Hanne Pallesen

Body, coping and self-identity. A qualitative 5-year follow-up study of stroke

Abstract Objective: The purpose of this article is to identify, from a long-term perspective, stroke survivors’ self-identity, their views of any associated disabilities and how they manage their lives after stroke. Methods: The interviews and analyses were conducted using a phenomenological qualitative method. A total of 10 men and 5 women, aged 42–84, participated. All had suffered first-time stroke 5 years earlier. Results: After 5 years, participants had greater acceptance of their situation compared with immediately after participating in the rehabilitation programme. However, they described how they still had to deal with the consequences of stroke. They had suffered further illnesses and additions to side effects of the stroke. In dealing with their disabilities and changes to self-identity and life patterns, they seemed to be in a continuous process of change that never truly stabilised. They coped with this continuous process in at least two different ways, including resignation or personal growth. Conclusion: Stroke survivors suffered considerable ongoing and changing difficulties in relation to disability, self-perception and to coping with a new life. This continuous process of change could be seen to drain their energy. The study shows that many survivors live a more home-centred life with fewer social relations and less active participation in their community. This can entail the risk of depression and loneliness. The study also shows, however, that adopting an optimistic approach to life can lead to continued learning about abilities and limitations, to the development of new skills and to the fashioning of a new self-identity. Implications for Rehabilitation This study suggests that stroke survivors should be offered individualised rehabilitation programmes that address not only physical activities but also psychological circumstances and existential issues. It is recommended that the interventions offered to the stroke survivor are unfolded through a pedagogical approach, so the individuals do not feel alienated or need to struggle in isolation. The programme should promote the individual’s motivation, the sense of being able to cope and an optimistic view of life. There is a need for further research focusing on identifying the factors that facilitate the individual’s positive approach to life and optimism. There is also the need to examine a variety of approaches to rehabilitation that emphasise empowerment and self-efficacy for stroke individuals in a variety of phases of rehabilitation and with various degrees of disability.

Virtual reality training for upper extremity in subacute stroke (VIRTUES): study protocol for a randomized controlled multicenter trial

BackgroundNovel virtual reality rehabilitation systems provide the potential to increase intensity and offer challenging and motivating tasks. The efficacy of virtual reality systems to improve arm motor function early after stroke has not been demonstrated yet in sufficiently powered studies. The objective of the study is to investigate whether VR training as an adjunct to conventional therapy is more effective in improving arm motor function in the subacute phase after stroke than dose-matched conventional training, to assess patient and therapist satisfaction when working with novel virtual reality training and to calculate cost-effectiveness in terms of resources required to regain some degree of dexterity.Methods/DesignRandomized controlled observer-blind trial.One hundred and twenty patients up to 12 weeks after stroke will be randomized to either a group receiving VR training or dose-matched and therapist attention-matched conventional arm training in addition to standard rehabilitation. During a period of four weeks the patients will be offered additional 4–5 training sessions a week of 45–60 minutes duration by a physiotherapist or an occupational therapist.Study outcomes: Arm motor function, dexterity and independence in daily life activities will be evaluated at baseline, post treatment and three months follow-up assessments with the Action Research Arm Test, Box and Blocks Test and the Functional Independence Measure, respectively. Patient and therapist satisfaction with the implementation of a VR rehabilitation system will also be assessed with questionnaires and interviews.DiscussionVirtual reality systems are promising tools for rehabilitation of arm motor function after stroke. Their introduction in combination with traditional physical and occupational therapy may enhance recovery after stroke, and at the same time demand little personnel resources to increase training intensity. The VIRTUES trial will provide further evidence of VR-based treatment strategies to clinicians, patients and health economists.Trial registrationClinicalTrials.gov NCT02079103

Using EFA and FIM rating scales could provide a more complete assessment of patients with acquired brain injury

