Effect of activity-based mirror therapy on lower limb motor-recovery and gait in stroke: A randomised controlled trial

Objective: To determine the effect of activity-based mirror therapy (MT) on motor recovery and gait in chronic poststroke hemiparetic subjects.

Design: A randomised, controlled, assessor-blinded trial.

Setting: Rehabilitation institute.

Participants: Thirty-six chronic poststroke (15.89?±?9.01 months) hemiparetic subjects (age: 46.44?±?7.89 years, 30 men and functional ambulation classification of median level 3).

Interventions: Activity-based MT comprised movements such as ball-rolling, rocker-board, and pedalling. The activities were provided on the less-affected side in front of the mirror while hiding the affected limb. The movement of the less-affected lower limb was projected as over the affected limb. Conventional motor therapy based on neurophysiological approaches was also provided to the experimental group. The control group received only conventional management.

Main outcome measures: Brunnstrom recovery stages (BRS), Fugl-Meyer assessment lower extremity (FMA-LE), Rivermead visual gait assessment (RVGA), and 10-metre walk test (10-MWT).

Results: Postintervention, the experimental group exhibited significant and favourable changes for FMA-LE (mean difference?=?3.29, 95% CI?=?1.23–5.35, p?=?.003) and RVGA (mean difference?=?5.41, 95% CI?=?1.12–9.71, p?=?.015) in comparison to the control group. No considerable changes were observed on 10-MWT.

Conclusions: Activity-based MT facilitates motor recovery of the lower limb as well as reduces gait deviations among chronic poststroke hemiparetic subjects.     

AAC technologies with visual scene displays and “just in time” programming and symbolic communication turns expressed by students with severe disability

Background: The current study investigated the impact of an intervention that included aided augmentative and alternative communication (AAC) technologies on the frequency of symbolic communication turns of school-age children, adolescents, and young adults with severe disability.

Method: Nine students ages 8–20 were engaged in interactive activities using an aided AAC system with visual scene displays (VSDs; concepts embedded within a photograph of a naturally occurring event), and “just-in-time” (JIT) programming (the capability to add new contexts “on the fly”). Effectiveness was evaluated using a single subject multiple probe across participants design.

Results: All participants demonstrated increases in symbolic communication turns upon introduction of the AAC technologies with VSDs using JIT technology.

Conclusions: AAC with VSDs and JIT programming may be effective in increasing symbolic communication for students with severe developmental disability. The fast and easy creation of VSDs and hotspots to provide communication may be a valuable tool for interventionists.     

Do patients with severe poststroke communication difficulties have a higher incidence of falls during inpatient rehabilitation? A retrospective cohort study

Background: Falls in hospital are common and serious complications of stroke. Associations have been found between communication disorders and increased rates of falls, but have received relatively little consideration as a risk factor for falls among stroke survivors.

Objectives: To investigate whether there is an association between severe communication impairment and falls among patients receiving inpatient rehabilitation after stroke.

Methods: A retrospective audit of 149 records of consecutive patients admitted to an inpatient rehabilitation facility after stroke over a two-year period was conducted. The relationship between falls and severe communication impairment was explored using (1) direct comparison of falls in patients with and without functional communication for the inpatient ward environment and (2) multivariate logistic regression to examine factors that may predict falls, including presence or absence of functional communication. In each analysis, falls were examined both as a binary outcome (fall or no fall), and the rate of falls per day.

Results: The 32 patients in the sample (21.7%) who were unable to communicate their basic needs were almost twice as likely to fall in hospital as those with functional communication (RR 1.94, 95% CI 1.15 to 3.24). Several commonly assessed factors were not significant predictors of falls (including falls history, polypharmacy, and cognitive impairment) in this population. Lack of functional communication was the strongest independent predictor of falls rate.

Conclusions: Findings suggest that severe communication disorders may be under recognized as a falls risk factor after stroke.     

Repetitive verbalization in Alzheimer’s disease

Background: Repetitive verbalization in Alzheimer’s disease (AD) refers to the tendency of AD patients to repeat the same story/question to the same listener.

Aim: Our study assessed whether this verbal perseveration might be related to episodic memory decline, values of teaching, inhibitory decline, and/or decline in cognitive theory of mind.

