Implementation of the Comprehensive Assessment Toolbox for Stroke in a Medical System

The need for outcome assessment in stroke management is a critical part of specialized stroke unit development. The Comprehensive Assessment Toolbox for Stroke was developed for this reason. This study describes the implementation of the Toolbox across a medical system as part of a stroke center of excellence. Toolbox data were collected from 2002 to 2004. Demographic data were analyzed. Patients were categorized by stroke severity. Outcome assessment tools were compared via paired sample t tests. Also, data were analyzed using multivariate methods followed by univariate analysis of variance. Patients improved in outcomes from admission through their hospital stays. Clinically significant improvements were made in the mild and moderately affected groups. The severe stroke group improved the least. Tracking patient outcomes in a consistent way helps with program assessment and comparison. Patients leave rehabilitation at a dependent level in many functional areas.     

Resuming previously valued activities post-stroke: who or what helps?

Purpose. In this article, we aim to develop the understanding of what helps or hinders resumption of valued activities up to 12-months post-stroke.

Method. As part of a longitudinal study, semi-structured interviews were conducted with 19 people with stroke and eight informal carers 12-months post-stroke. Interviews covered ongoing effects of stroke, experience of trying to resume activities highlighted as important pre-stroke and factors that influenced progress. Interviews were transcribed, coded and analysed in depth to explore this aspect of the experience of living with stroke.

Results. Valued activities discussed related to employment; domestic and social roles including driving; hobbies, sports and socialising. Outcomes for individuals were influenced by: aspects of physical or cognitive disability; environmental factors; the adaptability of the individual; support from others and professional help. Inability to resume activities impacted on people's sense of self and quality of life, but some tolerated change and presented themselves as adaptable.

Conclusions. This study indicates a long-term role for rehabilitation services such as: identifying the significance of different types of activities; providing access to support and treatment for debilitating symptoms such as fatigue and dizziness; addressing patients' emotional and behavioural responses to their condition; working with patients' wider social networks and where appropriate, supporting adaptation to a changed way of life.     

Cancer Rehabilitation: Does It Make a Difference?

Cancer is a significant cause of physical and cognitive disability. The concept of cancer rehabilitation was developed in the 1970s; it was a concept that led to funding support and to significant contributions to symptom management. A recent trend has been an increase in the number of cancer diagnoses and an increase in cancer survival rate. This suggests that more persons with cancer are living longer despite cancer-caused impairments. Interdisciplinary cancer rehabilitation programs are designed to help cancer patients achieve maximal functional ability and adapt to disabilities resulting from cancer or its treatments. Currently, there are few cancer rehabilitation programs in the United States. Information about the role of rehabilitation nursing in cancer patient care is scarce. The purposes of this article were to review the history of cancer rehabilitation; review functional outcomes that have been reported in current research; and identify the multiple, complex challenges that illustrate the role of a cancer rehabilitation clinical nurse specialist in the rehabilitation of cancer patients.     

An observation-based intervention for stroke rehabilitation: experiences of eight individuals affected by stroke

Purpose.?To explore eight individuals’ experiences and responses to taking part in a personalised observation-based intervention for stroke rehabilitation.

Methods.?Eight participants who had experienced a cerebrovascular accident were recruited to a 16-week observation-based intervention. Participants were interviewed face-to-face to explore their responses to, and experiences of, taking part in the intervention. A list of topics, derived from the intervention process and earlier studies provided a provisional structure for the interview. All interviews were transcribed, coded and analysed using inductive content analysis to explore the impact of the observational intervention for these participants.

Results.?Three main themes emerged: physical function, behaviour change and DVD content. Lower order themes were also identified. These included: interaction with the physiotherapist; ability to complete tasks; and increased motivation to (re)engage in activities of everyday living.

Conclusion.?The findings suggest that a programme of action observation, linked to individualised and meaningful motor behaviours can provide a valid intervention for individuals affected by stroke by serving as a motivating agent to (re)engage in activities which they had believed they could not perform following their stroke. There was also evidence for positive affect on psychological wellbeing and motor function.     

