Understanding stroke survivorship: expanding the concept of poststroke disability

Are age-predicted equations valid in predicting maximum heart rate in individuals after stroke?

PURPOSE

To investigate the validity of six age-predicted maximum heart rate (HRmax) equations after stroke.

MATERIAL AND METHODS

Sixty individuals (54 (12) years; 64 (69) months after stroke) were included. A Cardiopulmonary Exercise Test (CPET) performed on a treadmill obtained the HRmax. The most used age-predicted equations were investigated: (1) 220-age, proposed by Fox; (2) 206.9- (0.67 × age), proposed by Gellish; (3) 208- (0.7 × age), proposed by Tanaka; (4) 216.6- (0.84 × age), proposed by Astrand; (5) 164- (0.72 × age) and (6) 200- (0.92 × age) proposed by Brawner.

RESULTS

No statistically significant agreement was found between the HRmax obtained by the CPET and the one predicted by the equations 1-5 (-0.18 ≤ 95% confidence interval ≤0.79). A significant and moderate agreement was found between the HRmax obtained by the CPET and the one predicted by equation (6) (95% CI= 0.05-0.75; Intraclass Correlation Coefficient= 0.51). Bland-Altman plots showed that equations (1-4) and (6) overestimated the HRmax. Equation (6) presented the lower mean difference.

CONCLUSIONS

The equations developed for non-disabled individuals (1-4) are not adequate to be used in individuals after a stroke. Equation (6) (Brawner) showed the best results to be used in individuals after stroke; however, it should be used cautiously.

Yoga in the Rehabilitation of Post-Stroke Sequelae: A Non-Inferiority Randomized Controlled Trial

Introduction: Stroke survivors can experience various consequences that affect their physical and psychological balance. Yoga seems to be relevant for this population as it allows to work on both the body and the mind. The first objective of this study was to investigate the non-inferiority of yoga compared with conventional physical activity in improving physical function in patients with chronic post-stroke sequelae. The secondary objective was to investigate the superiority of yoga in improving the mental health of these patients. Methods: A randomized controlled trial was conducted. Thirty-six patients were randomized into two groups to practice a yoga program (YOG'AVC) or the Fitness and Mobility Exercise (FAME) program. Patients were assessed in a blinding mode pre- (T0) and post-program (T1) and 3-4 months after completion (T2). The physical assessments were the Berg Balance Scale, timed up and go test, 6-minute walk test, and quadriceps strength measured by hand-held dynamometer. Questionnaire assessments were: Activities-specific Balance Confidence Scale-Simplified, State-Trait Anxiety Inventory, Beck's Depression Inventory, and the Reintegration to Normal Living Index. Results: The YOG'AVC program was not inferior to the FAME program in improving balance, functional mobility and muscle strength. Both groups showed significant improvement (p < 0.05) between T0 and T1 in their anxiety, depression, and reintegration to normal life scores, with no significant difference between groups. Discussion: Both programs seem to be valuable in improving the physical abilities and psychological well-being of chronic post-stroke patients. However, further studies are required to confirm the difference between these programs.

Validity of the two-minute walk test to assess exercise capacity and estimate cardiorespiratory fitness in individuals after stroke: a cross-sectional study

OBJECTIVES

The purpose of this study was to investigate the construct validity of the 2-minute walk test (2MWT) to assess the exercise capacity and the criterion-concurrent validity of the 2MWT and the 6-minute walk test (6MWT) to estimate the cardiorespiratory fitness of ambulatory individuals with chronic stroke. In addition, to provide an equation to predict the distance covered in the 6MWT and another to predict the peak oxygen consumption (VO2peak) for these individuals.

METHODS

This is a cross-sectional and prospective study. A convenience sample with 57 individuals with chronic stroke was recruited. The 2MWT, the 6MWT and the cardiopulmonary exercise test (CPET) were performed in a laboratory. The Spearman's correlation coefficient was used to investigate the validity. To develop the equations, stepwise multiple linear regression analysis was used.

RESULTS

A significant correlation of very high magnitude between the distance covered in the 2MWT and the 6MWT was found (rs = 0.93; p < 0.001). A significant correlation of moderate magnitude between the distance covered in the 2MWT and the VO2peak (rs = 0.53; p < 0.001) similar to the correlation between the 6MWT and the VO2peak (rs = 0.55; p < 0,001) were found. Furthermore, an equation was developed to predict the VO2peak (R2 = 0.690; p < 0.001; VO2peak = 13.532 + 0.078*distance walked in the 2MWT +4.509*sex-0.172*age), and another to predict the distance covered in the 6MWT (R2 = 0.827; p < 0.001; MWT = -1.867 + 3.008*distance walked in the 2MWT).

CONCLUSION

2MWT showed adequate construct and concurrent validity. Furthermore, it is possible to use the prediction equations developed to estimate the VO2peak or the distance covered in the 6MWT.

The prevalence of apathy in stroke patients: A systematic review and meta-analysis

BACKGROUND

Apathy is a frequent neuropsychiatric disorder in stroke patients. However, its prevalence rates have conflicting results across studies. This meta-analysis aimed to estimate the overall prevalence of apathy in stroke patients from 1990 to 2022.

METHODS

PubMed, Web of Science, Embase and PsycINFO were systematically searched to identify relevant articles published from January 1, 1990 to October 29, 2022. Literature quality was assessed with the National Institutes of Health Study Quality Assessment Tool. The pooled prevalence, subgroup analyses and meta-regression were calculated by STATA 16.0.

RESULTS

A total of 39 observational studies involving 5168 stroke patients were eligible for this meta-analysis. The pooled prevalence of apathy in stroke patients was 33.0% (95% CI, 27.6-38.4). Subgroup analyses showed that the pooled prevalence of apathy among stroke patients was higher in Japan (36.6%), China (33.7%) and Turkey (63.5%) compared to that in other countries (30.2%). The pooled prevalence of apathy was higher in ischemic stroke samples (36.1%) than in hemorrhagic stroke samples (14.4%). The pooled prevalence of apathy measured with the Apathy Evaluation Scale (38.3%) was the highest in stroke patients. Meta-regression presented that higher literature quality was significantly associated with lower prevalence, while stroke severity, mean age and female percentage were not significantly associated with the prevalence of apathy in stroke patients.

CONCLUSION

Our findings revealed that the overall prevalence of apathy in stroke patients was 33.0% based on the current evidence. Furthermore, the prevalence was significantly correlated with countries, stroke subtypes, apathy criteria, and literature quality.

Effect of a telephone and web-based problem-solving intervention for stroke caregivers on stroke patient activities of daily living: A randomized controlled trial

OBJECTIVE

To test for effects of a problem-solving intervention for stroke caregivers on stroke survivor activities of daily living.

DESIGN

Two-arm parallel randomized clinical trial with repeated measures at 11 weeks and 19 weeks.

SETTING

Medical centers for US military Veterans.

SUBJECTS

Caregivers of stroke survivors.

INTERVENTION

A registered nurse guided caregivers in using problem-solving strategies emphasizing creative thinking, optimism, planning, and expert information to address challenges associated with caregiving. Caregivers in the intervention completed one telephone orientation session followed by eight online, asynchronous messaging center sessions. The messaging center sessions involved (a) education on the Resources and Education for Stroke Caregivers' Understanding and Empowerment website (https://www.stroke.cindrr.research.va.gov/en/), (b) supportive communication between the nurse and caregiver, (c) nurse and caregiver interactions to improve problem-solving, and (d) maintain adherence to discharge planning instructions.

MAIN OUTCOME

The Barthel Index was used to measure activities of daily living.

RESULTS

174 participants (standard care n = 88, intervention n = 86) were enrolled at baseline. There were no significant differences between groups at baseline. Change scores in activities of daily living between baseline and 11 weeks were significantly higher in the intervention group than the standard care group (group difference = 6.43, 95% confidence interval: 1.28, 11.58). Group differences in change scores between baseline and 19 weeks were not statistically significant (group difference = 3.89, 95% confidence interval: -3.58, 11.36).

