Louise Connell

Use of Time by Stroke Patients. A Comparison of Four European Rehabilitation Centers

Background and Purpose— Differences exist between European countries in the proportion of patients who die or become dependent after stroke. The aim of the present study was to identify differences in the use of time by stroke patients in 4 rehabilitation centers in 4 European countries. Methods— In each of the 4 centers, 60 randomly selected stroke patients were observed at 10-minute intervals using behavioral mapping. Observations took place on 30 weekdays selected at random, on equal numbers of morning, afternoon, and evening sessions. A logistic generalized estimating equation model with correction for differences in case mix and multiple testing was used for the analysis. Results— Overall time available from different professions was the highest in the United Kingdom, but patients in the United Kingdom spent on average only 1 hour per day in therapy. This was significantly less than patients in Belgium and Germany, who spent ≈2 hours, and patients in Switzerland who spent ≈3 hours per day in therapy. In all centers, patients spent less than half their time in interactions and >72% of the time in nontherapeutic activities. Conclusions— Important differences in the use of time were established, which appeared dependent on management decisions rather than the number of staff available. Patients in the Swiss and German centers spent more time in therapy, possibly because of the structured organization of rehabilitation. Further studies will verify whether this has an effect on outcome.

Somatosensory impairment after stroke: frequency of different deficits and their recovery

Objective: To investigate the frequency of somatosensory impairment in stroke patients within different somatosensory modalities and different body areas, and their recovery. Design: Prospective observational study. Setting: Two stroke rehabilitation units. Subjects: Seventy patients with a first stroke (36 men, 34 women; average age, 71, SD 10.00 years; average time since stroke onset, 15 days) were assessed on admission and two, four and six months after stroke. Interventions: Not applicable. Main measure: Nottingham Sensory Assessment. Results: Somatosensory impairment was common after stroke; 7—53% had impaired tactile sensations, 31—89% impaired stereognosis, and 34—64% impaired proprioception. When comparing somatosensory modalities within body areas the kappa values were low (kappa values <0.54). Recovery occurred over time, though not significantly in lower limb tactile sensations. Stroke severity was the main factor influencing initial somatosensory impairment, but accounted for a small amount of the variance (21—41%). Initial somatosensory impairment was significantly related to somatosensory ability at six months, accounting for 46—71% of the variance. Conclusions: Proprioception and stereognosis were more frequently impaired than tactile sensations. The different somatosensory modalities showed only slight agreement between impairment within the same body areas, suggesting that the modalities are independent of each other and all should be assessed. High agreements were found between different body areas for each somatosensory modality. Somatosensory impairment was associated with stroke severity, however low variance indicated other factors were involved.

The psychometric properties and clinical utility of measures of walking and mobility in neurological conditions: a systematic review:

Objective: To identify psychometrically robust and clinically feasible measures of walking and mobility in people with neurological conditions Data sources: MEDLINE, CINAHL, EMBASE, PEDro and AMED. Review methods: Independent reviewers selected and extracted data from articles that assessed the reliability, validity, sensitivity to change or clinical utility of measures of walking and mobility in adult neurological conditions. Measures with ‘good’ psychometrics and 9/10 clinical utility scores were recommended. Results: Seventeen measures were selected. Of these, the 5-m and 10-m walk tests, six-minute walk test, High Level Mobility Assessment Tool (HiMAT) and the Rivermead Mobility Index (RMI) reached the required standards and are usable in clinical practice. None of the recommended measures assessed wheelchair mobility. The least frequently assessed property was sensitivity to change. Further measures could be recommended if the minimal detectable change were demonstrated. Conclusion: The 5-m, 10-m and six-minute walk test, High Level Mobility Assessment Tool and the Rivermead Mobility Index are psychometrically robust measures of walking and mobility and are feasible for use in clinical practice.

