Participation after stroke compared to normal aging

Identifying emotional contributors to participation post-stroke

BACKGROUND

Participation in daily activities is the ultimate goal of stroke rehabilitation. Emotional factors have been considered as contributors to participation, but associations between emotional factors and participation post-stroke have not been fully explored.

OBJECTIVE

To investigate the extent to which emotional factors contribute to participation post-stroke.

METHODS

73 participants were included. Three participation outcomes were used as dependent variables in three models: (1) Stroke Impact Scale (SIS) Participation/Role Function, (2) Activity Card Sort (ACS), and (3) Reintegration to Normal Living (RNL). Main independent variables were six emotional factors: SIS Emotion Function (General emotion), Visual Analog Mood Scale energetic and happy subscales, Patient Health Questionnaire-9 (Depression), State-Trait Anxiety Inventory-Trait Anxiety Scale, and Apathy Evaluation Scale. Covariates of stroke severity and social support were included.

RESULTS

Model 1 showed stroke severity (β = -0.300) and depression (β = -0.268) were significant contributors to SIS Participation/Role Function (R² = 0.368, p < .05). Model 2 indicated that happiness (β = 0.284) and apathy (β = -0.330) significantly contributed to ACS total activity retention (R² = 0.247, p < .05). Model 3 revealed that anxiety (β = -0.348), apathy (β = -0.303), stroke severity (β = -0.184), and social support (β = 0.185) were significant contributors to RNL total score (R² = 0.583, p < .05).

CONCLUSIONS

Results suggested that emotional measures of apathy, depression, anxiety, and happiness, but not general emotion, were important contributors to participation post-stroke. These findings suggest that rehabilitation professionals should address individual emotional contributors to facilitate participation post-stroke.

Perceived Community Participation and Associated Factors in People With Stroke

Objective

To examine individual- and environmental-level factors associated with perceived participation performance and satisfaction in people with chronic stroke.

Design

Cross-sectional study using secondary data analysis of baseline data from a randomized controlled trial.

Setting

Community-based setting.

Participants

Community-dwelling adults with mild to moderate stroke (N=113; mean age=57 years; 58 males).

Interventions

Not applicable.

Main Outcome Measures

Main outcomes were measured with the Reintegration to Normal Living Index (perceived participation performance) and Patient-Reported Outcome Measure Information System satisfaction with participation in social roles (perceived participation satisfaction). Other variables collected included personal (eg, age, perceived recovery), health-related (eg, time since stroke, number of comorbidities), body function-related (eg, Stroke Impact Scale, Center for Epidemiologic Studies Depression Scale), and environmental (eg, World Health Organization Quality of Life Short Form Environmental subscale) data.

Results

Depression, fatigue, mobility, and environmental support showed moderate to strong, statistically significant associations with participation performance and satisfaction in people with stroke. Perceived recovery was moderately associated with participation performance but not with participation satisfaction.

Conclusions

Returning to participation is a complex process after stroke. Results suggest that various personal, body function-related, and environmental factors are associated with participation performance and satisfaction.

The Double Mediating Effect of Family Support and Family Relationship Satisfaction on Self-Compassion and Meaning in Life among Korean Baby Boomers

This study identified the relationship between self-compassion and meaning in life among Korean baby boomers and examined the double mediating effect of family support and family relationship satisfaction on this relationship. For this purpose, data were collected from 400 baby boomers (born between 1955-1963) using the self-compassion, meaning in life, family support, and family relationship satisfaction scales. PROCESS Macro 3.5 Model 6 was used to analyze the double mediating effects. The results revealed that first, there was a significant correlation between the self-compassion, meaning in life, family support, and family relationship satisfaction of this study. Second, in the relationship between self-compassion and the meaning in life, family support, and family relationship satisfaction were found to have a partial mediating effect and a double mediating effect. The implications and limitations of these findings are also discussed.

Explicit versus implicit lower extremity sensory retraining for post-stroke chronic sensory deficits: a randomized controlled trial

PURPOSE

Sensory impairment post-stroke limits rehabilitation of balance and gait. This study aims to compare the effect of explicit sensory retraining (ESR) versus implicit repeated exposure (IRE) to stimuli of the lower extremity, assessing their effects on sensation, balance, and gait in individuals with chronic post-stroke sensory impairment.

MATERIALS AND METHODS

A two-arm parallel double-blind multicenter randomized controlled trial was conducted in physical therapy outpatient clinics. Volunteers with chronic sensory impairment post-stroke participated in 10 sessions of 45 min ESR or IRE, according to a detailed protocol. Outcome measures assessed sensation, balance, mobility, and participation.

RESULTS

A total of 64 participants were recruited (ESR, n = 34; IRE, n = 30). The intention-to-treat pre-post analysis demonstrated clinically meaningful changes for both interventions (10-31% improvement for the various measures), with no between-group difference or time × group interaction. The effect size for the time effect varied, with the largest being 0.63 for the miniBEST.

CONCLUSIONS

Sensory rehabilitation treatment by either ESR or IRE led to similar clinically significant changes in the performance of the lower extremity and participation in subjects with sensory loss post-stroke. Both treatment protocols are easy to implement in an outpatient clinic.  .

CLINICALTRIALS.GOV REGISTRATION

NCT01988220. Implications for rehabilitationStandardized, structured, sensory-focused training can improve balance and gait in subjects with chronic post-stroke sensory impairment.Both explicit and implicit learning-based sensory protocols focused on the lower extremity effectively improved balance, mobility, and gait abilities, resulting in enhanced participation of individuals in the chronic post-stroke phase.A series of ten 45-minute treatment sessions in outpatient clinics lead to clinically significant improvements.