CONCLUSIONS

This web-based caregiver intervention improved stroke survivor activities of daily living by 11 weeks, but intervention effects were undetectable after 19 weeks.

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.

What are the Outcomes After Primary Total Hip and Knee Arthroplasty in Patients With Prior Cerebrovascular Accidents?

BACKGROUND

For patients who have a history of cerebrovascular accident (CVA) with neurological sequelae undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), we sought to determine mortality rate, implant survivorship, complications, and clinical outcomes.

METHODS

Our total joint registry identified CVA sequelae patients undergoing primary THA (n = 42 with 25 on affected hip) and TKA (n = 56 with 34 on affected knee). Patients were 1:2 matched based upon age, sex, body mass index, and surgical year to a non-CVA cohort. Mortality and implant survivorship were evaluated via Kaplan-Meier methods. Clinical outcomes were assessed via Harris Hip scores or Knee Society scores . Mean follow-up was 5 years (range, 2-12).

RESULTS

For CVA sequelae and non-CVA patients, respectively, the 5-year patient survivorship was 69 versus 89% after THA (HR = 2.5; P = .006) and 56 versus 90% after TKA (HR = 2.4, P = .003). No significant difference was noted between groups in implant survivorship free from any reoperation after THA (P > .2) and TKA (P > .6). Postoperative CVA occurred at an equal rate in CVA sequelae and non-CVA patients after TKA (1.8%); none after THA in either group. The magnitude of change in Harris Hip scores (P = .7) and Knee Society scores (P = .7) were similar for CVA sequelae and non-CVA patients.

CONCLUSION

Complications, including the risk of postoperative CVA, implant survivorship, and outcome score improvement are similar for CVA sequelae and non-CVA patients. A 2.5-fold increased risk of death at a mean of 5 years after primary THA or TKA exist for CVA sequelae patients.

Development of the "Kalmer" relaxation intervention: co-design with stroke survivors with aphasia

PURPOSE

Anxiety is common after stroke and more prevalent in survivors with aphasia. Relaxation is an effective first-line therapy. The current study aimed to obtain the perspectives of stroke survivors with aphasia to inform the development of an accessible, technology-based, relaxation intervention.

MATERIALS AND METHODS

Qualitative co-design methods were used with twelve people with aphasia after stroke. The "Kalmer" Relaxation treatment package materials were iteratively based on participants' experiences and preferences; barriers and facilitators to treatment compliance were explored. Participants were also asked to consider how the intervention might be evaluated in a research trial.

RESULTS

A thematic analysis highlighted the importance and need for the development of an appropriate and inclusive relaxation product, to be implemented by health professionals early post-stroke. Several behavioural strategies to improve treatment adherence were recommended. Participants had varying perspectives on clinically meaningful treatment outcomes.

CONCLUSIONS

Overall, a co-designed accessible relaxation product was viewed as a necessary component of usual stroke care. Acceptability and feasibility and preliminary efficacy of the "Kalmer" intervention should be trialled in future studies. IMPLICATIONS FOR REHABILITATIONCo-designing psychological interventions for people with aphasia after stroke is needed to meet the needs of this at-risk population.Technology-based relaxation interventions to manage anxiety after stroke are viewed positively by people with aphasia and deemed acceptable and feasible.Clinical trials of these co-designed relaxation interventions are required before recommending integration into routine practice.

Evaluation of an online intervention for improving stroke survivors' health-related quality of life: A randomised controlled trial

BACKGROUND

The aim of this trial was to evaluate the effectiveness of an online health behaviour change intervention-Prevent 2nd Stroke (P2S)-at improving health-related quality of life (HRQoL) amongst stroke survivors at 6 months of follow-up.

METHODS AND FINDINGS

A prospective, blinded-endpoint randomised controlled trial, with stroke survivors as the unit of randomisation, was conducted between March 2018 and November 2019. Adult stroke survivors between 6 and 36 months post-stroke with capacity to use the intervention (determined by a score of ≥4 on the Modified Rankin Scale) and who had access and willingness to use the internet were recruited via mail-out invitations from 1 national and 1 regional stroke registry. Participants completed baseline (n = 399) and 6-month follow-up (n = 356; 89%) outcome assessments via computer-assisted telephone interviewing (CATI). At baseline the sample had an average age of 66 years (SD 12), and 65% were male. Randomisation occurred at the end of the baseline survey; CATI assessors and independent statisticians were blind to group allocation. The intervention group received remote access for a 12-week period to the online-only P2S program (n = 199; n = 28 lost at follow-up). The control group were emailed and posted a list of internet addresses of generic health websites (n = 200; n = 15 lost at follow-up). The primary outcome was HRQoL as measured by the EuroQol Visual Analogue Scale (EQ-VAS; self-rated global health); the outcome was assessed for differences between treatment groups at follow-up, adjusting for baseline measures. Secondary outcomes were HRQoL as measured by the EQ-5D (descriptive health state), diet quality, physical activity, alcohol consumption, smoking status, mood, physical functioning, and independent living. All outcomes included the variable 'stroke event (stroke/transient ischaemic attack/other)' as a covariate, and analysis was intention-to-treat. At 6 months, median EQ-VAS HRQoL score was significantly higher in the intervention group than the control group (85 vs 80, difference 5, 95% CI 0.79-9.21, p = 0.020). The results were robust to the assumption the data were missing at random; however, the results were not robust to the assumption that the difference in HRQoL between those with complete versus missing data was at least 3 points. Significantly higher proportions of people in the intervention group reported no problems with personal care (OR 2.17, 95% CI 1.05-4.48, p = 0.0359) and usual activities (OR 1.66, 95% CI 1.06-2.60, p = 0.0256) than in the control group. There were no significant differences between groups on all other secondary outcomes. The main limitation of the study is that the sample comprises mostly 'well' stroke survivors with limited to no disability.

CONCLUSIONS

The P2S online healthy lifestyle program improved stroke survivors' self-reported global ratings of HRQoL (as measured by EQ-VAS) at 6-month follow-up. Online platforms represent a promising tool to engage and support some stroke survivors.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12617001205325.

The MMT of Elbow Flexion and the AFE Predict Impairment and Disability at 3 Weeks in Patients With Acute Stroke

Objective

This study aimed to investigate whether upper extremity motor function assessment within 72 h from stroke onset can predict the functional outcomes of the upper extremity.

Design

This was a prospective, cohort study of patients with a first unilateral hemispheric stroke between May 2018 and March 2020. The motor arm item of the National Institutes of Health Stroke Scale, manual muscle testing of the elbow and forearm, and active finger extension scale were assessed within 72 h after stroke onset. The Fugl-Meyer assessment upper extremity motor score and action research arm test were assessed at discharge from the acute hospital. Multiple regression analysis was used to study predictors of upper extremity motor function at discharge from the acute hospital. The adjustment variables included age, sex, thumb localizing test, and visuospatial function.

Results

Sixty acute stroke patients were recruited. The model with the highest coefficient of determination for the Fugl-Meyer assessment upper extremity motor score at discharge was the elbow flexion model (R² = 0.76), followed by the active finger extension model (R² = 0.69). For the action research arm test, the highest model was the active finger extension model (R² = 0.64), followed by the elbow flexion model (R² = 0.63).

Conclusion

The manual muscle testing of elbow flexion and the active finger extension may be useful for predicting impairment and disability at 3 weeks in patients with acute stroke.

Adaptive sports for promoting physical activity in community-dwelling adults with stroke: A feasibility study

BACKGROUND

Despite proven health benefits of regular participation in physical activities (PA), adults with stroke fail to achieve recommended levels of PA. Sports being an enjoyable activity is more likely to encourage participation. Therefore, the objectives of the present study are i) to develop and test the feasibility of adaptive sports for promoting PA and Quality of Life (QoL) in community-dwelling adults with stroke, and ii) to explore the participants perception and experiences of playing adaptive sports.

