Consulting Service Users: The Stroke Association Home Therapy Project

In 1999, the Stroke Association set up a project to promote home-based occupational therapy for patients who had had a stroke and been discharged home from hospital. As part of the service evaluation, focus groups for service users and carers were set up in two of the sites to consult users about the changes in their quality of life during the period of the home therapy. A total of 11 service users and 9 carers attended the groups, representing 30% of the service users and 27% of the carers involved in the project. The group discussion was taped and transcribed and then analysed using a framework approach.

The group members described their personal experiences of recovery from and limitations after the stroke and reported improvements in life issues during the period of their home therapy. The content and organisation of the service and the relationships with project staff were felt to influence the effectiveness of the occupational therapy. Other issues that affected the perceived outcome for the service users included individual choice, age, stroke consequences, other rehabilitation and community services and social limitations. This consultation process allowed the service users to describe the strengths and weaknesses of the service and provided valuable feedback that could be used to design the content and application of future home therapy services.

The efficacy of thermocoagulation of the tibial nerve and a polypropylene ankle-foot orthosis on spasticity of the leg in stroke patients: results of a randomized clinical trial

Objective: To investigate the efficacy of thermocoagulation of the tibial nerve and a polypropylene ankle-foot orthosis (AFO) on spasticity of the leg in stroke patients with a spastic equinus or equinovarus foot.

Design: A placebo-controlled randomized clinical trial with a 2 x 2 factorial design.

Setting: Outpatient clinic, Department of Rehabilitation Medicine, Academisch Ziekenhuis Vrije Universiteit Amsterdam.

Subjects: 60 stroke patients (17 women, 43 men), with a median age of 58 years and a median period of 34 months poststroke, with at least independent walking capacities at home.

Main outcome measures: Change in spasticity, muscle tone, ankle clonus, Achilles tendon reflex, ankle range of motion (ROM), motor function of the leg, and balance, measured six and 15 weeks after randomization.

Results: Thermocoagulation, rather than the AFO, reduced spasticity, muscle tone, Achilles tendon hyperexcitability, and ankle clonus. At six-week follow- up, the effects on Achilles tendon reflex and ankle clonus were the most pronounced; reflex excitability was reduced in 59% of the patients treated with thermocoagulation, as compared to 14% of the placebo-treated patients, whereas ankle clonus was reduced in 55% and 0% of the patients, respectively. Reduced spasticity was found in 35% of the actively treated, as compared to 10% of the placebo-treated patients. For muscle tone, the percentages of improved patients in each group were 45% and 24%, respectively. After 15 weeks the differences between the groups were smaller. No clinically relevant improvement was found with regard to ROM, the Fugl-Meyer lower extremity and balance scores, walking ability and walking speed.

Conclusion: Thermocoagulation is effective for the reduction of spasticity in stroke patients with a spastic equinus or equinovarus foot. No effect on spasticity of the AFO could be demonstrated. When the efficacy of thermocoagulation and the AFO are judged in terms of functional abilities, however, the effects seem of little value.

Effect of an overground training session versus a treadmill training session on timed up and go in hemiparetic patients

BACKGROUND

Timed Up and Go (TUG) performance is reduced following stroke. Gait training improves gait-related activities in hemiparetic patients. However, no study has compared the impact of a single overground training session with a treadmill training session on gait-related activities (assessed by TUG).

OBJECTIVE

To compare the immediate effect of a single overground training session versus a single treadmill training session on TUG performance in hemiparetic patients.

METHODS

In this randomized controlled clinical trial, 56 hemiparetic patients were randomized to 1 or 2 distinct groups: a single gait training session overground (O group) or on a treadmill (T group). Time taken to perform the TUG (in seconds) was assessed before and immediately after the completion of each session.

RESULTS

Time taken to perform the TUG decreased significantly, and to a similar extent, in both groups following the training session (O group, 5.9%; T group, 5.2%).

CONCLUSIONS

An overground training session and a treadmill training session were equally effective in improving TUG performance in hemiparetic patients. Hemiparetic patients should be encouraged to walk regularly overground including turns for 20 minutes without stopping. This is an easy and inexpensive self-rehabilitation method to improve functional gait-related activities involved in the TUG test.

