J.M.A. Visser-Meily

Comparing contents of functional outcome measures in stroke rehabilitation using the International Classification of Functioning, Disability and Health

Purpose. To examine the content of outcome measures that are frequently used in stroke rehabilitation and focus on activities and participation, by linking them to the International Classification of Functioning, Disability and Health (ICF). Method. Constructs of the following instruments were linked to the ICF: Barthel Index, Berg Balance Scale, Chedoke McMaster Stroke Assessment Scale, Euroqol-5D, Functional Independence Measure, Frenchay Activities Index, Nottingham Health Profile, Rankin Scale, Rivermead Motor Assessment, Rivermead Mobility Index, Stroke Adapted Sickness Impact Profile 30, Medical Outcomes Study Short Form 36, Stroke Impact Scale, Stroke Specific Quality of Life Scale and Timed Up and Go test. Results. It proved possible to link most constructs to the ICF. Most constructs fitted into the activities and participation component, with mobility being the category most frequently covered in the instruments. Although instruments were selected on the basis of their focus on activities and participation, 27% of the constructs addressed categories of body functions. Approximately 10% of the constructs could not be linked. Conclusions. The ICF is a useful tool to examine and compare contents of instruments in stroke rehabilitation. This content comparison should enable clinicians and researchers to choose the measure that best matches the area of their interest.

Prevalence and Determinants of Cognitive Complaints after Aneurysmal Subarachnoid Hemorrhage

Background: To investigate the prevalence of cognitive complaints after subarachnoid hemorrhage (SAH) and the relationships between cognitive complaints and cognitive impairments, disability and emotional problems. Methods: Cognitive complaints were assessed with the Checklist for Cognitive and Emotional Consequences following stroke (CLCE-24) in 111 persons who visited our outpatient clinic 3 months after SAH. Associations between cognitive complaints and cognitive functioning, demographic characteristics, disability and emotional problems were examined using Spearman correlations and linear regression analysis. Results: In this study group, 105 patients (94.6%) reported at least one cognitive or emotional complaint that hampered everyday functioning. The most frequently reported cognitive complaints were mental slowness, short-term memory problems and attention deficits. All cognitive domains, disability, depressive symptoms and feelings of anxiety were significantly associated with the CLCE-24 cognition score. In the final regression model, memory functioning (β value –0.21), disability (–0.28) and depressive symptoms (0.40) were significant determinants of cognitive complaints, together explaining 35.4% of the variance. Conclusion: Cognitive complaints are common after SAH and associated with memory deficits, disability and depressive symptoms. Rehabilitation programs should focus on these symptoms and deficits.

Responsiveness of functional health status measures frequently used in stroke research

Purpose. To compare the responsiveness of several functional health status measures frequently used in stroke research, namely the Barthel Index (BI), Functional Independence Measure (FIM), Frenchay Activities Index (FAI) and Stroke-Adapted Sickness Impact Profile 30 (SA-SIP 30). Method. Patients with a first-ever supratentorial stroke admitted for inpatient rehabilitation were included. Complete datasets for 163 patients were available for analysis. Floor/ceiling effects and responsiveness, quantified by effect sizes, were studied for the periods between rehabilitation admission and six months post stroke (subacute phase) and between six and 12 months post stroke (chronic phase). Results. Effect sizes in the subacute phase were similar and were classified as large for the BI, FIM total and FIM motor score. The FIM cognitive score showed a considerable ceiling effect and had the smallest effect size in the subacute phase. In the chronic phase, the FAI and SA-SIP 30 detected the most changes and had moderate effect sizes. Conclusions. BI, FIM total and FIM motor score, FAI and SA-SIP 30 were responsive measures. We recommend the use of the BI in the subacute phase and the use of the FAI and SA-SIP 30 in the chronic phase, especially for the stroke rehabilitation population.

Social activity contributes independently to life satisfaction three years post stroke

Objective: To determine social activity and life satisfaction three years post stroke and to investigate the contribution of social activity to life satisfaction controlled for the influence of demographic, physical and cognitive disabilities and social support. Design: Cross-sectional study. Subjects: One hundred and sixty-five patients with a stroke. Main measures: The Life Satisfaction questionnaire (LiSat-9), the Social Support List – Interaction (SSL-12-I), the Barthel Index, the Mini-Mental State Examination (MMSE) and the Frenchay Activities Index. Results: In total, 165 stroke patients participated, of whom 112 (67.9%) reported that they were satisfied with life as a whole. Socially inactive patients were significantly less often satisfied (50%, nu2009=u200926) than socially moderately (74.4%, nu2009=u200964) and socially highly active (81.5%, nu2009=u200922) patients. Lowest satisfaction ratings were found for sexual life (40.6%, nu2009=u200958). The socially inactive group was most satisfied with their partner relationship (85.1%, nu2009=u200940), the moderately and highly socially active group with their self-care ability (87.2%, nu2009=u200975 and 96.3%, nu2009=u200926, respectively). ADL and social activity were moderately correlated with life satisfaction. Social activity was found to explain an additional variance of the LiSat-9 total score (6.9%) and overall life satisfaction item (5.2%) after controlling for demographic variables, social support, ADL and cognitive functioning. Conclusions: Three years post stroke, many patients report ongoing dissatisfaction with various life domains. Social activity was related to life satisfaction.

