Validation of the extended ICF core set for stroke from the patient perspective using focus groups

Purpose: The extended international classification of functioning, disability and health (ICF) core set for stroke is an application of the ICF of the World Health Organisation (WHO) with the purpose to represent the typical spectrum of functioning of persons with stroke. The objective of the study was to add evidence to the validation of the extended ICF core set for stroke from the perspective of patients using focus groups to explore the aspects of functioning and health important to persons with stroke. Method: The sampling of patients followed the maximum variation strategy. Sample size was determined by saturation. The focus groups were digitally recorded and transcribed verbatim. After qualitative data analysis, the resulting concepts were linked to ICF categories and compared to the categories included in the extended ICF core set for stroke. Results: Sixty patients participated in 15 focus groups. The content of 131 out of 166 ICF categories contained in the extended ICF core set for stroke was reported by the persons with stroke. The content of 31 additional categories that are not covered in the extended ICF core set for stroke was raised. Conclusions: The existing version of the extended ICF core set for stroke could be confirmed almost entirely from patient perspective.

Implications for Rehabilitation:

• The extended ICF Core Set for stroke can be used to create a functioning profile for persons after stroke to identify problems and resources considering a client-centred approach.

• This study shows which aspects of the environment of persons after stroke are relevant from the clients’ perspective and should be integrated in the rehabilitation process.

• This study provides a basis for the further development of the ICF, especially with regard to its update in relevant aspects from clients’ perspective after stroke.

     

Third-party disability in carers of people with dysphagia following non-surgical management for head and neck cancer

Purpose: Third-party disability pertains to the consequences of a person’s impairment which impacts on the functioning and ability of their family members or significant others. With the emergence of research demonstrating the pervasive effects of dysphagia following head and neck cancer (HNC) on the carer, the aim of this study was to identify the International Classification of Functioning, Disability and Health (ICF) domains and categories that describe the third-party disability of carers of people with dysphagia following HNC. Method: Twelve carers of people with dysphagia following HNC participated in individual semi-structured, in-depth interviews. Categories and sub-categories identified from the qualitative analysis were mapped to the ICF using the established linking rules. Results: The majority of the categories and sub-categories from the qualitative analysis were successfully linked to the ICF with most linking to the Activities and Participation component. A number of contextual factors were also identified as impacting on the functioning of carers. Conclusions: The ICF can be successfully used to describe the third-party disability in carers of people with dysphagia following HNC management. This information could be used by clinicians, researchers and policy makers to help establish evidence-based guidelines that include carers in the assessment and management of dysphagia associated with HNC.

• Implications for Rehabilitation

• Clinical levels of distress and reduced quality of life have been associated with caring for a person with dysphagia following head and neck cancer.

• The flow-on effects of dysphagia experienced by a carer or close family member can be understood as a third-party disability, which impacts on their functioning, activities and participation in the context of the environment and personal factors.

• Using the ICF to describe the indirect effects of dysphagia on the carer may help to guide the assessment and support of this population, and advocate for the inclusion of the concerns of the carer in dysphagia management.

     

A comparative review of measurement instruments to inform and evaluate effectiveness of disability inclusive development

Abstract

Purpose: A review of existing measurement instruments was conducted to examine their suitability to measure disability prevalence and assess quality of life, protection of disability rights and community participation by people with disabilities, specifically within the context of development programs in low and middle-income countries. Methods: From a search of PubMed and the grey literature, potentially relevant measurement instruments were identified and examined for their content and psychometric properties, where possible. Criteria for inclusion were: based on the WHO’s International Classification of Functioning Disability and Health (ICF), used quantitative methods, suitable for population-based studies of disability inclusive development in English and published after 1990. Characteristics of existing instruments were analysed according to components of the ICF and quality of life domains. Results: Ten instruments were identified and reviewed according to the criteria listed above. Each version of instruments was analysed separately. Only three instruments included a component on quality of life. Domains from the ICF that were addressed by some but not all instruments included the environment, technology and communication. Conclusion: The measurement instruments reviewed covered the range of elements required to measure disability-inclusion within development contexts. However no single measurement instrument has the capacity to measure both disability prevalence and changes in quality of life according to contemporary disability paradigms. The review of measurement instruments supports the need for developing an instrument specifically intended to measure disability inclusive practice within development programs.

• Implications for Rehabilitation

• Surveys and tools are needed to plan disability inclusive development.

• Existing measurement tools to determine prevalence of disability, wellbeing, rights and access to the community were reviewed.

