Identifying Occupational Performance Barriers of Stroke Survivors: Utilization of a Home Assessment

Quality and Accessibility of Home Assessment mHealth Apps for Community Living: Systematic Review

BACKGROUND

Home assessment is a critical component of successful home modifications, enabling individuals with functional limitations to age in place comfortably. A high-quality home assessment tool should facilitate a valid and reliable assessment involving health care and housing professionals, while also engaging and empowering consumers and their caregivers who may be dealing with multiple functional limitations. Unlike traditional paper-and-pencil assessments, which require extensive training and expert knowledge and can be alienating to consumers, mobile health (mHealth) apps have the potential to engage all parties involved, empowering and activating consumers to take action. However, little is known about which apps contain all the necessary functionality, quality appraisal, and accessibility.

OBJECTIVE

This study aimed to assess the functionality, overall quality, and accessibility of mHealth home assessment apps.

METHODS

mHealth apps enabling home assessment for aging in place were identified through a comprehensive search of scholarly articles, the Apple (iOS) and Google Play (Android) stores in the United States, and fnd.io. The search was conducted between November 2022 and January 2023 following a method adapted from PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Reviewers performed a content analysis of the mobile app features to evaluate their functionality, overall quality, and accessibility. The functionality assessment used a home assessment component matrix specifically developed for this study. For overall quality, the Mobile Application Rating Scale (MARS) was used to determine the apps' effectiveness in engaging and activating consumers and their caregivers. Accessibility was assessed using the Web Content Accessibility Guidelines (WCAG) 2.1 (A and AA levels). These 3 assessments were synthesized and visualized to provide a comprehensive evaluation.

RESULTS

A total of 698 apps were initially identified. After further screening, only 6 apps remained. Our review revealed that none of the apps used thoroughly tested assessment tools, offered all the functionality required for reliable home assessment, achieved the "good" quality threshold as measured by the MARS, or met the accessibility criteria when evaluated against WCAG 2.1. However, DIYModify received the highest scores in both the overall quality and accessibility assessments. The MapIt apps also showed significant potential due to their ability to measure the 3D environment and the inclusion of a desktop version that extends the app's functionality.

CONCLUSIONS

Our review revealed that there are very few apps available within the United States that possess the necessary functionality, engaging qualities, and accessibility to effectively activate consumers and their caregivers for successful home modification. Future app development should prioritize the integration of reliable and thoroughly tested assessment tools as the foundation of the development process. Furthermore, efforts should be made to enhance the overall quality and accessibility of these apps to better engage and empower consumers to take necessary actions to age in place.

Developing a Clinical Prediction Rule for Gait Independence at Discharge in Patients with Stroke: A Decision-Tree Algorithm Analysis

OBJECTIVES

To develop a clinical prediction rule (CPR) for gait independence at discharge in patients with stroke, using the decision-tree algorithm and to investigate the usefulness of CPR at admission to the rehabilitation ward.

MATERIALS AND METHODS

We included 181 subjects with stroke during the postacute phase. The Chi-squared automatic interaction detection analysis method with 10-fold cross-validation was used to develop two CPRs; CPR 1 using easily obtainable data available at admission; CPR 2 using easily obtainable data available 1 month after admission, for prediction of gait independence at discharge.

RESULTS

The degree of independence of toileting was extracted as a first node in the development of two CPRs to predict gait independence at discharge. CPR 1 included the presence of delirium. CPR 2 included problem-solving abilities. The accuracy and area under the curve of CPR 1 were 84.5% and 0.911, respectively; those of CPR 2 were 89.0% and 0.958, respectively.

CONCLUSIONS

Toileting independence is a key factor in predicting the gait independence for the discharge of patients with stroke during the postacute phase. Early intervention, during the acute phase, for delirium and cognitive decline, as well as for toileting, increases the possibility of gait independence at discharge.

Exploring the co-involvement of disabled adolescents in participatory action research; protocol for a critical interpretative synthesis

Background: Participatory action research (PAR) provides an opportunity for academic researchers and adolescents to co-conduct research within an area of shared interest. Reciprocal learning occurs as co-researchers acquire research skills and knowledge, and academic researchers gain understanding of the issue being examined, from the perspective of those with lived experience. All members of the research team have a shared responsibility for the research and decision-making processes. PAR has predominantly involved adults as co-researchers. However, in recent years more effort has been made to co-conduct research with adolescents. The aim of this review is to interrogate the practices of academic researchers employing a PAR approach when working along-side disabled adolescents.

