of interrelationships and interdependences among the influencing factors of perceived participation and autonomy. It also may be a significant complement to traditional variable-entered approaches and construct an optimized multidimensional perspective of participation and autonomy. Future research should focus on optimizing the living environment of older adults with stroke and hypertension to explore the model of rehabilitative intervention and help patients successfully reintegrate into their families/societies.

Preliminary analysis of the clinical feasibility of a practice intervention derived from the occupational therapy intervention process model for patients with stroke in the convalescence stage

Introduction:

This study lays the groundwork for the Occupational Therapy Intervention Process Model (OTIPM) run by occupational therapy practitioners for patients with stroke. We explored the feasibility of a treatment approach based on the OTIPM for patients with stroke and the clinical feasibility of evaluating the degree of a collaborative relationship between patients and occupational therapists.

Method:

This pilot trial was conducted as a one-group pre-test–post-test study and two-group comparison on 16 patients with stroke in the convalescence stage. We used the Canadian Occupational Performance Measure (COPM), Assessment of Motor and Process Skills (AMPS), Functional Independence Measure, Japan Stroke Scale of Motor Function, and the Collaborative Relationship Scale between clients and occupational therapists to assess outcomes.

Results:

Patients demonstrated a significant improvement on the outcome measures after intervention. Moreover, the good collaborative relationship group demonstrated significantly higher process skills in AMPS and satisfaction in COPM than the poor collaborative relationship group.

Conclusion:

This preliminary study revealed that short-term OTIPM for patients with stroke may be a feasible clinical practice. In addition, evaluating the degree of the difference in the collaborative relationship between patients and occupational therapists would be a feasible clinical practice.

Body structure/function impairments and activity limitations of post-stroke that predict social participation: a systematic review

BACKGROUND

Stroke is the leading cause of death and disability in Brazil, and its prognostic indicators of social reintegration are not well established yet.

OBJECTIVE

To identify body structure/function impairments and activity limitations in post-stroke that predict social participation restrictions in the community.

METHODS

cohort studies were selected, involving adult post-stroke participants, which investigated body structure and function impairments or activity limitations of post-stroke individuals as predictors of social participation in the community. Studies that included individuals with subarachnoid hemorrhage, other neurological disorders and participants in long-term care facilities were excluded. The Newcastle-Ottawa quality assessment scale was applied to assess the methodological quality. The results were synthesized according to the found exposures, considering the used statistical models.

RESULTS

Eleven articles were included, with a total of 2,412 individuals, 58.4% men, 83.7% ischemic stroke. Seven exposures were assessed across studies, in which 10 studies assessed body structure and function exposures (stroke severity, cognitive, executive, emotional and motor function), and 8 studies assessed activity exposures (daily living activity and walking ability).

CONCLUSION

There is some evidence that stroke severity, mental and motor deficits, limitations in activities of daily living and the ability to walk after a stroke can predict social participation in the community. PROSPERO registration CRD42020177591.

Validation of the Persian Version of the Engagement in Meaningful Activities Survey (EMAS) in an Iranian Stroke Population: Predictors of Participation in Meaningful Activities

IMPORTANCE

The inability to participate in meaningful activities is one of stroke survivors' main difficulties and has a negative effect on their satisfaction and quality of life.

OBJECTIVE

To assess the reliability and validity of the Persian version of the Engagement in Meaningful Activities Survey (EMAS-P) and predictors of participation in meaningful activity among chronic stroke survivors.

DESIGN

Cross-sectional.

SETTING

Medical and rehabilitation centers.

PARTICIPANTS

One hundred twenty-three people (75 men, 48 women) with chronic stroke.

OUTCOMES AND MEASURES

Participants were evaluated with the EMAS-P, Satisfaction With Life Scale (SWLS), Center for Epidemiologic Studies Depression Scale, Purpose in Life Test-Short Form (PIL-SF), 36-Item Short Form Health Survey (SF-36), and Life Satisfaction Index-Z (LSI-Z).

RESULTS

The EMAS-P showed good internal consistency (Cronbach's α = .95) and test-retest reliability (intraclass correlation coefficient = .87 for EMAS-P total score). Test-retest reliability for each EMAS-P item was moderate (κ = .40-.65). A significant correlation between the EMAS-P and PIL-SF (r = .86), SWLS (r = .83), LSI-Z (r = .75), and SF-36 subscales (rs = .52-.83) indicated the appropriate convergent validity. The EMAS-P's discriminative validity was also confirmed for age, depression level, and disability level among people with chronic stroke. Depression, disability level, gender, and fatigue were significant predictors of EMAS-P score.

CONCLUSIONS AND RELEVANCE

The results indicate that the EMAS-P has acceptable reliability and validity among Iranian people with chronic stroke. Moreover, the EMAS-P showed good discriminant validity for age, depression, and disability level among them. What This Article Adds: The EMAS-P is a reliable and valid scale for assessing the engagement of Iranian chronic stroke survivors in meaningful activities and thus should be helpful in both clinical research and practice.

Italian translation and cross-cultural validation of an assessment tool for participation in stroke survivors: the Frenchay Activities Index

PURPOSE

Participation needs to be assessed objectively, to state accurate rehabilitation objectives. The Frenchay Activities Index (FAI) is a widely used tool to measure participation in stroke patients. To date, no cross-culturally validated Italian version of FAI is available. This study provides a translation and cross-cultural adaptation of FAI into Italian, assessing its validity and reliability in sub-acute stroke patients.

METHODS

According to international guidelines, a multistep translation and cultural adaptation protocol of forward and backward translations was conducted by qualified linguists and independent native English translators and revised by a healthcare committee. Patients admitted to intensive inpatient rehabilitation after stroke were recruited. Structural validity, reliability (internal consistency, inter- and intra-rater reliability and measurement error), and construct validity were studied.

RESULTS

One hundred and seventy-three patients were included in this study. No significant observations in terms of comprehensibility and conceptual equivalence of the FAI Italian version emerged. The exploratory factorial analysis revealed the presence of two subscales (i.e., domestic chores and work/leisure). The internal consistency resulted good for the first and second subscale (α = 0.821 and 0.716, respectively). Intra- and inter-reliability showed an ICC > 0.90 for both subscales. SEM = 5.75% and 2.33% and MDC = 15.85% and 6.48% were found for the first and second subscale, respectively. Construct validity of first subscale was satisfactory, as 100.0% a priori hypotheses were met, while for the second subscale it was moderate, as 66.6% a priori hypotheses were respected.