• No single validated tool exists for population-based studies, uses quantitative methods and the components of the ICF to measure prevalence of disability, well-being of people with disability and their access to their communities.

• A measurement tool that reflects the UNCRPD and addresses all components of the ICF is needed to assist in disability inclusive development, especially in low and mid resource countries.

     

Developing an ICF core set for post-stroke disability assessment and verification in Taiwan: a preliminary study

Purpose: The purpose of this study was to develop an ICF core set for post-stroke disability assessment and verification of bio-psycho-social problems. Method: Using the Delphi method, a consensus process was conducted. In total, 24 multidisciplinary experts from different institutions completed the consensus process. The questionnaire for the study comprised 144 ICF second-level, stroke-relevant categories. A 5-point Likert-type scale was used by participants to weight the impact of each category on activities of daily life after a stroke. Consensus of ratings was assessed with Spearman’s rho and semi-interquartile range indices. The core set for post-stroke disability assessment and verification was developed from those categories with a mean score ≥4.0 found in the third round of the Delphi exercise. Results: The core set for post-stroke disability assessment and verification contained 51 categories. Of these, 18 categories were from the component body functions, one from body structures, 22 from activities and participation, and 10 from environmental factors. The mean (standard deviation) Spearman’s rho was 0.72 (0.14), and Cronbach’s α was 0.98. Conclusions: The preliminary core set for post-stroke disability assessment and verification can offer comprehensive information on the performance of daily-life activities of chronic stroke survivors. Further validation is required.

Implications for Rehabilitation

• To identify stroke patients with permanent difficulties in Taiwan, the ICF core set for post-stroke disability assessment and verification (PSDV) focused on chronic stroke survivors in the community.

• The PSDV core set which is closely linked to the Barthel Index and Functional Independence Measure can offer comprehensive information on activities of daily living in stroke patients in Taiwan.

• With the PSDV core set, stroke patients with hemineglect or dysphagia can be assessed.

     

Development of the MG-DIS: an ICF-based disability assessment instrument for myasthenia gravis

Abstract

Purpose: To develop a preliminary version of a disease-specific, patient-reported disability assessment instrument for myasthenia gravis (MG) based on the International Classification of Functioning, Disability and Health (ICF): the MG-DIS. Methods: Five consecutive steps were taken: literature review and selection of outcome measures; linking of measures’ concepts to ICF categories and selection of those reported by 30% of the instruments; comparison of linking results with a previous selection of MG-relevant ICF categories; patient interview; development of questions based on retained ICF categories. Results: Thirty-one papers containing 21 different outcome measures were found: 13 ICF categories were linked to them. Fifty-five items were retained after the comparison with the list of MG-specific categories, and were used for patient interview. Thirteen interviews were conducted before saturation of data was reached and the final list was composed of 42 categories: based upon them, 44 questions were developed. Conclusions: The preliminary version of the MG-DIS contains more information than each single MG-specific tool, in particular, for the component of environmental factors. Further research is needed to test its psychometric properties.

• Implications for Rehabilitation

• It is important that patient-reported outcome is incorporated in MG patient’s assessment.

• MG features can be evaluated with ICF-based methods.

• An MG-specific patient-reported disability assessment instrument can be used to monitor changes of functioning in patients on MG-specific treatments, and can be used in clinical trials as outcome measure.

     

H-GRASP: the feasibility of an upper limb home exercise program monitored by phone for individuals post stroke

Purpose: To investigate the feasibility of a phone-monitored home exercise program for the upper limb following stroke. Methods: A pre-post double baseline repeated measures design was used. Participants completed an 8-week home exercise program that included behavioural strategies to promote greater use of the affected upper limb. Participants were monitored weekly by therapists over the phone. The following feasibility outcomes were collected: Process (e.g. recruitment rate); Resources (e.g. exercise adherence rate); Management (e.g. therapist monitoring) and Scientific (e.g. safety, effect sizes). Clinical outcomes included: The Chedoke Arm and Hand Inventory, Motor Activity Log, grip strength and the Canadian Occupational Performance Measure. Results: Eight individuals with stroke were recruited and six participants completed the exercise program. All but one of the six participants met the exercise target of 60?minutes/day, 6 days/week. Participants were stable across the baseline period. The following post-treatment effect sizes were observed: CAHAI (0.944, p?=?0.046); MALQ (0.789, p?=?0.03) grip strength (0.947, p?=?0.046); COPM (0.789, p?=?0.03). Improvements were maintained at three and six month follow ups. Conclusions: Community dwelling individuals with stroke may benefit from a phone-monitored upper limb home exercise program that includes behavioural strategies that promote transfer of exercise gains into daily upper limb use.