Predictors of life satisfaction in stroke survivors and spousal caregivers after inpatient rehabilitation

A global measure of life satisfaction has become increasingly important as an adjunctive outcome of healthcare interventions for people with disabilities, including those caused by stroke. Life satisfaction of stroke survivors mayaffectcaregivingspouses, as well. The purpose of this study was to identify, among many physical and psychosocial variables, specific variables that were associated with life satisfaction at 12 months after discharge from inpatient rehabilitation, and variables that were predictive of life satisfaction 1 year later (at 24 months). Between 12 and 24 months, life satisfaction decreased for stroke survivors, while it increased for caregiving spouses. The relationship between the couple (mutuality) was the only variable that was a significant predictor of life satisfaction for both stroke survivors and their spouses.

Physical therapists' experiences updating the clinical management of walking rehabilitation after stroke: a qualitative study

BACKGROUND

Little is known about physical therapists' experiences using research evidence to improve the delivery of stroke rehabilitation.

OBJECTIVES

The purpose of this study was to explore how physical therapists use research evidence to update the clinical management of walking rehabilitation after stroke. Specific objectives were to identify physical therapists' clinical questions related to walking rehabilitation, sources of information sought to address these questions, and factors influencing the incorporation of research evidence into practice.

DESIGN AND METHODS

Two authors conducted in-depth telephone interviews with 23 physical therapists who treat people with stroke and who had participated in a previous survey on evidence-based practice. Data were analyzed with a constant comparative approach to identify emerging themes.

RESULTS

Therapists commonly raised questions about the selection of treatments or outcome measures. Therapists relied foremost on peers for information because of their availability, ease of access, and minimal cost. Participants sought information from research literature themselves or with the help of librarians or students. Research syntheses (eg, systematic reviews) enabled access to a body of research. Older therapists described insufficient computer and search skills. Most participants considered appraisal and application of research findings challenging and identified insufficient time and peer isolation as organizational barriers to the use of research.

CONCLUSIONS

Physical therapists require efficient access to research syntheses primarily to inform the measurement and treatment of walking limitation after stroke. Continuing education is needed to enhance skills in appraising research findings and applying them to practice. Older therapists require additional training to develop computer and search skills. Peer networks and student internships may optimize the exchange of new knowledge for therapists working in isolation.

Predictors of life satisfaction among stroke survivors and spousal caregivers: a narrative review

Stroke is a major cause of disability and death worldwide. It affects 15 million people globally and 60% either die or are permanently disabled as a result of stroke. In a rapidly aging population, stroke is expected to continue to be a major concern for survivors, their families and health and social care providers. Most stroke survivors live in the community and are assisted by family caregivers, especially spouses. However, stroke-related impairments and poststroke depression interfere with recovery and result in impaired relationships and reduced life satisfaction for the survivors and their spouses. New interventions are needed to assist stroke survivors and their spouses to cope with the many physical, emotional and environmental changes that result after stroke and enable survivors to become reintegrated into the community.

Rehabilitation needs for older adults with stroke living at home: perceptions of four populations

BACKGROUND

Many people who have suffered a stroke require rehabilitation to help them resume their previous activities and roles in their own environment, but only some of them receive inpatient or even outpatient rehabilitation services. Partial and unmet rehabilitation needs may ultimately lead to a loss of functional autonomy, which increases utilization of health services, number of hospitalizations and early institutionalization, leading to a significant psychological and financial burden on the patients, their families and the health care system. The aim of this study was to explore partially met and unmet rehabilitation needs of older adults who had suffered a stroke and who live in the community. The emphasis was put on needs that act as obstacles to social participation in terms of personal factors, environmental factors and life habits, from the point of view of four target populations.

METHODS

Using the focus group technique, we met four types of experts living in three geographic areas of the province of Québec (Canada): older people with stroke, caregivers, health professionals and health care managers, for a total of 12 groups and 72 participants. The audio recordings of the meetings were transcribed and NVivo software was used to manage the data. The process of reducing, categorizing and analyzing the data was conducted using themes from the Disability Creation Process model.

RESULTS

Rehabilitation needs persist for nine capabilities (e.g. related to behaviour or motor activities), nine factors related to the environment (e.g. type of teaching, adaptation and rehabilitation) and 11 life habits (e.g. nutrition, interpersonal relationships). The caregivers and health professionals identified more unmet needs and insisted on an individualized rehabilitation. Older people with stroke and the health care managers had a more global view of rehabilitation needs and emphasized the availability of resources.

