Noomi Katz

Functional disability and rehabilitation outcome in right hemisphere damaged patients with and without unilateral spatial neglect

OBJECTIVE To evaluate the impact of unilateral spatial neglect (USN) on the rehabilitation outcome and long-term functioning in activities of daily living (ADL) and instrumental ADL (IADL) of right hemisphere damaged (RHD) stroke patients. DESIGN Assessments of sensory-motor and cognitive impairment and of functional disability were conducted upon admission to rehabilitation, upon discharge from the rehabilitation hospital, and 6 months after discharge, up to a year postonset. SETTING The Loewenstein Rehabilitation Hospital, which receives patients from all general hospitals in Israel. PATIENTS Forty consecutive admissions of adult right-handed patients with a first, single, right hemispheric stroke proven by computed tomography. Based on their total score in the Behavioral Inattention Test for neglect, patients were divided into two groups: 19 with neglect (USN+) and 21 without neglect (USN-). OUTCOME MEASURES Functional Independence Measure, for ADL; The Rabideau Kitchen Evaluation, for IADL. RESULTS Impairment and disability levels of RHD patients with and without USN were clearly differentiated. Neglect is associated with lower performance on measures of impairment (sensory-motor and cognitive), as well as on measures of disability in ADL and IADL. Differences were significant in all testing periods. The recovery pattern of USN+ patients is slower and more attenuated. In both groups, most improvement occurs in the first 5 months after onset. USN is the major predictor of rehabilitation outcome from admission to follow-up. CONCLUSIONS The significance of neglect as a major source of stroke-related long-term disability justifies further research efforts to develop appropriate therapeutic modalities for this complex, multifactorial syndrome.

Video capture virtual reality as a flexible and effective rehabilitation tool

Video capture virtual reality (VR) uses a video camera and software to track movement in a single plane without the need to place markers on specific bodily locations. The users image is thereby embedded within a simulated environment such that it is possible to interact with animated graphics in a completely natural manner. Although this technology first became available more than 25 years ago, it is only within the past five years that it has been applied in rehabilitation. The objective of this article is to describe the way this technology works, to review its assets relative to other VR platforms, and to provide an overview of some of the major studies that have evaluated the use of video capture technologies for rehabilitation.

Activities, participation and satisfaction one-year post stroke

Purpose. To evaluate the chronic consequences of stroke in terms of activity limitations, restricted participation and dissatisfaction from life, and the relationship between these variables, in stroke survivors living in the community one-year post onset. Method. A total of 56 stroke patients (mean age: 57.7) who completed an in-patient rehabilitation programme, were evaluated one-year post onset in their homes, using the following instruments: Functional Independence Measure (FIM), Instrumental Activities of Daily Living Questionnaire (IADLq), Activity Card Sort (ACS), a work questionnaire, Life-Satisfaction Questionnaire (Li-Sat 9) and the Geriatric Depression Scale (GDS). Results. One year post stroke onset the mean FIM motor score was 75.88 (max score: 91), yet more than 50% of the sample still required assistance (usually mild to moderate) in dressing, bathing and use of stairs. The majority of the sample required full assistance in some IADL domains, notably meal preparation (77%), housekeeping (70%) and laundry (82%). Only one subject returned to paid employment and the mean activity level (ACS), representing the percentage of leisure and IADL activities retained from before stroke, was 42.8%. Satisfaction ratings were generally low but varied between domains. Only 39% were satisfied from ‘life as a whole’. The lowest satisfaction rates were noted for ‘vocational situation’ (14%), ‘leisure situation’ (34%) and ‘ability in self-care’ (43%), whereas the satisfaction rate from family life was high (84%). Significant correlations were found between overall life satisfaction scores and the overall FIM motor, IADLq, and ACS scores (Pearson r values: 0.32, 0.48 and 0.57, respectively). Activity level was found to be a significant predictor of satisfaction (p = 0.007) beyond that accounted for by demographic variables and depression. Conclusions. Stroke survivors dwelling in the community demonstrate long-standing dissatisfaction one-year post onset, correlating with activity limitation and restricted participation. The findings present a compelling need for rehabilitation services with a focus on participation in IADL and leisure activities, in order to improve the satisfaction of this population.

