Effect of residual lower-extremity function on strategies and execution time for raising and lowering trousers in patients with hemiparetic stroke: a cross-sectional study

Background/aims

There are no established methods for patients with hemiparetic stroke to practice the raising and lowering of trousers. The aim of this study was to investigate the use of different strategies by patients with hemiparetic stroke for lowering and raising trousers by using the non-paretic upper limb in the standing position, based on residual motor function in the paretic lower limb.

Methods

A total of 28 patients with hemiparetic stroke were included in the study (n=10, 12, and 6 with lower-limb Brunnstrom stages III, IV and V respectively). Endpoints were execution time and frequency of changing the manipulation region.

Results

Lower-limb Brunnstrom stages III, IV and V were associated with execution times of 24.1 ± 11.1, 18.1 ± 6.5 and 16.9 ± 9.6 seconds respectively, and the mean frequency of manipulation of trousers on the posterior paretic side was significantly lower than those of the anterior paretic, anterior non-paretic, and posterior non-paretic sides in all patients (P<0.05).

Conclusions

Motor function of the paretic lower limb did not affect the strategies used for lowering and raising trousers with the non-paretic upper limb. Manipulation of trousers on the posterior paretic side was especially difficult.

An audit of dressing practice by occupational therapists in acute stroke settings in England

Introduction

Dressing independence is commonly affected after stroke, with clinical guidelines recommending that dressing practice should routinely be provided for those with dressing difficulties. The aim of this study was to update the literature on current practice in the treatment of dressing problems in stroke rehabilitation units.

Method

A questionnaire survey of occupational therapists experienced in stroke care was sent to 157 stroke units in England.

Results

Responses were received from 70 stroke units. Frequency and duration of dressing practice varied substantially between units, with respondents typically providing dressing practice for six to 10 patients per week and spending 30 to 45 minutes per treatment session. Only 17 respondents (24.3%) stated that they regularly used standardised assessments of dressing ability. The functional approach was used more widely than the remedial approach. Service priorities, working environment and limitations of time and staffing were reported to influence dressing practice.

Conclusion

There is widespread variability in dressing practice. There is a lack of use of standardised dressing assessments, and therapists’ rationale for their choice of approach is unclear.

Description of an Occupational Therapy Intervention Aimed at Improving Outdoor Mobility

After a stroke people can find outdoor mobility difficult, but a targeted occupational therapy intervention has been shown to help people to get out of the house more often. This study describes the intervention.

The occupational therapists who provided the intervention kept records of the number and duration of therapy sessions, the goal of therapy and the activities undertaken. As part of the trial, functional and mobility outcome assessments were completed by the participants 4 and 10 months after recruitment and were used to compare the goals set with the goals achieved and the mobility performance.

Eighty-six participants were randomised to, and 78 received, the intervention. They received a median of 6 (mean 4.7, SD 1.9) sessions, with an average of 40 minutes per session. Sixty (77%) of the participants achieved their primary goal. Those who did not had greater functional limitations at the start of the study than those who did. Walking was the most common goal (17/78, 22%) and the most performed activity (135 times, 33%). Thirteen participants achieved walking and 12 of these were still walking outside at the 10-month assessment.

Three-quarters of people with stroke were therefore able to achieve their outdoor mobility goals after an occupational therapy intervention.

Dressing after a Stroke: A Survey of Current Occupational Therapy Practice

The objective of this study was to determine occupational therapists' beliefs about the influence of cognitive impairment on dressing difficulties and to ascertain current practice when treating dressing problems. The study design was a questionnaire survey of occupational therapists experienced in stroke care who treated patients with dressing difficulties.

Out of 137 questionnaires sent, 76 (55.5%) were returned. The frequency of dressing practice provided by the occupational therapists ranged from two to four times a week. Only 43% of the therapists used standardised assessments and the most common one used was the Rivermead Perceptual Assessment Battery. Apraxia was reported by 76% of the therapists as influencing a patient's ability to dress, neglect by 71 % and memory problems by 63%. Seventy-six per cent of the therapists reported that orientating clothing and relating it to body parts was a major dressing difficulty. Other dressing difficulties reported were sequencing by 56% and failing to dress the affected side by 34%. Ninety-eight per cent of the therapists spent time providing the practice of specific functional skills on a repetitive basis; however, 60% continued to use table-top tasks aimed at targeting a particular cognitive impairment.

The majority of the therapists felt that cognitive impairment was a major reason for dressing difficulties in stroke patients. With the exception of one, all the therapists provided repetitive practice on dressing tasks and over half continued to use table-top tasks. The evidence to support the types of treatment used by occupational therapists remains controversial. Further research into this area is required.