• Implications for Rehabilitation

• A repetitive, task-oriented home exercise program that utilizes telephone supervision may be an effective method for the treatment of the upper limb following stroke

• This program is best suited for individuals with mild to moderate level impairment and experience a sufficient level of challenge from the exercises

• An exercise program that includes behavioural strategies may promote transfer of exercise gains into greater use of the affected upper limb during daily activities

     

Young adults with intellectual disability transitioning from school to post-school: A literature review framed within the ICF

Purpose: The purpose of this review was to describe literature relating to transition for young people with an intellectual disability and identify gaps within the current knowledge base. Method: A narrative literature review was undertaken. Searches of databases Medline, CINAHL, PsycINFO, ERIC, ISI Web of Science and ProQuest 500 International provided relevant research articles. The search terms used were intellectual disability, transition, employment, and ICF as well as other terms derived from the ICF. Manual searches of reference lists identified additional studies. Furthermore, government websites were searched for relevant reports and policies. Results: Transition literature was explored by ICF domains; body functions and structures, activity and participation and contextual factors. Studies were identified in some but not all areas and included literature describing self-determination and participation in leisure activities for those with mild intellectual disability. However, significant gaps were found particularly for those with severe intellectual disability. Conclusions: The ICF is a useful tool in framing a review of transition literature for young people with intellectual disability due to the complexity and multi-faceted nature of transition. The important influence of environmental factors including family systems, post-school services and access to transport were highlighted as having considerable impacts on transition outcomes.

Implications for Rehabilitation

• The ICF is a useful tool in framing transition research to identify gaps.

• The current body of literature in transition from school for young adults with intellectual disabilities is too singularly focused and rarely considers those with moderate to severe intellectual disability.

• There has been little research on this topic in low and middle income countries.

• The scale of the impact of environmental factors on young people transitioning from school to post-school is currently under-represented.

• A holistic approach to post-school outcomes needs to be undertaken in future research.

     

Walking tests for stroke survivors: a systematic review of their measurement properties

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.

     

Coding of meaningful concepts in lymphedema-specific questionnaires with the ICF

Abstract

Purpose: To identify and quantify the meaningful concepts within questionnaires focusing on lymphedema using the International Classification of Functioning, Disability and Health (ICF). Methods: Electronic searches of Medline, EMBASE, CINAHL, CENtral and Pedro (2005–2010) were conducted. The concepts in the questionnaires were retrieved from the included studies and linked to the ICF. Results: Of the 2381 abstracts retrieved, 136 studies were included. The study population suffered from lymphedema in the upper limb (65%), in the lower limb (25%), in the midline (3%) and in combinations of these areas (7%). In total, 12 lymphedema-specific questionnaires were found (nine for the upper limb, two for the lower limb and one for lymphedema in general). A total of 301 concepts were extracted from the questionnaires, of which 271 (90%) could be linked to the ICF. There were 45 two-level ICF categories linked to concepts in ≥2 questionnaires; 13 in Body Functions, 6 in Body Structures, 16 in Activities and Participation and 10 in Environmental Factors. The most frequently measured categories were “Structure of upper extremity”, “Immunological system functions”, “Looking after one’s health”, “Sensation of pain”, “Touch functions”, “Dressing” and “Health services, systems and policies”. Conclusion: The ICF provides a valuable reference to identify concepts in questionnaires focusing on individuals with lymphedema.

• Implications for Rehabilitation

• Lymphedema is a chronic condition and the problems in physical functioning related to lymphedema can result in distress and loss of quality of life.

• ICF Core Sets for lymphedema consist of a lymphedema-specific selection of ICF categories, which makes it easier to implement the use of the ICF in medical and allied health care.

• ICF Core Sets for lymphedema can act as a framework for more unity in questionnaires concerning consequences of lymphedema.

• Part of the development process of ICF Core Sets for lymphedema is the linking of items from lymphedema-specific clinical questionnaires to ICF codes. The ICF codes most frequently used to link the items in the reviewed questionnaires were “Structure of upper extremity”, “Immunological system functions”, “Looking after one’s health”, “Sensation of pain”, “Touch functions”, “Dressing” and “Health services, systems and policies”.

