Sara Hayes

Associations between executive function and physical function poststroke: a pilot study

OBJECTIVES Associations between executive function and physical function poststroke have not been extensively studied. More complex physiotherapy interventions poststroke require a greater degree of cognitive ability, especially executive function. This pilot study aimed to inform the methodology of a larger study by examining the associations between executive function and the performance of basic and complex gait tasks in people poststroke. DESIGN A cross-sectional pilot study was conducted in a convenience sample of 20 participants recruited from a community-based voluntary stroke organisation and from the outpatient services of two urban hospitals. MAIN OUTCOME MEASURES A battery of tests was used to measure executive function (Trail Making Test, Stroop Word-Colour Test, Zoo Map test, Frontal Assessment Battery and Digit Span backward test). Basic and complex 10metre gait tests were used to mimic aspects of physiotherapy intervention poststroke. Other measures included the Mini-Mental State Examination (MMSE) and the Motor Assessment Scale (MAS). RESULTS Observational comparisons between participant executive function scores and age- and/or education-matched normative data demonstrated that executive dysfunction ranged between 55% and 100%. Poorer performance in measures of executive function was more frequently associated with poorer performance in complex gait tests compared with basic gait tests. The MAS was not significantly associated with any measure of executive function. CONCLUSIONS Executive dysfunction is a common sequel poststroke which may negatively affect physical performance. Physiotherapists should consider executive dysfunction when developing rehabilitation strategies to improve physical function poststroke.

The measurement and impairment of executive function after stroke and concepts for physiotherapy

Abstract Background: Physiotherapy intervention following stroke includes the performance of physical exercises that require both physical and cognitive resources. In addition to physical impairments after stroke, there also is a high prevalence of executive function impairment among this patient group. Traditionally, executive function has been associated with the domains of occupational therapy and neuropsychology. More recently, it has formed one of the defined domains of ‘functional cognition’, i.e. cognition required for daily activities which includes impairments that may be influential on the initiation and performance of exercise — an integral component of physiotherapy intervention following stroke. One aim of this review was to provide a description of commonly used measures of executive function after stroke which may be useful for physiotherapists. In addition, an examination of the prevalence of executive function impairment after stroke and its associations with physical performance and other variables was considered and will be discussed. Method: Five databases (CINAHL, PubMed, Embase, MEDLINE, and PsycINFO) were searched, using the keywords: executive function, stroke, physiotherapy, and executive function assessment. References in the articles identified were further screened for additional citations. The methodological quality of the articles included was evaluated using an adapted version of the Checklist for the Evaluation of Research Articles and the Physiotherapy Evidence Database (PEDro) scale. Major findings: Fourteen studies were included in this review. The randomized controlled trial was of moderate-to-high quality and the cross-sectional and longitudinal studies demonstrated substantial methodological shortcomings. The most commonly used tests of executive function were: Trail Making Test (n = 6), Stroop Task (n = 6), Digit Span Test (n = 4), Wisconsin Card Sorting Test (n = 4), and Verbal Fluency Test (n = 4). Six studies reported percentage of executive function impairment among people with stroke ranging from 3% to 63% and seven studies reported significant differences between mean stroke data and control or normative data in both acute and chronic stages post-stroke. Executive function impairment was associated with many aspects integral to physiotherapy rehabilitation, e.g. balance, mobility, rehabilitation participation, and activity of daily living ability. Executive function impairment was found irrespective of lesion location and severity. Conclusions: People presenting with executive function impairment may have difficulty initiating and completing a physiotherapy exercise programme and subsequently the success of rehabilitation may be compromised. Further attention of physiotherapists to the presence of executive function impairment after stroke may improve rehabilitation outcomes. However, poor methodological quality of the studies limited the strength of the conclusions of this review.

Cohort Study Comparing the Berg Balance Scale and the Mini-BESTest in People Who Have Multiple Sclerosis and Are Ambulatory.

Background The Berg Balance Scale (BBS) is a balance measure commonly used for people with multiple sclerosis (MS). The Mini-BESTest is an alternative based on balance systems. Objective The study objective was to compare the BBS and the Mini-BESTest for sensitivity to change, likelihood ratios for walking aid use and falls, and associations with clinical variables in people who have MS and are ambulatory. Design This was a cohort study with measurements before and after exposure to 8 weeks of routine physical therapy intervention. Methods For 52 participants who had a primary diagnosis of MS and who were independently mobile, with or without an aid, demographic details and a history of falls and near falls were collected. Participants completed the Mini-BESTest, Multiple Sclerosis Impact Scale-29, Multiple Sclerosis Walking Scale-12, BBS, Modified Fatigue Impact Scale, and Six-Minute Walk Test. Results No participant started with a baseline Mini-BESTest maximum score of 28, whereas 38.5% (n=20) started with a baseline BBS maximum score of 56. Statistically significant changes in the Mini-BESTest score (X̅=5.31, SD=3.5) and the BBS score (X̅=1.4, SD=1.9) were demonstrated. Effect sizes for the Mini-BESTest and the BBS were 0.70 and 0.37, respectively; standard response means for the Mini-BESTest and the BBS were 1.52 and 0.74, respectively. Areas under the receiver operating characteristic curves for the Mini-BESTest and the BBS were 0.88 and 0.77, respectively, for detecting mobility device use and 0.88 and 0.75, respectively, for detecting self-reported near falls. The Mini-BESTest had a higher correlation for each secondary measure than did the BBS. Limitations This study involved a sample of convenience; 61% of the participants did not use a walking aid. The order of testing was not randomized, and fall status was obtained through retrospective recall. Conclusions The Mini-BESTest had a lower ceiling effect and higher values on responsiveness tests. These findings suggest that the Mini-BESTest may be better at detecting changes in balance in people who have MS, are ambulatory, and have relatively little walking disability.

