The role of leisure in stroke rehabilitation

Personal factors, participation, and satisfaction post-stroke: A qualitative exploration

BACKGROUND

Decreased participation and life satisfaction are common post-stroke. Exploratory studies have indicated associations between these outcomes and personal factors. Information remains limited and experiences of people with stroke are not well-represented or understood.

AIMS/OBJECTIVES

The aim of this study was to explore how personal factors influence experiences of participation and life satisfaction for people with stroke living in the community.

MATERIAL AND METHODS

Qualitative in-depth semi-structured interviews were conducted with eight participants living in the community post-stroke, chosen purposively based on participation and life satisfaction levels. Data were interrogated using interpretative phenomenological analysis.

RESULTS

Three themes were identified: (1) What does participation mean to me? (2) Looking forward or looking back, and (3) Appraisals, avoidance, and "getting on with it". The first acknowledged the multifaceted nature of participation, although it was typically viewed as incorporating active involvement and social interaction. The additional two themes explored impacts of pre/post-stroke self-discrepancies and threat appraisals on participation and life satisfaction outcomes.

CONCLUSIONS AND SIGNIFICANCE

Relationships between participation and personal factors seem to be bidirectional. Life satisfaction appeared to be influenced by rumination on negative self-discrepancies based on difference in pre/post-stroke participation. Findings suggest there may be value in examining the influence of personal factor-related interventions on post-stroke outcomes.

Participation and autonomy five years after stroke: A longitudinal observational study

OBJECTIVE

Stroke is the second most common cause of disability in the world. The purpose of this study was to evaluate the participation and autonomy of persons with stroke, five years after a stroke, and to explore potential associations between factors and perceived restrictions in participation and autonomy.

METHODS

This five-year follow-up survey study included individuals diagnosed with a first-time stroke during 2009-2010, in Gothenburg. The survey included the Impact of Participation and Autonomy-questionnaire (IPA-E), which comprised five domains: Autonomy Indoor, Family Role, Autonomy Outdoor, Work & Education, and Social Life & Relationships. Logistic regression analyses were used to analyze factors associated with participation restrictions.

RESULTS

At 5 years after a stroke, 457 patients were alive; of these, 281 responded to the follow-up survey. Participation restrictions were most pronounced in the IPA-E domains of Autonomy Outdoors, Work/Education, and Social Life and Relationships. In contrast, restrictions were less pronounced in the IPA-E domains of Autonomy Indoors and Family Role. Severe stroke, older age, and female sex predicted participation restrictions at five years after a stroke. Participation restrictions were partly explained by feelings of depression at five years after stroke. Problems associated with participation restrictions were most frequently observed in the areas of mobility, leisure, and help/support from other people.

CONCLUSION

This study showed that participation and autonomy were restricted among persons with stroke at five years after the stroke. The domains perceived as most restricted were those that required high levels of physical, social, and cognitive abilities.

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.

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.

Well-being and instrumental activities of daily living after stroke

Objective: To explore the relationship between subjective well-being and competence in instrumental activities of daily living after stroke.

Design: Cross-sectional with evaluation at six months post stroke.

Subjects: Eighty-two patients admitted to an acute stroke unit, of whom 64 were seen at six months. The mean age was 77.5 years, 55% were females and 55% were living alone. Main outcome measures: The General Health Questionnaire (GHQ-20 version), a well-being scale, was factor analysed and yielded three dimensions, named ‘coping’, ‘anxiety’ and ‘satisfaction’ that served as main outcomes.

Results: Explanatory variables were the four subscales of the Nottingham IADL scale, the Ullevaal Aphasia Screening test, urinary continence and demographics. Structural equation modelling showed that the GHQ dimension ‘satisfaction’ related significantly to the Nottingham subscale ‘leisure activities’ (β = -0.38, p= 0.01), whereas ‘coping’ was indirectly associated with ‘leisure activities’ by its correlation with ‘satisfaction’ (R= 0.26, p= 0.01). None of the outcomes were statistically associated with aphasia, continence or the background variables.

Conclusion: ‘Leisure activities’ demonstrated the strongest association to subjective well-being as expressed by the ‘satisfaction’ dimension. In stroke rehabilitation leisure activities should be addressed when assessing function and planning intervention.