Motor and Functional Recovery After Stroke A Comparison of 4 European Rehabilitation Centers

Background and Purpose— Outcome after first stroke varies significantly across Europe. This study was designed to compare motor and functional recovery after stroke between four European rehabilitation centers. Methods— Consecutive stroke patients (532 patients) were recruited. They were assessed on admission and at 2, 4, and 6 months after stroke with the Barthel Index, Rivermead Motor Assessment of Gross Function, Rivermead Motor Assessment of Leg/Trunk, Rivermead Motor Assessment of Arm, and Nottingham Extended Activities of Daily Living (except on admission). Data were analyzed using random effects ordinal logistic models adjusting for case-mix and multiple testing. Results— Patients in the UK center were more likely to stay in lower Rivermead Motor Assessment of Gross Function classes compared with patients in the German center (&Dgr;OR, 2.4; 95% CI, 1.3 to 4.3). In the Swiss center, patients were less likely to stay in lower Nottingham Extended Activities of Daily Living classes compared with patients in the UK center (&Dgr;OR, 0.7; 95% CI, 0.5 to 0.9). The latter were less likely to stay in lower Barthel Index classes compared with the patients in the German center (&Dgr;OR, 0.6; 95%CI, 0.4 to 0.8). Recovery patterns of Rivermead Motor Assessment of Leg/Trunk and Rivermead Motor Assessment of Arm were not significantly different between centers. Conclusions— Gross motor and functional recovery were better in the German and Swiss centers compared with the UK center, respectively. Personal self-care recovery was better in the UK compared with the German center. Previous studies in the same centers indicated that German and Swiss patients received more therapy per day. This was not the result of more staff but of a more efficient use of human resources. This study indicates potential for improving rehabilitation outcomes in the UK and Belgian centers.

Stroke Rehabilitation in Europe What Do Physiotherapists and Occupational Therapists Actually Do

Background and Purpose— Physiotherapy (PT) and occupational therapy (OT) are key components of stroke rehabilitation. Little is known about their content. This study aimed to define and compare the content of PT and OT for stroke patients between 4 European rehabilitation centers. Methods— In each center, 15 individual PT and 15 OT sessions of patients fitting predetermined criteria were videotaped. The content was recorded using a list comprising 12 therapeutic categories. A generalized estimating equation model was fitted to the relative frequency of each category resulting in odds ratios. Results— Comparison of PT and OT between centers revealed significant differences for only 2 of the 12 categories: ambulatory exercises and selective movements. Comparison of the 2 therapeutic disciplines on the pooled data of the 4 centers revealed that ambulatory exercises, transfers, exercises, and balance in standing and lying occurred significantly more often in PT sessions. Activities of daily living, domestic activities, leisure activities, and sensory, perceptual training, and cognition occurred significantly more often in OT sessions. Conclusion— This study revealed that the content of each therapeutic discipline was consistent between the 4 centers. PT and OT proved to be distinct professions with clear demarcation of roles.

Anxiety and depression in the first six months after stroke. A longitudinal multicentre study

Purpose. To document the prevalence, severity and time course of anxiety and depression in stroke rehabilitation patients in four European countries. Method. At two, four and six months post-stroke, the prevalence and severity of anxiety and depression were determined in 532 consecutively recruited patients, using the Hospital Anxiety and Depression Scale. Time course of prevalence and severity was examined, using Cochran-Q and Friedman-tests, respectively. We identified whether the numbers of anxious/depressed patients at each time point comprised the same individuals. Results. Prevalence of anxiety ranged between 22% and 25%; depression between 24% and 30%. Median severity ranged between 4 and 5. No significant differences between centres occurred (p > 0.05). Prevalence of both disorders was not significantly different over time. Severity of anxiety decreased between four and six months; severity of depression remained stable. About 40% of the patients with initial anxiety remained anxious at six months. Some 11% and 7% of those initially not anxious became anxious at four or six months after stroke, respectively. Depression showed a similar pattern. Conclusions. Despite differences in patient profiles and intensity of rehabilitation, no significant differences occurred between centres in prevalence and severity of both disorders. Anxiety was almost as common as depression and additional patients became anxious/depressed at each time point.

Clinical reality of measuring upper-limb ability in neurologic conditions: a systematic review.

OBJECTIVE To review the psychometric properties and clinical utility of upper-limb measurement tools in people with neurologic conditions to provide recommendations for practice. DATA SOURCES MEDLINE, CINAHL, EMBASE, PEDro, and AMED. STUDY SELECTION Independent reviewers searched, selected, and extracted data from articles that assessed reliability, validity, ability to detect change, and clinical utility of measures of the upper limb in adult neurologic conditions. DATA EXTRACTION Measures with good psychometrics and 8 or higher (out of 10) clinical utility scores were recommended. DATA SYNTHESIS The searches identified 31 measures of the upper limb. However, only 2 measures fulfilled all of the psychometric and clinical utility criteria; the Box and Block Test and the Action Research Arm Test. CONCLUSIONS The Box and Block and the Action Research Arm Tests produce robust data and are feasible for use in clinical practice. Future development of new or existing measures should ensure the construct and content validity of the measure is clearly identified, standardized guidelines are easily available, and ensure that it is individualized and contemporary. Attention to measures of upper-limb activity for people who are unable to grip objects is also needed.

