The role of biopsychosocial factors in the rehabilitation process of individuals with a stroke

The effects of rehabilitation potential on activities of daily living in patients with stroke in Taiwan: a prospective longitudinal study

OBJECTIVE

This study aimed to explore the effect of three-dimensional rehabilitation potential on the activity of daily living (ADL) among patients with stroke in rehabilitation wards.

DESIGN

Prospective longitudinal study.

SETTING

Two rehabilitation wards situated within a nationally recognized referral centre in Northern Taiwan, followed by subsequent discharge.

PARTICIPANTS

A total of 101 participants were admitted due to either a primary or recurring incident of infarction or haemorrhagic stroke, subsequently being transferred to the rehabilitation ward of a medical centre.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehabilitation potential included biological (swallowing ability, muscle power, and urinary incontinence), psychological (rehabilitation motivation and cognitive function), and social (social support) dimensions. The rehabilitation treatment outcome was activities of daily living measured using the Barthel Index. Time-variant variables, including swallowing ability, rehabilitation motivation, social support, and ADL, were collected at the time of transfer to the rehabilitation ward, 1-3 days before discharge, and 1 month after discharge.

RESULTS

The results of the generalized estimating equations model revealed that poor swallowing ability, lower muscle power, and urinary incontinence in the biological dimension, along with lower rehabilitation motivation and moderate cognitive impairment in the psychological dimension, are significant indicators of rehabilitation potential among stroke patients. When the different dimensional rehabilitation potential was considered overall, both biological and psychological indicators can still predict ADL outcomes during and after inpatient rehabilitation therapy. Of these indicators, swallowing ability and rehabilitation motivation were positively correlated with ADL over time. Further, increased rehabilitation motivation enhanced the protective effect of swallowing ability on ADL.

CONCLUSION

Important indicators of rehabilitation potential, which can predict ADL outcomes, were identified for stroke patients in the rehabilitation ward. Policymakers can design appropriate intervention plans to enhance the rehabilitation potential and improve the effectiveness of inpatient rehabilitation treatment for stroke patients.

Predictive utility of self-efficacy in early stroke rehabilitation

INTRODUCTION

A biopsychosocial approach entailing person-centered factors provides valuable insight to post-stroke rehabilitation potential. The consideration of an individual's belief in their capabilities, known as self-efficacy, may prove especially informative in the inpatient rehabilitation setting where motor learning often occurs.

OBJECTIVE

To assess the predictive utility of self-efficacy in functional independence status change during inpatient rehabilitation.

METHODS

Individuals with stroke admitted to an inpatient rehabilitation facility (IRF) completed an assessment battery near IRF admission and discharge involving motor assessments, participant-reported self-efficacy (Stroke Self-Efficacy Questionnaire), and functional independence status evaluation (sum of self-care and mobility Quality Indicators (QI) from the IRF-Patient Assessment Instrument). Linear regression was performed to determine the predictive performance of self-efficacy on QI change during IRF stay while accounting for age, time post-stroke, and IRF length of stay. Regression procedures were repeated for separate subgroups based on initial motor impairment level.

RESULTS

Thirty individuals with stroke (14 females, age = 67.0 ± 9.80 years, 10.4 ± 3.46 days post-stroke) were enrolled. Self-efficacy at IRF admission explained a significant percentage of variance in QI Change for the cohort (R2 = 30.7%, p = .001) and for the moderate to severe motor impairment subgroup (n = 12; R2 = 49.9%, p = .010). After accounting for confounders, self-efficacy remained a significant predictor for the cohort (n = 30) model.

DISCUSSION

Findings generated from this work support the predictive utility of self-efficacy in early post-stroke motor recovery. The inclusion of self-efficacy in a multi-faceted evaluation framework may therefore optimize rehabilitation outcomes by providing therapists with additional knowledge to better tailor an individual's care.

Assessing the factors that influence the utilization and delivery of rehabilitation services among persons with Parkinson's disease: A scoping review

RATIONALE

Rehabilitation has the potential to significantly improve the lives of people and, most importantly, for persons with Parkinson's disease (PD). Although numerous studies have reported the benefits of rehabilitation for persons with PD (PwPD), these services are still limited and underutilized even when patients exhibit problems that require rehabilitation.

AIMS AND OBJECTIVES

This review aims to describe the (a) indication for referral for rehabilitation services, (b) patterns of referral for rehabilitation and (c) factors that facilitate or hinder the utilization and delivery of rehabilitation services among PwPD.

METHODS

A comprehensive literature search was conducted across selected databases, African Journals Online, EBSCOhost (CINAHL, Africa-wide), PubMed, SCOPUS and Web of Science. Studies published in English from January 2002 until December 2022 were applied as limiters. Reference and grey data sources tracking were also conducted. Two reviewers conducted the study selection, screening of titles, abstracts and full text and data charting. A descriptive analysis was performed. Findings were narratively presented and illustrated with tables, diagrams and descriptive formats as appropriate.

RESULTS

Twelve studies were included in the review; however, none were from Africa. Impairments and activity limitations were the key functioning problems indicated for rehabilitation. Age, gender, income, race, disease stage, specific functioning problems, quality of life and care by a neurologist were the main predictors for referral to rehabilitation. Physiotherapy, occupational therapy and speech and language therapy were the most utilized rehabilitation services and were sometimes utilized together. The rate of rehabilitation service utilization among PwPD ranged from 0.9% to 62.5%. Lack of referrals and limited rehabilitation units/professionals were the common barriers to rehabilitation service utilization.

CONCLUSION

Per the studies reviewed, utilization of rehabilitation services is generally low among PwPD. Lack of referral and nonavailability of professionals are cited as barriers to access. Adequate measures are needed to improve rehabilitation services for all PwPD.

Social rhythm and implications on functionality of patients after stroke

The study aimed to assess the regularity, intensity, frequency, and period of activities comprising social rhythm and associate them with the functionality of stroke patients. The sample consisted of 73 patients (41 men and 32 women) with a mean age of 60 years (±10). Social rhythm was assessed by Social Rhythm Metric (SRM) and Activity Level Index (ALI). The functionality was evaluated using the International Classification of Functioning, Disability, and Health (ICF). Data were analyzed using Student's t-test, ANOVA, and Chi-square test. The mean SRM was 5.1 ± 0.9, and ALI was 58.3 ± 14.9. Notably, 40% of the patients exhibited both low regularity and low intensity of activities. Six SRM activities, performed with low frequency (going outside, starting work, exercising, snacking, watching other TV programs, and going home), exhibited a tendency to have periods that deviated from the expected 24-hour daily cycle. ICF domains most associated with SRM were: d2-General tasks and demands, d3-Communication, d4-Mobility, d5-Self care, d8-Major life areas, and d9-Community, social and civic life. The results indicated changes in social rhythm with implications for patient functionality. Screening for disruptions in social rhythm could be part of the functional assessment during the rehabilitation process for post-stroke patients.

