Influence of Environmental Factors on Social Participation Post-Stroke

Measures and Influencers of Reintegration for the Stroke Patient: A Systematic Review

ABSTRACT

BACKGROUND: Stroke survivors may experience continued difficulties with reintegration, including challenges participating in social roles and performing activities of daily living across settings (eg, home, work). This article assessed the reintegration measures currently used in this clinical population, defining factors that most influence reintegration for these persons. METHODS: A systematic review of PubMed, Scopus, and the Cumulative Index to Nursing and Allied Health Literature databases explored reintegration measures and factors influencing reintegration in stroke populations. Study inclusion criteria for this review were as follows: data-based articles (quantitative and qualitative), studies measuring reintegration or examining outcomes of reintegration, participants being adult stroke populations, and studies published in English. The resulting articles were critically analyzed, and common themes regarding barriers, facilitators, and influencers of reintegration were established. RESULTS: A total of 24 articles met the inclusion criteria and were synthesized for use in this systematic review. Across stroke populations, 13 reintegration tools were used. A few factors, including residual stroke impairments, unmet needs, social support, and sociodemographic characteristics, are currently known to influence reintegration for this population. CONCLUSION: Reintegration must be uniformly defined and measured to best support stroke survivors, and further investigation into influential factors is critical to advance this goal. This review defines current assessments and factors influencing reintegration within stroke populations. Achieving these goals is critical to optimizing reintegration efforts and designing quality-of-life-improving nursing interventions for affected persons.

Towards an interdisciplinary "science of the mind": A call for enhanced collaboration between philosophy and neuroscience

In recent decades, the neuroscientific community has moved from describing the neural underpinnings of mental phenomena-as characterized by experimental psychology and philosophy of mind-to attempting to redefine those mental phenomena based on neural findings. Nowadays, many are intrigued by the idea that neuroscience might provide the "missing piece" that would allow philosophers (and, to an extent, psychologists, too) to make important advances, generating new means that these disciplines lack to close knowledge gaps and answer questions like "What is Free Will?" and "Do humans have it?." In this paper, we argue that instead of striving for neuroscience to replace philosophy in the ongoing quest to understanding human thought and behavior, more synergetic relations should be established, where neuroscience does not only inspire philosophy but also draws from it. We claim that such a collaborative coevolution, with the two disciplines nourishing and influencing each other, is key to resolving long-lasting questions that have thus far proved impenetrable for either discipline on its own.

Orofacial dysfunction after stroke-A multidisciplinary approach

OBJECTIVE

This paper describes the study protocol in an ongoing clinical trial evaluating oral screen training as part of a post-stroke rehabilitation programme. Baseline data were related to four domains: dysphagia, lip function, masticatory performance and patient-related outcome measures (PROM).

BACKGROUND

Stroke is one of the most common causes of disability-adjusted life years, and dysphagia is a common remaining problem after stroke. Rehabilitation using oral screen training has been suggested to improve swallowing, but evidence is still insufficient.

MATERIALS AND METHODS

Patients diagnosed with stroke with persisting objective and/or subjective swallowing dysfunction after primary rehabilitation were assessed for eligibility. In total, 25 patients were included. Objective function was assessed by swallowing capacity test (SCT), lip force and masticatory performance, subjective function by EAT-10 and NOT-S and PROM by LiSat-11 and ESAS.

RESULTS

Baseline data presented a heterogeneous pattern with no significant association between objective and subjective dysfunction. Most of the participants (20/25) showed impaired swallowing capacity in SCT, and 23/24 revealed orofacial dysfunction according to NOT-S. The most common subjective item reported was chewing and swallowing problems (19/24).

CONCLUSION

The heterogenous findings in the included tests and the lack of correlations emphasise the importance of multidisciplinary approaches to identify objective and subjective orofacial post-stroke dysfunction in clinical practice to be able to offer evidence-based individualised care. The included participants were representative of stroke patients with dysphagia, which supports proceeding with the planned intervention.

Social participation mediates the relationship between self-efficacy and loneliness among people with stroke during COVID-19: a cross-sectional study

BACKGROUND

People post-stroke experience increased loneliness, compared to their healthy peers and loneliness may have increased during COVID due to social distancing. How social distancing affected loneliness among people after stroke is unknown. Bandura's self-efficacy theory suggests that self-efficacy may be a critical component affecting individuals' emotions, behaviors, attitudes, and interpretation of everyday situations. Additionally, previous studies indicate that self-efficacy is associated with both loneliness and social participation. This study investigates relationships among self-efficacy, social participation, and loneliness in people with stroke.

OBJECTIVES

Determine how social participation affects the relationship between self-efficacy and loneliness in people with stroke during the COVID-19 pandemic.

METHODS

44 participants were community-dwelling individuals, ≥ 6 months post-stroke who participated in a 2-hour phone interview. A regression-based mediation analysis was conducted using these measures: Participation Strategies Self-Efficacy Scale, Activity Card Sort for social participation, and UCLA Loneliness Scale for loneliness.

RESULTS

The total effect of self-efficacy on loneliness was significant (b = -0.36, p = .01). However, social participation fully mediated the relationship between self-efficacy and loneliness (indirect effect, b = -0.11, 95% CI [-0.24, -0.01]; direct effect, b = -0.25, 95% CI [-0.03, 0]).

CONCLUSIONS

Self-efficacy is associated with both social participation and loneliness in people with stroke in this cross-sectional study. Mediation analysis findings suggest that interventions focused on increasing social participation may prevent or potentially alleviate loneliness in people with stroke who have low self-efficacy.

Effect of Early Rehabilitation Services After Discharge on Social Activity Among Chronic Stroke Survivors: A Multicenter Prospective Study

BACKGROUND

Social inactivity after a stroke leads to adverse outcomes, making social activity after discharge important for chronic stroke survivors. This study aimed to investigate the effects of early rehabilitation services after discharge on social activity among chronic stroke survivors.

METHODS

The participants were prospectively recruited from 3 convalescent hospitals. Receipt of early rehabilitation services after discharge for chronic stroke survivors was defined as the utilization of day care or home-based rehabilitation services by the Japanese long-term care insurance system. Social activity was assessed using the Frenchay Activities Index (FAI) premorbid and at 3, 6, and 12 months after discharge. In this study, the outcome was defined as the change in the FAI score from 3 to 12 months after discharge. Multivariate regression analysis was performed to examine the effect of access to rehabilitation on changes in FAI.

RESULTS

Ninety stroke survivors (age 67.2±11.6 years, 52 male) were enrolled. The FAI showed improvements by 27.4% and 1.4% from 3 to 12 months after discharge in the rehabilitation and nonrehabilitation groups, respectively. Multivariate regression analysis showed that access to rehabilitation after discharge was positively associated with the FAI change from 3 to 12 months after discharge (B=30.3, β=0.38, 95% confidence interval=11.13-49.47, P=0.002).

CONCLUSIONS

Early rehabilitation services after discharge were significantly associated with increased social activity.

Gender differences in participation one year after stroke: exploring biopsychosocial predictors for women and men

BACKGROUND

Women appear to have a higher risk for long term restrictions in participation than men. This gender difference is poorly understood, as solely biomedical factors have been examined to date.

OBJECTIVES

The aims of this study are (1) to map gender differences in participation outcome one year after stroke, and (2) to identify demographic, stroke-related, or psychological predictors of participation for women and men separately.

METHODS

A total of 326 patients (mean age 66.5 ± 12.4y, 35.0% women) completed the restriction and satisfaction subscales of the Utrecht Scale of Evaluation of Rehabilitation-Participation (USER-P) at one year after stroke. Bivariate and multiple linear regression analyses were performed.

