Intra- and interpersonal effects of coping style and self-efficacy on anxiety, depression and life satisfaction in patient-partner couples after stroke

Many stroke patients and partners suffer from anxiety, depression, and low life satisfaction. Psychological factors such as coping style and self-efficacy can be protective factors within individuals. The close relationship between stroke patients and partners suggests that there may be interdependence in psychological functioning. The aim of this study was to examine intra- and interpersonal effects of coping style and self-efficacy on anxiety, depression, and life satisfaction in patient-partners couples. In this prospective cohort study, pro-active coping (UPCC), general self-efficacy (GSES), anxiety (HADS-A), depression (HADS-D), and life satisfaction (1-6 scale) were assessed in 215 couples at 2 and 12 months post-stroke. Effects within couples were assessed using structural equation modelling. Several intra- and interpersonal effects of coping style and self-efficacy at 2 months post-stroke were related to emotional health at 12 months post-stroke. Most effects were intrapersonal effects. The interpersonal effects were small but showed that pro-active coping by the patient was associated with lower anxiety of the partner. Higher self-efficacy of the partner was associated with lower depression scores and higher life satisfaction of the patient. This study underscores the importance of a dyadic approach to post-stroke functioning. It supports a family-based approach for treating post-stroke emotional problems.

Nurse-led stroke aftercare addressing long-term psychosocial outcome: a comparison to care-as-usual

PURPOSE

To examine whether nurse-led stroke aftercare is beneficial for long-term psychosocial outcome of community-dwelling persons with stroke.

MATERIALS AND METHODS

Comparative effectiveness research design in which a prospective stroke aftercare cohort (n = 87) was compared to care-as-usual (n = 363) at six- and 12-months post stroke. Changes over time in cognitive and emotional problems experienced in daily life, fatigue and stroke impact on daily life were examined for stroke aftercare only. Multilevel modelling was used to compare stroke aftercare to care-as-usual concerning anxiety and depression symptoms, social participation and quality of life, over time.

RESULTS

Sample characteristics did not differ between cohorts except for stroke type and on average, more severe stroke in the stroke aftercare cohort (p < 0.05). Following stroke aftercare, anxiety and emotional problems decreased significantly (p < 0.05), whereas care-as-usual remained stable over time in terms of anxiety. No significant changes over time were observed on the other outcome domains.

CONCLUSIONS

Nurse-led stroke aftercare showed to be beneficial for emotional well-being in comparison to care-as-usual. Providing psychoeducation and emotional support seem effective elements but adding other therapeutic elements such as self-management strategies might increase the effectiveness of nurse-led stroke aftercare.Implications for rehabilitationRoutine stroke follow-up care should pay attention to psychosocial and emotional outcome in a systematic manner, in addition to secondary prevention.Healthcare professionals such as (specialized) nurses are needed to appropriately address the hidden cognitive and emotional consequences of stroke.Providing psychoeducation and emotional support in stroke aftercare diminish insecurities and worries in community-dwelling persons with stroke, leading to better outcomes.

Screening and patient-tailored care for emotional and cognitive problems compared to care as usual in patients discharged home after ischemic stroke (ECO-stroke): a protocol for a multicenter, patient-blinded, cluster randomized controlled trial

Background

Ischemic stroke patients with a good outcome in terms of motor functioning and communication are likely to be discharged home without further rehabilitation. A significant number of these patients experience cognitive and emotional problems resulting in lower quality of life and decreased participation in society. This paper presents the protocol of a study examining the clinical effectiveness, cost-effectiveness and implementation of an intervention focused on screening and patient-tailored care for cognitive and emotional problems as compared to usual care in patients discharged home after ischemic stroke.

Methods / design

A multicenter, patient-blinded, cluster randomized controlled trial will be performed. Centers will be randomized (1:1) to the intervention group or the usual care group. Patients (> 18 years old) with a neurological confirmed diagnosis of ischemic stroke who can be discharged home without follow-up treatment at an outpatient rehabilitation clinic will be included. In the intervention group, patients will receive a short, individualized, semi-structured consultation by specialized nurses in addition to usual care. This consultation includes 1) screening for cognitive and emotional problems, 2) screening for restrictions in participation, 3) promotion of self-management strategies and 4) a decision tool for referral to rehabilitation services. The intervention will be performed approximately 6 weeks after the stroke at the neurology outpatient clinics and will take approximately 60 min. The control group will receive care as usual. Both groups will be followed-up at 6 weeks, 3 months and 12 months after stroke. The primary outcome will be the level of participation measured with the Restriction subscale of the Utrecht Scale for Evaluation of Rehabilitation on the level of Participation (USER-Participation-R) at 12 months. A cost-effectiveness analysis and process evaluation will be performed alongside.