Adapting an immersive virtual reality system for rehabilitation

The purpose of this paper is to present an overview of the adaptations that have been done to VividGroups Gesture Xtreme projected VR scenarios in order to facilitate their use in neurological rehabilitation. First, the scenarios and the adaptation (control of the type, speed, location and direction of all stimuli) are briefly described. The advantages and limitations of the adapted VR system as a rehabilitation tool are presented. Next, initial results and two examples of case studies, one a patient following stroke and one who requires balance training as a result of complete spinal cord injury, are used to illustrate applications of this VR system to rehabilitation. Copyright

Textbook of Neural Repair and Rehabilitation: Virtual reality in neurorehabilitation

This chapter provides an overview of applications of virtual reality (VR) to rehabilitation. A key concept related to VR is immersion. Immersion relates to the extent to which the VR system succeeds in delivering an environment which refocuses a users sensations from the real world to a virtual world. Virtual environments are usually experienced with the aid of special hardware and software for input and output. Visual information is commonly displayed by head mounted displays (HMDs), projection systems or flat screens of varying size. VR applications in rehabilitation are expanding at a rapid pace and a large variety of platforms and programs are currently being used and developed. It has been used as a medium for the assessment and rehabilitation of cognitive processes. The ultimate goal of VR-based intervention is to enable clients to become more able to participate in their own real environments in an independent manner.

Video-capture virtual reality system for patients with paraplegic spinal cord injury.

This article presents results from a feasibility study of a video-capture virtual reality (VR) system used with patients who have paraplegic spinal cord injury (SCI) and who need balance training. The advantages of the VR system include providing the user with natural control of movements, the ability to use as many parts of the body as are deemed suitable within the context of therapeutic goals, and flexibility in the way the system can be adapted to suit specific therapeutic objectives. Thirteen participants with SCI experienced three virtual environments (VEs). Their responses to a Short Feedback Questionnaire showed high levels of presence. We compared performance in the environments with a group of 12 nondisabled participants. Response times for the patient group were significantly higher and percentage of success was significantly lower than that for the nondisabled group. In addition, significant moderate correlations were found between performance within a VE and static balance ability as measured by the Functional Reach Test. This study is a first step toward future studies aimed at determining the potential of using this VR system during the rehabilitation of patients with SCI.

Validation of the Virtual MET as an assessment tool for executive functions

The purpose of this study was to establish ecological validity and initial construct validity of a Virtual Multiple Errands Test (VMET) as an assessment tool for executive functions. It was implemented within the Virtual Mall (VMall), a novel functional video-capture virtual shopping environment. The main objectives were (1) to examine the relationships between the performance of three groups of participants in the Multiple Errands Test (MET) carried out in a real shopping mall and their performance in the VMET, (2) to assess the relationships between the MET and VMET of the post-stroke participants level of executive functioning and independence in instrumental activities of daily living, and (3) to compare the performance of post-stroke participants to those of healthy young and older controls in both the MET and VMET. The study population included three groups; post-stroke participants (n = 9), healthy young participants (n = 20), and healthy older participants (n = 20). The VMET was able to differentiate between two age groups of healthy participants and between healthy and post-stroke participants thus demonstrating that it is sensitive to brain injury and ageing and supports construct validity between known groups. In addition, significant correlations were found between the MET and the VMET for both the post-stroke participants and older healthy participants. This provides initial support for the ecological validity of the VMET as an assessment tool of executive functions. However, further psychometric data on temporal stability are needed, namely test–retest reliability and responsiveness, before it is ready for clinical application. Further research using the VMET as an assessment tool within the VMall with larger groups and in additional populations is also recommended.

