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3.
Purpose: To evaluate the effectiveness of a 16-week self-management intervention on physical activity level and self-management skills (self-efficacy, proactive coping and problem solving skills) in persons with chronic SCI. Method and design: Multicenter randomized controlled trial (RCT). Eighty persons with a SCI for at least 10 years and aged 18 to 65 will randomly be assigned to the intervention (self-management) or the control group (information provision). During the 16-week self-management intervention (one home-visit, five group and five individual sessions) active lifestyle will be stimulated and self-management skills will be taught. Data will be collected at baseline (T0), 16 (T1) and 42 (T2) weeks after baseline. Primary outcome measure is level of daily physical activity (self-report/objectively measured). Secondary outcome measures are self-managements skills, stage of behaviour change and attitude. Conclusion: This is the first RCT on self-management in people with chronic spinal cord injury. This trial will provide knowledge on the effects of a self-management intervention on physical active lifestyle in persons with a long-term SCI. Implications for Rehabilitation Persons with long-term SCI benefit from a higher activity level in terms of health- and psychological benefits. Self-management interventions have shown to be effective in modifying behaviours and preventing health problems in different chronic disorders. This study aims to enhance a physically active lifestyle in persons with long-term SCI by improving self-management skills (self-efficacy, problem solving & proactive coping) through a self-management intervention.
4.
Purpose: To provide an overview of walking tests including their measurement properties that have been used in stroke survivors. Method: Electronic databases were searched using specific search strategies. Retrieved studies were selected by using specified inclusion criteria. A modified consensus-based standards for the selection of health status measurement instruments (COSMIN) checklist was applied for methodological quality assessment of the included studies. A quality assessment for statistical outcomes was used to assess measurement properties of the walking tests. Tests that were included were categorized according to the framework of the international classification of functioning, disability and health (ICF). Results: Thirty-two studies, evaluating 23 walking tests, were included. The tests assessed walking using the outcome measures of walking speed, walking distance, functional ambulation and walking on different surfaces. The methodological design and statistical methods of most studies evaluating reliability and criterion validity were sufficient, and found the outcome measures to be reliable and valid. However, data on measurement error, minimal important difference and minimal important change were lacking and responsiveness was correctly evaluated in one study only. Conclusions: Many walking tests have been clinimetrically evaluated in stroke survivors. Most walking tests were found to be reliable and valid. Implications for Rehabilitation Many tests assessing walking in stroke survivors are available in the literature. The Six Minute Walk Test, Ten Metre Comfortable Walk Test, Ten Metre Fast Walk Test, Functional Ambulation Categories and Six Metre Walk Test on parquet and carpet have been most frequently clinimetrically evaluated. These tests amongst others, have been shown to be valid, reliable and feasible for stroke survivors. With the wide variety of walking tests, it is important to choose an appropriate walking test suiting the specific aim of the clinician or researcher.
5.
Purpose: To systematically review self-management interventions to determine their efficacy for people with stroke in relation to any health outcome and to establish whether stroke survivors with aphasia were included. Method: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, The Cochrane Library, and IBSS and undertook gray literature searches. Randomized controlled trials were eligible if they included stroke survivors aged 18?+?in a “self-management” intervention. Data were extracted by two independent researchers and included an assessment of methodological quality. Results: 24 studies were identified. 11 out of 24 reported statistically significant benefits in favor of self-management. However, there were significant limitations in terms of methodological quality, and meta-analyses ( n=?8 studies) showed no statistically significant benefit of self-management upon global disability and stroke-specific quality of life at 3?months or ADL at 3 or 6?months follow-up. A review of inclusion and exclusion criteria showed 11 out of 24 (46%) studies reported total or partial exclusion of stroke survivors with aphasia. Four out of 24 (17%) reported the number of stroke survivors with aphasia included. In nine studies (38%) it was unclear whether stroke survivors with aphasia were included or excluded. Conclusions: Robust conclusions regarding the effectiveness of poststroke self-management approaches could not be drawn. Further trials are needed, these should clearly report the population included. - Implications for rehabilitation
There is a lack of evidence to demonstrate the effectiveness of self-management approaches for stroke survivors. It is unclear whether self-management approaches are suitable for stroke survivors with aphasia, particularly those with moderate or severe aphasia. Further research is needed to understand the optimal timing for self-management in the stroke pathway and the format in which self-management support should be offered.