     

Recovery-related anxiety and disability following upper limb injury: the importance of context

Abstract

Purpose: Anxiety following traumatic upper limb injury is common and may affect rehabilitation outcomes. Most previous research has focused on psychiatric anxiety disorders among those with severe injuries. The aims of this study were to determine the prevalence of anxiety among patients with mild to moderate traumatic upper limb injuries, to investigate the correlation between anxiety and disability, and to provide preliminary validation of the Recovery-Related Anxiety Questionnaire (RRAQ). Method: Eighty-four adults with a recent traumatic upper limb injury completed the State & Trait Anxiety Inventory (STAI), the Pain Anxiety Symptoms Scale (PASS-20), the RRAQ and the shortened Disability of the Arm, Shoulder and Hand Questionnaire (QuickDASH). Prevalence rates of anxiety were calculated and linear regression analysis was used to identify predictors of QuickDASH scores. Results: All participants reported some anxiety, with higher levels of recovery-related anxiety than general anxiety. In linear regression analysis, the four types of anxiety accounted for 29% of the variability in QuickDASH scores. The RRAQ accounted for 19% of the variability in QuickDASH scores. Conclusions: Recovery-related forms of anxiety appear to be more common and more strongly associated with disability than general anxiety symptoms for patients with mild to moderate traumatic upper limb injuries.

• Implications for Rehabilitation

• Following mild to moderate traumatic upper limb injury, anxiety about the injury and recovery is common.

• Recovery-related anxiety is more strongly associated with disability than general anxiety symptoms.

• Phrasing questions about anxiety directly associated with the recovery experience may give greater insight into the anxiety patients with mild to moderate upper limb injuries are experiencing.

• This insight may help clinicians to directly address recovery-related issues, potentially decreasing disability experienced by patients.

     

Validity,reliability and ease of use of the disabilities of arm,shoulder and hand questionnaire in adults following stroke

Purpose: The Disabilities of Arm, Shoulder and Hand (DASH) questionnaire is a patient reported outcome measure for evaluating upper limb function in people with musculoskeletal conditions. While the DASH has good psychometric properties when used with people with musculoskeletal conditions, it has not been tested with adults after stroke.

Methods: Data for n?=?61 adults following stroke (aged 32–93 years, 44% male) were analyzed to test validity and reliability of the DASH for use with a stroke population. Data included demographic and clinical attributes, DASH scores (baseline and four weeks later) and Patient Rated Wrist Evaluation (PRWE) measures.

Results: Internal consistency was good (Cronbach alpha 0.92, SEM 6.65). Factor analysis and Rasch modeling suggested that the questionnaire comprised three subscales: pain, impact and function. Concurrent validity between the DASH and PRWE (Spearman’s Rho r_s?=_?0.41) was moderate. The scale was perceived by clinicians to be useful, quick and simple to administer. The DASH had low four-week test-retest reliability (ICC 0.56 [95% Cl 0.05–0.79]).

Conclusions: The DASH is considered to have acceptable validity when used with adults following stroke. Test–retest reliability was low but further research is needed to establish whether this is a result of condition-related change or the stability of the measure.

• Implications for Rehabilitation

• The DASH questionnaire examines upper limb function in task performance and appears to be a useful tool, which is simple to administer in the clinical setting with adults following stroke.

• Upper limb function post stroke can be meaningfully assessed using the DASH as it has good internal consistency and moderate concurrent validity.

• Rasch analysis and factor analysis suggests that the tool appears to consist of three subscales: pain, impact and function. The total score of the DASH may be less meaningful than the totals of these subscales.

• The test–retest reliability of the DASH requires further research; over a four-week period DASH stability was poor in a group of people with moderate to severe upper limb impairment.

     

Reflective action assessment with a prospective clinical problem solving tool in the context of rehabilitation medicine: an illustrative case study

Purpose: This study describes a case formulation approach applying a prospective ICF derived clinical tool to assess rehabilitation needs for a community dwelling stroke survivor with care from an outpatient rehabilitation medicine clinic. Method: Case history data on the person were assessed for rehabilitation management planning using a prospective tool to interlink current with projected future functional status in everyday settings. Implicit assessment with reflective action informed decision points at each stage of the rehabilitation process. Results: As a result of reflective action using the prospective tool, rehabilitation management led to significant changes in client participation after limitations to mobility and self care were mapped to the living conditions of the stroke survivor. The context sensitive rehabilitative plan resulted in higher subjective health-related quality of life in the stroke survivor and significant other and enhanced their capacity for participation. Conclusions: Reflective action informed assessment applying ICF concepts to clinical problem solving resulted in positive gains in health-related quality of life in a stroke survivor.