Abstract Purpose: In some hospitals, patients exhibit significant heterogeneity of function at admission and discharge. The current study aims to assess if concurrent usage of the Early Functional Assessment (EFA) and Functional Independence Measure (FIM®) is warranted and practical in rehabilitation centers with diverse patient groups and outcomes. Methods: This retrospective study examined a data set of all patients with concurrent EFA and FIM scores admitted to a single rehabilitation center (4076 scores from 1251 patients). The patients had acquired brain injury of multiple etiologies and a range of severities. Results: The EFA scale was more able to characterize the function of lower functioning patients according to the FIM while the FIM scale was more able to characterize the function of higher functioning patients according to the EFA. This was highlighted by 21% of assessments with the lowest FIM score (18) having corresponding EFA scores of 22–76 and 27% of assessments with the highest EFA score (>90) having corresponding FIM scores of 38–126. Conclusions: In rehabilitation centers with diverse patient groups and outcomes, the FIM and EFA scale could be used to characterize the heterogeneity of function in patients with acquired brain injury. The EFA/FIM scale could be used concurrently in certain patients providing a more complete view of patients throughout the rehabilitation process. Implications for Rehabilitation Rehabilitation scales can be administered on multiple occasions to track the progress of a patient throughout the rehabilitation process; however, a lot of popular scales (such as the FIM®) are limited containing ceiling and floor effects for higher and lower functioning patients, respectively. In rehabilitation centers with diverse patient groups and outcomes, the FIM and EFA scale could be used to characterize the heterogeneity of function in patients with acquired brain injury. Concurrent usage of the scales could be indicated for some patients and each scale could provide information that the other scale does not provide however the FIM and EFA scales should be administered solely for EFA scores >90 (FIM administered solely) and the lowest FIM scores (EFA administered solely).

Early rehabilitation of patients with severe acquired brain injury: Strategies to promote participation

Abstract Purpose: The aim of this study was to explore the experiences of professional specialists in early rehabilitation who face demanding pedagogical challenges in facilitating and promoting participation of the severe acquired brain injury patient. Method: In a qualitative study, using phenomenological philosophy and thinking, the experiences of specialist professional experts were investigated. Data were generated in five individual interviews and one focus-group interview. The interview questions were grounded in a preliminary field study. In a four-step phenomenological analysis, empirical themes were identified, using the computer program N-Vivo10; they were structured and organized, and the results were theoretically stated and supported. Results: Important practice knowledge emerged in this study that led to the proposal of a determined, client-centred approach when facilitating the promotion of severe acquired brain injury patients’ participation in early rehabilitation. Four factors are important in this approach: (i) gain contact, (ii) register responses, (iii) intentional interaction, (iv) partial participation. Together they constitute the elements in a proposal for a new model: the GRIP model. Conclusion: The four factors that shape the GRIP model can enrich neurorehabilitation services and support professional experts in early rehabilitation interventions with severe acquired brain injury patients regaining participation and functioning in everyday life.

Health and functioning in a stroke population five years after first incidence

Purpose: To isolate characteristics of a stroke population five years after first stroke, focusing on functioning and health. Methods: The subjects in the present study were identified in a computerized National Bureau of Health Register over a six month period in 2003 in a well-defined area of 353,284 inhabitants. Results: Survival rate five years after first stroke was 52%. As regards functioning 50% of the group were able to look after own affairs. Thirty-one percent reported themselves as being moderately disabled. Seventeen percent had moderate to severe disability. In the responding group 53% below 65 years of age were disability pensioners. Half of the responding group had suffered a further stroke or another severe illness during the previous five years. There was a positive correlation between functioning and health. Conclusion: Stroke survivors cannot be seen as a homogenous group as regard to functioning and health five years after the incidence. It is recommended that professionals identify th...

Virtual Reality Training for Upper Extremity in Subacute Stroke (VIRTUES) A multicenter RCT

Objective: To compare the effectiveness of upper extremity virtual reality rehabilitation training (VR) to time-matched conventional training (CT) in the subacute phase after stroke. Methods: In this randomized, controlled, single-blind phase III multicenter trial, 120 participants with upper extremity motor impairment within 12 weeks after stroke were consecutively included at 5 rehabilitation institutions. Participants were randomized to either VR or CT as an adjunct to standard rehabilitation and stratified according to mild to moderate or severe hand paresis, defined as ≥20 degrees wrist and 10 degrees finger extension or less, respectively. The training comprised a minimum of sixteen 60-minute sessions over 4 weeks. The primary outcome measure was the Action Research Arm Test (ARAT); secondary outcome measures were the Box and Blocks Test and Functional Independence Measure. Patients were assessed at baseline, after intervention, and at the 3-month follow-up. Results: Mean time from stroke onset for the VR group was 35 (SD 21) days and for the CT group was 34 (SD 19) days. There were no between-group differences for any of the outcome measures. Improvement of upper extremity motor function assessed with ARAT was similar at the postintervention (p = 0.714) and follow-up (p = 0.777) assessments. Patients in VR improved 12 (SD 11) points from baseline to the postintervention assessment and 17 (SD 13) points from baseline to follow-up, while patients in CT improved 13 (SD 10) and 17 (SD 13) points, respectively. Improvement was also similar for our subgroup analysis with mild to moderate and severe upper extremity paresis. Conclusions: Additional upper extremity VR training was not superior but equally as effective as additional CT in the subacute phase after stroke. VR may constitute a motivating training alternative as a supplement to standard rehabilitation. ClinicalTrials.gov identifier: NCT02079103. Classification of evidence: This study provides Class I evidence that for patients with upper extremity motor impairment after stroke, compared to conventional training, VR training did not lead to significant differences in upper extremity function improvement.