Methods & Procedures: Thirty mild AD patients and 33 control older adults were asked to perform four verbal fluency tasks, and repeated words were retained as an index of repetitive verbalization. Participants were also administered the Grober and Buschke episodic memory task, scales of values of teaching, the Hayling inhibition task, and the false-belief task for the cognitive theory of mind.

Outcomes & Results: Results showed more repetitive verbalization in AD patients than in control older adults. Repetitive verbalization was significantly correlated with inhibition and episodic memory in AD patients. As for control older adults, repetitive verbalization was significantly correlated with values of teaching and inhibition. Regression analyses showed that repetitive verbalization was significantly predicted by inhibition in AD patients and values of teaching in control older adults.

Conclusions: Repetitive verbalization may reflect the difficulty in inhibiting irrelevant stimuli in AD patients, but it may serve as a tool to ensure transmission of personal knowledge in normal aging. Our findings suggest distinct functions of repetitive verbalization in normal aging and AD.     

Perceptions of patient-provider communication and receipt of mental health treatment among older adults with depressive symptoms

Objectives: This study aimed to: (1) determine if and how perceptions towards healthcare providers differ between older adults with and without clinically signifcant depressive symptoms (CSDS), and (2) assess whether perceptions towards providers are associated with receipt of mental health treatment among older adults with CSDS.

Methods: Data from the 2013 and 2014 Medical Expenditure Panel Survey were used to examine CSDS prevalence, receipt of mental health treatment, and perceptions of provider communication among community-dwelling adults ≥ age 65 (N = 6,936) using four of the ‘How Well Doctors Communicate’ composite items from the Consumer Assessment of Healthcare Providers and Systems(CAHPS). Multivariate logistic regression was used.

Results: CSDS are associated with greater odds of having ‘poor’ perceptions of provider communication on all four CAHPS communication measures. Perceptions of provider communication are similar among older adults with CSDS who received and did not receive mental health treatment, except on an item measuring a provider's ability to explain information in ways patients understand.

Conclusion: Older adults with CSDS have more negative perceptions of the quality of their communication with healthcare providers than their peers. Healthcare systems should consider how to accommodate these patients’ unique needs and communication preferences to ensure receipt of quality care.     

Exploring dimensions of social support and resilience when providing care at the end of life: a qualitative study

Background: Research shows that formal and informal social support can facilitate resilience in carers. There is a paucity of research exploring social support and resilience amongst recently bereaved informal carers.

Aim: To examine how the presence or absence of distinct dimensions of social support facilitate or hinder resilience in recently bereaved informal carers.

Participants: 44 bereaved carers, who had been identified by GP as ‘main carer’ of someone recently deceased (3–12 months), aged between 38 and 87 years old (mean= 67).

Methods: Thematic analysis then the Ecological Framework of Resilience as an organisational tool to develop overarching themes in the data. We used the Sherbourne and Stewart model to identify social support that was lacking as well as social support that was present.

Results: A range of social support types were identified. There was an emphasis on the importance of relationships with both health professionals and family members, including the care recipient. However, social support was not necessary for resilience if the participant had other resources.

Conclusions: Social support for carers providing end of life care is almost exclusively based around end of life care ‘work’. In comparison to other research our study suggests that relationships with family and health professionals are paramount. Multidimensional support is needed for carers to enhance their resilience.     

Pain intensity,depressive symptoms,and functional limitations among older adults with serious mental illness

Objective: To examine pain-related activity interference as a mediator for the relationship between pain intensity and depressive symptoms among older adults with serious mental illness (SMI).

Method: Ordinary least-squares regressions were used to investigate the mediation analysis among older adults with SMI (n = 183) from community mental health centers. Analyses used secondary data from the HOPES intervention study.

Results: Higher pain intensity was associated with greater pain-related activity interference. Higher pain intensity and pain-related activity interference were also associated with elevated depressive symptoms. Finally, greater pain-related activity interference significantly mediated the association between higher pain intensity and elevated depressive symptoms.