Person and Environment Factors Supporting Self-Care Performance and Social Participation After Mild Stroke

Mild stroke survivors seldom receive occupational therapy services as their deficits are assumed to be minor enough to not affect their daily occupations. Yet many mild stroke survivors report deficits in self-care performance and social participation. This study investigates person and environment factors influencing self-care performance and social participation among mild stroke survivors, using the Person-Environment-Occupation-Performance (PEOP) model. A retrospective cohort analysis of 736 mild stroke survivors was conducted using electronic health records. Person factors included demographic characteristics and clinical characteristics, and environment factors included the Social Vulnerability Index. The analysis included logistic regression. Approximately, 10% of patients reported deficits in self-care or social participation. Disability level was the only person factor associated with self-care performance. Person factors affecting social participation included mobility and unemployment. Socioeconomic status was associated with both occupation measures. Occupational therapy practitioners must address the person and environment factors affecting mild stroke survivors' self-care performance and social participation.

Professional reintegration among professionally active Portuguese stroke survivors: a multicentric study

PURPOSE

To assess professional reintegration, the perceived impact of stroke on work, and the main determinants of return to work (RTW) among stroke survivors.

MATERIALS AND METHODS

A cross-sectional study was performed, based on a cohort of stroke survivors. A structured questionnaire was administered to previously working stroke survivors, 18-24 months post-stroke. Data on sociodemographic characteristics, stroke features and their impact on work, access to rehabilitation services during hospital admission and after discharge, social support, and professional reintegration were reported by 553 stroke survivors.

RESULTS

On average, 56.6% (95% CI 52.4-60.8) of stroke survivors resumed professional activity, 20 months after stroke. Approximately 90% of survivors who RTW, returned to the same job and same function they performed before stroke. The majority did not receive reintegration support. The main determinants of RTW were lower age, higher socioeconomic status, and better functional status.

CONCLUSIONS

Professional reintegration and vocational support after stroke, remained below the international goals for community reintegration of stroke survivors. Future studies should explore the impact of professional and social reintegration on the psychological health and quality of life of stroke survivors and the barriers, challenges, and strategies used to overcome them, to allow for effective professional reintegration policies.

Personalizing Injury Management and Recovery: A Cross-Sectional Investigation of Musculoskeletal Injuries and Quality of Life in Athletes

Purpose

The study explores the impact of Musculoskeletal Injuries on the quality of life in youth athletes, aiming to understand the extent of these injuries' effects on their physical and mental wellbeing.

Patients and Methods

This cross-sectional study included 130 youth athletes, using questionnaires to collect data on demographics, training exposures (averaging 11±3.8 hours/week), overuse symptoms (using the Oslo Sports Trauma Research Center Overuse Injury Questionnaire), acute injury history, and overall wellbeing (assessed by the RAND 36-item Short Form Health Survey).

Results

Findings indicated that 55.4% of participants had suffered an acute injury in the past 6 months, leading to an average of 4 weeks of time loss. The mean score for OSTRC-O Scores was 16.8±6.4, with knee overuse averaging 21.3± 8.8. In terms of wellbeing, physical and mental health scores were 82.4±15.3 and 81.7±14.1 respectively. There were significant correlations between higher overuse scores and poorer physical functioning (r=-0.42), bodily pain (r=-0.38), vitality (r=-0.32), and mental health (r=-0.31). Acute injuries were linked with worse physical functioning and role limitations. Regression analysis showed that both overuse and acute injuries predicted poorer physical health.

Conclusion

The study underscores the significant prevalence of musculoskeletal injuries among youth athletes and delineates their profound impact on the quality of life, encompassing both the physical and mental health realms. These findings advocate for the critical integration of preventive measures and personalized training protocols, spotlighting the pivotal role of comprehensive biopsychosocial strategies in nurturing athletes' overall wellbeing. By prioritizing the quality of life as a key outcome, this research advocates for a more nuanced approach to injury management and recovery.

Factors Determining the Functional Efficiency of Patients After Ischemic Stroke After Neurological Rehabilitation

Introduction

The factors determining the level of functional efficiency in patients after ischemic stroke are: age, sex, physical condition, mental activity before stroke, previous neurological deficits, comorbidities, nutritional status and the course of the stroke.

Aim

Assessment of the functional efficiency of patients before and after rehabilitation due to ischemic stroke and determination of the influence of selected factors on the effects of rehabilitation measured by functional efficiency.

Material and Methods

The study was conducted in neurological rehabilitation centers among 82 people diagnosed with ischemic stroke. The examination was performed twice: on admission to the ward and after a month of neurological rehabilitation. The diagnostic survey method, the Barthel scale, the NRS 2002 scale were used, and the BMI was calculated.

Results

The functional efficiency level of the patients was varied, higher after one month of rehabilitation (p <0.05). Among the patients who achieved a lower level of functional efficiency, the following factors had a significant influence: underweight and overweight (p = 0.002), risk of malnutrition (p = 0.002), right-sided paresis (p = 0.016), limited physical activity before stroke (p = 0.01) and the later rehabilitation period (p = 0.01). There was no correlation between sociodemographic data and the level of efficiency of patients after a stroke after one month of rehabilitation.

Conclusion

The level of functional efficiency after rehabilitation improved in all patients, however, to a different extent depending on the nutritional status and physical activity. Therefore, it is important to to undertake rehabilitation in the shortest possible time.

Acceptance of disability in stroke: a systematic review

BACKGROUND

Evidence for the association between acceptance of disability (AOD) and positive rehabilitation outcomes, as well as for the use of AOD measurements in stroke rehabilitation practice, has increased in the international literature in the last decade. However, measurement tools for AOD are heterogenous and there has not been a systematic review summarizing the current evidence on the use of AOD measures and factors associated with AOD.

OBJECTIVE

This study aimed to summarize current evidence on measurement tools used, present existing AOD scores in people with stroke and identify risk factors for and protective factors against poor AOD in people with stroke.

METHODS

The original design and protocol of this systematic review were registered with PROSPERO. The included studies were published from 2008 to 2020 and identified from 5 databases-PubMed, EMBASE, CINAHL Plus, PsycInfo, and the Cochrane Library-using the following inclusion criteria: participants diagnosed with stroke and aged ≥16 years, measurement of AOD, and published in English in a peer-reviewed scientific journal. Review articles were excluded.

