Arlene A. Schmid

Improvements in Speed-Based Gait Classifications Are Meaningful

Background and Purpose— Gait velocity is a powerful indicator of function and prognosis after stroke. Gait velocity can be stratified into clinically meaningful functional ambulation classes, such as household ambulation (<0.4 m/s), limited community ambulation (0.4 to 0.8 m/s), and full community ambulation (>0.8 m/s). The purpose of the current study was to determine whether changes in velocity-based community ambulation classification were related to clinically meaningful changes in stroke-related function and quality of life. Methods— In subacute stroke survivors with mild to moderate deficits who participated in a randomized clinical trial of stroke rehabilitation and had a baseline gait velocity of 0.8 m/s or less, we assessed the effect of success versus failure to achieve a transition to the next class on function and quality of life according to domains of the Stroke Impact Scale (SIS). Results— Of 64 eligible participants, 19 were initially household ambulators, and 12 of them (68%) transitioned to limited community ambulation, whereas of 45 initially limited community ambulators, 17 (38%) became full community ambulators. Function and quality-of-life SIS scores after treatment were significantly higher among survivors who achieved a favorable transition compared with those who did not. Among household ambulators, those who transitioned to limited or full community ambulation had significantly better SIS scores in mobility (P=0.0299) and participation (P=0.0277). Among limited community ambulators, those who achieved the transition to full community ambulatory status had significantly better scores in SIS participation (P=0.0085). Conclusions— A gait velocity gain that results in a transition to a higher class of ambulation results in better function and quality of life, especially for household ambulators. Household ambulators possibly had more severe stroke deficits, reducing the risk of “ceiling” effects in SIS-measured activities of daily living and instrumental activities of daily living. Outcome assessment based on transitions within a mobility classification scheme that is rooted in gait velocity yields potentially meaningful indicators of clinical benefit. Outcomes should be selected that are clinically meaningful for all levels of severity.

Barriers and facilitators to exercise among stroke survivors

&NA; Physical activity after stroke may prevent disability and stroke recurrence; yet, physical impairments may inhibit post‐stroke exercise and subsequently limit recovery. The goal of this study was to elicit barriers to and facilitators of exercise after stroke. We conducted three focus groups and achieved content saturation from 13 stroke survivors—eight men and five women—85% of whom were African American and 15% White, with a mean age of 59 years. We coded and analyzed the transcripts from the focus groups for common themes. Participants across groups reported three barriers (physical impairments from stroke, lack of motivation, and environmental factors) and three facilitators (motivation, social support, and planned activities to fill empty schedule) to exercise after stroke. Exercise activity can provide a purpose and structure to a stroke survivors daily schedule, which may be interrupted after stroke. In addition, receiving social support from peers and providers, as well as offering stroke‐specific exercise programming, may enhance physical activity of stroke survivors including those with disabilities. We intend to incorporate these findings into a post‐stroke self‐management exercise program.

Balance and Balance Self-Efficacy Are Associated With Activity and Participation After Stroke: A Cross-Sectional Study in People With Chronic Stroke