Discussion

This trial is the first to evaluate clinical effectiveness, cost-effectiveness and implementation of screening and patient-tailored care for cognitive and emotional problems compared to care as usual in patients discharged home after ischemic stroke. Potentially, this will improve the outcomes for patients with frequently occurring cognitive and emotional problems after stroke.

Trial registration

Netherlands Trial Register: NL7295, registered 25 September 2018

Which approach to measure cognitive functioning should be preferred when exploring the association between cognitive functioning and participation after stroke?

A variety of approaches are currently used to explore the relationship between cognitive functioning and participation after stroke. We aimed to gain insight into the preferred approach to measure cognitive functioning when exploring the association between cognitive functioning and participation in the long term after stroke. In this inception cohort study 128 individuals with stroke participated and were assessed at a single time point three to four years after the event. Participation was measured using the Restrictions subscale of the Utrecht Scale for Evaluation of Rehabilitation-Participation. Subjective cognitive complaints were assessed using the Cognition subscale of the Checklist for Cognitive and Emotional Consequences (CLCE-24-C). Objective cognitive performance was measured using the Montreal Cognitive Assessment (MoCA) and a neuropsychological test battery (NTB) testing multiple cognitive domains. Participation showed a strong correlation (r = 0.51) with the CLCE-24-C and moderate correlations with the domains of visuospatial perception (r = 0.37) and mental speed (r = 0.36). Backward linear regression analyses showed that participation restrictions were best explained by the combination of the CLCE-24-C and a test for visuospatial perception (R²= 0.31). Our findings suggest the use of a combination of subjective cognitive complaints and objective cognitive performance to explore the relationship between cognitive functioning and participation after stroke.

The economic impact of mental healthcare consumption before and after stroke in a cohort of stroke patients in the Netherlands: a record linkage study

Background

Post-stroke healthcare consumption is strongly associated with a mental health diagnosis. This study aimed to identify stroke patients who utilised mental healthcare facilities, explored their mental healthcare consumption pre-stroke and post-stroke, and examined possible predictors of costs incurred by mental healthcare consumption post-stroke.

Methods

Three databases were integrated, namely the Maastricht University Medical Centre (MUMC) Medical Administration, the Stroke Registry from the Department of Neurology at MUMC, and the Psychiatric Case Registry South-Limburg. Patients from the MUMC who suffered their first-ever stroke between January 1 2000 and December 31 2004 were included and their records were analysed for mental healthcare consumption from 5 years preceding to 5 years following their stroke (1995–2009). Regression analysis was conducted to identify possible predictors of mental healthcare consumption costs.

Results

A total of 1385 patients were included and 357 (25.8%) received services from a mental healthcare facility during the 10-year reference period around their stroke. The costs of mental healthcare usage increased over time and peaked 1 year post-stroke (€7057; 22% of total mental healthcare costs). The number of hospitalisation days and mental healthcare consumption pre-stroke were significant predictors of mental healthcare costs. Explained variances of these models (costs during the 5 years post-stroke: R² = 15.5%, costs across a 10 year reference period: R² = 4.6%,) were low.

Conclusion

Stroke patients have a significant level of mental healthcare comorbidity leading to relatively high mental healthcare costs. There is a relationship between stroke and mental healthcare consumption costs, but results concerning the underlying factors responsible for these costs are inconclusive.

An economic evaluation of an augmented cognitive behavioural intervention vs. computerized cognitive training for post-stroke depressive symptoms

Background

Stroke survivors encounter emotional problems in the chronic phase after stroke. Post-stroke depressive symptoms have major impact on health-related quality of life (HRQol) and lead to increased hospitalization and therefore substantial healthcare costs. We present a cost-effectiveness and cost-utility evaluation of a cognitive behavioural therapy augmented with occupational and movement therapy to support patients with a stroke with depressive symptoms in goal-setting and goal attainment (augmented CBT) in comparison with a computerized cognitive training program (CogniPlus) as a control intervention.