Propensity-matched analysis of the gap between capacity and actual performance of dressing in patients with stroke

[Purpose] Dressing is an activity of daily living for which stroke patients often show discrepancies between capacity and actual performance. The aim of this study was to elucidate the physical function and unilateral spatial neglect in stroke patients that reduce their level of actual performance despite having the capacity for dressing independently. [Subjects and Methods] This retrospective study included 60 first-time stroke patients judged by occupational therapists as able to dress independently. The patients were divided into two groups according to their FIM(®) instrument scores for dressing the upper and lower body: an independent group with both scores ≥6 and an assistance group with one or both scores ≤5. After adjusting for confounding factors through propensity score matching, the groups were compared by using Stroke Impairment Assessment Set items, the Simple Test for Evaluating Hand Function of both upper limbs, and the Berg balance scale. [Results] The assistance group had a significantly lower score for the Berg balance scale than the independent dressing group (31.0 ± 12.3 vs. 47.8 ± 7.4). [Conclusion] The results of the present study suggested that the balance function has an effect on the discrepancy between dressing capacity and performance.

Using an interview study of transport use by people who have had a stroke to inform rehabilitation

Introduction: Many people who have had a stroke want to get out of their house more often. This study explored attitudes and barriers to the use of transport with the aim of informing rehabilitation.

Method: Semi-structured interview study of 24 community-dwelling people who had had a stroke, purposively sampled to find people with a variety of recent experiences of transport. Interviews were taped and transcribed. Analysis was by constant comparative methodology, to develop emerging themes and concepts.

Results: Interviewees wanted to travel for specific purposes but also for its own sake. Many could no longer use their car. This gave them less flexibility to travel and reduced their autonomy. Barriers to using alternative forms of transport were fear of injury or embarrassment from falling, an associated lack of confidence, inadequate information about transport services, perceptions about the cost of taxis and pavement vehicles (scooters) and environmental factors such as the weather. Those who could drive, or who lived with someone who did, gave the most positive descriptions of transport use. Those reliant on family or friends felt they could ask only for help getting to health-related appointments and those who used specialist transport services provided the most negative descriptions of transport.

Conclusions: Many of the barriers to transport use after stroke may be amenable to intervention. An intervention package capable of re-enabling people to drive or be driven, to use a pavement scooter safely, to provide information about the alternatives and to encourage best use of public transport is worth developing.

Motor Function Cutoff Values for Independent Dressing in Stroke Patients

OBJECTIVE

This study established motor function cutoff values for dressing independence in inpatients with stroke.

METHODS

Ninety-eight first-time inpatients with stroke were divided into groups on the basis of independence level in dressing, and receiver operating characteristic curves were determined for balance, motor function of affected limbs, trunk function, motor function of unaffected upper limb, and cognitive function.

RESULTS

Area under the curve for the Berg Balance Scale (BBS) was highest for the different motor functions. In distinguishing independence group and supervision or less level group, the cutoff value for the BBS was 44 points (sensitivity = 85%, specificity = 93%). In distinguishing supervision or higher level group and dependence group, the cutoff value for the BBS was 32 points (sensitivity = 94%, specificity = 79%).

CONCLUSION

Balance was strongly correlated with the level of dressing independence, and cutoff values for the BBS were indicators of the balance required to reach independent and supervision levels of dressing.

Simple Indicator to Judge the Independence Level Required in Dressing in a Hospital Ward for Patients with Stroke

BACKGROUND

This study aimed to create a simple and objective indicator for use by inexperienced nurses and family members of patients to judge the assistance level required for dressing in a hospital, while encouraging independence in activities of daily living among inpatients with stroke using the Berg balance scale.

METHODS

We retrospectively analyzed the data of 108 hospitalized patients with first stroke in a rehabilitation hospital ward. Receiver operating characteristic curves were used to identify the Berg balance scale item with the highest discriminatory power against independence level in dressing.

RESULTS

For comparisons between the independence and supervision or less level groups, the area under the curve of the sum score of "Retrieving object from floor" and "Standing with one foot in front" was .954, and the calculated cutoff value was 6/5 (sensitivity, 86%; specificity, 94%). For comparisons between the supervision or higher level and dependence groups, the area under the curve of the score of "Retrieving object from floor" was .930, and the calculated cutoff value was 2/1 (sensitivity, 93%; specificity, 81%).

CONCLUSIONS

Our results suggested that Berg balance scale items are individually and in combination simple and useful indicators to judge independence level in dressing in a hospital ward for patients with stroke. These indices appear to be appropriate for individuals who are unfamiliar with Berg balance scale, such as inexperienced nurses and family members of patients.

Relationship between dressing and motor function in stroke patients: a study with partial correlation analysis

[Purpose] The aim of the present study was to elucidate which motor functions are most or more important for dressing performance before and after rehabilitation. [Subjects] Seventy-nine first episode stroke patients in a hospital convalescent rehabilitation ward. [Methods] The relationships between motor function of the affected upper and lower limbs, unaffected side function, trunk function, balance, cognitive function, and independence level in dressing were examined at admission and discharge using partial correlation analysis. [Results] Independence level of dressing correlated with motor function of the affected upper limb and balance at admission, but correlated only with balance at discharge. [Conclusion] Balance function was strongly associated with level of dressing independence. The effect of gross motor function of the affected upper and lower limbs on the level of independence in dressing may thus be smaller than originally expected. Enhanced balance ability can be important for learning single-handed actions of self-dressing during rehabilitation.