The correlation between occupational performance and well-being in stroke patients

[Purpose] This study was performed to evaluate the occupational performance of stroke patients and their environment by occupational self-assessment and to investigate the relationship between occupational performance and well-being. [Subjects and Methods] This study enrolled ninety-two stroke patients who were receiving occupational therapy at a general hospital, a rehabilitation hospital, or a community welfare center in the cities of Busan and Gimhae, Republic of Korea. Occupational performance and well-being were investigated with Occupational Self-Assessment Version 2.2 and the Personal Well-being Index-Adult. [Results] Analysis of the correlation between occupational performance as assessed by the "Myself" and "My Environment" sections of Occupational Self-Assessment Version 2.2 and well-being revealed moderate positive correlation for both sections. [Conclusion] The relationship between occupational performance and well-being was identified. Further studies are needed to reveal whether improvement of occupational performance could affect well-being in various dimensions.

The relationship between bilateral knee muscle strength and gait performance after stroke: the predictive value for gait performance

[Purpose] The purpose of this study was to assess the relationships between bilateral knee extension strengths and gait performance in subjects with poststroke hemiparesis and to predict gait performance by the paretic and nonparetic knee extension strength. [Subjects and Methods] This was a correlational study in which 238 consecutive inpatients with poststroke hemiparesis were enrolled. Knee extensor muscle strengths in paretic and nonparetic lower limbs were measured with a handheld dynamometer, and the presence or absence of impaired gait was also determined. [Results] The mean strength in the paretic lower limb was 0.90 Nm/kg, and that in the nonparetic lower limb was 1.24 Nm/kg. Discriminant analysis classified the difference between the possibility and impossibility of gait by knee extensor muscle strength (standardized discriminant coefficient: paretic, 1.32; nonparetic, 0.55). Thus, paretic and nonparetic knee extension strengths were integrated in the strength index. A threshold level of 2.0 provided the best balance between positive and negative predictive values for the strength index. [Conclusion] The results indicated that both paretic and nonparetic knee extension strengths were related to gait performance. The strength index deduced from bilateral knee extension strengths may serve as a clinically meaningful index for rehabilitation assessment and training.

Participation in leisure activity and exercise of chronic stroke survivors using community-based rehabilitation services in seongnam city

OBJECTIVE

To clarify how participation in leisure activities and exercise by chronic stroke survivors differs before and after a stroke.

METHODS

Sixty chronic stroke survivors receiving community-based rehabilitation services from a health center in Seongnam City were recruited. They completed a questionnaire survey regarding their demographic characteristics and accompanying diseases, and on the status of their leisure activities and exercise. In addition, their level of function (Korean version of Modified Barthel Index score), risk of depression (Beck Depression Inventory), and quality of life (SF-8) were measured.

RESULTS

After their stroke, most of the respondents had not returned to their pre-stroke levels of leisure activity participation. The reported number of leisure activities declined from a mean of 3.9 activities before stroke to 1.9 activities post-stroke. In addition, many participants became home-bound, sedentary, and non-social after their stroke. The most common barriers to participation in leisure activities were weakness and poor balance, lack of transportation, and cost. The respondents reported a mean daily time spent on exercise of 2.6±1.3 hours. Pain was the most common barrier to exercise participation.

CONCLUSION

Chronic stroke survivors need information on leisure activities and appropriate pain management.

Long-Term Changes in Participation After Stroke

BACKGROUND AND PURPOSE

People who have had a stroke may have difficulty resuming some of their previous activities, which leads to a decline in their participation in daily activities and social roles. The purposes of this study were to compare participation 6 months (T1) and between 2 and 4 years (T2) after discharge from a rehabilitation unit and to verify if any changes were associated with changes in personal and environmental factors.

METHOD

Participation of people who had had a stroke was measured at T1 and T2 with the Assessment of Life Habits.

RESULTS

A significant reduction (p < .001) in participation in daily activities was observed, specifically in the following categories: nutrition, p < .001; fitness, p = .004; personal care, p < .001; and housing, p = .001. However, participation in social roles was maintained during this period (p = .10). The increased perception of technology as a facilitator (environmental factor) over time explained a part of the decline in participation (R2 = 0.13).

CONCLUSION

Factors associated with the reduction in participation in daily activities should be further studied in order to prevent this decline.

Rasch analysis of the London Handicap Scale in stroke patients: a cross-sectional study

BACKGROUND

Although activity and participation are the target domains in stroke rehabilitation interventions, there is insufficient evidence available regarding the validity of participation measurement. The purpose of this study was to investigate the psychometric properties of the London Handicap Scale in community-dwelling stroke patients, using Rasch analysis.