Methods

A trial-based economic evaluation was conducted from a societal perspective with a time horizon of 12 months. Stroke patients (aged 18+ years) with signs of depression (Hospital Anxiety and Depression Scale (HADS) – subscale depression > 7) were eligible to participate. Primary outcomes were the HADS and Quality Adjusted Life Years (QALYs) based on the three-level five-dimensional EuroQol (EQ-5D-3 L). Missing data were handled through mean imputation (costs) and multiple imputation (HADS and EuroQol), and costs were bootstrapped. Sensitivity analyses were performed to test robustness of baseline assumptions.

Results

Sixty-one patients were included. The average total societal costs were not significantly different between the control group (€9,998.3) and the augmented CBT group (€8,063.7), with a 95 % confidence interval (−5,284, 1,796). The augmented CBT intervention was less costly and less effective from a societal perspective on the HADS, and less costly and slightly more effective in QALYs, in comparison with the control treatment. The cost-effectiveness and cost-utility analyses provided greater effects and fewer costs for the augmented CBT group, and fewer effects and costs for the HADS. Based on a willingness to pay (WTP) level of €40,000 per QALY, the augmented CBT intervention had a 76 % chance of being cost-effective. Sensitivity analyses showed robustness of results.

Conclusion

The stroke-specific augmented CBT intervention did not show convincing cost-effectiveness results. In addition to other literature, this study provided new insights into the potential cost-effectiveness of an adjusted cognitive behavioural therapy intervention. However, as our study showed a 76 % chance of being cost-effective for one outcome measure (QALY) and did not provide convincing cost-effectiveness results on the HADS we recommend further research in a larger population.

Life satisfaction post stroke: The role of illness cognitions

OBJECTIVE

To describe illness cognitions two months and two years post stroke and to investigate changes in illness cognitions over time. We also examined the associations between illness cognitions and life satisfaction at two months and two years post stroke and investigated if changes in illness cognitions predicted life satisfaction two years post stroke, taking demographic and stroke-related factors and emotional symptoms into account.

METHODS

Prospective cohort study in which 287 patients were assessed at two months and two years post stroke. The illness cognitions helplessness (maladaptive), acceptance (adaptive) and perceiving benefits (adaptive) were measured with the Illness Cognition Questionnaire. Life satisfaction was assessed with two life satisfaction questions. Correlational and regression analyses were performed.

RESULTS

Patients experienced both maladaptive and adaptive illness cognitions two months and two years post stroke. Only acceptance increased significantly from two months to two years post stroke (p≤0.01). Helplessness, acceptance and perceiving benefits were significantly associated with life satisfaction at two months (R2=0.42) and two years (R2=0.57) post stroke. Furthermore, illness cognitions two months post stroke and changes in illness cognitions predicted life satisfaction two years post stroke (R2=0.57).

CONCLUSION

Illness cognitions and changes in illness cognitions were independently associated with life satisfaction two years post stroke. It is therefore important during rehabilitation to focus on reducing maladaptive behavior and feelings to promote life satisfaction, and on promoting adaptive illness cognitions.

Use of an electronic cognitive aid by a person with Korsakoff syndrome

OBJECTIVE

The purpose of the current study was to evaluate the feasibility and the effectiveness of the use of a customized personal digital assistant (PDA) to support cognitive functioning in a person with Korsakoff syndrome.

METHOD

The PDA was compared with no external support and the use of a memory watch in a single case experimental design. Three main personal goal tasks were defined: "arrive at appointments on time", "execute a long-term task successfully", and "remember to ask for medication".

RESULTS

No significant differences were found between the use of the memory watch and the use of the customized PDA. PDA use was perceived as feasible and effective and was considered as a more comprehensive aid than the memory watch.

CONCLUSION

This study shows that a person with Korsakoff syndrome is able to use and benefit from a customized PDA. Replication of these findings in a larger effectiveness study is necessary.

Validity and feasibility of a learning style instrument for brain injury rehabilitation

PURPOSE

Identifying learning styles of acquired brain injury (ABI) patients may aid the learning process by tailoring to the patient's learning needs and preferences. Currently, there is no learning style instrument for ABI patients. We therefore determined the validity and feasibility of the Adapted Learning Style Inventory (A-LSI) for patients with ABI.

