Predictors of handicap situations following post-stroke rehabilitation

Purpose : Many stroke survivors have to cope with impairments and disabilities that may result in the occurrence of handicap situations. The purpose of the study was to explore bio-psycho-social predictors of handicap situations six months after discharge from an intensive rehabilitation programme. Methods : At discharge from a rehabilitation programme, participants were evaluated with instruments measuring motor, sensory, cognitive, perceptual, affective and psychosocial impairments and disabilities that may play a role in the development of handicap. Some other demographic and clinical variables, and those related to rehabilitation, were also collected. Six months later, they were re-assessed in their own environment in order to document their handicap level with the Assessment of Life Habits (LIFE-H). Results : One hundred and thirty-two stroke patients participated in the discharge evaluation and 102 of them also participated in the handicap measurement. Relationships between handicap level and impairments and disabilities were all statistically significant. Multiple regression analyses indicated that affect, lower extremity co-ordination, length of stay in rehabilitation, balance, age and comorbidity at the end of an intensive rehabilitation programme are the best predictors of handicap situations six months later (adjusted R 2 : 68.1%). Conclusions : In spite of its exploratory nature, this study revealed that, among a substantial number of personal characteristics, some were more related to a handicap measure and have greater predictive value. Other studies should be carried out to validate these findings and to consider more environmental factors in order to better understand factors related to the development of handicap situations.     

Association between personal and environmental factors and the occurrence of handicap situations following a stroke

Background and purpose: Little is known about the potential role of environmental factors in the handicap creation process following a stroke. The objective of this study was to explore the presence of a relationship between environmental factors and the occurrence of handicap following a stroke, taking into consideration age and the level of impairments and disabilities. Methods: This is a cross-sectional study where data were collected 6 months after discharge from an intensive functional rehabilitation unit. A convenience sample of 51 participants was recruited at the time of their admission to the rehabilitation unit for rehabilitation post-stroke. Perceived influence of environmental factors was measured using the Measure of the Quality of the Environment (MQE). Handicap situations were measured with the Assessment of Life Habits (LIFE-H). Impairments and disabilities comprised six domains (cognition, perception, depression, communication, sensorimotor function and comorbidity) assessed using a variety of measuring tools from which a composite score was derived. Results: Fifty-one participants aged 40-97 years old took part in this study. Perceived obstacles in the environment, together with age and the level of impairments and disabilities, explained 58.9% of the variation in the LIFE-H (handicap level). Taken alone, the perceived obstacles (total score) explained 6.2% . The perceived facilitators (total score) in the environment were not found to be related to the presence of handicap situations. Conclusion: Increased level of impairments and disabilities, advanced age and perceived barriers in the physical and social environment contribute to the handicap creation process following a stroke.     

Association between personal and environmental factors and the occurrence of handicap situations following a stroke

Background and purpose : Little is known about the potential role of environmental factors in the handicap creation process following a stroke. The objective of this study was to explore the presence of a relationship between environmental factors and the occurrence of handicap following a stroke, taking into consideration age and the level of impairments and disabilities. Methods : This is a cross-sectional study where data were collected 6 months after discharge from an intensive functional rehabilitation unit. A convenience sample of 51 participants was recruited at the time of their admission to the rehabilitation unit for rehabilitation post-stroke. Perceived influence of environmental factors was measured using the Measure of the Quality of the Environment (MQE). Handicap situations were measured with the Assessment of Life Habits (LIFE-H). Impairments and disabilities comprised six domains (cognition, perception, depression, communication, sensorimotor function and comorbidity) assessed using a variety of measuring tools from which a composite score was derived. Results : Fifty-one participants aged 40-97 years old took part in this study. Perceived obstacles in the environment, together with age and the level of impairments and disabilities, explained 58.9% of the variation in the LIFE-H (handicap level). Taken alone, the perceived obstacles (total score) explained 6.2%. The perceived facilitators (total score) in the environment were not found to be related to the presence of handicap situations. Conclusion : Increased level of impairments and disabilities, advanced age and perceived barriers in the physical and social environment contribute to the handicap creation process following a stroke.     

Predictors of long-term participation after stroke

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

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

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

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

Awareness of disabilities in stroke rehabilitation--a clinical trial

Purpose : To investigate the frequency of unawareness of disabilities after stroke during the rehabilitation stage, the relationship of unawareness with neuroanatomical variables, and the impact of unawareness on functional outcomes.