A case of dressing apraxia? A case study

Dressing apraxia is defined as the condition in which automatic, spontaneous capacity for dressing is lost ( Brain, 1941 ). This case report details the rehabilitation of a 58-year-old man who required protracted ITU care for endocarditis complicated by bilateral hemispheric embolic infarcts. At presentation to the rehabilitation unit he exhibited significant visuo-perceptual changes and difficulties with dressing, domestic and community-based tasks. He developed insight into his spatial impairments and, following a period of intervention, compensated for these difficulties. However the dressing difficulties remained despite intervention. This is an unusual presentation and one that might typically be considered dressing apraxia.

This case report aims to highlight the importance of considering apraxia related to dressing within a differential diagnosis of visuo-perceptual impairments. Our report suggests that there may be justification in the classification of dressing apraxia as an impairment outside the broader terms of ideomotor and ideational apraxia. It also highlights the difficulty in treating apraxia related to dressing particularly when the affected person has minimal insight into their difficulties.

The DRESS trial: a feasibility randomized controlled trial of a neuropsychological approach to dressing therapy for stroke inpatients

OBJECTIVE

To investigate two approaches to treating patients with persistent dressing problems and cognitive difficulties following stroke.

DESIGN

Pilot randomized controlled trial.

SETTING

Inpatient stroke rehabilitation service.

SUBJECTS

Seventy consecutive stroke patients with persistent dressing problems and accompanying cognitive difficulties at two weeks after their stroke.

INTERVENTIONS

Patients were randomly allocated to six weeks of either a systematic neuropsychological approach, based on analysis of dressing problems and further cognitive testing, or to the control group who received conventional (functional) dressing practice. Both groups received treatment three times a week in accordance with two separately prepared manuals.

MAIN MEASURES

Nottingham Stroke Dressing Assessment (NSDA), Line Cancellation, 10-hole peg transfer test, Object Decision, Gesture Imitation. Patients were assessed at six weeks after randomization by an independent assessor masked to group allocation.

RESULTS

Both neuropsychological and functional groups improved performance on the NSDA over the treatment period (31% and 22%, respectively) but there was no significant difference between groups at six weeks. However, the neuropsychological group showed a significantly greater improvement on a line cancellation test of visual neglect (t(62) = 2.1, P < 0.05) and a planned subanalysis for those with right hemisphere damage showed a trend towards better dressing outcome (P = 0.07, one-tailed).

CONCLUSIONS

Results demonstrate the potential benefits of a systematic neuropsychological approach to dressing therapy, particularly for patients with right hemisphere damage. This study suggests the need for a phase III study evaluating the efficacy of a systematic neuropsychological approach in treating dressing difficulties, targeting patients with right hemisphere stroke and visuospatial impairments.

Normal Movement and Functional Approaches to Rehabilitate Lower Limb Dressing following Stroke: A Pilot Randomised Controlled Trial

Dressing difficulties are common following stroke. However, specific interventions lack evidence. This pilot single-blind randomised controlled trial investigated normal movement and functional approaches to rehabilitate lower limb dressing, given to four eligible stroke inpatients. The Nottingham Stroke Dressing Assessment, Rivermead Motor Assessment and Canadian Occupational Performance Measure were taken at baseline, discharge and 8 weeks. The small sample lacked power. Preliminary results indicated that while all patients improved with occupational therapy, approaches may differ in rates of motor recovery, independence and treatment duration. A total sample of 30 is required for more conclusive research to inform lower limb dressing interventions.

Predicting Recovery of Upper-Body Dressing Ability After Stroke

OBJECTIVE

To identify predictors of the recovery of independent dressing ability after stroke.

DESIGN

Prospective cohort study.

SETTING

Rehabilitation unit at a university hospital.

PARTICIPANTS

Sixty-three consecutive stroke patients were enrolled in the study. Twelve patients were not able to complete the study because they were discharged or transferred to another hospital before study completion.

INTERVENTION

Fifty-one patients underwent and completed 15 days of dressing training based on the time-delay method, which included the 10 component actions of upper-body dressing and 4 cues given by therapists.

MAIN OUTCOME MEASURES

The dressing item of the FIM instrument, Brunnstrom motor recovery stages, presence or absence of deep and tactile sensation, Rey-Osterrieth complex figure test, Kohs block design test, body image test, Weintraub cancellation task, and presence or absence of the visual extinction phenomenon and the motor impersistence phenomenon.

RESULTS

The FIM upper-body dressing item score and the cancellation task score at the start of training were significantly better in patients who achieved independence in dressing within 15 training days than in patients who did not (P < .05). The motor impersistence phenomenon was found less frequently among patients who achieved independence in upper-body dressing than among patients who did not (P < .05). However, logistic regression analysis showed that only the FIM score for upper-body dressing on the first day of training was a significant independent predictor of dressing ability at the end of training (odds ratio, 4.33; 95% confidence interval, 1.51-12.37). The receiver operating characteristic curve indicated that a cutoff score of 3 would provide the best balance between sensitivity and specificity for the FIM upper-body dressing item. The positive predictive value of this cutoff score was .90, and the negative predictive value was .70.

CONCLUSIONS

Our findings indicate that the FIM upper-body dressing score on the first day of dressing training is an independent predictor of recovery of upper-body dressing ability after stroke.