Evaluation of virtual shopping in the VMall: Comparison of post-stroke participants to healthy control groups

Objective. To investigate the potential use of the VMall as an evaluation tool for rehabilitation by (1) describing its use with 14 post-stroke participants and (2) by comparing performance within the VMall of the post-stroke participants to healthy control participants.

Design. Criterion standard.

Setting. University of Haifa and the Chaim Sheba Medical Center.

Participants. Fourteen post-stroke participants and 93 healthy participants from three age groups (children, young adults and older adults).

Procedure. The participants experienced the VMall and shopped for four grocery items and then completed feedback questionnaires.

Main outcome measures. The experience of the stroke participants is described in detail. The duration and number of mistakes made during a four-item shopping task within the VMall, overall feedback, and perceived exertion.

Results. Significant differences were found between each of the three healthy groups and the stroke group for the mean total time to shop (F(3,97) = 23.28, P < 0.000). The participants' overall feedback on the VMall was positive with no differences between the groups.

Conclusions. The VMall as used with the four-item shopping task was found to significantly differentiate between healthy to stroke participants. The shopping task was challenging for the stroke participants which have positive implications for treatment effectiveness.     

Art after stroke: the qualitative experience of community dwelling stroke survivors in a group art programme

Purpose.?This study aimed to qualitatively explore the experience of community dwelling stroke survivors' participation in an arts health group programme and possible health benefits to quality of life (QOL) and wellbeing.

Method.?Sixteen participants were conveniently sampled to participate in two group art programmes, both held weekly over a period of 8 weeks. Qualitative data were collected through two focus groups (n == 9) and individual interviews (n == 11). Qualitative analysis of the data was undertaken, using a grounded theory approach incorporating constant comparison.

Results.?Age ranged from 43 to 81 years. Four themes emerged including: experience of stroke, benefit of art, benefit for self and benefit of group experience. Participants experienced improved confidence, self-efficacy, QOL and community participation through involvement in an arts health programme.

Conclusions.?The implementation of an arts health programme after stroke made a substantial impact on well-being and QOL. Results from this study are promising and this is a model that warrants rigorous investigation regarding the impact of art on QOL and wellbeing. This study also highlighted the need for community resources to address community re-integration and service provision in the form of age appropriate, activity-based groups for stroke survivors.     

信号式功能性电刺激对脑卒中患者认知功能的影响

目的：探讨信号式功能性电刺激对脑卒中患者认知功能的影响。方法：脑卒中偏瘫患者34例,分为A组8例、B组8例、C组7例及D组11例,分别配合给予信号式功能性电刺激、国产低频电刺激、肌电反馈电刺激及操作同A组,但无电刺激输出。于治疗前、治疗后20d时用简易精神评定量表（MMSE）及功能综合评定量表（FCA）的认知部分对各组患者进行精神状态及认知功能评定。结果：经过20d的治疗,A、C组FCA认知部分和MMSE评分与治疗前及B、D组比较均有明显提高（P〈0.05）;A组与C组治疗前后的差值比较差异无统计学意义。B、D组与治疗前及治疗后2组间差值比较均差异无统计学意义。结论：信号式功能性电刺激与肌电反馈电刺激治疗均可促进脑卒中患者受损的神经功能恢复,改善情绪障碍,提高认知功能。     

Predicting employment outcomes of rehabilitation clients with orthopedic disabilities: a CHAID analysis

Purpose. To examine demographic and service factors affecting employment outcomes of people with orthopedic disabilities in public vocational rehabilitation programs in the United States.

Method. The sample included 74,861 persons (55% men and 45% women) with disabilities involving the limbs or spinal column who were closed either as rehabilitated or not rehabilitated by their state-run vocational rehabilitation agencies in the fiscal year 2001. Mean age of participants was 41.4 years (SD = 11.2). The dependent variable is employment outcomes. The predictor variables include a set of personal history variables and rehabilitation service variables.