CONCLUSION

FAI-I provides a tool for professionals to measure participation in Italian stroke patients in health and social care settings.

Capability, opportunity, motivation, and social participation after stroke

BACKGROUND

Stroke survivors report limited social participation, despite it being an important rehabilitation outcome. Interdisciplinary interventions for increasing social participation amongst stroke survivors lack theoretical guidance and evidence-based approaches. The Behavior Change Wheel (BCW) theorizes that capability, opportunity, and motivation contribute to behavior change.

OBJECTIVES

This study applied the BCW to understand the relationship between social participation and stroke survivors' capability, opportunity, and motivation.

METHODS

In this cross-sectional study, we recruited 30 community-dwelling adult stroke survivors. Assessments explored the frequency and satisfaction of social participation; physical and psychological capability; environmental accessibility and social opportunity; and motivation. A linear regression analysis was done.

RESULTS

Motivation (R² change = 29.3%, ß = 0.55) and environmental opportunity (R² change = 11%, ß = 0.39) were statistically significant predictors of social participation frequency. Motivation (R² change = 36.9%, ß = 0.61) was the only statistically significant predictor of satisfaction with social performance.

CONCLUSIONS

Motivation and environmental accessibility are statistically significant independent predictors of frequency of social participation after stroke. Motivation is the strongest predictor of satisfaction with social participation. Clinicians may support stroke survivors to promote social participation using approaches that increase motivation and environmental accessibility. Development of such theoretically sound interventions may be guided by the BCW.

Scoping study of definitions of social participation: update and co-construction of an interdisciplinary consensual definition

Background

considering the importance of social participation for quality of life and active ageing in older adults, it is an important target of social and health professionals’ interventions. A previous review of definitions of social participation in older adults included articles up to 2009; new publications and changes in the social context (e.g. social media and the COVID-19 pandemic) justify continuing this work.

Objective

this paper provides an updated inventory and synthesis of definitions of social participation in older adults. Based on a critical review by content experts and knowledge users, a consensual definition is proposed.

Methods

using a scoping study framework, four databases (MEDLINE, CINAHL, AgeLine, PsycInfo) were searched with relevant keywords. Fifty-four new definitions were identified. Using content analysis, definitions were deconstructed as a function of who, how, what, where, with whom, when, and why dimensions.

Results

social participation definitions mostly focused on people’s involvement in activities providing interactions with others in society or the community. According to this new synthesis and input from content experts and knowledge users, social participation can be defined as a person’s involvement in activities providing interactions with others in community life and in important shared spaces, evolving according to available time and resources, and based on the societal context and what individuals want and is meaningful to them.

Conclusion

a single definition may facilitate the study of active ageing and the contribution of older adults to society, socioeconomic and personal development, benefits for older adults and society, self-actualisation and goal attainment.

The Contribution of Frailty to Participation of Older Adults

Background: Participation, which is involvement in life situations, is an important indicator of human health and well-being of older adults. Frailty is known to be related to difficulties in activities of daily living (ADL) but the association with participation restriction has not been sufficiently researched. Therefore, we aimed to (1) to assess the correlations between frailty, ADL, and participation; and (2) to identify the contribution of frailty to explaining the participation restriction of older adults. Methods: A cross-sectional study included home visits to community-dwelling older adults aged 75 and older. The Reintegration to Normal Living Index (RNL-I) assessed participation, PRISMA-7 assessed frailty, and the Functional Independence Measure and IADL questionnaire assessed the basic and instrumental ADL. Cognition, which may explain participation, was also assessed (The Montreal Cognitive Assessment) and demographic information was collected. Results: Older adults (N = 121, 60 women), aged 75 to 91 years (mean (SD)—79.6 (3.1)), were included. Older adults demonstrated full to restricted participation (RNL-I-mean (SD)—78.2 (18.0)/100). Frailty was identified in 39 (32%) older adults (mean (SD) PRISMA-7—2.9 (1.4)/7points). A negative moderate significant correlation was found between participation and frailty (r = −0.634, p < 0.001). The variance of participation was significantly explained by frailty, 31.5%, and basic ADL, 5.6% (after controlling for age and cognition); the total model explained 44.6% (F = 23.29, p < 0.001). Conclusions: Frailty is significantly associated with participation restriction. Since participation has many health benefits, understanding which factors are associated to participation is central to developing interventions for older adults. These findings may help health professionals in the future develop interventions for maintaining and promoting the participation of older adults.

Visualization-Driven Time-Series Extraction from Wearable Systems Can Facilitate Differentiation of Passive ADL Characteristics among Stroke and Healthy Older Adults

Wearable technologies allow the measurement of unhindered activities of daily living (ADL) among patients who had a stroke in their natural settings. However, methods to extract meaningful information from large multi-day datasets are limited. This study investigated new visualization-driven time-series extraction methods for distinguishing activities from stroke and healthy adults. Fourteen stroke and fourteen healthy adults wore a wearable sensor at the L5/S1 position for three consecutive days and collected accelerometer data passively in the participant’s naturalistic environment. Data from visualization facilitated selecting information-rich time series, which resulted in classification accuracy of 97.3% using recurrent neural networks (RNNs). Individuals with stroke showed a negative correlation between their body mass index (BMI) and higher-acceleration fraction produced during ADL. We also found individuals with stroke made lower activity amplitudes than healthy counterparts in all three activity bands (low, medium, and high). Our findings show that visualization-driven time series can accurately classify movements among stroke and healthy groups using a deep recurrent neural network. This novel visualization-based time-series extraction from naturalistic data provides a physical basis for analyzing passive ADL monitoring data from real-world environments. This time-series extraction method using unit sphere projections of acceleration can be used by a slew of analysis algorithms to remotely track progress among stroke survivors in their rehabilitation program and their ADL abilities.

