Leisure activity after stroke

Prevalence, patterns, and predictors of patient-reported non-motor outcomes at 30 days after acute stroke: Prospective observational hospital cohort study

BACKGROUND

Adverse non-motor outcomes are common after acute stroke and likely to substantially affect quality of life, yet few studies have comprehensively assessed their prevalence, patterns, and predictors across multiple health domains.

AIMS

We aimed to identify the prevalence, patterns, and the factors associated with non-motor outcomes 30 days after stroke.

METHODS

This prospective observational hospital cohort study-Stroke Investigation in North and Central London (SIGNAL)-identified patients with acute ischemic stroke or intracerebral hemorrhage (ICH) admitted to the Hyperacute Stroke Unit (HASU) at University College Hospital (UCH), London, between August 1, 2018 and August 31, 2019. We assessed non-motor outcomes (anxiety, depression, fatigue, sleep, participation in social roles and activities, pain, bowel function, and bladder function) at 30-day follow-up using the Patient-Reported Outcome Measurement Information System-Version 29 (PROMIS-29) scale and Barthel Index scale.

RESULTS

We obtained follow-up data for 605/719 (84.1%) eligible patients (mean age 72.0 years; 48.3% female; 521 with ischemic stroke, 84 with ICH). Anxiety (57.0%), fatigue (52.7%), bladder dysfunction (50.2%), reduced social participation (49.2%), and pain (47.9%) were the commonest adverse non-motor outcomes. The rates of adverse non-motor outcomes in ⩾ 1, ⩾ 2 and ⩾ 3 domains were 89%, 66.3%, and 45.8%, respectively; in adjusted analyses, stroke due to ICH (compared to ischemic stroke) and admission stroke severity were the strongest and most consistent predictors. There were significant correlations between bowel dysfunction and bladder dysfunction (κ = 0.908); reduced social participation and bladder dysfunction (κ = 0.844); and anxiety and fatigue (κ = 0.613). We did not identify correlations for other pairs of non-motor domains.

CONCLUSION

Adverse non-motor outcomes were very common at 30 days after stroke, affecting nearly 90% of evaluated patients in at least one health domain, about two-thirds in two or more domains, and almost 50% in three or more domains. Stroke due to ICH and admission stroke severity were the strongest and most consistent predictors. Adverse outcomes occurred in pairs of domains, such as with anxiety and fatigue. Our findings emphasize the importance of a multi-domain approach to effectively identify adverse non-motor outcomes after stroke to inform the development of more holistic patient care pathways after stroke.

Life and Leisure Activities following Stroke or Transient Ischaemic Attack (TIA): An Observational, Multi-Centre, 6-Month Follow-Up Study

OBJECTIVE

To examine changes in leisure participation following stroke/transient ischaemic attack (TIA) and explore its relationship to modifiable and non-modifiable participant characteristics.

DESIGN

An observational study design with self-report questionnaires collected at two time points (baseline and 6-months).

SETTING

The study was conducted across 21 hospital sites in England, Wales, and Northern Ireland.

PARTICIPANTS

Participants were aged 18+ and had experienced a first or recurrent stroke or TIA and had a post-stroke/TIA modified Rankin score (mRS) of ≤3.

PROCEDURE

Research practitioners at each site approached potential participants. Individuals who agreed to participate completed a baseline questionnaire whilst an inpatient or at a first post-stroke/TIA clinic appointment. A follow-up questionnaire was posted to participants with a freepost return envelope. Two questionnaires were developed that collected demographic information, pre-stroke/TIA mRS, social circumstances (e.g., employment situation) and incorporated the shortened Nottingham Leisure Questionnaire (sNLQ).

RESULTS

The study recruited eligible participants (N = 3295); 2000 participants returned questionnaires at follow-up. Data showed three participant variables were significant predictors of engagement in leisure activities post-stroke/TIA: age, sex, and deprivation decile. There was an overall decline in the number and variety of leisure activities, with an average loss of 2.2 activities following stroke/TIA. Only one activity, "exercise/fitness" saw an increase in engagement from baseline to follow-up; watching TV remained stable, whilst participation in all other activities reduced between 10% and 40% with an average activity engagement reduction of 22%.

CONCLUSIONS

Some groups experienced a greater reduction in activities than others-notably older participants, female participants, and those living in a low socioeconomic area.

REGISTRATION

researchregistry4607.

STRENGTHS AND LIMITATIONS OF THIS STUDY

1. This is the largest-ever study to survey life and leisure activity engagement following stroke/TIA. 2. Survey responses were self-reported retrospectively and, therefore, may have been misreported, or misremembered. 3. Despite the large cohort, there were few participants, and so respondents, from ethnic minority groups.