Results. The chi-squared automatic interaction detector (CHAID) analysis indicated that job placement services significantly enhanced competitive employment outcomes but were significantly underutilized (only 25% of the clients received this service). Physical restoration and assistive technology services along with support services such as counseling also contributed to positive employment outcomes. Importantly, clients who received general assistance, supplementary security income, and/or social security disability insurance benefits had a significant lower competitive employment rates (45%) than clients without such work disincentives (60%).

Conclusion. The data mining approach (i.e., CHAID analysis) provided detailed information and insight about interactions among demographic variables, service patterns, and competitive employment rates through the segmentation of the sample into mutually exclusive homogeneous subgroups.     

Predicting employment outcomes of rehabilitation clients with orthopedic disabilities: A CHAID analysis

Purpose.?To examine demographic and service factors affecting employment outcomes of people with orthopedic disabilities in public vocational rehabilitation programs in the United States.

Method.?The sample included 74,861 persons (55% men and 45% women) with disabilities involving the limbs or spinal column who were closed either as rehabilitated or not rehabilitated by their state-run vocational rehabilitation agencies in the fiscal year 2001. Mean age of participants was 41.4 years (SD?=?11.2). The dependent variable is employment outcomes. The predictor variables include a set of personal history variables and rehabilitation service variables.

Results.?The chi-squared automatic interaction detector (CHAID) analysis indicated that job placement services significantly enhanced competitive employment outcomes but were significantly underutilized (only 25% of the clients received this service). Physical restoration and assistive technology services along with support services such as counseling also contributed to positive employment outcomes. Importantly, clients who received general assistance, supplementary security income, and/or social security disability insurance benefits had a significant lower competitive employment rates (45%) than clients without such work disincentives (60%).

Conclusion.?The data mining approach (i.e., CHAID analysis) provided detailed information and insight about interactions among demographic variables, service patterns, and competitive employment rates through the segmentation of the sample into mutually exclusive homogeneous subgroups.     

脑卒中偏瘫患者早期康复效果的观察

采用随机的对照方法,比较65例脑卒中早期康复患者的近期预后和63例非康复患者的近期预后,发现早期康复组的运动功能和ADL均优于对照组(P<0.0005),且前者废用表现较轻P(<0.0005)。证明早期康复的效果是非常明显的。     

Predicting goal achievement during stroke rehabilitation for Medicare beneficiaries

Abstract

Purpose: Few studies have investigated the ability of treatment teams to predict functional improvement and whether an association between predicted goals and discharge function in patients with stroke exists. This study investigated goal prediction during stroke rehabilitation delivered in inpatient rehabilitation facilities (IRF) and the factors associated with goal prediction. Methods: A serial, cross-sectional design analyzing the Medicare IRF Patient Assessment Instrument dataset. The sample included 179?479 admissions for stroke aged over 65 years in 968 IRFs. Generalized estimating equations (GEE) controlled for facility cluster effects were used for analysis of time trends for length of stay (LOS), predicted Functional Independence Measure (FIM) scores, discharge FIM scores and predicted-discharge difference FIM scores (goal FIM scores minus discharge FIM scores). GEE models were employed to determine the correlation between predicted FIM and discharge FIM scores and factors associated with goal achievement. Results: Mean LOS, predicted FIM scores and discharge FIM scores decreased 1.8?d, 2.2 points and 3.6 points, respectively, while predicted-discharge difference FIM scores increased 1.3 points. Discharge goals were not met 78.9% of the time. After controlling for patient characteristics, each predicted FIM point was associated with 0.6 discharge FIM points (p?<?0.0001). Factors associated with not meeting or exceeding goals were: age (odds ratio; OR?=?0.997), African Americans (OR?=?0.905), number of comorbidities (OR?=?0.970), number of complications (OR?=?0.932) and right brain stroke (OR?=?0.869). Factors associated with meeting or exceeding goals were: LOS (OR?=?1.03), admission FIM score (OR?=?1.02) and females (OR?=?1.05). Conclusions: Trends for lower goals and lower discharge function occurred over time. A correlation existed between predicted FIM scores and discharge FIM scores. Patient factors were associated with goal achievement.