Neuroimaging risk factors for participation restriction after acute ischemic stroke: 1-year follow-up study

The aim of the present study was to determine the neuroimaging predictors of poor participation after acute ischemic stroke. A total of 443 patients who had acute ischemic stroke were assessed. At 1-year recovery, the Reintegration to Normal Living Index was used to assess participation restriction. We also assessed the Activities of Daily Living Scale and modified Rankin Scale (mRS) score. Brain MRI measurement included acute infarcts and pre-existing abnormalities such as enlarged perivascular spaces, white matter lesions, ventricular-brain ratio, and medial temporal lobe atrophy (MTLA). The study included 324 men (73.1%) and 119 women (26.9%). In the univariate analysis, patients with poor participation after 1 year were older, more likely to be men, had higher National Institutes of Health Stroke Scale (NIHSS) score on admission, with more histories of hypertension and atrial fibrillation, larger infarct volume, more severely enlarged perivascular spaces and MTLA, and more severe periventricular hyperintensities and deep white matter hyperintensities. Patients with participation restriction also had poor activities of daily living (ADL) and mRS score. Multiple logistic regression showed that, in model 1, age, male gender, NIHSS score on admission, and ADL on follow-up were significant predictors of poor participation, accounting for 60.2% of the variance. In model 2, which included both clinical and MRI variables, male gender, NIHSS score on admission, ADL on follow-up, and MTLA were significant predictors of poor participation, accounting for 61.2% of the variance. Participation restriction was common after acute ischemic stroke despite good mRS score. Male gender, stroke severity, severity of ADL on follow-up, and MTLA may be predictors of poor participation.

Trial registration number ChiCTR1800016665.

To What Extent is Walking Ability Associated with Participation in People after Stroke?

OBJECTIVES

This study aims to 1) identify the relation between walking ability and participation after stroke and 2) explore whether change in walking ability is associated with change in participation over time in community living-people after stroke.

MATERIALS AND METHODS

Fifty-two people after stroke were assessed at baseline and after a 6-week gait training intervention. People were included between two weeks and six months after stroke. The Utrecht Scale for Evaluation of Rehabilitation-Participation was used to measure participation. Assessment of walking ability included the six-minute walking test for walking endurance, Timed-up & Go test for functional mobility, Mini Balance Evaluation Systems Test for dynamic balance, and total duration of walking activity per day to measure walking activity.

RESULTS

At baseline, six-minute walking test, Timed-up & Go test, and Mini Balance Evaluation Systems Test were univariately associated with participation (P < 0.001). Backward multiple regression analysis showed that the Mini Balance Evaluation Systems Test independently explained 55.7% of the variance in participation at baseline. Over time, only change in the six-minute walking test was positively associated with change in participation (R² = 0.087, P = 0.040).

CONCLUSIONS

Cross-sectional associations showed that walking ability, and especially dynamic balance, contributes to participation after stroke. Dynamic balance, as underlying variable for walking, was an important independently related factor to participation after stroke which needs attention during rehabilitation. Longitudinally, improvement in walking endurance was significantly associated with improvement in participation, which indicates the relevance of training walking endurance to improve participation after stroke.

Prevalence and associated factors of premature discontinuation of antiplatelet therapy after ischemic stroke: a nationwide population-based study

BACKGROUND

We tried to evaluate the prevalence of premature discontinuation of antiplatelets and its affecting factors after ischemic stroke using large-sized representative national claims data.

METHODS

Patients aged 20 years or older with newly confirmed ischemic stroke who started aspirin or clopidogrel for the first time were selected from 2003 to 2010 National Health Insurance Service-National Sample Cohort (NHIS-NSC) of South Korea (n = 4621), a randomly collected sample which accounts for 2.2% (n = 1,017,468) of total population (n = 46,605,433). The prevalence of discontinuation of antiplatelets was measured every 6 months until the 24 months since the first prescription. Then we classified the participants into 2 groups according to the discontinuation status at 12 months and assessed the factors influencing premature discontinuation of antiplatelets within 12 months.

RESULTS

Among total participants, 35.5% (n = 1640) discontinued antiplatelets within 12 months and 58.5% (n = 2704) discontinued them within 24 months. The remaining 41.5% (n = 1917) continued them for 24 months or more. In the multivariate logistic regression analysis, initiating treatment with aspirin monotherapy [adjusted OR (aOR), 2.66, 95% CI 2.17-3.25] was the most prominent determinant of premature discontinuation within 12 months followed by CCI score ≥ 6 (aOR 1.50, 95% CI 1.31-1.98), and beginning treatment with clopidogrel monotherapy (aOR 1.41, 95% CI 1.15-1.72). Rural residency (aOR 1.36, 95% CI 1.14-1.62), < 4 total prescribed drugs (aOR 1.24, 95% CI 1.05-1.47), lower income (aOR 1.20, 95% CI 1.03-1.40 for middle income class and OR 1.21, 95% CI 1.02-1.45 for low income class), and ages ≥70 years (aOR 1.15, 95% CI 1.00-1.31) were also significantly associated with premature discontinuation of antiplatelets within 12 months.

CONCLUSIONS

The prevalence of premature discontinuation of antiplatelets after ischemic stroke was quite high. Thus, by understanding factors associated with premature discontinuation, a more strategic approach is required for the physicians to improve persistence with antiplatelets.

Effect of antiplatelet persistence on long-term mortality and predictors of non-persistence in ischemic stroke patients 75 years and older: a nationwide cohort study

Background

We aimed to provide real-world evidence on the benefit of persistence with antiplatelet therapy (APT) on long-term all-cause mortality (ACM) in ischemic stroke patients aged 75 years and older.

Methods

Newly diagnosed ischemic stroke patients aged 75 years and older who initiated aspirin or clopidogrel for the first time were chosen from 2003 to 2010 National Health Insurance Service-National Sample Cohort (NHIS-NSC) of Korea (n = 887), a random cohort sample accounting for 2.2% (n = 1,017,468) of total population (n = 46,605,433). Then subjects were divided into persistent (n = 556) and non-persistent (n = 321) groups according to the persistent status at 6 months. Survivor analysis was performed between the two groups and predictors of non-persistence were analyzed by multivariate logistic regression analysis. Patients were followed up until death or December 31, 2013.

Results

Non-persistence with APT was significantly associated with increased risk of ACM (adjusted hazard ration [aHR] 2.13, 95% confidence interval [CI] 1.72–2.65), cerebro-cardiovascular disease (CVD) mortality (aHR 2.26, 95% CI 1.57–3.24), and non-CVD mortality (aHR 2.06, 95% CI 1.5702.70). More comorbidities (Charlson comorbidity index score ≥ 6) (adjusted odds ratio [aOR], 2.56, 95% CI 1.43–4.55), older age (aOR 1.52, 95% CI 1.11–2.09 for 80–84 years, aOR 1.73, 95% CI 1.17–2.57 for ≥85 years), and less than 4 total prescribed drugs (aOR 1.54, 95% CI 1.08–2.21) were independent predictors of non-persistence.