RESULTS

Five measurement tools for AOD were reported. The Revised Acceptance of Disability Scale (ADS-R) and the acceptance subscale of the Illness Cognition Questionnaire (ICQ) had the highest internal consistency. Scores ranged from 71.7 to 74.2 on the ADS-R, 16.9-18.3 on the ICQ, 16.5-26.9 on the Acceptance of Illness Scale, and 87.8-93.2 on the Attitudes towards Disabled Persons Form A. Poorer function and depressive symptoms were associated with poor AOD, whereas religious beliefs, support from others, and an understanding of stroke were associated with better AOD.

CONCLUSIONS

The ADS-R and the acceptance subscale of the ICQ are currently the most reliable measurement tools for measuring AOD in people with stroke. Further research to validate the measurement tools is required. This may help to identify people who require additional support.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42017077063; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=77063.

Agreement between 30-day and 90-day modified Rankin Scale score and utility-weighted modified Rankin Scale score in acute intracerebral hemorrhage: An analysis of ATACH-2 trial data

The relationship between 30- and 90-day modified Rankin Scale (mRS) scores in intracerebral hemorrhage (ICH) patients was evaluated. This post hoc cohort analysis of the ATACH-2 trial included patients with acute ICH who were alive at 30 days and who had mRS scores reported at 30 and 90 days. The mRS score was then converted to a utility (EuroQol-5 Dimension-3 Level [EQ-5D-3L])-weighted mRS score. After adjustment of 30-day mRS score for key covariates using multivariable ordinal regression, the relationship between 30-day and observed 90-day functional outcome was assessed via absolute difference in the utility-weighted version. Of the 1000 trial subjects, 898 met inclusion criteria. This low-moderate severity ICH cohort had a median baseline GCS score of 15 and median hematoma volume of 9.7 mL. Observed 30-day mRS had the largest association with observed 90-day values (χ2 = 302.9, p < 0.0001). Patients generally either maintained the same mRS scores between 30 and 90 days (48 %) or experienced a 1-point (32 %) or 2-point (10 %) improvement by 90 days. The mean ± standard deviation (SD) EQ-5D-3L at 90 days was 0.67 ± 0.26. Following adjustment, the mean absolute difference between predicted and observed utility-weighted 90-day mRS scores was 0.006 ± 0.13 points and less than the estimated minimal clinically important difference of 0.13 points. The difference in average utility-weighted mRS scores at 30 and 90 days was not clinically relevant, suggesting 30-day score may be a reasonable proxy for 90-day values in patients with ICH when 90-day values are not available.

Evaluation of the functional outcome and mobility of patients after stroke depending on their cognitive state

The study aimed to analyze the functional outcome and mobility in stroke patients depending on their cognitive state. 180 patients after first stroke were divided into four groups: 48 patients without symptoms of cognitive impairment (G1); 38 with mild cognitive impairment without dementia (G2); 47 with mild dementia (G3); 47 with moderate dementia (G4). The Mini Mental State Examination (MMSE), Barthel Index (BI), Sitting Assessment Scale (SAS), Berg Balance Scale, Trunk Control Test and Test Up & Go were used. The tests were carried out at the time of admission to the ward (T1) and at the time of discharge (T2). A statistically significant improvement was demonstrated in all parameters in almost all groups. No significant difference was observed only in groups G1 and G4 in SAS head. Statistically significant differences in BI results in T2 between groups G1 and G4 were noted. The lowest change in BI was observed in the G4. Regression analysis showed that MMSE and BI at T1 and MMSE score at T2 explained the functional status at T2. Cognitive dysfunction at the time of admission to the ward and discharge may determining the patient's functional status at the time of discharge from the ward.

Unmet needs in long-term outpatient rehabilitative care: a qualitative and multi-perspective study in Japan

PURPOSE

This study explores the experiences and unmet needs related to post-discharge long-term rehabilitation from triadic perspective of male patients with stroke, caregivers, and rehabilitation professionals.

METHODS

This is an exploratory qualitative study using in-depth interviews conducted in two outpatient rehabilitation facilities in Japan. Nine male patients with stroke, ten caregivers, and five rehabilitation professionals participated in this study. The data were coded, followed by thematic analysis.

RESULTS

Patients who did not achieve further physical recovery regardless of their efforts experienced a loss of motivation and lost sight of their goals. Moreover, caregivers regarded such patients as lazy and reported feeling frustrated with them. Furthermore, patients and caregivers had unmet needs regarding communication with professionals and psychological and emotional care. In contrast, professionals perceived time constraints on outpatient rehabilitation service provision and sometimes narrowed the scope of the care approach to physical function aspects for providing services efficiently. They also expressed difficulties in identifying patients' needs, values, and meaningful goals.

CONCLUSIONS

These findings suggest that in Japanese post-stroke outpatient rehabilitation, there is a need to adopt a comprehensive care approach, enhance the quality of communication, and involve caregivers in the rehabilitation process in limited-resource situations.IMPLICATIONS FOR REHABILITATIONIn long-term outpatient rehabilitation services in the community, stroke patients and their caregivers often face a physical recovery plateau.A comprehensive approach such as enhancing the quality of communication and providing psychological and emotional care -other than physical rehabilitation- is needed, particularly once the patient physical recovery stagnates.Involving caregivers in the rehabilitation process may be helpful for rehabilitation professionals to understand a potential problem that the patient cannot express but the caregiver can.It can be crucial to develop strategies that enable the rehabilitation professionals to provide a comprehensive care approach and prevent too much reliance on physical rehabilitation under the time-constraint situation in outpatient rehabilitation services.

Stroke Survivors and their Physiotherapists' Perceptions of Recovery: A Multiple Methods Approach

Purpose

This multiple-methods study examined perceptions of recovery among stroke survivors and their physiotherapists at discharge from an in-patient rehabilitation program.

Method

The Functional Independence Measure (FIM) and Chedoke McMaster Stroke Assessment Activity Inventory scores were collected from chart review and the following outcome measures were completed by interview: Stroke Impact Scale (SIS) global recovery, Hospital Anxiety Depression Scale, and Montreal Cognitive Assessment. Physiotherapists also completed the SIS global recovery for each participant. Spearman and Pearson correlations between SIS recovery and observed measures were completed. The stroke survivors had a short interview about their perception of recovery and what recovery meant to them, and their physiotherapists answered two written questions about each participant's recovery. Responses were coded and categorized based on the International Classification of Functioning.

