Are rehabilitation and/or care co-ordination interventions delivered in the community effective in reducing depression,facilitating participation and improving quality of life after stroke?

Purpose.?To conduct a systematic review to explore the effectiveness of community-based rehabilitation interventions delivered by allied health professionals and/or nursing staff in reducing depression, facilitating participation and improving health-related quality of life (HRQoL) post-inpatient stroke rehabilitation.

Method.?A search was conducted in the databases of MEDLINE, PEDro, CINAHL and the Cochrane Library. Publications were classified into categories based on the type of the interventions. Best evidence synthesis and meta-analysis were utilised to determine the level of evidence.

Results.?Fifty-four studies were included in the review, and divided into nine broad intervention categories. Meta-analysis demonstrated significant reduction in depression with exercise interventions (n == 137; effect estimate SMD: ?2.03, 95%%CI: ?3.22, ?0.85). Community-based interventions targeting participation and leisure domains showed moderate evidence for improvement in global participation measures and HRQoL. Comprehensive rehabilitation demonstrated limited evidence for depression and participation, and strong evidence for HRQoL

Conclusions.?There is limited to moderate evidence supporting some rehabilitation interventions in affecting the outcomes of depression, participation and HRQoL post-stroke. Heterogeneity of the studies made evidence synthesis difficult. Further consideration needs to be given to the type and timing of outcome measures selected to represent the domains of participation and HRQoL.     

Understanding physical factors associated with participation in community ambulation following stroke

Purpose.?This study examined the association between impaired physical function and participation in community ambulation following stroke. We hypothesised that participation would be significantly less following stroke, and that physical impairments would be associated with participation.

Method.?Using a case–control design 30 survivors of stroke aged 45 and older and 30 controls provided health status information and a self-report of participation in community ambulation (number of trips and walking-related activities (WRA) reported prospectively over a 12-day period). The association of physical impairments (strength, range of motion, sensation, muscle tone, vision, and activity limitations (gait speed and performance on complex walking tasks)) with level of participation was analysed using negative binomial regression and goodness of fit.

Results.?Participants included 30 individuals with and 30 without stroke, average age 68 years, majority were Caucasian women. Average time since stroke was 40 months. Participation in survivors of stroke was characterised by fewer trips and WRA and lower satisfaction (p < 0.001). Usual gait speed, balance, muscle strength and muscle length were impaired (p < 0.001) in stroke vs. controls, and associated with number of trips and WRA (p < 0.05). However, these factors explained less than very little of the variance in participation.

Conclusions.?While individual factors were associated with level of participation, results failed to accurately predict participation in community ambulation following stroke. Other factors, such as depression, cognition and self-efficacy may be stronger determinants of participation.     

Validation of the NHANES ADL scale in a sample of patients with report of cervical pain: Factor analysis,item response theory analysis,and line item validity

Background.?Few functional outcomes scales have used Item Response Theory (IRT) for validation. IRT allows individual line item validations and offers substantial advantages over classic methods of scale validation or the simplest from of IRT known as Rasch. Rasch analysis reduces data to dichotomous variables thus decreasing the sensitivity of Likert-type data responses.

Purpose.?The purpose of this study was to create an outcome scale associated with the latent trait of functioning and disability, validated using IRT, in a population with report of cervical pain.

Methods.?Using the NHANES database, a recently created scale (NHANES ADL scale) was analysed using factor analysis, internal analyses of consistency, IRT, and comparison with internal measures of functioning and disability.

Results.?The newly created NHANES ADL scale demonstrated uni-dimensionality, was internally reliable, and was correlated to internal measures of functioning and disability. Additionally, the majority of the scale items demonstrate strong discrimination and suitable thresholds.

Discussion.?The NHANES ADL scale effectively measures physical, social, and emotional disability in patients with a cervical impairment, and may be an efficient measure of perceived limitations from working and generalized daily physical activity.

Conclusion.?The newly created NHANES ADL scale demonstrates internal consistency, unidimensionality, and line item validity. The NHANES ADL scale appears to be a useful instrument in measurement of functioning and disability in patients with report of cervical pain.     