METHOD

We included 99 patients with ABI and 42 healthy controls. Learning styles were determined and subgroups were used to evaluate the validity of the A-LSI. Furthermore, rehabilitation professionals' perceptions on learning style and the A-LSI were evaluated.

RESULTS

In the patient group, the A-LSI yielded the following learning styles: 4 doers, 54 observers, 2 deciders and 39 thinkers. A similar distribution was found for the control group (3, 28, 0 and 11, respectively). Spearman correlations revealed moderate internal validity. Content validity of the A-LSI was also moderate; 11 out of 19 patients recognized themselves in their A-LSI learning style. Furthermore, 12 rehabilitation professionals reported positive and negative aspects of the A-LSI and suggestions for using learning style in rehabilitation.

CONCLUSIONS

Rehabilitation professionals were generally positive about using learning style in ABI rehabilitation. This study, however, raises doubts about the validity and feasibility of the A-LSI for this population.

IMPLICATIONS FOR REHABILITATION

Rehabilitation professionals are generally positive about the assessment and implementation of learning style in rehabilitation. The A-LSI seems to be an inappropriate learning style instrument for individuals with ABI. There is a need for a more practical instrument to assess learning style directly at start of rehabilitation.

[Patients with brain injury in a psychiatric setting; assessment of health care needs and received care]

BACKGROUND

In some Dutch mental health care organisations specific neuropsychiatric departments have been developed for patients with brain injury.

AIM

To identify the characteristics of patients with brain injury who form a specific population in mental health care and to determine whether such patients require either specialised care or a special type of care.

METHOD

A cross-sectional analysis of typical brain injury inpatients was performed. We noted the age and gender of these patients and recorded any previous periods of inpatient care. We listed patients’ impairments, the diagnoses they had been given and the treatment they had received. This inventory formed the basis of our conclusions.

RESULTS

The typical clinical patient with brain injury in this setting was a male of 51 years or older, most probably affected by a stroke or traumatic brain injury, admitted for a period of 6 months, many years after the incident. He was mostly referred from home or hospital by a physician and was expected to return home again. A combination of cognitive and psychiatric impairments was often found. Physically the patient had no or only mild disabilities, but societal participation was low and many cognitive-affective disorders were seen. Treatment was relatively infrequent and mostly directed at daily activities. The most frequent diagnosis was & lquo;cognitive deficits not otherwise specified’. Irritability, agitation, apathy and depression were frequent symptoms.

CONCLUSION

This inventory suggests that brain injury patients in a mental health care setting need special care which is not available in other health care settings.

Long-term neuropsychological performance in a cohort of children and adolescents after severe paediatric traumatic brain injury

OBJECTIVE

The purpose of the present study was to evaluate progress in neuropsychological performance in children and adolescents with severe paediatric traumatic brain injury (TBI), from admission to the rehabilitation centre up to 3-12 years after the trauma.

METHODS

Children and adolescents (n = 31, mean age at injury 11.8 years, SD = 3.8; at follow-up 18.8 years; SD = 4.5) who all had suffered a TBI participated. A comprehensive neuropsychological test battery was administered at the start of rehabilitation (T1), around discharge (T2) and in the long-term (at least 3 years after rehabilitation; T3). T1 and T2 were clinical assessments; T3 was executed as a follow-up measurement for this study.

RESULTS

At T1 and T2, most problems were in the domains of attention, memory and executive functioning. At the start of rehabilitation most deficits were with performal intelligence (61%); at discharge (mean length of stay 411 days) considerably less children had severe deficits on the intelligence domain (23%). At long-term follow-up, most problems were in the domains attention, mental speed and memory. From admission to discharge 42% of the children improved on two or more cognitive tests; from discharge to follow-up this percentage was 13%.

CONCLUSIONS

In this unique study a clinical cohort of children with severe TBI was followed for many years after injury. Most cognitive deficits were found in the early phase of rehabilitation. Most children did improve on cognitive functioning (40%) during the first year after their injury, whereas at follow-up most children had not changed. At follow-up, more than half of the children (54%) attended a regular school or had a regular job, corresponding to their age and pre-morbid functioning.