Methods/design: A critical interpretive synthesis (CIS) will be conducted, allowing for a diverse range of evidence to be drawn from. A systematic search of nine databases, from 1990 onwards, will be conducted first. Reference checking will occur to elicit further relevant data. Following screening, further purposive sampling will be completed to facilitate the development of concepts and theory in line with the on-going analysis and synthesis of findings. Data analysis will involve interpretation of included papers in relation to the principles of PAR and a ‘best-practice’ framework will be developed. During analysis particular emphasis will be given to the identification of potential social barriers to the participation of disabled adolescents in PAR.   

Discussion: PAR is widely employed but little is known about its use when working with disabled adolescents. This current CIS will critically question the current practices of academic researchers employing PAR when working along-side disabled adolescents and future research through the best practice framework we will develop.

Home Modification Assessments for Accessibility and Aesthetics: A Rapid Review

PURPOSE

The purpose of this study was to identify assessments used to evaluate the homes of people with disabilities in terms of accessibility, usability, activities, comfort/satisfaction, and aesthetics.

BACKGROUND

The home is increasingly becoming an environment for healthcare as more people desire to age in place. Research indicates home environmental modifications to be beneficial to promote a better person-environment fit, especially when using a standardized assessment approach. There is not a comprehensive list of assessments that address home modifications, adaptations, or interior designs for people with disabilities.

METHOD

Researchers conducted a rapid review of articles, with data collection scales, instruments, and procedures for home modifications published between 2000 and 2017.

RESULTS

A total of 26 articles met the inclusion criteria, resulting in the identification of 33 distinct assessments, including 18 assessments evaluating the accessibility of home modifications, 3 assessments examining usability, 15 assessments addressing activities of daily living or functional activities, and 5 assessments addressing comfort and/or satisfaction. No assessments for aesthetics were located.

CONCLUSION

Researchers developed a list of assessments that could be used for research or practice. Further research is needed to address the lack of assessments focusing on the aesthetics or attractiveness of home modifications, as well as more assessments tailored to specific diagnoses and population groups.

A structural equation model of falls at home in individuals with chronic stroke, based on the international classification of function, disability, and health

PURPOSE

To use structural equation model (SEM) to explain falls at home in individuals with chronic stroke, based on the International Classification of Functioning, Disability and Health (ICF).

MATERIALS AND METHODS

A cross sectional observation study was conducted in home-dwelling individuals with chronic stroke (N = 236; 148 non-fallers, 88 fallers). Participants were assessed; structural impairments using Modified Ashworth Scale, Fugl-Meyer Assessment upper (FMA-UE), lower (FMA-LE), and sensory function, ankle plantarflexor strength; activity limitations using Timed Up and Go Test, Step Test, Berg Balance Scale, Barthel Index (BI); participation restrictions using Stroke Impact Scale-participation (SIS-P); and contextual factors using home hazard environments, home safety surroundings, risk behaviors, and Fall-related Self Efficacy. The measurement model was analyzed by confirmatory factor analysis. The SEM was conducted to analyze a structural model of falls at home.

RESULTS

FMA-UE was significantly (p<0.01) associated with FMA-LE, combining as one variable in the structural impairments. In the measurement model, variables were fit to their domains, except variables of contextual factors, but the ICF domains did not correspond to disability. A structural model of falls at home demonstrated a significant (p<0.01) direct path of contextual factors and activity limitations with falls at home. The structural impairments showed a significant (p<0.01) direct path with activity limitations. All variables, except BI, SIS-P and risk behaviors, related to their domains in the structural model.

CONCLUSIONS

A structural model of falls at home proposes contextual factors being the strongest association with falls at home that home hazard environments seem the most influence in its domain. The activity limitations presented by balance ability are directed to falls at home. The structural impairments are associated with falls at home through activity limitations. Home assessment to decrease home hazard environments is suggested to prevent falls at home for individuals with chronic stroke.