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6.
AbstractPurpose: The utility of self-management with people from minority ethnic backgrounds has been questioned, resulting in the development of culturally specific tools. Yet, the use of stroke specific self-management programmes is underexplored in these high risk groups. This article presents the experience of stroke therapists in using a stroke specific self-management programme with stroke survivors from minority ethnic backgrounds. Methods: 26 stroke therapists with experience of using the self-management programme with stroke survivors from minority ethnic backgrounds participated in semi-structured interviews. These were audio recorded, transcribed verbatim and analysed thematically. Results: Three themes were identified. One questioned perceived differences in stroke survivors interaction with self-management based on ethnicity. The other themes contrasted with this view demonstrating two areas in which ethnic and cultural attributes were deemed to influence the self-management process both positively and negatively. Aspects of knowledge of health, illness and recovery, religion, family and the professionals themselves are highlighted. Conclusions: This study indicates that ethnicity should not be considered a limitation to the use of an individualized stroke specific self-management programme. However, it highlights potential facilitators and barriers, many of which relate to the capacity of the professional to effectively navigate cultural and ethnic differences. - Implications for Rehabilitation
Stroke therapists suggest that ethnicity should not be considered a barrier to successful engagement with a stroke specific self-management programme. Health, illness and recovery beliefs along with religion and the specific role of the family do however need to be considered to maximize the effectiveness of the programme. A number of the facilitators and barriers identified are not unique to stroke survivors from ethnic minority communities, nor shared by all. The therapists skills at negotiating identified barriers to self-management are highlighted as an area for further development.
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7.
AbstractPurpose: To provide a review of the 2nd International Symposium on Gait and Balance in Multiple Sclerosis (MS), emphasizing interventions in gait and balance for people with MS. Method: Review of current research on interventions used with people having MS and with people having other disorders that may provide novel insights into improving gait and balance and preventing falls in people with MS (pwMS). Results: Nine speakers provided evidence-based recommendations for interventions aimed at improving gait and balance dysfunction. Speaker recommendations covered the following areas: balance rehabilitation, self-management, medications, functional electrical stimulation, robotics, sensory augmentation, gait training with error feedback and fall prevention. Conclusions: The causes of gait and balance dysfunction in pwMS are multifactorial and therefore may benefit from a wide range of interventions. The symposium provides avenues for exchange of evidence and clinical experience that is critical in furthering physical rehabilitation including gait and balance dysfunction in MS. - Implications for Rehabilitation
Approaches to improve Gait and Balance dysfunction in Multiple Sclerosis. Balance exercises that include training of sensory strategies. Self-management and self-management support. Pharmacologic intervention, such as Dalfampradine. Functional electrical stimulation that may provide the extra stimulation to influence coordinated leg movements needed for walking.
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9.
Purpose: The use of standardised outcome measures is an integral part of stroke rehabilitation and is widely recommended as good practice. However, little is known about how measures are actually used or their impact. This study aimed to identify current clinical practice; how healthcare professionals working in stroke rehabilitation use outcome measures and their perceptions of the benefits and barriers to use. Method: Eighty-four Health Care Professionals and 12 service managers and commissioners working in stroke services across a large UK county were surveyed by postal questionnaire. Results: Ninety-six percent of clinical respondents used at least one measure, however, less than half used measures regularly during a patient’s stay. The mean number of tools used was 3.2 (SD = 1.9). Eighty-one different tools were identified; 16 of which were unpublished and unvalidated. Perceived barriers in using outcome measures in day-to-day clinical practice included lack of resources (time and training) and lack of knowledge of appropriate measures. Benefits identified were to demonstrate the effectiveness of rehabilitation interventions and monitor patients’ progress. Conclusions: Although the use of outcome measures is prevalent in clinical practice, there is little consistency in the tools utilised. The term “outcome measures” is used, but staff rarely used the measures at appropriate time points to formally assess and evaluate outcome. The term “measurement tool” more accurately reflects the purposes to which they were put and potential benefits. Further research to overcome the barriers in using standardised measurement tools and evaluate the impact of implementation on clinical practice is needed. Implications for Rehabilitation Health professionals working in stroke rehabilitation should work together to agree when and how outcome measures can be most effectively used in their service. Efforts should be made to ensure that standardised tools are used to measure outcome at set time-points during rehabilitation, in order to achieve the anticipated benefits. Communication between service providers and commissioners could be improved to highlight the barriers in using standardised measures of outcome.