Measurement properties of self-report physical activity assessment tools for patients with stroke: a systematic review

BACKGROUND

Individuals with stroke demonstrate low levels of physical activity. Self-report measures of physical activity are frequently used and the choice of the best one to use for each purpose and context should take into account the measurement properties of these instruments.

OBJECTIVE

To summarize the measurement properties and clinical utility of self-report measures of physical activity of post-stroke subjects and to evaluate both the methodological quality of the studies and the quality of the measurement properties.

METHODS

Searches were made in MEDLINE, EMBASE, PEDro, LILACS, and SCIELO. Two reviewers independently screened studies that investigated measurement properties or clinical utility of self-report measures of physical activity in post-stroke subjects. The studies' methodological quality, quality of the measurement properties, and clinical utility were evaluated.

RESULTS

From the 11,826 identified studies, 19 were included. Six self-report tools were evaluated: The Activity card sort, Coded activity diary, Frenchay activities index (FAI), Human activity profile (HAP), Multimedia activity recall for children and adults, and the Nottingham leisure questionnaire. The methodological quality of the studies ranged from "poor" to "good". Most of the results regarding the quality of the measurement properties were doubtful. None of the self-report tools had their content validity investigated. The FAI and HAP showed the highest clinical utility scores.

CONCLUSIONS

Content validity needs to be better investigated to determine if the instruments actually measure the physical activity domain. Further studies with good methodological quality are required to assist clinicians and researchers in selecting the best instrument to measure physical activity levels.

Occupational Life in the Home Environment: The Experiences of People with Disabilities

Background

There is a need to empirically explore the occupational engagement of people with disabilities to support the development of occupational therapy interventions.

Purpose

This study describes how people with disabilities experience their occupational lives in their home environment.

Method

Thirteen people with physical disabilities living at home were interviewed and data were subsequently analysed using a constant comparative method.

Results

The findings showed that interactions between the individuals and their environment influenced their experiences of engaging in occupations and the meaning of their home. Occupations formed three categories: always performed with others, occasionally disrupted or deprived. These were particularly related to the social support that was provided under different conditions. This condition formed a central category: access to social support for occupations. Their experiences of performing occupations in the home also formed another central category: transformed meaning of the home.

Practice Implications

By understanding enabling conditions as well as barriers to occupational engagement, effective occupational therapy interventions can be developed to support the occupational lives of people with disabilities.

Examining the relationships between environmental barriers and leisure in community-dwelling individuals living with stroke

OBJECTIVE:

To characterize environmental barriers to leisure participation among individuals living with stroke; examine relationships between environmental barriers and leisure interest and satisfaction; and investigate participant factors associated with the perception of environmental barriers.

DESIGN:

Survey.

SETTING:

Community.

PARTICIPANTS:

Convenience sample of 51 community-dwelling adults less than six months post stroke.

INTERVENTIONS:

Not applicable.

MAIN OUTCOME MEASURE(S):

Craig Hospital Inventory of Environmental Factors-Short Form.

RESULTS:

Physical and structural environmental barriers were reported as the most frequent and large barrier to leisure participation ( n = 26 (51%) rated as "monthly or more," n = 12 (24%) rated as "big problem"). While attitude and support and policy barriers were not as commonly encountered, participants labeled these as "big problem(s)" (attitude and support n = 6 (12%), policy n = 7 (14%)). The presence of depressive symptoms was associated with the frequency in which attitudinal and support (rho = 0.50, P < 0.001), physical and structural (rho = 0.46, P < 0.001), and service and assistance (rho = 0.28, P = 0.04) barriers were reported, as well as magnitude of attitude and support barriers (rho = 0.48, P < 0.001). In multivariable regression analysis, depressive symptoms and walking capacity explained 21% of the variance of the frequency of attitude and support barriers ( P = 0.004), where depressive symptoms was an independent correlate ( P = 0.004). No other factors were associated with environmental barriers to leisure participation.

CONCLUSION:

Individuals with stroke report frequent and large physical and structural environmental barriers to leisure participation, which may be associated with the presence of depressive symptoms.