Predicting fatigue 1 year after aneurysmal subarachnoid hemorrhage

Fatigue is an important contributor to quality of life in patients who survive aneurysmal subarachnoid hemorrhage (SAH), but the determinants of this fatigue are unclear. We assessed the occurrence of fatigue 1xa0year after SAH and its relation to physical or cognitive impairment, passive coping, and emotional problems, measured 3xa0months after SAH. This was a prospective cohort study of 108 patients who visited our SAH outpatient clinic 3xa0months after SAH and who were living independently in the community 1xa0year after SAH. Fatigue was evaluated using the Fatigue Severity Scale (FSS). Analysis of variance was used to analyze the data. Fatigue (FSSxa0≥4) was present in 77 patients (71%). Mean FSS scores were 4.1 (SD 1.6) in the group of patients having ‘neither physical nor cognitive impairment,’ 5.2 (1.4) having ‘either physical or cognitive impairment,’ and 5.9 (0.9) having ‘both physical and cognitive impairments.’ Mean FSS scores were higher in patients scoring high on passive coping (85 vs. 58%; RR 1.46, 95% CI 1.13–1.87), anxiety (84 vs. 55%; RR 1.53, 95% CI 1.17–2.02), or depression (85 vs. 62%; RR 1.36, 95% CI 1.08–1.72) than in patients without these complaints. Relationships between these complaints and FSS scores were higher in patients having neither physical nor cognitive impairments than in patients having physical or cognitive impairments. Fatigue is common after SAH and is related to physical and cognitive impairments. In patients with neither physical nor cognitive impairments, passive coping style and emotional problems are important predictors of fatigue.

Poststroke Fatigue: Who Is at Risk for an Increase in Fatigue?

Background. Several studies have examined determinants related to post-stroke fatigue. However, it is unclear which determinants can predict an increase in poststroke fatigue over time. Aim. This prospective cohort study aimed to identify determinants which predict an increase in post-stroke fatigue. Methods. A total of 250 patients with stroke were examined at inpatient rehabilitation discharge (T0) and 24 weeks later (T1). Fatigue was measured using the Fatigue Severity Scale (FSS). An increase in post-stroke fatigue was defined as an increase in the FSS score beyond the 95% limits of the standard error of measurement of the FSS (i.e., 1.41 points) between T0 and T1. Candidate determinants included personal factors, stroke characteristics, physical, cognitive, and emotional functions, and activities and participation and were assessed at T0. Factors predicting an increase in fatigue were identified using forward multivariate logistic regression analysis. Results. The only independent predictor of an increase in post-stroke fatigue was FSS (OR 0.50; 0.38–0.64, P < 0.001). The model including FSS at baseline correctly predicted 7.9% of the patients who showed increased fatigue at T1. Conclusion. The prognostic model to predict an increase in fatigue after stroke has limited predictive value, but baseline fatigue is the most important independent predictor. Overall, fatigue levels remained stable over time.

Predictors of long-term Health-Related Quality of Life in patients with aneurysmal subarachnoid hemorrhage

OBJECTIVEnTo determine the predictive value of physical and psychological factors assessed three months after aneurysmal subarachnoid hemorrhage (SAH) for health-related quality of life (HRQoL) one year after the SAH.nnnDESIGNnProspective cohort study.nnnSUBJECTSnPatients with SAH (n=113) who visited our SAH-outpatient clinic three months after SAH and who were living independently in the community one year after SAH.nnnMETHODSnHRQoL was evaluated using the Stroke Specific Quality of Life scale (SS-QoL). We used Spearman correlations, Somersd, and linear regression analyses. Independent variables were demographic and SAH characteristics, cognitive and emotional complaints, depressive symptoms, anxiety, cognitive functioning, and passive coping style.nnnRESULTSnIn the regression analysis, female gender (beta value -0.17), cognitive complaints (-0.31 ), cognitive functioning (0.40) and passive coping style (-0.23) were independent predictors, and together explained 45.9% of the variance of the SS-QoL total score.nnnCONCLUSIONnFemale gender, cognitive complaints, cognitive functioning and passive coping style assessed at 3 months after SAH are important predictors of HRQoL 1 year after SAH. Early interventions to improve cognitive and emotional functioning should be evaluated for their ability to improve long-term HRQoL after SAH.