The reliability and validity of the PALOC-s: a post-acute level of consciousness scale for assessment of young patients with prolonged disturbed consciousness after brain injury

The objective of the study was the validation of the Post-Acute Level of Consciousness scale (PALOC-s) for use in assessing levels of consciousness of severe brain injured patients in a vegetative state or in a minimally conscious state. A cohort of 44 successively admitted patients (between 2 and 25 years of age), who were treated in an early intensive neurorehabilitation programme, were included in the study. Each patient was examined, using the Western Neuro Sensory Stimulation Profile (WNSSP) and the Disability Rating Scale (DRS), once every two weeks resulting in 327 examinations (all videotaped). To determine the reliability of the PALOC-s, six observers rated one videotape of each patient. One of the observers rated the same tapes a second time, 3-4 months later. Validity was determined by correlating 100 ratings of one observer with the scores on the WNSSP and the DRS. To determine the responsiveness of the PALOC-s, the size of change between the scores of the first and last examinations was calculated. The inter-observer correlations and agreement scores varied between .82 and .95. The intra-observer correlation and agreement scores varied between .94 and .96. Correlations with the WNSSP varied between .88 and .93, and with the DRS between .75 and .88. The responsiveness was significantly high (t=8.2), with a standardised effect size of 1.30. It is concluded that the PALOC-s is a reliable, valid, and responsive observation instrument provided it is administered after a structured assessment by an experienced and trained clinician. The PALOC-s is feasible for use in clinical management, as well as in outcome research.

Transfer effects of a cognitive strategy training for stroke patients with apraxia

The objective of this study was to evaluate transfer effects of cognitive strategy training for stroke patients with apraxia. During 8 weeks, 29 apraxic patients received cognitive strategy training to teach them how to perform activities of daily living (ADL) as independently as possible. ADL functioning was assessed at the rehabilitation centre at baseline and after 8 weeks of training. In addition, assessment took place at the patients' own homes after 8 weeks of training and 5 months after the start of the training. The performance of both trained and nontrained tasks was observed. Patients performed trained tasks and nontrained tasks at the same level of independency at the rehabilitation centre as well as at home, indicating transfer of training effects. These effects turned out to be stable over time.

[There are also suitable treatments during the chronic phase following a stroke]

In contrast to the chronic phase, for the acute and rehabilitation phases following a stroke it is sufficiently clear what care is adequate care. Most stroke patients no longer have contact with healthcare professionals in the chronic phase. In this phase, new psychosocial problems may develop. Long (3, 5, 12 and 29 years) post stroke, 4 patients (aged 38-67 years) presented at an outpatient rehabilitation clinic with new complaints: social problems, emotional changes and cognitive impairments. Their relatives (spouses and children) perceived a substantial burden. A short-term outpatient, multidisciplinary rehabilitation programme was offered to them. The International Classification of Functioning, Disability and Health model was used to evaluate the health problems in relation to the environmental and personal factors. Psycho-education, learning cognitive strategies, supporting the family, and starting new leisure activities were important parts of the rehabilitation programme to increase participation and quality of life. The chronic phase following a stroke is not a stable phase and in this phase, rehabilitation interventions can be helpful too and should therefore be offered.

[Cognition problems during rehabilitation of stroke patients in a nursing home]

In many regions in the Netherlands the care for stroke patients is organised in a coordinated stroke service. Within these stroke services, each year more patients are referred to nursing homes for a period of rehabilitation. A stroke leads to lasting cognitive and emotional consequences in more than half of the stroke patients. These consequences interfere with the daily life of the patients and their caregivers. Due to the nature and severity of these problems specific care is needed in the nursing home. In the present article a procedure for cognitive screening in a nursing home is described and data of a large group of patients are presented. These data clearly show the magnitude of the cognitive problems: high percentages of impairments are found in many cognitive domains. In the discussion therefore arguments are given for specialised care - assessment as well as treatment - in the nursing home for stroke patients with cognitive deficits.

[Checklist for the detection of cognitive and emotional consequences after stroke (CLCE-24)]

BACKGROUND AND PURPOSE

Cognitive and emotional problems are common after stroke and screening is essential. In this paper a new screening instrument is presented and its usability is investigated.

METHODS

A group of stroke patients (N = 69) were interviewed using the new instrument, the CLCE-24, six months post stroke. Moreover extensive neuropsychological testing was conducted (including MMSE/CAMCOG).