RESULTS

Women reported worse scores for restrictions in participation compared to men (median 75.4 versus 87.9 respectively, p = 0.001), especially in physical activities such as daytrips and going out. Satisfaction with participation was similar between women and men. Worse cognitive functioning (β = 0.17) was associated with more restrictions in participation in men only, other predictors of restrictions in participation were similar between women and men. The presence of depressive symptoms (β = -0.49) was associated with worse satisfaction with participation in men, whereas an increased stroke severity (β = -0.29) and the presence of maladaptive psychological factors (β = -0.36) were associated with worse satisfaction with participation in women.

CONCLUSIONS

Women experience more restrictions in participation compared to men one year after stroke. Taking into account gender-specific predictors of participation in stroke aftercare is important, as different biopsychosocial factors contribute to problems in participation across women and men.

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.

Bidirectional temporal associations between sleep and affect and cognitive symptoms among community-dwelling stroke survivors: An ecological momentary assessment study

INTRODUCTION

Sleep plays a critical role in daily functioning and stroke recovery but receives little attention in stroke rehabilitation. Sleep disturbances are linked to affective and cognitive impairments, but temporal associations between sleep and affect and cognitive symptoms are less clear. Understanding these temporal associations may inform new directions in intervention and prevention to support continued stroke recovery.

OBJECTIVE

To examine the bidirectional temporal associations between sleep and affect and cognitive symptoms among community-dwelling stroke survivors.

DESIGN

A secondary analysis of a longitudinal observational study involving 7 days of ecological momentary assessment (EMA), during which participants completed eight EMA surveys and a sleep diary per day. Multilevel modeling was used to analyze data.

SETTING

Community.

PARTICIPANTS

Community-dwelling stroke survivors (N = 40).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

EMA measures of depressed affect, cheerful affect, and cognitive symptoms. Sleep quality and duration as measured using a sleep diary.

RESULTS

Between-person sleep quality was negatively associated with next-day depressed affect (B = -.16; p = .028) and positively associated with next-day cheerful affect (B = .63; p < .001). Inversely, between-person depressed affect was negatively associated with next night sleep quality (B = -.77; p = .015), and vice versa for cheerful affect (between-person: B = .45; p < .001; within-person: B = .09; p = .008). Long sleep (>9 hours) was positively associated with next-day cognitive symptoms (B = .13; p = .002), whereas cognitive symptoms were associated with a higher odds of long sleep the following night (odds ratio [OR] = 0.25; p = .047).

CONCLUSIONS

This study identified the bidirectional associations of sleep with affect and cognitive symptoms in the context of the everyday life of stroke survivors. The findings suggest that interventions addressing sleep quality and duration may impact affect and cognitive symptoms, and vice versa.

Social Support Mediates the Association Between Abilities and Participation After Stroke

Stroke survivors face participation restrictions, yet little is known regarding how social support affects the association between an individual's abilities and participation. Through a Person-Environment-Occupation-Performance (PEOP) model lens, social support was examined as a potential mediator between ability and participation in cognitively and mobility-demanding activities for stroke survivors with aphasia (persons with aphasia [PWA]) and without aphasia (persons without aphasia [PWOA]). A cross-sectional design, including PWA (n = 50) and PWOA (n = 59) examined associations among person factors (physical impairment, cognition), an environmental factor (social support), and occupational participation through cognitively- and mobility-demanding activity subscales of the Activity Card Sort. Cognition was associated with participation in cognitively demanding activities for both groups, though social support was a mediator only for PWA. Physical impairment was associated with participation in mobility-demanding activities for PWOA, though social support did not mediate that relationship. Social support is key to PWA participating in cognitively demanding activities post-stroke.

The precarity of patient participation - a qualitative interview study of experiences from the acute stroke and rehabilitation journey

INTRODUCTION

Active patient participation is an important factor in optimizing post-stroke recovery, yet it is often low, regardless of stroke severity. The reasons behind this trend are unclear.

PURPOSE

To explore how people who have suffered a stroke, perceive the transition from independence to dependence and whether their role in post-stroke rehabilitation influences active participation.

METHODS

In-depth interviews with 17 people who have had a stroke. Data were analyzed using systematic text condensation informed by the concept of autonomy from enactive theory.

RESULTS

Two categories emerged. The first captures how the stroke and the resultant hospital admission produces a shift from being an autonomous subject to "an object on an assembly line." Protocol-based investigations, inactivity, and a lack of patient involvement predominantly determine the hospital context. The second category illuminates how people who have survived a stroke passively adapt to the hospital system, a behavior that stands in contrast to the participatory enablement facilitated by community. Patients feel more prepared for the transition home after in-patient rehabilitation rather than following direct discharge from hospital.

CONCLUSION

Bodily changes, the traditional patient role, and the hospital context collectively exacerbate a reduction of individual autonomy. Thus, an interactive partnership between people who survived a stroke and multidisciplinary professionals may strengthen autonomy and promote participation after a stroke.

Experiences With Mobile Health-Enabled Ambulatory Monitoring Among Stroke Survivors: A Qualitative Study

Inquiring into the experiences of stroke survivors toward ambulatory monitoring is crucial for optimizing user adoption, design, implementation, and sustainability of ambulatory monitoring in the stroke population. This study was aimed to identify facilitators and barriers for ambulatory monitoring among stroke survivors, as well as their suggestions for development and implementation of ambulatory monitoring. We conducted individual semi-structured interviews with 40 stroke survivors who received ambulatory monitoring. The interviews were analyzed using thematic content analysis. Six themes about facilitators associated with ambulatory monitoring emerged: (1) user support, (2) technological features, (3) convenience, (4) personal strategies, (5)social influence, and (6)time commitment. Three themes about barriers to using ambulatory monitoring emerged: (1) personal factors, (2) functionality, (3) study design. Three themes about suggestions emerged: (1) personalization, (2) functionality, and (3) interactive feedback. As mobile health technology is becoming more popular, the findings of this study provide timely implications and practical considerations for ambulatory monitoring in the stroke population.

Associations of Circadian Rest-Activity Rhythms With Affect and Cognition in Community-Dwelling Stroke Survivors: An Ambulatory Assessment Study

BACKGROUND

Rest-activity rhythm (RAR) is a modifiable behavioral factor associated with affect and cognition. Identifying RAR characteristics associated with affect and cognition among stroke survivors provides insight into preventing poststroke affective and cognitive impairment.

OBJECTIVE

To examine the associations of RAR characteristics with affect and cognition among community-dwelling stroke survivors.

METHODS

Forty participants with mild stroke (mean age = 52.8; 42.5% female; 55% White) reported their affect and cognitive complaints using ecological momentary assessment and wore an accelerometer for 7 consecutive days and completed the National Institutes of Health Toolbox Cognition Battery. RAR characteristics were extracted using parametric and non-parametric approaches. Multivariable linear regressions were used to identify RAR characteristics associated with affect and cognition.

RESULTS

Later onset of rest (B = 0.45; P = .008) and activity (B = 0.36; P = .041) were positively associated with depressed affect. These associations were reversed for cheerful effect (rest onset: B = -0.42; P = .017; activity onset: B = -0.39; P = .033). Cheerful affect was also positively associated with relative amplitude (ie, distinctions in activity levels between rest and activity; B = .39; P = .030). Intra-daily variability (ie, RAR fragmentation; B = 0.35; P = .042) and later onset of activity (B = .36; P = .048) were positively associated with cognitive complaints. Less erratic RAR was positively associated with fluid cognition (B = 0.29; P = .036); RAR fragmentation was positively associated with crystallized cognition (B = 0.39; P = .015).

CONCLUSIONS

We identified RAR correlates of affect and cognition among stroke survivors, highlighting the value of managing RAR and sleep in stroke rehabilitation. Future studies should test whether advancing the onset of rest and activity, promoting a regular active lifestyle, and improving rest and sleep in the nighttime protect stroke survivors from affective and cognitive impairment.

