Marghuretta D. Bland

Assessment of upper extremity impairment, function, and activity after stroke: Foundations for clinical decision making

The purpose of this review is to provide a comprehensive approach for assessing the upper extremity (UE) after stroke. First, common UE impairments and how to assess them are briefly discussed. Although multiple UE impairments are typically present after stroke, the severity of ones impairment, paresis, is the primary determinant of UE functional loss. Second, UE function is operationally defined and a number of clinical measures are discussed. It is important to consider how impairment and loss of function affect UE activity outside of the clinical environment. Thus, this review also identifies accelerometry as an objective method for assessing UE activity in daily life. Finally, the role that each of these levels of assessment should play in clinical decision making is discussed to optimize the provision of stroke rehabilitation services.

Dose‐response of task‐specific upper limb training in people at least 6 months post stroke: A Phase II, single‐blind, randomized, controlled trial

The objectives of this work were to (1) determine whether higher doses of motor therapy in chronic poststroke hemiparesis result in better outcomes, compared to lower doses, and (2) evaluate potential modifiers of the dose‐response relationship.

Prediction of Discharge Walking Ability From Initial Assessment in a Stroke Inpatient Rehabilitation Facility Population

OBJECTIVES To (1) determine which clinical assessments at admission to an inpatient rehabilitation facility (IRF) most simply predict discharge walking ability, and (2) identify a clinical decision rule to differentiate household versus community ambulators at discharge from an IRF. DESIGN Retrospective cohort study. SETTING IRF. PARTICIPANTS Two samples of participants (n=110 and 159) admitted with stroke. INTERVENTIONS A multiple regression determined which variables obtained at admission (age, time from stroke to assessment, Motricity Index, somatosensation, Modified Ashworth Scale, FIM, Berg Balance Scale, 10-m walk speed) could most simply predict discharge walking ability (10-m walk speed). A logistic regression determined the likelihood of a participant achieving household (<0.4m/s) versus community (≥0.4-0.8m/s; >0.8m/s) ambulation at the time of discharge. Validity of the results was evaluated on a second sample of participants. MAIN OUTCOME MEASURE Discharge 10-m walk speed. RESULTS Admission Berg Balance Scale and FIM walk item scores explained most of the variance in discharge walk speed. The odds ratio of achieving only household ambulation at discharge was 20 (95% confidence interval [CI], 6-63) for sample 1 and 32 (95% CI, 10-96) for sample 2 when the combination of having a Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 was present. CONCLUSIONS A Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 at admission indicates that a person with stroke is highly likely to only achieve household ambulation speeds at discharge from an IRF.

The brain recovery core: Building a system of organized stroke rehabilitation and outcomes assessment across the continuum of care

This Special Interest article describes a multidisciplinary, interinstitutional effort to build an organized system of stroke rehabilitation and outcomes measurement across the continuum of care. This system is focused on a cohort of patients who are admitted with the diagnosis of stroke to our acute facility, are discharged to inpatient and/or outpatient rehabilitation at our free-standing facility, and are then discharged to the community. This article first briefly explains the justification, goals, and purpose of the Brain Recovery Core system. The next sections describe its development and implementation, with details on the aspects related to physical therapy. The article concludes with an assessment of how the Brain Recovery Core system has changed and improved delivery of rehabilitation services. It is hoped that the contents of this article will be useful in initiating discussions and potentially facilitating similar efforts among other centers.

Restricted Active Range of Motion at the Elbow, Forearm, Wrist, or Fingers Decreases Hand Function

The purpose of this study was to investigate how restricting active range of motion (AROM) at various upper extremity segments influenced hand function in younger and older populations. Eighteen younger (27+/-4yr) and 15 older subjects (67+/-6yr) participated. A repeated-measures study design was used with six test conditions: one condition without AROM restrictions and five conditions with AROM restrictions (shoulder, elbow, forearm, wrist, fingers). AROM was restricted using customized braces. Hand function was measured using total time to complete the Jebsen-Taylor Test of Hand Function. We found that the older group took longer than the younger group to complete the Jebsen, and that restricting AROM at the elbow, forearm, wrist, or fingers resulted in decreased hand function for both groups. Because restricted AROM is a consequence of a variety of diseases and conditions, it is important to know how restricted AROM at multiple upper extremity segments affects hand function.

Clinician Adherence to a Standardized Assessment Battery Across Settings and Disciplines in a Poststroke Rehabilitation Population

OBJECTIVES (1) To examine clinician adherence to a standardized assessment battery across settings (acute hospital, inpatient rehabilitation facilities [IRFs], outpatient facility), professional disciplines (physical therapy [PT], occupational therapy, speech-language pathology), and time of assessment (admission, discharge/monthly), and (2) to evaluate how specific implementation events affected adherence. DESIGN Retrospective cohort study. SETTING Acute hospital, IRF, and outpatient facility with approximately 118 clinicians (physical therapists, occupational therapists, speech-language pathologists). PARTICIPANTS Participants (N=2194) with stroke who were admitted to at least 1 of the above settings. All persons with stroke underwent standardized clinical assessments. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Adherence to Brain Recovery Core assessment battery across settings, professional disciplines, and time. Visual inspections of 17 months of time-series data were conducted to see if the events (eg, staff meetings) increased adherence ≥5% and if so, how long the increase lasted. RESULTS Median adherence ranged from .52 to .88 across all settings and professional disciplines. Both the acute hospital and the IRF had higher adherence than the outpatient setting (P≤.001), with PT having the highest adherence across all 3 disciplines (P<.004). Of the 25 events conducted across the 17-month period to improve adherence, 10 (40%) resulted in a ≥5% increase in adherence the following month, with 6 services (60%) maintaining their increased level of adherence for at least 1 additional month. CONCLUSIONS Actual adherence to a standardized assessment battery in clinical practice varied across settings, disciplines, and time. Specific events increased adherence 40% of the time with those gains maintained for >1 month 60% of the time.