METHODS

Two focus groups were conducted among the eight experts and a person with stroke to develop adaptive sports. To test the feasibility of these adaptive sports, in a multi methods study eighteen community dwelling adults with stroke were recruited. Participants played adaptive sports twice a week for two months in a community center. Participants pre and post intervention PA levels and QoL were measured. Participants were also interviewed at the end of the program to explore their experiences of participation in adaptive sports.

RESULTS

At the end of the program retention rate of the participants was 83.33% and there was a significant improvement in PA levels, while the improvement in QoL was not statistically significant. Participants expressed positive experience with the program. There were no adverse events during or after the participation. Health benefits, fitness, and fun were reported as facilitators, while lack of access to the sporting facility and lack of caregiver support were reported as barriers to participation.

CONCLUSION

Adaptive sports appear to be safe, feasible, and well accepted by the adults with stroke.

Survival and outcomes for stroke survivors living in care homes: a prospective cohort study

Background

Stroke survivors living in care homes require high levels of support with everyday living. The aims of this study were to describe the survival, health status and care received by stroke survivors living in care homes at 1-year post-stroke, compared with those in their own homes.

Methods

A total of 3,548 stroke survivors with a first ever stroke between 1998 and 2017 in the South London Stroke Register were identified for survival analysis. A total of 2,272 were included in the 1-year follow-up analysis. Cox regression and Kaplan–Meier plots were used to describe survival, stratified into four 5-year cohorts. Health status, medications and rehabilitation received at 1-year post-stroke were compared using descriptive statistics.

Results

Over the 20-year period, survival improved for stroke survivors discharged to their own home (P < 0.001) but not for those discharged to care homes (P = 0.75). Care home residents were highly disabled (median Barthel index: 6/20, interquartile range: 2–10). Rates of secondary stroke prevention medications at 1-year follow-up increased over time for care home residents, including antiplatelets from 12.3 to 38.1%, although still lower than for those in their own homes (56.3%). Speech and language problems were common in the care home population (40.0%), but only 16% had received speech and language therapy.

Conclusions

Rates of secondary stroke prevention prescribing increased over 20 years but remained lower in care home residents. The lower levels of rehabilitation received by stroke survivors in care homes, despite their higher levels of disability, suggest a gap in care and urgent need for restorative and/or preventative rehabilitation.

Significant Increase of Erectile Dysfunction in Men With Post-stroke: A Comprehensive Review

Men with erectile dysfunction (ED) are considered to be at risk from stroke events. Conversely, post-stroke patients are also at high risk of ED, whereas a quantitative result from all the relevant studies has not been previously addressed. Therefore, we have performed a comprehensive review and meta-analysis on this issue. This study was registered on PROSPERO (ID No. CRD42021226618). Twenty studies with a total of 3,382 stroke events were included, of which six studies were included for quantitative analysis, and the remaining 14 studies were calculated for the ratio of ED. Synthetic results from four eligible studies providing the ED cases showed that stroke patients were associated with a significantly higher risk of ED than the general population [pooled relative risk (RR) = 3.32, 95% confidence interval (CI): 1.25–8.82, P = 0.016]. Men with stroke were also found to be associated with a significant decline in International Index of Erectile Function −5 (IIEF-5) score as compared with the healthy controls [three studies, standard mean differences (SMD) = −1.8, 95% CI: −2.94 to −0.67, P = 0.002]. The prevalence of ED in post-stroke patients among 14 studies ranged from 32.1 to 77.8%, which was dramatically higher than that of the general population. The result of the GRADE-pro revealed that the quality of the evidence in this study was moderate. The present study has confirmed the high prevalence of ED in men with stroke. ED in stroke patients is a result of both neurological and psychological factors. Rehabilitative interventions rather than phosphodiesterase-5 (PDE-5) inhibitors are recommended to improve the erectile function for those survivors with ED.

Validation of a translated Chinese version of the Participation Strategies Self-Efficacy Scale: a cross-sectional study

PURPOSE

To examine the psychometric properties of a Chinese version of the Participation Strategies Self-Efficacy Scale (PS-SES) among stroke survivors.

METHODS

The PS-SES was translated into Chinese. A cross-sectional descriptive study was conducted with 336 stroke survivors recruited from the neurology departments of five hospitals in China. Reliability, concurrent validity, and construct validity of the scale were determined.

RESULTS

The Chinese version of the PS-SES (PS-SES-C) showed good internal consistency and test-retest reliability, with a Cronbach's α of 0.98 and an intraclass correlation coefficient of 0.79. There was a moderate to strong positive correlation between the PS-SES-C and Chinese version of the General Self-Efficacy Scale (r = 0.59, p < .001), positive correlations between the PS-SES-C and Chinese versions of the Modified Barthel Index (r = 0.59, p < .001), Rivermead Mobility Index (r = 0.70, p < .001), and Reintegration to Normal Living Index (r = 0.70, p < .001), and a negative correlation between the PS-SES-C and National Institutes of Health Stroke Scale (r = -0.63, p < .001). Known-group validity and factorial validity were also supported.

CONCLUSIONS

The PS-SES-C is a reliable and valid instrument for assessing self-efficacy in managing the participation of Chinese stroke survivors.Implications for rehabilitationSelf-efficacy significantly predicts activity and participation in stroke survivors and is a major outcome measure in many stroke rehabilitation programmes.The translated Chinese version of the Participation Strategies Self-efficacy Scale is a valid and reliable tool to evaluate stroke survivors' self-efficacy in managing participation.The Chinese version of the Participation Strategies Self-efficacy Scale can be used to assess stroke recovery among the Chinese population in clinical and research settings.

Grace Notes: feasibility of a manualized intervention to advance spiritual well-being for clients with acquired brain injury

Spiritual well-being appears to contribute to mental health and adaptation in adults with acquired brain injury (ABI). ABI-related interventions, including those associated with spirituality, must be specifically designed with learning-related impairments in mind. We conducted a feasibility study of a manualized intervention to support spiritual well-being after ABI called Grace Notes. The goal is to provide clients with time tested, easily accessible spiritual practices that help them experience deeper feelings of being in relationship with their Higher Power as they understand it. Findings suggest that Grace Notes can be implemented by both its developer with the context of an interdisciplinary outpatient rehabilitation program and a rehabilitation clinician as a stand-alone group. People with ABI appear to be interested in a spiritually intervention that draws from a variety of spiritual practices and traditions. Further study related to the efficacy of spiritual well-being intervention after ABI is warranted.

Development and implementation of a stroke rehabilitation integrated care pathway in an Italian no profit institution: an observational study

BACKGROUND

To standardize assessment and coordinate processes in stroke rehabilitation, an integrated care pathway (ICP) was developed in an Italian Rehabilitation and Research Institution by a knowledge-translation interdisciplinary process, from evidence-based guidelines to rehabilitation practice. The ICP was implemented in two pilot Tuscan rehabilitation Centers.

AIM

The purpose of this study was to describe ICP development and assess the ICP effects on postacute stroke inpatient rehabilitation outcomes.

DESIGN

Prospective observational study, before and after comparison.

SETTING

Two Tuscan inpatient rehabilitation centers.

POPULATION

Patients accessing either centers for intensive rehabilitation after acute stroke.

METHODS

Two cohorts were prospectively recruited before (2015-2017) and after (2018) implementation of the pathway. The primary outcome was change in activities of daily living disability, assessed by the modified Barthel Index (mBI) from admission to discharge. Secondary outcomes included length of stay (LOS), adverse outcomes, and changes in communication ability, trunk control, pain, ambulation, bladder catheter (Y/N), bedsores (Y/N).

RESULTS

In 2015-2017, 443 postacute stroke patients (mean age 77±11 years, 47% women), while in 2018, 84 patients (mean age 76±13 years, 61% women) were admitted to the two facilities. Comparing the 2018 vs. the 2015-17 cohort, the mean mBI increase was not substantially different (26 vs. 24 points), nor were LOS (37±18 vs. 36±16 days), adverse outcomes, discharge destination, and improvement of ambulation, pain, and communication (P>0.05). Instead, a significantly higher improvement of trunk control (trunk control test: 69.6±33.2 vs. 79.0±31.3, P=0.019), and a higher percentage of bedsore resolution (13% vs. 5%, P=0.033), and bladder catheter removal (37% vs. 17% P<0.001) were observed in 2018 vs. 2015-2017.