Course of Social Participation in the First 2 Years After Stroke and Its Associations With Demographic and Stroke-Related Factors

Background. Many persons with stroke experience physical, cognitive, and emotional problems that contribute to restrictions in social participation. There is, however, a lack of knowledge on the long-term course of participation over time post-stroke. Objective. To describe the time course of participation up to 2 years post-stroke and to identify which demographic and stroke-related factors are associated with this time course. Methods. This was a multicenter, prospective cohort study following 390 persons with stroke from hospital admission up to 2 years (at 2, 6, 12, and 24 months). Multilevel modeling with linear and quadratic time effects was used to examine the course of the frequency of vocational and social/leisure activities, experienced restrictions, and satisfaction with participation. Results. The frequency of vocational activities increased up to 1 year post-stroke and leveled off thereafter. Older and lower-educated persons showed less favorable courses of participation than younger and higher-educated persons, respectively. The frequency of social/leisure activities decreased post-stroke. Participation restrictions declined up to 1 year post-stroke and leveled off thereafter. Persons dependent in activities of daily living (ADL) kept experiencing more restrictions throughout time than independent persons. Satisfaction with participation increased slightly over time. Conclusions. Changes in participation occurred mostly in the first year post-stroke. Particularly older and lower-educated persons, and those dependent in ADL showed less favorable courses of participation up to 2 years post-stroke. Clinicians can apply these findings in identifying persons most at risk of long-term unfavorable participation outcome and, thus, target rehabilitation programs accordingly.

Usability of a Low-Cost Head Tracking Computer Access Method following Stroke

Assistive technology devices for computer access can facilitate social reintegration and promote independence for people who have had a stroke. This work describes the exploration of the usefulness and acceptability of a new computer access device called the Nouse™ (Nose-as-mouse). The device uses standard webcam and video recognition algorithms to map the movement of the user's nose to a computer cursor, thereby allowing hands-free computer operation. Ten participants receiving in- or outpatient stroke rehabilitation completed a series of standardized and everyday computer tasks using the Nouse™ and then completed a device usability questionnaire. Task completion rates were high (90%) for computer activities only in the absence of time constraints. Most of the participants were satisfied with ease of use (70%) and liked using the Nouse™ (60%), indicating they could resume most of their usual computer activities apart from word-processing using the device. The findings suggest that hands-free computer access devices like the Nouse™ may be an option for people who experience upper motor impairment caused by stroke and are highly motivated to resume personal computing. More research is necessary to further evaluate the effectiveness of this technology, especially in relation to other computer access assistive technology devices.

Generalisation of the Effects of Leisure Rehabilitation for Stroke Patients

A randomised controlled trial was used to evaluate the effectiveness of a leisure rehabilitation programme on functional performance and mood. The subjects were randomly allocated to three groups: a leisure rehabilitation group, a conventional occupational therapy group and a control group. The subjects assigned to the leisure and conventional occupational therapy groups received individual treatment at home on discharge from hospital. Baseline assessments were carried out on admission to the study and at 3 and 6 months after discharge from hospital by an assessor who was ‘Mind’ to group allocation. The subjects receiving leisure rehabilitation performed significantly better in mobility and psychological well-being than the subjects in the other two groups.

The Nottingham Leisure Questionnaire for Stroke Patients

Although leisure is now regarded as an Important aspect of life, there is no suitable instrument to measure the leisure activity of stroke patients in this country. An instrument was therefore developed and its reliability tested. The majority of results for the inter-rater reliability study were ‘excellent’, and ‘excellent’ or ‘good’ for the test re-test reliability study. It is suggested that the tool has potential for clinical use.

An Investigation into the Leisure Occupations of Older Adults

Participating in leisure is known to enhance physical wellbeing, mental health and social functioning. There is, however, little knowledge of the current level of engagement in leisure occupations by older adults in the United Kingdom. Therefore, the aim of this study was to explore the current leisure occupations of adults over 60 years who considered themselves to be healthy and to identify the motivations that underpinned participation in those occupations.

Structured interviews were conducted with 70 adults with a mean age of 72 years. The majority of the participants (51, 73%) reported engaging in leisure occupations. The range of leisure occupations was wide and included walking, sailing, listening to music, emailing and volunteering. Of these, 23% were active leisure, 18% passive leisure, 24% social leisure, 20% hobbies and 15% other leisure occupations. Content analysis was adopted to explain the motivators for taking part in these leisure occupations. It was found that enjoyment, pleasure and relaxation were the key motivators.

This study shows that the majority of well older people are participating in leisure occupations and feeling positive about doing so. Further research is required to establish the role that occupational therapists can have in encouraging older adults to continue with or develop new leisure occupations to enhance health and quality of life.