What do people with MS want from a web-based resource to encourage increased physical activity behaviour?

abstract Purpose: To investigate what people with multiple sclerosis (PwMS) want from a web-based resource that encourages physical activity (PA). Methods: Three focus groups (n = 22) and 11 semi-structured interviews were conducted. The semi-structured interviews were conducted using Skype (audio only) or telephone. Interviews were audio-recorded, transcribed verbatim and the thematic analysis approach described by Braun and Clarke was performed. Results: The themes from the data were: (1) Content – important information to include, (2) Presentation – varying format, different abilities, (3) Interactivity – build a sense of community and (4) Reach the Audience – let people know. Participants believed the web resource to be a good idea and suggested that the content of resource should include a focus on the knowledge of the benefits of being physically active. Illustrating the types of exercise in which PwMS could participate in was also discussed. Ensuring information was stratified by mobility level and that the resource was interactive, portraying a ‘Sense of Community’ and use of success stories, was also suggested by participants. Conclusions: The data suggest that PwMS want a variety of information from a variety of sources and that this information is to be both stratified and interactive. These results will be used to inform the development of the ‘Activity Matters’ website which will aim to enable PwMS to become more physically active. Implications for Rehabilitation People with multiple sclerosis (PwMS) want information on the benefits of being physically active in order to change physical inactivity behaviours. Offering PwMS a range of exercise options that can be stratified by mobility and physical activity levels may further enable them to become more physically active. Peer support and creating a sense of community are important components when aiming to motivate PwMS to become more physically active.

Comparing the clinical-effectiveness and cost-effectiveness of an internet-delivered Acceptance and Commitment Therapy (ACT) intervention with a waiting list control among adults with chronic pain: study protocol for a randomised controlled trial

Introduction Internet-delivered psychological interventions among people with chronic pain have the potential to overcome environmental and economic barriers to the provision of evidence-based psychological treatment in the Irish health service context. While the use of internet-delivered cognitive–behavioural therapy programmes has been consistently shown to have small-to-moderate effects in the management of chronic pain, there is a paucity in the research regarding the effectiveness of an internet-delivered Acceptance and Commitment Therapy (ACT) programme among people with chronic pain. The current study will compare the clinical-effectiveness and cost-effectiveness of an online ACT intervention with a waitlist control condition in terms of the management of pain-related functional interference among people with chronic pain. Methods and analysis Participants with non-malignant pain that persists for at least 3 months will be randomised to one of two study conditions. The experimental group will undergo an eight-session internet-delivered ACT programme over an 8-week period. The control group will be a waiting list group and will be offered the ACT intervention after the 3-month follow-up period. Participants will be assessed preintervention, postintervention and at a 3-month follow-up. The primary outcome will be pain-related functional interference. Secondary outcomes will include: pain intensity, depression, global impression of change, acceptance of chronic pain and quality of life. A qualitative evaluation of the perspectives of the participants regarding the ACT intervention will be completed after the trial. Ethics and dissemination The study will be performed in agreement with the Declaration of Helsinki and is approved by the National University of Ireland Galway Research Ethics Committee (12/05/05). The results of the trial will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals. Trial registration number ISRCTN18166896.

Minimum number of days required for a reliable estimate of daily step count and energy expenditure, in people with MS who walk unaided

BACKGROUND AND PURPOSE The purpose of this study was to examine the minimum number of days needed to reliably estimate daily step count and energy expenditure (EE), in people with multiple sclerosis (MS) who walked unaided. METHODS Seven days of activity monitor data were collected for 26 participants with MS (age=44.5±11.9years; time since diagnosis=6.5±6.2years; Patient Determined Disease Steps=≤3). Mean daily step count and mean daily EE (kcal) were calculated for all combinations of days (127 combinations), and compared to the respective 7-day mean daily step count or mean daily EE using intra-class correlations (ICC), the Generalizability Theory and Bland-Altman. RESULTS For step count, ICC values of 0.94-0.98 and a G-coefficient of 0.81 indicate a minimum of any random 2-day combination is required to reliably calculate mean daily step count. For EE, ICC values of 0.96-0.99 and a G-coefficient of 0.83 indicate a minimum of any random 4-day combination is required to reliably calculate mean daily EE. For Bland-Altman analyses all combinations of days, bar single day combinations, resulted in a mean bias within ±10%, when expressed as a percentage of the 7-day mean daily step count or mean daily EE. CONCLUSIONS A minimum of 2days for step count and 4days for EE, regardless of day type, is needed to reliably estimate daily step count and daily EE, in people with MS who walk unaided.