Implications for Rehabilitation

• Reflective inquiry about the use of The International Classification of Disability, Functioning and Health (ICF) enables extension of its applicability in clinical practice settings.

• An ICF-based tool is proposed to interlink the ICF and ICD in rehabilitation case management.

• A case study is used to highlight the use of an ICF-based tool in the context of rehabilitation medicine.

     

The effects of four different stroke patterns on manual wheelchair propulsion and upper limb muscle strain

Purpose: To evaluate the effects of stroke pattern on handrim biomechanics and upper limb electromyography (EMG) in experienced wheelchair users. Method: Subjects propelled their own wheelchair on a level, motor-driven treadmill using each of four identified stroke patterns: arcing, double loop (DL), semi-circular (SC) and single loop (SL). Upper limb EMG and measurements taken from an instrumented wheelchair wheel were compared for each pattern. A one-way ANOVA with Bonferroni correction (p < 0.05) was used to check for significant differences. Results: The DL and SC patterns produced the best overall results. The DL pattern led to a significantly longer contact angle and significantly less braking moment than the SL and arcing patterns, and a significantly lower cadence than the SL pattern. The SC pattern led to a significantly longer contact angle than the SL pattern and the lowest peak force and impact of any pattern. There were no significant differences in integrated EMG (IEMG); however, the DL and arcing patterns produced lower combined IEMG values. Conclusions: When traversing level terrain, wheelchair users should push with either the DL or SC patterns. Between the two, the DL pattern required less muscle activity and may be a better choice for experienced wheelchair users.

Implications for Rehabilitation

• Manual wheelchair propulsion is essential for many individuals with lower limb impairments; however, it often leads to upper limb pain, which can limit mobility and quality of life.

• Stroke patterns that reduce upper limb demand can help users reduce their risk of pain.

• The double loop (DL) and semi-circular (SC) stroke patterns produced the best combinations of handrim biomechanics and are therefore recommended for use.

• Due to an observed increase in elbow muscle activity, individuals who use the DL pattern are not encouraged to switch to the SC pattern.

     

The process of re-engagement in personally valued activities during the two years following stroke

Purpose: Engagement in valued activities is often difficult for people who have experienced stroke. A deeper understanding of the process of re-engagement in personally valued activities would be helpful to those designing interventions to address participation post-stroke. Method: Six community-dwelling individuals recovering from a first stroke were interviewed at 6, 9, 12, 18 and 24 months post-stroke. A grounded theory approach was used to construct a substantive theory of re-engagement in valued activities during this period. Results: Two core concepts, social connection and being in charge were identified. Both led to activity engagement and risk taking to test abilities. These led to lowering of current expectations and activity adaptation which supported hope for recovery and further testing. Alternatively, difficulties perceived to be related to ageing led to disengagement. Conclusions: Rehabilitation practice that addresses and supports autonomy, social connection, risk taking, adaptation and hope among stroke survivors may help individuals regain personally valued activities post-stroke.

Implications for Rehabilitation

• This qualitative study shows that the process of re-engagement in valued activities during the 2 years following stroke was constructed around two core concepts: social connection and being in charge.

• Rehabilitation practice that supports autonomy, social connection, risk taking, adaptation and hope among stroke survivors may help individuals regain personally valued activities post-stroke.

     

Development and preliminary evaluation of a novel low cost VR-based upper limb stroke rehabilitation platform using Wii technology

Purpose: This paper proposes a novel system (using the Nintendo Wii remote) that offers customised, non-immersive, virtual reality-based, upper-limb stroke rehabilitation and reports on promising preliminary findings with stroke survivors. Method: The system novelty lies in the high accuracy of the full kinematic tracking of the upper limb movement in real-time, offering strong personal connection between the stroke survivor and a virtual character when executing therapist prescribed adjustable exercises/games. It allows the therapist to monitor patient performance and to individually calibrate the system in terms of range of movement, speed and duration. Results: The system was tested for acceptability with three stroke survivors with differing levels of disability. Participants reported an overwhelming connection with the system and avatar. A two-week, single case study with a long-term stroke survivor showed positive changes in all four outcome measures employed, with the participant reporting better wrist control and greater functional use. Activities, which were deemed too challenging or too easy were associated with lower scores of enjoyment/motivation, highlighting the need for activities to be individually calibrated. Conclusions: Given the preliminary findings, it would be beneficial to extend the case study in terms of duration and participants and to conduct an acceptability and feasibility study with community dwelling survivors.