• Implications for Rehabilitation

• Using the Functional Independence Measure, rehabilitation teams set lower goals for stroke rehabilitation in inpatient rehabilitation facilities during first 5.5 years of the IRF-PAI dataset.

• Discharge FIM scores also trended lower and fell at faster rate than goal FIM scores.

• Teams’ goal FIM scores averaged nearly 12 points higher than discharge FIM scores, and over 75% of patients did not reach goals for the rehabilitation stay.

• Factors associated with meeting or exceeding goals were: length of stay, admission FIM scores and being a female. Factors associated with not meeting or exceeding goals were: age, number of comorbidities and complications, having a right-brain stroke and being African American.

     

脑卒中患者全程康复护理效果的比较

目的研究全程康复护理干预对脑卒中患者患侧肢体感觉运动功能和生活质量的影响。方法将80 例急性脑卒中患者随机分为实验组41人和对照组39人。实验组患者进行早期康复护理并持续至出院后3月,于入院时、出院时和出院后3月分别行患侧肢体感觉运动功能评估;于出院后1周和出院后3月行生活质量评定。结果康复组患者患肢运动功能(A部、B部、C部、D部、G部)明显提高,生活质量亦有明显提高,统计学检验有意义(P<0．05或P<0．01),而感觉功能、关节疼痛分值(E部、F部)经检验差异无显著意义(P>0．05)。结论全程康复护理干预可有效提高脑卒中患者患肢运动功能和生活质量。     

Racial disparities in outcomes of inpatient stroke rehabilitation

OBJECTIVE: To determine whether race is associated with outcomes of inpatient stroke rehabilitation. DESIGN: Retrospective cohort study. SETTING: A community-based inpatient rehabilitation facility. PARTICIPANTS: Poststroke patients (N=1002) admitted to a community-based inpatient rehabilitation facility between 1995 and 2001. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional improvement at discharge from the rehabilitation facility, discharge disposition, and functional improvement at 3 months after discharge. Inpatient and follow-up data were collected from the facility's electronic patient database. We used the FIM instrument to assess functional status at admission, discharge, and follow-up. RESULTS: In multivariable models, blacks achieved less functional improvement at discharge (-1.9 FIM points, P=.02) compared with whites and, despite worse FIM scores, were more likely to be discharged to home (adjusted odds ratio=1.7; 95% confidence interval, 1.1-2.5). Although Asian-American patients did not differ from whites in terms of functional improvement at discharge or disposition, they had less improvement at 3 months following discharge (-6.3 FIM points, P=.005). CONCLUSIONS: We identified racial disparities in poststroke outcomes in a community-based inpatient rehabilitation facility. Future research in stroke rehabilitation should explore the consistency of these findings across settings and if they are confirmed, identify explanatory mediators to better inform efforts to eliminate racial disparities.     

Community-dwelling stroke survivors: function is not the whole story with quality of life

OBJECTIVE: To compare function and quality of life in community-dwelling stroke survivors at 1, 3, and 5 years after stroke. DESIGN: A community-based, cross-sectional study of 3 retrospective cohorts. SETTING: Community-dwelling stroke survivors in Australia. PARTICIPANTS: The 3 cohorts comprised 30 participants each at 1, 3, and 5 years poststroke discharge from a tertiary referral hospital. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Stroke severity, comorbidity, medications used, and demographic information were recorded. Poststroke function was assessed using the Modified Rankin Scale, Mini-Mental State Examination, Stroke Impact Scale, and Multidimensional Scale of Perceived Social Support. RESULTS: This cross-sectional study provides insights into trends in stroke survivors over time. A high proportion of stroke survivors use community services, even those who are independent with activities of daily living. Although there was little attrition in medication use over time except for warfarin, this was from a baseline of suboptimal compliance and adherence with stroke preventive therapies. Stroke survivors report high levels of perceived social support; however, emotional well-being was low overall. The data suggest that those who are independent at 1 year tend to remain independent, although this was an extrapolation from serial cross-sections and needs to be explored in a longitudinal study. CONCLUSIONS: Stroke survivors' function does not change significantly over time. A high proportion of survivors require community services. The development of needs-related effective long-term service delivery models is required.