CONCLUSIONS

Compared to prior practice, ICP was associated to improvement of trunk control recovery, bladder catheter removal, and bedsores resolution. Further ICP implementation on a larger scale is needed to verify improvements of stroke inpatient rehabilitation outcomes.

CLINICAL REHABILITATION IMPACT

An evidence-based stroke rehabilitation ICP was interdisciplinary developed and implemented in two rehabilitation centers of a multicenter Italian health group. ICP implementation as to inpatient intensive postacute stroke rehabilitation was associated to improved trunk control recovery, bladder catheter removal, and bedsore resolution. Further ICP implementation will allow multicenter studies and quality benchmarking.

Effects of Combined Interventions with Aerobic Physical Exercise and Cognitive Training on Cognitive Function in Stroke Patients: A Systematic Review

(1) Background: Stroke is a major cause of permanent disability in multiple functions, including the cognitive domain. Since both cognitive training and aerobic physical exercise may exert positive effects on cognition after stroke, one may expect synergistic benefits when combining both interventions. (2) Methods: We carried out a systematic search of studies testing, in adult stroke patients, whether structured aerobic exercise combined with cognitive training led to higher cognitive benefits than either of these interventions when applied singly, or than interventions not including aerobic exercise or cognitive training. (3) Results: Five fair-quality randomized controlled trials fulfilled the search criteria. Exercise intensity was moderate-vigorous and cognitive training was mainly computer-based. The studies were heterogeneous regarding the cognitive tests used, and for this reason, a meta-analysis was not performed. Only three studies included follow-up assessment. The combined intervention was associated with pre-post improvement in at least one cognitive test in all the studies, and with higher positive effects compared to other conditions (although statistical significance was not always reached) in four studies. (4) Conclusions: Further trials including a long-term follow-up and comprehensive neuropsychological testing should be undertaken to determine whether combined aerobic exercise and cognitive training leads to additive cognitive benefits after stroke.

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.

A Systematic Review of the Incidence, Prevalence, Costs, and Activity and Work Limitations of Amputation, Osteoarthritis, Rheumatoid Arthritis, Back Pain, Multiple Sclerosis, Spinal Cord Injury, Stroke, and Traumatic Brain Injury in the United States: A 2019 Update

OBJECTIVES

To present recent evidence on the prevalence, incidence, costs, activity limitations, and work limitations of common conditions requiring rehabilitation.

DATA SOURCES

Medline (PubMed), SCOPUS, Web of Science, and the gray literature were searched for relevant articles about amputation, osteoarthritis, rheumatoid arthritis, back pain, multiple sclerosis, spinal cord injury, stroke, and traumatic brain injury.

STUDY SELECTION

Relevant articles (N=106) were included.

DATA EXTRACTION

Two investigators independently reviewed articles and selected relevant articles for inclusion. Quality grading was performed using the Methodological Evaluation of Observational Research Checklist and Newcastle-Ottawa Quality Assessment Form.

DATA SYNTHESIS

The prevalence of back pain in the past 3 months was 33.9% among community-dwelling adults, and patients with back pain contribute $365 billion in all-cause medical costs. Osteoarthritis is the next most prevalent condition (approximately 10.4%), and patients with this condition contribute $460 billion in all-cause medical costs. These 2 conditions are the most prevalent and costly (medically) of the illnesses explored in this study. Stroke follows these conditions in both prevalence (2.5%-3.7%) and medical costs ($28 billion). Other conditions may have a lower prevalence but are associated with relatively higher per capita effects.

CONCLUSIONS

Consistent with previous findings, back pain and osteoarthritis are the most prevalent conditions with high aggregate medical costs. By contrast, other conditions have a lower prevalence or cost but relatively higher per capita costs and effects on activity and work. The data are extremely heterogeneous, which makes anything beyond broad comparisons challenging. Additional information is needed to determine the relative impact of each condition.

Depression impedes neuroplasticity and quality of life after stroke

Background and Purpose:

Depression following a stroke/poststroke depression (PSD) has been newly recognized as one of the most common complications after stroke. PSD may affect neuroplasticity and quality of life. The purpose of present study was to find out effects of depression on functional recovery, quality of life and neuroplasticity in patients with acute stroke.

Methods:

A total of 76 cases were recruited for the study and out of which 44 were available for the analysis after six months. Patients were divided into three groups according to severity of depression: Group A (without depression), Group B (mild-to-moderate depression), and Group C (severe depression) on the basis of Patient Health Questionnaire-9 (PHQ-9) scale scores. All patients were assessed for depression by PHQ-9, and for quality of life by Stroke Specific Quality of Life (SSQOL) scale. Neuroplasticity was assessed by measuring levels of serum brain-derived neurotrophic factor.

Results:

Quality of life was observed to be significantly affected by depression (P ≤ 0.05). The most commonly affected characteristics were energy, family roles, mobility, self-care, social roles, upper extremity function, and work productivity. Serum BDNF levels were also affected significantly by depression (P ≤ 0.05).

Conclusion:

PSD is a serious complication, affecting quality of life and neuroplasticity (BDNF) in patients. Decreased neuroplasticity further may affect functional improvement.

Understanding End-of-Life Preferences: Predicting Life-Prolonging Treatment Preferences Among Community-Dwelling Older Americans

OBJECTIVES

To determine how demographic, socioeconomic, health, and psychosocial factors predict preferences to accept life-prolonging treatments (LPTs) at the end of life (EOL).

METHODS

This is a retrospective cohort study of a nationally representative sample of community-dwelling older Americans (N = 1648). Acceptance of LPT was defined as wanting to receive all LPTs in the hypothetical event of severe disability or severe chronic pain at the EOL. Participants with a durable power of attorney, living will, or who discussed EOL with family were determined to have expressed their EOL preferences. The primary analysis used survey-weighted logistic regression to measure the association between older adult characteristics and acceptance of LPT. Secondarily, the associations between LPT preferences and health outcomes were measured using regression models.

RESULTS

Approximately 31% of older adults would accept LPT. Nonwhite race/ethnicity (odds ratio [OR] 0.54; 95% CI 0.41, 0.70; white vs. nonwhite), self-realization (OR 1.34; 95% CI 1.01, 1.79), attendance of religious services (OR 1.44; 95% CI 1.07, 1.94), and expression of preferences (OR 0.54; 95% CI 0.40, 0.72) were associated with acceptance of LPT. LPT preferences were not independently associated with mortality or disability.

CONCLUSIONS

Approximately one-third of older Americans would accept LPT in the setting of severe disability or severe chronic pain at the EOL. Adults who discussed their EOL preferences were more likely to reject LPT. Conversely, minorities were more likely to accept LPT. Sociodemographics, physical capacity, and health status were poor predictors of acceptance of LPT. A better understanding of the complexities of LPT preferences is important to ensuring patient-centered care.

Impact of post-stroke disability and disability-perception on health-related quality of life of stroke survivors: the moderating effect of disability-severity

OBJECTIVE

The influence of disability-perception on health-related quality of life (HRQoL) remains unclear. This study investigated impact of disability and disability-perception on HRQoL of stroke survivors and explores the moderating effect of disability-severity.

METHODS

Post-stroke disability, disability-perception/acceptance and HRQoL were assessed in 102 stroke survivors using the World Health Organisation Disability Assessment Schedule, Attitudes towards Disabled Persons Form-A and Short Form-36, respectively.

RESULTS

There was significant disability score of at least 42 in the participants with severe disability accounting for 76.5% while 52% of them having positive disability-perception. Although no sex difference exists in their HRQoL, their score was just fair (46.1 ± 1.9) with their physical health being most affected. Severe disability impacted negatively on their HRQoL but disability-perception had no significant effect except in 'role limitation due to the emotional problem' domain. Only severe disability moderated the effects of disability on the overall HRQoL (R ² change = 3.2%; p = 0.018). Disability-severity (mild/moderate and severe disability) moderated the effects of disability level on their physical health (R ² change = 3.1% and 6%; p = 0.012 and 0.0001, respectively).