Participation and Functional Independence in Adults With Recessive Spastic Ataxia of Charlevoix-Saguenay

Background. Autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS) is a progressive disorder where upper and lower extremities motor performances may bring participation restriction. Purpose. To document participation in adults with ARSAC and explore associations with motor performances. Method. Twenty-eight participants took part in the study. Participation was assessed using the LIFE-H. Motor performance was assessed using several outcomes including the SARA, LEMOCOT, Berg Balance Scale, 10-Meter Walk Test, and Finger-to-nose Test. Findings. Participation was significantly lower in the wheelchair user subgroup. Also, for 29 activities out of 77, at least 15% of participants reported severely disrupted participation. Participation was correlated with upper and lower limbs coordination, walking ability, balance, disease severity, and fine dexterity (Spearman r = .41–0.85, p < .03). Implications. Results showed significant participation restrictions and suggest that interventions aiming to improve or compensate upper and lower limbs functions could help to decrease disease burden.

The impact of the COVID-19 pandemic on engagement in activities of daily living in persons with acquired brain injury

PRIMARY OBJECTIVES

This study examined (a) the impact of coronavirus disease-2019 (COVID-19) pandemic on engagement in activity participation in persons with acquired brain injury (ABI); and (b) whether changes in activity participation during the pandemic were associated participants' health-related quality of life (HRQoL).

RESEARCH DESIGN

Exploratory online survey study.

METHODS

Eighty-seven respondents with ABI and 98 healthy adults (HA) participated in this study. Engagement in activity participation during COVID-19 was calculated as a percentage of the activities participants performed before the pandemic.

MAIN RESULTS

Participants with ABI modified their activities less than HA in order to maintain level of engagement in activity participation. They stopped performing more activities during the pandemic compared to HA and compared to their pre-pandemic engagement. Both groups continued to do similar percentage of activities without modifications compared to before the pandemic. Better HRQoL in both groups was predicted by a larger percentage of activities continued and fewer activities stopped.

CONCLUSION

Results emphasize the importance of addressing activity participation changes during situations where there are disruptions of the individual's habits and routines in order to minimize negative consequences of such changes.

Adaptação transcultural do Subjective Index of Physical and Social Outcome (SIPSO) para aplicação no Brasil

Objetivo: A restrição na participação é uma consequência significativa para indivíduos pós-Acidente Vascular Cerebral (AVC). No Brasil, não há instrumentos disponíveis que contemplem de forma abrangente a participação nesta população. Portanto, o objetivo deste estudo foi adaptar transculturalmente o Subjective Index of Physical and Social Outcome(SIPSO) para uso no Brasil. O SIPSO é um questionário com 10 itens, abrangendo questões de participação consideradas significativas para indivíduos pós-AVC. Métodos: O processo de adaptação transcultural envolveu as seguintes etapas: tradução, retrotradução, síntese das traduções, análise por um comitê de especialistas e teste da versão pré-final. Resultados: Observou-se equivalência semântica adequada entre as versões original e retrotraduzida. Durante a reunião de especialistas, foi realizada adequação dos itens às regras gramaticais da língua portuguesa. No teste da versão pré-final, em um item do instrumento foi reportada dificuldade de compreensão, sendo acrescentado um exemplo para ampliar a possibilidade de compreensão do item. Conclusão: O SIPSO-Brasil apresentou satisfatório grau de equivalência semântica, idiomática, cultural, conceitual e operacional. Contudo, estudos posteriores devem ser realizados para a continuidade da investigação da validade da versão adaptada do instrumento.

Unmet care needs of community-dwelling stroke survivors: a systematic review of quantitative studies

OBJECTIVES

Understanding the unmet needs of community-dwelling stroke survivors is essential for further intervention. This systematic review was performed to summarise their unmet needs from a quantitative viewpoint.

DESIGN

Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

A comprehensive search of six databases was conducted from inception to February 2020: PubMed, EMBASE, CINAHL, PsycINFO, SCOPUS and CBM. The methodological quality of the studies was assessed. Unmet needs were categorised, and a pooled analysis of the main outcomes was conducted.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included quantitative studies focused on the unmet needs of stroke survivors who live at homes rather than in any other institutionalised organisation.

RESULTS

In total, 32 of 2660 studies were included, and 1980 unmet needs were identified. The prevalence of patients with unmet needs ranged from 15.08% to 97.59%, with a median of 67.20%; the median number of unmet needs per patient ranged from 2 to 8 (0-31). The prevalence of unmet needs was high at 6 months post-stroke (62.14%) and 2 years post-stroke (81.37%). After categorisation, the main concerns among these patients were revealed to be information support, physical function and mental health; a few studies reported unmet needs related to leisure exercise, return to work and so on. Additionally, differences in the measurement tools used across studies affect what unmet needs participants report.

CONCLUSIONS

Sufficient, accurate, individualised and dynamic information support is a priority among community-dwelling stroke survivors. Physical function and mental health are also the most significant concerns for re-achieving social participation. It is essential to design and disseminate standard, effective and time-saving tools to assess unmet needs.

TRIAL REGISTRATION NUMBER

CRD42018112181.