Conclusions: These findings demonstrate that pain and depressive symptoms may be linked to functional limitations. Clinicians and researchers in the mental health field should better address pain-related activity interference among older adults with SMI, especially among those with higher pain intensity and elevated depressive symptoms.     

Pharmacogenetics and levodopa induced motor complications

Aim: L-dopa remains the most effective symptomatic therapy for Parkinson's disease (PD) but unfortunately, its chronic use is often associated with motor complications. This review highlights the importance of pharmacogenetics in an individualised PD therapeutic approach.

Material and Methods: review of the literature was done.

Results: PD patients show remarkable heterogeneity in their response to L-dopa and this profound interindividual heterogeneity suggests that there is a genetic predisposition.

Conclusions: The impact of the genetic makeup of every individual on PD treatment appears to be of great importance in order to achieve not only the optimum therapeutic effect, but also with minimal side effects.     

Views and experiences of care home staff on managing behaviours that challenge in dementia: a national survey in England

Aim: To determine the views of care home (CH) staff in relation to experiencing and managing behaviour that challenges (BtC) in dementia and their experiences of training.

Method: Cross-sectional survey using a self-report questionnaire, distributed to staff employed in a 20% sample of all registered dementia-specialist CHs in England, either by postal or direct distribution.

Results: Questionnaires were returned from 352 care staff (25%), representing 5% of all dementia-specialist CHs, half were CH without nursing. Respondents estimated caring for 14,585 residents, 9,361 with dementia and 5,258 with BtC. 30.2% of residents with dementia were estimated as being prescribed a medicine to control BtC. BtC reported as experienced by most respondents were: shouting (96.6%), verbal aggression (96.3%) and physical aggression (95.7%), with physical aggression viewed as most difficult to manage. Top behaviours experienced every shift were: wandering (77.8%), perseveration (68.2%) and restlessness (68.2%).

Approaches such as assessing residents, knowing them and treating them as individuals, identifying triggers, having time for them and using an appropriate style of communication, were viewed as key to managing BtC, rather than guideline-specific interventions such as massage, aromatherapy and animal-assisted therapy.

Only 38% agreed/strongly agreed medicines were useful to control BtC, which was related to the extent to which they were prescribed. Training was available, but variable in quality with on-line training being least useful and on-the job training most desirable.

Conclusion: BtC are commonly and frequently experienced by care staff, who consider individual approaches, having time and good communication are key to successful management.     

A how-to guide to aphasia services: celebrating Professor Linda Worrall’s contribution to the field

Background: This article recognises Professor Linda Worrall’s contribution to aphasiology and discusses research themes which have grown from her work.

Aims: To review, summarise, and discuss literature relating to four themes which have emerged from the work of Professor Worrall: (1) Research capacity building; (2) Implementation of research evidence in clinical practice; (3) Meaningful outcome measurement; and (4) Improvement of psychological and emotional outcomes.

Main contribution: A review of the literature, with examples of practical applications.

Conclusions: The work of Professor Worrall has greatly influenced the field of aphasia; her legacy is the research capacity she has built in Australia and around the world.     

French translation and validation of a fragile X syndrome screening checklist

Background: Fragile X syndrome (FXS) is the most common cause of inherited intellectual disability among men. This syndrome is frequently underdiagnosed in adults. The aim of this study was to develop and validate a French translation of the screening checklist Fragiele-X screeningslijst.

Method: The validation sample for the translated checklist included 22 pairs of men between the ages of 18 and 52, matched by age and degree of intellectual impairment.

Results: The translated checklist achieved coefficients of 0.92 for internal consistency, 0.90 for test-retest reliability and 0.65 for inter-rater reliability. These psychometric properties are commensurate with those of the original checklist.

Conclusion: Therefore, the translated checklist developed in this study can be considered a valid screening instrument for the detection of FXS in men with intellectual disabilities.

Abbreviations: FXS: fragile X syndrome; FMR1: fragile X mental retardation 1 (gene)     

A Note on the “One Case per Stagger Position” Character of Common Multiple-Baseline Intervention Designs

Purpose: To overcome the constraint of common multiple-baseline designs that only one case per stagger position is permitted.

Methods: Three alternative strategies for assigning more than one case to each stagger position are examined.