RESULTS

Patients, relatives and assessors (a psychologist) were positive about its use. The interview with the CLCE-24 took 11.1 minutes on average (5-35 minutes). Eighty percent of the patients had complaints; 73% had cognitive problems, while 51% had emotional problems. Patients with at least one complaint on the CLCE-24 scored lower on the MMSE (t=2.5; p = 0.01) and the CAMCOG (t= 2.5; p= 0.02) compared to patients without complaints.

CONCLUSIONS

The CLCE-24 can be applied by professionals in primary care for identification of cognitive and emotional complaints after stroke. Further research and implementation in clinical practice and the stroke service is recommended.

EFNS guidelines on cognitive rehabilitation: report of an EFNS task force

Disorders of language, spatial perception, attention, memory, calculation and praxis are a frequent consequence of acquired brain damage [in particular, stroke and traumatic brain injury (TBI)] and a major determinant of disability. The rehabilitation of aphasia and, more recently, of other cognitive disorders is an important area of neurological rehabilitation. We report here a review of the available evidence about effectiveness of cognitive rehabilitation. Given the limited number and generally low quality of randomized clinical trials (RCTs) in this area of therapeutic intervention, the Task Force considered, besides the available Cochrane reviews, evidence of lower classes which was critically analysed until a consensus was reached. In particular, we considered evidence from small group or single cases studies including an appropriate statistical evaluation of effect sizes. The general conclusion is that there is evidence to award a grade A, B or C recommendation to some forms of cognitive rehabilitation in patients with neuropsychological deficits in the post-acute stage after a focal brain lesion (stroke, TBI). These include aphasia therapy, rehabilitation of unilateral spatial neglect (ULN), attentional training in the post-acute stage after TBI, the use of electronic memory aids in memory disorders, and the treatment of apraxia with compensatory strategies. There is clearly a need for adequately designed studies in this area, which should take into account specific problems such as patient heterogeneity and treatment standardization.

EFNS guidelines on cognitive rehabilitation: report of an EFNS task force

Disorders of language, spatial perception, attention, memory, calculation and praxis are a frequent consequence of acquired brain damage [in particular, stroke and traumatic brain injury (TBI)] and a major determinant of disability. The rehabilitation of aphasia and, more recently, of other cognitive disorders is an important area of neurological rehabilitation. We report here a review of the available evidence about effectiveness of cognitive rehabilitation. Given the limited number and generally low quality of randomized clinical trials (RCTs) in this area of therapeutic intervention, the Task Force considered, besides the available Cochrane reviews, evidence of lower classes which was critically analysed until a consensus was reached. In particular, we considered evidence from small group or single cases studies including an appropriate statistical evaluation of effect sizes. The general conclusion is that there is evidence to award a grade A, B or C recommendation to some forms of cognitive rehabilitation in patients with neuropsychological deficits in the post-acute stage after a focal brain lesion (stroke, TBI). These include aphasia therapy, rehabilitation of unilateral spatial neglect (ULN), attentional training in the post-acute stage after TBI, the use of electronic memory aids in memory disorders, and the treatment of apraxia with compensatory strategies. There is clearly a need for adequately designed studies in this area, which should take into account specific problems such as patient heterogeneity and treatment standardization.

[Cognitive screening in stroke patients in rehabilitation: standards for clinical practice]

Shortened neuropsychological assessment (cognitive screening) is usually conducted in order to gain insight into the cognitive functioning of stroke patients quickly and globally in order to identify in an early stage factors which can facilitate or hamper the rehabilitation process, to formulate recommendations concerning extensive neuropsychological assessment and to enable recommendations concerning treatment and consultation. Ideally every stroke patient should receive neuropsychological testing during the first few weeks after admission to a rehabilitation setting. Cognitive screening is an efficient way to assess all patients for the psychologist as well as the rest of the rehabilitation team, and is less distressing for the patients than extensive neuropsychological testing. For standard use of cognitive screening, normative data are a useful tool; however, for some well known and frequently used neuropsychological tests there are no normative data for Dutch stroke patients available. In this paper we therefore present the results of a standardized cognitive screening which is used in the Hoensbroeck Rehabilitation Centre since 1996. The results are based on a stroke population of 275 persons, being tested during the first two months after suffering from a first stroke. In addition, a group of forty healthy partners of the stroke patients were assessed with the same battery of tests, in order to generate norms for healthy matched persons. The results of the two groups can be used as norms in comparable clinical settings.