METHODS

Participants were 170 community-dwelling stroke survivors. The data were analyzed using Winsteps (version 3.62) with the Rasch model to determine the unidimensionality of item fit, the distribution of item difficulty, and the reliability and suitability of the rating process for the London Handicap Scale.

RESULTS

Data of 16 participants did not fit the Rasch model and there were no misfitting items. The person separation value was 2.42, and the reliability was .85; furthermore, the rating process for the London Handicap Scale was found to be suitable for use with stroke patients.

CONCLUSIONS

This was the first trial to investigate the psychometric properties of the London Handicap Scale using Rasch analysis; the results supported the suitability of this scale for use with stroke patients.

Changes in the couple relationship in dementia care

Spouse carers of people with dementia face unique challenges as they adapt to the demands of caring whilst experiencing significant losses in their couple relationship. The ‘professionalization’ of carers by services has been criticized, and recent UK government guidance proposes that carers receive an assessment of psychological need. This study explored spouse carers’ experiences. Semi-structured interviews were conducted with seven spouses, recruited though local Alzheimer’s Societies, who were caring for their partners with mid-stage dementia at home. The data were analysed using interpretative phenomenological analysis. Four overarching themes emerged: ‘connectedness and separateness’; ‘tension between meeting own needs and meeting needs of spouse’; ‘knowing and not knowing the future’; and ‘seeking control — emotional and practical strategies’. With the progressive decline in their partners’ functioning, spouse carers experienced an ongoing process of re-evaluation and re-positioning of themselves in relation to their partner and their couple relationship. Implications for services highlight the importance of support groups and psychological support.

Psychosocial consequences of stroke: A long-term population-based follow-up

PRIMARY OBJECTIVE

To investigate psychosocial status among nationally representative groups of stroke patients at long intervals post-stroke.

METHODS AND PROCEDURES

From a Danish national register of hospitalizations, three representative groups of surviving patients were selected who had suffered a stroke 5, 10 and 15 years previously. A follow-up postal questionnaire was sent to them comprising items concerning symptomatology, functioning and social conditions, together with the Nottingham Health Profile (NHP).

MAIN OUTCOMES AND RESULTS

Longer follow-up intervals were associated with younger age at stroke and better functioning at discharge. At follow-up, the majority of patients reported difficulties with attention, memory and emotional control, irrespective of follow-up interval. Return to employment, social relations and leisure activities were affected, but were comparatively better at longer follow-up intervals, as was self-rated functioning and several NHP symptom scales. However, multi-variate analyses suggest that these positive changes with time appear to be mediated by attrition related to age at stroke and discharge functioning rather than time since stroke itself.

CONCLUSIONS

Symptomatology, functioning and social conditions remain affected and perhaps stagnant in long-term survivors of stroke.

Effectiveness of two rehabilitation strategies provided by nurses for stroke patients in Mexico

OBJECTIVE

Rehabilitation strategies have been developed to improve functional state in stroke patients. The main objective of this study was to evaluate the effectiveness of the early rehabilitation at hospital and its continuity at home provided by nurses, on the functional recovery of basic and social activities in stroke patients compared with conventional care.

DESIGN

A randomised clinical trial was carried out in three general hospitals of the Mexican Institute of Social Security (IMSS) in Mexico City between April 2003-May 2004.

PARTICIPANTS

Stroke patients.

METHODS

Two rehabilitation strategies provided by nurses for stroke patients were compared: physiotherapy plus caregiver education in rehabilitation (strategy 1, S1) vs. education alone (strategy 2, S2). The main outcome variables were the basic (Barthel index) and social (Frenchay activities index) activities of daily living, of each patient. Age, sex, morbidity, stroke symptoms, complications, neurological damage (Canadian Scale), cognitive state (mini-mental state examination questionnaire) and duration of hospitalisation were defined as the control variables. Patients were evaluated at baseline and months one, three and six thereafter.

RESULTS

One hundred and ten patients with ischaemic stroke were enrolled and randomised; 59 were assigned to S1 and 51 to S2. Comparison of the outcome variables showed that patients improved significantly over time, but no differences were observed between groups. We observed no significant difference in strategy performance with regard to the basic and instrumental activities of daily living.

RELEVANCE TO CLINICAL PRACTICE

Participants who received physiotherapy with additional caregiver education benefit no more than those whose caregivers received education alone. Those countries that do not have integral rehabilitation programmes for stroke patients should understand their importance and budget resources for them. Meanwhile, both caregiver education and nurses trained in specific care and physiotherapy are alternatives that benefit these patients.