Early rehabilitation and participation in focus – a Danish perspective on patients with severe acquired brain injury

Abstract Early neurorehabilitation is an interdisciplinary field. Thus, in order to eliminate unnecessary barriers for individuals with severe acquired brain injury in early rehabilitation, we need rehabilitation science that supports both quantitative and qualitative research methods. Participation can be studied directly and indirectly. This commentary proposes that active participation and the “lived body” are essential terms in early rehabilitation of severe ABI patients, and a description of how these terms are interpreted and handled in the practice is needed.

Body and Self-Identity in Stroke Rehabilitation

The experience of stroke is variously described in several studies as a rupture in everyday life, a change that is constantly present, and as a new aspect of life to which the individual has to relate [1-14]. The stroke is described as a sudden and overwhelming reversal [1,2,8,13], and an essential severance [5,10] that separates stroke survivors from their earlier life and forces them into a new and foreign existence [1,4,6,10]. For some, it takes a long time before they understand that something serious and inexorable has taken place and before they understand the extent of the consequences [1,10]. A stroke has also a significant influence on mood (underlying state of mind) [7], personality [6,10], capabilities [5,10], activities [2,6] roles and social relations [4,14] and on self-identity [3].

Interdisciplinary facilitation of the minimal participation of patients with severe brain injury in early rehabilitation

Abstract Aim: The purpose of the study was to shed light on the participatory aspect of early rehabilitation, when contact, communication and interaction between the patients and the professionals is minimal, because of the patients’ severe brain injury and complex conditions. Methodology: A qualitative study was chosen. The field study involved five patients (aged 39–64) and included: participant observation and video recordings of 41 rehabilitation situations, five individual interviews and one focus group interview with multidisciplinary rehabilitation experts; together with document review of hospital charts and memos. The data were analyzed using a four-step phenomenological analysis and NVivo 10. Major findings: Participation comes into play in various practices around the patient. Three main themes seem to be important: (1) The dynamic interplay of the multidisciplinary team as an element that influences participation, (2) significant relational encounters and meetings as aspects that impact on the promotion of participation, and (3) significant frameworks that affect involvement, engagement and participation. Principal conclusion: Patients’ participation and recovery are facilitated by a combination of the clinicians’ professional skills, their ability to create a rehabilitation environment in which patients can perform activities, the right framework for the meeting, and a suitable approach, to facilitate fruitful interaction with the patients.

How is individualization in constraint-induced movement therapy performed? A qualitative observational study

Abstract The aim of the study was to investigate relationships between the design of tasks and impairments in constraint-induced movement therapy (CIMT) and significant principles of in situ individualization in group-based performance of the intervention, focusing on quality of performance versus compensatory strategies in the more affected upper limb. Non-participatory observations of four individuals undergoing CIMT group training with a physiotherapist were conducted, followed by theme-based content analysis using concepts from practice knowledge and movement analysis as analytical tools. The material was characterized by the physiotherapist focusing on the quality of movements by interacting and making a variety of adjustments. Most tasks were too challenging in terms of shoulder stability and were performed using compensatory strategies. It appeared essential that participants’ could solve the task with optimal movement quality in addition to experiencing meaning and success. In conclusion, the physiotherapist’s individualizations in situ appeared to be based on goal attainment through optimization of movement quality. Interlinking the design of tasks with the individual patient’s underlying impairments, elements from activities in daily life and sense-making seem essential. Impairments occurred owing to high demands of dynamic stability in the shoulder, which may be a reason why participants in CIMT often use compensatory strategies.