Determinants of participation restriction among community dwelling stroke survivors : a path analysis

Background: Apart from promoting physical recovery and assisting in activities of daily living, a major challenge in stroke rehabilitation is to minimize psychosocial morbidity and to promote the reintegration of stroke survivors into their family and community. The identification of key factors influencing long-term outcome are essential in developing more effective rehabilitation measures for reducing stroke-related morbidity. The aim of this study was to test a theoretical model of predictors of participation restriction which included the direct and indirect effects between psychosocial outcomes, physical outcome, and socio-demographic variables at 12 months after stroke.--------- Methods: Data were collected from 188 stroke survivors at 12 months following their discharge from one of the two rehabilitation hospitals in Hong Kong. The settings included patients' homes and residential care facilities. Path analysis was used to test a hypothesized model of participation restriction at 12 months.---------- Results: The path coefficients show functional ability having the largest direct effect on participation restriction (β = 0.51). The results also show that more depressive symptoms (β = -0.27), low state self-esteem (β = 0.20), female gender (β = 0.13), older age (β = -0.11) and living in a residential care facility (β = -0.12) have a direct effect on participation restriction. The explanatory variables accounted for 71% of the variance in explaining participation restriction at 12 months.---------- Conclusion: Identification of stroke survivors at risk of high levels of participation restriction, depressive symptoms and low self-esteem will assist health professionals to devise appropriate rehabilitation interventions that target improving both physical and psychosocial functioning.

Social Participation of Community Dwelling Stroke Survivors [Published Abstract: From the Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Conference 2009]

Disability following a stroke can impose various restrictions on patients’ attempts at participating in life roles. The measurement of social participation, for instance, is important in estimating recovery and assessing quality of care at the community level. Thus, the identification of factors influencing social participation is essential in developing effective measures for promoting the reintegration of stroke survivors into the community. Data were collected from 188 stroke survivors (mean age 71.7 years) 12 months after discharge from a stroke rehabilitation hospital. Of these survivors, 128 (61 %) had suffered a first ever stroke, and 81 (43 %) had a right hemisphere lesion. Most (n = 156, 83 %) were living in their own home, though 32 (17 %) were living in residential care facilities. Path analysis was used to test a hypothesized model of participation restriction which included the direct and indirect effects between social, psychological and physical outcomes and demographic variables. Participation restriction was the dependent variable. Exogenous independent variables were age, functional ability, living arrangement and gender. Endogenous independent variables were depressive symptoms, state self-esteem and social support satisfaction. The path coefficients showed functional ability having the largest direct effect on participation restriction. The results also showed that more depressive symptoms, low state self-esteem, female gender, older age and living in a residential care facility had a direct effect on participation restriction. The explanatory variables accounted for 71% of the variance in explaining participation restriction. Prediction models have empirical and practical applications such as suggesting important factors to be considered in promoting stroke recovery. The findings suggest that interventions offered over the course of rehabilitation should be aimed at improving functional ability and promoting psychological aspects of recovery. These are likely to enhance stroke survivors resume or maximize their social participation so that they may fulfill productive and positive life roles.

Depression among Chinese stroke survivors six months after discharge from a rehabilitation hospital

Aim and objective: The primary aim was to examine the prevalence of poststroke depression in Chinese stroke survivors six months after discharge from a rehabilitation hospital. A second aim was to determine whether six-month poststroke depression was associated with psychological, social and physical outcomes and demographic variables.---------- Background: There has been increasing recognition of the influence of depression on poststroke recovery. While some previous studies report associations between depression and social, psychological, physical and clinical outcomes, few studies had sufficient sample sizes for regression analysis thereby limiting the clinical applicability of their findings. ---------- Design: A cross-sectional design was used.---------- Method: Data were collected from 124 male and 86 female stroke survivors (mean age 71Æ7, SD 10Æ2 years). The Geriatric Depression Scale was used to measure depression, the State Self-esteem Scale to measure state self-esteem, the London Handicap Scale to measure participation restriction, the Social Support Questionnaire to measure satisfaction with social support and the Modified Barthel Index to measure functional ability. Results. Forty-two survivors (20Æ5%) reported mild and 33 (16Æ1%) reported severe depression. The presence of depression was associated with low levels of state self-esteem, social support satisfaction and functional ability. Logistic regression analysis revealed that these variables were statistically significant in predicting the probability of having depression (p < 0Æ05). ---------- Conclusions: Analyses in the present study revealed distinct patterns of correlates of depression, and the results were in agreement with prior studies that depression has a consistent positive ssociation with physical disability, living arrangements and social support and no significant association with the different types of brain lesion. Relevance to clinical practice. There is a need, routinely, to assess stroke survivors for depression and, where necessary, to intervene with the aim of enhancing psychological and social well-being.