Holistic group rehabilitation – a short cut to adaptation to the new life after mild acquired brain injury

Purpose.?The purpose was to explore and understand what patients with mild acquired brain injury ((mABI)) consider is effective in a holistic therapy group rehabilitation programme and how the programme affects the rehabilitation process.

Methods.?Thematic interviews were conducted with ten informants with diagnosed mABI. They were recruited through purposive sampling after completing a group rehabilitation programme. The data were analysed using a constant comparative method.

Results.?The programme provided the informants with awareness of their difficulties in daily life. They were thus motivated to develop compensatory strategies for better function. The core category ‘process of change’ and four sub-categories were defined: ‘the group process’, ‘the individual’, ‘family’ and ‘work’. These describe how the programme supported illness management strategies, e.g. setting and maintaining boundaries, coping with and accepting the hard facts of disability. Body awareness training was important. Work capacity was regarded as a measure of recovery. Social relations concentrated on meaningful exchanges.

Conclusion.?When meeting patients with mABI it is important to consider that, despite apparently well functioning; they might suffer from disabling symptoms that affect performance of daily life. A holistic group rehabilitation programme with integrated information properly provides a short cut to facilitating awareness and adjustment.     

Quality of life: An important outcome measure in a trial of very early mobilisation after stroke

Purpose.?Commencing an early and active mobilisation programme in the acute stages of stroke may have important physical and psychological benefits that might improve long-term quality of life. We hypothesised that patients who received very early mobilisation (VEM) would experience better quality of life than those receiving standard care (SC).

Methods.?The study was a Phase II single-blind randomised controlled trial: VEM patients received earlier (within 24?h of stroke onset) and more intensive physical therapy than SC patients for the first 14 days (or until discharge). Quality of life was measured using the Assessment of Quality of Life (AQoL) questionnaire, administered face-to-face by a blinded assessor at 12 months post-stroke.

Results.?Seventy-one individuals with stroke (VEM 38, SC 33) were recruited. At follow-up, the median overall AQoL score was higher in VEM patients (0.32) than SC patients (0.24). This group difference was not significant (p?=?0.17), but it was significant at the 75th percentile (p?=?0.003) in favour of VEM. VEM patients also reported higher quality of life than SC patients in the physical function related ‘Independent Living’ domain of the AQoL (p?=?0.03 adjusted for age; p?=?0.04 adjusted for stroke severity).

Conclusions.?VEM may help improve long-term quality of life after stroke, particularly in relation to functional independence, but this requires further examination.     

Factors associated with quality of life and caregiver strain amongst frail older adults referred to a community rehabilitation service: implications for service delivery

Purpose.?To identify factors contributing to reduced quality of life and increased caregiver strain in an older population referred to a community rehabilitation team and to recommend service delivery models.

Methods.?Analytical cross-sectional study arising from baseline assessments from 107 subjects drawn from a randomised controlled trial of community rehabilitation service delivery models.

Setting.?A community rehabilitation team based in Brisbane, Queensland, Australia.

Measures.?Primary outcome variables include quality of life (EQ-5D & VAS) and Carer Strain Index. Predictor variables include participation in functional activities, history of falls, number of medications, number of co-morbidities, depression, environmental hazards, physical function and nutrition. Association between variables assessed using linear regression.

Results.?Major factors contributing to reduced quality of life were having reduced participation in daily activities, depression, and having poor vision. Having poor nutrition and no longer driving also contributed to poor quality of life. The major factor contributing to increased caregiver strain was reduced participation in daily activities by the older person.

Conclusions.?Community rehabilitation services working with older populations must adopt models of care that screen for and address a wide range of factors that contribute to poor quality of life and caregiver strain.     

Evaluation of activity limitation and social participation,and the effects of reconstructive surgery in people with disability due to leprosy: a prospective cohort study

Purpose.?To assess how activity limitation and social participation of individuals with leprosy-related disability change over time, and to quantify the effect of reconstructive surgery.

