The Mobility Scale for Acute Stroke Patients: intra-rater and inter-rater reliability

Objective: With increasing pressure for accountability in the Australian health service, clinicians require reliable and valid measurement tools for assessing the physical status of stroke patients in the acute setting prior to entering rehabilitation, so that predictions can be made about the potential length of stay in rehabilitation and level of outcome. In response to the lack of suitable measures of physical disability for acute stroke patients, the Mobility Scale for Acute Stroke Patients was developed. The aim of this paper was to investigate the intra-rater and inter-rater reliability of the scale.

Method: Five tasks, which incorporate functional movements from lying to walking, were assessed using a six-point scale based on the level of assis tance. Stroke patients were filmed while being assessed by an experienced examiner using the Mobility Scale. Twenty-one clinicians viewed 10 video- taped performances of each activity.

Results: The intra-rater reliability from the viewing sessions one month apart was excellent for 92% of the judgements (weighted kappa >0.75). The weighted kappa values for inter-rater reliability were all in the excellent agreement range above 0.75.

Conclusion: The results of this study showed that the Mobility Scale has a high degree of reliability using this testing procedure. The reliability of the Mobility Scale in the clinical setting and its validity in predicting length of stay and outcome are being investigated.

The role of the physical environment in stroke recovery: Evidence-based design principles from a mixed-methods multiple case study

Hospital design can impact patient outcomes, but there is very little healthcare design evidence specific to stroke rehabilitation facilities. Our aim was to explore, from the patient perspective, the role of the physical environment in factors crucial to stroke recovery, namely, stroke survivor activity (physical, cognitive, social), sleep, emotional well-being, and safety. We conducted a mixed-methods multiple-case study at two inpatient rehabilitation facilities in Victoria, Australia, (n = 20 at Case 1, n = 16 at Case 2) using "walk-through" semi-structured interviews, behavioural mapping, questionnaires, and retrospective audit. Four interrelated themes emerged: 1) entrapment and escape; 2) power, dependency, and identity in an institutional environment; 3) the rehabilitation facility is a shared space; and 4) the environment should be legible and patient-centred. Quantitative data revealed patterns in patient activity; stroke survivors spent over 75% of their time in bedrooms and were often inactive. Convergent mixed methods analysis was used to generate a new conceptual model of the role of the physical environment in stroke survivors' behaviour and well-being, highlighting the importance of variety and interest, privacy without isolation, and patient-centred design. This model can be used by designers, healthcare providers, and policy makers to inform the design of rehabilitation environments.

Robotic task specific training for upper limb neurorehabilitation: a mixed methods feasibility trial reporting achievable dose

PURPOSE

Robotic devices for upper-limb neurorehabilitation allow an increase in intensity of practice, often relying on video game-based training strategies with limited capacity to individualise training and integrate functional training. This study shows the development of a robotic Task Specific Training (TST) protocol and evaluate the achieved dose.

MATERIALS AND METHODS

Mixed-method study. A 3D robotic device for the upper limb, was made available to therapists for use during neurorehabilitation sessions. A first phase allowed clinicians to define a dedicated session protocol for TST. In a second phase the protocol was applied and the achieved dose was measured.

RESULTS

First phase (N = 5): a specific protocol, using deweighting for assessment, followed by customised passive movements and then active movement practice was developed. Second phase: the protocol was successfully applied with all participants (N = 10). Intervention duration: 4.5 ± 0.8 weeks, session frequency: 1.4 ± 0.2sessions/week, session length: 42 ± 9mins, session density: 39 ± 13%, intensity: 214 ± 84 movements/session, difficulty: dn = 0.77 ± 0.1 (normalised reaching distance) and Ɵ = 6.3 ± 23° (transverse reaching angle). Sessions' density and intensity were consistent across participants but clear differences of difficulty were observed. No changes in metrics were observed over the intervention.

CONCLUSIONS

Robotic systems can support TST with high therapy intensity by modulating the practice difficulty to participants' needs and capabilities.

Prediction of length of hospital stay following stroke

The aim of this study was to investigate the potential of using an assessment of initial physical disability post stroke to predict length of hospital stay (LOS). A series of 106 patients with a primary diagnosis of stroke, admitted consecutively to St Vincent's Hospital Rehabilitation Unit over a 2-year period, was assessed at 2 weeks post stroke using the Mobility Scale for Acute Stroke (MSAS). This scale assesses the level of assistance required for a patient to perform five mobility tasks: bridging, sitting from supine, sitting, sitting to standing, and walking. A model utilizing MSAS data explained 69% of the variation in LOS. The results of this study may assist in developing resource utilization models in stroke rehabilitation.

The Ankle Lunge Test for measurement of dorsiflexion in individuals following stroke; reliability, validity and evaluation of change following intervention for spasticity of the lower limb

INTRODUCTION

The Ankle Lunge Test (ALT) is a reliable method of measuring weight bearing ankle dorsiflexion range, a key component of gait, in healthy ankles and a range of musculoskeletal conditions. The aim of this study is to evaluate the reliability and concurrent validity of the ALT in people with stroke and investigate whether change in ALT is observed following treatment of spasticity with Botulinum Toxin.

METHODOLOGY

Repeated Measure Design: Forty stroke survivors were recruited for reliability testing. Twenty three stroke survivors were evaluated with the ALT before and after treatment of the lower limb with Botulinum Toxin. Measurement with the ALT was performed for all participants. For the reliability group, two physiotherapists evaluated the ALT on Day 1 and one therapist re-evaluated the ALT one to 5 days later. For the change evaluation group, the ALT was tested prior to and six to eight weeks after intervention. Other measures evaluated were velocity, the Functional Ambulation Category, Timed Up and Go and the Modified Tardieu Scale.

RESULTS

Intra-rater, inter-rater and test-retest reliability yielded intra-class correlation coefficients at or above 0.92. Moderate correlations were found between the ALT and velocity r = 0.605 (p < 0.01), the Timed Up and Go r = -0.598 (p < 0.01) and the Functional Ambulation Category r = 0.380 (p < 0.05). Following intervention with Botulinum Toxin, there was significant (p < 0.02) improvement in the ALT; pre-median 20 mm (IQR -25 to 35) to post-median 21 mm (IQR 0 to 40) and the Timed Up and Go; pre-median 21.40 s (IQR 13.43 to 28.82) to post-median 20.08 s (IQR 14.06 to 28.47).

CONCLUSION/SIGNIFICANCE

The ALT is a reliable and valid measure which may be applied in clinical practice to evaluate change in weight bearing ankle dorsiflexion in people with stroke.