Computers in Neurorehabilitation: What Role do they Play? Part 1

This article is in two parts. The first part introduces the concept of a structured approach in the assessment of patients in neurorehabilitation. The overall role of computers is broken down into seven potential areas where they may be of benefit: communication, motor skills, cognitive functions, social skills, mood, work and leisure. There are many different treatment approaches that are used with computers in neurorehabilitation, ranging from remediation of lost skills to adaptation of function. The second part uses a case study to demonstrate the methods of assessment and the practical techniques that are used to overcome everyday issues. The overall conclusion is that computers can become an integral part of neurorehabilitation and it is essential for occupational therapists to gain a greater insight into their use in order to enhance their patients' independence and quality of life.

The Use of Transport by Stroke Patients

The objectives of this research were to survey the use of transport by stroke patients in the community and study its relationship to their activities of daily living and mood.

The records of 90 consecutive stroke patients receiving community occupational therapy in a rehabilitation trial were surveyed for entries of therapy related to transport. A further 50 stroke patients in the same study were surveyed about their use of transport one year after discharge from hospital.

In the survey of occupational therapy notes, a transport assessment had been recorded for all 90 patients. Of these, 22 patients had been given leaflets describing the range of transport options locally but had been unable to use these options.

In the survey of transport use, 42/50 (84%) patients surveyed at one year responded. Twenty-one (50%) had used transport on their own, six of whom scored <26/66 on the Extended Activities of Daily Living scale (indicating that they needed help in most activities of daily living). Twenty-one (50%) patients had not travelled alone, four of whom scored >48/66 on the Extended Activities of Daily Living scale (very able in activities of daily living). Only 1 (2%) patient had used specialist transport and 22 (52%) reported that they did not get out as much as they wished.

Despite receiving advice, these patients did not use specialist transport options, yet many still wanted to get out more. The reason for this is unclear but it is not due simply to physical disability.

Evaluation of a pilot service designed to provide support following stroke: a randomized cross-over design study

Objective: To evaluate a day service for people aged 18–55 years who had a stroke.

Design: A randomized cross-over study design was used, randomly allocating individuals to attend the service for six months followed by a period of no attendance for six months.

Setting: A day service pilot project was launched in Cardiff in July 1995 for people who were aged between 18 and 55 years and had a stroke. It met one day a week.

Subjects: Twenty-six participants were recruited to the study between June 1998 and February 2000. Their mean age was 48 years (SD = 7).

Interventions: The service aimed to offer participants the opportunity to identify and pursue meaningful and realistic opportunities within the community. A range of activities occurred at the service including creative activities and social outings.

Main outcome measures: The Barthel ADL Index, Extended ADL Scale, Nottingham Leisure Questionnaire, Short Form 36, the Hospital Anxiety and Depression Scale, the Canadian Occupational Performance Measure, the Role Checklist and the Semantic Differential Self Concept Scale were used to assess the outcomes from the service.

Results: Attending the service increased occupational performance and satisfaction with performance but there was no evidence that depression and anxiety were reduced or that quality of life and self-concept were improved.

Conclusion: Although there were some gains from attending the service there were also many unmet needs. Further research is required to continue to identify how best to meet the needs of individuals post stroke under retirement age.

A randomized controlled trial of leisure rehabilitation after stroke

A three-group pre-test-post-test design was used to evaluate the effectiveness of a leisure rehabilitation programme. Subjects were randomly allocated to the leisure rehabilitation group, the conventional occupational therapy group, or the control group. Baseline assessments of leisure were carried out on admission to the study and at three months and six months after discharge from hospital. The results showed an increase in the leisure scores for the leisure rehabilitation group only. There was an age imbalance in the study but, after analysis of co- variance, the results were upheld.

Focus on Leisure Repertoire in the Oldest Old: The Umeå 85+ Study

This study elucidates the oldest olds’ leisure repertoire and how this repertoire varies due to gender, where they live, and cognitive status. A validated 20-item leisure interest checklist with four subscales was used to measure leisure participation and investigate the leisure repertoire among participants. The oldest old were most likely to be interested in, perform, be motivated for, and perceive well-being from social activities, cultural activities, and TV/video/movies. The respondents were least likely to be interested in, perform, be motivated for, and perceive well-being from equipment sports and ball games. Some gender, geographic differences, and differences in cognitive status were found. The oldest old were more likely to endorse the same activities across all subscales of the checklist, but the linear magnitude varied across sub-scales. The relationships between performance and the other subscales suggested that a sense of engagement or participation is related to actual performance.