CONCLUSION

Better knowledge of partially met or unmet rehabilitation needs expressed by the different types of people involved should lead to increased attention being paid to education for caregivers, orientation of caregivers towards resources in the community, and follow-up of patients' needs in terms of adjustment and rehabilitation, whether for improving their skills or for carrying out their activities of daily living.

Psychometric Evaluation of the Original and Canadian French Version of the Activities-Specific Balance Confidence Scale Among People With Stroke

OBJECTIVE

To evaluate the internal and absolute reliability and construct validity of the Activities-Specific Balance Confidence (ABC) scale and a new Canadian French version (ABC-CF) of it among people with stroke.

DESIGN

Cross-sectional data from a randomized controlled trial.

SETTING

Community.

PARTICIPANTS

Ninety-one people with a residual walking deficit between 57 and 386 days poststroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The ABC and ABC-CF scales, Berg Balance Scale (BBS), comfortable and maximum gait speeds, Timed Up & Go (TUG) test, 6-minute walk test (6MWT), Barthel Index, physical function scale of the Medical Outcomes Study 36-Item Short-Form Health Survey, Geriatric Depression Scale (GDS), and the EQ-5D visual analog scale (EQ VAS).

RESULTS

Internal consistency (Cronbach alpha) was .94 and .93 and the standard error of measurement was 5.05 and 5.13 for the ABC (n=51) and the ABC-CF (n=35) scales, respectively. Spearman rho values ranged from .30 to .60 for the ABC scale and from .45 to .68 on the ABC-CF scale for associations with scores on the BBS, comfortable and maximum gait speeds, TUG, 6MWT, Barthel Index, physical function scale, GDS, and EQ VAS.

CONCLUSIONS

Evidence of internal and absolute reliability and of construct validity of the ABC and the ABC-CF scales supports their use for cross-sectional measurements of balance self-efficacy among community-dwelling people in the first year poststroke.

Rehabilitation of West Nile Fever (WNF) encephalitis in elderly

In the summer of 2000, an outbreak of WNF affected Israel. Thirty-two elderly patients were admitted to Meir Hospital. WNF encephalitis may result in residual functional damage. However, little information is available regarding the rehabilitation of these patients. Five elderly subjects with residual functional damage were referred to geriatric rehabilitation. Patients were treated with the routine program for neurological rehabilitation after stroke, including daily physiotherapy and occupational therapy. All five were over 77 years and independent before admission. The mean FIM score on admission was 71 (S.D. = +/-8.5) and increased to 102 (S.D. = +/-14) on discharge. MMSE on admission was 60% (S.D. = +/-7.5%), and increased to over 90% on discharge in all of the patients. Clock Completion Test was normal in four on admission, and improved to normal in the fifth patient on discharge. WNF encephalitis may present with functional and intellectual impairment in the elderly. Routine geriatric neurological rehabilitation may benefit those with prolonged functional decline.

Additional task-related practice improves mobility and upper limb function early after stroke: A randomised controlled trial

The purpose of this study was to investigate whether additional practice of either upper limb or mobility tasks improved functional outcome during inpatient stroke rehabilitation. This prospective, randomised, single blind clinical trial recruited 30 stroke subjects into either an Upper Limb or a Mobility Group. All subjects received their usual rehabilitation and an additional session of task-related practice using a circuit class format. Independent assessors, blinded to group allocation, tested all subjects. Outcome measures used were three items of the Jebsen Taylor Hand Function Test (JTHFT), two arm items of the Motor Assessment Scale (MAS), and three mobility measures, the Timed Up and Go Test (TUGT), Step Test, and Six Minute Walk Test (6MWT). Both groups improved significantly between pre- and post-tests on all of the mobility measures, however only the Upper Limb Group made a significant improvement on the JTHFT and MAS upper arm items. Following four weeks training, the Mobility Group had better locomotor ability than the Upper Limb Group (between-group differences in the 6MWT of 116.4 m, 95% CI 31.4 to 201.3 m, Step Test 2.6 repetitions, 95% CI -1.0 to 6.2 repetitions, and TUGT -7.6 sec, 95% CI -15.5 to 0.2 sec). The JTHFT dexterity scores in the Upper Limb Group were 6.5 sec (95% CI -7.4 to 20.4 sec) faster than the Mobility Group. Our findings support the use of additional task-related practice during inpatient stroke rehabilitation. The circuit class format was a practical and effective means to provide supervised additional practice that led to significant and meaningful functional gains.