Conclusions

Persistent with APT after ischemic stroke featured long-term mortality benefit even in patients aged 75 years and older. Thus, improving APT persistence for ischemic stroke patients in this age group is also recommended by understanding factors associated with non-persistence.

Differences in Societal Participation Across Diagnostic Groups: Secondary Analyses of 8 Studies Using the Utrecht Scale for Evaluation of Rehabilitation-Participation

OBJECTIVE

To determine differences in participation problems between diagnostic groups and to examine diagnosis as a determinant of participation with and without statistically accounting for confounders.

DESIGN

Secondary analyses of data from 8 studies.

SETTING

Community, the Netherlands.

PARTICIPANTS

Participants (N=1735) in diagnostic groups: stroke (n=534), subarachnoid hemorrhage (n=104), other acquired brain injury (n=163), progressive neurologic diseases (n=112), acute coronary syndrome (n=536), and spinal cord injury (n=286).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participation was measured with the Utrecht Scale for Evaluation of Rehabilitation-Participation. This measure has 3 scales: Restrictions, Satisfaction, and Frequency. In this study, scores were also computed for 3 domains across these scales: Productivity, Leisure, and Social. Scores ranged from 0 (worst) up to 100 (best). Possible confounders were age, sex, level of education, marital status, and time since onset of the condition.

RESULTS

Significant differences were found in levels of participation between diagnostic groups. Individuals with acute coronary syndrome showed better participation scores in all scales and domains compared with most or all other diagnostic groups, except for the Social domain. Individuals with progressive neurologic diseases showed the lowest (worst) Restriction and Satisfaction scores, whereas those with stroke showed the lowest Frequency scores. After correcting for confounders, diagnosis explained significant proportions of the variance of participation (Frequency, 6.4%; Restrictions, 15.1%; Satisfaction, 5.1%; Productivity, 13.2%; Leisure, 13.8%; Social, 6.9%).

CONCLUSIONS

Participation problems occurred in all 6 diagnostic groups within this study. Differences were found in participation between diagnostic groups, demonstrating diagnosis-specific participation profiles, including after correcting for confounders.

Does rTMS Targeting Contralesional S1 Enhance Upper Limb Somatosensory Function in Chronic Stroke? A Proof-of-Principle Study

BACKGROUND

Somatosensory deficits are prevalent after stroke, but effective interventions are limited. Brain stimulation of the contralesional primary somatosensory cortex (S1) is a promising adjunct to peripherally administered rehabilitation therapies.

OBJECTIVE

To assess short-term effects of repetitive transcranial magnetic stimulation (rTMS) targeting contralesional (S1) of the upper extremity.

METHODS

Using a single-session randomized crossover design, stroke survivors with upper extremity somatosensory loss participated in 3 rTMS treatments targeting contralesional S1: Sham, 5 Hz, and 1 Hz. rTMS was delivered concurrently with peripheral of sensory electrical stimulation and vibration of the affected hand. Outcomes included 2-point discrimination (2PD), proprioception, vibration perception threshold, monofilament threshold (size), and somatosensory evoked potential (SEP). Measures were collected before, immediately after treatment, and 1 hour after treatment. Mixed models were fit to analyze the effects of the 3 interventions.

RESULTS

Subjects were 59.8 ± 8.1 years old and 45 ± 39 months poststroke. There was improvement in 2PD after 5-Hz rTMS for the stroke-affected (F(2, 76.163) = 3.5, P = .035) and unaffected arm (F(2, 192.786) = 10.6, P < .0001). Peak-to-peak SEP amplitudes were greater after 5-Hz rTMS for N33-P45 (F(2, 133.027) = 3.518, P = .032) and N45-P60 (F(2, 67.353) = 3.212, P = .047). Latencies shortened after 5-Hz rTMS for N20 (F(2, 69.64) = 3.37, P = .04), N60 (F(2, 47.343) = 4.375, P = .018), and P100 (F(2, 37.608) = 3.537, P = .039) peaks. There were no differences between changes immediately after the intervention and an hour later.

CONCLUSIONS

Short-term application of facilitatory high-frequency rTMS (5Hz) to contralesional S1 combined with peripheral somatosensory stimulation may promote somatosensory function. This intervention may serve as a useful adjunct in somatosensory rehabilitation after stroke.

Poststroke Cognitive Impairment Negatively Impacts Activity and Participation Outcomes: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to investigate whether cognition is associated with activity and participation outcomes in adult stroke survivors. Five databases were systematically searched for studies investigating the relationship between general- and domain-specific cognition and longer-term (>3 months) basic activities of daily living (ADL), instrumental ADLs, and participation outcomes. Eligibility for inclusion, data extraction, and study quality was evaluated by 2 reviewers using a standardized protocol. Effect sizes (r) were estimated using a random-effects model. Sixty-two publications were retained for review, comprising 7817 stroke survivors (median age 63.57 years, range:18-96 years). Median length of follow-up was 12 months (range: 3 months-11 years). Cognition (all domains combined) demonstrated a significant medium association with all 3 functional outcomes combined, r=0.37 (95% CI, 0.33-0.41), P<0.001. Moderator analyses revealed these effects persisted regardless of study quality, order in which outcomes were collected (sequential versus concurrent), age, sample size, or follow-up period. Small to medium associations were also identified between each individual cognitive domain and the separate ADL, instrumental ADL, and participation outcomes. In conclusion, poststroke cognitive impairment is associated with early and enduring activity limitations and participation restrictions, and the association is robust to study design factors, such as sample size, participant age, follow-up period, or study quality. Cognitive assessment early poststroke is recommended to facilitate early detection of disability, prediction of functional outcomes, and to inform tailored rehabilitation therapies.