Emotion processing and social participation following stroke: study protocol

BACKGROUND

The International Classification of Functioning, Disability and Health (ICF) defines participation as a person's performance in life situations, including the size of social networks, and satisfaction with social contacts. Stroke survivors are known to experience a reduction in the number of their social networks and contacts, which cannot be explained solely in terms of activity limitations caused by physical impairment. Problems of emotional processing, including impaired mood, emotion regulation and emotion perception, are known to occur following stroke and can detrimentally influence many aspects of social interaction and participation. The aim of this study is to investigate whether emotion processing impairments predict stroke survivors' restricted social participation, independent of problems with activity limitation.

METHODS/DESIGN

We aim to recruit 125 patients admitted to NHS Grampian with a confirmed diagnosis of stroke. All participants will be assessed on measures of emotion processing, social participation and activity limitation at approximately one month post stroke and again at approximately one year post stroke in order to assess change over time.

DISCUSSION

It is important to develop a greater understanding of the emotional factors which may underlie key social deficits in stroke recovery in an ageing population where stroke is one of the leading causes of severe, complex disability. This research may enable us to identify those who are risk of participation restriction and target them in the acute stroke phase of stroke so that adverse outcome is avoided and rehabilitation potential is fulfilled.

A Geriatric Day Hospital: Who Improves the Most?

This study compared the changes in some bio-psychosocial variables (functional independence, nutritional risk, pain, balance and walking, grip strength, general well-being, psychiatric profile, perception of social support, leisure satisfaction, and caregivers' feeling of burden) in four categories of clients during their program at a geriatric day hospital (GDH). The study also evaluated whether or not improvements, if any, were maintained 3 months after discharge. One-hundred-and-fifty-one people, categorized by primary reason for admission, were assessed at the GDH with reliable and valid tools, at admission and at discharge. Three months after discharge, they were reassessed with the same tools. Overall, two categories of clients, stroke / neurological diseases and musculoskeletal disorders / amputations, improved the most. For the gait disorders and falls group, only the functional independence score improved, but not at a clinically significant level. Finally, clients in the cognitive function disorders / psychopathologies group improved the most on their well-being scores and caregivers' burden decreased the most. All gains were maintained up to 3 months after discharge, except for leisure satisfaction. With the exception of clients who attended the GDH because of gait disorders and falls, the improvements and maintenance achieved in each category occurred in the domains where improvement had been hoped for, because of the particular disabilities in question and because of the nature of the GDH services offered.

Patient perceptions having suffered a stroke in Galway

Of the estimated 10,000 people annually who have a stroke in Ireland, about 7500 will continue to live with some residual disability. This study explored older people's perceptions of health, level of independence as well as the factors that enhanced or diminished ability to maintain quality of life after stroke. A grounded theory approach was used and 20 stroke survivors were interviewed. Analysis of the data revealed three main themes: concepts of health and independence, sense of loss, and environmental factors. Despite their disability most participants continued to have a positive concept of health. Participants overall adopted a functional approach toward independence and those with severe disabilities felt less independent. Many reported a profound sense of loss in terms of identity and role function. Environmental factors including availability of transport and social connections had a significant impact on quality of life. Most participants appeared to be struggling to adapt to their disability and subsequent experiences in a rather unsupportive environment.

Effect of a home leisure education program after stroke: a randomized controlled trial

OBJECTIVE

To evaluate the effect of a leisure education program on participation in and satisfaction with leisure activities (leisure-related outcomes), and well-being, depressive symptoms, and quality of life (primary outcomes) after stroke.

DESIGN

Randomized controlled trial.

SETTING

Home and community.

PARTICIPANTS

Sixty-two people with stroke.

INTERVENTION

Experimental participants (n=33) received the leisure education program at home once a week for 8 to 12 weeks. Control participants (n=29) were visited at home at a similar frequency. Participants were evaluated before and after the program by a blinded assessor.

MAIN OUTCOME MEASURES

Change from preintervention to postintervention in: minutes of leisure activity per day, number of leisure activities, the Leisure Satisfaction Scale, the Individualized Leisure Profile, the General Well-Being Schedule (GWBS), the Center for Epidemiological Studies Depression Scale, and the Stroke-Adapted Sickness Impact Profile (SA-SIP30).

RESULTS

There was a statistically significant difference in change scores between the groups for satisfaction with leisure with a mean difference of 11.9 points (95% confidence interval [CI], 4.2-19.5) and participation in active leisure with a mean difference of 14.0 minutes (95% CI, 3.2-24.9). There was also a statistically significant difference between groups for improvement in depressive symptoms with a mean difference of -7.2 (95% CI, -12.5 to -1.9). Differences between groups were not statistically significant on the SA-SIP30 (0.2; 95% CI, -1.3 to 1.8) and GWBS (2.2; 95% CI, -5.6 to 10.0).