Theory-based self-management programs for promoting recovery in community-dwelling stroke survivors : a systematic review

Background Post-stroke recovery is demanding. Increasing studies have examined the effectiveness of self-management programs for stroke survivors. However no systematic review has been conducted to summarize the effectiveness of theory-based stroke self-management programs. Objectives The aim is to present the best available research evidence about effectiveness of theory-based self-management programs on community-dwelling stroke survivors’ recovery. Inclusion criteria Types of participants All community-residing adults aged 18 years or above, and had a clinical diagnosis of stroke. Types of interventions Studies which examined effectiveness of a self-management program underpinned by a theoretical or conceptual framework for community-dwelling stroke survivors. Types of studies Randomized controlled trials. Types of outcomes Primary outcomes included health-related quality of life and self-management behaviors. Secondary outcomes included physical (activities of daily living), psychological (self-efficacy, depressive symptoms), and social outcomes (community reintegration, perceived social support). Search Strategy A three-step approach was adopted to identify all relevant published and unpublished studies in English or Chinese. Methodological quality The methodological quality of the included studies was assessed using the Joanna Briggs Institute critical appraisal checklist for experimental studies. Data Collection A standardized JBI data extraction form was used. There was no disagreement between the two reviewers on the data extraction results. Data Synthesis There were incomplete details about the number of participants and the results in two studies, which makes it impossible to perform meta-analysis. A narrative summary of the effectiveness of stroke self-management programs is presented. Results Three studies were included. The key issues of concern in methodological quality included insufficient information about random assignment, allocation concealment, reliability and validity of the measuring instruments, absence of intention-to-treat analysis, and small sample sizes. The three programs were designed based on the Stanford Chronic Disease Self-management program and were underpinned by the principles of self-efficacy. One study showed improvement in the intervention group in family and social roles three months after program completion, and work productivity at six months as measured by the Stroke Specific Quality of Life Scale (SSQOL). The intervention group also had an increased mean self-efficacy score in communicating with physicians six months after program completion. The mean changes from baseline in these variables were significantly different from the control group. No significant difference was found in time spent in aerobic exercise between the intervention and control groups at three and six months after program completion. Another study, using SSQOL, showed a significant interaction effect by treatment and time on family roles, fine motor tasks, self-care, and work productivity. However there was no significant interaction by treatment and time on self-efficacy. The third study showed improvement in quality of life, community participation, and depressive symptoms among the participants receiving the stroke self-management program, Stanford Chronic Disease Self-management program, or usual care six months after program completion. However, there was no significant difference between the groups. Conclusions There is inconclusive evidence about the effectiveness of theory-based stroke self-management programs on community-dwelling stroke survivors’ recovery. However the preliminary evidence suggests potential benefits in improving stroke survivors’ quality of life and self-efficacy.

Comparison of kinematic variables obtained by inertial sensors among stroke survivors and healthy older adults in the Functional Reach Test: cross-sectional study

Background Balance dysfunction is one of the most common problems in people who suffer stroke. To parameterize functional tests standardized by inertial sensors have been promoted in applied medicine. The aim of this study was to compare the kinematic variables of the Functional Reach Test (FRT) obtained by two inertial sensors placed on the trunk and lumbar region between stroke survivors (SS) and healthy older adults (HOA) and to analyze the reliability of the kinematic measurements obtained. Methods Cross-sectional study. Five SS and five HOA over 65. A descriptive analysis of the average range as well as all kinematic variables recorded was developed. The intrasubject and intersubject reliability of the measured variables was directly calculated. Results In the same intervals, the angular displacement was greater in the HOA group; however, they were completed at similar times for both groups, and HOA conducted the test at a higher speed and greater acceleration in each of the intervals. The SS values were higher than HOA values in the maximum and minimum acceleration in the trunk and in the lumbar region. Conclusions The SS show less functional reach, a narrower, slower and less accelerated movement during the FRT execution, but with higher peaks of acceleration and speed when they are compared with HOA.