A six-week, resource-efficient mobility program after discharge from rehabilitation improves standing in people affected by stroke: Placebo-controlled, randomised trial

Although intervention is effective in reducing the disability associated with stroke, limited resources mean that physiotherapy services often cease by six months after stroke. The purpose of this clinical trial was to investigate the efficacy of resource-efficient physiotherapy services in improving mobility and quality of life after stroke. Twenty-six people with residual walking difficulties after stroke were randomised into an experimental or control group after discharge from physiotherapy services. The experimental group participated in a six-week, home-based mobility program. The control group participated in a six-week, home-based program of upper-limb exercises (i.e. 'sham' mobility exercises). Subjects met with the therapist for prescription of exercises only three times during the six weeks. Strategies used to offset potential problems associated with minimal subject-therapist interaction included videotaped instructions to encourage correct performance of exercises, modification of the environment and involvement of carers to enhance safety, and telephone contact and self-monitoring to promote compliance. Standing (Functional Reach), walking (MAS Item 5) and quality of life (SA-SIP30) were measured prior to, immediately after, and two months after intervention ceased by an assessor who was blinded to group allocation. Subjects in the experimental group demonstrated significant improvement in standing compared to the control group (p = 0.01) which was maintained two months after the cessation of intervention (p = 0.04). There was no difference between the groups in walking (p = 0.50) or quality of life (p = 0.70). The six-week, resource-efficient mobility program was effective in improving some of the mobility in people after discharge from stroke rehabilitation. The provision of resource-efficient programs is recommended wherever possible so that people affected by stroke may continue rehabilitation for longer.

Postural control during sit-to stand and gait in stroke patients

OBJECTIVE

To investigate the relationship of sit-to-stand and gait performance in hemiplegic stroke patients.

DESIGN

A total of 40 chronic stroke patients with hemiplegia and 22 age-matched healthy subjects were included in this study. Data of a motion analysis system and three force platforms were collected in a rehabilitation unit of a medical center.

RESULTS

Laboratory sit-to-stand measurement and gait analysis were evaluated in both groups via three AMTI (Advanced Mechanical Technology Inc.) force platforms and a Vicon 370 system (six high-resolution cameras and one AMTI force plate), respectively. The sit-to-stand and gait parameters of hemiplegic patients were correlated significantly, especially in rising speed and the maximal vertical force of both legs during rising.

CONCLUSIONS

Hemiplegic stroke patients, who could stand up within 4.5 sec or who had a maximal vertical force difference of less than 30% of body weight between both legs, had better gait performance than the others did.

The influence of social support and perceived control on handicap and quality of life after stroke

It has been suggested that external factors, such as perceived control of life and social support, influence the interactions of impairment, disability and handicap in the WHO model. Therefore, we assessed the effect of these two factors on the relationships between disability, handicap and quality of life in patients recovering from stroke. One hundred individuals, retrospectively and randomly selected from participants in an inpatient stroke rehabilitation program, were tested one year after discharge, using the Functional Independence Measure, the London Handicap Scale, the Life Satisfaction Assessment, the Tel-Aviv Social Support Instrument, and the Perceived Stress Scale. Impairment, disability, handicap and quality of life after stroke correlated positively and significantly with each other. Significant moderation of the influence that disability exerts on handicap was affected by perception of control, and by the influence of handicap over quality of life by social support. Thus, external factors can cause inconsistent interactions between components of the WHO model. Patient outcome may be improved if such factors are considered.

Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial

OBJECTIVE

To evaluate the immediate and retention effects of a 4-week training program on the performance of locomotor-related tasks in chronic stroke.

DESIGN

Randomized, controlled pilot study with 2-month follow-up.

SETTING

Rehabilitation center.

SUBJECTS

A convenience sample consisting of 12 chronic stroke subjects was used. Subjects were randomly assigned to the experimental or the control group. Three subjects withdrew from the study.

