A qualitative study exploring views and experiences of people with stroke undergoing transcranial direct current stimulation and upper limb robot therapy

Background Neurorehabilitation technologies used mainly in research such as robot therapy (RT) and transcranial direct current stimulation (tDCS) can promote upper limb motor recovery after stroke. Understanding the feasibility and efficacy of stroke rehabilitation technologies for upper limb impairments is crucial for effective implementation in practice. Small studies have explored views of RT by people with stroke; however experiences of people receiving tDCS in combination with RT have never been explored. Objective To explore views and experiences of people with sub-acute and chronic stroke that had previously taken part in a randomised controlled trial involving tDCS and RT for their impaired upper limb. Methods An interview study includes open and closed questions. Face-to-face interviews were audio recorded. Open-ended question responses were transcribed and analyzed using thematic analysis; closed questions were analyzed using descriptive analysis. Results Participants felt that RT was enjoyable (90%) and beneficial for their affected arm (100%). From the open question data, it was found that the intervention was effective for the impaired arm especially in the sub-acute stage. Main reported concerns were that tDCS caused painful, itching and burning sensations and RT was sometimes tiring and difficult. Participants recommended that future research should focus on designing a more comfortable method of tDCS and develop a robot that promotes hand movements. Conclusions This study provides new knowledge about the benefits and barriers associated with these technologies which are crucial to the future effective implementation of these tools in practice.

The Trunk Impairment Scale: a new tool to measure motor impairment of the trunk after stroke

Objective: To examine the clinimetric characteristics of the Trunk Impairment Scale (TIS). This newly developed scale evaluates motor impairment of the trunk after stroke. The TIS scores, on a range from 0 to 23, static and dynamic sitting balance as well as trunk co-ordination. It also aims to score the quality of trunk movement and to be a guide for treatment.

Design: Two physiotherapists observed each patient simultaneously, but scored independently. Each patient was re-examined by one of the therapists.

Subjects: Twenty-eight patients in a rehabilitation setting.

Results: Kappa and weighted kappa values for item per item reliability ranged for all but two, from 0.62 to 1. All percentages of agreement exceeded 81%. Intraclass correlations (ICC) for the summed scores of the different subscales were between 0.85 and 0.99. Test–retest and interobserver reliability for the TIS total score (ICC) was 0.96 and 0.99, respectively. The 95% limits of agreement for the test–retest and interexaminer measurement error were -2.90, 3.68 and -1.84, 1.84, respectively. Cronbach alpha coefficients for internal consistency ranged from 0.65 to 0.89. Content validity was defined. Spearman rank correlations with the Barthel Index (r5=0.86) and the Trunk Control Test (r5=0.83) was used to examine construct and concurrent validity, respectively.

Conclusions: Analysis of different clinimetric parameters support the use of the TIS in both clinical use and future stroke research. Guidelines for treatment and level of quality of trunk activity can be derived from the assessment.

Defining the content of individual physiotherapy and occupational therapy sessions for stroke patients in an inpatient rehabilitation setting. Development, validation and inter-rater reliability of a scoring list

Objective : To develop a valid and reliable scoring list to define the content of individual physiotherapy and occupational therapy sessions for stroke patients in inpatient rehabilitation.

Design : A list was developed based on previous lists, neurological textbooks and recorded therapy sessions. Content validity was verified and inter-rater reliability evaluated on videos of treatment sessions. In each of four rehabilitation centres, a researcher recorded and scored five physiotherapy and five occupational therapy sessions. These 40 treatment sessions were also scored by the first author. The scores of the researchers and first author were statistically compared.

Settings and subjects : Forty stroke patients in four European rehabilitation centres.

Results : The scoring list consists of 49 subcategories, divided into 12 categories: mobilization; selective movements; lying (balance); sitting (balance); standing (balance); sensory and visual perceptual training and cognition; transfers; ambulatory activities; personal activities of daily living; domestic activities of daily living; leisure- and work-related activities; and miscellaneous. Comparing the frequency of occurrence of the categories resulted in intraclass correlation coefficients, indicating high reliability for eight categories, good for one, and fair for two. One category was not observed. Spearman rank correlation coefficients were high to very high for 24 subcategories and moderate for four. Twenty-one subcategories contained too few observations to enable calculation of Spearman rank correlation coefficients. Average point-to-point percentage of agreement in time of the treatment sessions equalled 76.6 ± 16.2%.