Education in stroke prevention: Efficacy of an educational counselling intervention to increase knowledge in stroke survivors

BACKGROUND Motivational interviewing and stages of change are approaches to increasing knowledge and effecting behavioural change. This study examined the application of this approach on stroke knowledge acquisition and changing individual lifestyle risk factors in an outpatient clinic. METHODS RCT in which 200 participants were allocated to an education-counselling interview (ECI) or a control group. ECI group participants mapped their individual risk factors on a stage of change model and received an appointment to the next group lifestyle class. Participants completed a stroke knowledge questionnaire at baseline (T1), post-appointment, and three months (T3) post-appointment. Passive to active changes in lifestyle behaviour were self-reported at three months. RESULTS There was a statistically significant difference between groups from T1 toT3 in stroke knowledge (p < 0.001). While there was a significant shift from a passive to active stage of change for the overall study sample (p < 0.000), there was no significant difference between groups on the identified risk factors. CONCLUSIONS Although contact with patients in ambulatory clinical settings is limited due to time constraints, it is still possible to improve knowledge and initiate lifestyle changes utilizing motivational interviewing and a stage of change model. Stroke nurses may wish to consider these techniques in their practice setting.

Parameterization and reliability of single-leg balance test assessed with inertial sensors in stroke survivors: a cross-sectional study

Background and purpose There are no published studies on the parameterisation and reliability of the single-leg stance (SLS) test with inertial sensors in stroke patients. Purpose: to analyse the reliability (intra-observer/inter-observer) and sensitivity of inertial sensors used for the SLS test in stroke patients. Secondary objective: to compare the records of the two inertial sensors (trunk and lumbar) to detect any significant differences in the kinematic data obtained in the SLS test. Methods Design: cross-sectional study. While performing the SLS test, two inertial sensors were placed at lumbar (L5-S1) and trunk regions (T7–T8). Setting: Laboratory of Biomechanics (Health Science Faculty - University of Málaga). Participants: Four chronic stroke survivors (over 65 yrs old). Measurement: displacement and velocity, Rotation (X-axis), Flexion/Extension (Y-axis), Inclination (Z-axis); Resultant displacement and velocity (V): RV=(Vx2+Vy2+Vz2)−−−−−−−−−−−−−−−−−√ Along with SLS kinematic variables, descriptive analyses, differences between sensors locations and intra-observer and inter-observer reliability were also calculated. Results Differences between the sensors were significant only for left inclination velocity (p = 0.036) and extension displacement in the non-affected leg with eyes open (p = 0.038). Intra-observer reliability of the trunk sensor ranged from 0.889-0.921 for the displacement and 0.849-0.892 for velocity. Intra-observer reliability of the lumbar sensor was between 0.896-0.949 for the displacement and 0.873-0.894 for velocity. Inter-observer reliability of the trunk sensor was between 0.878-0.917 for the displacement and 0.847-0.884 for velocity. Inter-observer reliability of the lumbar sensor ranged from 0.870-0.940 for the displacement and 0.863-0.884 for velocity. Conclusion There were no significant differences between the kinematic records made by an inertial sensor during the development of the SLS testing between two inertial sensors placed in the lumbar and thoracic regions. In addition, inertial sensors. Have the potential to be reliable, valid and sensitive instruments for kinematic measurements during SLS testing but further research is needed.

Training of Reaching in Stroke Survivors With Severe and Chronic Upper Limb Paresis Using a Novel Nonrobotic Device: A Randomized Clinical Trial

Background and Purpose—Severe upper limb paresis is a major contributor to disability after stroke. This study investigated the efficacy of a new nonrobotic training device, the Sensorimotor Active Rehabilitation Training (SMART) Arm, that was used with or without electromyography-triggered electrical stimulation of triceps brachii to augment elbow extension, permitting stroke survivors with severe paresis to practice a constrained reaching task.

Methods—A single-blind, randomized clinical trial was conducted with 42 stroke survivors with severe and chronic paresis. Thirty-three participants completed the study, of whom 10 received training using the SMART Arm with electromyography-triggered electrical stimulation, 13 received training using the SMART Arm alone, and 10 received no intervention (control). Training consisted of 12 1-hour sessions over 4 weeks. The primary outcome measure was “upper arm function,” item 6 of the Motor Assessment Scale. Secondary outcome measures included impairment measures; triceps muscle strength, reaching force, modified Ashworth scale; and activity measures: reaching distance and Motor Assessment Scale. Assessments were administered before (0 weeks) and after training (4 weeks) and at 2 months follow-up (12 weeks).