Participation in social and leisure activities while re-constructing the self: understanding strategies used by stroke survivors from a long-term perspective

PURPOSE

To further understand social and leisure (SL) participation after stroke and how it can be supported in a long-term perspective, this study aims to deepen the understanding of strategies used by long-term stroke survivors in relation to SL activities.

MATERIALS AND METHODS

The study has a qualitative design, using a grounded theory approach, and is based on in-depth interviews with 10 persons who had a stroke 15 years ago and four of their family members.

RESULTS

The findings comprise nine different strategies used by the participants. These had two overarching purposes; to protect and re-construct the post-stroke self and to enable participation in valued SL activities despite challenges. The findings are summarized in one overarching theme: "Employing different strategies to balance costs and rewards of engagement in social and leisure activities".

CONCLUSIONS

Strategies for SL participation involves balancing different priorities in life and can change over time as they are continuously influenced by various personal and environmental conditions. These findings contribute to an improved understanding of why and how people hold on to activities, give up activities and find new activities after a stroke. It also highlights the need for a long-term perspective on stroke rehabilitation and support.IMPLICATIONS FOR REHABILITATIONRe-engagement in social and leisure activities after stroke is a long-term process and various types of support may be needed during different stages of recovery and adaptation.Successful rehabilitation interventions build on an understanding of each individual's priorities, goals and strategies and how these may change or manifest over time.Special attention should be given to the individual's perception of costs and benefits in relation to engagement in activities, and the role that it has for the person's identity.By providing knowledge and supporting the use of adequate coping strategies, rehabilitation professionals can help patients find a new and accepted post-stroke identity.

Factor Structure of the Short-Form of Center for Epidemiological Studies Depression Scale for People With Physical Disabilities

This study aimed to examine the factor structure of the short-form of Center for Epidemiological Studies Depression Scale (CES-D-11) using confirmatory factor analysis (CFA). We extracted data from 670 people with physical disabilities (PWPD) from the Korea Welfare Panel. To investigate the model fit regarding factor structure, a one-factor model, four-factor model, and four-factor within bifactor model, as reported in previous studies, were examined using CFA, and goodness-of-fit indices were compared. As a result of the analysis, the four-factor model and the four-factor within bifactor model satisfied the criteria of correspondence with goodness-of-fit indices. Reliability of the four individual factors ranged from 0.722 to 0.834, indicating acceptable reliability. Validity and reliability of the four-factor within bifactor structure was confirmed through CFA and reliability analysis. In future studies using the CES-D-11 to measure depression in PWPD, comparison between four sub-factors and total scores might be possible.

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

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

Optimizing Participation of Older Adults with Cognitive Deficits Post-stroke: Types of Help and Caregiver Burden

Cette étude a examiné les types d’aide fournis par des proches aidants qui visaient à optimiser la participation de personnes aînées ayant des déficits cognitifs (personnes aidées) consécutifs à un accident vasculaire cérébral (AVC), et la façon dont ces types d’aide différaient selon le niveau de fardeau des proches aidants. Un devis longitudinal mixte a été utilisé. Douze proches aidants d’aînés ayant subi un AVC ont complété un questionnaire sur le fardeau du proche aidant et ont participé à des entrevues semi-structurées qui ont été réalisées trois semaines, trois mois et six mois suivant le congé de l’hôpital (soins aigus), de l’unité de réadaptation fonctionnelle intensive ou de l’hôpital de jour. Les personnes aidées ont passé des tests cognitifs et ont rempli un questionnaire sur la participation sociale. Les types d’aide fournis par les proches aidants ont différé selon la quantité d’aide apportée, selon le niveau de préoccupation associé au bien-être de la personne aidée et selon l’impact sur la vie sociale du proche aidant. Il est intéressant de constater que les types d’aide favorisant la participation, l’estime de soi et le maintien des capacités n’étaient pas associés à un impact négatif sur la vie sociale des proches aidants. Une meilleure compréhension des relations entre les différents types d’aide et le fardeau des proches aidants permettrait d’optimiser le soutien fourni pour la participation sociale d’aînés ayant subi un AVC sans augmenter le fardeau de leurs proches aidants.

Social Participation Determines Quality of Life Among Urban-Dwelling Older Adults With Stroke in a Developing Country

BACKGROUND AND PURPOSE

Poor quality of life (QoL) is a well-recognized consequence after stroke. Quality of life is influenced by a complex interaction between personal and environmental factors. Most previous investigations of the QoL after stroke have focused on personal factors, for example, physical deficits directly resulting from stroke. The influence of environmental factors, including social participation, is relatively understudied partly due to its high variation across different sociocultural contexts. The purpose of this study was to investigate the determinants of QoL among older adults with stroke living in an urban area of a developing country.

METHODS

This cross-sectional observational study included 75 older adults who were at least 3 months poststroke and 50 age-matched healthy controls. Depressive symptoms were quantified using the World Health Organization Quality of Life Brief version (WHOQoL-BREF). Physical function was examined using Functional Ambulation Category, grip strength, 5 times Sit-to-Stand test, and Box and Block tests. The Montreal Cognitive Assessment and visual-manual reaction time were used to index cognitive function. Depressive symptom was quantified using the Patient Health Questionnaire-9. The Barthel Index and Fatigue Severity Scale were used to quantify activity limitation. Social participation and environmental participation were assessed using the Assessment of Life Habit and Craig Hospital Inventory of Environment Factors, respectively. Linear stepwise regression models were used to determine explanators for WHOQoL-BREF domain scores.