A community-based exercise and education scheme for stroke survivors: a randomized controlled trial and economic evaluation

Objective: The evaluation of a community-based exercise and education scheme for stroke survivors.

Design: A single blind parallel group randomized controlled trial.

Setting: Leisure and community centres in the south-west of England.

Subjects: Stroke survivors (median (IQR) time post stroke 10.3 (5.4—17.1) months). 243 participants were randomized to standard care (124) or the intervention (119).

Intervention: Exercise and education schemes held twice weekly for eight weeks, facilitated by volunteers and qualified exercise instructors (supported by a physiotherapist), each with nine participants plus carers or family members.

Method: Participants were assessed by a blinded independent assessor at two weeks before the start of the scheme, nine weeks and six months. One-year follow-up was by postal assessment.

Main measures: Primary outcomes: Subjective Index of Physical and Social Outcome (SIPSO); Frenchay Activities Index; Rivermead Mobility Index. NHS, social care and personal costs. Secondary outcomes included WHOQoL-Bref.

Analysis: Intention-to-treat basis, using non-parametric analysis to investigate change from baseline. Economic costs were compared in a cost-consequences analysis.

Results: There were significant between-group changes in SIPSO physical at nine weeks (median (95% confidence interval (CI)), 1 (0, 2): P = 0.022) and at one year (0 (—1, 2): P = 0.024). (WHOQol-Bref psychological (6.2 (—0.1, 9.1): P = 0.011) at six months. Mean cost per patient was higher in the intervention group. The difference, excluding inpatient care, was £296 (95% CI: —£321 to £913).

Conclusion: The community scheme for stroke survivors was a low-cost intervention successful in improving physical integration, maintained at one year, when compared with standard care.

Meeting stroke survivors’ perceived needs: a qualitative study of a community-based exercise and education scheme

Objective: A qualitative study using a phenomenological approach, to explore stroke survivors’ needs and their perceptions of whether a community stroke scheme met these needs.

Methods: Semi-structured in-depth interviews of 12 stroke survivors, purposively selected from participants attending a new community stroke scheme. Interpretative phenomenological analysis of interviews by two researchers independently.

Results: Participants attending the community stroke scheme sought to reconstruct their lives in the aftermath of their stroke. To enable this they needed internal resources of confidence and sense of purpose to ‘create their social self’, and external resources of ‘responsive services’ and an ‘informal support network’, to provide direction and encouragement. Participants felt the community stroke scheme met some of these needs through exercise, goal setting and peer group interaction, which included social support and knowledge acquisition.

Conclusion: Stroke survivors need a variety of internal and external resources so that they can rebuild their lives positively post stroke. A stroke-specific community scheme, based on exercise, life-centred goal setting, peer support and knowledge acquisition, is an external resource that can help with meeting some of the stroke survivor’s needs.

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.

Knee Muscle Strength, Gait Performance, and Perceived Participation After Stroke

OBJECTIVE

To assess the relation between knee muscle strength, gait performance, and perceived participation in subjects with chronic mild to moderate poststroke hemiparesis.

DESIGN

Descriptive analysis of convenience sample.

SETTING

University hospital.

PARTICIPANTS

Fifty men and women (mean age, 58+/-6.4y) 6 to 46 months poststroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Isokinetic concentric knee extension and flexion strength was measured at 60 degrees /s. Gait performance was assessed by Timed Up & Go, comfortable and fast gait speed, stair climbing ascend and descend, and 6-minute walk test. Perceived participation was assessed with the Stroke Impact Scale.

RESULTS

There was a significant correlation (P < .01) between knee muscle strength and gait performance for the paretic but not for the nonparetic lower limb. Strength for the paretic limb explained 34% to 50% of the variance in gait performance; the addition of strength for the nonparetic limb explained at most a further 11% of the variance in gait performance. There was a significant correlation (P < .01) between gait performance and perceived participation; gait performance explained 28% to 40% of the variance in perceived participation.

CONCLUSIONS

Knee muscle strength is a moderate to strong predictor of walking ability in individuals with chronic mild to moderate poststroke hemiparesis. Walking ability influences perceived participation, but the strengths of the relations indicate that other factors are also important.

Predictors of long-term participation after stroke

PURPOSE

(1) To explore factors that predict long-term participation after stroke (2-4 years after discharge from rehabilitation), and (2) to determine factors that predict both short- and long-term participation.