INTERVENTION

Both experimental and control groups participated in exercise classes three times a week for 4 weeks. The exercise class for the experimental group focused on strengthening the affected lower limb and practicing functional tasks involving the lower limbs, while the control group practiced upper-limb tasks.

MAIN OUTCOME MEASURES

Lower-limb function was evaluated by measuring walking speed and endurance, peak vertical ground reaction force through the affected foot during sit-to-stand, and the step test.

RESULTS

The experimental group demonstrated significant immediate and retained (2-month follow-up) improvement (p < or = .05) compared with the control group in walking speed and endurance, force production through the affected leg during sit-to-stand, and the number of repetitions of the step test.

CONCLUSION

The pilot study provides evidence for the efficacy of a task-related circuit class at improving locomotor function in chronic stroke.

The accuracy of predicting functional recovery in patients following a stroke, by physiotherapists and patients

BACKGROUND AND PURPOSE

The potential for post-stroke recovery and the range of predictive variables has been studied extensively. Knowledge of these variables alongside other factors, such as performance in therapy and professional experience, enable ongoing predictions to be made by members of the rehabilitation team. Patients' own predictions for their recovery has yet to receive much attention in this area of research. The aim of this study was to compare the predictive accuracy of the physiotherapist and the stroke patient with regard to functional change during a period 6-12 weeks post-stroke.

METHOD

The stroke sample (N = 29) came from two National Health Service Trusts as did the physiotherapists (N = 4). No comparisons were made between the hospitals and data was coded for anonymity. Estimations were made by both physiotherapists and patients regarding items on each of the three sections of The Rivermead Motor Assessment (RMA). Intra-class correlation coefficients (ICCs) were used to describe agreement of each set of predictions with the achieved RMA scores. The results reported here represent the main emphasis of the research; however, other areas were also screened (for example, change in cognition, language and quality of life) by use of basic standardized measures. Recovery was also compared to other known predictive variables, such as age, severity of stroke and urinary incontinence.

RESULTS

At follow-up assessment it was found that both physiotherapists' and patients' predictions demonstrated high and significant agreement with the achieved RMA scores at 12 weeks (ICCs ranging from 0.727 to 0.968). Physiotherapists' predictions demonstrated marginally higher levels of agreement than patients' predictions.

CONCLUSIONS

The degree of accuracy demonstrated by both physiotherapists and patients was considerable. The patient group was perhaps the more notable as no subject had had prior knowledge of a stroke. The implications in respect of lay persons' involvement in decision making and in the rehabilitative process, alongside the health professionals, are perhaps worthy of closer consideration.

Dependence and perceived difficulty in daily activities in community-living stroke survivors 2 years after stroke: a study of instrumental structures

BACKGROUND AND PURPOSE

There is a need for better understanding of the structure of instruments for functional outcome assessment after discharge from rehabilitation. One purpose of the study was to contribute to the analysis of instrumental dimensionality. Another purpose was to compare disability in stroke patients within the younger age range 2 years after onset of stroke with that at discharge with respect to both dependence and patients' perceived difficulty and to extend the assessments with instrumental activities.

METHODS

We studied 68 stroke survivors aged 18 to 71 years at onset (59% aged <55 years) by means of interviews in their home, using activities from the Functional Independence Measure (FIM) and Instrumental Activity Measure (IAM) for ratings of dependence and perceived difficulty. Rasch analysis was used to construct calibrated linear measures and to evaluate the level of fit.

RESULTS

Acceptable models for comparison of dependence between discharge and follow-up were found for the physical and the social-cognitive items in FIM. However, personal care and social-cognitive items showed an increased level of dependence at follow-up compared with at discharge. A combination of physical activities from FIM and IAM also gave acceptable models for both dependence and perceived difficulty, and the hierarchical orders of activities are presented. In general, there was agreement between the ratings of dependence and perceived difficulty, but with some discrepancies. Men found it harder to be independent in such instrumental activities as cooking and cleaning than women; the opposite was true for small-scale shopping and locomotion outdoors. Subjects aged > or =55 years had slightly higher level of dependence and perceived difficulty in IAM activities than those below that age.