RESULTS

Individuals with stroke demonstrated significantly worse QoL on all WHOQoL-BREF domains compared with healthy controls. Stroke was a strong determinant for QoL and explained 16% to 43% of variances. Adding other outcome measures significantly improved the robustness of the models (R change = 12%-32%). The physical, psychological, social, and environmental domains of WHOQoL-BREF were all explained by the LIFE-H scores (β = -10.58, -3.37, 4.24, -5.35, respectively), while psychological, social, and environmental domains were explained by Montreal Cognitive Assessment scores (β = .47, 0.78, 0.54, respectively).

CONCLUSION

Social participation and cognition were strong determinants of QoL among urban-dwelling older adults with stroke. Social and recreational activities and cognitive rehabilitation should therefore be evaluated as potential strategies to improve the well-being of older adults affected by stroke.

Community mobility after stroke: a systematic review

Background Stroke is the leading cause of severe disability and many survivors report long-term physical or cognitive impairments that may impact their ability to achieve community mobility (CM).

PURPOSE

To determine the extent to which people with chronic stroke achieve CM compared to age-matched norms or non-neurologically impaired controls. Methods The StrokEDGE outcome measures were searched to identify validated tools that included >25% of items addressing CM. MEDLINE, CINAHL, Google Scholar, PubMed, PEDro and the Cochrane databases were searched from 2001 to 2015 with the identified outcome measures cross-referenced against search terms related to stroke and CM.

INCLUSION CRITERIA

utilized a validated CM outcome measure, chronic (>3 months post) stroke survivors, and randomized controlled trial, observational or cohort study design. One reviewer screened the studies and performed data extraction and three performed quality appraisal. Fourteen studies met all inclusion criteria. Results Stroke survivors have impaired CM as demonstrated by 30-83% of normative or non-stroke subject CM scores. As time post-stroke increased, CM improved only slightly. Factors found to correlate with the CM were age, education, general well-being, emotional state, motor function and coordination, independence in activities of daily living, balance, endurance and driving status. Limitations of this review include a relatively high functioning cohort, no meta-analysis and reliance on outcome measures not specifically designed to measure CM. Conclusion Survivors of stroke may experience a significant decrease in CM compared to people without neurological injury. Rehabilitation addressing motor function, coordination, independence in activities of daily living, balance and endurance may be important for achieving higher levels of CM. Outcome measures directly addressing CM are needed.

Developing a falls prevention program for community-dwelling stroke survivors in Singapore: client and caregiver perspectives

PURPOSE

Drawing on the perspectives of stroke survivors, family members and domestic helpers, this study explores participants' experiences of self-perceived fall risk factors after stroke, common fall prevention strategies used, and challenges to community participation after a fall.

METHODS

Semi-structured interviews were conducted in Singapore with community-dwelling stroke survivors with a previous fall (n = 9), family caregivers (n = 4), and domestic helpers (n = 4) who have cared for a stroke survivor with a previous fall. Purposive sampling was used for recruitment; all interviews were audio-recorded with permission and transcribed. Thematic analysis was conducted using NVivo (v10) software.

RESULTS

All participants shared their self-perceived intrinsic and extrinsic fall risk factors and main challenges after a fall. For stroke participants and family caregivers, motivational factors in developing safety strategies after a previous fall(s) include social connectedness, independent living and community participation. For family caregivers and domestic helpers, the stroke survivor's safety is their top priority, however this can also lead to over-protective behavior outside of the rehabilitation process.

CONCLUSIONS

Reducing the risk of falls in community-dwelling stroke survivors seems to be more important than promoting community participation among caregivers. The study findings highlight that a structured and client-centered fall prevention program targeting stroke survivors and caregivers is needed in Singapore. Implications for rehabilitation Falls after stroke can lead to functional decline in gait and mobility and restricted self-care activities. Community-dwelling stroke survivors develop adaptive safety strategies after a fall and want to be socially connected. However, caregivers see the safety of the stroke survivors as their top priority and demonstrate over-protective behaviors. Fall prevention programs for community-dwelling stroke survivors should target both stroke survivors and their caregivers. A structured and client-centered fall prevention program targeting at multiple risk factors post-stroke is needed for community-living stroke survivors.

Gender differences in physical activity and health-related behaviors among stroke survivors: data from the 5th Korea National Health and Nutrition Examination Survey

BACKGROUND

Physical activity and health-related behaviors are important in primary prevention of stroke and are also recommended for secondary prevention. Gender differences in physical activity and health-related behaviors have been reported in various populations and diseased states but data is lacking on stroke survivors.

OBJECTIVES

To assess gender disparities in physical activity in stroke patients and to investigate possible reasons for such disparities.

METHODS

This is a cross-sectional study using nationwide data from the 5th Korean National Health and Nutrition Examination Survey (2010-2012). A total of 9539 participants (stroke (n = 170), non-stroke (n = 9369)) between the ages of 40-80, with no problems walking were included. Physical activity, smoking, and alcohol drinking of stroke survivors were assessed by gender and compared with non-stroke groups. Multiple logistic regression was used to estimate the odds ratios (ORs) for insufficient physical activity and possible explanatory variables for gender differences.

RESULTS

Women showed higher prevalence of insufficient physical activity after adjusting for age (OR = 7.32, 95% CI: 1.89-28.32) compared to men. Medical conditions such as depression and comorbidities failed to explain the low physical activity in women with stroke but adding socioeconomic factors to the model nullified the gender difference in physical activity.

CONCLUSION

In order to reduce noted gender disparities in physical activity following stroke, more focused effort to increase physical activity in women, especially with lower socioeconomic status, has to be considered.