Method : Sixty consecutive patients (36 with right, 24 with left hemisphere damage) admitted to rehabilitation hospital with a first, single, unilateral stroke were evaluated at admission, discharge and at 1-year post onset of stroke. Unawareness of disabilities was operationally defined as the discrepancy between therapist and patient's rating on the motor scale of the functional independence measure (FIM). Functional outcomes included FIM, instrumental activities of daily living (IADL) scale, activity card sort (ACS) and safety rating scale.

Results : Unawareness of disabilities was found in 44/60 patients at admission and 24/57 at discharge. There was no significant difference between the hemisphere groups in the frequency of unawareness at both times. Discharge unawareness in the right hemisphere group was significantly associated with lesions in the frontal and temporal lobes, and with lesion size. Unawareness in the left hemisphere damaged group was not associated with any neuroanatomical variables. A negative impact of unawareness at admission on functional outcomeswas not found, but it was found that unawareness at discharge was a negative predictor of activity level (ACS score) at follow up, after controlling for the severity of initial disability level.

Conclusions : Unawareness of disabilities is a significant issue in stroke rehabilitation. Unawareness that persists to discharge from rehabilitation correlates with neuroanatomical variables in right hemisphere damaged patients, and is a negative predictor for some rehabilitation outcomes at follow-up.     

Inter-observer reliability of clinical outcome measures in a lower limb amputee population

Purpose : In an attempt to find a more clinically useful functional outcome measure specifically tailored for lower limb amputees undergoing inpatient prosthetic rehabilitation, a 6-month prospective assessment of inter-rater reliability for Harold Wood - Stanmore Mobility Scale Data, including two handicap scales, was undertaken. An analysis of the data is presented in this paper.

Methods : An inter-rater reliability study was undertaken using four observers to complete admission and discharge scores for the three disability/handicap scales on 14 consecutive patients over 6 months.

Results : The disability mobility scale demonstrated perfect observer agreement on admission and at discharge the inter-rater reliability for this measure was high (0.83). By contrast, reliability between observers for admission scores on the handicap mobility scale was poor at 0.49 but reasonably high on discharge (0.83). On admission, inter-rater reliability for handicap physical independence was very low (0.15). At discharge, reliability improved to 0.69 being more consistent with results achieved for the other axes.

Conclusions : This study confirms the good inter-rater reliability demonstrated previously in the literature but reveals poor inter-rater reliability for the two handicap scales. The latter will require modification before they can be used with confidence in conjunction with the disability scale.     

Impairment,disability, and life satisfaction in Parkinson's disease

Purpose : To determine the correlation of motor and musculoskeletal impairments with disability scores and life satisfaction. Musculoskeletal impairments might be due to the impact of motor impairments, however some cases may have these impairments even before the disease is diagnosed.

Methods : 48 consecutive patients (32 male, 16 female) with Parkinson's disease with a mean age of 65.6, mean age of onset of the disease of 59.8, and Hoehn and Yahr staging system 1-4 participated. Unified Parkinson's disease rating scale, modified Schwab and England activities of daily living scale and life satisfaction index were used. Also New York modified mobility rating scale for c-spine and upper extremities and trunk and lower extremities was performed.

Results : Motor and musculoskeletal impairments were correlated with the disability score. Bradykinesia, and tremor were correlated with upper and lower extremity range of motion limitation, but rigidity was not. Bradykinesia was correlated with life satisfication. Having had the disease longer was related to upper extremity range of motion limitation.

Conclusions : Motor and musculoskeletal impairments are correlated with disability scores. Bradykinesia and musculoskeletal impairments are correlated with life satisfication. Patients with Parkinson's disease might benefit from a rehabilitation programme focusing on motor impairments such as bradykinesia as well as musculoskeletal impairments even in the early stages of the disease.     

Functional outcome in patients with critical illness polyneuropathy

Purpose: To evaluate the functional outcome of intensive care patients with critical illness polyneuropathy (CIP), 6 and 12 months after the onset.

Methods: Design: A prospective observational cohort study and a cross-sectional study.

Setting: University hospital in the Netherlands.

Patients: Eight consecutive intensive care patients with CIP for the prospective study and eight patients diagnosed with CIP in the past 6 months for the cross-sectional study.

Main outcome measures: Functional outcome regarding body functions and structure, activities, participation and perceived quality of life.