CONCLUSION

Significant disability exists among stroke survivors and impaired their HRQoL while disability-severity moderating the effect. More stroke survivors have positive attitude towards their disability and impact positively on their physical health.

Assessing environmental barriers by means of the swedish craig hospital inventory of environmental factors among people post-stroke

BACKGROUND

When occupational therapists address environmental barriers to occupational engagement, some barriers might not be possible to reduce for single individuals, because decisions have to be taken at community or societal level, for example changes in public transport. Investigating environmental barriers by means of the Swedish Craig Hospital Inventory of Environmental Factors (CHIEF-S) may increase our understanding of the environmental impact on occupation engagement and the methodological challenges to assess environmental barriers.

AIMS

To investigate and describe the magnitude of encountered environmental barriers in a group of people post-stroke and to assess psychometric properties of the CHIEF-S.

MATERIAL AND METHODS

In total, 34 participants, who had sustained a stroke in Sweden were recruited.

RESULTS

The participants reported in average 2,7 barriers and the total frequency-magnitude score of barriers (CHIEF-S score) was 0.45. The Cronbach's α for the total CHIEF-S was 0.80 and the analysis of test-retest reliability revealed ICC = 0.86. The entire instrument demonstrated better psychometric properties than the single sub-scales.

CONCLUSION

In this study, the frequency-magnitude of environmental barriers encountered by people post-stroke are reported at a group level and adds information to the cumulative knowledge generation on perceived environmental barriers in the society. However, to inform which interventions are needed at a more detailed level, other data collection methods have to be added.

Clustering of functioning and disability profile based on the WHO disability assessment schedule 2.0 - a nationwide databank study

Objective: To compare and cluster the health status and disability restrictions associated with eight major physiological functions of body systems, using functioning domains of WHO Disability Assessment Schedule 2.0.Design: Retrospective analyses of a nation-wide disability database.Setting: Population-based study.Participants: Records from patients >18 years of age with disability were obtained from the Taiwan Data Bank of Persons with Disability (July 2012-November 2017). Disability functioning profile of the following diagnosis were analyzed: stroke, schizophrenia, hearing loss, liver cirrhosis, chronic kidney disease, congestive heart failure, burn, head and neck cancer.Interventions: Not applicable.Main Outcome Measures: Demographic data, severity of impairment, and Disability Assessment Scale scores were obtained and analyzed. Radar charts were constructed using the WHO Disability Assessment Schedule 2.0. functioning domain score. Degree of similarity between any two given diagnosis was assessed by cluster analysis, comparing the Euclidean distances between radar chart data points among the six domains.Results: Based on cluster analysis of similarities between functioning domain profiles, the eight diagnoses were grouped into different disability clusters. Four clusters of disability were named according to the type restriction patterns: global-impact cluster (stroke); interaction-restriction cluster (schizophrenia, hearing loss); physical-limitation cluster, (liver cirrhosis, CKD, and congestive heart failure); and specific-impact cluster (burn, head and neck cancer). The rates of institutionalization and unemployment differed between the four clusters.Conclusion: We converted WHO Disability Assessment Schedule 2.0. functioning domain scores into six-dimensioned radar chart, and demonstrate disability restrictions can be further categorized into clusters according to similarity of functioning impairment. Understanding of disease-related disabilities provides an important basis for designing rehabilitation programs and policies on social welfare and health that reflect the daily-living needs of people according to diagnosis.Implication for RehabilitationThe use of radar charts provided a direct visualization of the scope and severity of disabilities associated with specific diagnoses.Diagnosis-related disabilities can be organized into clusters based on similarities in WHODAS 2.0 disability domain profiles.Knowledge of the characteristics of disability clusters is important to understand disease-related disabilities and provide a basis for designing rehabilitation.

Cardiopulmonary exercise testing and aerobic treadmill training after stroke: Feasibility of a controlled trial

PURPOSE

To investigate the feasibility and safety of a randomized controlled trial that performed cardiopulmonary exercise testing and 12 weeks of aerobic treadmill training in individuals in the chronic phase after stroke.

METHODS

The following data were recorded: number of individuals contacted to participate, that attended in the evaluation session, and that were included (recruited) in the study; retention, attendance and adherence rates; reasons for exclusion, withdrawal, non-attendance and non-completing exercise; adverse events.

RESULTS

From 230 individuals that were contacted, 39 (17%) attended the evaluation session and 22 (9.6%) were recruited in the study, 11 in each group (control and experimental). The main source of recruitment was other research projects (43.5%). The main reason for exclusion was unavailability (22%). Six out of 39 individuals (15.4%) that attended in the evaluation session were not able to perform the cardiopulmonary exercise testing. All subjects included showed a respiratory exchange ratio ≥1.0 (considered as maximal effort in the CPET). Retention rate was 81% and the main reason of withdrawal was unavailability (75%). The overall attendance rate was 88% and the main reason for non-attendance was illness/sickness (20.8%). The adherence rate was 99% and the reasons for non-completing sessions were illness/sickness (60%) or delay (40%). No serious adverse events occurred.

CONCLUSION

Recruitment rate was low, retention rate was moderate, attendance and adherence rates were high. No serious adverse events occurred. It was feasible and safe to execute a randomized clinical trial that performed cardiopulmonary exercise testing and 12 weeks of aerobic treadmill training.

The addition of the MEP amplitude of finger extension muscles to clinical predictors of hand function after stroke: A prospective cohort study

BACKGROUND

Within the first 72 hours after stroke, active finger extension is a strong predictor of long-term dexterity. Transcranial magnetic stimulation may add prognostic value to clinical assessment, which is especially relevant for patients unable to follow instructions.

OBJECTIVE

The current prospective cohort study aims at determining whether amplitude of motor evoked potentials of the extensor digitorum communis (EDC) can improve clinical prediction after stroke when added to clinical tests.

METHODS

the amplitude of motor evoked potentials of the affected EDC muscle at rest was measured in 18 participants within 4 weeks after stroke, as were the ability to perform finger extension and the Fugl-Meyer Motor Assessment of the upper extremity (FMA_UE). These three determinants were related to the FMA_UE at 26 weeks after stroke (FMA_UE26), both directly, and via the proportional recovery prediction model. The relation between amplitude of the motor evoked potentials and FMA_UE26 was evaluated for EDC. For comparison, also the MEP amplitudes of biceps brachii and adductor digiti minimi muscles were recorded.

RESULTS

Patients' ability to voluntarily extend the fingers was strongly related to FMA_UE26, in our cohort there were no false negative results for this predictor. Our data revealed that the relation between amplitude of motor evoked potential of EDC and FMA_UE26 was significant, but moderate (rs = 0.58) without added clinical value. The other tested muscles did not correlate significantly to FMA_UE26.

CONCLUSIONS

Our study demonstrates no additional value of motor evoked potential amplitude of the affected EDC muscle to the clinical test of finger extension, the latter being more strongly related to FMA_UE26.

Pooled cohort risk equation and subclinical cerebrovascular diseases

BACKGROUND AND PURPOSE

In 2013, the American College of Cardiology/American Heart Association (ACC/AHA) introduced a novel pooled cohort risk (PCR) model for atherosclerotic cardiovascular disease. In this study, we evaluated the relationship between the PCR score and cerebral large- and small-vessel diseases (cLVD and cSVD) in a healthy population, METHODS: We assessed consecutive health check-up volunteers from 2006 to 2013. We calculated the estimated 10-year atherosclerotic cardiovascular disease risk as the PCR score based on the 2013 ACC/AHA guidelines. We evaluated both cSVD/cLVD, including the prevalence of cLVD, lacunes and cerebral microbleed (CMB), and the volume of white matter hyperintensity (WMH). In addition to PCR score, the risk factors that were associated with outcome variables at P < 0.10 in univariate analysis were included for further multivariable linear or regression analyses.