The Validity and Reliability of the Microsoft Kinect for Measuring Trunk Compensation during Reaching

Compensatory movements at the trunk are commonly utilized during reaching by persons with motor impairments due to neurological injury such as stroke. Recent low-cost motion sensors may be able to measure trunk compensation, but their validity and reliability for this application are unknown. The purpose of this study was to compare the first (K1) and second (K2) generations of the Microsoft Kinect to a video motion capture system (VMC) for measuring trunk compensation during reaching. Healthy participants (n = 5) performed reaching movements designed to simulate trunk compensation in three different directions and on two different days while being measured by all three sensors simultaneously. Kinematic variables related to reaching range of motion (ROM), planar reach distance, trunk flexion and lateral flexion, shoulder flexion and lateral flexion, and elbow flexion were calculated. Validity and reliability were analyzed using repeated-measures ANOVA, paired t-tests, Pearson’s correlations, and Bland-Altman limits of agreement. Results show that the K2 was closer in magnitude to the VMC, more valid, and more reliable for measuring trunk flexion and lateral flexion during extended reaches than the K1. Both sensors were highly valid and reliable for reaching ROM, planar reach distance, and elbow flexion for all conditions. Results for shoulder flexion and abduction were mixed. The K2 was more valid and reliable for measuring trunk compensation during reaching and therefore might be prioritized for future development applications. Future analyses should include a more heterogeneous clinical population such as persons with chronic hemiparetic stroke.

Prevalence, Patterns, and Predictors of Multimorbidity in Adults With Acquired Brain Injury at Admission to Staged Community-Based Rehabilitation

OBJECTIVES

To describe the prevalence, patterns, and predictors of multimorbidity in adults with an acquired brain injury (ABI) on presentation to a community-based neurorehabilitation service.

DESIGN

Retrospective cohort study using routinely collected admissions and clinical data.

SETTING

Community-based neurorehabilitation.

PARTICIPANTS

Individuals (N=263) with non-traumatic brain injury (NTBI; n=187 [71.1%]) versus traumatic brain injury (TBI; n=76 [28.9%]).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Comorbidity was defined as the co-occurrence of at least one chronic condition in conjunction with a primary diagnosis of ABI. Multimorbidity was defined as the co-occurrence of 2 or more chronic conditions across 2 or more body systems, in conjunction with a primary diagnosis of ABI.

RESULTS

Comorbidity was present in 72.2% of participants overall, whereas multimorbidity was present in 35.4% of the cohort. The prevalence of comorbidity (76% vs 63%; P=.036) and multimorbidity (40% vs 24%; P=.012) was higher in NTBI compared with participants with TBI. Participants with NTBI had a higher prevalence of physical health multimorbidities, including cardiovascular (44% vs 6%; P<.001) and endocrine (34% vs 10%; P=.002) disease, whereas participants with TBI had a higher prevalence of mental health conditions (79% vs 48%; P<.001). Depression (36.3%) and hypertension (25.8%) were the most common diagnoses. Increasing age was the only significant predictor of multimorbidity.

CONCLUSIONS

Most participants experienced multimorbidity. Effective management of multimorbidity should be included as part of individual rehabilitation for ABI and planning of resource allocation and service delivery. The results of this study can help guide the provision of treatment and services for individuals with ABI in community-based rehabilitation. Our study highlights access to mental health, cardiovascular, endocrine, and neurology services as essential components of rehabilitation for ABI.

Psychometric properties of Meaningful Activity Participation Assessment (MAPA) in chronic stroke survivors

BACKGROUND

Meaningful Activity Participation Assessment (MAPA) is an appropriate tool for assessing both objective and subjective aspects of participation.

OBJECTIVES

This study aimed to investigate the psychometric properties of MAPA in chronic stroke survivors.

METHODS

Translation of MAPA was done according to the standard protocol of forward-backward translation. One hundred and seven chronic stroke survivors participated in this study. In addition to the MAPA, they were assessed by Satisfaction With Life Scale (SWLS), Center for Epidemiologic Studies of Depression Scale (CES-D), Life Satisfaction Index-Z (LSI-Z), Purpose in Life Test-Short Form (PIL-SF), and 36-Item Short-Form Survey (SF-36). To investigate the test-retest reliability, 37 participants were reassessed by MAPA after two weeks. Reliability, construct and known-groups validity were evaluated for MAPA.

RESULTS

The results showed an acceptable internal consistency (Cronbach's α = 0.79) and good test-retest reliability (ICC = 0.92) of MAPA. A significant moderate to high correlation was found between the MAPA and PIL-SF, CES-D, LSI-Z, SWLS, and different subscales of SF-36 (r = 0.32-0.65). MAPA showed good ability to differentiate between young adults (age≤ 65 years) and older adults (age> 65 years) with chronic stroke (P = .005) as well as between chronic stroke survivors with different levels of disability (P < .001).

CONCLUSIONS

The MAPA has appropriate reliability and validity in chronic stroke survivors and is suggested to be used in research and clinical settings.

Cognitive predictors of a performance-based measure of instrumental activities of daily living following stroke

BACKGROUND

To inform cognitive interventions that target functional capacity for individuals who have survived stroke, an evaluation of predictors of daily functioning is necessary. The current literature is limited regarding identifying the associations between objective cognitive functioning and objective performance of Instrumental Activities of Daily Living (IADLs).

OBJECTIVES

To investigate the relationship between objectively measured cognitive domains/executive functions and performance on an objective measure of IADLs following a stroke.

METHODS

Cross-sectional examination of 52 participants who have survived strokes and completed assessments of immediate memory, visuospatial/constructional skills, language, attention, delayed memory, executive functions (i.e., inhibition and flexibility, concept-formation and problem-solving, abstract thinking, deductive thinking, and verbal abstraction), and a performance-based measure of IADLs (UCSD Performance-based Skills Assessment; UPSA).

RESULTS

Results indicated significant correlations between the UPSA and immediate memory, visuospatial/constructional skills, language, delayed memory, and executive functions (i.e., concept formation and problem-solving, flexibility of thinking, and verbal abstraction). A hierarchical multiple regression, controlling for age, severity of stroke, side of stroke, and depressive symptoms and including the cognitive measures individually significantly associated with the UPSA, explained approximately 62% of the variance in overall UPSA performance. This regression demonstrated that only language significantly predicted UPSA total score, in the context of multiple variables.

CONCLUSIONS

Cognitive functioning is significantly associated with IADL functioning post-stroke, and considering multiple domains of cognitive functioning together largely explains the performance of IADLs.