10.
Purpose: The aim of this systematic review was to examine the psychometric properties of published clinical sitting measurement scales containing dynamic tasks in individuals following stroke. Method: Databases, including Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, EMBASE, Cochrane, PubMed and Allied and Complementary Medicine Database (AMED) were searched from inception to December 2015. The search strategy included terms relating to sitting, balance and postural control. Two reviewers independently selected and extracted data from the identified articles and assessed the methodological quality of the papers using the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist. Results: Fourteen clinical sitting measurement scales (39 papers) containing dynamic tasks met the inclusion criteria and various measurement properties were evaluated. The methodological quality of the majority of the included studies was rated as poor to fair using the COSMIN checklist, with common limitations including small sample size and inappropriate use of statistical methods. Conclusions: This review was unable to identify measures with sufficient psychometric properties to enable recommendation as preferred tools. However, measures were identified that warrant further specific psychometric investigations to fulfil requirements for a high quality measure. - Implications for Rehabilitation
Fourteen clinical sitting balance scales containing dynamic tasks are available to measure sitting balance with individuals following stroke. No single scale has sufficient psychometric properties to enable recommendation as a preferred tool for measuring sitting balance with stroke survivors. Use of a balance scale or dedicated sitting balance measure containing static and dynamic sitting items should be utilised to monitor progress for individuals following stroke with more severe deficits.
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11.
ABSTRACTPurpose: Evidence shows that effective self-management behaviors have the potential to improve health outcomes, quality of life, self-efficacy and reduce morbidity, emergency visits and costs of care. A better understanding of self-management interventions (i.e. programs that help with managing symptoms, treatment, physical and psychological consequences) is needed to achieve a positive impact on health because most children with a disability now live well into adulthood. Method: A systematic review of self-management interventions for school age youth with physical disabilities was undertaken to assess their effectiveness. Comprehensive electronic searches using international web-based reference libraries were conducted for peer-reviewed and gray literature published between 1980 and January 2012. Eligible studies examined the effectiveness of self-management interventions for children and youth between 6 and 18 years of age with congenital or acquired physical disabilities. Studies needed to include a comparison group (e.g. single group pre/post-test design) and at least one quantifiable health-related outcome. Results: Of the 2184 studies identified, six met the inclusion criteria; two involved youth with spina bifida and four with juvenile arthritis. The majority of the interventions ran several sessions for at least 3 months by a trained interventionist or clinician, had one-to-one sessions and meetings, homework activities and parental involvement. Although outcomes varied between the studies, all of the interventions reported at least one significant improvement in either overall self-management skills or a specific health behavior. Conclusions: While self-management interventions have the potential to improve health behaviors, there were relatively few rigorously designed studies identified. More studies are needed to document the outcomes of self-management interventions, especially their most effective characteristics for children and youth with physical disabilities. - Implications for Rehabilitation
There is some evidence to suggest that self-management interventions for children and youth with spina bifida and arthritis can improve self-management behaviors and health outcomes. Parents’ involvement should be considered in encouraging self-management behaviors at different stages of their child’s development. Much work is needed to explore the longer term implications of self-management interventions for youth with physical disabilities as well as the impact on health care utilization.
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12.
Purpose: To evaluate effectiveness of a face-to-face and an online fatigue self-management programme and to compare these to two control groups (information-only and no-intervention) in a sample of adults (n?=?115) with neurological conditions reporting extreme fatigue. Method: Non-equivalent pre-test post-test control group design using the Fatigue Impact Scale, Personal Wellbeing Index and Activity Card Sort as primary outcome measures. Results: Participants in the two intervention groups and the information-only group showed clinically significant improvements in fatigue over time (p?<?0.05). When compared to the no-intervention group, face-to-face participants showed significantly greater improvement in overall and cognitive fatigue, while participants in the online group showed significant improvement in self-efficacy and stress. Conclusion: Participation in either the online or face-to-face programme appears to result in improved self-management, however, with different potency depending on outcomes. The improvement in the online information only group further complicates the understanding of the results. With few other comparisons of online and face-to-face self-management protocols available, further research is needed to understand differential impacts which may be related to the delivery format, the rural versus urban split of participants or other unknown factors. Implications for Rehabilitation The fatigue self-management programme supports people to self-manage extreme fatigue, a common side effect of neurological conditions. Both online and face-to-face versions are available. In comparison to a no-intervention group, participants in the face-to-face version had decreased fatigue levels while those in the online version were better able to self-manage depression and stress and to improve their self-efficacy. Online programmes may reach people with poorer baseline scores, partially explaining the difference in outcomes.