RESULTS

A total of 2720 participants were evaluated (mean age, 57 years, male sex, 54%). In multivariable analysis, PCR score was associated with WMH volume [β = 0.361; 95% confidence interval (CI), 0.320-0.402, P < 0.001], cLVD [adjusted odds ratio (aOR), 1.66; 95% CI, 1.29-2.16, P < 0.001], lacunes (aOR, 1.80; 95% CI, 1.52-2.14, P < 0.001) and CMBs (aOR, 1.75; 95% CI, 1.40-2.19, P < 0.001). Furthermore, PCR score also showed dose-response tendencies according to the burden of cLVD, WMH, lacunes and CMB.

CONCLUSIONS

A higher PCR score based on the ACC/AHA guidelines is closely associated with a higher prevalence and burden of cLVD and cSVD.

Home program practices for supporting and measuring adherence in post-stroke rehabilitation: a scoping review

BACKGROUND

After stroke, individuals face a variety of impairments that impact function. Increasingly, rehabilitation for these impairments has moved into the community and home settings through the use of home programs. However, adherence to these programs is often low, limiting effectiveness.

OBJECTIVE

This scoping review investigated home program implementation and measurement of adherence with persons post-stroke to identify commonly reported practices and determine areas for further research.

METHODS

The electronic databases of PubMed, CINAHL, Scopus, Cochrane Database of Systematic Reviews, and PEDro were searched. Studies focused on post-stroke rehabilitation with an independent home program were selected. Qualitative studies, commentaries, and single-case studies were excluded. Title and abstract screenings were completed by two reviewers with a third for tie-breaking. The full-text review was completed by two reviewers using consensus to resolve any differences. Of the 1,197 articles initially found only 6% (n = 70) met criteria for data extraction. Elements for data extraction included: type of study, area of intervention, description of home program, presence of strategies to support adherence, methods to measure adherence and reported adherence.

RESULTS

Most commonly reported strategies to support home practice were the use of technology, personalization, and written directions. Only 20 studies reported achieving adherence at or greater than 75% and 18 studies did not report adherence outcomes.

CONCLUSIONS

Future investigations that directly compare and identify the most effective strategies to support adherence to home programs for this population are warranted. The implementation of guidelines for reporting adherence to home programs is recommended.

Clinical Validation of Nursing Diagnoses Related to Self-Care Deficits in Patients with Stroke

To clinically validate the defining characteristics of nursing diagnoses related to self-care deficits in feeding, bathing, toileting, and dressing in patients with stroke. A diagnostic accuracy study was conducted with a sample of 135 patients with stroke. Sensitivity and specificity were calculated based on the latent class analysis method using the random effects model. The prevalence of diagnoses was 23.5% for Bathing self-care deficit, 18.5% for Dressing self-care deficit, 13.3% for Toileting self-care deficit, and 7.5% for Feeding self-care deficit. Fourteen defining characteristics were sensitive, and 17 were specific. Hemorrhagic stroke and note 4 on the Rankin scale was associated with self-care deficits. Of the 37 defining characteristics of the four diagnoses studied, 19 were clinically validated according to the latent class analysis model. These most accurate clinical indicators contribute to the development of the care plan for patients with stroke.

Impaired Cognitive Performance in Endothelial Nitric Oxide Synthase Knockout Mice After Ischemic Stroke: A Pilot Study

OBJECTIVES

Cognitive dysfunction and dementia are common following ischemic stroke. Endothelial nitric oxide synthase (eNOS) has been found to play an important role in neurologic function and cognition. The purpose of the present study was to assess the specific role of eNOS in cognitive performance after stroke.

DESIGN

Male wild-type and mice lacking eNOS (eNOS) underwent middle cerebral artery occlusion or sham-surgery. Primary outcomes were repeated measures of neurologic score, limb asymmetry, sensory/motor function, and spatial memory/learning assessed at intervals up to 28 days postsurgery. Group differences in brain microglia activation and infiltration and levels of interferon-gamma were examined.

RESULTS

There was no genotype × surgery interaction effect on the pattern of change in neurologic score, limb asymmetry, or sensory motor function across the 28 days postsurgery. In the Morris water maze, eNOS-/- middle cerebral artery occlusion mice displayed learning and memory deficits not evident in wild-type middle cerebral artery occlusion mice. Poorer spatial memory and learning in eNOS-/- middle cerebral artery occlusion mice was associated with a reduction in the number of activated microglia in the striatum on the lesion side and decreased brain tissue levels of interferon-gamma.

CONCLUSIONS

This study's data support a role for eNOS in cognitive performance after stroke. This finding may lead to the development of novel interventions to treat poststroke cognitive deficits.

[Multimorbidity profile associated with disability among the elderly living in the Metropolitan Region of Belo Horizonte, Brazil]

The scope of this paper was to investigate the associations of disability in three domains (BADL, IADL and mobility) with cardiovascular diseases, diabetes and multimorbidity profile, among the elderly living in the Metropolitan Region of Belo Horizonte (MRBH). A cross-sectional study was conducted with a representative sample of 2,172 elderly persons (60 years and over). Disability, for each domain (BADL, IADL and mobility), was assessed as reporting great difficulty or need for help to perform at least one activity among those investigated, and self-reported diseases included arterial hypertension, myocardial infarction or angina, stroke, diabetes, and combinations of these diseases. Adjusted Poisson regression was used, and the attributable population fraction was also estimated. A major contribution of Cerebral Vascular Accidents (strokes) to disability in all domains was observed, especially BADLs, as well as the presence of infarction or angina in disability in IADLs and mobility, especially when combined with diabetes and hypertension. The multimorbidity profile can be used to identify vulnerable groups, which should be the target of prevention and rehabilitation, reducing the financial and social cost of this event among the elderly.

A controlled study analyzing the temporal activity patterns of individuals with stroke compared to healthy adults

Introduction

The understanding of the temporal pattern of individuals can add a wider perspective to interventions. Therefore, the present study is aimed toward analysis of the temporal activity pattern of individuals with stroke compared to healthy adults.

Method

This study is a prospective, case–control, analytic research study. The study sample comprised 50 individuals with stroke and 50 individuals without disease, for 80% power with a 5% type 1 error. The Modified Occupational Questionnaire was administered to assess the temporal activity pattern. Individuals identified the activities performed at each hour of the day and data was analyzed.

Results

The temporal activity pattern of individuals with stroke differed from healthy controls; education and play activities were not part of stroke participants’ daily routines. Also, participation in work, leisure and social participation activities was significantly different for people with stroke compared to healthy controls ( p < 0.01 ). The study group assigned very low values to the activities; the value perceived by individuals differed significantly between groups ( p < 0.01 ).

Conclusion

Clinicians are in a position to enable individuals’ time use and help to engage them in meaningful activity. Individuals with stroke may benefit from a program focusing on the temporal aspect of activities.

Development of a novel positive psychology-based intervention for couples post-stroke

OBJECTIVE

Stroke provides challenges for survivors and partner caregivers. Stroke survivors and caregivers are interconnected in their emotional health, including depression, a common stroke sequelae. The purpose of this study was to develop and test the feasibility of a dyadic positive psychology-based intervention (PPI) for couples coping poststroke.

DESIGN

Community-dwelling couples consisted of 1 partner who had a stroke ≥6 months ago and a cohabiting partner caregiver. One or both partner(s) had to report depressive symptoms. The PPI consisted of 1 brief face-to-face training session and an 8-week self-administered intervention in which participants were instructed to engage in at least 2 activities alone and 2 together each week. Two dyads were randomly assigned to a waitlist control to test feasibility of this process. Baseline, postintervention, and 3-month follow-up assessments and post-program feedback were obtained. Descriptive statistics were used to analyze sample characteristics, recruitment and retention rates, adherence, key pre- and postintervention outcomes, and satisfaction with the intervention.

RESULTS

Eleven of 20 couples responding to recruitment letters were enrolled in the study. Ten of 11 dyads completed the program. All participants engaged in activities for at least 6 of 8 weeks. Feedback data indicated participant satisfaction with the intervention, and key outcome measures demonstrated adequate variability.