Results: Nine patients (56%) died within one year. Functional outcome, participation and subjective health status in survivors varied widely at 6 and 12 months. After 12 months, physical functioning was improved in all patients. However activities related to mobility outdoors, autonomy, participation and quality of life were restricted in most patients.

Conclusions: The majority of survivors have persistent functional disabilities in activities, reduced quality of life and restrictions in autonomy and participation one year after the onset of CIP. Prolonged rehabilitation treatment is necessary for an increasing number of intensive care patients who develop CIP, in order to reduce handicaps and achieve optimal autonomy and social participation.     

Coping with the consequences of a stroke

BACKGROUND AND PURPOSE: Having a stroke constitutes a major life event which engenders some types of adaptation in order to try to resume to a "normal" life. The objectives of this study were (1) to explore the type of coping strategies used following a stroke; (2) to verify if coping strategies change over time, and (3) to verify if the coping strategies used are related to age, gender, actualization of potential, handicap level and depression. METHODS: A convenience sample of 76 participants who had had a stroke was recruited upon discharge from a functional intensive rehabilitation unit. Data were collected 2 weeks later and 6 months later in their own home. Coping strategies were measured using a modified version of the Ways of Coping Questionnaire. Actualization of potential was measured using the Measure of the Actualization of Potential and handicap level was quantified with the LIFE-H. Finally, the Beck Depression Inventory was used to evaluate the presence of depressive symptoms. CONCLUSION: The results suggest that long after the end of an intensive rehabilitation programme, some coping strategies might be more effective in dealing with the consequences of a stroke whereas others might be related to some form of inadaptation. However, the results should be treated with caution. More research on coping following a stroke using mixed methodologies is needed.     

Impairments, disabilities and handicap pattern in konzo - a non-progressive spastic para/tetraparesis of acute onset

Purpose: To assess impairments, disabilities and handicap pattern in konzo.

Method: The study included 17 konzo subjects, of which three were males and 14 females (mean age 21, median 18 years). A detailed neurological examination was performed on all subjects. Subsequently, an assessment of impairments, disabilities and handicap was done with a constructed rating scale partially based on the ICIDH-2 framework.

Results: The overall disablement picture in all subjects consisted of motor dysfunction in lower limbs leading to limitations in walking and movement activities, and restrictions in mobility. Hip mobility was severely impaired in most cases (15/17). Although konzo subjects showed normal muscle power in upper limbs (13/17), they had impaired fine motor function (10/17).

Conclusion: Further studies are needed to assess the effectiveness of the WHO criteria for konzo in defining its forms. The applicability of the ICIDH-2 framework in this study demonstrates the possibility of its use as a common language among researchers in the field of motor disorders. However, a revision is suggested of its taxonomy, and a definition of operational criteria to clarify the content of different qualifiers provided to assess the level of functioning or disability.     

Predictors of quality of life following stroke

Purpose : To determine the factors predicting quality of life during the course of rehabilitation following stroke.

Method : Two hundred and fifteen stroke patients aged 41-93 were studied over a period of three months. Measurement of quality of life, functional ability, social support, demographic and treatment data were taken on admission to the rehabilitation hospital, at two weeks and three months. The instruments used were the Sickness Impact Profile (SIP), the Modified Barthel Index (MBI) and The Social Support Questionnaire, short form (SSQ6).

Results : Length of stay, previous stroke, functional ability and social support were found to be significantly correlated with quality of life. Stepwise multiple regression analysis indicated that functional ability, psychological and physical SIP dimensions, social support satisfaction at two weeks and previous stroke explained 47% of the variance in sickness impact at three months following stroke. The factors predicting 53% of the variance in sickness impact at two weeks were baseline functional ability, psychological and physical SIP.

Conclusions : The findings indicate that both psychosocial and physical factors are important in predicting quality of life in stroke rehabilitation. Determining such predictors at an early stage will help to guide clinical decisions throughout rehabilitation.     

A comparison of consumer-directed and agency-directed personal assistance services programmes

Purpose: To compare a consumer-directed personal assistance services (PAS) programme with an agency-directed PAS programme.

Method: A convenience sample was used for this cross-sectional study with one data collection point. Outcomes were compared for consumer-directed and agency-directed PAS. Hierarchical regressions were also used to determine the predictors of outcomes across PAS programmes. In-home interviews were conducted by a trained data collector from April 2000 to December 2001.