Reproducibility and validity of the Dutch Life Habits Questionnaire (LIFE-H 3.0) in older adults

Objective: To examine the reproducibility, the discriminant and convergent validity and feasibility of the Dutch translation of the self-administered Life Habits Questionnaire (LIFE-H).

Design: Three cross-sectional community-based studies on clinimetric properties of a measurement instrument.

Subjects: Older adults (n = 85) with functional limitations due to various chronic illnesses and healthy older adults (n = 40).

Measurement protocol: Participants of the reproducibility study (n = 35) filled out the LIFE-H twice in a two-week time period. In the discriminant validity study (n = 120), LIFE-H scores of healthy and ill subjects were compared. In the convergent validity study (n = 63), correlations were examined between LIFE-H, the Impact on Participation and Autonomy questionnaire and the London Handicap Scale.

Results: The test—retest reliability showed a satisfactory intraclass correlation coefficient for the total overall score (0.80) but not for the categories scores. The discriminant validity study showed significant differences between the healthy and ill subjects for the 10 separate categories (P < 0.01) and the total score (P < 0.001). The correlations between the LIFE-H categories and total scores and the Impact on Participation and Autonomy Questionnaire (0.80—0.82) and London Handicap Scale (0.89—0.92) were strong. Feasibility testing showed that the subjects experienced difficulties due to the long and fairly complex instructions and structure of the LIFE-H.

Conclusions: The clinimetric properties of the LIFE-H were moderate to good. The validity of LIFE-H was as good as the validity of the Impact on Autonomy and Participation and the London Handicap Scale, but the latter questionnaires were shorter and much easier to administer.

Balance Confidence: A Predictor of Perceived Physical Function, Perceived Mobility, and Perceived Recovery 1 Year After Inpatient Stroke Rehabilitation

OBJECTIVE

To estimate the effect of balance confidence measured at 1 month poststroke rehabilitation on perceived physical function, mobility, and stroke recovery 12 months later.

DESIGN

Longitudinal study (secondary analysis).

SETTING

Multisite, community-based.

PARTICIPANTS

Community-dwelling individuals (N=69) with stroke living in a home setting.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Activities-specific Balance Confidence scale; physical function and mobility subscales of the Stroke Impact Scale 3.0; and a single item from the Stroke Impact Scale for perceived recovery.

RESULTS

Balance confidence at 1 month postdischarge from inpatient rehabilitation predicts perceived physical function (model 1), mobility (model 2), and recovery (model 3) 12 months later after adjusting for important covariates. The covariates included in model 1 were age, sex, basic mobility, and depression. The covariates selected for model 2 were age, sex, balance capacity, and anxiety, and the covariates in model 3 were age, sex, walking capacity, and social support. The amount of variance in perceived physical function, perceived mobility, and perceived recovery that balance confidence accounted for was 12%, 9%, and 10%, respectively.

CONCLUSIONS

After discharge from inpatient rehabilitation poststroke, balance confidence predicts individuals' perceived physical function, mobility, and recovery 12 months later. There is a need to address balance confidence at discharge from inpatient stroke rehabilitation.

Test-Retest Reliability and Validity of the Malay Version Life Habits Assessment (LIFE-H 3.1) to Measure Social Participation in Adults With Physical Disabilities

BACKGROUND AND PURPOSE

Social participation restriction is a common barrier encountered by older adults and individuals with physical disabilities. To best direct the limited resource to support social services for individuals with disability, there is a need to objectively measure social participation restriction. A number of tools to measure levels of social participation are available, but none of them has been translated into the Malay language. This cross-sectional study examined the test-retest reliability and concurrent validity of the Life Habits Assessment (LIFE-H 3.1) that had been translated and culturally adapted to the Malay language.

METHODS

Seventy-five individuals with physical disabilities (age, mean [standard deviation] = 58 [10] years; 49 males) participated in this study. Participants were interviewed twice with the Malay version LIFE-H 3.1, approximately 1 week apart. The Barthel Index (BI) and the World Health Organization Assessment of Quality of Life-Brief version (WHOQoL-BREF) were administered in the first interview as well. Intraclass correlation coefficients and the Bland-Altman Bias D were used to examine test-retest reliability. The Spearman correlation coefficients were computed to quantify the correlation between the Malay version LIFE-H 3.1 and the BI and the WHOQoL-BREF, respectively, to examine the concurrent validity of the Malay version LIFE-H 3.1. Furthermore, standard error of measurement and minimal detectable change were calculated.

RESULTS

The Malay version LIFE-H 3.1 had excellent test-retest reliability as evidenced by good to excellent intraclass correlation coefficients (0.71-0.95) and minimal Bland-Altman biases (0.01-0.12). The correlations between the Malay version LIFE-H 3.1 and the BI were fair to good (r = 0.28-0.69). The correlations between the Malay version LIFE-H 3.1 and the WHOQoL-BREF were weak to fair, ranging from 0.02 to 0.57.

CONCLUSIONS

The Malay version LIFE-H 3.1 demonstrates excellent test-retest reliability and satisfactory validity. This questionnaire is an appropriate tool to assess social participation in rehabilitation for native Malay language speakers.

