N. Frances Horgan

Association between timed up-and-go and memory, executive function, and processing speed

To determine which cognitive tests are independently associated with performance on the Timed Up‐and‐Go Test (TUG).

Factors associated with community reintegration in the first year after stroke: a qualitative meta-synthesis.

Abstract Purpose: Although acute stroke care has improved survival, many individuals report dissatisfaction with community reintegration after stroke. The aim of this qualitative meta-synthesis was to examine the barriers and facilitators of community reintegration in the first year after stroke from the perspective of people with stroke. Methods: A systematic literature search was conducted. Papers that used qualitative methods to explore the experiences of individuals with stroke around community reintegration in the first year after stroke were included. Two reviewers independently assessed the methodological quality of papers. Themes, concepts and interpretations were extracted from each study, compared and meta-synthesised. Results: From the 18 included qualitative studies four themes related to community reintegration in the first year after stroke were identified: (i) the primary effects of stroke, (ii) personal factors, (iii) social factors and (iv) relationships with professionals. Conclusions: This review suggests that an individual’s perseverance, adaptability and ability to overcome emotional challenges can facilitate reintegration into the community despite persisting effects of their stroke. Appropriate support from family, friends, the broader community and healthcare professionals is important. Therapeutic activities should relate to meaningful activities and should be tailored to the individual stroke survivor. Implications for Rehabilitation: Stroke survivors feel that rehabilitation in familiar environments and therapeutic activities that reflect real-life could help their community re-integration. In addition to the physical sequelae of stroke, emotional consequences of stroke should be addressed during rehabilitation. Healthcare professionals can provide clear and locally relevant advice to facilitate aspects of community reintegration, including the return to driving and work.

Using Timed Up and Go and Usual Gait Speed to Predict Incident Disability in Daily Activities Among Community-Dwelling Adults Aged 65 and Older

OBJECTIVES To compare the ability of Timed Up and Go (TUG) and usual gait speed (UGS) to predict incident disability completing basic activities of daily living (ADL) and instrumental ADL (IADL) in older adults free of disability at baseline, and to provide estimates for the probability of incident disability at different levels of baseline mobility performance. DESIGN Data from the first 2 waves of The Irish Longitudinal Study on Ageing, a study assessing health, economic, and social aspects of ageing in adults aged ≥50 years. SETTING A nationally representative, population-based sample of community-dwelling adults. PARTICIPANTS Participants aged ≥65 years who completed mobility tests during a health assessment, had no reported difficulty in ADL/IADL, and had a Mini-Mental State Examination score ≥24 were re-interviewed after 2 years (n=1664). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Participants completed the TUG and UGS at baseline and indicated difficulty in a number of basic ADL and IADL at follow-up. RESULTS Receiver operating characteristic analysis indicated that TUG and UGS are acceptable tools to predict disability in ADL and IADL (area under the curve [AUC]=.65-.75) with no significant difference between them (P>.05). Both were excellent predictors of difficulty in higher-level functioning tasks such as preparing hot meals, taking medications, and managing money (AUC>.80). Predictive probabilities were obtained across a range of performance levels. CONCLUSIONS TUG and UGS have similar predictive ability in relation to incident disability in basic ADL and IADL. Predictive probabilities can be used to identify those most at risk and in need of particular services. Since improving physical function can prevent or delay dependence in ADL/IADL, TUG and UGS can also provide performance goals and feedback during exercise interventions.

Community re-integration and long-term need in the first five years after stroke: results from a national survey

Abstract Purpose: Acute stroke care continues to improve but the later stroke recovery phase remains less well understood. The aim of this study was to document self-reported need in relation to stroke recovery and community re-integration among community-dwelling persons up to five years post-stroke. Methods: A national survey was carried out in Ireland. Participants were recruited through stroke advocacy organisations and health professionals. Existing validated questionnaires were adapted with permission. The final questionnaire assessed respondents’ perceptions of their community re-integration and on-going needs. Results: A total of 196 stroke survivors, aged 24–89 years responded. Over 75% of respondents reported experiencing mobility, emotional, fatigue and concentration difficulties post-stroke. Emotional problems and fatigue demonstrated the highest levels of unmet need. Families provided much support with 52% of people needing help with personal care post-stroke. Forty-two per cent of respondents in a relationship felt that it was significantly affected by their stroke. In addition, 60% of respondents reported negative financial change. Only 23% of those <66 years had worked since their stroke, while 60% of drivers returned to driving. Conclusions: Stroke had a personal, social and economic impact. Emotional distress and fatigue were common and satisfaction with the help available for these problems was poor. Implications for Rehabilitation Professionals should recognise that family members provide high levels of support post-stroke while dealing with changes to personal relationships. Emotional, concentration and fatigue problems post-stroke require recognition by health professionals. A greater focus on return-to-work as part of stroke rehabilitation may be of value for patients of working age.