Results

A total of 31 stroke survivors with a mean age of 66.6 years (SD 10.7) and six physiotherapists participated. Nineteen stroke survivors were interviewed. The stroke survivors' SIS recovery scores correlated with FIM-motor change (rs = 0.36 p = 0.04) and the SIS-recovery scores reported by the physiotherapists (r = 0.51; p < 0.01). In relation to the factors related to recovery, the physiotherapists' focus was therapeutic mainly considering motor recovery while the stroke survivors' responses were broad, including being able to achieve recovery goals and nutrition. However, both perceived recovery to include functional activities.

Conclusions

SIS global recovery question helps to measure the overall perceived percentage of recovery. However, the complete picture of recovery is only possible with the stroke survivors' and physiotherapists' perceptions of recovery and what recovery means to them.

Factors associated with the effectiveness of immersive virtual therapy in alleviating depressive symptoms during sub-acute post-stroke rehabilitation: a gender comparison

BACKGROUND

The large-scale digitalization of healthcare has induced shifts in patient preferences, prompting the introduction of therapies utilizing novel technologies. In this context, the targeted application of these interventions is deemed as crucial as assessing their overall effectiveness. The aim of this study was to characterize the patient profile who benefited most from immersive virtual reality (VR) therapy.

METHODS

Based on the results from the previous randomized controlled trial study, we employed an exploratory study design to determine the factors associated with the most significant mental health improvement. A secondary analysis was conducted on a sample of 83 participants, with further analysis of participants with elevated depression symptoms, as indicated by a score of > 10 on the 30-item Geriatric Depression Scale (GDS-30). Both groups participated in a similar post-stroke rehabilitation program; however, the experimental group also received additional VR therapy through an immersive VR garden intervention. The GDS-30 was used to assess mood and depressive symptoms, and sociodemographic, cognitive status as well as stroke-related variables were considered as potential factors.

RESULTS

In both the experimental (mean change 5.3) and control groups (mean change 2.8), interventions significantly reduced depressive symptoms, with a more pronounced difference in the experimental group (p < 0.05). When examining gender differences, women exhibited greater improvement in the GDS, with mean between-group differences of 5.0 for the total sample and 6.0 for those with elevated depressive symptoms. Sociodemographic factors, cognitive status, and time from stroke were not found to be factors that alter the effectiveness of VR therapy.

CONCLUSIONS

While VR therapy as an adjunctive treatment for post-stroke rehabilitation seems especially effective for women with elevated depressive symptoms, the results should be interpreted with caution due to the study's small experimental group size. Traditional methods showed reduced effectiveness in women compared to men; thus, developing technologically advanced and gender-specific approaches can lead to more tailored therapy.

TRIAL REGISTRATION

NCT03830372 (February 5, 2019).

Development of prediction models for domestic chores resumption among mild stroke patients three months after discharge from specialized rehabilitation wards: A multi-center prospective cohort study

BACKGROUND

Whether stroke patients resume domestic chores is one of the major issues associated with their quality of life. Prediction models for domestic chores resumption among stroke survivors can be useful for setting goals and planning rehabilitation.

OBJECTIVES

To develop prediction models for individual domestic chores resumption among mild stroke patients three months after discharge from specialized rehabilitation wards.

METHODS

Ninety-one stroke patients admitted to specialized rehabilitation wardswere included in the analyses. We assessed the prestroke and three months post-discharge frequencies of six domestic chore items of the Frenchay Activities Index. Demographics and candidate predictors such as paralysis severity, cognitive function, walking speed, and self-efficacy were collected at discharge. Binary logistic regression analyses were performed to build prediction models for individual domestic chores resumption after stroke.

RESULTS

The preparing meals model included walking speed (OR = 1.05) and cognitive function (OR = 1.29) as predictors; washing up model, walking speed (OR = 1.04); washing clothes model, walking speed (OR = 1.06), and number of family members living together (OR = 0.42); light housework model, walking speed (OR = 1.06); heavy housework model, walking speed (OR = 1.03), cognitive function (OR = 1.38), and self-efficacy (OR = 1.91); and local shopping model, walking speed (OR = 1.05), age (OR = 0.94), and number of family members living together (OR = 0.61).

CONCLUSIONS

Our models may be useful in clinical practice to streamline the setting of goals and development of therapeutic strategies for individual domestic chores resumption among mild stroke patients.

Analysis of the current status of rehabilitation motivation and its influencing factors in older adults with stroke: a cross-sectional study

Objective

Among stroke patients, exercise adherence is an important factor in reducing the rate of physical disability and mortality. Rehabilitation exercise after stroke is a safe and effective measure to restore normal body functions, but the analysis of factors influencing patients' motivation for rehabilitation is not well established. Therefore, this study will explore the influencing factors of rehabilitation motivation in older adults with stroke so as to reduce the disability rate of stroke.

Method

A convenience sampling method was used to study 350 patients in a stroke ward of a tertiary care hospital in Jinzhou, Liaoning Province. Patients' general demographic data, Multidimensional Scale of Perceived Social Support (PSSS), Questionnaire of Exercise Adherence (EAQ), Tampa scale of kinesiophobia (TSK-11), and Motivation in stroke patients for rehabilitation scale (MORE) were assessed. ANOVA or t-test analysis, correlation analysis, and linear regression analysis were used to explore the factors influencing the motivation for rehabilitation in older adults with stroke.

Results

The results showed that stroke patients' motivation for rehabilitation was at a moderate level. Perceived social support, exercise adherence, and stroke motivation were positively correlated (r = 0.619, p < 0.01; r = 0.569, p < 0.01), and kinesiophobia was negatively correlated with stroke motivation (r = -0.677, p < 0.01). Time of stroke, location of the lesion, perceived social support, exercise adherence, and kinesiophobia are influential factors affecting patients' motivation to recover.

Conclusion

In the rehabilitation program for older adult patients with stroke, healthcare providers should specify targeted rehabilitation measures according to the different degrees of the patient's condition, so as to improve the effectiveness of rehabilitation medical implementation.

The factors that influence the adaptation process 6 months after a stroke: A path analysis

OBJECTIVE

The purpose of this study was to identify the determinant factors that influence the adaptation process and quality of life after a stroke.

METHODS

This study is an observational study using a cross-sectional design. Respondents were patients who were 6 months post-discharge after non-hemorrhagic strokae and their family caregivers. Information about respondents was taken from medical record data at two regional general hospitals in West Kalimantan Province, Indonesia. A total of 80 patients were selected using a consecutive sampling method. Theoretical models of patient and caregiver factors that influence adaptation responses and post-stroke quality of life were tested using path analysis.