Predictors of Return to Driving After Stroke

Objective Although returning to driving is a major concern for many survivors of stroke, predicting who will return to driving after a stroke is often difficult for rehabilitation professionals. The primary aim of this study was to identify patient factors present at admission to an inpatient rehabilitation hospital that can be used to identify which patients who have had acute stroke will and will not return to driving. Design After comparing returners and nonreturners on demographic and clinical characteristics, a logistic regression model with return to driving as the outcome variable was built using the backward stepwise method. Results Thirty-one percent (48/156) of the patients who had been driving before their stroke returned to driving 6 mos after stroke. The final regression model, using Functional Independence Measure cognition and lower extremity Motricity Index scores, predicted the driving outcome with an accuracy of 75% (107/143). Conclusions Patients with lower Functional Independence Measure cognition and lower extremity Motricity Index scores at admission to inpatient rehabilitation are less likely to return to driving at 6 mos. This model could be used by rehabilitation professionals to help counsel patients and their families and focus treatment goals.

An exploratory analysis of the self-reported goals of individuals with chronic upper-extremity paresis following stroke

Abstract Purpose: To classify the self-identified goals of individuals post-stroke with chronic upper extremity (UE) paresis, and determine if age, UE functional capacity and pre-stroke hand dominance influence overall goal selection. Method: Sixty-five subjects participated. Using the Canadian Occupational Performance Measure (COPM) to establish treatment goals, the top five goals were categorized using the Occupational Therapy Practice Framework into five categories: activities of daily living (ADLs), instrumental activities of daily living (IADLs), leisure, work and general UE movement. A Chi-square analysis determined if age, UE functional capacity (measured by the Action Research Arm Test) and UE hand dominance influenced individual goal selection. Results: The majority of goals were in the ADL (37%) and IADL (40%) categories. A small percentage (12%) was related to general UE movement. Individuals with moderate UE functional capacity identified more ADL goals than those with higher UE functional capacity. There was not a difference between age and UE dominance across all five goal areas. Conclusions: Individuals with chronic UE paresis had specific goals that were not influenced by age or hand dominance, but partially influenced by severity. General UE movement goals were identified less than goals related to specific activities. Implications for Rehabilitation Considering the specificity of individual goals following stroke, it is recommended that clinicians regularly utilize a goal setting tool to help establish client goals. It is recommended that clinicians further inquire about general goals in order to link upper extremity deficits to functional activity limitations. Age, upper extremity functional capacity and hand dominance have little influence on the rehabilitation goals for individuals with chronic paresis after stroke.

Quantifying Change During Outpatient Stroke Rehabilitation: A Retrospective Regression Analysis

OBJECTIVE To examine change and individual trajectories for balance, upper extremity motor capacity, and mobility in people poststroke during the time they received outpatient therapies. DESIGN Retrospective analyses of an observational cohort using hierarchical linear modeling. SETTING Outpatient rehabilitation. PARTICIPANTS Persons poststroke (N=366). INTERVENTIONS Usual outpatient physical and occupational therapy. MAIN OUTCOMES MEASURES Berg Balance Scale (BBS), Action Research Arm Test (ARAT), and walking speed were used to assess the 3 domains. Initial scores at the start of outpatient therapy (intercepts), rate of change during outpatient therapy (slopes), and covariance between slopes and intercepts were modeled as random effects. Additional variables modeled as fixed effects were duration (months of outpatient therapy), time (days poststroke), age (y), and inpatient status (if the patient went to an inpatient rehabilitation facility [IRF]). RESULTS A patient with average age and time started at 37 points on the BBS with a change of 1.8 points per month, at 35 points on the ARAT with a change of 2 points per month, and with a walking speed of .59m/s with a change of .09m/s per month. When controlling for other variables, patients started with lower scores on the BBS and ARAT or had slower walking speeds at admission if they started outpatient therapy later than average or went to an IRF. CONCLUSIONS Patients generally improved over the course of outpatient therapy, but there was considerable variability in individual trajectories. Average rates of change across all 3 domains were small.

Enhanced Medical Rehabilitation: Effectiveness of a clinical training model

BACKGROUND Patient engagement in medical rehabilitation can be greatly influenced by their provider during therapy sessions. We developed Enhanced Medical Rehabilitation (EMR), a set of provider skills grounded in theories of behavior change. EMR utilizes 18 motivational techniques focused on providing frequent feedback to patients on their effort and progress and linking these to patient goals. OBJECTIVE To examine the effectiveness of a clinical training protocol for clinicians to do EMR, as measured by clinician adherence. METHODS A physical therapist, physical therapist assistant, occupational therapist, and certified occupational therapist assistant were trained in EMR. Training consisted of five formal training sessions and individual and group coaching. Adherence to EMR techniques was measured during two phases: Pre-Training and Maintenance, with an a priori target of 90% adherence by clinicians to each EMR technique. RESULTS With training and coaching, clinician adherence per therapeutic activity significantly improved in 13 out of 18 items (p < 0.05). The target of 90% adherence was not achieved for many items. CONCLUSIONS Our training and coaching program successfully trained clinicians to promote patient engagement during therapeutic service delivery, although not typically to 90% or greater adherence. Ongoing coaching efforts were necessary to increase adherence.