Results: Participants in the consumer-directed programme reported more choices over PAS and satisfaction with PAS. Self-reported outcomes were primarily predicted by the following variables: service arrangement, type of provider, importance of directing PAS, health status, number of personal assistants used in past 12 months, sufficient PAS hours received, and social support.

Conclusions: Consumer-directed PAS enhances outcomes for many persons with disabilities. Self-reported outcomes are affected by many factors that could be addressed in PAS programme development.     

Vocational training integrated into inpatient psychosomatic rehabilitation--short and long-term results from a controlled study

Purpose. The aim of this study was to determine the impact of a vocational training programme on short- and long-term results after psychosomatic rehabilitation.

Method. 1,590 inpatients were screened for vocational integration. A high-risk group of 266 patients was randomly assigned to the vocational training programme plus psychosomatic treatment; treatment- as- usual served as a control condition. An occupational training was conducted at local companies, closely integrated into psychosomatic treatment. Vocational attitudes and adjustment were studied at intake, discharge, three, 12 and 24 month follow-ups.

Results. More than half of the study participants were unemployment and/or long-term work-disabled harbouring strong negative attitudes toward return to work. Forty-six percent of the intervention group declined from participation, but complied with follow-up investigation. At discharge, participants of the vocational training programme had become more optimistic regarding resuming work. One year following discharge, participants of the training programme reported less absence from work. After 24 months, vocational adjustment had improved considerably among programme participants, and declined among controls and refusers.

Conclusion. An intensive vocational training programme is effective in promoting positive attitudes to work, reducing work disability and promoting return-to-work. However, a randomized design may be not optimal; evaluation necessitates long-term follow-up.     

Late multidisciplinary rehabilitation in young people after stroke

Purpose: Stroke has a major impact on physical and cognitive ability, and quality of life. This study aims to examine the effect of multidisciplinary rehabilitation on outcome in an Irish young stroke population.

Method: Fifty consecutive patients younger than 65 were prospectively recruited to this observational study. Physical and cognitive ability, and quality of life were measured on admission and discharge.

Results: All patients were transferred to the rehabilitation unit from the acute hospital where they had received their initial management. Median length of time from stroke onset to transfer was 112 days. After a median of 70 days, 43 patients were discharged home. Patients made significant gains in physical (Barthel index 12 to 18) and cognitive ability (mini-mental state examination 22 to 25). Quality of life improved in all eight domains of the 36-item Short Form with four domains returning to levels seen in the general population.

Conclusions: This study documents the improvements in physical and cognitive abilities, and quality of life in a sample of patients in rehabilitation. A comprehensive rehabilitation programme that includes acute and late multidisciplinary phases can improve the outcome of patients following stroke.     

Return to work after lower limb amputation

Purpose. To review the literature on return to work after lower limb amputation.

Method. A comprehensive review of literature on return to work after lower limb amputation was carried out, searching MEDLINE and PubMED.

Results. Most authors found return-to-work rate to be about 66%. Between 22 and 67% of the subjects retained the same occupation, while the remainder had to change occupation. Post-amputation jobs were generally more complex with a requirement for a higher level of general educational development and were physically less demanding. The return to work depends on: general factors, such as age, gender and educational level; factors related to impairments and disabilities due to amputation (amputation level, multiple amputations, comorbidity, reason for amputation, persistent stump problems, the time from the injury to obtaining a permanent prosthesis, wearing comfort of the prosthesis, walking distance and restrictions in mobility); and factors related to work and policies (salary, higher job involvement, good support from the implementing body and the employer and social support network).

Conclusions. Subjects have problems returning to work after lower limb amputation. Many have to change their work and/or work only part-time. Vocational rehabilitation and counselling should become a part of rehabilitation programme for all subjects who are of working age after lower limb amputation. Better cooperation between professionals, such as rehabilitation team members, implementing bodies, company doctors and the employers, is necessary.     

Rehabilitation psychology: meeting the needs of individuals with acquired disabilities in Ireland

Purpose. The current articles reviews the epidemiology of disability in Ireland, discusses the political and social factors which have increased focus on disability issues and offers training guidelines for rehabilitation psychology based on those of the APA's Rehabilitation Psychology Division.