METHODS

Biopsychosocial data of people who had had a stroke were measured at discharge from an intensive rehabilitation unit using valid instruments. Six months later (n=102) as well as 2-4 years later (n=66), social participation of the survivors was measured in their living environments. Participation was estimated with the Assessment of Life Habits (LIFE-H), which includes 12 categories of daily activities and social roles.

RESULTS

From multivariate regression analyses, the best predictors of long-term participation after stroke appear to be age, comorbidity, motor coordination, upper extremity ability and affect. Age, comorbidity, affect and lower extremity coordination are the best predictors of participation after stroke at both measurement times.

CONCLUSIONS

With the exception of age, these factors may be positively modified and thus warrant special attention in rehabilitation interventions.

Parents' leisure: the impact of raising a child with down syndrome

A healthy and productive life depends upon the balance between work, leisure, and activities of daily living. Gaining or regaining that balance is a core concept within occupational therapy. Raising a child with special needs is one factor that challenges parents in achieving a balance. The purpose of this research was to describe factors that affect the leisure occupations of these parents. A qualitative approach was used in which in-depth interviews and the adapted Barth Time Construction were administered to four married couples that were raising children with Down syndrome who were between seven and nine years of age. Data was examined through content analysis. Results indicated that the parents of children with Down syndrome had limitations in time available for leisure, changes in types of leisure engaged in, and an increase in planning for leisure activities. Despite overall satisfaction with the manner in which they allocated their time, parents frequently noted the potential benefits of incorporating more leisure into their daily lives. Limitations of the study include type and size of sample.

Participation after stroke compared to normal aging

OBJECTIVE

To examine the reduction in participation of people who have had a stroke compared with healthy people with normal aging.

DESIGN

Participation of people who had a stroke was compared with participation of healthy subjects.

SUBJECTS/PATIENTS

Forty-six people who had a stroke for 2-4 years and 46 healthy participants matched on age, sex and living environment.

MEASUREMENTS

Participation was estimated with the Assessment of Life Habits (LIFE-H). The LIFE-H (short version 2.1) is composed of 58 daily activities and social roles associated to the 12 categories of the Disability Creation Process model. The LIFE-H gives separate scores for each category, for 2 main subsections "Daily activities" and "Social roles" and a total score.

RESULTS

Scores of healthy subjects did not reach the maximum value (9/9) of the LIFE-H, their mean scores varying from 6.3 to 8.6, according to the categories. These scores are higher than of the participants with stroke for all categories (scores varying from 3.9 to 6.5; p-values from 0.002 to <0.001), except the interpersonal relationships category (score of 7.8 vs 8.0) where no difference was found (p=0.49). The disruption in participation after stroke varies according to the categories of the LIFE-H, but is more important in the daily activities categories.

CONCLUSION

The comparison of the scores obtained by the 2 groups suggests that a part of the reduction in participation in daily activities and social roles after stroke is attributable to normal aging and not entirely to the stroke itself. It helps to focus interventions on activities and roles disruption domains that are really attributable to stroke.

A study of interventions and related outcomes in a randomized controlled trial of occupational therapy and leisure therapy for community stroke patients

OBJECTIVE

To undertake a detailed analysis of therapy provided in a multicentred randomized controlled trial of activities of daily living (ADL) and leisure (TOTAL), testing the hypothesis that specific interventions given in the trial affected specific aspects of outcome.

SUBJECTS

Three hundred and nine stroke patients who had been randomly allocated to receive either occupational therapy aimed at ADL activities (n = 156) or leisure (n = 153).

MEASURES

Number, duration and type of activity undertaken per patient. Barthel Index, Extended Activities of Daily Living Scale (EADL) and Nottingham Leisure Questionnaire (NLQ) six months after entry to the study.

METHOD

Activities that had been used in treatment were coded and categorized. Frequently used activities identified. These activities were matched to items from the six-month outcome measures. Patient independence in these outcome items was compared between the leisure and ADL groups.

RESULTS

Three hundred and nine therapy record forms were returned. Patients received a median of ten sessions with a median duration of 55 minutes. The ADL group received significantly more, mobility training, transfer training, cleaning, dressing, cooking and bathing training (chi-squared, p < 0.05). Sport, creative activities, games, hobbies, gardening, entertainment and shopping were used significantly more in the leisure group (chi-squared, p < 0.05) than the ADL group. Fifteen items from the outcome measures were identified as specific to these interventions. There were no statistically significant differences in outcome on these 15 items between the ADL and leisure groups (chi-squared, p > 0.05).