Occupational adaptation - analyzing the maturity and understanding of the concept through concept analysis

Background: Occupational adaptation is a key occupational therapy concept, yet lacks clarity and consensus, impacting on its application in practice, theory and research. Concept analysis is a rigorous methodology which enables identification of unique features, gaps in knowledge, and the need for further concept refinement.Aim: This study aimed to determine the conceptual maturity of occupational adaptation, and identify steps needed to understand and use occupational adaptation.Methods: Four databases were searched using the term 'occupational adaptation' and a principle-based concept analysis was conducted from epistemological, pragmatic, linguistic, and logical perspectives. A mapping of the concept's evolution and analysis of the maturity of its structural features also occurred.Results: Seven hundred and fourty-eight papers were identified, which reduced to 161 after abstract and full-text review. A diverse range of applications and two primary theoretical frames of reference were identified. The definition, attributes, preconditions, outcomes, and boundaries of the concept lacked maturity, limiting clinical utility.Conclusions and significance: Occupational adaptation is a concept applied across many practice and research contexts, yet the concept is not fully mature. Concept refinement is required before further applied research is conducted. A shared understanding of occupational adaptation through refinement and research may consolidate its importance and future utility.

Minimal clinically important difference for the Fugl-Meyer assessment of the upper extremity in convalescent stroke patients with moderate to severe hemiparesis

[Purpose] To estimate the minimal clinically important difference for the Fugl-Meyer assessment of the upper extremity by using anchor-based methods in stroke patients with moderate to severe hemiparesis. [Participants and Methods] Fourteen patients who were hospitalized in a convalescent phase rehabilitation ward were included in this study. Fugl-Meyer assessment of the upper extremity was used to assess the impairment prior to intervention and at follow-up (six weeks later). Participants were asked to evaluate the degree of improvement of paresis of the upper extremity using the global rating of change scale at follow-up. The mean change in Fugl-Meyer assessment scores in the group of patients who answered "a little better, meaningful in daily life" in the global rating of change scale was considered as the minimal clinically important difference. [Results] The mean post-onset period of participants for analysis was 49.4 days. The minimal clinically important difference of the Fugl-Meyer assessment scores were 12.4 (upper extremity), 5.6 (upper arm), and 4.9 (wrist/hand). [Conclusion] A score of 12.4 in the Fugl-Meyer assessment of the upper extremity is likely to be perceived as meaningful in stroke patients with moderate to severe hemiparesis.

'No one prepared me to go home': Cerebrovascular accident survivors' experiences of community reintegration in a peri-urban context

BACKGROUND

The South African health system has policies and strategies to ensure effective rehabilitation and reintegration of individuals who have survived a cerebrovascular accident into their respective communities. However, implementation of such guidelines remains an issue.

AIM

This study sought to explore cerebrovascular accident (CVA) survivors' experiences of community integration.

SETTING

The study was located in a peri-urban community within the KwaZulu-Natal Province, South Africa.

METHODS

An explorative qualitative study with eight purposively selected CVA survivors was conducted via semi-structured individual interviews. Data were audio-recorded and manually transcribed prior to thematic analysis. Trustworthiness of the study was maintained by strategies such as analyst triangulation, an audit trail and use of thick descriptions. Ethical principles of autonomy, informed consent, confidentiality and privacy were also maintained in the study.

RESULTS

Six themes emerged that highlighted (1) loss of autonomy and roles, (2) barriers to community reintegration, (3) social isolation of participants, (4) finding internal strength, (5) enablers of community reintegration including the positive influence of support and the benefits derived from rehabilitation and (6) recommendations for rehabilitation.

CONCLUSION

The study revealed both positive and negative influences that impact CVA survivors' ability to effectively reintegrate into their respective communities following a CVA. Recommendations include the need for education and awareness around access to rehabilitation services for CVA survivors, advice on how to improve CVA survivors' ability to mobilise in the community and make environmental adaption to facilitate universal access, provision of home programmes and caregiver training for continuity of care and for inclusion of home-based rehabilitation into current models of care.