OBJECTIVES To (1) examine the relationships between multiple poststroke mobility variables (gait speed, walking capacity, balance, balance self-efficacy, and falls self-efficacy) and activity and participation; and (2) determine which poststroke mobility variables are independently associated with activity and participation. DESIGN This is the primary analysis of a prospective cross-sectional study completed to understand the impact of mobility on activity and participation in people with chronic stroke. SETTING University-based research laboratory, hospitals, and stroke support groups. PARTICIPANTS People (N=77) with stroke greater than 6 months ago were included in the study if they were referred to occupational or physical therapy for physical deficits as a result of the stroke, completed all stroke related inpatient rehabilitation, had residual functional disability, scored a ≥4 out of 6 on the short, 6-item Mini-Mental State Examination, and were between the ages of 50 and 85. INTERVENTIONS Not applicable, this is a cross-sectional data collection of 1 timepoint. MAIN OUTCOME MEASURES We measured activity and participation with the validated International Classification of Functioning, Disability and Health Measure of Participation and Activities. Other variables included gait speed (10-meter walk), walking capacity (6-minute walk), balance (Berg Balance Scale), balance self-efficacy (Activities Specific Balance Confidence Scale), and falls self-efficacy (Modified Falls Efficacy Scale). RESULTS Only balance self-efficacy was found to be independently associated with poststroke activity (β=-.430, P<.022, 95% confidence interval [CI], -.247 to -.021) and participation (β=-.439, P<.032, 95% CI, -.210 to -.010). CONCLUSIONS Among people with chronic stroke, balance self-efficacy, not physical aspects of gait, was independently associated with activity and participation. While gait training continues to be important, this study indicates a need to further evaluate and address the psychological factors of balance and falls self-efficacy to obtain the best stroke recovery.

Effect of a 12-Week Yoga Intervention on Fear of Falling and Balance in Older Adults: A Pilot Study

OBJECTIVE To determine whether fear of falling (FoF) and balance improved after a 12-week yoga intervention among older adults. DESIGN A 12-week yoga intervention single-armed pilot study. SETTING A retirement community in a medium-sized university town in the Midwest. PARTICIPANTS A convenience sample of adults (N=14) over the age of 65 years who all endorsed an FoF. INTERVENTION Each participant took part in a biweekly 12-week yoga intervention. The yoga sessions included both physical postures and breathing exercises. Postures were completed in sitting and standing positions. MAIN OUTCOME MEASURES We measured FoF with the Illinois FoF Measure and balance with the Berg Balance Scale. Upper- and lower-body flexibility were measured with the back scratch test and chair sit and reach test, respectively. RESULTS FoF decreased by 6%, static balance increased by 4% (P=.045), and lower-body flexibility increased by 34%. CONCLUSIONS The results indicate that yoga may be a promising intervention to manage FoF and improve balance, thereby reducing fall risk for older adults. Rehabilitation therapists may wish to explore yoga as a modality for balance and falls programming; however, future research is needed to confirm the use of yoga in such programming.

Fear of Falling: An Emerging Issue After Stroke

Abstract Purpose: Qualitative data regarding stroke survivors’ recovery experiences were used to describe factors important in the development of fear of falling (FoF) during the first 6 months after stroke. Method: Stroke survivors were interviewed 1 and 6 months after stroke to obtain data on their experiences related to stroke recovery trajectory. Analyses identified FoF as a naturally occurring part of stroke survivors’ descriptions of their everyday lives. Interviews were reexamined to identify and describe personal experiences related to FoF in this population. Results: Forty-two (32%) veterans who participated in the larger study discussed FoF during the first 6 months after stroke. Analyses indicate three important factors may be associated with the development of poststroke FoF: (a) the initial fall coinciding with stroke onset, (b) perception of poststroke body changes, and (c) a pervasive everyday fear of future falls. Conclusion: These factors related to FoF need to be further studied in the poststroke population. It is possible that individualized interventions may be necessary to assist stroke survivors to manage FoF, decrease fear, and reduce falls after discharge home poststroke.

Is walking faster or walking farther more important to persons with chronic stroke