A controlled clinical trial investigating the effects of cycle ergometry training on exercise tolerance, balance and quality of life in patients with Parkinson's disease

Purpose: To establish the effect of a 6-week programme of cycle ergometry training on exercise tolerance, balance, activities of daily living (ADL) and quality of life in individuals with Parkinson’s disease (PD). Method: Twenty-three subjects were recruited from the Parkinson’s database of the neurology service in a large urban teaching hospital. Quasi-experimental study of interrupted time-series design was conducted with subjects acting as their own control. Assessments were carried out at baseline, week 7 following the control phase, and week 14 following the intervention phase. Intervention consisted of 30-min cycle ergometry training once weekly. Outcome measures included Six Minute Walk Test, Physiological Cost Index, Berg Balance Scale, Timed Up and Go Test (TUAG), ADL and mobility sections of the Unified Parkinson’s disease Rating Scale (UPDRS) and the Parkinson’s disease questionnaire (PDQ). Results: Statistically significant improvements were noted for the Berg Balance Scale (p = 0.003), TUAG (p = 0.019) and ADL (p = 0.006) and mobility (p = 0.021) sections of the UPDRS. A trend towards improvement was found for exercise tolerance. No significant effect on quality of life was found. Conclusion: A 6-week programme of cycle ergometry training did not significantly influence exercise tolerance in this sample, but improved balance, functional abililty and PD-related disability were noted. Implications for Rehabilitation Individuals with Parkinson’s disease demonstrate lower levels of exercise tolerance than healthy controls. Individuals with Parkinson’s disease could participate in 30 min of cycle ergometry training, with no rest periods required. Cycle ergometry training has a positive effect on balance, function and PD-related disability.

Outcomes among older people in a post-acute inpatient rehabilitation unit

Purpose: Designated multidisciplinary rehabilitation units have been shown to provide several benefits for the frail older population. The aim of this research was to evaluate changes in strength, mobility, balance, endurance, frailty and quality of life (QoL) following a 6-week multidisciplinary inpatient rehabilitation programme. Method: This was a prospective, observational study performed in a post-acute multidisciplinary geriatric inpatient rehabilitation service. A consecutive sample of heterogenous frail older adults (n = 32) participated. Subjects were assessed on admission to the rehabilitation service (T1) and following 6 weeks of rehabilitation (T2). A range of outcome measures were used to assess function and QoL: Berg Balance Scale (BBS), Timed Up and Go (TUG), 6-Minute Walk Test (6MWT), Barthel Index (BI), EuroQol-Visual Analogue Scale (EQ-VAS), Clinical Frailty Scale (CFS), lower limb and grip dynamometry. Results: The majority were female (n = 25), the mean age was 82.9 years (SD 6.35). The median length of stay was 49 days. Patients improved significantly between T1 and T2 assessments in the BBS (p ≤ 0.0001); TUG (p ≤ 0.0001); 6MWT (p ≤ 0.0001); BI (p ≤ 0.0001); EQ-VAS (p = 0.002); CFS (p ≤ 0.0001); and in some aspects of grip and lower limb strength. Conclusion: This study has demonstrated that positive outcomes occurred in a range of measures in an older, frail inpatient rehabilitation population. Implications for Rehabilitation Elderly inpatients undergoing rehabilitation programmes improve across a range of measures looking at impairment, activity, participation and quality of life. However, gains were modest and patients did not attain their baseline level of performance after a 6-week programme of inpatient rehabilitation. Using outcome measures in clinical rehabilitation practice can facilitate comparison between units and can form the basis for future research in this population.

Barriers and facilitators associated with return to work after stroke: a qualitative meta-synthesis

Abstract Purpose: To enhance the employment outcomes of individuals who experience a stroke, it is essential to understand the factors that determine successful return to work. The aim of this systematic review was to examine barriers to and facilitators of return to work after stroke from the perspective of people with stroke through the process of a qualitative meta-synthesis. Methods: A systematic literature search was conducted. Studies that employed qualitative methods to explore the experiences of individuals with stroke around return to work after stroke were included. The methodological quality of the studies was assessed by two independent reviewers. Overarching themes, concepts and interpretations were extracted from each individual study, compared and meta-synthesized. Results: Fifteen studies were included and the overall methodological quality of the studies was good. Four broad themes emerged as factors associated with return to work after stroke. These included (i) the nature of the effects of stroke, (ii) the preparatory environment, (iii) personal coping strategies and internal challenges and (iv) the meaning of work. Conclusion: Return to work after stroke is a complex process which can be facilitated or impeded by organizational, social or personal factors, as well as accessibility to appropriate services. Implications for Rehabilitation Following a period of dedicated inpatient rehabilitation, there is a need to integrate community-support services to optimize return to work among stroke survivors. A dedicated community stroke support liaison officer may help to facilitate the transition between the hospital and the community and workplace environment. Education provided by healthcare professionals is necessary in the community and the workplace to ensure that family, friends and employers are aware of the impairments, activity limitations and participation restrictions of the stroke survivor.