CONCLUSIONS

The results indicate the effectiveness of the leisure education program for improving participation in leisure activities, improving satisfaction with leisure and reducing depression in people with stroke.

Arm and leg impairments and disabilities after stroke rehabilitation: relation to handicap

OBJECTIVES

(1) To examine the relationships between measures of impairment and disability for the arm and leg with a measure of handicap and (2) to identify the impairment or disability most strongly related to handicap situations.

DESIGN

Prospective cohort study.

SETTING

Intensive functional rehabilitation unit and community.

PATIENTS

One hundred and two persons who had a stroke.

MAIN OUTCOME MEASURES

Arm and leg impairments and disabilities were evaluated with reliable and valid tests at discharge from rehabilitation. Six months later, handicap situations were evaluated with the Assessments of Life Habits (LIFE-H).

RESULTS

Arm and leg impairments and disabilities are correlated with handicap situations. Disability of the leg is more strongly associated with handicap than arm disability. Arm and leg disabilities are not statistically more strongly related to handicap than arm and leg impairments.

CONCLUSIONS

The high correlations found between handicap situations and the impairment and disability measures of the leg provide new information that support the importance of mobility to promote integration after stroke.

Development and validation of the Nottingham Leisure Questionnaire (NLQ)

OBJECTIVES

To reduce the length of the Nottingham Leisure Questionnaire (NLQ) in order to make it more suitable for postal use, and to evaluate its test-retest reliability, sensitivity, stability and validity in relation to other measures of activities of daily living (ADL), mood and handicap.

METHOD

The NLQ was shortened and the response categories collapsed. Results from a previous trial which had used the NLQ were reanalysed to establish if significant group differences were maintained. The new version of the NLQ was subsequently tested for test-retest reliability on a new group of patients from the Nottingham stroke register who were asked to complete it twice. The new NLQ and other measures were sent to patients in a multicentre rehabilitation trial (TOTAL) six and twelve months after recruitment for postal completion.

SUBJECTS

One hundred and thirty-seven consecutive patients from the Nottingham stroke register and 466 patients with a stroke in a multicentre rehabilitation trial.

RESULTS

The original NLQ was reduced from 37 to 30 items and from five to three response categories. Data from an earlier study were reanalysed and differences between treatment groups remained. The results of a test-retest analysis using kappa showed that six items had excellent agreement, 15 good and nine fair, suggesting acceptable test-retest reliability. Results from the rehabilitation trial showed that the subjects performed all items and few additional activities were suggested. Higher NLQ scores were associated with higher subscores on the Nottingham Extended Activities of Daily Living Scale (NEADL) and lower NLQ scores with living alone and worse emotional health.

CONCLUSION

The NLQ has been successfully modified for postal self-administration but there is potential for further development.

A multicentre randomized controlled trial of leisure therapy and conventional occupational therapy after stroke. TOTAL Study Group. Trial of Occupational Therapy and Leisure

OBJECTIVE

To evaluate the effects of leisure therapy and conventional occupational therapy (OT) on the mood, leisure participation and independence in activities of daily living (ADL) of stroke patients 6 and 12 months after hospital discharge.

DESIGN

Multicentre randomized controlled trial.

SETTING AND PARTICIPANTS

Four hundred and sixty-six stroke patients from five UK centres.

MAIN OUTCOME MEASURES

The General Health Questionnaire (12 item), the Nottingham Extended ADL Scale and the Nottingham Leisure Questionnaire, assessed by post, with telephone clarification.

RESULTS

Four hundred and forty (94%) and 426 (91%) subjects were alive at 6 and 12 months, respectively. Three hundred and seventy-four (85% of survivors) and 311 (78% of survivors) responded at 6 and 12 month follow-up respectively. At six months and compared to the control group, those allocated to leisure therapy had nonsignificantly better GHQ scores (-1.2: 95% CI -2.9, +0.5), leisure scores (+0.7, 95% CI -1.1, +2.5) and Extended ADL scores (+0.4: 95% CI -3.8, +4.5): the ADL group had nonsignificantly better GHQ scores (-0.1: 95% CI -1.8, +1.7) and Extended ADL scores (+1.4: 95% CI -2.9, +5.6) and nonsignificantly worse leisure scores (-0.3: 95% CI -2.1, +1.6). The results at 12 months were similar.