An machine learning model to predict quality of life subtypes of disabled stroke survivors

OBJECTIVE

Stroke causes serious physical disability with impaired quality of life (QoL) and heavy burden on health. The goal of this study is to explore the impaired QoL typologies and their predicting factors in physically disabled stroke survivors with machine learning approach.

METHODS

Non-negative matrix factorization (NMF) was applied to clustering 308 physically disabled stroke survivors in rural China based on their responses on the short form 36 (SF-36) assessment of quality of life. Principal component analysis (PCA) was conducted to differentiate the subtypes, and the Boruta algorithm was used to identify the variables relevant to the categorization of two subtypes. A gradient boosting machine(GBM) and local interpretable model-agnostic explanation (LIME) algorithms were used to apply to interpret the variables that drove subtype predictions.

RESULTS

Two distinct subtypes emerged, characterized by short form 36 (SF-36) domains. The feature difference between worsen QoL subtype and better QoL subtype was as follows: role-emotion (RE), body pain (BP) and general health (GH), but not physical function (PF); the most relevant predictors of worsen QoL subtypes were help from others, followed by opportunities for community activity and rehabilitation needs, rather than disability severity or duration since stroke.

INTERPRETATION

The results suggest that the rehabilitation programs should be tailored toward their QoL clustering feature; body pain and emotional-behavioral problems are more crucial than motor deficit; stroke survivors with worsen QoL subtype are most in need of social support, return to community, and rehabilitation.

Social participation, resilience, and coping tendency in a sample of stroke survivors: a multi-centre cross-sectional study in China

OBJECTIVES

To investigate the association between resilience and social participation and examine the mediation of resilience on coping strategies and social participation.

DESIGN

A multi-centre cross-sectional study performed from April to July 2022.

PARTICIPANTS

The study sample comprised 239 stroke survivors (53.1% male). The mean age of participants was 65.4 years.

METHODS

The study was conducted at 3 neurorehabilitation centres in Shanghai, China. The Utrecht Scale for Evaluation of Rehabilitation Participation (USER-P) was used to measure both objective and subjective social participation. Resilience was evaluated using the Connor-Davidson Resilience Scale (CD-RISC), while positive coping tendency was assessed using the Simplified Coping Style Questionnaire (SCSQ). Multivariate linear regression was employed, taking into account confounding factors. In cases where a significant interaction effect was observed, simple slope analysis was conducted to explore the relationship between positive coping tendency and social participation at different levels of resilience.

RESULTS

The mean scores of social participation frequency, restriction, and satisfaction were 21.80 ± 15.13, 38.92 ±  26.48, and 63.34  ± 22.35, respectively. Higher resilience level was independently associated with higher social participation frequency (B = 0.210, p < 0.001), less participation restriction (B = 0.584, p < 0.001), and higher participation satisfaction (B = 0.250, p < 0.001). Moreover, higher resilience was correlated with more positive coping tendency. More positive coping tendency was related to higher social participation frequency and less participation restriction, but not to social participation satisfaction. Furthermore, individuals at different resilience levels moderated the effect of positive coping tendency on social participation frequency.

CONCLUSION

This study underlines the importance of resilience as a potential intervention in enhancing both objective and subjective social participation in stroke survivors, and provides insights into increasing the efficacy of positive coping strategies on social participation.

Characterizing the impact of multiple chronic conditions on return to participation in chronic stroke survivors

BACKGROUND

Each year, 795,000 Americans experience a stroke. As stroke mortality declines, more individuals are in the chronic phase of recovery (>6 months post-stroke). Over 80% of stroke survivors have multiple, chronic health conditions (MCC). While the relationship between MCC and mortality and function during acute recovery has been explored, less is known about how MCC burden affects participation in chronic stroke survivors.

OBJECTIVE

This study investigated whether MCC burden is related to participation in those with chronic stroke.

METHODS

Two hundred and sixty-six participants with chronic (≥6 months) stroke were included in this cross-sectional and retrospective analysis. Participants had a mean age of 62.2 ± 12.8 years, and time since stroke (TSS) of 36.0 ± 44.6 months (114F/152 M). Participants completed the 6-minute Walk Test (6MWT), Activities-Specific Balance Confidence Scale (ABC), Modified Cumulative Illness Rating Scale (MCIR) to quantify the presence and severity of chronic illness across 14 body systems, and the Stroke Impact Scale - Participation subscale (SIS-P). Participation (SIS-P) was the dependent variable. Independent variables were entered into a sequential regression model in three blocks: demographic variables, physical capacity (6MWT distance) and balance self-efficacy (ABC), and MCC burden (MCIR).

RESULTS

After adjusting for age, sex, and time since stroke, physical capacity and balance self-efficacy explained 31.4% (p < 0.001), and the MCC burden explained 2.0% (p = 0.004). Higher participation was related to lower MCC burden.

CONCLUSIONS

MCC burden is a significant contributor to variance in participation in chronic stroke survivors, above and beyond demographics, physical capacity, and self-efficacy, and therefore should be considered when creating rehabilitation programs to improve participation.

How older adults relate to their own voices: a qualitative study of subjective experiences of the aging voice

AIM

The aim of this study was to investigate how otherwise healthy older adults with self-assessed voice problems relate to their voice and voice changes.

METHOD

Focus groups were conducted at an activity center to identify how older adults reflect on their own voice and the aging voice in general. The interviews were audio recorded and transcribed. The analysis was done using thematic content analysis.

RESULTS

The analysis resulted in three main themes: "communicational aspects of the aging voice," "consequences of deteriorating vocal and communicative capacity," and "attitudes, strategies, and ideas". The participants considered voice to be an important communication tool and presented what could be interpreted as awareness regarding their voice. Voice changes were considered a natural part of aging. This attitude was also an important reason why the participants had not sought medical care for their voice problems. The participants discussed ideas concerning extended voice use to maintain a functioning voice when aging. Simultaneously, voice changes due to aging were considered to have a negative effect on communication and social participation.

CONCLUSIONS

The voice is important for older adults, and an insufficient voice can affect communication and social participation. Information about aging voice and voice exercises, for example from speech language pathologists, could be of interest among older adults. Further studies on the voice of older adults are needed regarding how they experience their voice and the general aspects of a healthy aging voice.

Learning to flourish in a new reality: a thematic analysis of couples' experience of participation in a positive psychology intervention post-stroke

PURPOSE

Explore the experiences of couples engaging in a positive psychology intervention post-stroke (ReStoreD: Promoting Resilience after Stroke in Dyads).

MATERIALS AND METHODS

This is a secondary analysis of qualitative data collected following an 8-week self-administered dyadic positive psychology intervention (Clinical Trial number: NCT03335358). Participants included dyads consisting of one partner who had a stroke at least three months prior and their cohabiting partner. Couples had to be community-dwelling and one or both had to report depressive symptoms. A thematic analysis was conducted on semi-structured feedback interviews from 26 dyads (n = 77 interviews).

RESULTS

Two primary themes with multiple secondary themes were identified, depicting the experiences of couples post-stroke while engaging in the ReStoreD intervention. Primary and secondary themes included: changes in self (learning about the self, building new coping strategies, and acting with intention) and changes in the relationship (awareness of spouse, spending more positive time together, being more intentional in the relationship, and increased/improved communication).

CONCLUSIONS

Individuals and couples post-stroke often experience negative mood changes, poor health outcomes, and decreased participation. Implementation of ReStoreD activities in the clinical setting can be a valuable and impactful way to encourage and foster positive experiences and re-engagement post-stroke.Implications for RehabilitationThrough dyadic positive psychology intervention activities, rehabilitation professionals can build upon existing strengths and resources to encourage couples to increase their awareness and development of positive coping strategies as individuals and couples.Positive psychology intervention activities can be implemented by rehabilitation professionals at inpatient and outpatient settings through self-directed, low-cost, and time-efficient strategies to increase engagement in positive activities at home.