CONCLUSIONS

The self-administered dyadic PPI is feasible for implementation with couples poststroke. The PPI represents a first step in a novel dyadic approach in this population. Recruitment, enrollment and attrition rates, and feedback will be used to inform a larger randomized trial. (PsycINFO Database Record

Functional and cognitive variables predicting successful use of chopsticks or a spoon by the paretic upper extremity in patients following stroke: a cross-sectional study

BACKGROUND

The factors necessary for successful use of chopsticks or a spoon, by patients with a paretic upper extremity (UE) following stroke are unknown.

OBJECTIVES

We identified the functional capacities and interactions related to chopsticks or spoon use in patients with right hemiplegia following stroke.

METHODS

Participants were 139 stroke patients with right hemiplegia who required rehabilitation, divided into the following three categories: able to use chopsticks, able to use a spoon, or unable to use a spoon. We collected sociodemographic data, medical data, physical and cognitive function data, and functional grades associated with chopsticks or spoon use by the paretic dominant UE while eating. We identified a complex interaction of variables relating to functional use of chopsticks or a spoon using a classification and regression tree analytic process.

RESULTS

Patients with UE Brunnstrom recovery stage (BRS) >IV, and a Hasegawa Dementia Scale - Revised (HDS-R) score >16 had a 91.3% probability of being able to use chopsticks. Moreover, patients with a UE BRS of >IV, and the HDS-R score ≤16 had a 66.7% probability of being able to use a spoon. By contrast, patients with a UE BRS of ≤IV had a 90.5% probability of not being able to use a spoon.

CONCLUSIONS

The interaction of BRS as a measure of UE function and HDS-R score as a measure of cognitive function affect the ability of patients with stroke histories to functionally use the paretic UE to operate chopsticks or a spoon.

Effects of aerobic training on physical activity in people with stroke: protocol for a randomized controlled trial

BACKGROUND

Post-stroke physical inactivity is explained by several factors related to the stroke, which have been suggested as the causes and consequences of functional declines and health problems. Therefore, it is important to increase physical activity levels and reduce the time spent in low-energy expenditure activities after a stroke. Since the maintenance of cardiorespiratory fitness is a significant predictor of physical activity levels post-stroke, it may be important to investigate whether aerobic training is effective in increasing physical activity levels and reducing the time spent in low-energy expenditure activities in this population. The efficacy of aerobic training on these variables is not well known. The primary objective of this trial will be to investigate the effects of aerobic treadmill training on physical activity levels and on time spent in low-energy expenditure activities in people with stroke. The secondary aim will be to evaluate the effects of the training on cardiorespiratory fitness, endurance, depression, mobility, quality of life, and participation.

METHODS/DESIGN

A randomized controlled trial, with blinded assessments, will be performed in a community-based setting. Altogether, 22 adults with a diagnosis of stroke (>6 months) who are sedentary or insufficiently active will be included. Participants will be randomly assigned to either: (1) aerobic treadmill training (experimental group, at 60-80% of their heart rate reserve) or (2) walking outside (control group, below 40% of heart rate reserve). Both groups will attend 40-min training sessions, three times per week over 12 weeks, in groups of two to four participants, with a trained physiotherapist. Primary outcomes are physical activity levels and time spent in low-energy expenditure activities (Multi-sensor SenseWear Mini® and Human Activity Profile). Secondary outcomes are cardiorespiratory fitness (peak oxygen uptake VO2peak and ventilatory threshold), endurance, depression, mobility, quality of life, and participation. The effects of the training will be analyzed from the collected data using intention to treat. Between-group differences will be measured by two-way repeated measures ANOVA, considering the baseline, post-training, and 4-week follow-up.

DISCUSSION

The results of this trial will likely provide valuable new information on the effects of aerobic treadmill training on physical activity levels and on time spent in low-energy expenditure activities of individuals with stroke, through changes in cardiorespiratory fitness.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02798237 . Registered on 13 June 2016.

Excitatory Repetitive Transcranial Magnetic Stimulation Induces Contralesional Cortico-Cerebellar Pathways After Acute Ischemic Stroke: A Preliminary DTI Study

Background: Repetitive transcranial magnetic stimulation (rTMS) is proved to be effective in facilitating stroke recovery. However, its therapeutic mechanism remains unclear. The present study aimed to investigate changes in white matter fractional anisotropy (FA) after excitatory rTMS to better understand its role in motor rehabilitation.

Materials and Methods: Acute stroke patients with unilateral subcortical infarction in the middle cerebral artery territory were recruited. The patients were randomly divided into an rTMS treatment group and a sham group. The treatment group received a 10-day 5 HZ rTMS applied over the ipsilesional primary motor area beginning at about 4 days after stroke onset. The sham group received sham rTMS. Diffusion tensor imaging (DTI) data were collected in every patient before and after the rTMS or sham rTMS. Voxel-based analysis was used to study the difference in FA between the two groups. The trial of this article has been registered on the ClinicalTrials.gov and the identifier is NCT03163758.

Results: Before the rTMS, there is no significant difference in FA between the two groups. Differently, after the treatment, the rTMS group showed increased FA in the contralesional corticospinal tract, the pontine crossing tract, the middle cerebellar peduncle, the contralesional superior cerebellar peduncle, the contralesional medial lemniscus, and the ipsilesional inferior cerebellar peduncle. These fasciculi comprise the cortex-pontine-cerebellum-cortex loop. Increased FA was also found in the body of corpus callosum and the contralesional cingulum of the treatment group compared with the sham.

Conclusion: The greater connectivity of contralesional cortico-cerebellar loop and the strengthening of interhemispheric connection may reflect contralesional compensation facilitated by the excitatory rTMS, which gives us a clue to understand the therapeutic mechanism of rTMS.

Employment sustainability after return to work among Japanese stroke survivors

Purpose

Few studies have investigated the work continuance rate among stroke survivors who return to work (RTW). The objective of this study was to investigate work sustainability after RTW and the causes of recurrent sickness absence (RSA) among Japanese stroke survivors.

Methods

Data on stroke survivors were collected from an occupational health register. The inclusion criteria were as follows: employees who were aged 15–60 years old and returned to work after an episode of sick leave due to a clinically certified stroke that was diagnosed during the period from 1 January 2000 through 31 December 2011.

Results

284 employees returned to work after their first episode of stroke-induced sick leave. The work continuance rate for all subjects was 78.8 and 59.0% at one and 5 years after the subjects’ RTW, respectively. After returning to work, the subjects worked for a mean of 7.0 years. Of 284 employees who returned to work, 86 (30.3%) experienced RSA. The RSA were caused by recurrent strokes in 57.0% (49/86) of cases, mental disorders in 20.9% (18/86) of cases, and fractures (often due to accidents involving steps at train stations or the subject’s home) in 10.5% (9/86) of cases. 21 employees resigned after returning to work. The resignation rates at 1 and 5 years were 4.9 and 7.6%, respectively. According to the multivariate analysis including all variables, the subjects in the ≥ 50 year group were at greater risk of work discontinuation than the ≤ 49 year (reference) age group (HR: 2.26, 95% CI 1.39–3.68).

Conclusions

Occupational health professionals need to provide better RTW support to stroke survivors and should pay particularly close attention to preventing recurrent strokes, mental disorders, and fractures.

Exosomes in Acquired Neurological Disorders: New Insights into Pathophysiology and Treatment

Exosomes are endogenous nanovesicles that play critical roles in intercellular signaling by conveying functional genetic information and proteins between cells. Exosomes readily cross the blood-brain barrier and have promise as therapeutic delivery vehicles that have the potential to specifically deliver molecules to the central nervous system (CNS). This unique feature also makes exosomes attractive as biomarkers in diagnostics, prognostics, and therapeutics in the context of multiple significant public health conditions, including acquired neurological disorders. The purpose of this review is to summarize the state of the science surrounding the relevance of extracellular vesicles (EVs), particularly exosomes, to acquire neurological disorders, specifically traumatic brain injury (TBI), spinal cord injury (SCI), and ischemic stroke. In total, ten research articles were identified that examined exosomes in the context of TBI, SCI, or stroke; these manuscripts were reviewed and synthesized to further understand the current role of exosomes in the context of acquired neurological disorders. Of the ten published studies, four focused exclusively on TBI, one on both TBI and SCI, and five on ischemic stroke; notably, eight of the ten studies were limited to pre-clinical samples. The present review is the first to discuss the current body of knowledge surrounding the role of exosomes in the pathophysiology, diagnosis, and prognosis, as well as promising therapeutic strategies in TBI, SCI, and stroke research.