Poststroke hand swelling and oedema: prevalence and relationship with impairment and disability

Objective: To examine the prevalence of swelling and oedema of the hand in stroke patients and relationships with impairments and disability. Design: Cross-sectional. Setting: Stroke unit at Rehabilitation Centre De Hoogstraat, the Netherlands. Subjects: Eighty-eight adult stroke patients who were admitted for clinical rehabilitation during one year (2000). Measurements and methods: Assessment took place two weeks after admission to the rehabilitation centre. Degree of swelling was measured with a hand volumeter and oedema was defined as a volumeter score deviating more than two standard deviations from the expected score derived from population data. Further assessment included tonus (Modified Ashworth Score), sensibility, tactile inattention, carefulness, and motor function (Utrecht Arm/Hand Test). Arm disability was measured with Frenchay Arm Test and Nine-hole Peg Test. Results: Some degree of hand swelling was present in 72.7% and oedema in 33.0% of our patients. Swelling and oedema were significantly more often seen in patients with hypertonic fingers and impaired sensibility. Patients with hand oedema had significantly worse Frenchay Arm Test and Nine-hole Peg Test scores. Conclusions: Swelling and oedema of the hand are common among stroke patients in clinical rehabilitation.

Post-Traumatic Stress Disorder in Patients 3 Years after Aneurysmal Subarachnoid Haemorrhage

Background: Subarachnoid haemorrhage (SAH) from a ruptured intracranial aneurysm accounts for approximately 5% of all strokes. Post-traumatic stress disorder (PTSD) is common in the early phase after recovery from aneurysmal SAH. The aim of our study was to examine the prevalence of PTSD 3 years after SAH, its predictors, and relationship with health-related quality of life (HRQoL) in patients living independently in the community. Methods: From a prospectively collected cohort of 143 patients with aneurysmal SAH who visited our outpatient clinic 3 months after SAH, 94 patients (65.7%) completed a mailed questionnaire 3 years after SAH. We assessed PTSD with the Impact of Event Scale and HRQoL with the Stroke-Specific Quality of Life Scale (SS-QoL). The χ2 and t tests were used to investigate if patients who returned the questionnaires were different from those who did not reply. Non-parametric tests (χ2 and Mann-Whitney tests) were used to test for differences between patients with and without PTSD. Relative risks and 95% confidence intervals were calculated. Results: No relevant differences in demographic (age, sex, education) or SAH characteristics (clinical condition on admission, complication, location of aneurysm, Glasgow Outcome Scale score at 3 months) were seen between participants and drop-outs. In 24 patients (26%), Impact of Event Scale scores indicated PTSD. Passive coping style (relative risk, 5.7; 95% confidence interval, 2.1-15.3), but none of the demographic or SAH-related factors, predicted PTSD. The mean SS-QoL total score was 4.2 (SD 1.1), indicative of a relatively satisfactory HRQoL. PTSD was associated with lower HRQoL (p < 0.001), a mean SS-QoL score of 4.4 (SD 1.0) without PTSD, and a mean SS-QoL score of 3.5 (SD 1.1) with PTSD. Conclusions: Even 3 years after SAH, 1 out of 4 patients had PTSD, which was associated with reduced HRQoL. Passive coping style was the most important predictor. There is a need to organize SAH care with more attention to and treatment of PTSD. Strategies shown to reduce PTSD in other conditions should be tested for effectiveness in SAH patients.

Validity of the Barrow Neurological Institute (BNI) Screen for Higher Cerebral Functions in Stroke Patients with Good Functional Outcome

Cognitive impairments are often under diagnosed in stroke patients with good functional outcome. There is a need for a cognitive screening instrument that is sufficiently sensitive to cognitive impairments in these stroke patients. For this goal, we tested the feasibility and validity of the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS). Stroke patients with good functional outcome (Barthel Index 19/20) within 1 year poststroke were administered the BNIS and a brief neuropsychological assessment (NPA) including tests for perception, language, memory, attention, reasoning, and executive functioning. We compared the BNIS with the NPA to investigate its feasibility, internal consistency, floor and ceiling effects, concurrent validity, sensitivity and specificity. Fifty-four stroke patients were included. It took significantly less time to administer the BNIS (median = 16 minutes) than the NPA (median = 32.7 minutes). The BNIS showed good internal consistency (alpha = .82) and no floor or ceiling effects. The recommended cutoff values yielded good sensitivity and low to good specificity, depending on age. Except for perception (Spearman correlation .33), BNIS domain scores were significantly (0.44–0.55) associated with matching neuropsychological tests. This study provides promising results for the BNIS as a measure to detect cognitive impairments in stroke patients with good functional outcome.