The Moderating Role of Motivation in the Real-Time Associations of Fatigue, Cognitive Complaints, and Pain With Depressed Mood Among Stroke Survivors: An Ecological Momentary Assessment Study

OBJECTIVE

Stroke symptoms fluctuate during the day as stroke survivors participate in daily activities. Understanding the real-time associations among stroke symptoms and depressed mood, as well as the role of motivation for daily activities, informs, and post-stroke symptom management in the context of everyday living. This study aimed to (1) investigate the real-time associations of fatigue, cognitive complaints, and pain with depressed mood and (2) examine the role of motivation for daily activity participation as a potential moderator of these associations in stroke survivors.

DESIGN

A prospective cohort study involving 7 days of ecological momentary assessment (EMA), during which participants completed 8 EMA surveys per day. Multilevel modeling was used to analyze data.

SETTING

Community.

PARTICIPANTS

Forty community-dwelling stroke survivors (N=40).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

EMA measures of depressed mood, stroke symptoms (physical and mental fatigue, cognitive complaints, and pain), and motivation (autonomous motivation, controlled motivation).

RESULTS

Higher levels of within- and between-person physical fatigue, mental fatigue, cognitive complaints, and pain were momentarily associated with greater depressed mood (Ps<.001). Within-person autonomous motivation significantly buffered the momentary associations of physical fatigue (B=-0.06, P<.001), mental fatigue (B=-0.04, P=.032), and pain (B=-0.21, P<.001) with depressed mood.

CONCLUSIONS

Findings indicate the momentary associations of fatigue, cognitive complaints, and pain with depressed mood in stroke survivors. Autonomous motivation underpinning daily activity participation was found to buffer the associations of fatigue and pain with depressed mood. Promoting autonomous motivation for daily activity participation may be viable for preventing and mitigating poststroke depression.

Clinical Features to Predict the Use of a sEMG Wearable Device (REMO®) for Hand Motor Training of Stroke Patients: A Cross-Sectional Cohort Study

After stroke, upper limb motor impairment is one of the most common consequences that compromises the level of the autonomy of patients. In a neurorehabilitation setting, the implementation of wearable sensors provides new possibilities for enhancing hand motor recovery. In our study, we tested an innovative wearable (REMO^®) that detected the residual surface-electromyography of forearm muscles to control a rehabilitative PC interface. The aim of this study was to define the clinical features of stroke survivors able to perform ten, five, or no hand movements for rehabilitation training. 117 stroke patients were tested: 65% of patients were able to control ten movements, 19% of patients could control nine to one movement, and 16% could control no movements. Results indicated that mild upper limb motor impairment (Fugl-Meyer Upper Extremity ≥ 18 points) predicted the control of ten movements and no flexor carpi muscle spasticity predicted the control of five movements. Finally, severe impairment of upper limb motor function (Fugl-Meyer Upper Extremity > 10 points) combined with no pain and no restrictions of upper limb joints predicted the control of at least one movement. In conclusion, the residual motor function, pain and joints restriction, and spasticity at the upper limb are the most important clinical features to use for a wearable REMO^® for hand rehabilitation training.

Motivation, Physical Activity, and Affect in Community-Dwelling Stroke Survivors: An Ambulatory Assessment Approach

BACKGROUND

Motivation is a frequently reported but far less studied driver for post-stroke physical activity participation. Motivation and physical activity may be important contributors to the prevention management and alleviation of affective symptoms among stroke survivors.

PURPOSE

To investigate the real-time associations between motivation, physical activity, and affect in the daily lives of community-dwelling stroke survivors using ecological momentary assessment (EMA) and accelerometry.

METHODS

Forty community-dwelling stroke survivors wore an accelerometer on the thigh and completed EMA surveys assessing motivation (autonomous motivation, controlled motivation) and affect (negative affect, positive affect) eight times daily for 7 days. Multivariate regression analysis and multilevel modeling investigated the associations between motivation, physical activity, and affect.

RESULTS

Greater autonomous motivation for physical activity was associated with less sedentary behavior (β = -0.40, p = .049) and more moderate-to-vigorous physical activity (β = 0.45, p = .020) participation in daily life. Greater autonomous motivation was momentarily associated with less depressed affect (β = -0.05, p < .001) and greater positive affect (β = 0.13, p < .001). Moreover, greater controlled motivation was momentarily associated with greater depressed affect (β = 0.06, p < .001). More intense physical activity was momentarily associated with greater positive affect (β = 0.13, p = .016). No moderating effect of motivation on the association between physical activity and affect was found.

CONCLUSIONS

Motivation and physical activity are momentarily associated with affect among stroke survivors. Assessing and fostering autonomous motivation may be beneficial for promoting physical activity and managing positive and depressed affect as stroke survivors return to the community.

Associations Between Basic Psychological Need Satisfaction and Motivation Underpinning Daily Activity Participation Among Community-Dwelling Survivors of Stroke: An Ecological Momentary Assessment Study

OBJECTIVE

Grounded in the self-determination theory (SDT), this study aimed to examine the real-time associations between basic psychological need satisfaction and motivation underpinning daily activity participation among survivors of stroke.

DESIGN

Repeated-measures observational study involving 7 days of ambulatory monitoring; participants completed ecological momentary assessment (EMA) surveys via smartphones 8 times daily. Multilevel models were used to analyze EMA data for concurrent (same survey) and lagged (next survey) associations.

SETTING

General community.

PARTICIPANTS

Forty community-dwelling survivors of stroke (N=40).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

EMA measures of basic psychological needs (autonomy, competence, relatedness) and motivation (autonomous motivation, controlled motivation).

RESULTS

In concurrent analyses, increased autonomy (B=0.21; 95% confidence interval, 0.16-0.26; P<.001), competence (B=0.10; 95% confidence interval, 0.02-0.19; P=.021), and relatedness (B=0.10; 95% confidence interval, 0.06-0.13; P<.001) were momentarily associated with higher autonomous motivation. Conversely, increased autonomy (B=-0.19; 95% confidence interval, -0.27 to -0.10; P<.001) and competence (B=-0.09; 95% confidence interval, -0.17 to -0.01; P=.020) were momentarily associated with lower controlled motivation. Contrary to SDT, increased relatedness was momentarily associated with higher controlled motivation (B=0.10; 95% confidence interval, 0.05-0.14; P<.001). In lagged analyses, no momentary associations were detected between basic psychological needs and motivation (Ps>.05).

CONCLUSIONS

Findings suggest that basic psychological need satisfaction is momentarily associated with motivation for daily activity participation. Additional research is warranted to examine the associations of different orientations of relatedness with autonomous and controlled motivation. Supporting basic psychological needs may foster autonomous motivation of survivors of stroke to enhance daily activity participation after stroke.

Enhancing the role of the social network in activity (re)engagement post-stroke: a focus group study with rehabilitation professionals

BACKGROUND

People post-stroke are at risk of not being able to participate in valued activities. It is important that rehabilitation professionals prepare people post-stroke for the transition home and provide needed support when they live at home. Several authors have suggested that members of the broad social network should play an active role in rehabilitation. This includes informing them about the importance of activity (re)engagement post-stroke and learning strategies to provide support. It is not clear when and how the broad social network can best be equipped to provide adequate activity support. This study aimed to explore stroke professionals' perspectives on strategies that establish a social network that supports activity (re)engagement of people post-stroke, when strategies are best implemented, and the factors that influence the implementation of these strategies.

METHODS

Two focus groups were executed. Content analysis was used to analyze the transcripts of the recorded conversations.

RESULTS

Eighteen professionals with various professional backgrounds and roles in treating people post-stroke participated. Strategies to establish a supportive social network included identifying, expanding, informing, and actively engaging network members. Working with the network in the immediate post-stroke phase was regarded as important for improving long-term activity outcomes. Participants expressed that most strategies to equip the social network to support people post-stroke need to take place within community care. However, the participants experienced difficulties in implementing network strategies. Perceived barriers included interprofessional collaboration, professional knowledge, self-efficacy, and financial structures.