Purpose: The purposes of this mixed-methods study were to (1) investigate whether walking faster or walking farther was more important for getting “out and about” to persons with chronic stroke and (2) explore explanations for walking preferences. Method: A convenience sample of 77 adults with chronic stroke completed questionnaires and walking outcomes in one visit. Participants were asked whether walking faster or farther was more important to them for getting “out and about”, and differences between response groups (faster vs. farther) were evaluated. Participants also described their preference for walking faster or farther. Qualitative responses were analyzed using content analysis. Results: The majority of participants (76%; n = 58) reported walking farther was more important, while 18% (n = 14) reported walking faster was more important. Statistically significant differences were not found between response groups for any variable. Primary themes identified from participant preferences for walking faster included: (1) faster speed equals better walking ability and (2) getting places faster/quicker. Primary themes from preferences for walking farther included: (1) engaging in activity and participation within home and community; (2) walking farther at a slower pace; and (3) fatigue with walking. Conclusions: Individual preferences for walking faster versus walking farther by persons with chronic stroke should be considered by clinicians when making decisions for rehabilitation. Implications for Rehabilitation Individual preferences for walking faster versus walking farther by patients with chronic stroke should be considered by rehabilitation clinicians when making decisions about examination and intervention. The majority of participants with chronic stroke in this study indicated the importance of walking farther in order to better engage in activities both at home and away from home. Interventions that focus on improving endurance and energy conservation may need to be used for persons with chronic stroke who want to walk father in order to maximize their potential for walking longer distances.

Evaluation of Stepped Care for Chronic Pain (ESCAPE) in Veterans of the Iraq and Afghanistan Conflicts: A Randomized Clinical Trial

IMPORTANCE Despite the prevalence and the functional, psychological, and economic impact of chronic pain, few intervention studies of treatment of chronic pain in veterans have been performed. OBJECTIVE To determine whether a stepped-care intervention is more effective than usual care, as hypothesized, in reducing pain-related disability, pain interference, and pain severity. DESIGN, SETTING, AND PARTICIPANTS We performed a randomized clinical trial comparing stepped care with usual care for chronic pain. We enrolled 241 veterans from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn with chronic (>3 months) and disabling (Roland Morris Disability Scale score, ≥7) musculoskeletal pain of the cervical or lumbar spine or extremities (shoulders, knees, and hips) in the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial from December 20, 2007, through June 30, 2011. The 9-month follow-up was completed by April 2012. Patients received treatment at a postdeployment clinic and 5 general medicine clinics at a Veterans Affairs medical center. INTERVENTIONS Step 1 included 12 weeks of analgesic treatment and optimization according to an algorithm coupled with pain self-management strategies; step 2, 12 weeks of cognitive behavioral therapy. All intervention aspects were delivered by nurse care managers. MAIN OUTCOMES AND MEASURES Pain-related disability (Roland Morris Disability Scale), pain interference (Brief Pain Inventory), and pain severity (Graded Chronic Pain Scale). RESULTS The primary analysis included 121 patients receiving the stepped-care intervention and 120 patients receiving usual care. At 9 months, the mean decrease from baseline in the Roland Morris Disability Scale score was 1.7 (95% CI, -2.6 to -0.9) points in the usual care group and 3.7 (95% CI, -4.5 to -2.8) points in the intervention group (between-group difference, -1.9 [95% CI, -3.2 to -0.7] points; P=.002). The mean decrease from baseline in the Pain Interference subscale score of the Brief Pain Inventory was 0.9 points in the usual care group and 1.7 points in the intervention group (between-group difference, -0.8 [95% CI, -1.3 to -0.3] points; P=.003). The Graded Chronic Pain Scale severity score was reduced by 4.5 points in the usual care group and 11.1 points in the intervention group (between-group difference, -6.6 [95% CI, -10.5 to -2.7] points; P=.001). CONCLUSIONS AND RELEVANCE A stepped-care intervention that combined analgesics, self-management strategies, and brief cognitive behavioral therapy resulted in statistically significant reductions in pain-related disability, pain interference, and pain severity in veterans with chronic musculoskeletal pain. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00386243.