Rationale. With the growing number of individuals with acquired (vs developmental) disabilities in Ireland, there is increased recognition of the need to train psychologists to assist persons with acquired disabilities (e.g. spinal cord injury, acquired brain injury, stroke, etc.) in adjusting to their impairments, reintegrating back into their communities and reducing the long-term financial costs associated with disability.

Conclusion. Social and political factors suggest that the time is right to develop rehabilitation psychology as a specialty in Ireland given the increased focus on disability in Ireland, including recently passed disability legislation (i.e. 2005 Disability Bill), international events (e.g. 2003 Dublin World Special Olympics) and increases in rehabilitation training programmes (i.e. medicine; physio, occupational and speech therapy).     

Motor and functional recovery in patients with post-stroke depression

Purpose: Depression is very common following stroke. Correlation between post-stroke depression (PSD) and functional outcome has been shown, but differential impact both on functional and motor recovery has not been deeply investigated. This study evaluates the influence of PSD on motor and functional outcome.

Method: One hundred and seventeen acute stroke patients were selected in an intensive rehabilitation department, and divided into two groups according to the presence of PSD (PSD + and PSD -). Screening measures were DSM-IV criteria, the Geriatric Depression Scale and the Cornell Scale. Outcomes were evaluated on the basis of the Barthel Index (BI) and the Fugl - Meyer Assessment Scale (FMA). Measurements were performed at admission to the department (T1), discharge (T2) and follow up (T3) in a whole period of 3 months from stroke.

Results: Both groups showed a significant improvement in all outcome measures. Improvement differences were not significant on FMA scores in either group at each assessment; the PSD group had a significant higher improvement on BI score at follow-up. According to the logistic model, from T1 to T2 and from T1 to T3, only motor recovery shows a significant relation with functional recovery; from T2 to T3 PSD is the only significant factor related to functional recovery.

Conclusions: PSD is not an influencing factor for motor recovery. Results show a negative impact of PSD on the functional recovery process after discharge and not during hospitalisation. Discharge appears to be a critical step for management of PSD.     

Religion and disability: clinical, research and training considerations for rehabilitation professionals

Purpose. This article (i) reviews existing research on the relationships that exist among spirituality, religion, and health for persons with disabilities; and (ii) compares different theoretical coping models (i.e., spiritual vs. psychoneuroimmunological).

Background. Over the past decade interest has increased in relationships among spirituality, religion, and health in both the mainstream media (e.g., Newsweek) and scientific literature (e.g., Koenig). In general, research has concluded that religion and spirituality are linked to positive physical and mental health outcomes. Most religion and health research has focused on populations with life-threatening diseases (e.g., cancer, cardiovascular disorders, AIDS) with minimal attention to persons with chronic, life-long disabling conditions such as brain injury, spinal cord injury, and stroke. However, religion is used by many individuals with disabilities to help them adjust to their impairments and to give new meaning to their lives.

Conclusions. Religion and spirituality are important coping strategies for persons with disabilities. Practical suggestions for rehabilitation professionals are provided regarding: (a) strategies to enhance religious coping; (b) methods to train rehabilitation professionals about religious issues; and (c) issues to consider regarding future research on rehabilitation and religion.     

Recovery plateau following stroke: Fact or fiction?

Purpose. 'Plateau' is an expression frequently used in relation to decisions to discharge patients from physiotherapy following stroke. This paper critically considers the concept of recovery plateau in stroke, exploring (i) the evidence for plateau, (ii) potential contributing factors, and (iii) the consequences for patients, therapists and services.

Search strategy. The concept of recovery plateau in stroke was reviewed drawing on standard critical appraisal methodology for the search strategy and critique. Electronic searches using Web of Knowledge, MEDLINE, CINAHL, Department of Health Website and the Cochrane Library from the earliest dates of coverage until February 2005 identified quantitative and qualitative literature related to stroke, plateau, recovery, outcome, rehabilitation and physiotherapy.

Discussion. The concept of plateau is ambiguous. Recovery has been considered to plateau within the first 6 months, yet recent studies indicate later recovery is possible. We suggest that 'plateau' relates not only to the patient's physical potential, but is influenced by how recovery is measured, the intensity and type of therapy, patients' actions and motivations, therapist values, and service limitations.

Conclusion. 'Plateau' is conceptually more complex than previously considered. Current conceptualizations may limit potential recovery and hinder service development. Research into plateau which takes account of contextual issues of therapy provision is required.