RESULT

Caregiver coping, self-efficacy, and illness acceptance had a direct effect on the post-stroke psychosocial adaptation response by 58.1%, with self-efficacy contributing the most (β = 0.668, P < .0001). Self-efficacy, illness acceptance, and healthy behavior had a direct effect on the physiological adaptation response by 24.3%, where self-efficacy also contributed the most (β = 0.272, P < .014). Psychosocial adaptation and physiological adaptation had a direct effect on the quality of life by 54.6%, where psychosocial adaptation showed the largest contribution (β = 0.63, P < .0001).

CONCLUSION

Self-efficacy contributes the most to both psychosocial and physiological adaptations 6 months after stroke. Psychosocial adaptation and self-efficacy have been proven to be the determinant factors that contribute the most to the quality of life of patients 6 months after stroke.

Physical Activity, Psychological and Functional Outcomes in Non-Ambulatory Stroke Patients during Rehabilitation-A Pilot Study

Despite the extensive literature on stroke rehabilitation, there are few studies that comprehensively show non-ambulatory stroke patients. The aim of the study was to explore the dynamics of the change in physical activity (PA), psychological and functional outcomes, and the correlation between them in non-ambulatory patients during early in-patient post-stroke rehabilitation. Measurements were taken on 21 participants at the beginning of and 6 weeks post-conventional rehabilitation with the Barthel Index (BI), Berg Balance Scale (BBS), Trunk Control Test (TCT), Stroke Impact Scale (SIS), General Self-Efficacy Scale, Stroke Self-Efficacy Questionnaire (SSEQ), the original scale of belief in own impact on recovery (BiOIoR), Hospital Anxiety and Depression Scale, Acceptance of Illness Scale and when the patient could walk—Time Up & Go and 6 Minute Walk Test. Daily PA was assessed over 6 weeks using a Caltrac accelerometer. Only outcomes for BI, BBS, TCT, SIS, and SSEQ significantly improved 6 weeks post-rehabilitation. PA energy expenditure per day significantly increased over time (p < 0.001; effect size = 0.494), but PA only increased significantly up to the third week. PA change was correlated with BiOIoR post-treatment. Self-efficacy in self-management mediated improvement in SIS. The BiOIoR and confidence in self-management could be important factors in the rehabilitation process.

Pre-stroke socioeconomic status predicts upper limb motor recovery after inpatient neurorehabilitation

BACKGROUND

Lower socioeconomic status (SES) is associated with higher mortality rates and the likelihood of receiving less evidence-based treatment after stroke. In contrast, little is known about the impact of SES on recovery after discharge from inpatient rehabilitation. The aim of this study was to investigate the influence of SES on long-term recovery after stroke.

PATIENTS AND METHODS

In a prospective, observational, multicentre study, inpatients were recruited towards the end of rehabilitation. The 12-month follow-up focussed on upper limb motor recovery, measured by the Fugl-Meyer score. A clinically relevant improvement of ≥5.25 points was considered recovery. Patient-centric measures such as the Patient-reported Outcomes Measurement Information System-Physical Health (PROMIS-10 PH) provided secondary outcomes. Information on schooling, vocational training, income and occupational status pre-stroke entered a multidimensional SES index. Multivariate logistic regression models calculating odds ratios (ORs) and corresponding confidence intervals (CIs) were applied. SES was added to an initial model including age, sex and baseline neurological deficit. Additional exploratory analyses examined the association between SES and outpatient treatment.

RESULTS

One hundred and seventy-six patients were enrolled of whom 98 had SES and long-term recovery data. Model comparisons showed the SES-model superior to the initial model (Akaike information criterion (AIC): 123 vs. 120, Pseudo R²: 0.09 vs. 0.13). The likelihood of motor recovery (OR = 17.12, 95%CI = 1.31; 224.18) and PROMIS-10 PH improvement (OR = 20.76, 95%CI = 1.28; 337.11) were significantly increased with higher SES, along with more frequent use of outpatient therapy (p = .02).

CONCLUSIONS

Higher pre-stroke SES is associated with better long-term recovery after discharge from rehabilitation. Understanding these factors can improve outpatient long-term stroke care and lead to better recovery.KEY MESSAGEHigher pre-stroke socioeconomic status (SES) is associated with better long-term recovery after discharge from rehabilitation both in terms of motor function and self-reported health status.Higher SES is associated with significantly higher utilization of outpatient therapies.Discharge management of rehabilitation clinics should identify and address socioeconomic factors in order to detect individual needs and to improve outpatient recovery. Article registration: clinicaltrials.gov NCT04119479.

Investigating the effect of self-management program on stroke's patients' self-efficacy

Background and aim

Stroke patients face various challenges that affect their self-efficacy. The purpose of this study is to evaluate the effect of a self-management program on the self-efficacy of patients with Stroke.

Methods and materials

This study is a clinical trial, in which 72 patients with stroke participated in this study. They were selected based on the convenience sampling method and assigned to either intervention or control group (36 patients in each group) randomly. The intervention group received 5A based self-management program for 6 weeks (in-person and off-site) and the control group received only routine care includes stroke training booklets and post-discharge care training by the ward nurse. Data were collected through demographic and jones self-efficacy questionnaires, before, immediately after, and 3 months after interventions in both groups and were analyzed with descriptive and analytical statistics using SPSS software (with independent t-test, Chi-square, Fisher and analysis of variance with repeated measures with a significance level of 0.05).

Results

Before interventions, the two study groups had no statistically significant difference regarding demographic variables and the mean score of self-efficacy. Immediately and 3 months after interventions, the mean score and mean changes of self-efficacy score in the intervention group were significantly greater than in the control group(p < 0.001).

Conclusion

The results of the present study show the appropriate effect of self-management program on self-efficacy of stroke patients. These results can be used by different members of healthcare teams to improve patients’ self-efficacy.

Trial registration

This study is registered by Iranian Registry of Clinical Trials with decree code: IRCT20190712044181N2 (registration date: 05-11-2019).

Implementation of a biopsychosocial approach into physiotherapists' practice: a review of systematic reviews to map barriers and facilitators and identify specific behavior change techniques

PURPOSE

Our first objective was to map the barriers and facilitators to the implementation of a biopsychosocial approach into physiotherapists' practice within the Theoretical Domains Framework (TDF). Our second objective was to identify the specific behavior change techniques (BCT) that could facilitate this implementation.