CONCLUSIONS

Strategies to involve the social network of people post-stroke are not fully implemented. Although identifying members of a social network should begin during inpatient rehabilitation, the main part of actively engaging the network will have to take place when the people post-stroke return home. Implementing social network strategies requires a systematic process focusing on collaboration, knowledge, attitude, and skill development.

Multimodal Ambulatory Monitoring of Daily Activity and Health-Related Symptoms in Community-Dwelling Survivors of Stroke: Feasibility, Acceptability, and Validity

OBJECTIVE

To examine the feasibility, acceptability, and validity of multimodal ambulatory monitoring, which combines accelerometry with ecological momentary assessment (EMA), to assess daily activity and health-related symptoms among survivors of stroke.

DESIGN

Prospective cohort study involving 7 days of ambulatory monitoring; participants completed 8 daily EMA surveys about daily activity and symptoms (mood, cognitive complaints, fatigue, pain) while wearing an accelerometer. Participants also completed retrospective assessments and an acceptability questionnaire.

SETTING

Community.

PARTICIPANTS

Forty survivors of stroke (N=40).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Feasibility was determined using attrition rate and compliance. Acceptability was reported using the acceptability questionnaire. Convergent and discriminant validity were determined by the correlations between ambulatory monitoring and retrospective self-reports. Criterion validity was determined by the concordance between accelerometer-measured and EMA-reported daily activity.

RESULTS

All participants completed the study (attrition rate=0%). EMA and accelerometer compliance were 93.6 % and 99.7%, respectively. Participants rated their experience with multimodal ambulatory monitoring positively. They were highly satisfied (mean, 4.8/5) and confident (mean, 4.7/5) in using ambulatory monitoring and preferred it over traditional retrospective assessments (mean, 4.7/5). Multimodal ambulatory monitoring estimates correlated with retrospective self-reports of the same and opposing constructs in the predicted directions (r=-0.66 to 0.72, P<.05). More intense accelerometer-measured physical activity was observed when participants reported doing more physically demanding activities and vice versa.

CONCLUSIONS

Findings support the feasibility, acceptability, and validity of multimodal ambulatory monitoring in survivors of mild stroke. Multimodal ambulatory monitoring has potential to provide a more complete understanding of survivors' daily activity in the context of everyday life.

Self-reported emotional health and social support but not executive function are associated with participation after stroke

BACKGROUND

Participation restrictions continue to be prevalent for community-dwelling stroke survivors. Research is needed to understand the associated post-stroke factors that limit or facilitate optimal participation and quality of life.

OBJECTIVES

To investigate emotional health, executive functioning (EF), and social support as predictors of participation restrictions post-stroke.

METHODS

Cross-sectional data collected from participants ≥ 6 months after mild stroke with and without aphasia (N = 114) were analyzed using three participation outcome measures: Reintegration to Normal Living Index (RNL), Activity Card Sort (ACS), and the Stroke Impact Scale (SIS) Version 2.0 Participation/Role Function domain. Predictor variables investigated were emotional health (SIS Emotion domain scores), EF (Delis Kaplan Executive Function System Trail Making Condition 4: DKEFS), social support (Medical Outcomes Study Social Support Survey: MOS-SSS), stroke severity (National Institutes of Health Stroke Scale: NIHSS), and education level.

RESULTS

Using multiple regression, these predictors accounted for 26.4% to 40% of the variance for the three participation outcomes. Emotional health was a significant independent predictor across all three measures. Social support was a significant predictor of participation as measured on the RNL. Executive function was not a significant predictor of participation when controlling for the other predictor variables.

CONCLUSIONS

Emotional health and social support should be considered as modifiable factors that could optimize meaningful participation and quality of life.

The efficacy and safety of Jin's three-needle therapy vs. placebo acupuncture on anxiety symptoms in patients with post-stroke anxiety: A study protocol for a randomized controlled trial

Background

A large number of clinical RCTs have verified that Jin's three-needle therapy (JTNT) has a great contribution to promoting the function of paralyzed limbs and relieving anxiety disorders for patients with post-stroke anxiety (PSA). However, there is still a lack of sham needle control, and its placebo effect cannot be ruled out. This study firstly verifies the real effectiveness of JTNT. Besides, the changes in serum indexes on the hypothalamic-pituitary-adrenal axis (HPA axis) are observed dynamically by the Enzyme-Linked ImmunoSorbent Assay (ELISA). The activation of different brain regions by JTNT is recorded using resting functional magnetic resonance imaging (rs-fMRI). Therefore, we can provide more practical and powerful evidence-based medical evidence for clinical decisions.

Method

This is a 16 week parallel, single-blind, random, controlled trial, including baseline, 4 weeks of treatment, and 12 weeks of follow-up. A total of 114 participants will be randomly divided into three groups in the proportion of 1:1:1. Participants will receive Jin's three-needle therapy in the active acupuncture group and accept sham needle treatment in the sham acupuncture group. In the waitlist control group, patients will not receive any acupuncture treatment. Outcomes cover three types of indicators, including scale indicators, serum indicators, and imaging indicators. The primary outcome is the change in the performance of anxiety symptoms, which is estimated by the 14-item Hamilton Anxiety Rating Scale (HAMA-14) and the 7-item Generalized Anxiety Disorder scale (GAD-7). Secondary outcomes are physical recovery and daily quality of life, which are evaluated by the National Institute of Health stroke scale (NIHSS) and the Modified Barthel Index Score (MBI Scale). Therefore, the assessment of the scale is carried out at baseline, 2nd, 4th, 8, 12, and 16 weeks. Adrenocorticotropin and cortisol will be quantitatively detected by ELISA at baseline and 4 weeks after treatment. In addition, regional homogeneity analysis (ReHo) will be used to record the activity of brain regions at baseline and 4 weeks after intervention.

Discussion

The study aims to provide high-quality clinical evidence on the effectiveness and safety of JTNT for patients with PSA. In addition, this trial explores a possible mechanism of JTNT for patients with PSA.

Clinical trial registration

Chinese Clinical Trial Registry, identifier [ChiCTR2200058992].

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 longitudinal association between movement behavior patterns and the course of participation up to one year after stroke

PURPOSE

(1) To investigate the differences in the course of participation up to one year after stroke between distinct movement behavior patterns identified directly after discharge to the home setting, and (2) to investigate the longitudinal association between the development of movement behavior patterns over time and participation after stroke.

MATERIALS AND METHODS

200 individuals with a first-ever stroke were assessed directly after discharge to the home setting, at six months and at one year. The Participation domain of the Stroke Impact Scale 3.0 was used to measure participation. Movement behavior was objectified using accelerometry for 14 days. Participants were categorized into three distinct movement behavior patterns: sedentary exercisers, sedentary movers and sedentary prolongers. Generalized estimating equations (GEE) were performed.

RESULTS

People who were classified as sedentary prolongers directly after discharge was associated with a worse course of participation up to one year after stroke. The development of sedentary prolongers over time was also associated with worse participation compared to sedentary exercisers.

CONCLUSIONS

The course of participation after stroke differs across distinct movement behavior patterns after discharge to the home setting. Highly sedentary and inactive people with stroke are at risk for restrictions in participation over time.Implications for rehabilitationThe course of participation in people with a first-ever stroke up to one year after discharge to the home setting differed based on three distinct movement behavior patterns, i.e., sedentary exercisers, sedentary movers and sedentary prolongers.Early identification of highly sedentary and inactive people with stroke after discharge to the home setting is important, as sedentary prolongers are at risk for restrictions in participation over time.Supporting people with stroke to adapt and maintain a healthy movement behavior after discharge to the home setting could prevent potential long-term restrictions in participation.