Step-Count Accuracy of 3 Motion Sensors for Older and Frail Medical Inpatients

OBJECTIVE To measure the step-count accuracy of an ankle-worn accelerometer, a thigh-worn accelerometer, and a pedometer in older and frail inpatients. DESIGN Cross-sectional design study. SETTING Research room within a hospital. PARTICIPANTS Convenience sample of inpatients (N=32; age, ≥65 years) who were able to walk 20m independently with or without a walking aid. INTERVENTIONS Patients completed a 40-minute program of predetermined tasks while wearing the 3 motion sensors simultaneously. Video recording of the procedure provided the criterion measurement of step count. MAIN OUTCOME MEASURES Mean percentage errors were calculated for all tasks, for slow versus fast walkers, for independent walkers versus walking-aid users, and over shorter versus longer distances. The intraclass correlation was calculated, and accuracy was graphically displayed by Bland-Altman plots. RESULTS Thirty-two patients (mean age, 78.1±7.8y) completed the study. Fifteen (47%) were women, and 17 (51%) used walking aids. Their median speed was .46m/s (interquartile range [IQR], .36-.66m/s). The ankle-worn accelerometer overestimated steps (median error, 1% [IQR, -3% to 13%]). The other motion sensors underestimated steps (median error, 40% [IQR, -51% to -35%] and 38% [IQR -93% to -27%], respectively). The ankle-worn accelerometer proved to be more accurate over longer distances (median error, 3% [IQR, 0%-9%]) than over shorter distances (median error, 10% [IQR, -23% to 9%]). CONCLUSIONS The ankle-worn accelerometer gave the most accurate step-count measurement and was most accurate over longer distances. Neither of the other motion sensors had acceptable margins of error.

Access to Rehabilitation at Six Months Post Stroke: A Profile from the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) Study

Background and Purpose: Stroke is the third leading cause of death and disability. Few studies have assessed the profile and adequacy of access to rehabilitation services after ischaemic stroke both in the inpatient and community setting. The objectives of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) study were to assess the disability and rehabilitation profile, adherence with rehabilitation recommendations and needs of patients 6 months following hospital admission for stroke. Methods: A rehabilitation prescription was completed before hospital discharge for each participant, and adherence to this prescription was assessed at 6 months to determine whether patients received their recommended rehabilitation needs. Results: Two hundred and fifty six patients were recruited to ASPIRE-S. The average age was 69 (SD 12.8). A majority (n = 221, 86%) were referred to the hospital multidisciplinary team, 59% (n = 132) were referred to all services (physiotherapy (PT), occupational therapy (OT), speech and language therapy (SLT)). Fifty-four percent (n = 119) of patients (seen by the multidisciplinary team) were referred for further rehabilitation in the community on discharge. Of these 119 patients, 112 (95%) recalled receiving community rehabilitation services. However, while most (68%) patients were referred for several disciplines (PT, OT, SLT), the most commonly recalled therapy (55%) was from a single discipline. The most commonly recommended frequency of therapy required was on a weekly basis. Sixty-one patients (51%) reported a delay in services, with some still awaiting services at 6 months. Conclusion: Results from this prospective study revealed that a significant number of patients (57%) did not receive the therapy recommended on discharge. Future initiatives should include the development of policies, which support more effective, equitable multidisciplinary rehabilitation for stroke patients in the community.

First year post-stroke healthcare costs and fall-status among those discharged to the community

Introduction Falls are common post-stroke events but their relationship with healthcare costs is unclear. The aim of this study was to examine the relationship between healthcare costs in the first year after stroke and falls among survivors discharged to the community. Patients and methods Survivors of acute stroke with planned home discharges from five large hospitals in Ireland were recruited. Falls and healthcare utilisation data were recorded using inpatient records, monthly calendars and post-discharge interviews. Cost of stroke was estimated for each participant from hospital admission for one year. The association of fall-status with overall cost was tested with multivariable linear regression analysis adjusting for pre-stroke function, stroke severity, age and living situation. Results A total of 109 stroke survivors with complete follow-up data (mean age = 68.5 years (SD = 13.5 years)) were included. Fifty-three participants (49%) fell following stroke, of whom 28 (26%) had recurrent falls. Estimated mean total healthcare cost was €20,244 (SD=€23,456). The experience of one fall and recurrent falls was independently associated with higher costs of care (p = 0.02 and p < 0.01, respectively). Discussion The observed relationship between falls and cost is likely to be underestimated as aids and adaptions, productivity losses, and nursing home care were not included. Conclusion This study points at differences across fall-status in several healthcare costs categories, namely the index admission, secondary/tertiary care (including inpatient re-admissions) and allied healthcare. Future research could compare the cost-effectiveness of inpatient versus community-based fall-prevention after stroke. Further studies are also required to inform post-stroke bone-health management and fracture-risk reduction.