Participation needs of older adults having disabilities and receiving home care: met needs mainly concern daily activities, while unmet needs mostly involve social activities

BACKGROUND

Participation is a key determinant of successful aging and enables older adults to stay in their homes and be integrated into the community. Assessing participation needs involves identifying restrictions in the accomplishment of daily and social activities. Although meeting participation needs involves older adults, their caregivers and healthcare providers, little is known about their respective viewpoints. This study thus explored the participation needs of older adults having disabilities as perceived by the older adults themselves, their caregivers and healthcare providers.

METHODS

A qualitative multiple case study consisted of conducting 33 semi-structured interviews in eleven triads, each composed of an older adult, his/her caregiver and a healthcare provider recruited in a Health and Social Services Centre (HSSC) in Québec, Canada. Interview transcripts and reviews of clinical records were analyzed using content analysis and descriptive statistics based on thematic saliency analysis methods.

RESULTS

Aged 66 to 88 years, five older adults had physical disabilities, five had mild cognitive impairment and one had psychological problems, leading to moderate to severe functional decline. Caregivers and healthcare providers were mainly women, respectively retired spouses and various professionals with four to 32 years of clinical experience. Participation needs reported by each triad included all domains of participation. Needs related to daily activities, such as personal care, nutrition, and housing, were generally met. Regarding social activities, few needs were met by various resources in the community and were generally limited to personal responsibilities, including making decisions and managing budgets, and some community life activities, such as going shopping. Unmet needs were mainly related to social activities, involving leisure, other community life activities and interpersonal relationships, and some daily activities, including fitness and mobility.

CONCLUSIONS

This study highlights the complexity of older adults' participation needs, involving daily as well as social activities. Properly assessing and addressing these needs is thus necessary to improve older adults' health and well-being. Discrepancies in the various actors' perceptions of participation needs must be further explored. Additional research would help better understand how to optimize the contribution of community organizations and caregivers.

Optimizing social participation in community-dwelling older adults through the use of behavioral coping strategies

PURPOSE

This study aimed to (1) determine the categories of behavioral coping strategies most strongly correlated with optimal seniors' social participation in different activity and role domains and (2) identify the demographic, health and environmental factors associated with the use of these coping strategies optimizing social participation.

METHOD

The sample consisted of 350 randomly recruited community-dwelling older adults (≥65 years). Coping strategies and social participation were measured, respectively, using the Inventory of Coping Strategies Used by the Elderly and Assessment of Life Habits questionnaires. Information about demographic, health and environmental factors was also collected during the interview.

RESULTS

Regression analyses showed a strong relationship between the use of cooking- and transportation-related coping strategies and optimal participation in the domains of nutrition and community life, respectively. Older age and living alone were associated with increased use of cooking-related strategies, while good self-rated health and not living in a seniors' residence were correlated with greater use of transportation-related strategies.

CONCLUSIONS

Our study helped to identify useful behavioral coping strategies that should be incorporated in disability prevention programs designed to promote community-dwelling seniors' social participation. However, the appropriateness of these strategies depends on whether they are used in relevant contexts and tailored to specific needs.

IMPLICATIONS FOR REHABILITATION

Our results support the relevance of including behavioral coping strategies related to cooking and transportation in disability prevention programs designed to promote community-dwelling seniors' social participation in the domains of nutrition and community life, respectively. Older age and living alone were associated with increased use of cooking-related strategies, while good self-rated health and not living in a seniors' residence were correlated with greater use of transportation-related strategies. These factors should be considered in order to optimize implementation of these useful strategies in disability prevention programs. The appropriateness of these selected strategies depends on whether they are used in relevant contexts and tailored to specific needs.

Participation in leisure activity and exercise of chronic stroke survivors using community-based rehabilitation services in seongnam city

OBJECTIVE

To clarify how participation in leisure activities and exercise by chronic stroke survivors differs before and after a stroke.

METHODS

Sixty chronic stroke survivors receiving community-based rehabilitation services from a health center in Seongnam City were recruited. They completed a questionnaire survey regarding their demographic characteristics and accompanying diseases, and on the status of their leisure activities and exercise. In addition, their level of function (Korean version of Modified Barthel Index score), risk of depression (Beck Depression Inventory), and quality of life (SF-8) were measured.

RESULTS

After their stroke, most of the respondents had not returned to their pre-stroke levels of leisure activity participation. The reported number of leisure activities declined from a mean of 3.9 activities before stroke to 1.9 activities post-stroke. In addition, many participants became home-bound, sedentary, and non-social after their stroke. The most common barriers to participation in leisure activities were weakness and poor balance, lack of transportation, and cost. The respondents reported a mean daily time spent on exercise of 2.6±1.3 hours. Pain was the most common barrier to exercise participation.

CONCLUSION

Chronic stroke survivors need information on leisure activities and appropriate pain management.

Changes in Participation After a Mild Stroke: Quantitative and Qualitative Perspectives

PURPOSE AND METHOD

This descriptive study is aimed at documenting changes in participation level (accomplishment of daily activities and social roles) from quantitative (n = 35) and qualitative (n = 5) perspectives in individuals who have had a first "mild" stroke compared to their prestroke level. With advances in technology (e.g., increased use of thrombolitic therapy), the prevalence of mild stroke is expected to increase. Yet these strokes are rarely referred to rehabilitation, and little is known about the consequences of stroke on patients' lives.

CONCLUSION

Results of both methods confirmed significant impact of the stroke on participation level that is persistent even 6 months poststroke.

Community reintegration of stroke survivors: the effect of a community navigation intervention

AIM

The overall aim of the proposed study is to examine a newly implemented navigation intervention intended to support stroke survivors' community integration during the first year following hospital discharge in four regions of Ontario, Canada.