Upper Limb Stroke Rehabilitation Using Surface Electromyography: A Systematic Review and Meta-Analysis

Background

Upper limb impairment is common after stroke, and many will not regain full upper limb function. Different technologies based on surface electromyography (sEMG) have been used in stroke rehabilitation, but there is no collated evidence on the different sEMG-driven interventions and their effect on upper limb function in people with stroke.

Aim

Synthesize existing evidence and perform a meta-analysis on the effect of different types of sEMG-driven interventions on upper limb function in people with stroke.

Methods

PubMed, SCOPUS, and PEDro databases were systematically searched for eligible randomized clinical trials that utilize sEMG-driven interventions to improve upper limb function assessed by Fugl-Meyer Assessment (FMA-UE) in stroke. The PEDro scale was used to evaluate the methodological quality and the risk of bias of the included studies. In addition, a meta-analysis utilizing a random effect model was performed for studies comparing sEMG interventions to non-sEMG interventions and for studies comparing different sEMG interventions protocols.

Results

Twenty-four studies comprising 808 participants were included in this review. The methodological quality was good to fair. The meta-analysis showed no differences in the total effect, assessed by total FMA-UE score, comparing sEMG interventions to non-sEMG interventions (14 studies, 509 participants, SMD 0.14, P 0.37, 95% CI –0.18 to 0.46, I² 55%). Similarly, no difference in the overall effect was found for the meta-analysis comparing different types of sEMG interventions (7 studies, 213 participants, SMD 0.42, P 0.23, 95% CI –0.34 to 1.18, I² 73%). Twenty out of the twenty-four studies, including participants with varying impairment levels at all stages of stroke recovery, reported statistically significant improvements in upper limb function at post-sEMG intervention compared to baseline.

Conclusion

This review and meta-analysis could not discern the effect of sEMG in comparison to a non-sEMG intervention or the most effective type of sEMG intervention for improving upper limb function in stroke populations. Current evidence suggests that sEMG is a promising tool to further improve functional recovery, but randomized clinical trials with larger sample sizes are needed to verify whether the effect on upper extremity function of a specific sEMG intervention is superior compared to other non-sEMG or other type of sEMG interventions.

A Chinese version of the Measure of Stroke Environment (MOSE): psychometric evaluation in stroke survivors

PURPOSE

To translate the MOSE from English to Chinese and investigate the psychometric properties of the Chinese-translated version of the Measure of Stroke Environment (MOSE).

MATERIALS AND METHODS

The MOSE was translated into Chinese using a cultural adaptation process. To validate this Chinese version, 311 stroke survivors were recruited to complete the questionnaire. The psychometric properties of the MOSE were evaluated by determining item analysis, test-retest reliability, internal consistency, content validity, construct validity, and floor/ceiling effects, respectively.

RESULTS

The MOSE was translated without any major difficulties. Regarding psychometric performances, a moderate level of correlation between the items and the domains (r > 0.4), and the significant differences in items between the high group and the low group were tested by independent sample t-tests (p < 0.05). The test-retest reliability was excellent (Intraclass Coefficient Correlation = 0.938). Very high internal consistency was also observed (Cronbach's α = 0.945, split-half reliability = 0.778). An acceptable I-CVI ranged from 0.714 to 1.000 and a high S-CVI of 0.973. Correlations with the subscales of the WHODAS 2.0 were significant in similar domains reflecting good convergent validity. No floor or ceiling effects were observed.

CONCLUSION

This study provides psychometric evidence supporting the use of the Chinese version of the MOSE among stroke survivors.IMPLICATIONS FOR REHABILITATIONThe Measure of Stroke Environment was translated into Chinese through a rigorous cultural adaptation process.MOSE-C is now a reliable and valid tool for Chinese-speaking survivors who have suffered from a stroke.It is necessary to assess the perceived environmental barriers of stroke survivors and develop targeted intervention programs in China.

Self-Perceived ADL/IADL Function is Influenced by Residual Neurological Impairment, Aphasia, and Anxiety

BACKGROUND.

Self-perceptions of performance of activities of daily living (ADL) and instrumental activities of daily living (IADL) are reduced following stroke. Research investigating contributing factors is lacking.

PURPOSE.

We examined the extent to which aphasia status, neurological impairment and poststroke depression, and anxiety contribute to self-perceived ADL/IADL function.

METHOD.

Seventy-six community-dwelling individuals at least 6 months poststroke, 44 with and 32 without aphasia, participated in the cross-sectional study. The Stroke Impact Scale (SIS) ADL/IADL domain was the primary outcome measure with aphasia status, residual neurological impairment, depressive symptoms, and anxiety as predictor variables.

FINDINGS

Aphasia status, residual neurological impairment, and anxiety were independent predictors of self-perceived ADL/IADL function, together accounting for more than half the variance. Depression was not associated with ADL/IADL.

IMPLICATIONS.

Clinician awareness of the influence of anxiety on self-perceived ADL/IADL function, particularly for people with aphasia, may lead to future interventions that improve self-perceived ADL/IADL function.

Impact of Environmental Factors on Post-Stroke Disability: An Analytical Cross-Sectional Study

OBJECTIVES

Identify how environmental barriers and facilitators are associated with disability in stroke survivors.

MATERIALS AND METHODS

An analytical, cross-sectional study was conducted involving individuals in the chronic stage of stroke. The dependent variable was disability, which was assessed using the World Health Organization Disability Assessment Schedule (WHODAS-2.0). Environmental factors (independent variable) were evaluated using the Measure of the Quality of the Environment (MQE). Multiple linear regression analysis was performed to estimate the impact of the environment on disability following a stroke.

RESULTS

Seventy-five individuals (mean age: 54.2 + 9.8 years) were analyzed. The most frequent environmental facilitators were related to technology, social networks, and public services. The main barriers were related to the physical environment. Environmental barrier was a predictor of both overall disability [F(1.73) = 4.24; R²=0.06; β = -0.23; t = -2.06; p=0.04] and participation [F(1.73) = 10.45; R²=0.13; β = -0.35; t = -3.23; p = 0.01]. Environmental facilitators were not correlated with disability.

CONCLUSION

Environmental barriers explained 13% of the variation in restrictions to social participation and were also a significant predictor of overall disability. The main barriers were related to the physical environment. Identifying environmental factors related to disability in stroke victims can assist in the planning of guided therapy.

Mirror Therapy Rehabilitation in Stroke: A Scoping Review of Upper Limb Recovery and Brain Activities

Background

Mirror therapy (MT) has been used as a treatment for various neurological disorders. Recent application of electroencephalogram (EEG) to the MT study allows researchers to gain insight into the changes in brain activity during the therapy.

Objective

This scoping review is aimed at mapping existing evidence and identifying knowledge gaps about the effects of MT on upper limb recovery and its application for individuals with chronic stroke.

Methods and Materials

A scoping review through a systematic literature search was conducted using PubMed, CINAHL, PsycINFO, and Scopus databases. Twenty articles published between 2010 and 2020 met the inclusion criteria. The efficacy of MT on upper limb recovery and brain activity during MT were discussed according to the International Classification of Functioning, Disability and Health (ICF).

Results

A majority of the studies indicated positive effects of MT on upper limb recovery from the body structure/functional domain. All studies used EEG to indicate brain activation during MT.

Conclusion

MT is a promising intervention for improving upper limb function for individuals with chronic stroke. This review also highlights the need to incorporate EEG into the MT study to capture brain activity and understand the mechanism underlying the therapy.