Effects of walking distance over robot-assisted training on walking ability in chronic stroke patients

An understanding of the dose-response during training is important to identify the rehabilitation programs to obtain the improvement in chronic stroke patients. The purpose of this study was to determine whether distance-dose (distance walked across all sessions) during robot-assisted training affects the change of walking speed and distance in chronic stroke patients after intervention. Fifteen chronic stroke patients were enrolled in this study. The patients performed 8 gait training sessions using the Hybrid Assistive Limb (HAL) for 3 weeks. Gait speed, stride length, cadence, and 2-minute walk test (2MWT) were measured before and post-intervention. Total walking distance (distance walked across all sessions) in individual patients were also measured. Gait speed, stride length, cadence, and 2-minute walk test (2MWT) improved significantly after training. The average of walking distance for 8 sessions in individual patients was 3793.3 ± 2105.3 m. Moreover, the change of gait speed (r = 0.53) and 2MWT (r = 0.70) were positively correlated with the walking distance during 8 sessions. This study of finding demonstrated that greater total distance walked over all sessions of training using the HAL is directly associated with the better walking outcomes in patients with chronic stroke. Further researches with a larger number of patients and a control group are needed to quantify the study results more precisely.

Factors related to post-stroke depression during the first 2 weeks after stroke

Introduction

This study aimed to clarify factors associated with post-stroke depression in patients with acute stroke within 2 weeks of onset.

Method

Eighty-eight patients with stroke were divided into post-stroke depression ( n = 49) and non-post-stroke depression ( n = 39) groups based on their Hamilton Depression Rating Scale scores. We evaluated stroke severity, upper limb function, activities of daily living, frontal lobe/cognitive function, and level of apathy. Activity levels were measured using an ActiGraph GT9X Link system. Mann–Whitney U-tests were used to determine differences between the two groups. Spearman’s rank correlation and logistic regression analyses were also performed.

Results

The post-stroke depression and non-post-stroke depression groups exhibited significant differences in National Institutes of Health Stroke Scale scores at admission and discharge; Functional Independence Measure exercise items, cognitive items, and total items at admission; Fugl-Meyer Assessment scores; and Apathy Rating Scale scores. Logistic regression indicated that Fugl-Meyer Assessment scores were associated with post-stroke depression.

Conclusion

Stroke severity, paralysis, and physical function/activities of daily living ability are associated with post-stroke depression in the acute phase. Our findings suggest that increases in physical impairment severity are associated with increased post-stroke depression risks. Rehabilitation professionals should focus on identifying post-stroke depression in early post-stroke stages.

Self-Perception of Physical Function Contributes to Participation in Cognitively- and Physically-Demanding Activities After Stroke

Background: Persons with and without aphasia experience decreased participation in meaningful activities post-stroke that result in reduced autonomy and poorer quality of life. Physical, cognitive, and/or communication deficits are prevalent post-stroke and many activities given up are purported to require high levels of communicative, cognitive, or physical skill. However, the relationship between deficits after stroke and participation in life activities that appear to require high skill levels in these three areas has not been investigated fully.

Objectives: The objectives of this study are to: (1) determine differences in reported participation in communicatively-, cognitively-, or physically-demanding activities in persons after stroke with and without aphasia living in the community, and to (2) investigate whether performance on commonly used self-perception assessments of these three areas predicts reported participation in activities requiring higher levels of skill in these domains.

Methods: In a cross-sectional design, 82 individuals at least 6 months post-stroke with (N = 34) and without aphasia (N = 48) were administered a battery of neuropsychological and participation-based assessments. Supported communication techniques maximized inclusion of individuals with aphasia. A series of regression analyses investigated the relationship between self-perceived communicative, cognitive, and physical functioning and reported participation in activities post-stroke that required high amounts of skilled function in these areas.

Results: People with and without aphasia did not differ in terms of the percentage retained in communicatively-, cognitively-, or physically-demanding activities. All individuals retained higher levels of participation in communicatively- and cognitively-demanding activities (at least 60% retained), compared to participation inphysically-demanding activities (about 50% retained). The strongest predictor for retaining participation in two of the three domains of activities was self-perception of physical function, though much of the variance remained unexplained. Self-perception of communication was not related to participation retention in any of the three domains.

Significance of Impact: Rehabilitation professionals should be aware of the impact that a variety of communicative, cognitive, and physical factors may have on participation post-stroke. Self-perceptions of impairments in communication and cognition may not directly predict participation in activities requiring high levels of communicative and/or cognitive skill, at least for those with mild impairment, even though activities requiring those skills are given up or done less after stroke.

Sex differences in stroke

Sex disparities within the field of stroke, including subarachnoid hemorrhages (SAHs), have been in focus during the last 2 decades. It is clear that stroke incidence is higher in men, and also that men have their first stroke earlier than women. On the other hand, women have more severe strokes, mainly because cardioembolic strokes are more common in women. This leads to higher case fatality and worse functional outcome in women. It has often been pointed out that women more often have nontraditional stroke symptoms, and therefore may seek medical help later. After discharge from the hospital, female stroke survivors live alone in many cases and are dependent on external care. Therefore, these women frequently rate their quality of life (QoL) lower than men do. Female spouses more often provide help to their male stroke survivors than the reverse, and they accept a heavier burden. These caregivers are at high risk for depression, low QoL, and low psychologic wellbeing. SAH is a special form of stroke, often caused by a ruptured aneurysm. It is about 20% more common in women. The case fatality is high, but does not differ between the sexes.

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

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

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Contextual determinants of participation after stroke: a systematic review of quantitative and qualitative studies

PURPOSE

From a patient's perspective, participation is a major determinant of quality of life. We aimed to review contextual factors, both personal and environmental, potentially associated with post-stroke participation.

METHODS

PubMed, PsycINFO, and Web of Science were searched for original quantitative and qualitative studies that investigated contextual factors of post-stroke participation, measured participation as the primary outcome, and met inclusion criteria.

RESULTS

Socio-demographic determinants were mostly unrelated with participation or showed discordant and inconclusive results. Although less investigated, psychosocial/psychological factors, particularly self-esteem and acceptance, were associated with participation in most studies. Motivation was found in qualitative studies, but discordant in quantitative ones. Environmental factors were even less investigated and mainly in qualitative studies among patients with communication disabilities. Among these, social support and attitude of others appeared to be major determinants of participation as well as physical environment and societal environment (services and polices).