MATERIALS AND METHODS

We conducted a review of systematic reviews to identify barriers and facilitators to the use of a biopsychosocial approach by physiotherapists and we mapped them within the TDF domains. We then analyzed these domains using the Theory and Techniques tool (TaTT) to identify the most appropriate BCTs for the implementation of a biopsychosocial approach into physiotherapists' practice.

RESULTS

The barriers and facilitators to the use of a biopsychosocial approach by physiotherapists were mapped to 10 domains of the TDF (Knowledge; skills; professional role; beliefs about capabilities; beliefs about consequences; intentions; memory, attention and decision processes; environmental context; social influences; emotion). The inclusion of these domains within the TaTT resulted in the identification of 33 BCTs that could foster the use of this approach by physiotherapists.

CONCLUSIONS

Investigating the implementation of a biopsychosocial approach into physiotherapists' practice from a behavior change perspective provides new strategies that can contribute to successfully implement this approach.Implications for RehabilitationThe implementation of a biopsychosocial approach into physiotherapists' practice is a complex process which involves behavior changes influenced by several barriers and facilitators.Barriers and facilitators reported by physiotherapists when implementing a biopsychosocial approach can be mapped within 10 domains of the Theoretical Domain Framework.Thirty-three behavior change techniques (e.g., verbal persuasion about capability, problem solving, restructuring the physical environment, etc.) were identified to foster the implementation of a biopsychosocial approach and specifically target barriers and facilitators.By using a behavior change perspective, this study highlights new strategies and avenues that can support current efforts to successfully implement the use of a biopsychosocial approach into physiotherapists' practice.

Using Large-Scale Sensor Data to Test Factors Predictive of Perseverance in Home Movement Rehabilitation: Optimal Challenge and Steady Engagement

Persevering with home rehabilitation exercise is a struggle for millions of people in the US each year. A key factor that may influence motivation to engage with rehabilitation exercise is the challenge level of the assigned exercises, but this hypothesis is currently supported only by subjective, self-report. Here, we studied the relationship between challenge level and perseverance using long-term, self-determined exercise patterns of a large number of individuals (N = 2,581) engaging in home rehabilitation with a sensor-based exercise system without formal supervision. FitMi is comprised of two puck-like sensors and a library of 40 gamified exercises for the hands, arms, trunk, and legs that are designed for people recovering from a stroke. We found that individuals showed the greatest perseverance with the system over a 2-month period if they had (1) a moderate level of motor impairment and (2) high but not perfect success during the 1st week at completing the exercise game. Further, a steady usage pattern (vs. accelerating or decelerating use) was associated with more overall exercise, and declines in exercise amount over time were associated with exponentially declining session initiation probability rather than decreasing amounts of exercise once a session was initiated. These findings confirm that an optimized challenge level and regular initiation of exercise sessions predict achievement of a greater amount of overall rehabilitation exercise in a group of users of commercial home rehabilitation technology and suggest how home rehabilitation programs and exercise technologies can be optimized to promote perseverance.

A Comparative Analysis of Functional Status and Mobility in Stroke Patients with and without Aphasia

All researchers agree that aphasia is a serious consequence of a stroke, but they also report contradictory data regarding the functional outcome. The aim of this study was, therefore, to assess the functional outcomes of stroke patients with and without aphasia, who were undertaking a regular rehabilitation programme.

MATERIALS AND METHODS

The study group consisted of 116 post-stroke patients, including 54 patients without aphasia (G1) and 62 patients with aphasia (G2). The following tests were used before (T1) and after (T2) rehabilitation measurement points: Barthel Index (BI), Sitting Assessment Scale (SAS), Berg Balance Scale (BBS), Trunk Control Test (TCT), Test Up & Go (TUG) and the Timed Walk Test (TWT).

RESULTS

The group of post-stroke patients with aphasia had a significantly longer time since a stroke on admission, a significantly longer length of stay in the ward and significantly worse SAS and TCT scores at T2, compared to patients without aphasia. Both groups achieved significant improvement in all studied parameters (SAS, TCT, BI, BBS, TUG and TWT). Aphasia was a predictor of functional status in the stroke patients group, but only at the time of admission to the ward.

CONCLUSIONS

Patients with and without aphasia have an equal likelihood of improving their functional status and returning to independence. Aphasia should not be an absolute factor that excludes stroke patients from research studies on their functional status.

Leveraging Factors of Self-Efficacy and Motivation to Optimize Stroke Recovery

The International Classification of Functioning, Disability and Health framework recognizes that an individual's functioning post-stroke reflects an interaction between their health condition and contextual factors encompassing personal and environmental factors. Personal factors significantly impact rehabilitation outcomes as they determine how an individual evaluates their situation and copes with their condition in daily life. A key personal factor is self-efficacy-an individual's belief in their capacity to achieve certain outcomes. Self-efficacy influences an individual's motivational state to execute behaviors necessary for achieving desired rehabilitation outcomes. Stroke rehabilitation practice and research now acknowledge self-efficacy and motivation as critical elements in post-stroke recovery, and increasing evidence highlights their contributions to motor (re)learning. Given the informative value of neuroimaging-based biomarkers in stroke, elucidating the neurological underpinnings of self-efficacy and motivation may optimize post-stroke recovery. In this review, we examine the role of self-efficacy and motivation in stroke rehabilitation and recovery, identify potential neural substrates underlying these factors from current neuroimaging literature, and discuss how leveraging these factors and their associated neural substrates has the potential to advance the field of stroke rehabilitation.

An Evidence-Based Nursing Intervention Decreases Anxiety, Depression, Sleep Quality and Somatic Symptoms of Patients with Acute Ischemic Stroke

PURPOSE

This study aimed to explore the effects of evidence-based nursing (EBN) intervention on anxiety, depression, sleep quality and somatic symptoms of patients with acute ischemic stroke (AIS).

METHODS

The eligible AIS patients were randomized into the intervention group and control group in a 1:1 ratio. Patients in both groups received routine nursing care. On the basis of routine nursing, patients in the intervention group also received EBN. Self-rating anxiety scale (SAS), self-rating depression scale (SDS), Pittsburgh Sleep Quality Index (PSQI), and the Patient Health Questionnaire-15 (PHQ-15) were used to assess patients' anxiety, depression, sleep quality, and somatic symptoms at baseline (T0) and 6 months after intervention (T1), respectively.

RESULTS

There was no difference in SAS, SDS, PSQI, and PHQ-15 scores at T0 between the 2 groups (all P > 0.05). Comparing to the control group, the intervention group had significantly lower SAS and SDS scores at T1 (P = 0.002, P < 0.001, respectively). The SAS and SDS score changes (T1-T0) were more evident in the intervention group than in the control group (all P < 0.001). No difference of PSQI or PHQ-15 score between the 2 groups was observed at T1. However, the PSQI and PHQ-15 score changes were more evident in the intervention group than in the control group (P = 0.044 and P = 0.007, respectively).