Results: The three recommended strategies achieve the objective while maintaining the study’s internal and statistical-conclusion validities.

Conclusions: ExPRT, a freely available Excel-based randomization-test package, can be used to assist in both the design and statistical analysis associated with each of the strategies.     

Factors affecting rehabilitation and use of upper limb after stroke: views from healthcare professionals and stroke survivors

Background: Training of the upper limb (UL) is limited in stroke rehabilitation, and about 50% of stroke survivors do not regain useful function in their upper limb.

Objectives: This study explored what factors affect rehabilitation and use of upper limb after stroke from a stroke survivor and healthcare professional perspective to better understand low engagement in UL rehabilitation in the chronic stages of stroke.

Method: Eight chronic stroke survivors and 21 healthcare professionals took part in semi-structured interviews or in one of three focus groups, respectively.

Results: Thematic analysis revealed three main themes: Availability of resources, Healthcare professional–patient relationship, and Psychosocial factors. Availability of resources and Healthcare professional–patient relationship indicated that due to resource pressures and a lack of communication and education, positive upper limb rehabilitation behaviors (e.g. engaging and integrating the upper limb in daily activity) were not always established in the early stages post-stroke. Psychosocial factors illustrated the cognitive and psychological barriers to sustained engagement with upper limb rehabilitation.

Conclusion: The findings indicate that stroke survivors and healthcare professionals have very similar understandings of barriers to UL activity, and positive upper limb rehabilitation behaviors are not always established early in recovery post-stroke. Increased resources and healthcare professional–patient relationships seem key factors to establishing positive perceptions of UL rehabilitation. Addressing psychosocial issues and resource limitations may help sustain engagement with UL rehabilitation.     

Impaired lexical selection and fluency in post-stroke aphasia

Background: Deficits in fluent language production are a hallmark of aphasia and may arise from impairments at different levels in the language system. It has been proposed that difficulty resolving lexical competition contributes to fluency deficits.

Aims: The present study tested this hypothesis in a novel way: by examining whether narrative speech production fluency is associated with difficulty resolving lexical competition in spoken word recognition as measured by sensitivity to phonological neighborhood density.

Methods & Procedures: Nineteen participants with aphasia and 15 neurologically intact older adults identified spoken words that varied in phonological neighborhood density and were presented in moderate noise.

Outcomes & Results: Neurologically intact participants exhibited the standard inhibitory effect of phonological neighborhood density on response times: slower recognition of spoken words from denser neighborhoods. Among participants with aphasia, the inhibitory effect of phonological neighborhood density (less accurate recognition of spoken words from denser neighborhoods) was smaller for participants with greater fluency. The neighborhood effect was larger for participants with greater receptive vocabulary knowledge, indicating that the fluency effect was not a result of general lexical deficits.

Conclusions: These results are consistent with the hypothesis that impaired lexical selection is a contributing factor in fluency deficits in poststroke aphasia.     

Neighborhood social cohesion and cognitive function in U.S. Chinese older adults—findings from the PINE study

Objectives: The projected increase in the population of older adults in the United States entails a pressing need to examine risk and protective factors associated with cognitive function. This study aims to examine the association between neighborhood social cohesion and cognitive function among older Chinese adults in the United States.

Method: Using the first epidemiological survey of older Chinese Americans and applying ordinary least squares and quantile regressions, this study examines the association between neighborhood social cohesion and various domains of cognitive function.

Results: Results show that neighborhood social cohesion is independently associated with most domains of cognitive function (i.e. global cognition score, and its components such as the Chinese Mini-Mental State Examination and executive function and episodic memory measures).

Conclusion: This study represents one of a few initial efforts that examined the association between neighborhood social cohesion and cognitive function for Chinese older adults in the United States. Our findings suggest that socially cohesive neighborhoods can provide enriched environments where active lifestyles can be encouraged, and cognitive skills and abilities can be stimulated, practiced, and preserved for older adults.     

Language mixing patterns in a bilingual individual with non-fluent aphasia

Background: Language mixing in bilingual speakers with aphasia has been reported in a number of research studies, but the reasons for the mixing and whether it reflects typical or atypical behaviour has been a matter of debate.