Balance Is Associated with Quality of Life in Chronic Stroke

Abstract Objective: To investigate the association between balance and quality of life (QOL) in chronic stroke survivors by (1) examining the associations between balance and QOL scores; (2) identifying the frequency of balance impairment and poststroke falls; and (3) determining the differences in QOL scores between persons with and those without balance impairment. Methods: This is a secondary analysis of a cross-sectional study. People who had a stroke more than 6 months earlier from 3 Midwest states were included in the study if they met the following criteria: were referred to occupational or physical therapy for poststroke physical deficits; had self-reported stroke-related physical deficits; completed all stroke-related rehabilitation; had residual functional disability; had a score of ≥4 out of 6 on the short 6-item Mini-Mental State Examination; and were between 50 and 85 years old (n = 59). The main outcome measures included the Berg Balance Scale (BBS) to assess balance and the Stroke Specific Quality of Life Scale (SS-QOL) to assess QOL. Number of falls since stroke was self-reported. Results: Mean BBS score was 44 ± 8 and mean SS-QOL score was 46 ± 8; these scores were significantly correlated (r = .394, P = .002). Seventy-six percent of the sample reported a fall since stroke. Persons with balance impairment (BBS score ≤46; n = 29; 49%) had an average BBS score of 39 ± 7 and significantly worse SS-QOL scores than those without balance impairment (42 ± 8 vs 49 ± 7; P = .001). Conclusion: In the chronic stroke population, balance impairment and fall risk are associated with lower QOL scores. If balance can be improved and maintained into the chronic phases of stroke, it is likely that individuals will benefit with improved QOL.

Circumstances and consequences of falls among people with chronic stroke

Falls are common after stroke; however, circumstances and consequences are relatively unknown. Our objectives were to identify the differences between fallers and non-fallers among people with chronic stroke, identify the circumstances of fall events, and examine the consequences of the falls. This is a secondary data analysis; all participants included sustained a stroke. Variables included demographics, stroke characteristics, and comorbidities. Falls were collected via self-report, and circumstances and consequences were derived from participant description of the event and categorized as appropriate. Among 160 participants, 53 (33%) reported a fall during the 1 yr period. Circumstances of falls were categorized as intrinsic or extrinsic. Location and circumstance of the fall were included: 70% occurred at home and 40% were associated with impaired physical or mental state (e.g., inattention to tying shoes). Additionally, 21% of falls were associated with activities of daily living and mobility and 34% with slips or trips. The majority who fell sustained an injury (72%). Injuries ranged from bruising to fractures, and 55% of those with an injury sought medical care (32% to emergency department). Poststroke falls are associated with an alarming rate of injury and healthcare utilization. Targeting mental and physical states may be key to fall prevention.

Fatigue and Pain: Relationships with Physical Performance and Patient Beliefs after Stroke

Abstract Background: Fatigue and pain are common after stroke, potentially impacting stroke recovery. Objective: This study examines the frequency and impact of fatigue and pain in people with chronic stroke. Method: Seventy-seven people with chronic stroke completed a one-time assessment consisting of a battery of self-report and performance tools to describe and quantify mobility issues post stroke. We assessed the proportion of individuals with fatigue and pain and the relationship between fatigue and pain and other variables including gait (10-meter walk and 6-minute walk test), balance (Berg Balance Scale), activity and participation (ICF Measure of Participation and Activities), chronic disease self-efficacy (Chronic Disease Self-Efficacy Scale), and balance self-efficacy (Activity-Specific Balance Confidence Scale). Additionally, subgroup comparisons were made between participants with and without coexisting fatigue and pain. Results: Fatigue and pain were reported by 66% and 45% of study participants, respectively. Thirty-four percent of the sample reported co-existing fatigue and pain. Participants with coexisting fatigue and pain demonstrated significantly lower chronic disease and balance self-efficacy and decreased activity than participants without coexisting fatigue and pain. Individually, fatigue correlated with balance, chronic disease self-efficacy, balance self-efficacy, activity, and participation, whereas pain correlated with chronic disease self-efficacy, balance self-efficacy, and activity. Conclusion: Fatigue and pain are common after stroke and are negatively correlated with outcomes important to rehabilitation. Efforts focused on examining the impact of interventions on fatigue and pain are warranted. It is possible that changes to these body structure limitations could positively impact functional recovery and community re-entry after stroke.