CONCLUSIONS

Personal factors, particularly psychological and psychosocial factors, were identified as positively associated with post-stroke participation. Environmental factors such as support, relationships, and positive attitudes towards patients were major facilitators of participation as well as physical environment and accessibility to appropriate services. Most of these factors are modifiable and should be addressed to improve patient participation.Implications for RehabilitationPsychosocial factors (motivational aspects, acceptance of a new condition, self-esteem) and environmental factors (social support, attitudes towards the patient, physical environment, access to health, social services and policies) were identified as determinants of post-stroke participation.A structured evaluation of determinants of participation may be used in clinical practice to propose appropriate support and then improve patients' recoveryPrograms to improve patients' psychosocial skills such as self-esteem, acceptance, motivation should be tested and implemented, and policies to develop appropriate services accessibility should be encouraged.

Social Support as a Predictor of Community Participation After Stroke

Participation is a primary goal of neurorehabilitation; however, most individuals post stroke experience significant restrictions in participation as they attempt to resume their everyday roles and routines. Despite this emphasis on participation, there is a paucity of evidence-based interventions for optimizing this outcome and a limited understanding of factors that contribute to poor participation outcomes. Caregiver support at discharge from inpatient rehabilitation positively influences physical and psychological outcomes after stroke but more research is needed to understand the association between social support and participation. This study aimed to examine the independent contribution of perceived social support to participation 3 months post discharge from inpatient stroke rehabilitation. This study was a secondary analysis of the Stroke Recovery in Underserved Populations 2005–2006 data. Participants were adults ≥55 years old, living in the community 3 months post discharge from inpatient rehabilitation for ischemic stroke (n = 422). Hierarchical linear regressions were performed. The primary variables of interest were the PAR-PRO Measure of Home and Community Participation and the Duke–University of North Carolina Functional Social Support Questionnaire. Perceived social support at discharge from inpatient rehabilitation for ischemic stroke contributed uniquely to the variance in participation 3 months later (β = 0.396, P < 0.001) after controlling for race, sex, age, years of education, comorbidities, stroke symptoms, depression, FIM Motor, and FIM Cognitive. Social support accounted for 12.2% of the variance in participation and was the strongest predictor of participation relative to the other independently significant predictors in the model including FIM Motor and depression. There is already a focus on caregiver training during inpatient rehabilitation related to basic self-care, transfers, and medical management. These findings suggest the need for rehabilitation professionals to also address social support during discharge planning in the context of promoting participation. Given the findings, expanding caregiver training is necessary but novel interventions and programs must be carefully developed to avoid increasing caregiver burden.

Perceived participation and its determinants among young and middle-aged stroke survivors following acute care one month after discharge

PURPOSE

To describe the perceived participation and assess its determinants among young and middle-aged stroke patients following acute care one month after discharge in mainland China.

METHODS

Two hundred and twenty-three patients were consecutively recruited from two tertiary hospitals and were followed up 1 month after discharge in the outpatient department or their communities to assess their participation by using the Impact on Participation and Autonomy Questionnaire, with 23 patients lost to follow-up. Determinants (i.e., sociodemographic, diseased-related, physical, psychological, and social factors) of participation were identified in four domains: indoor autonomy; outdoor autonomy; family role; and social life.

RESULTS

The overall perceived participation of our respondents was good to fair. Forty-six (23.0%), 32 (16.0%), 13 (6.5%), and 19 (9.5%) perceived their participation as "very good" in the domains of indoor autonomy, family role, outdoor autonomy and social life, respectively. Stroke severity, depressive symptoms, and social support were the common determinants of participation for all the domains, with stroke severity being the strongest correlate. Activities of daily living was associated with indoor autonomy, family role, and outdoor autonomy, but not associated with social life.

CONCLUSIONS

The perceived participation of our respondents is relatively optimistic. Physical health along with mental and social status can affect participation. Tailored strategies should be implemented early in the rehabilitation phase to promote stoke survivors' participation in all the domains.Implications for rehabilitationAlthough the overall perceived participation of young and middle-aged stroke patients was fair to good, attention should be paid to their family roles.The strategies should be mainly focused on reducing the stroke severity to improve patients' participation.Improving patients' depressive symptom and social support can also be helpful for improving their participation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Participation in work and leisure activities after stroke: A national study

BACKGROUND

Stroke is a common and debilitating neurological disorder having a negative impact on quality of life.

OBJECTIVES

We aimed to compare differences in participation in work and leisure activities between patients with and without a self-reported stroke at the national level in France.

METHODS

This study used cross-sectional data from the Disability Health Survey that was administered in people's homes (DHH) in 2008 and in institutions (DHI) in 2009. Stroke history and levels of participation in work and leisure activities were collected by interviews. The levels of participation in these activities were compared between participants with and without a history of stroke.

RESULTS

Among the 33,785 interviewed participants, 1725 reported a history of stroke. After weighting, this represented a mean (SD) of 766,641 (36,650) people among 49 million adults living in France. After adjustment, as compared with people without stroke, those with stroke were less likely to work (odds ratio 0.19 [95% confidence interval 0.13-0.27]), use the telephone (0.21 [0.17-0.25]) and drive (0.25 [0.21-0.32]). In the age group 19-59 years, as compared with people without stroke, those with stroke less frequently worked (35.9% vs. 72.2%), drove (54.3% vs. 81.3%) and participated in sports (26.6% vs. 55.8%).

CONCLUSIONS

Overall, our study indicates that people with a history of stroke report more difficulties in participating in work and leisure activities than those without a history of stroke.

Return to work predicts perceived participation and autonomy by individuals with stroke

Purpose: Participation in activities of everyday life is seen as main goal of rehabilitation after a stroke and return to work is an important factor to consider for the substantial number of persons having a stroke at working age. The current study aims to investigate whether returning to work would predict self-perceived participation and autonomy in everyday life after a stroke, from a long-term perspective.Materials and methods: Persons with first-ever stroke at age 18-63 years in 2009-2010, Gothenburg, were included. As 5-year follow-up, the Impact on Participation and Autonomy questionnaire was sent out, investigating self-perceived participation/autonomy in five levels, and work status was investigated from national sick-absence registers. Prediction of work on participation/autonomy was investigated with logistic regression.Results: A total of 109 participants (49%) responded to the questionnaire. The majority (69-94%) perceived very good participation/autonomy in all domains and 59% were working 5 years after stroke. Working was a significant predictor of high participation/autonomy in all domains of the questionnaire.Conclusions: Being able to return to work after a stroke seems to be important for self-perceived participation/autonomy. This emphasizes the importance of work-oriented information and rehabilitation after a stroke at working age.Implications for rehabilitationThe current study shows that the majority report high self-perceived participation and autonomy in everyday life and 59% are working 5 years after a stroke in working age.To work 5 years after a stroke was a significant predictor for self-perceived participation and autonomy in everyday life.Since stroke is becoming more common among working age persons and work seem important for perceived participation and autonomy, to optimize the return to work by for instance work-oriented information and vocational rehabilitation is important.