Method.?Individuals with disability due to leprosy who accepted invitations for assessment at a leprosy clinic between March and July 2007 were interviewed using the SALSA Scale (measuring activity limitation) and the Participation Scale (assessing social participation). All participants were offered reconstructive surgery. Follow-up interviews were done 1 year after the first interview or 1 year after surgery. The main outcomes were changes in SALSA score and Participation score. We used analysis of variance to identify the effects of independent factors on mean SALSA and Participation scores.

Results.?We interviewed 222 participants, 15 of whom took up the offer of surgery and 207 who did not. Comparison of SALSA Scale scores at baseline and 1 year revealed that activity limitation did not significantly change over time in individuals who declined surgery; however, participants who had surgery showed a significant improvement at 1 year (p?<?0.001). Social participation improved over time in both groups, but the difference was significant only in the non-surgery group (p?<?0.001).

Conclusions.?The findings suggest that reconstructive surgery has beneficial effects on functioning. Evaluation of the need for, and effect of, surgery in larger studies is recommended.     

Recovery after stroke: a 1-year profile

Purpose.?To document the course of recovery in a group of first stroke patients, with stroke of moderate severity, over a 1-year period. Evaluation of recovery is important for estimating rehabilitation needs.

Method.?One-year observational study of 23 acute first stroke patients. Recovery was assessed at 15 specific intervals using measures of impairment, activity, social participation and quality of life.

Results.?There were significant changes in impairment (p < 0.05) and motor disability over 1 year (F ratio = 75.627, d.f. = 4, p ≤ 0.0001) including the period between 6 and 12 months though recovery did appear to slow down after a 9-week ‘turning point’. Significant improvements in social participation were also seen between 6 and 12 months (p = 0.0021). Quality of life did not change and patients' quality of life scores indicated levels of ‘severe distress' at 6 (57.8 [8.8]) and 12 months (58.9 [8.6]).

Conclusions.?Recovery after stroke was detectable beyond 6 months using detailed measures. This demonstration of late recovery has therapeutic implications. An increased understanding of the course of recovery following stroke could provide a basis for evaluating the varied aspects of therapeutic intervention in stroke rehabilitation.     

Whiplash patients' experience of a multimodal rehabilitation programme and its usefulness one year later

Objective.?The study aimed to explore and analyse how, 1 year after completing a rehabilitation programme, persons with long-term pain due to whiplash-associated disorders (WAD) experienced their participation, and what knowledge and strategies they had gained from it for handling their daily occupations.

Methods.?The study had an emergent design. Thematised research interviews were conducted with nine informants. The results were analysed according to the constant-comparison grounded-theory method.

Results.?Data analysis resulted in one core category, ‘learning to manage WAD, a rehabilitation process’, and three associated categories: ‘chaos in life’, ‘a light in the tunnel’ and ‘managing long-term pain’. The core category and the categories describe the process the informants underwent from how they experienced life when starting rehabilitation to one year after completion.

Conclusion.?The informants described living with long-term whiplash-associated pain as ‘chaos’ before the rehabilitation programme. Participation helped them realise that there was a possible way for them to control their pain, regain their daily occupation and return to work. One year after rehabilitation the informants had started to accept their situation and regain occupations and life roles.     

Alexithymia in respiratory rehabilitation

Purpose.?To date, there are no studies that have investigated the role of alexithymia in respiratory rehabilitation. We aimed to observe the prevalence of alexithymia in patients attending respiratory rehabilitation and to verify the presence of a difference between alexithymics and non-alexithymics responsiveness to the respiratory rehabilitation standard protocol.

Methods.?A prospective cohort study evaluating the influence of alexithymia on functional recovery of in-patients afferent to the Respiratory Rehabilitation Unit of IRCCS San Raffaele Pisana. Sixty patients were consecutively enrolled into the study and evaluated for alexithymia, anxiety and depression. Functional recovery was assessed with the six-minute walking test (6MWT). Prior and post-completion of this test dyspnoea, oxygen saturation and cardiac frequency were recorded.