CONCLUSIONS

Changes in the hierarchical order of activities should be taken into account in follow-up studies. Differences in the environment between hospital and home, as well as differences in support and motivation, might explain the relatively larger degree of dependence at follow-up compared with at discharge and indicate the need for further rehabilitation efforts. Instrumental activities could be combined with FIM activities in a model. For individual items, ratings of both dependence and perceived difficulty may provide further insight into the disablement process.

Stroke rehabilitation: assessing stroke survivors' long-term learning needs

What are the long-term learning needs of stroke survivors who must adapt to living with stroke-related disabilities? A broad-based educational needs assessment was conducted to find answers to this question and to gain insight into the concerns and challenges facing stroke survivors who have returned to living in the community. Stroke survivors, family members, and rehabilitation healthcare professionals were surveyed; positive responses strongly indicated that there was interest in learning more about the selected topics. Although there was congruence across all groups, healthcare professionals indicated that they felt more strongly than either patients or patients' family members that stroke survivors need to learn more about the facts and statistics of strokes. Stroke survivors and family members indicated a stronger interest in learning about complementary therapies such as massage, acupuncture, and the role of food and vitamins. Time since stroke was an influencing factor for both stroke survivors and family members in their responses to how strongly they wanted to learn about various topics. The findings from this needs assessment formed the basis for an educational course that uses a holistic approach to address the physical, emotional, social, economic, and spiritual aspects of adapting to living with stroke-related disabilities.

Walking ability of stroke patients: efficacy of tibial nerve blocking and a polypropylene ankle-foot orthosis

OBJECTIVE

To investigate the efficacy of tibial nerve blocking by percutaneous radiofrequency thermocoagulation and an ankle-foot orthosis on the walking ability of stroke patients with a spastic equinus or equinovarus foot.

DESIGN

A placebo-controlled randomized clinical trial with a 2 x 2 factorial design and with a 3-month follow-up.

SETTING

Outpatient clinic of a department of rehabilitation medicine.

SUBJECTS

Sixty stroke patients (17 women, 43 men) with a median age of 58 years and a median period of 34 months poststroke were allocated to one of four treatment groups.

MAIN OUTCOME MEASURES

Changes in walking ability (measured with the Sickness Impact Profile category "ambulation"; possible score range, 0% to 100%) and walking speed after 3 months.

RESULTS

With respect to walking ability, the efficacy of thermocoagulation as compared with placebo thermocoagulation was .56% (95% confidence interval [CI] -3.01% to 4.13%), whereas the efficacy of the ankle-foot orthosis as compared with the placebo ankle-foot orthosis was 2.72% (95% CI -.94% to 6.38%). To study the potential synergistic effect of both treatments, a multivariate model was used; interaction between both treatments was small, .83% (95% CI -6.73% to 8.40%). Analysis restricted to the compliers (n = 30) showed an increased efficacy of thermocoagulation and a decreased efficacy of the ankle-foot orthosis. The changes in comfortable and maximal safe walking speed were less than .10m/sec and were neither clinically nor statistically significant (the median baseline values for the total group were .42m/sec and .56m/sec, respectively).

CONCLUSION

No support was found for the beneficial effects of either thermocoagulation of the tibial nerve or a polypropylene ankle-foot orthosis in 5 degrees of dorsiflexion on the walking ability of stroke patients.

Patients' conceptions of their life situation within the first week after a stroke event: a qualitative analysis

The aim of this study was to find out how stroke patients conceived their life situation within the first week of the acute care phase as seen from the nurses' viewpoint. Six patients were interviewed within 3 weeks from their first stroke, using questions based on a holistic philosophy and analysed with the phenomonographic approach. Two main categories emerged from the results: the feeling of unreality and the awareness of a changed role in life, together with six subcategories; feeling of a changed perception of the body; feeling of being confused; loss of capability; awareness of confined life space; the importance of support and encouragement; and the will to look for new opportunities. The study concludes that the body change resulting from a stroke leads to both physical and psychological trauma, in which the psychological crisis can be very deep and best described as a personal catastrophe. The patient's capability to receive and understand information becomes blocked, which influences both the nurse and the patient's next of kin with regard to their care of the patient. Conversations with the patient must be frequent so that the acute care can be evaluated and agreement reached between the patient's wishes and the nurses' objectives. The results indicate the significance of intervention programmes based on crisis theory within the first week of a stroke event.