Executive dysfunction and balance function post-stroke: A cross-sectional study

OBJECTIVES This study investigated the: (1) prevalence of executive dysfunction (ED); (2) demographic and clinical differences between participants with ED and without ED and; (3) independent association between executive function (EF) and balance post-stroke. DESIGN Prospective observational cross-sectional study. SETTING Four large acute hospitals. PARTICIPANTS Convenience sample of people with first stroke. MAIN OUTCOME Balance function. SECONDARY OUTCOMES EF, stroke severity, depression and global cognition. METHODS Descriptive statistics were used to report the prevalence of ED post-stroke. Comparisons of demographic and clinical characteristics were made between participants with ED and participants without ED using independent t-tests. Hierarchical multiple linear regression analysis determined the association between EF and balance post-stroke. RESULTS Participant (n=100) age ranged from 31 to 98 years, time since stroke ranged from 4 to 180 days and the participants reported formal education ranging from 7 to 21 years. Participants with ED had more severe strokes (BADS) [median (IQR) vs. median (IQR), p-value] [(44 (16) vs. (51 (7), p<0.01], poorer global cognition [24 (6) vs. 29 (2), p<0.01] and poorer balance [29 (40) vs. 46.5 (17), p<0.01] in comparison with participants without ED. Age (β=-0.24, p<0.05), years in education, (β=-0.21, p<0.05), stroke severity (β=0.71, p<0.01), time since stroke, (β=-0.17, p<0.01) and EF (β=0.19, p<0.05) were independently associated with balance post-stroke. The total variance in balance explained by the model was 72%. CONCLUSIONS ED is independently associated with balance post-stroke. Physiotherapists should consider this when developing rehabilitation strategies to improve balance post-stroke.

Physical Fitness Training for Patients With Stroke

Cardiorespiratory and musculoskeletal fitness are low after stroke. Interventions to improve physical fitness after stroke could have a range of physical, cognitive, and psychosocial benefits. The primary aims of this updated review1 were to determine whether physical fitness training after stroke reduces death, dependence, and disability. The secondary aims were to assess the effects of training on adverse events, risk factors, physical fitness, mobility, physical function, quality of life, mood, and cognitive function. Cognition outcomes have become an important poststroke intervention target and are, therefore, added to this review update. ### Search Methods We searched the Cochrane Stroke Group Trials Register (last searched February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 1: searched February 2015), MEDLINE (1966 to February 2015), EMBASE (1980 to February 2015), CINAHL (1982 to February …

Social Cognitive Theory Correlates of Physical Activity in Inactive Adults with Multiple Sclerosis

Background There is a growing body of evidence that physical activity (PA) improves symptoms of multiple sclerosis (MS). Despite the benefits of PA, people with MS are relatively inactive compared with their healthy counterparts. This study investigated associations between social cognitive theory (SCT) constructs and energy expenditure (EE) as an objective measure of PA in a sample of inactive people with MS. Methods Participants (n = 65) completed several questionnaires and were assessed using standardized outcome measures as part of a cross-sectional analysis of baseline data from a randomized controlled trial (Step it Up). Results The bivariate correlation analysis indicated that of all SCT constructs, only exercise self-efficacy was significantly correlated with EE (r = 0.297, P = .022). Multiple linear regression analysis found that exercise self-efficacy independently explained 9% of the variance in EE (R2 = 0.088). A model including exercise self-efficacy, exercise goal setting, exercise planning, and exercise benefits explained 17% of the variance in EE (F4,54 = 2.741, P = .038, R2 = 0.169). In this model, only exercise self-efficacy was significantly associated with EE scores (Exercise Self-Efficacy Scale β = .320, P = .016). Conclusions The constructs of SCT explained little of the variance of objectively measured PA in a sample of inactive people with MS who volunteered for an exercise trial. The only significant variable was exercise self-efficacy, which confirms the importance of enhancing it through PA interventions.

Interventions for preventing falls in people with multiple sclerosis

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: The aim of this review is to evaluate the effectiveness of interventions designed to reduce the rate of falls in people with multiple sclerosis (MS). Specific objectives include comparing the effectiveness of single, multiple and multifactorial interventions designed to reduce the rate of falls in people with MS.