13.
Purpose: The objective of this study was to assess the psychometric properties of the Stroke Impact Scale (SIS). Methods: Data was derived from a study assessing a community-based stroke rehabilitation program. Patients were administered the SIS and Euroqol-5D (EQ-5D-5L) on admission to the study, and at six month and 12 month follow-up. The psychometric performance of each domain of the SIS was assessed at each time point. Results: A total of 164 patients completed outcome measures at baseline, 108 patients at six months and 37 patients at 12 months. Correlation of the SIS domains with the EQ-5D-5L suggested that the dimensions of health contributing to a patient’s perception of health-related quality of life changes over time. Conclusion: The SIS performed well in a sample of patients undergoing stroke rehabilitation in the community. Our findings suggest that the multidimensionality of the SIS may allow health professionals to track patient progress and tailor rehabilitation interventions to target the dimensions of health that are most important to a patient’s overall health and perceived quality of life over time. - Implications for Rehabilitation
There is an increased need for valid and reliable measures to evaluate the outcomes of patients recovering from stroke in the community. The Stroke Impact Scale (SIS) measures multiple domains of health and is well-suited for use in patients recovering from stroke in the community. There is a high level of internal consistency in the eight SIS domains with no evidence of floor effects; ceiling effects were noted for several domains. Correlation of the SIS with the Euroqol-5D suggested that the dimensions of health contributing to a patient’s perception of health related quality of life changes over time.
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14.
Purpose: To summarize the potential origins of fatigue poststroke from a neuromuscular perspective, including stroke-induced alterations at the cortical, spinal and muscle levels. Method: Perspective based on narrative literature review. Results: Fatigue is a highly prevalent, but poorly understood symptom poststroke. Neuromuscular fatigue has central and peripheral origins. Individuals with stroke experienced greater central fatigue and less peripheral fatigue during voluntary contractions of the paretic leg in comparison to healthy participants. Neuromuscular adaptations to stroke create an increased susceptibility to central fatigue, which may be a contributing factor to the increased perception of tiredness during performance of activities of daily living. Future studies should investigate whether intervention-induced cortical plasticity, gains in muscle strength and endurance will attenuate self-reported fatigability. Conclusions: Fatigue is a common and debilitating consequence of stroke. Neuromuscular fatigue of central origin may contribute to self-reported fatigue. Continued focused and properly designed research studies should provide substantial insight into the therapeutic interventions that will improve the management of fatigue poststroke. Implications for Rehabilitation Fatigue is a common and debilitating consequence of stroke, which has received little attention in clinical rehabilitation. Insufficient understanding of the pathophysiology of poststroke fatigue limits advances in its treatment. Neuromuscular fatigue of central origin may contribute to the self-reported fatigue poststroke. Although speculative, rehabilitation interventions that foster neuroplasticity, muscle strength and endurance may have a role in the management of fatigue poststroke.
15.