CONCLUSION

EBN invention significantly improved anxiety, depression, sleep quality and somatic symptoms of patients with AIS.

Family Functioning is Associated with Post-Stroke Depression in First-Ever Stroke Survivors: A Longitudinal Study

BACKGROUND

Post-stroke depression (PSD) can aggravate the mortality and recurrence rate in stroke patients. The relationship between family functioning and PSD at different phases after a first-ever stroke is unclear. The purpose of this longitudinal study was to investigate the patterns and relationship of family functioning and PSD at acute hospitalization and 6 months post-discharge in first-ever stroke survivors.

METHODS

This is a longitudinal study conducted in Guangzhou, China. Family functioning and depression were measured by the Short Form Family Assessment Device (SF-FAD) and Self-Rating Depression Scale (SDS) at baseline and 6 months post-discharge. Multiple linear regression analysis was used to explore the relationship between family functioning and PSD.

RESULTS

The prevalence of PSD at acute hospitalization and 6 months post-discharge was 32.9% and 20.0%, respectively. SDS scores decreased significantly from baseline to 6 months post-discharge, while SF-FAD scores did not change significantly during this period. The Pearson correlation coefficient showed that SF-FAD scores were positively associated with SDS scores at the two time points (r ₁ = 0.341, r ₂ = 0.510, P < 0.05). Multiple linear regression analyses indicated that SF-FAD scores could predict PSD at baseline (unstandardized coefficient: 7.010, P < 0.05) and 6 months post-discharge (unstandardized coefficient: 9.672, P < 0.001).

CONCLUSION

This study found that first-ever stroke survivors had good family functioning at baseline and 6 months post-discharge. The findings in this study verified that poor family functioning is positively associated with PSD at different phases post-stroke. Good family functioning is an important protective factor against PSD.

Social Determinants of Health in Physiatry: Challenges and Opportunities for Clinical Decision Making and Improving Treatment Precision

Physiatry is a medical specialty focused on improving functional outcomes in patients with a variety of medical conditions that affect the brain, spinal cord, peripheral nerves, muscles, bones, joints, ligaments, and tendons. Social determinants of health (SDH) play a key role in determining therapeutic process and patient functional outcomes. Big data and precision medicine have been used in other fields and to some extent in physiatry to predict patient outcomes, however many challenges remain. The interplay between SDH and physiatry outcomes is highly variable depending on different phases of care, and more favorable patient profiles in acute care may be less favorable in the outpatient setting. Furthermore, SDH influence which treatments or interventional procedures are accessible to the patient and thus determine outcomes. This opinion paper describes utility of existing datasets in combination with novel data such as movement, gait patterning and patient perceived outcomes could be analyzed with artificial intelligence methods to determine the best treatment plan for individual patients in order to achieve maximal functional capacity.

Effects of early rehabilitation nursing intervention on nerve function and daily living in patients with stroke hemiplegia

OBJECTIVE

To explore the effects of early rehabilitation nursing on the rehabilitation of stroke hemiplegia patients.

METHODS

A total of 80 patients with stroke admitted to Ningxiang People's Hospital were selected as the research subjects for analysis. Among them, 40 patients received early rehabilitation nursing intervention after admission and were enrolled in the observation group. The other 40 patients received only general nursing intervention who were enrolled in the control group. National Institutes of Health Stroke Scale (NIHSS) and Ruminative responses scale (RRS) were used to evaluate the nerve function of the two groups of patients before and after treatment. Fugl-Meyer motor function assessment (FMA) was applied to evaluate their athletic ability, and activity of daily living (ADL) score and Barthel index were utilized to evaluate their living ability. The adverse reactions and nursing satisfaction were compared between the two groups.

RESULTS

After treatment, NIHSS score and RRS score in the observation group were lower than those in the control group (P<0.05). FMA score, ADL score and Barthel index were higher in the observation group than those of the control group (P<0.05). After treatment, NIHSS score and RRS score were both lower than those before treatment (P<0.05), while FMA score, ADL score and Barthel index were higher than those before treatment (P<0.05). There was no difference in the incidence of adverse reactions between the two groups (P>0.05). The nursing satisfaction of the observation group was higher than that of the control group (P<0.05).

CONCLUSION

Early rehabilitation nursing can effectively improve the nerve function, athletic ability and living ability of stroke hemiplegia patients, which is worth popularizing in clinic.

Vocational rehabilitation for young stroke survivors in Gauteng public healthcare: Occupational therapists' perceptions1

BACKGROUND

The prevalence of working-aged stroke survivors is increasing yearly. Stroke is an expensive disease, causing financial burden to the government, the family and caregivers of the patient, thus making it imperative for working-aged stroke survivors to work to remain financially independent. Survivors' need to work necessitates occupational therapists to shift their focus from basic activities of daily living, to rehabilitating work.

OBJECTIVES

This study aimed to determine the perceptions of occupational therapists working with younger stroke survivors in public hospitals and clinics in Gauteng South Africa, about rehabilitating working-aged stroke survivors' work ability.

METHODS

Ethical clearance was obtained. A qualitative research design was used to obtain narrative, descriptive data from six focus groups. Therapists from public healthcare settings, who had more than six months' experience and had worked in neurological rehabilitation within the six months preceding the focus group, were invited to participate. Focus groups were audio recorded and transcribed. Inductive content analysis was used to identify themes and categories.

RESULTS

Few participants are involved in rehabilitating younger stroke survivors' work ability or facilitating return to work (RTW). The study identified perceived barriers and enablers to rendering OT services that meet working-aged stroke survivors' needs.

CONCLUSIONS

Despite enabling employment equity laws in South Africa, OTs working in the public sector appear to experience a sense of futility when trying to rehabilitate young stoke survivors to RTW. Fragmentation of the public sector and limited resources impede successful RTW for working-aged stroke survivors. Survivors' employment status and motivation to RTW facilitated rehabilitating work ability.

What can virtual reality offer to stroke patients? A narrative review of the literature

BACKGROUND

Studies demonstrated the efficacy of virtual reality (VR) as a method supporting the post-stroke neuro-rehabilitation process by activating motor learning processes. Nevertheless, stroke is frequently accompanied by serious psychological problems including depression, which is associated with an increased risk of mortality, lower post-stroke physical activity, and higher disability in stroke patients.

OBJECTIVES

To explore the current use of VR as a method supporting the neuro-rehabilitation process, both in physical and psychological dimensions.