BACKGROUND

Stroke is a leading cause of disability worldwide. Stroke survivors living in the community require regular, ongoing follow-up to assess recovery, prevent deterioration and maximize health outcomes. Internationally published evidence, often conducted in large urban centres, suggests that community reintegration services are an important component of the continuum of care for stroke survivors. This evidence, however, often does not address the particular challenges inherent in smaller urban and rural contexts.

DESIGN

The design of this 2-year mixed-method study will use cohort and focused ethnography.

METHODS

The three stages of this study include: (1) collection of quantitative data to profile the health status, support and extent of community reintegration of stroke survivors; (2) collection of qualitative data from stroke survivors and their care partners about community reintegration and navigation; and following triangulation of findings (3) knowledge translation activities. This study was ethically approved by the academic Research Ethics Board and clinical Research Ethics Board (Sudbury, Ontario) and funded by the Ontario Stroke Network (Canada).

DISCUSSION

Results will describe experiences and outcomes of a community navigation intervention. Engagement of multiple stakeholders has the potential to develop a shared understanding of community reintegration and generate evidence informed recommendations for service enhancement at critical points in stroke recovery to support survivor and community well-being.

The YOU CALL-WE CALL randomized clinical trial: Impact of a multimodal support intervention after a mild stroke

BACKGROUND

Comparison of a multimodal intervention WE CALL (study initiated phone support/information provision) versus a passive intervention YOU CALL (participant can contact a resource person) in individuals with first mild stroke.

METHODS AND RESULTS

This study is a single-blinded randomized clinical trial. Primary outcome includes unplanned use of health services (participant diaries) for adverse events and quality of life (Euroquol-5D, Quality of Life Index). Secondary outcomes include planned use of health services (diaries), mood (Beck Depression Inventory II), and participation (Assessment of Life Habits [LIFE-H]). Blind assessments were done at baseline, 6, and 12 months. A mixed model approach for statistical analysis on an intention-to-treat basis was used where the group factor was intervention type and occasion factor time, with a significance level of 0.01. We enrolled 186 patients (WE=92; YOU=94) with a mean age of 62.5 ± 12.5 years, and 42.5% were women. No significant differences were seen between groups at 6 months for any outcomes with both groups improving from baseline on all measures (effect sizes ranged from 0.25 to 0.7). The only significant change for both groups from 6 months to 1 year (n=139) was in the social domains of the LIFE-H (increment in score, 0.4/9 ± 1.3 [95% confidence interval, 0.1-0.7]; effect size, 0.3). Qualitatively, the WE CALL intervention was perceived as reassuring, increased insight, and problem solving while decreasing anxiety. Only 6 of 94 (6.4%) YOU CALL participants availed themselves of the intervention.

CONCLUSIONS

Although the 2 groups improved equally over time, WE CALL intervention was perceived as helpful, whereas YOU CALL intervention was not used.

CLINICAL TRIAL REGISTRATION

URL: http://www.controlled-trials.com. Unique identifier: ISRCTN95662526.

Social Participation after Stroke: One-Year Follow-Up of Stroke Survivors in Nigeria

Background. Stroke may negatively affect social participation in survivors. Aims. This study assessed the pattern of social participation in a sample of Nigerian stroke survivors across the first 12 months after stroke. Methods. Stroke survivors were consecutively recruited while on admission at a tertiary health institution. The London handicap scale was used to assess social participation at 1, 3, 6, 9, and 12 months at the homes of the stroke survivors. Overall and domain-specific patterns of social participation were examined independently and also in relation to initial stroke severity. Results. Overall social participation significantly improved over 12 months (), while significant improvements were observed only in the mobility, physical independence, and work and leisure domains at P equals 0.04, 0.04, and 0.05, respectively. In spite of the improvement in the work and leisure domain, the domain recorded the lowest level of participation. Social participation also differed by initial stroke severity with severe stroke survivors having the lowest level of participation across 12 months after stroke. Conclusions. The poor outcome in the work and leisure domain of social participation and in individuals with initial severe stroke has implications for planning and provision of appropriate long-term stroke rehabilitation.

Measuring participation after stroke: a review of frequently used tools

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

Transportation Use in Community-Dwelling Older Adults: Association with Participation and Leisure Activities

Les objectifs de cette étude étaient de comparer la participation selon les moyens de transport utilisés, et d’estimer l’association entre le transport, les facteurs personnels et environnementaux avec la participation chez les personnes âgées habitant dans la communauté. Les participants incluaient 90 adultes âgés de 65 ans et plus (moyenne d’âge = 76.3 ans ; ET = 7.7). Ils étaient classifiés selon le moyen de transport utilisé le plus souvent: conducteur, passager, transport en commun, marche, ou transport adapté/taxi. La participation a été mesuré avec le « Craig Handicap Assessment and Reporting Technique (CHART) » et le « Nottingham Leisure Questionnaire (NLQ) ». Somme toute, les résultats ont indiqué que les conducteurs, utilisateurs de transport en commun et ceux qui utilisaient la marche avaient des niveaux de participation plus élevés comparativement aux passagers et utilisateurs de transport adapté/taxi. Cette étude suggère que les cliniciens devraient considérer l’utilisation du transport chez les personnes âgées afin d’encourager et de maximiser leur participation.