• Implications for Rehabilitation

• Low-cost, off-the-shelf game sensors, such as the Nintendo Wii remote, are acceptable by stroke survivors as an add-on to upper limb stroke rehabilitation but have to be bespoked to provide high-fidelity and real-time kinematic tracking of the arm movement.

• Providing therapists with real-time and remote monitoring of the quality of the movement and not just the amount of practice, is imperative and most critical for getting a better understanding of each patient and administering the right amount and type of exercise.

• The ability to translate therapeutic arm movement into individually calibrated exercises and games, allows accommodation of the wide range of movement difficulties seen after stroke and the ability to adjust these activities (in terms of speed, range of movement and duration) will aid motivation and adherence – key issues in rehabilitation.

• With increasing pressures on resources and the move to more community-based rehabilitation, the proposed system has the potential for promoting the intensity of practice necessary for recovery in both community and acute settings.

     

Explicit motor sequence learning with the paretic arm after stroke

Purpose: Motor sequence learning is important for stroke recovery, but experimental tasks require dexterous movements, which are impossible for people with upper limb impairment. This makes it difficult to draw conclusions about the impact of stroke on learning motor sequences. We aimed to test a paradigm requiring gross arm movements to determine whether stroke survivors with upper limb impairment were capable of learning a movement sequence as effectively as age-matched controls.

Materials and methods: In this case-control study, 12 stroke survivors (10–138 months post-stroke, mean age 64 years) attempted the task once using their affected arm. Ten healthy controls (mean 66 years) used their non-dominant arm. A sequence of 10 movements was repeated 25 times. The variables were: time from target illumination until the cursor left the central square (onset time; OT), accuracy (path length), and movement speed.

Results: OT reduced with training (p?p?>?0.1). We quantified learning as the OT difference between the end of training and a random sequence; this was smaller for stroke survivors than controls (p?=?0.015).

Conclusions: Stroke survivors can learn a movement sequence with their paretic arm, but demonstrate impairments in sequence specific learning.

• Implications for Rehabilitation

• Motor sequence learning is important for recovery of movement after stroke.

• Stroke survivors were found to be capable of learning a movement sequence with their paretic arm, supporting the concept of repetitive task training for recovery of movement.

• Stroke survivors showed impaired sequence specific learning in comparison with age-matched controls, indicating that they may need more repetitions of a sequence in order to re-learn movements.

• Further research is required into the effect of lesion location, time since stroke, hand dominance and gender on learning of motor sequences after stroke.

     

Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction

Purpose: This study examined the role of anxiety and upper limb dysfunction, amongst other variables, as predictors of health related quality of life (HRQOL) 6 months after stroke. Method: Participants: Stroke survivors (n = 85) who had previously participated in a randomised controlled trial of a physiotherapy intervention. Dependent variable: HRQOL – Nottingham Health Profile (NHP). Predictor variables: Mood – Hospital Depression and Anxiety Scale; Upper Limb Functioning - Action Research Arm Test; Rivermead Motor Assessment; Activities of Daily Living – Modified Barthel Index; Clinical and demographic factors. Results: Anxiety and depression significantly predicted 49% of variance in overall HRQOL (p < 0.05), but only anxiety significantly predicted NHP pain (13% variance, p < 0.001), emotional reactions (41% variance, p < 0.001), sleep (19% variance, p = 0.02) and social isolation (23% variance, p = 0.02). Depression and anxiety together significantly predicted 30% variance in energy level (p < 0.001). UL motor impairment and activities of daily living predicted 36% of variance in NHP physical activity score (p < 0.001). Conclusions: This study indicates that where anxiety is assessed, it appears more important in determining HRQOL than depression. UL impairment and ADL independence predicted perceived physical activity. Management strategies for anxiety and therapy for UL recovery long after stroke onset are likely to benefit perceived HRQOL.

Implications for Rehabilitation

• Anxiety is a major predictor of quality of life six months after stroke.

• Post-stroke anxiety should be routinely assessed in rehabilitation.

• Appropriate management strategies for anxiety should occur during rehabilitation with follow-up into the chronic post-stroke period.

• Upper limb impairment is a stronger predictor of perceptions of physical activity than independence in activities daily living six months after stroke.

• Rehabilitation of the upper limb should continue into the chronic post-stroke period.