Results—Both SMART Arm groups demonstrated significant improvements in all impairment and activity measures after training and at follow-up. There was no significant difference between these 2 groups. There was no change in the control group.

Conclusions—Our findings indicate that training of reaching using the SMART Arm can reduce impairment and improve activity in stroke survivors with severe and chronic upper limb paresis, highlighting the benefits of intensive task-oriented practice, even in the context of severe paresis.

Training-induced modifications of corticospinal reactivity in severely affected stroke survivors

When permitted access to the appropriate forms of rehabilitation, many severely affected stroke survivors demonstrate a capacity for upper limb functional recovery well in excess of that formerly considered possible. Yet, the mechanisms through which improvements in arm function occur in such profoundly impaired individuals remain poorly understood. An exploratory study was undertaken to investigate the capacity for brain plasticity and functional adaptation, in response to 12-h training of reaching using the SMART Arm device, in a group of severely affected stroke survivors with chronic upper limb paresis. Twenty-eight stroke survivors were enroled. Eleven healthy adults provided normative data. To assess the integrity of ipsilateral and contralateral corticospinal pathways, transcranial magnetic stimulation was applied to evoke responses in triceps brachii during an elbow extension task. When present, contralateral motor-evoked potentials (MEPs) were delayed and reduced in amplitude compared to those obtained in healthy adults. Following training, contralateral responses were more prevalent and their average onset latency was reduced. There were no reliable changes in ipsilateral MEPs. Stroke survivors who exhibited contralateral MEPs prior to training achieved higher levels of arm function and exhibited greater improvements in performance than those who did not initially exhibit contralateral responses. Furthermore, decreases in the onset latency of contralateral MEPs were positively related to improvements in arm function. Our findings demonstrate that when severely impaired stroke survivors are provided with an appropriate rehabilitation modality, modifications of corticospinal reactivity occur in association with sustained improvements in upper limb function.

The efficacy of SMART Arm training early after stroke for stroke survivors with severe upper limb disability:a protocol for a randomised controlled trial

Recovery of upper limb function after stroke is poor. The acute to subacute phase after stroke is the optimal time window to promote the recovery of upper limb function. The dose and content of training provided conventionally during this phase is however, unlikely to be adequate to drive functional recovery, especially in the presence of severe motor disability. The current study concerns an approach to address this shortcoming, through evaluation of the SMART Arm, a non-robotic device that enables intensive and repetitive practice of reaching by stroke survivors with severe upper limb disability, with the aim of improving upper limb function. The outcomes of SMART Arm training with or without outcome-triggered electrical stimulation (OT-stim) to augment movement and usual therapy will be compared to usual therapy alone.

The education needs of caregivers of stroke survivors in acute and community settings

Stroke is a major cause of chronic illness in Australia, where it is estimated that between 200,000 and 250,000 people live with disabilities due to stroke. Given stroke's effect on survivors and the accompanying burden on caregivers, attention should be given to addressing the needs of caregivers of stroke survivors because they are central to supporting survivors living in the community. Research has shown that the information needs of caregivers are not being met across healthcare settings. Thus, some attention must be given to the development of educational materials that address caregiver needs. In this study we interviewed caregivers to determine their perspectives on support and educational needs at two different stages in the recovery of the stroke survivor: the acute hospital and the community. Despite a high level of uncertainty among caregivers in the acute and community settings, limited information was provided to assist them in their new role. A multifaceted approach would involve the development and implementation of specifically designed educational materials for caregivers, the use of a tool such as a patient-held record to assist in and improve the continuity and communication of care, and the provision of ongoing support from a stroke nurse practitioner who would follow stroke survivors from the acute setting to the community. This approach should be evaluated so that the important issue of addressing caregiver needs is given its due attention.