Apathy and residual neurological impairment are associated with community reintegration after mild stroke

This study investigated the influence of apathy and positive social support on community reintegration after stroke. A prospective, correlational, cross-sectional design was used. 85 community dwelling participants with and without aphasia were included (≥ 18 years of age, first stroke, ≥ 6 months post-stroke). The Reintegration to Normal Living Index (RNL) measured poststroke participation. The Apathy Evaluation Scale (AES) and Positive Social Interaction domain of the Medical Outcomes Study Social Support Survey assessed apathy and social support respectively. NIH Stroke Scale measured residual neurological impairment. Apathy, social support, and stroke impairment together were strongly associated with the RNL and accounted for 51% of total variance in the RNL. The AES and NIHSS were independent predictors of the RNL, though positive social interaction failed to reach significance. Persons with and without apathy differed significantly on the RNL. Therefore, stroke rehabilitation should address apathy as a potential target for intervention. Future research should determine factors that mediate the relationship between poststroke apathy and community reintegration.

Experiences of stroke survivors and measurement of post stroke participation and activity across seasons-A mixed methods approach

Participation and activity post stroke can be limited due to adverse weather conditions. This study aimed to: Quantify and compare summer and winter participation and activity, and explore how community dwelling people with stroke describe their feelings about their level of participation and activity by season. This embedded mixed-methods observational study took place in a city with weather extremes. Community dwelling individuals at least one year post-stroke, able to walk ≥50 metres +/- a walking aide were included. Evaluations and interviews occurred at participants’ homes in two seasons: Reintegration to Normal living Index (RNL), Activities-specific Balance Confidence (ABC) and descriptive outcomes. Participants wore activity monitors for one week each season. Analysis included descriptive statistics, non-parametric tests and an inductive approach to content analysis. Thirteen individuals participated in quantitative evaluation with eight interviewed. Mean age 61.5 years, 62% female and mean 6.2 years post-stroke. No differences between winter-summer values of RNL, ABC, or activity monitor outcomes. However, participants felt they could do more and were more independent in summer. The winter conditions such as ice, snow, cold and wind restricted participation and limited activities. Nonetheless, many participants were active and participated despite the winter challenges by finding other ways to be active, and relying on social supports and personal motivation. The qualitative findings explained unexpected quantitative results. Participants described many challenges with winter weather, but also ways they had discovered to participate and be active despite these challenges. Changes to future studies into seasonal differences are suggested.

Social Participation as a Predictor of Morbid Thoughts and Suicidal Ideation among the Elderly Population: A Cross-Sectional Study on Four Low-Middle-Income Countries

Social wellbeing constitutes a critical aspect of one’s health, quality of life, and overall psychosocial wellbeing. Social isolation and perceived loneliness are growing public health concerns as they are considered to be important risk factor for poor physical and mental health outcomes. Not much is known about how the level of one’s social participation is associated with morbid thought and suicidal ideation. In the present study, we aimed to investigate whether social participation shows any significant correlation with morbid thought and suicidal ideation among the elderly population. Methods: Cross-sectional data were collected from Wave 1 of the Study of Global AGEing and Adult Health (SAGE). The sample population consisted 2018 men and women aged 65 years and above from the following countries: China (n = 787), Ghana (n = 278), India (n = 560), and Russia (n = 396). Outcome variables of self-reported occurrence of morbid thoughts and suicide ideation during the past 12 months were reported. Results: A great majority of the participants reported not participating in activities such as public meetings (84.6%), club meeting (49.6%), neighborhood activities (46%), and religious activities (57.2%). Those who reported attending public meetings several times a year had a higher likelihood of reporting having morbid thoughts (predicted probability = 1.24, 95% CI = 1.02, 1.52). However, the association was no longer significant after stratifying by sex. Attending clubs (marginal effect = 0.61, 95% CI = 0.49, 0.76) and neighborhood activities (predicted probability = 0.71, 95% CI = 0.58, 0.88) several times a year showed protective effects against morbid thoughts. Being visited by friends several times a month (predicted probability = 0.52, 95% CI = 0.40, 0.67) and visiting friends (predicted probability = 0.61, 95% CI = 0.50, 0.75) several times a year also showed lower likelihood of morbid thoughts. Similar effects were observed for attending social gatherings with colleagues and social events as well. Conclusions: The present findings suggest that there exist significantly positive associations between participation in social activities and morbid thoughts and suicidal ideation among the elderly population in the sample countries. More in-depth studies are necessary to investigate the barriers to participation in social activities as well as the role of the quality of social relationships with experiencing suicidal thoughts.

Apathy, Cognitive Impairment, and Social Support Contribute to Participation in Cognitively Demanding Activities Poststroke

Objective

To understand the extent to which apathy, cognition, and social support predict participation in activities with cognitive demands.

Design

Prospective, quantitative correlational, cross-sectional study. Setting. Outpatient treatment centers and community stroke support groups located in St. Louis, MO, and Boston, MA. Participants. 81 community-dwelling individuals ≥ 6-month poststroke with and without aphasia. Measures. Participants completed the Activity Card Sort (ACS), Apathy Evaluation Scale (AES), Medical Outcomes Study Social Support Survey (MOS-SSS), and Delis-Kaplan Executive Function System (DKEFS) Design Fluency and Trail-Making subtests.

Results

Cognitive deficits limit participation in activities with high cognitive demands. Apathy and positive social interaction influence participation, regardless of high or low cognitive demands. Poststroke aphasia did not impact return to participation in activities with high and low cognitive demands. Conclusions and Relevance. Cognitive deficits seen poststroke contribute to participation only for activities with high cognitive demands. Apathy has a significant and negative influence on participation overall. Social support is a modifiable contextual factor that can facilitate participation. Poststroke apathy can be detrimental to participation but is not well recognized. The availability of companionship from others to enjoy time with can facilitate participation.

The role of the social network during inpatient rehabilitation: A qualitative study exploring the views of older stroke survivors and their informal caregivers

BACKGROUND

After discharge, stroke survivors and their informal caregivers need support from their social networks to resume their most valued activities. Rehabilitation professionals could help them establish a strong support system.

OBJECTIVE

Explore how older stroke survivors and their primary informal caregivers expect to resume their valued activities after discharge, and discover their ideas about involving, informing and educating their family members, friends and important others during inpatient rehabilitation so that, once home, they will have adequate support.

METHODS

We conducted semi-structured interviews with stroke survivors from three geriatric rehabilitation centres and their primary informal caregivers, used the pictures of daily activities to elicit their perspectives, and applied a descriptive and interpretive design to data analysis.

RESULTS

Many participants had no concrete idea about how to resume their activities after discharge but nevertheless were optimistic they would. They expected help to be available and saw no need for professionals to involve their network during inpatient rehabilitation. However, once they had insight into the challenges to expect after discharge, they often appreciated the idea of professionals contacting their network. To better understand the challenges after discharge, it was helpful if professionals provided concrete, honest information about the stroke's consequences for daily life. Actually doing daily activities also helped gain better insights.

CONCLUSIONS

To enhance insight in the need of social support after discharge, we suggest that rehabilitation professionals are honest about what to expect and let stroke survivors explore their valued activities in a realistic context more often.

Does COVID-19 Impact Less on Post-stroke Aphasia? This Is Not the Case

Background

The coronavirus disease 2019 (COVID-19) pandemic has greatly affected people’s mental health resulting in severe psychological consequences. One of the leading causes of long-term disability worldwide is aphasia. The language changes experienced by a person with aphasia (PWA) often have a sudden and long-lasting negative impact on social interaction, quality of life, and emotional wellbeing. The main aim of this study was to investigate the impact of COVID-19 on the different psychosocial dimensions which affect PWA.

Methods

This retrospective study included 73 PWA and 81 elderly matched controls. All patients were in the chronic phase. They were all discharged from rehabilitation services, which left them with different degrees of language deficits (i.e., severe vs. mild vs. moderate). All participants were administered the hospital anxiety and depression scale (HADS) through an online survey. PWA also took part in the stroke and aphasia quality of life scale questionnaire (SAQOL-39).