Participation in Occupational Performance: Reliability and Validity of the Activity Card Sort:

The Activity Card Sort (ACS) is a comprehensive instrument for assessing participation in occupational performance of instrumental, social-cultural, and leisure activities. The purpose of the study was to determine the reliability and validity of the ACS within different adult and older adult groups. The study included 263 participants comprising 5 groups of 61 healthy adults, 61 healthy older adults, 40 spouses or caregivers of individuals with Alzheimers, 45 individuals with multiple sclerosis, and 56 individuals 1 year after having a stroke. The ACS was adapted to the Israeli culture in a previous study with the authors permission. The final version that was used in this analysis included 88 picture cards of adults performing instrumental, social-cultural, and low and high physical leisure activities that the clients sort into five categories. The ACS provides a “retained activity level” score that is the percentage of activities in which a person is currently engaged divided by those with whom he or she was involved in the past. In addition, comparisons between all groups of current activity levels were analyzed. The ACS had high internal consistency (Cronbach alpha in each area) for instrumental activities of daily living (IADL) and social-cultural activities (.82, .80), and lower for low and high physical leisure activities (.66, .61). A one-way analysis of variance (ANOVA) that compared groups of participants on total retained activity level and individual activity areas showed a significant group effect on all comparisons (p<.000) that support construct validity. Post hoc Scheffe tests revealed significant differences between most groups. The same results were found for current activity level. The results support the reliability and validity of the ACS and provide a basis for its clinical use.

Unawareness and/or denial of disability: implications for occupational therapy intervention.

Occupational therapy focus on client-centred, occupational performance intervention may become complicated by the phenomena of self-awareness. The problem of awareness deficits in clients with neurological disorders may be attributed to neurological impairment of self-awareness and/or psychological denial of disability. These phenomena present themselves more commonly in combination than dichotomously and have implications for treatment outcomes. Individuals with impaired self-awareness or denial face difficulties with motivation and participation in therapy, and the adoption of compensatory strategies, which ultimately impacts on rehabilitation outcome. The extent of unawareness versus denial can be assessed by observation of a clients behavior and this information can be very useful in directing the treatment approach. The purpose of this paper is, therefore, to discuss the phenomenon of unawareness and/or denial of disability and its importance to successful rehabilitation outcomes, current thinking and research conducted in different countries. Also, detailed case examples of three clients representing three major populations of traumatic brain injury, stroke and schizophrenia who may exhibit unawareness and/or denial of disability will be presented, including intervention strategies for both phenomena.

Anosognosia for Hemiplegia in Stroke Rehabilitation

Objective: The purpose of this study was to investigate anosognosia for hemiple gia (AHP) in the rehabilitation phase after onset of stroke. Methods: Forty-six hemi plegic stroke patients, 29 with right hemisphere damage (RHD) and 17 with left hemi sphere damage (LHD) were evaluated ∼1 month after onset of stroke. Anosognosia was evaluated with an implicit measure designed to assess anosognosic behaviors (choosing between unimanual and bimanual tasks), in addition to a traditional ex plicit verbal measure. Results: AHP was found m 28% of the RHD and 24% of the LHD group. The majority of patients with AHP in the RHD group had large lesions involving the frontal, parietal, or temporal lobes and had coexisting sensory deficits and unilateral spatial neglect, whereas the LHD patients with AHP had predominantly small subcortical lesions and no sensory or attentional deficits. The functional out comes of AHP patients in both hemisphere groups revealed their inability to retain safety measures at discharge from rehabilitation (p < 0.036) and their need for assis tance in basic and instrumental activities of daily living at follow-up. Conclusions: AHP presents a significant risk for negative functional outcome in stroke rehabilita tion. The underlying mechanisms of AHP may be different for left and right hemi sphere patients, therefore requiring different intervention approaches. Key Words: Anosognosia—Cerebrovascular accident—Rehabilitation outcome.