CONCLUSIONS

We found no evidence that specific ADL or leisure interventions led to improvements in specific relevant outcomes. We believe that these findings should prompt a review of the relationship between process and outcome of occupational therapy.

Handicap after stroke: how does it relate to disability, perception of recovery, and stroke subtype?: the north North East Melbourne Stroke Incidence Study (NEMESIS)

BACKGROUND AND PURPOSE

Knowledge of patterns of handicap after stroke and of the relationship among handicap, disability, perception of recovery, and stroke subtype is limited. The aim of this study was to assess handicap 3 and 12 months after first-ever stroke in a community-based study.

METHODS

All strokes occurring in a population of 133 816 people were found and assessed. Patients were classified as having cerebral infarction (CI) or intracerebral hemorrhage (ICH) according to imaging or autopsy findings. Cases of CI were categorized using the Oxfordshire stroke classification. Handicap, disability, and perception of recovery were assessed 3 and 12 months after stroke using the London Handicap Scale, Barthel Index, and the question "Have you made a complete recovery from your stroke?" The association between disability and handicap was examined using Pearson's correlation. Differences in handicap among subtypes of CI were evaluated using one-way ANOVA.

RESULTS

There were 264 cases of CI or ICH. Of surviving patients, 113 (59%) were assessed at 3 months and 107 (64%) at 12 months. The domains of handicap most affected were physical independence and occupation. Only half the variance in handicap was due to disability. Of patients without disability, those who claimed complete recovery were less handicapped than those who claimed incomplete recovery. Patients with total anterior circulation infarction were more handicapped at 3 and 12 months than those with other subtypes of CI.

CONCLUSIONS

Stroke patients were handicapped across many domains. Handicap is only partly explained by disability. Stroke subtype should be considered in the interpretation of outcome data.

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.

The Subjective Index of Physical and Social Outcome (SIPSO): a new measure for use with stroke patients

OBJECTIVE

To develop a measure of social integration following stroke.

DESIGN

Question and response scale generation from qualitative interview-based work followed by item and factor analytic methods of test construction. Analysis of the psychometric properties of final index.

MEASURES

Frenchay Activities Index, Nottingham Health Profile, Wakefield Depression Inventory, Barthel Index.

SETTING

Community setting, Bath, UK.

SUBJECTS

Two hundred and sixty survivors of stroke, discharged at least six months previously from a general hospital.

RESULTS

A 10-item Subjective Index of Physical and Social Outcome (SIPSO) was developed. Each question is scored on a scale of 0-4 with a low score indicating a poor level of integration. From the 157 completed questionnaires, total scores ranged from 0 to 40 with a median of 24 (interquartile range 15-32). Initial testing of the psychometric properties of the SIPSO suggest that it is able to provide assessment of two distinct areas of patient integration. From analysis of completed questionnaires it is suggested that questions 1-5 on the SIPSO measure a factor related to physical functioning/mobility whilst questions 6-10 measure a factor related to social/emotional functioning. Internal consistency, test-retest reliability and construct validity were established.

CONCLUSIONS

The SIPSO provides a brief, valid and reliable assessment of an individual's ability to reintegrate to a 'normal' lifestyle. The SIPSO differs from other measures in that it provides assessment of both quantity and quality of activities and interaction, reflecting an individual's ability to reintegrate to his/her own satisfaction. As a 10-item self-report questionnaire the SIPSO can be administered quickly and cheaply to large numbers of patients.

Stroke rehabilitation. 4. Stroke outcome and psychosocial consequences

This self-directed learning module highlights recent research in assessment of stroke outcomes and management of the psychosocial consequences of stroke. It is a part of the chapter on stroke rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses predictive factors for mortality and functional recovery; proposed case mix adjustment and prospective payment systems for stroke rehabilitation; continuum of care and utilization of acute, nursing home, outpatient and home health rehabilitation programs; reintegration and socialization after stroke; vocational rehabilitation of stroke patients; and management of the psychosocial effects of stroke on patients and families.

Stroke. 1: A paradigm case in nursing rehabilitation

This is the first of two articles which consider rehabilitation following a stroke. Although stroke is a major cause of morbidity and mortality in the UK there have been relatively few studies describing its long-term effects. Despite relatively good functional recovery, in many cases a number of stroke survivors still experience 'long-term misery'. This article argues for an expanded range of outcomes in stroke rehabilitation and for greater attention to be paid to the psychological needs of stroke survivors and their carers. Areas of deficit in stroke rehabilitation are described, as is the currently poorly developed nursing role.