Purpose: To evaluate the extent to which the principles of chronic pain or illness self-management (SM) programs might be adapted to focus on the workplace concerns of adults with persistent or recurrent pain and lead to new workplace intervention opportunities. Method: Eight SM programs were selected as representative evidence-based programs and then compared to extract common instructional elements. Elements were analyzed for potential application to four workplace problem domains identified by workers with pain: activity interference, negative self-perceptions, interpersonal challenges, and the inflexibility of work. Results: Of 24 instructional elements, 17 were shared by at least half of the SM programs. Instructional elements judged to be best suited for dealing with workplace concerns included those focused on reducing pain and discomfort, making informed decisions, communicating effectively, and dealing with thoughts and feelings. However, aspects of the workplace that may alter the feasibility or effectiveness of SM strategies include the level of physical demands and limitations, job leeway, and the nature of workplace roles and relationships. Conclusions: Principles and methods of SM intervention programs are generally well suited to address pain-related problems in the workplace, but tailoring of messages may be necessary to incorporate the unique organizational, physical, and social aspects of work into psycho-educational programs. Implications for Rehabilitation Chronic pain is a growing problem among working age adults that can contribute to workplace difficulties and disability. Pain self-management interventions applying psycho-educational techniques are generally well-suited for dealing with workplace problems. Pain self-management interventions may reduce pain and discomfort in the workplace, help with job-related problem-solving and decision-making, provide methods for communicating needs effectively, and deal with negative thoughts and feelings at work. Applying existing pain self-management techniques in the workplace requires that some changes be made to incorporate the unique organizational, physical, and social aspects of the workplace.
16.
Purpose: This study investigates the effectiveness of Lokomat + conventional therapy in recovering walking ability in non-ambulatory subacute stroke subjects involved in inpatient rehabilitation. Method: Thirty first-ever stroke patients completed 8 weeks of intervention. One group ( n?=?16) received Lokomat therapy twice a week, combined with three times 30?min a week of conventional overground therapy. The second group ( n?=?14) received conventional assisted overground therapy only, during a similar amount of time (3.5?h a week). The intervention was part of the normal rehabilitation program. Primary outcome measure was walking speed. Secondary outcome measures assessed other walking- and mobility-related tests, lower-limb strength and quality of life measures. All outcome measures were assessed before and after the intervention and at wk 24 and wk 36 after start of the intervention. Results: Patients showed significant ( p?Conclusion: These results indicate that substituting Lokomat therapy for some of conventional therapy is as effective in recovering walking ability in non-ambulatory stroke patients as conventional therapy alone. - Implications for Rehabilitation
Recovery of walking after stroke is important. Robot-assisted therapy is currently receiving much attention in research and rehabilitation practice as devices such as the Lokomat seem to be promising assistive devices. Technical developments, sub-optimal study designs in literature and new therapy insights warrant new effectiveness studies. Results of a financially and practically feasible study indicate that substituting Lokomat therapy for some of conventional therapy is as effective in recovering walking ability in non-ambulatory stroke patients as compared to conventional overground therapy alone.
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17.
Purpose: To test the feasibility of a handwriting retraining program with adults after stroke; specifically the feasibility of: (i) recruiting people with stroke to the study, (ii) delivering the handwriting retraining program and (iii) outcome measures of handwriting performance. Method: A quasi-experimental pre-test post-test design was used. A four-week, home-based handwriting retraining program was delivered by an occupational therapist using task-specific practice. Legibility, speed, pen control and self-perception of handwriting were measured at baseline and completion of the program. Legibility was scored by a blinded rater. Results: Seven adults with stroke were recruited (eligibility fraction 43% of those screened, and enrolment fraction 78% of those eligible). There were no dropouts. Although, recruitment was slow the intervention was feasible and acceptable to adults with stroke. No statistically or clinically significant changes in legibility were reported in this small sample, but a ceiling effect was evident for some outcome measures. The study was not powered to determine efficacy. Conclusions: Delivery of a four-week handwriting intervention with eight supervised sessions in the community was feasible; however, recruitment of an adequate sample size would require greater investment than the single site used in this pilot. - Implications for Rehabilitation
Handwriting difficulty is common following hemiparesis after stroke, however research addressing handwriting retraining for adults with stroke is lacking. A four-week home-based handwriting program using task-specific practice and feedback was feasible to deliver and appropriate for adults with stroke. Improving handwriting legibility and neatness across a range of tasks were important goals for adults with handwriting impairment.
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18.