Measures of sensation in neurological conditions: a systematic review:

Objective: To systematically review the psychometric properties and clinical utility of measures of sensation in neurological conditions to inform future research studies and clinical practice. Data sources: Electronic databases (MEDLINE, CINAHL, EMBASE and AMED) were searched from their inception to December 2010. Review methods: Search terms were used to identify articles that investigated any sensory measures in neurological conditions. Data about their psychometric properties and clinical utility were extracted and analyzed independently. The strength of the psychometric properties and clinical utility were assessed following recommendations. 1 Results: Sixteen sensory measures were identified. Inter-rater reliability and redundancy of testing protocols are particular issues for this area of assessment. Eleven were rejected because they were not available for a researcher or clinician to use. Of the remaining five measures, the Erasmus MC modifications of the Nottingham Sensory Assessment and the Sensory section of the Fugl–Meyer Assessment showed the best balance of clinical utility and psychometric properties. Conclusion: Many measures of sensory impairment have been used in research but few have been fully developed to produce robust data and be easy to use. At present, the sensory section of the Fugl–Meyer Assessment and the Erasmus MC modifications of the Nottingham Sensory Assessment show the most effective balance of usability and robustness, when delivered according to the operating instructions.

Use of time by physiotherapists and occupational therapists in a stroke rehabilitation unit: A comparison between four European rehabilitation centres

Purpose. The aim of this study was to compare the time allocated to therapeutic activities (TA) and non-therapeutic activities (NTA) of physiotherapists (PT) and occupational therapists (OT) in stroke rehabilitation units in four European countries. Method. Therapists documented their activities in 15-min periods for two weeks. They recorded: activity, number of patients, number of stroke patients, involvement of other people, location and frequency of each activity. Kruskal-Wallis tests and negative binomial regression models were used to compare activities between professional groups and between units. Results. The average proportion of TA per day ranged between 32.9% and 66.1% and was higher for PT than for OT in each unit. For OT, significant differences emerged between the units in the proportion of time allocated to TA compared to NTA with British OTs spending significantly less time in TA. In the Belgian unit, three times less time was spent on patient-related co-ordination activities (e.g., administration, ward rounds) compared to the British and Swiss units. Conclusions. Time allocation differed between PT and OT and between units, affecting the time available for TA. Further investigation is necessary to study the effect of work organization in stroke rehabilitation units on the efficiency of rehabilitation regimes.

The effectiveness of virtual reality interventions in improving balance in adults with impaired balance compared with standard or no treatment: a systematic review and meta-analysis

Objective: To evaluate whether virtual reality interventions, including interactive gaming systems, are effective at improving balance in adults with impaired balance. Design: Systematic review and meta-analysis of randomized control trials. Methods: Studies were identified from electronic databases (CENTRAL, MEDLINE, EMBASE, AMED, CINAHL, PyschINFO, PyschBITE, OTseeker, Ei Compendex, and Inspec) searched to November 2011, and repeated in November 2012. Two reviewers selected studies meeting inclusion criteria and quality of included studies assessed using a Joanna Briggs Institute appraisal tool. Data was pooled and a meta-analysis completed. The systematic review was reported following guidance of the PRISMA statement. Results: A total of 251 articles were screened. Eight randomized control trials were included. These studies presented the results of 239 participants, with various aetiologies, and used a variety of virtual reality systems. The number of falls was documented in only one included study. Meta-analysis was completed on data from the Berg Balance Scale, walking speed, 30 second sit-to-stand test, and Timed Up and Go Test, and favoured standard therapy when compared with standard plus virtual reality interventions. Conclusions: There was a notable inconsistency in the outcome measures, experimental, and control interventions used within the included studies. The pooled results of the studies showed no significant difference. Therefore this review cannot support nor refute the use of virtual reality interventions, rather than conventional physiotherapy, to improve balance in adults with impaired balance.