Aims: In this study, we tested the hypothesis that language mixing behaviour in bilingual aphasia reflects lexical retrieval difficulty.

Methods & procedures: We recruited a Hebrew-English bilingual participant with mild-moderate non-fluent agrammatic aphasia and assessed his languages at three timepoints. We analysed the participant’s Hebrew and English production for retrieval during single-word naming, sentences, and discourse, and identified all instances of language mixing.

Outcomes & Results: We found that there was a greater frequency of language mixing during production of more difficult lexical items, namely the post-morbidly less proficient language (compared to the more proficient language), function words (compared to content words), and single-word naming (compared to retrieval in the context of connected speech tasks), but not for verbs (compared to nouns).

Conclusions: In this bilingual participant with non-fluent aphasia, language mixing behaviour closely resembles lexical retrieval difficulty. Thus, we suggest that bilingual speakers with aphasia may mix their languages as a strategy to maximise communication.     

Perspectives about support challenges facing health workers assisting older adults with and without intellectual disability in rural versus urban settings in Australia

Aims: Life expectancy for both sexes in Australia exceeds 80 years, with individuals with intellectual disability also increasingly living into older age. This research aimed to comparatively examine perceptions of staff supporting either older adults or age peers with lifelong intellectual disability.

Methods: This project asked 420 medical, health, and support workers about training adequacy, health services access, and trigger points for premature institutionalisation. This paper is based on a subsample of 196 respondents who provided quantitative and qualitative responses.

Results: There was considerable variation in confidence in supporting ageing individuals, while only 23.7% of doctors reported their training was adequate to support adults ageing with intellectual disability. A lack of services and poor carer health were identified as triggers for premature institutionalisation.

Conclusions: The study revealed key differences in staff perceptions of support provision and training adequacy when comparing ageing individuals with intellectual disability to the general ageing population.     

To what extent is subjective well-being in late adulthood related to subjective and objective memory functioning? Five-year cross-lagged panel analyses

Background: Population aging motivated a focus in contemporary research on factors, e.g. cognitive functioning, that contribute to ‘aging well.’ However, something that has been overlooked is relation between memory functioning, determined by objective tests as well as subjective memory ratings, and subjective well-being (SWB).

Objectives: The aim of the present study was to investigate cross-sectional and longitudinal (cross-lagged) relationships between episodic memory (both subjective and objective) and SWB.

Method: A total of 586 older individuals (60–90 years) were assessed on multiple measures of the targeted constructs at baseline (Time 1) as part of the Betula cohort study. Five years later (Time 2), 354 of the participants returned for follow-up measurements and were included in cross-lagged panel analyses.

Results: As expected, objective memory and subjective memory showed a pattern of cross-sectional age deficits and a mean level longitudinal decline was observed for objective memory. By contrast, SWB showed stable mean levels both across age and time. No cross-sectional or cross-lagged associations were observed between SWB and objective memory, whereas subjective memory and SWB showed a cross-sectional association.

Conclusion: The results underscore that successful aging is a multifaceted construct with no or only weak associations between the investigated components. However, SWB and rate of change at the individual level should be considered to define successful aging.     

Estimation of skeletal muscle mass in patients with spinocerebellar ataxia type 3 and 10

Background: Neurodegenerative diseases may progress to a level in which patients present spontaneous weight loss, resulting in increased falls and functional disabilities when the disease is associated with muscle mass depletion.

Objective: Evaluate the muscle compartment in patients presenting spinocerebellar ataxia (SCA) type 3 and 10.

Methods: Forty-six patients presenting SCA type 3 and 10 were assessed and 76 volunteers were selected to the control group. In order to evaluate the muscle compartment, muscle mass anthropometric measurements were assessed and total skeletal muscle mass calculated through a predictive equation.

Results: Women with SCA3 presented greater weight loss and muscle mass reduction compared to those with SCA10 and the control group. Among the predictive measurements, calf muscle circumference showed a more significant correlation with total skeletal muscle mass (p = 0.718).

Conclusion: Patients presenting both types of ataxia did not show severe depletion in their nutritional status; however, those with SCA3 displayed greater weight loss and muscle mass reduction compared to the SCA10 group.