Results.?Alexithymia was not found to be significantly affecting the functional recovery of participants in respiratory rehabilitation. The distance walked at the 6MWT (6MWD) increased in both alexithymics and non-alexithymics (p_alexithymics?=?0.014; p_{non-alexithymics}?<?0.0001). Dyspnoea strongly improved among non-alexithymics, although a signal for improvement was also found in alexithymics (p_alexithymics?=?0.046; p_{non-alexithymics}?=?0.0001).

Conclusions.?These findings suggest that alexithymia did not have a significant impact on functional recovery of patients in respiratory rehabilitation.     

Is walking endurance associated with activity and participation late after stroke??

Purpose.?After stroke, impaired walking ability may affect activity and participation. The aim was to investigate whether self-reported activity and participation were associated with walking endurance late after stroke.

Method.?A non-randomised sample of 31 persons with a mean age of 59.7 years and time since stroke of 7–10 years was studied. Walking endurance was measured by the 6-minute walk test (6MWT). Self-reported activity and participation were measured by the Physical Activity Scale for the Elderly and the Stroke Impact Scale. Relationships were analysed with linear regression.

Results.?A regression model including activities of daily living and 6MWT explained 44%%, mobility and 6MWT explained 25%% and a model including physical activity level and 6MWT explained 21%% of the variation in activity. Regarding participation, the explanatory level of the model of participation and 6MWT was 30%%.

Conclusions.?Walking distance several years after stroke was partly associated with self-reported difficulties in activity and participation.     

Perceptions of family participation among parents of children with cerebral palsy followed from infancy to toddler hood

Background.?Little is known about the way parents of children with cerebral palsy (CP) perceive their involvement in family and personal life situations, also called ‘family participation’.

Purpose.?To investigate the perception of family participation among parents of preschool children with CP.

Method.?Semi-structured interviews were used to describe how parents (n = 53) of children with CP (aged 18 months) perceive participation with respect to family activities and their personal activities. In addition, using a combined score of family and personal activities, we investigated the changes of parental (n = 36) perceived family participation over time (followed from 18 months onwards until 42 months of age).

Results.?At the child's age of 18 months, a substantial percentage of parents expressed a feeling of being restricted in their family activities (45%) or personal activities (53%). The longitudinal data show that over the 24-month follow-up significant more parents perceived to be restricted in family participation (p = 0.008; Cochran's Q test).

Conclusions.?A child with CP in a family may lead to parents perceiving restrictions in family participation. These restrictions arise early in the life of a child with CP and may become more prominent as the child grows older.     

Patients' experiences of the impact of chronic back pain on family life and work

Purpose.?The emotional distress caused by pain is one of the most disruptive aspects of living with the condition. This study investigates how individuals experience pain and its consequences for family life and work.

Method.?Unstructured interviews, using the ‘Framework’ approach with topic guide, were recorded and transcribed. Patients were sampled for age, sex, ethnicity and occupation from new referrals with spinal pain (SP) to a rheumatology outpatient clinic. Eleven patients (five males and six females) were interviewed in English (n?=?9) or their preferred language (n?=?2). Interviews were read in depth twice to identify the topics. Data were extracted in phrases and sentences using thematic content analysis.

Results.?Emergent themes reported were relationships with: spouses and partners (n?=?7), children/parents (n?=?6), with other family and friends (n?=?7) and work-related issues (n?=?11). Patients valued support from family but expressed concerns about causing them worry. Work-related issues included physical and emotional efforts to keep working when in pain, fear of losing employment and financial problems.

Conclusion.?Patients expressed anxiety about how their pain affected other family members, regret at losing full work capacity and worry about financial consequences. The lived experience of chronic SP has ramifications that go beyond the individual, reaching into work and social relationships.     