CONCLUSION

In contrast to the findings of previous smaller trials, neither of the additional OT treatments showed a clear beneficial effect on mood, leisure activity or independence in ADL measured at 6 or 12 months.

Social reintegration after stroke: the first stages in the development of the Subjective Index of Physical and Social Outcome (SIPSO)

OBJECTIVE

To ensure at outset the content validity of a measure (to be developed) of social integration following stroke.

DESIGN

Qualitative study, using in-depth interviews with patients at least six months following stroke.

SETTING

Community setting, Bristol, UK.

SUBJECTS

Thirty survivors of stroke, discharged at least six months previously from a neurological rehabilitation unit in a district general hospital.

RESULTS

Patients reported a change, usually for the worse, in their levels of integration following stroke. More specifically they alluded to a decrease in both the quantity and quality of activities, especially with regard to leisure and those activities occurring outside the home. Social interaction was reduced in most patients, in terms of frequency and quality of contact. From the data, six dimensions of change in quality of interaction emerged. Finally, changes in patients' physical and financial environments were reported. Based on the findings, four diagrams were developed, providing a structure for questionnaire development.

CONCLUSIONS

The results of this study confirm the findings of previously reported research. An individual's level of social integration can be affected by stroke in a wide variety of areas and along many different dimensions. Data from this study have highlighted the importance of the patient's subjective impression of the quality of both functional and social performance. This has provided the opportunity to develop a questionnaire based on the patient's perspective, rather than that of health professionals.

Changes in the quality of life of hemiplegic stroke patients with time: a preliminary report

To evaluate the influence of time on the quality of life of hemiplegic stroke patients living at home, we analyzed a sample of 45 outpatients. The sample was divided into two groups, according to the delay between the discharge time from hospital and the assessment (Group 1, fewer than 6 mo; Group 2, more than 6 mo after discharge). We hypothesized that patients in Group 2 would have a lower level of quality of life than patients in Group 1. Disability was assessed with the Functional Independence Measure, and the quality of life was assessed with the Reintegration to Normal Living Index. Both groups were comparable with regard to demographic and stroke characteristics. There was no statistically significant difference in Functional Independence Measure scores (global and subscales). Reintegration to Normal Living Index-perception of self subscale scores were significantly lower in Group 2. At the item level, quality of life scores were also significantly lower in Group 2 for indoor mobility (Mann-Whitney U test; P = 0.001), self-care needs (P = 0.005), personal relationships (P = 0.02), and the handling of life events (P = 0.05). These results confirm our hypothesis and suggest that quality of life may deteriorate in some domains over time, even when the disability level is unchanged, but these results need to be replicated in prospective studies with larger samples of stroke survivors.

Development of a neurological rehabilitation environment: an observational study

BACKGROUND

Engagement in therapeutic activity among stroke inpatients is advocated by many rehabilitation professionals. However, there is a lack of published evidence to indicate whether this is currently being achieved.

OBJECTIVE

To investigate the extent and types of 'rehabilitation' activities on a new neurological rehabilitation ward, and examine change in patients' behaviour related to the new environment and new initiatives.

DESIGN

Five one-week observation periods were conducted over two years, with a total of 67 patients being observed. A comparison was made with results of an earlier study of stroke patients' activities conducted at the same hospital.

RESULTS

Patients spent an average 43 min per day with therapists (9% of the working day) and this was only marginally supplemented by self-exercise (2% of the working day--approximately 10 min). However, the provision of a new rehabilitation environment was associated with a marked decrease in the time patients spent at their bedsides, and a decrease in time spent passively gazing or watching others.

CONCLUSIONS

Overall there was some positive change in patients' behaviour. We suggest that structured guidance is required from the whole multidisciplinary team to stimulate more self-directed therapy practice and recreation.

The role of leisure in stroke rehabilitation

Stroke patients often fail to resume full lives, even if they make a good physical recovery, and social and leisure pursuits show a particular decline. The usual goals of rehabilitation are mobility and independence in self-care, but recovery in a broader sense may be impeded if health professionals concentrate exclusively on these. Leisure has been shown to be closely associated with life satisfaction and would be a worthwhile, and now measurable, goal of rehabilitation. Elderly people show a decline in leisure activity which has been studied extensively and may provide a useful model for the more rapid decline seen in stroke patients. Further research is needed to confirm the finding that specialized occupational therapy can be effective in raising leisure activity, and to show whether this will translate into improved psychological well-being.