Bilateral and unilateral arm training improve motor function through differing neuroplastic mechanisms: a single-blinded randomized controlled trial

BACKGROUND AND PURPOSE

This randomized controlled trial tests the efficacy of bilateral arm training with rhythmic auditory cueing (BATRAC) versus dose-matched therapeutic exercises (DMTEs) on upper-extremity (UE) function in stroke survivors and uses functional magnetic resonance imaging (fMRI) to examine effects on cortical reorganization.

METHODS

A total of 111 adults with chronic UE paresis were randomized to 6 weeks (3×/week) of BATRAC or DMTE. Primary end points of UE assessments of Fugl-Meyer UE Test (FM) and modified Wolf Motor Function Test Time (WT) were performed 6 weeks prior to and at baseline, after training, and 4 months later. Pretraining and posttraining, fMRI for UE movement was evaluated in 17 BATRAC and 21 DMTE participants.

RESULTS

The improvements in UE function (BATRAC: FM Δ = 1.1 + 0.5, P = .03; WT Δ = -2.6 + 0.8, P < .00; DMTE: FM Δ = 1.9 + 0.4, P < .00; WT Δ = -1.6 + 0.7; P = .04) were comparable between groups and retained after 4 months. Satisfaction was higher after BATRAC than DMTE (P = .003). BATRAC led to significantly higher increase in activation in ipsilesional precentral, anterior cingulate and postcentral gyri, and supplementary motor area and contralesional superior frontal gyrus (P < .05). Activation change in the latter was correlated with improvement in the WMFT (P = .01).

CONCLUSIONS

BATRAC is not superior to DMTE, but both rehabilitation programs durably improve motor function for individuals with chronic UE hemiparesis and with varied deficit severity. Adaptations in brain activation are greater after BATRAC than DMTE, suggesting that given similar benefits to motor function, these therapies operate through different mechanisms.

Communication and aging

People with communication disorders form a diverse group with some experiencing long-standing disorders and others the onset of new disorders in old age. Regardless of age at onset, the burden of communication disorders is cumulative and has important implications for health care providers. Communication serves many roles for older people, not only establishing and maintaining social affiliations but also providing access to health care services. Health care providers should be aware of potential communication disorders and make provision for quiet environments, reading materials at appropriate literacy levels, and longer appointments for people with communication difficulties.

Study protocol of the YOU CALL--WE CALL TRIAL: impact of a multimodal support intervention after a "mild" stroke

Background

More than 60% of new strokes each year are "mild" in severity and this proportion is expected to rise in the years to come. Within our current health care system those with "mild" stroke are typically discharged home within days, without further referral to health or rehabilitation services other than advice to see their family physician. Those with mild stroke often have limited access to support from health professionals with stroke-specific knowledge who would typically provide critical information on topics such as secondary stroke prevention, community reintegration, medication counselling and problem solving with regard to specific concerns that arise. Isolation and lack of knowledge may lead to a worsening of health problems including stroke recurrence and unnecessary and costly health care utilization.

The purpose of this study is to assess the effectiveness, for individuals who experience a first "mild" stroke, of a sustainable, low cost, multimodal support intervention (comprising information, education and telephone support) - "WE CALL" compared to a passive intervention (providing the name and phone number of a resource person available if they feel the need to) - "YOU CALL", on two primary outcomes: unplanned-use of health services for negative events and quality of life.

Method/Design

We will recruit 384 adults who meet inclusion criteria for a first mild stroke across six Canadian sites. Baseline measures will be taken within the first month after stroke onset. Participants will be stratified according to comorbidity level and randomised to one of two groups: YOU CALL or WE CALL. Both interventions will be offered over a six months period. Primary outcomes include unplanned use of heath services for negative event (frequency calendar) and quality of life (EQ-5D and Quality of Life Index). Secondary outcomes include participation level (LIFE-H), depression (Beck Depression Inventory II) and use of health services for health promotion or prevention (frequency calendar). Blind assessors will gather data at mid-intervention, end of intervention and one year follow up.

Discussion

If effective, this multimodal intervention could be delivered in both urban and rural environments. For example, existing infrastructure such as regional stroke centers and existing secondary stroke prevention clinics, make this intervention, if effective, deliverable and sustainable.

Trial Registration

ISRCTN95662526

Transient ischemic attack before nonlacunar ischemic stroke in the elderly

BACKGROUND

Several studies suggest transient ischemic attack (TIA) may be neuroprotective against ischemic stroke analogous to preinfarction angina's protection against acute myocardial infarction. However, this protective ischemic preconditioning-like effect may not be present in all ages, especially among the elderly. The purpose of this study was to determine the neuroprotective effect of TIAs (clinical equivalent of cerebral ischemic preconditioning) to neurologic damage after cerebral ischemic injury in patients over 65 years of age.

METHODS

We reviewed the medical charts of patients with ischemic stroke for presence of TIAs within 72 hours before stroke onset. Stroke severity was evaluated by the National Institutes of Health Stroke Scale and disability by a modified Rankin scale.

RESULTS

We evaluated 203 patients (>or=65 years) with diagnosis of acute ischemic stroke and categorized them according to the presence (n = 42, 21%) or absence (n = 161, 79%) of TIAs within 72 hours of stroke onset. Patients were monitored until discharged from the hospital (length of hospital stay 14.5 +/- 4.8 days). No significant differences in the National Institutes of Health Stroke Scale and modified Rankin scale scores were observed between those patients with TIAs and those without TIAs present before stroke onset at admission or discharge.

CONCLUSION

These results suggest that the neuroprotective mechanism of cerebral ischemic preconditioning may not be present or functional in the elderly.