Evaluation of change in fatigue,self-efficacy and health-related quality of life,after a group educational intervention programme for persons with neuromuscular diseases or multiple sclerosis: a pilot study

Purpose.?An intervention for persons with neuromuscular diseases (NMD) or multiple sclerosis (MS) who experienced severe fatigue was developed which aimed at educating participants in maintaining a balance between capacity and load in their daily activities. This pilot study evaluated the results of this intervention.

Methods.?Persons with NMD or MS who experienced severe fatigue were included. Outcome measures were: fatigue (Fatigue Severity Scale), health-related quality of life (HRQoL; SF-36) and self-efficacy (ALCOS-16). Changes in scores between the start of the intervention (T0) and 3 months post-intervention (T1) were tested with the Wilcoxon tests in the complete group and in subgroups (gender, education, high/low self-efficacy).

Results.?Forty-three persons participated. Significant improvements of HRQoL were found for the domains role-physical, mental health and general health perceptions. Subgroup analyses showed more improvement in males (fatigue, role-physical, vitality, bodily pain, general health perceptions), participants with lower education (role-physical, vitality) and participants with low self-efficacy at T0 (self-efficacy, mental health, general health perceptions) than in females, participants with higher education and participants with higher initial self-efficacy.

Conclusion.?This pilot-study provides preliminary evidence for the effectiveness of a group educational intervention in improving HRQoL without increasing fatigue in persons with NMD and MS.     

Job coach factors associated with community-based employment service programme outcome measures for people with disabilities – a Taiwan case study

Purpose.?The aim of this study is to explore whether/which job coach factors were significantly associated with the community-based employment service (CBES) programme outcome measures in Taiwan.

Method.?This study used the 2003–2005 CBES programme for People with Disabilities Database in Taipei City in Taiwan (n?=?3924) to do a secondary data analysis using hierarchical multiple linear regression.

Results.?This study found that ‘occurrences of the services provided by the job coaches’ variable was definitely the dominant predictor and explained additional 19.6% and 27.8% of the variances of annual salary and annual working month outcome measures, respectively. In addition, among six composition variables of ‘occurrences of the services provided by the job coaches’, ‘occurrences of follow-up guidance’, ‘occurrences of intensive guidance’, and ‘occurrences of consultation before interviews with employer/director of human resources’ were more powerful than the other three in predicting outcomes.

Conclusions.?Job coach factors in this study were significantly correlated with CBES programme outcome measures for people with disabilities in Taiwan after controlling for the socio-demographic variables. It indicates that the more inputs in the people with disabilities made by job coaches equates to better outcomes in this Taiwan case study.     

The health and psychosocial functioning of caregivers of children with neurodevelopmental disorders

Purpose.?Children with neurodevelopmental disorders (Neuro) pose complex parenting challenges, particularly if the condition co-occurs with behaviour problems. Such challenges are likely to impact caregiver health and well-being. This study explores the extent to which caregivers of children with both ‘Neuro’ and behaviour problems differ in their physical and psychosocial outcomes from caregivers of children with either condition or neither condition.

Method.?The first wave of data collected in the National Longitudinal Survey of Children and Youth in Canada (1994) was used to identify four groups of caregivers of 4 to 11-year-old children: caregivers of children with a ‘Neuro’ disorder and externalising behaviour problems (Both; n = 414), caregivers of children with a ‘Neuro’ disorder only (Neuro Only; n = 750), caregivers of children with an externalising behaviour problem only (Ext Only; n = 1067), and caregivers of children with neither health condition (Neither; n = 7236).

Results.?Caregivers in the ‘Both’ group were least likely to report excellent or very good health, and more frequently reported chronic conditions such as asthma, arthritis, back problems, migraine headaches, and limitations in activities as compared to the ‘Neither’ group. This group also exhibited higher depression scores, experienced more problematic family functioning, and reported lower social support than the ‘Neither’ group. Scores for caregivers in the ‘Ext Only’ and ‘Neuro Only’ groups tended to lie between the ‘Both’ and ‘Neither’ group scores and often did not differ from one another.