AbstractPurpose: To summarize measurement instruments used to evaluate activity limitations and participation restrictions in patients with chronic fatigue syndrome (CFS) and review the psychometric properties of these instruments. Method: General information of all included measurement instruments was extracted. The methodological quality was evaluated using the COSMIN checklist. Results of the measurement properties were rated based on the quality criteria of Terwee et?al. Finally, overall quality was defined per psychometric property and measurement instrument by use of the quality criteria by Schellingerhout et?al. Results: A total of 68 articles were identified of which eight evaluated the psychometric properties of a measurement instrument assessing activity limitations and participation restrictions. One disease-specific and 37 generic measurement instruments were found. Limited evidence was found for the psychometric properties and clinical usability of these instruments. However, the CFS-activities and participation questionnaire (APQ) is a disease-specific instrument with moderate content and construct validity. Conclusion: The psychometric properties of the reviewed measurement instruments to evaluate activity limitations and participation restrictions are not sufficiently evaluated. Future research is needed to evaluate the psychometric properties of the measurement instruments, including the other properties of the CFS-APQ. If it is necessary to use a measurement instrument, the CFS-APQ is recommended. - Implications for Rehabilitation
Chronic fatigue syndrome (CFS). Chronic fatigue syndrome causes activity limitations and participation restrictions in one or more areas of life. Standardized, reliable and valid measurement instruments are necessary to identify these limitations and restrictions. Currently, no measurement instrument is sufficiently evaluated with persons with CFS. If a measurement instrument is needed to identify activity limitations and participation restrictions with persons with CFS, it is recommended to use the CFS-APQ in clinical practice and scientific research.
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19.
Purpose: The purpose was to compare the effectiveness of robotic-assisted body weight supported treadmill training using the Lokomat ® to over-ground gait training (OGT) in adults with chronic stroke. Methods: Participants were randomly assigned to the Lokomat ® or OGT interventions. Both protocols included 40 sessions over 8 weeks. Primary outcome measures were the 10-meter walk test and 6-minute walk distance. Secondary measures included the Functional Independence Measure TM locomotion score, Fugl-Meyer Lower Extremity Motor Score (FM-LE), Barthel Index, and Stroke Impact Scale. Blinded assessors tested the participants at baseline, post-intervention, and 3-month follow-up. Results: Eleven Lokomat ® and nine OGT participants completed the study. Within group differences in the FM-LE score and Barthel Index occurred over time from baseline to post-intervention and baseline to 3-month follow-up. No other within group differences and no between group differences were observed. Conclusions: Although walking measures did not show significant changes between groups, LE motor function and physical functional levels improved over time within both groups. The Lokomat ® may allow aggressive locomotor training, particularly for the lower functioning patients who wish to improve walking ability due to apparent eased therapist physical burden, when compared to OGT, although an increased risk of skin breakdown is present. Implications for Rehabilitation Survivors of chronic stroke can continue to improve in motor recovery and functional ability after intensive over-ground or robotic-assisted locomotor training. Over-ground and robotic-assisted locomotor training appear to equivalently enhance motor recovery and functional ability in low functioning survivors of chronic stroke. Risk of skin breakdown is significant with roboticassisted locomotor training.
20.
Purpose: The incidence of stroke is of global concern, and the rates of recurrence are high. Many risk factors are related to lifestyle behaviours and, as such, are amenable to change. Implementation of effective secondary prevention interventions is essential; however, little is known about influences on participation and adherence. This review and meta-aggregation aimed to improve understanding of stroke survivor and family member perspectives of secondary prevention interventions. Methods: We searched 11 databases, e.g. Medline and PsycINFO. We included qualitative studies that focused on adult stroke survivors and family members who had participated in a multimodal stroke secondary prevention intervention. Critical appraisal and data extraction were performed independently by two reviewers. A meta-aggregation of qualitative findings was conducted. Results: Five papers were included. One hundred and three findings were extracted and grouped into 14 categories from which three synthesised findings emerged: feeling supported, acquiring knowledge and gaining confidence. Conclusions: The findings highlight the perceived benefits of participation in secondary prevention group interventions from the perspective of stroke survivors and family members, i.e. feeling supported, by others with shared understanding and by knowledgeable health professionals, acquiring new knowledge and gaining confidence. These findings may be used to inform development of patient-centred interventions and thereby assist in improving health outcomes. - Implications for Rehabilitation
Health professionals should consider implementing group-based secondary prevention interventions. The content of group-based secondary prevention interventions should be person-centred, i.e. meaningful and relevant to the individual. Stroke survivors and family members are more likely to comply with advice and information provided by expert and experienced health professionals.
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