METHODS

An exploratory review was conducted with a narrative synthesis. PubMed was used for literature search. Search includes the use of VR in physical rehabilitation, and as support therapy in psychiatric disorders. Both primary research and systematic reviews were included.

RESULTS

In neurological disorders rehabilitation, out of 22 studies, 16 concerned stroke survivors. In psychiatric disorders, 44 literature reviews were included.

CONCLUSION

The studies confirmed the effectiveness of various forms of VR treatment in the alleviation of psychological and behavioral problems and psychiatric disorders. There is a shortage of VR-based technological solutions that would, besides physical rehabilitation, offer stroke patients therapeutic tools to alleviate psychological disturbance and improve the patient's mood and motivation. Such solutions will most likely become a field of intensive research in the coming years.

Analysis of the Degree of Acceptance of Illness Among Patients After a Stroke: An Observational Study

Introduction

The aim of this study was to analyse the level of illness and disability acceptance in stroke patients undergoing regular rehabilitation at two time points, before rehabilitation and after 3 weeks, and to answer the following questions: What is the functional and emotional status of stroke patients, characterized by a lower and higher level of illness acceptance before and after the 3-week rehabilitation period? What factors, including clinical, sociodemographic, functional and emotional, are associated with the degree of illness acceptance in patients who have suffered a first stroke?

Sample and Methods

The study included 64 patients after first stroke, aged 50–87 years. The following tests were used: Acceptance of Illness Scale, Geriatric Depression Scale, Rivermead Mobility Index and Barthel Index. Tests were conducted at two time points, the first before rehabilitation and the second after 3 weeks of regular rehabilitation.

Results

The study group had an average level of acceptance of their illness and disability, both before and after 3 weeks of rehabilitation. After rehabilitation process, statistically significant improvements were achieved in acceptance of illness, mood disorders, functional status, mobility and locomotion. Low levels of illness acceptance were observed in stroke patients with a poorer functional condition, with mood disorders, with primary and vocational education.

Conclusion

The results suggest that the level of illness acceptance may be an important factor in the rehabilitation of stroke patients; however, further studies are necessary.

The Role of Self-Efficacy in the Recovery Process of Stroke Survivors

Introduction

Belief in one’s personal capabilities are conducive to achieving success and provides additional energy for action. The stronger the conviction of one’s self-efficacy, the higher the self-goals and the stronger the commitment to achieving them, despite any adversities. Our knowledge regarding the role of self-efficacy in post-stroke rehabilitation is still scarce.

Aim of the Study

The study aimed to analyze characteristics related to high self-efficacy levels before and after rehabilitation and to determine the role of self-efficacy in this process.

Materials and Methods

The study involved 99 stroke survivors. Participants’ mental and functional state were assessed using Generalized Self-Efficacy Scale (GSES), Barthel Index (BI), Acceptance of Illness Scale (AIS), Geriatric Depression Scale (GDS), Visual Analogue Scale for Pain (VAS), Instrumental Activities of Daily Living (IADL) and Rivermead Mobility Index (RMI). Patients were evaluated twice: on admission (T₁) and 3 weeks into rehabilitation (T₂).

Results

Patients without self-efficacy improvement after 3 weeks of rehabilitation, on discharge from the ward demonstrated poorer well-being (p = 0.002, Hedges’ g = 0.63, 95% CI [0.24–1.08]), lower illness acceptance levels (p < 0.001, Hedges’ g = −0.78, 95% CI [−1.25 – −0.41]), poorer functional status in basic activities of daily living (p = 0.003, Hedges’ g = −0.62, 95% CI [−1 – −0.25]), locomotive abilities (p = 0.004, Hedges’ g = −0.58, 95% CI [−1.12 – −0.15]) and instrumental activities of daily living (p = 0.001, Hedges’ g = −0.71, 95% CI [−1.15 – −0.34]).

Conclusion

Self-efficacy level is significantly related to rehabilitation outcomes. A routine self-efficacy assessment during the rehabilitation process seems very important. Patients whose initial self-efficacy is low or remains unchanged despite rehabilitation require special attention. Close cooperation between all members of the therapeutic team is essential to strengthen, at each stage, the sense of self-efficacy in stroke survivors.

The use of total immersion in the rehabilitation process

The popularity of immersion, understood as absolute engrossment in a virtual world, has been growing year by year, due to new hi-tech sound, image and data-processing technologies. Man, because of human nature, is attracted to immersion as a way of experiencing new environments, which are often very different from those offered by the real world. Thanks to immersion in a virtual world, one can step into any desired computer-generated reality. This technology has found its use in the process of motor rehabilitation, likewise, psychological therapy. Total immersion in a virtual world creates the possibility for guided rehabilitation, utilising the appeal of am imaginary environment. Patients become more engaged and motivated to take part in the laborious and painstakingly long process leading to the recovery of their motor functions. Cooperation between physiotherapists and psychologists with engineers has resulted in the creation of new software solutions, and improved equipment, which can be tailored to meet the needs of patients with various mental problems or physical disfunctions and disabilities.

Predictors of Arm Nonuse in Chronic Stroke: A Preliminary Investigation

Background. Nonuse (NU) after stroke is characterized by failure to use the contralesional arm despite adequate capacity. It has been suggested that NU is a consequence of the greater effort and/or attention required to use the affected limb, but such accounts have not been directly tested, and we have poor understanding of the predictors of NU. Objective. We aimed to provide preliminary evidence regarding demographic, neuropsychological (ie, apraxia, attention/arousal, neglect), and psychological (ie, self-efficacy) factors that may influence NU in chronic stroke. Methods. Twenty chronic stroke survivors with mild to moderate sensory-motor impairment characterized by the Upper-Extremity Fugl-Meyer (UEFM) were assessed for NU with a modified version of the Actual Amount of Use Test (AAUT), which measures the disparity between amount of use in spontaneous versus forced conditions. Participants were also assessed with measures of limb apraxia, spatial neglect, attention/arousal, and self-efficacy. Using stepwise multiple regression, we determined which variables predicted AAUT NU scores. Results. Scores on the UEFM as well as attention/arousal predicted the degree of NU (P < .05). Attention/arousal predicted NU above and beyond UEFM (P < .05). Conclusions. The results are consistent with the importance of attention and engagement necessary to fully incorporate the paretic limb into daily activities. Larger-scale studies that include additional behavioral (eg, sensation, proprioception, spasticity, pain, mental health, motivation) and neuroanatomical measures (eg, lesion volume and white matter connectivity) will be important for future investigations.