Lower garment-lifting postural control characteristics during toilet-related activities in healthy individuals and a post-stroke hemiplegic patient undergoing rehabilitation

[Purpose] This study compared lower garment-lifting postural control characteristics during toilet-related activities between healthy participants and a post-stroke patient, and studied changes in the stroke patient's characteristics during rehabilitation. [Participants and Methods] Six healthy individuals and one stroke participant with right hemiparesis were asked to lift a pair of pants with the left arm while on the toilet. During the process, we measured the mean percentage of body weight (%BW) on each leg and the foot center of pressure (COP) using portable force plates. Measurements were conducted twice for the stroke participant during rehabilitation. [Results] In healthy participants, the %BW and respective COP indices for both legs were not different during lifting, but the COP sway velocity and excursion were greater in the anterior-posterior (AP) than the lateral axis in both legs. In the stroke participant, no marked change was seen in the high %BW of the non-paretic leg while lifting during rehabilitation, but both legs' COP positional asymmetry improved on the AP axis and the COP sway velocity and excursion of the non-paretic leg increased. [Conclusion] Facilitating selective COP mobility on the AP axis of the non-paretic leg during lower garment lifting could become an effective intervention for stroke patients.

The Clinimetric Properties of Instruments Measuring Home Hazards for Older People at Risk of Falling: A Systematic Review

Home hazards are associated with falls among older people living in the community. However, evaluating home hazards is a complex process as environmental factors vary according to geography, culture, and architectural design. As a result, many health practitioners commonly use nonstandardized assessment methods that may lead to inaccurate findings. Thus, the aim of this systematic review was to identify standardized instruments for evaluating home hazards related to falls and evaluate the clinimetric properties of these instruments for use by health practitioners. A systematic search was conducted in the Medline, CINAHL, AgeLine, Web of Science databases, and the University of Sydney Library CrossSearch Engine. Study screening, assessment, and quality ratings were conducted independently. Thirty-six studies were identified describing 19 instruments and three assessment techniques. The clinimetric properties varied between instruments. The Home Falls and Accidents Screening Tool, Home Safety Self-Assessment Tool, In-Home Occupational Performance Evaluation, and Westmead Home Safety Assessment were the instruments with high potential for evaluating home hazards associated with falls. Health practitioners can choose the most appropriate instruments for their practice, as a range of standardized instruments with established clinimetric properties are available.

Clinical effect size of an educational intervention in the home and compliance with mobile phone-based reminders for people who suffer from stroke: protocol of a randomized controlled trial

Background

Stroke is the third-leading cause of death and the leading cause of long-term neurological disability in the world. Cognitive, communication, and physical weakness combined with environmental changes frequently cause changes in the roles, routines, and daily occupations of stroke sufferers. Educational intervention combines didactic and interactive intervention, which combines the best choices for teaching new behaviors since it involves the active participation of the patient in learning. Nowadays, there are many types of interventions or means to increase adherence to treatment.

Objective

The aim of this study is to enable patients who have suffered stroke and been discharged to their homes to improve the performance of the activities of daily living (ADL) in their home environment, based on advice given by the therapist. A secondary aim is that these patients continue the treatment through a reminder app installed on their mobile phones.

Methods

This study is a clinical randomized controlled trial. The total sample will consist of 80 adults who have suffered a stroke with moderate severity and who have been discharged to their homes in the 3 months prior to recruitment to the study. The following tests and scales will be used to measure the outcome variables: Barthel Index, the Functional Independence Measure, the Mini-Mental State Examination, the Canadian Neurological Scale, the Stroke Impact Scale-16, the Trunk Control Test, the Modified Rankin Scale, the Multidimensional Scale of Perceived Social Support, the Quality of Life Scale for Stroke, the Functional Reach Test, the Romberg Test, the Time Up and Go test, the Timed-Stands Test, a portable dynamometer, and a sociodemographic questionnaire. Descriptive analyses will include mean, standard deviation, and 95% confidence intervals of the values for each variable. The Kolmogov-Smirnov (KS) test and a 2x2 mixed-model analysis of variance (ANOVA) will be used. Intergroup effect sizes will be calculated (Cohen’s d).

Results

Currently, the study is in the recruitment phase and implementation of the intervention has begun. The authors anticipate that during 2015 the following processes should be completed: recruitment, intervention, and data collection. It is expected that the analysis of all data and the first results should be available in early-to-mid 2016.

Conclusions

An educational intervention based on therapeutic home advice and a reminder app has been developed by the authors with the intention that patients who have suffered stroke perform the ADL more easily and use their affected limbs more actively in the ADL. The use of reminders via mobile phone is proposed as an innovative tool to increase treatment adherence in this population.

Trial Registration

ClinicalTrials.gov NCT01980641; https://clinicaltrials.gov/ct2/show/NCT01980641 (Archived by WebCite at http://www.webcitation.org/6WRWFmY6U).