Conclusions.?Caregivers of children with both neurodevelopmental disorders and behaviour problems exhibited a greater number of health and psychosocial problems. While addressing children's behaviour problems, health care professionals should also consider caregiver physical and psychosocial health as this may also have an impact on children's well-being.     

SWOT analysis of a pediatric rehabilitation programme: A participatory evaluation fostering quality improvement

Purpose.?To present the results of a strengths, weaknesses, opportunities and threats (SWOT) analysis used as part of a process aimed at reorganising services provided within a pediatric rehabilitation programme (PRP) in Quebec, Canada and to report the perceptions of the planning committee members regarding the usefulness of the SWOT in this process.

Method.?Thirty-six service providers working in the PRP completed a SWOT questionnaire and reported what they felt worked and what did not work in the existing model of care. Their responses were used by a planning committee over a 12-month period to assist in the development of a new service delivery model. Committee members shared their thoughts about the usefulness of the SWOT.

Results.?Current programme strengths included favourable organisational climate and interdisciplinary work whereas weaknesses included lack of psychosocial support to families and long waiting times for children. Opportunities included working with community partners, whereas fear of losing professional autonomy with the new service model was a threat. The SWOT results helped the planning committee redefine the programme goals and make decisions to improve service coordination. SWOT analysis was deemed as a very useful tool to help guide service reorganisation.

Conclusions.?SWOT analysis appears to be an interesting evaluation tool to promote awareness among service providers regarding the current functioning of a rehabilitation programme. It fosters their active participation in the reorganisation of a new service delivery model for pediatric rehabilitation.     

The Papworth Early Rehabilitation Programme: Vocational outcomes

Background.?There are 2.7 million people in the UK receiving incapacity benefits, costing approximately £18 billion pa. Government has adopted a policy of helping claimants back into work, through structured vocational rehabilitation schemes. There are no published results of vocational rehabilitation services in the UK. We present the results of the Papworth Trust vocational rehabilitation programme. Depending on the severity of their disability, the ‘Early Rehab Programme’ aims to get people on incapacity benefits: (a) into employment, (b) fit for and seeking work, (c) involved in voluntary work, (d) education, or (e) able to live independently.

Methods.?Retrospective chart survey and telephone follow up.

Setting.?Cambridgeshire.

Results.?Since 1995, 274 people attended for a preliminary interview, of which 107 subsequently started a full rehab programme. Eighty-seven were male and 20 female. Half had been unemployed for more than two years. Ninety-four completed the programme, of whom 53 had gained employment, 33 were ‘work ready’ and four were doing voluntary work. At long-term follow-up, 52 were employed, 12 were in voluntary work, and 7 had retired on medical grounds.

Conclusions.?This programme demonstrates that long-term Incapacity Benefit recipients can return to sustained employment, as shown in those who participated in the Papworth Trust's vocational rehabilitation programme.     

Psychosocial factors associated with the effects of physiotherapy in the acute hospital

Purpose.?To examine the associations between psychosocial factors and physical functioning at admission, and functional recovery during an acute hospital admission.

Method.?Included into this multi-centre cohort study were 642 patients with cardiopulmonary, musculoskeletal and neurological conditions recruited from 32 Swiss hospitals. Functional status was measured at admission and discharge using the Barthel Index (BI); BI change was used as an indicator for functional recovery. Sense of coherence (SOC) and depression were assessed at admission using the SOC questionnaire and the Hospital Anxiety and Depression Scale (HADS); patient motivation was judged at discharge by physiotherapists on a Visual Analogue Scale. Mixed effect regression was used to assess associations of SOC, depression and motivation with functional status at admission and functional recovery. Distinct models were built to control for sets of behavioural, socio-economic and disease-related variables.

Results.?Functional status at admission was significantly associated with SOC, depression and motivation. Functional recovery was significantly associated with motivation, but not with SOC. Significant associations between functional recovery and depression were found in some of the models.

Conclusions.?As motivation showed strong associations with functional recovery, future studies should examine how functional recovery is influenced by motivation and how motivation can be improved.