The behaviour of stroke patients in unsupervised computer-administered aphasia therapy

Little is known about how patients behave when they are undertaking programmes of work at home, between clinical sessions. Concern has been expressed about the possibility of potentially harmful behaviour patterns being adopted when computers are used in this mode of therapy. This paper reports on two sets of trials, each involving 10 patients; however, due to disk corruption, full data are available for a total of 17 subjects. Data were captured which enabled analysis of length of session, timing of session, and patterns of use over the 6-week period of each trial. No evidence of harmful behaviour was found. Patients tended to work in sessions broadly comparable in length with clinical practice. There was also a proportionate amount of work done in the evenings and at weekends, outside normal clinical hours.

On non-work activity preferences: relationships with occupational roles

Occupational therapy is to a great extent based on the idea of engaging patients in meaningful activities. Using mailed checklists this investigation examines the preference attached to 50 activities by 201 adult (25-55 years old) northern Swedes using a four-grade ordinal scale. The self-reported levels of activity preferences were related to age and gender. Factor analysis was used to analyse the inter-relationships between activity preferences. The possible effects of activity preferences on self-reported occupational role internalization (10 items) were examined using discriminant analyses. Activity preferences were gender-dependent for more than half of the activities while only 14 of them were age-dependent. The factor analysis grouped 41 of the activities into 15 factors which were labelled 'activity goals'. Fourteen of these were distinct classifiers (discriminant analyses) of the self-reported degree of internalization of 8/10 occupational roles. In this sample occupational role internalization has elsewhere been demonstrated to be closely related to several domains of life satisfaction, which in turn are closely associated with satisfaction with life as a whole. Taken together with those results the present investigation leads the authors to suggest this model: activity preferences-->occupational roles-->domain-specific life satisfaction-->happiness.

The influence of depression, social activity, and family stress on functional outcome after stroke

BACKGROUND AND PURPOSE

This study was designed to assess the quality of life after an active poststroke period of rehabilitation and to investigate the possibility of a return to a working environment for those still of working age.

METHODS

The study was conducted on 180 consecutive patients affected by stroke who were hospitalized for the first time and discharged at least 1 year before the study. The group consisted of 65% men and 35% women with a mean age 65.29 years (SD, 11.22). The period between the stroke and the interview ranged from 12 to 196 months, with a mean of 37.5 months. The average Rankin score on discharge from the rehabilitation center was 2.718 (moderate handicap). The interview took place at home after consent obtained by telephone. The questionnaire included general and personal information regarding the individuals, their socioeconomic position, and scales for daily activity, depression, social activity, and stress produced in the family. The control group consisted of 167 age-matched subjects.

RESULTS

A close correlation was observed in all patients between depression, social activity, and stress caused to relatives. The scores on the individual scales were clearly worse than those for control subjects. The patients received approximately 5 months of rehabilitation after the stroke. Differences emerged between men and women for depression and social activities, with the women scoring worse. In reference to daily life, 70% of prestroke ability was required on average after rehabilitation. The daily activity score at the time of the interview was also strongly influenced by the discharge score. The majority of patients were retired. Of the total, 20.64% returned to work, but not always to the same job and often after readapting to new conditions. Of this population, only 31.5% were women. With regard to the population aged younger than 65 years, 21.42% returned to work. Lesions in the dominant hemisphere do not necessarily seem to rule out return to work, even if associated with aphasia. The main discriminating element was the ability to understand language. The patients were often criticized by their cohabitants; the criticisms most often raised concerned apathy, irritability, and self-centeredness. Sexual activity was depressed in almost all cases.

CONCLUSIONS

Despite the progress made in studying cerebral vasculopathies, patients in the aftermath of a stroke still seem to live unsatisfactorily, as they did many years ago. Useful measures include valid treatment against spasticity, psychological assistance, and greater social support.

Self-reported prevalence of disability after subarachnoid haemorrhage, with special emphasis on return to leisure and work

The prevalences of motor and language impairments and of disabilities in activities of daily living (ADL), leisure and work were investigated in a consecutive series (n = 296) of long-term survivors of subarachnoid haemorrhage (SAH). Motor and language impairments were present in 17 and 20%, respectively. The majority reported independence in self-care (91%) and instrumental (80%) ADL, but among the self-care independent, 23% reported need of personal assistance. Leisure disability occurred in 48% and vocational disability in 40%. Hence, disabilities are more common after SAH than is indicated by occurrences of motor and language impairments. It is concluded that the discrepancy between the prevalences of impairments and of disabilities may be to a great extent caused by coping difficulties in relation to socio-demographic and geographic circumstances. The findings indicate a need for rehabilitative follow-up for virtually all SAH-patients.