Conclusions : The list is a valid and reliable tool for describing the content of physiotherapy and occupational therapy for stroke patients.

Sequence and onset of whole-body coordination when turning in response to a visual trigger: comparing people with Parkinson's disease and healthy adults

Turning round is a routine everyday activity that can often lead to instability. The purpose of this study was to investigate abnormalities of turning among people with Parkinson's disease (PwPD) through the measurement of sequence of body segments and latency response. Participants were asked to turn 180° and whole-body movements were recorded using CODAmotion and Visio Fast eye tracking equipment. Thirty-one independently mobile PwPD and 15 age-matched healthy controls participated in the study. We found that contrary to common belief, the head preceded movement of all other body segments (eyes, shoulders, pelvis, first and second foot). We also found interaction between group and body segment (P=0.005), indicating that overall, PwPD took longer to move from head to second foot than age-matched healthy controls. For PwPD only, interactions were found between disease severity and body segment (P<0.0001), between age group and body segment (P<0.0001) and between gender and body segments (P<0.0001). For each interaction, longer time periods were noted between moving the first foot after the pelvis, and moving the second foot after the first, and this was noted for PwPD in Hoehn and Yahr stage III-IV (in comparison to Hoehn and Yahr stage I-II); for PwPD who were under 70 years (in comparison with 70 years or over); and for ladies (in comparison with men). Our results indicate that in PwPD and healthy elderly, turning-on-the-spot might not follow the top-to-bottom approach we know from previous research.

P5-23-06: Monitoring of Quality Indicators Should Lead to Quality Measures. A Dynamic Clinical Pathway for the Treatment of Patients with Early Breast Cancer Is a Tool for Better Cancer Care: Implementation and Prospective Analysis between 2002–2010

Aim: To describe the effects of the development, implementation and prospective systematic evaluation and adaptation of a clinical care pathway for the management of patients with early breast cancer between 2002 and 2010) in a single breast unit.

Materials and methods: In 2002 a clinical pathway was developed by the multidisciplinary breast team of the Sint Augustinus Hospital for de diagnosis and treatment of patients with operable breast cancer. Performance measurements were documented systematically by care providers using an order communication, planning and result reporting system. Annual analysis of predefined clinical outcome measures and indicators was performed. Based on these data and evidence based guidelines the pathway was regularly adapted to improve patient care. Results: The annual number of patients included in the pathway (289 vs 390, p 0.01) ), proportion of patients with Tis-T1 tumors (42% vs 58 %, p 0.01), negative lymph nodes (44% vs 58%, p &lt; 0.01)) and no metastases at diagnosis (91.5% vs 95.9%) has risen significantly between 2002 and 2010. Histological subtypes remained the same. The average length of hospital stay (7.0 days vs 4.1 days, p 0.01) nearly halved and the proportion of breast conserving surgery (BCS) (43% vs 57%), preoperative guide wire localization (14% vs 27%) for impalpable lesions and use of sentinel node biopsy (0% vs 49%) increased significantly (p 0.01). Evolution of quality indicators defined by Eusoma (www.eusomadb.org/indicators.htm) between 2002 and 2010 shows a significant improvement of cancer care: proportion of positive of preoperative histologic diagnosis (59.7% vs 88.4%, p 0.001), more then 9 lymph nodes removed when axillary clearance performed (85.6 vs 91.4%, p&lt; 0.04), BCS for invasive carcinoma up to 3 cm (62.0% vs 82.6%, p 0.016), BCS for DCIS up to 20 mm (43.8% vs 78.6%, p 0.016), hormone therapy in endocrine sensitive tumor (84.8% vs 97.4%, p 0.002), adjuvant chemotherapy in ER negative (PT1c or N+) invasive carcinoma (72% vs 95.6% p 0.028), proportion of second surgery (25% vs 10%, p 0.001) and clear margins after last operation (95% vs 99%, p 0.02). All mandatory EUSOMA requirements were fulfilled in 2010. Patient satisfaction improved significantly over the years (13/19 measured parameters p &lt;0.05 between 2002–2010). Progression free 4 year survival was significantly higher for all patients, for T1 tumors only and for T2-T4 tumors only, treated in 2006–2008 compared to 1999–2002 and 2003–2005 (respectively p 0.006, p 0.05, p 0.06). Overall 4 year survival of the entire M0 population treated in 2006–2008 was significantly better (p 0.05)