Informal caregiving burden and perceived social support in an acute stroke care facility

Background

Providing informal caregiving in the acute in-patient and post-hospital discharge phases places enormous burden on the caregivers who often require some form of social support. However, it appears there are few published studies about informal caregiving in the acute in-patient phase of individuals with stroke particularly in poor-resource countries. This study was designed to evaluate the prevalence of caregiving burden and its association with patient and caregiver-related variables and also level of perceived social support in a sample of informal caregivers of stroke survivors at an acute stroke-care facility in Nigeria.

Methods

Ethical approval was sought and obtained. Fifty-six (21 males, 35 females) consecutively recruited informal caregivers of stroke survivors at the medical ward of a tertiary health facility in South-Southern Nigeria participated in this cross-sectional survey. Participants’ level of care-giving strain/burden and perceived social support were assessed using the Caregiver Strain Index and the Multidimensional Scale of Perceived Social Support respectively. Caregivers’ and stroke survivors’ socio-demographics were also obtained. Data was analysed using frequency count and percentages, independent t-test, analysis of variance (ANOVA) and partial correlation at α =0.05.

Results

The prevalence of care-giving burden among caregivers is 96.7% with a high level of strain while 17.9% perceived social support as low. No significant association was found between caregiver burden and any of the caregiver- or survivor-related socio-demographics aside primary level education. Only the family domain of the Multidimensional Scale of Perceived Social Support was significantly correlated with burden (r = − 0.295).

Conclusion

Informal care-giving burden was highly prevalent in this acute stroke caregiver sample and about one in every five of these caregivers rated social support low. This is a single center study. Healthcare managers and professionals in acute care facilities should device strategies to minimize caregiver burden and these may include family education and involvement.

Critical points in the experience of spouse caregivers of patients who have suffered a stroke. A phenomenological interpretive study

AIMS

To explore and document the experiences and values of spouse caregivers of stroke survivors. To gain more in-depth knowledge of how the act of caring and the adaption process affects caregiving spouses.

MATERIALS AND METHODS

Phenomenological, qualitative study. This study included spouses of stroke survivors who also served as primary caregivers. Individual, semi-structured, in-depth interviews were conducted, transcribed, and analysed using a thematic content analysis as proposed by Giorgi. Data was analysed and managed using Atlas-ti (version 7.0). This study was approved by our institution´s Complejo Hospitalario de Caceres Ethics and Research Committee.

RESULTS

Spouse caregivers of stroke survivors undergo a process of disruption in their private lives and relationships, marked by their caregiving duties. The experiences of spouses caring for stroke survivors is condensed into topics and subtopics: "Caregiving and that´s all" summarizes the sense of having no life horizons and also caregiver impossibility of moving away from caring role. Otherwise, "Breaking the couple´s life together" enlightens the further consequences of stroke in couples shared live biography, which needs to be understood and rebuilt. Finally, "Going through the (non) loss alone" alludes to how spouses reinterpret meaning of loss, which is not appreciated by others and that refers to the balance between stroke survival and any acquired global disability.

CONCLUSIONS

A comprehensive approach to the couple (family), from a psycho-socio-emotional and relational perspective, is essential for ensuring adequate quality of life for people who suffered a stroke as well as their caregivers. Spouses-caregivers must be considered as individuals living a transition process due to their unexpected disrupting change, which nurses should address through a comprehensive and integrated approach focused on transition care. Care resources must be adapted to the interpretation that the spouses have of their caregiving role and their relationship with the different components of the caregiving process.

Needs and rights awareness of stroke survivors and caregivers: a cross-sectional, single-centre questionnaire survey

OBJECTIVES

The needs and rights awareness of stroke survivors have not been reported in China. This study investigated the needs and rights awareness of stroke survivors and caregivers in Tianjin, China.

SETTING

A survey launched by the World Stroke Organization was conducted in Tianjin, China. The questionnaire included demands for psychological support, treatment and care, social support and information. Stroke survivors and their caregivers were interviewed face to face for the questionnaire. Between June 2014 and February 2015, stroke survivors were invited to participate if they were more than 18 years old and had experienced a stroke. Exclusion criteria were patients who had disorders of consciousness, significant cognitive impairment, aphasia, communication difficulties or psychiatric disorders. Only caregivers who were family members of the patients were chosen. Paid caregivers were excluded.

PARTICIPANTS

Two hundred and forty-eight stroke survivors and 212 caregivers were enrolled.

PRIMARY OUTCOME MEASURES

The correlations between levels of needs and potential effect factors were analysed. Levels of different needs were compared by age, gender and time since stroke.

RESULTS

Among the cohort, 95.6% stroke survivors and 92.5% caregivers agreed to each question in the questionnaire. The participants prioritised the needs for psychological support (99.4%), treatment and care (98.6%), social support (98%) and information (96.2%). The total score was negatively correlated with age (r=-0.255, p<0.01). Patients below 65 years old had higher scores than those 65 years or older (p<0.01), while male patients had higher scores than female patients (p<0.01).

CONCLUSIONS

The needs for psychological and emotional support, individual treatment, social support and information about stroke were eagerly reported by most survivors. The Bill of Rights must be recognised by the Chinese society, providing appropriate stroke care to every patient to optimise stroke outcomes.

Activity limitations and subjective well-being after stroke

OBJECTIVE

As limitations in activities of daily living are major components of many stroke outcome scales, we examined how well activity limitations predicted subjective well-being among stroke survivors in a nationally representative survey.

METHODS

Individuals with a self-reported history of stroke were identified from the National Health and Aging Trends Study. Subjective well-being (primary outcome) was assessed with a validated 7-item measure (higher = greater well-being) assessing emotions (cheerful, bored, full of life, and upset) and self-realization (purpose in life, self-acceptance, and environmental mastery). Activity limitations were defined by the receipt of help in any of 11 activities of daily living/instrumental activities of daily living. Multivariable linear regression assessed predictors of well-being including medical, physical, cognitive, psychological, and environmental factors.

RESULTS

A total of 738 stroke survivors age 65 or older were included (57% female, 9% African American, 6% Hispanic). Activity limitations were modestly associated with well-being after adjusting for demographic characteristics and availability of assistance (estimate -0.49, 95% confidence interval -0.61 to -0.37). However, in the fully adjusted model (R2 = 0.28), neither activity limitations nor physical capacity was associated with subjective well-being. Predictors of lower well-being in the final model included depressive symptoms, chewing/swallowing problems, pain that limited activity, and restricted participation in valued life activities. Income and executive function were modestly associated with improved well-being, while comorbidities and communication technology access were not associated.

CONCLUSIONS

Activity limitations were not associated with stroke survivors' subjective well-being after adjustment for other factors. While some predictors of well-being after stroke were identified, the determinants of well-being remained largely unexplained.

Promoting Physical Activity and Nutrition in People With Stroke

The prevalence of cardiovascular disease, diabetes, and obesity is high in people with stroke. Risk factors for these conditions include hypertension, high cholesterol, and physical inactivity. These risk factors are common in people with stroke and often go unmanaged. Engagement in healthy behaviors is important for managing and preventing these risk factors and comorbid conditions. More specifically, physical activity and nutrition are key health behaviors for the management and maintenance of health in people with stroke. These health behaviors, by their very nature, are also occupations; thus, they are influenced by client factors, performance skills and patterns, and environments and contexts. This article discusses physical activity and nutrition within the context of the Occupational Therapy Practice Framework: Domain and Process and proposes potential roles for occupational therapy practitioners and researchers in developing, testing, and providing physical activity and nutrition interventions for people with stroke.