Managing as carers of stroke survivors : strategies from the field

Family members are required to provide increasingly complex care to relatives in the home. Stroke is a major cause of disability and there is increasing pressure being placed on carers to provide on-going support to stroke survivors living in the community. This study involved interviewing carers to determine their perspectives on the support and educational needs they require and the coping strategies they used. Data analysis revealed that carers experienced considerable uncertainty about their role as carers and their future and that they used a number of coping strategies to manage in their caring role. The coping strategies adopted by the carers included remaining positive, adapting to change, comparing their situation with others who were worse off, changing their employment status, humour, switching off and using family support. It is important for health care professionals to understand the complex role of the carers and to advise them on strategies they can use to assist managing this role.

Informal care for stroke survivors. Results from the North East Melbourne stroke incidence study (NEMESIS)

Background and Purpose-: Informal caregivers play an important role in the lives of stroke patients, but the cost of providing this care has not been estimated. The purpose of this study was to determine the nature and amount of informal care provided to stroke patients and to estimate the economic cost of that care.

Methods-: The primary caregivers of stroke patients registered in the North East Melbourne Stroke Incidence Study (NEMESIS) were interviewed at 3, 6, and 12 months after stroke, and the nature and amount of informal care provided were documented. The opportunity and replacement costs of informal care for all first-ever-in-a-lifetime strokes (excluding subarachnoid hemorrhages) that occurred in 1997 in Australia were estimated.

Results-: Among 3-month stroke survivors, 74% required assistance with activities of daily living and received informal care from family or friends. Two thirds of primary caregivers were women, and most primary caregivers (>90%) provided care during family or leisure time. Total first-year caregiver time costs for all first-ever-in-a-lifetime strokes were estimated to be A$21.7 million (opportunity cost approach) or A$42.5 million (replacement cost approach), and the present values of lifetime caregiver time costs were estimated to be A$171.4 million (opportunity cost approach) or A$331.8 million (replacement cost approach).

Conclusions-: Informal care for stroke survivors represents a significant hidden cost to Australian society. Because our community is rapidly aging, this informal care burden may increase significantly in the future.

Defining quality of life for Chinese elderly stroke survivors

Purpose: This study aimed to identify the constituents and conceptual characteristics of the quality of life (QOL) of Chinese elderly stroke survivors, living in the community in Hong Kong.

Method: A triangulated approach was used to identify the QOL components for this population. This process involved a comparison of QOL components gathered from three different methods, namely, focus group interviews, review of the literature and the contents of the generic Hong Kong Chinese version of the World Health Organization Quality of Life Scale (CWHOQOL-HK). Five health professionals were involved in the comparison process. A percentage of inter-judge agreement was used to determine the reliability of the comparisons made between the judges.

Results: This study identified 36 components considered to contribute to the QOL of Chinese elderly stroke survivors in Hong Kong. The conceptual characteristics of their QOL generally concurred with those identified in the literature.

Conclusion: Both similarities and differences were found in the QOL components identified in this study when compared to those identified in studies of Western populations who are elderly and had a stroke. The contents of the CWHOQOL-HK scale were found to lack adequacy in representing the QOL of Chinese elderly stroke survivors in Hong Kong. Recommendations are given, based on the findings of this study, to overcome this limitation for its application as a QOL measure for this population.

Validation of comprehensive assessment of activities of daily living in stroke survivors

This study determined whether the Functional Independence Measure (FIM) and the Frenchay Activities Index (FAI) could be used together as a more comprehensive score to assess the activities of daily living (ADL) in stroke survivors. Subjects were recruited from stroke patients consecutively admitted to the inpatient neurology or rehabilitation department at a university hospital in southern Taiwan. We interviewed 209 first stroke survivors at least 1 year after stroke onset during their clinical visits, at home, or in long-term care institutions. Combinations of FIM and FAI as a comprehensive assessment of ADL were measured. All items of the FIM and the FAI were included in a non-parametric factor analysis to determine their underlying constructs. Two comprehensive functional independence scores were then computed as functions of the FIM and FAI scores. The distributional characteristics of the comprehensive scores were examined. Approximately 90% of the total variation was explained by three factors. One single factor comprised all the items from FIM, while the FAI items loaded on two other factors, suggesting that FIM supplements FAI without overlap in content. We further demonstrated that the presence of ceiling or floor effects when either the FIM or the FAI was used could be removed using combined scores of the two instruments. The FIM and the FAI assessed different domains with good construct validity. A comprehensive assessment of functional independence obtained by combining the FIM and the FAI scores is potentially more appropriate and useful for clinical and research applications in stroke patients.