Results

Although the comparison between two different time points [one month before (T0) and one month after the lockdown (T1)] led to a significant increase in depression and anxiety symptoms in both groups (PWA vs. control), lower rates of depression and anxiety were found in PWA compared to the healthy group. Significant deterioration was also present in PWA in the communication and psychosocial scales of the SAQOL-39 test, which correlated with the observed changes in the psychological domains. Interestingly, the results were not significantly influenced by the degree of aphasia severity. Similarly, in both groups, none of the demographic variables (gender, age, and educational level) significantly affected the scores in the different subscales.

Conclusions

This evidence which, at first glance, seems to suggest that PWA have been partially spared from the impact of COVID-19, actually masks a dramatic situation that has always characterized this population. Indeed, given that PWA already live in a state of social isolation and emotional instability, these conditions might have, paradoxically, limited the effects of the coronavirus. However, as our results showed a deterioration in the emotional state and communication skills of our patients, possible solutions are discussed in order to prevent further decline of their cognitive abilities.

The management of subacute and chronic vascular aphasia: an updated review

Background

Post-stroke aphasia (PSA) is an impairment of the generation or comprehension of language due to acute cerebrovascular lesions. Subacute phase span the 7th day to 24 weeks post-onset while > 6 months is termed chronic phase. Language recovery does not arise immediately in chronic PSA, unlike the acute phase. The majority of the treatment modalities in these two PSA phases are still in the infancy stage, facing dilemmas and considered experimental requiring constant updates. Hence, we aimed to upgrade the existing literature regarding available PSA management options, advances, and drawbacks pertaining to subacute and chronic phases.

Main text

In this review, we analyzed the management options for subacute and chronic vascular aphasia. MEDLINE, through PubMed, ScienceDirect, and Google Scholar were explored for English studies by utilizing the terms “stroke aphasia” Plus “vascular aphasia”; 160,753 articles were retrieved. The latest studies, published from 2016 to July 2020, were selected. Article headings and abstracts were analyzed for relevance and filtered; eventually, 92 articles were included in this review. Various management options were extracted as follows: noninvasive brain stimulation (NIBS), technology-based therapies, speech-language therapy (SLT), pharmacotherapy, music-based therapies, and psychosocial interventions.

Conclusion

The PSA therapy evolves towards more intense SLT therapy, yet the optimal dosage of the emerging high-intensity therapies is controversial. As spinal and cerebellar NIBS, Telespeech, and E-mental health mark PSA's future, distinct pharmacological options remain a dilemma. Across the continuum of care, PSA–depression comorbidity and inadequate PSA post-discharge education to patient’s families are the significant therapeutic challenges. Future therapeutic mechanisms, optimal dose/timing, and tolerability/safety exploration are obliged.

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.

Investigating predictors of community integration in individuals after stroke in a residential setting: A longitutinal study

Aim

To identify potential predictors of community integration in individuals after stroke using a residential setting-based strategy.

Method

A prospective cohort of post-stroke individuals was recruited from the Stroke Unit of the Roberto Santos General Hospital (UAVC-HGRS). All included individuals were aged over 18 years, received a diagnosis of ischemic stroke confirmed by neuroimaging and resided in the city of Salvador (Bahia, Brazil). Following discharge from the stroke unit, the individuals themselves, or their responsible parties, were contacted by telephone to schedule a home visit no less than three months after discharge. All subjects were examined in their homes, at which time the Community Integration Questionnaire (CIQ) was also applied. A robust linear regression model was used to assess community reintegration using CIQ score as the outcome variable.

Results

A total of 124 individuals effectively fulfilled the eligibility criteria: 51.6% were females, the median (IQR) age was 63(53–69) years, 82.3% were non-white, 53.2% were married, the median (IQR) of years of schooling was 6 (4–12) and family income averaged two minimum monthly wages. Investigated individuals presented a median (IQR) NIH Stroke Scale (NIHSS) score of 7 (4–12). Multivariate linear regression identified the following independent predictors of community integration: age (β = -0.095; 95% CI = -0.165 to -0.025; p = 0.008), diabetes mellitus (β = -2.348; 95% CI = -4.125 to -0.571; p = 0.010), smoking habit (β = -2.951; 95% CI = -5.081 to -0.821; p = 0.007), functional capacity upon hospital discharge (β = 0.168; 95% CI = 0.093 to 0.242; p = <0.001) and stroke severity (β = -0.163; CI = -0.318 to -0.009); p = 0.038).

Conclusions

Regardless of length of time since stroke, individuals present restrictions that compromise their reintegration into their respective communities. The demographic, clinical and functional factors identified herein as potential predictors should be considered when conducting regular follow-up, as well as in the rehabilitation of individuals after stroke with the purpose to identify the interventions necessary to optimize their reintegration into the community.

Do caregiver proxy reports and congruence of client-proxy activity participation goals relate to quality of life in people with aphasia?

BACKGROUND

Achieving activity participation goals is a key factor in quality of life (QOL) for people with aphasia (PWA), but expressing participation goals can be difficult for many of them. Proxy reports by caregivers may not accurately reflect the interests and participation goals of PWA, and discrepancies in these goals between PWA and their caregivers may affect QOL, based on the assumption that caregivers' awareness of their loved ones' unique participation goals may be important to increasing PWA activity participation.

AIMS

To examine everyday activities valued by PWA using the Life Interests and Values (LIV) Cards; to measure congruence between PWA and their caregivers on life participation goals; and to measure how congruence of PWA-caregiver participation goals related to QOL.

METHODS & PROCEDURES

A convenience sample of 25 PWA completed the LIV Card assessment and the Stroke Aphasia Quality of Life Scale-39 to assess participation goals and QOL. Participation goals were also evaluated with respect to age, time post-onset and aphasia severity. A total of 12 caregivers were administered the LIV Cards to calculate agreement between PWA-proxy activity reports and the relationship between agreement and QOL.

OUTCOMES & RESULTS

PWA endorsed wanting to participate more in a wide range of activities, with common interests in walking/running, going to the beach and eating out, among others. PWA-caregiver activity agreement was fair to moderate with point-to-point agreement averaging 70%. However, no relationship between degree of congruence in PWA-proxy pairs and QOL was found.

CONCLUSIONS & IMPLICATIONS

PWA have a variety of activity participation goals that can be integrated into intervention plans. Dependence on proxy respondents should be reduced as much as possible to support self-determination for PWA. What this paper adds What is already known on the subject Achieving activity participation goals is a key factor in QOL for PWA, but communicating about participation goals can be difficult for many of them. Because proxy reports by caregivers may not accurately reflect the interests and participation goals of PWA, this study examined how both PWA and their caregivers responded to an aphasia-friendly assessment for determining participation goals, and then compared level of agreement about these goals to QOL. Because activity participation is known to be an important factor in QOL, the reason for investigating how agreement relates to QOL is that caregivers' awareness of their loved ones' unique participation goals likely facilitates increased participation by PWA in their ongoing desired activities. The relationship between PWA-caregiver agreement regarding participation goals and QOL in PWA had not yet been investigated before this study. What this paper adds to existing knowledge This study adds additional as well as confirmatory information to the existing literature about life participation goals of community-dwelling individuals with chronic aphasia. Top activities endorsed by a group of 25 PWA are reported within four activity domains (home and community activities, creative and relaxing activities, physical activities, and social activities). Results indicated that agreement between PWA and their caregiver proxies on PWA's most desired activities was < 50%. However, the level of agreement between caregivers and proxies on participation goals was not significantly related to QOL in this sample. What are the potential or actual clinical implications of this work? PWA have a variety of participation goals that can be integrated into intervention plans to be carried out with clinicians, caregivers and family members. The use of proxy respondents when determining participation goals should be reduced as much as possible to support self-determination for PWA. Use of the LIV Cards, a picture-based sorting-task assessment, reduces the need for proxy responders and guesswork about the specific participation goals of PWA.

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.