Occupational gaps 5 years after stroke

OBJECTIVES

To investigate the incidence and number of occupational gaps 5 years after stroke and find possible predictors and explanatory factors for increased number of experienced gaps.

MATERIAL AND METHODS

The participants were diagnosed with first-time stroke in Gothenburg during 2009-2010. Medical records from their hospital stay were used to obtain baseline data. The Occupational Gaps Questionnaire and the Swedish stroke registers follow-up questionnaire were sent out. Data from the Occupational Gaps Questionnaire were used as a dependent variable and baseline data and questions from the stroke registry were used as independent variables in logistic regression.

RESULTS

Five years poststroke, 49.5% experienced a higher number of occupational gaps compared to a healthy reference population. Predictors for an increased number of gaps were higher age at stroke onset and a higher degree of functional dependency. Explanatory factors for an increased number of gaps in the study population were higher age at follow-up and feelings of depression.

CONCLUSIONS

Older age at the time of stroke and functional dependency can predict an increased number of occupational gaps. Older age and feelings of depression are connected to an increased number of occupational gaps. Individuals at risk should be provided with additional interventions to reduce participation restrictions.

Initial psychometric evaluation of the Community Participation Activation Scale

Background.

Current assessments do not capture the dynamic and complex process of managing different individual and environmental factors influencing community participation post-stroke.

Purpose.

The purpose of this study was to examine the psychometric properties of the Community Participation Activation Scale (CPAS) in persons with stroke.

Method.

Rating scale structure, unidimensionality, reliability and precision, construct validity, and differential item functioning of the CPAS were examined with 93 community-dwelling people with stroke.

Findings.

The CPAS consists of 15 action items and 10 attitude items. Person separation reliabilities of the action and attitude domains were .75 and .72, respectively, and internal consistency reliabilities were good (>.80). The CPAS showed low to moderate correlation with community integration and enfranchisement constructs.

Implications.

The CPAS may be used as an assessment to better understand an individual’s level of activation and to inform individually designed, participation-focused interventions, although it needs further improvement to be used as a clinical measure.

Exploring challenges at 6 months after stroke: what is important to patients for self-management?

Background/Aims:

Self-management models have recently been applied to stroke, but the most effective components are yet to be determined. To inform the ongoing refinement of stroke self-management programmes, this study explored challenges at 6 months after stroke.

Methods:

A total of 53 stroke survivors and 26 significant others were interviewed 6 months after stroke. Results were analysed qualitatively using thematic analysis.

Findings:

Stroke was experienced as a shocking and frightening event regardless of severity, and participants struggled to manage the consequences of their stroke. The stroke experience occurred within the context of more than one chronic condition and with competing demands of everyday life. Participants struggled to formulate a model of causation for their stroke, yet this appeared a necessary basis for action.

Conclusions:

The findings suggest that health care targeted at enhancing self-management, including self-management programmes, may benefit from encompassing a specific focus on participants' beliefs as an important foundation for recovery after stroke.

Predictors of Community Participation Among Individuals With First Stroke: A Thailand Study

Objective

To describe perceived participation among persons with first stroke and to identify the predictors based on the International Classification of Functioning, Disability and Health (ICF) concept of participation after stroke.

Methods

A total of 121 participants completed 4 questionnaires: the Impact on Participation and Autonomy (IPA), Personal Resource Questionnaire (PRQ2000), Hospital Anxiety and Depression Scale (HADS), and personal history. They were evaluated for their balance, motor function, functional and walking ability.

Results

The majority of participants perceived participation restriction in family role as poor to very poor. The best predictors of participation included social support, walking and balance, functional ability, number of secondary health problems and affected side, account for 66.6% of the variances in participation.

Conclusion

The study highlights the importance of social support, walking and balance performance, functional ability in daily living, and number of secondary health problems after stroke. These factors that facilitate participation after stroke should be addressed by health personnel during rehabilitation.

Scoping Review: The Trajectory of Recovery of Participation Outcomes following Stroke

Participation is a central concept in health and well-being and healthcare, yet operationalizing this concept has been difficult. Its definition, uses in healthcare, and impacts on recovery require ongoing research. Our review question goes like this: from the longitudinal evidence investigating participation among stroke survivors, what are the patterns of participation recovery in stroke survivors over time, and what interventions are used to improve participation? To fully understand these questions, we also ask, how is participation defined in the stroke literature, and what are the measures of participation used in the stroke literature? A systematic scoping review was undertaken using the search terms "stroke," "longitudinal," "participation," and "outcome" in seven databases. Articles included were published until April 2017, written in English, and had at least two longitudinal assessments of participation. Fifty-nine articles met the inclusion criteria. The International Classification of Functioning, Disability and Health was the most frequent definition of participation used (34%). There were 22 different measures of participation. Eight of ten studies demonstrated significant improvements in participation up to 12 months poststroke. Efficacy of interventions and their impact on participation varied. The various definitions, measures, and intervention efficacies of participation highlight the need for further research worldwide into achieving meaningful participation and quality of life among stroke survivors. Future practice should include participation as a main outcome measure.

Somatosensory deficits

The analysis and interpretation of somatosensory information are performed by a complex network of brain areas located mainly in the parietal cortex. Somatosensory deficits are therefore a common impairment following lesions of the parietal lobe. This chapter summarizes the clinical presentation, examination, prognosis, and therapy of sensory deficits, along with current knowledge about the anatomy and function of the somatosensory system. We start by reviewing how somatosensory signals are transmitted to and processed by the parietal lobe, along with the anatomic and functional features of the somatosensory system. In this context, we highlight the importance of the thalamus for processing somatosensory information in the parietal lobe. We discuss typical patterns of somatosensory deficits, their clinical examination, and how they can be differentiated through a careful neurologic examination that allows the investigator to deduce the location and size of the underlying lesion. In the context of adaption and rehabilitation of somatosensory functions, we delineate the importance of somatosensory information for motor performance and the prognostic evaluation of somatosensory deficits. Finally, we review current rehabilitation approaches for directing cortical reorganization in the appropriate direction and highlight some challenging questions that are unexplored in the field.