Conclusion: Although the patient characteristics changed over the years due to better screening, this clinical pathway for the treatment of patients operable breast cancer proved to be an important tool to improve the quality of patient care and patient satisfaction. Better adherence to guidelines and constant feedback of treatment data to the breast team contributes to a superior patient outcome. Measuring quality indicators proved useful to develop quality measures improving patient care.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-23-06.

Discriminant ability of the Trunk Impairment Scale: A comparison between stroke patients and healthy individuals

PURPOSE

The Trunk Impairment Scale (TIS) is a standardized scale to evaluate the trunk function in stroke patients. It was the aim of this study to determine the discriminant ability of the TIS by comparing stroke patients with healthy individuals. Further, the variables that had an influence on obtaining a high score on the TIS in healthy subjects were examined.

METHOD

Forty stroke patients and 40 age- and sex-matched healthy individuals were included in the study. TIS scores from the stroke patients and healthy individuals were compared using the Wilcoxon ranked sum test.

RESULTS

Sub-scale and total TIS scores showed significant differences between stroke patients and healthy individuals (P < 0.0001). Univariate analysis and logistic regression analysis further revealed that younger persons, women and people who are more active in daily life have a higher chance of obtaining a high score on the TIS.

CONCLUSIONS

The TIS discriminates between stroke patients and healthy individuals. A submaximal score on the TIS was found in 45% of the healthy subjects suggesting that a lower score on the TIS still indicates normal trunk function and full participation in daily life.

Assesing motor impairment of the trunk in patients with traumatic brain injury: reliability and validity of the trunk impairment scale

Introduction: Literature regarding trunk assessment after Traumatic Brain Injury (TBI) is limited. The Trunk Impairment Scale (TIS) is a newly developed tool which is intended to assess static and dynamic sitting balance and trunk co-ordination.Aim: It was the aim of this study to examine the reliability andvalidity of the TIS in TBI patients.Methods: Thirty TBI subjects were recruited from within arehabilitation setting. Two researchers observed each subjectsimultaneously, but scored independently. Each subject wasre-examined by one of the raters.Results: Kappa and weighted kappa values for all items ranged from 0.34 to 1. All percentages of agreement were 70% or higher. Intraclass correlation (ICC) coefficients for the sub-scale scores were between 0.72 and 0.88. Test-retest and inter-rater reliability for the total TIS score (ICC) was 0.88 and 0.95, respectively. The 95% limits of agreement for the test-retest and interexaminer measurement error interval were -4,4 and -3,3, respectively. The construct validity was evaluated by means of the Spearman rank correlation coefficient between the TIS and the Barthel Index (r=0.59, p=.0007).Discussion and conclusion: Fair to perfect item agreement was found but the reliability of certain items requiresfurther attention. Acceptable sub-scale and total TIS reliability and validity justify the use of the TIS in TBI treatmentand research.

Expression of chymotrypsin(ogen) in the thioredoxin reductase deficient mutant strain of Escherichia coli AD494(DE3) and purification via a fusion product with a hexahistidine-tail

A reliable protocol was designed for fast expression and purification of recombinant chymotrypsin(ogen). The zymogen was overexpressed in soluble form as a (His)6-fusion construct in the cytoplasm of the thioredoxin reductase deficient Escherichia coli strain AD494(DE3). This allowed purification of chymotrypsinogen in a highly selective affinity chromatography capture step using a Ni-NTA column. After activation with enterokinase, the enzymatically active chymotrypsin was purified in a polishing step using a modified soybean trypsin inhibitor agarose column. This expression system and the use of affinity chromatography for capture and polishing, offers an easier and faster route to recombinant chymotrypsin(ogen) than the previously described use of Saccharomyces cerevisiae.