EFNS guidelines on cognitive rehabilitation: report of an EFNS task force

In 1999, a Task Force was set up under the auspices of the European Federation of Neurological Societies with the aim to evaluate the existing evidence for the clinical effectiveness of cognitive rehabilitation. This review led to the development of a set of guidelines to be used in the management of adult patients with cognitive disorders due to acquired focal neurological damage.

Rehabilitation of stroke patients with apraxia: the role of additional cognitive and motor impairments

PURPOSE

The present study investigated which additional cognitive and motor impairments were present in stroke patients with apraxia and which of these factors influenced the effects of treatment.

METHOD

A group of 33 patients with apraxia were treated according to the guidelines of a therapy programme based on teaching patients strategies to compensate for the presence of apraxia. Patients were treated at occupational therapy departments in general hospitals, rehabilitation centres and nursing homes. The outcome of the strategy training was studied in a pre-post test design; measurements were conducted at baseline and after 12 weeks of therapy. The pretreatment scores of the patients with apraxia were compared to normscores and scores of a control group of patients without apraxia (n = 36) to investigate which impairments are present. The following variables were analysed in order to determine which factors influence outcome: additional neuropsychological deficits (comprehension of language, cognitive impairments due to dementia, neglect and short term memory), level of motor functioning, severity of apraxia and performance on activities of daily living (ADL), and some relevant patient characteristics (gender, age, type of stroke, time since stroke, and location of treatment).

RESULTS

The results showed that the presence of apraxia is associated with the presence of additional cognitive and motor impairments. The successful outcome of strategy training was not negatively influenced by cognitive comorbidity. The outcome seemed to be more prominent in patients who were more severely impaired at the start of rehabilitation in terms of the degree of motor impairments, the severity of apraxia and the initial ADL dependence. The ADL observations, however, displayed a ceiling effect, which was taken into account in discussing the results. Demographic variables, especially age, did not predict the outcome of treatment.

CONCLUSIONS

We suggest that the effect of this training is stronger in more severely disabled patients. However, neither the presence of additional cognitive impairments nor the severity of motor problems nor old age should be an indication for refraining from treating apraxia.

A diagnostic test for apraxia in stroke patients: internal consistency and diagnostic value

The internal consistency and the diagnostic value of a test for apraxia in patients having had a stroke are presented. Results indicate that the items of the test form a strong and consistent scale: Cronbach's alpha as well as the results of a Mokken scale analysis present good reliability and good scalability. The diagnostic value of the test was determined by comparison of test results in three groups of patients: 44 stroke patients with apraxia (patients), 35 stroke patients without apraxia (patient controls), and 50 healthy nursing home residents with no history of stroke (normal controls). The diagnostic value is expressed by means of the sensitivity and specificity and the predictive value of the test. In addition, Receiver Operator Characteristics (ROC) curves are presented. The sensitivity and specificity of the apraxia test appear to be good: all values are higher than 80%. The test also has high predictive value. The ROC curves illustrate that the test is sufficiently discriminative to allow a differentiation between persons with apraxia and persons without apraxia.

Outcome of strategy training in stroke patients with apraxia: a phase II study

OBJECTIVE

Evaluation of a therapy programme for stroke patients with apraxia. The programme is based on teaching patients strategies to compensate for the presence of apraxia. This programme was designed for assessment and treatment by occupational therapists.

DESIGN

The outcome was studied in a pre-post test design. Measurements were conducted at baseline and 12 weeks later.

SUBJECTS

Thirty-three stroke patients with apraxia were treated at occupational therapy departments n general hospitals, rehabilitation centres and nursing homes.

MAIN OUTCOME MEASURES

The following measurements were conducted: an apraxia test, a motor functioning test, observation of activities of daily living (ADL), Barthel Index, and an ADL questionnaire for the therapist and the patient.

RESULTS

The patients showed large improvements in ADL functioning on all measures and small improvements on the apraxia test and the motor functioning test. The effect sizes for the disabilities, ranging from 0.92 to 1.06, were large compared to the effect sizes for apraxia (0.34) and motor functioning (0.19). The significant effect of treatment is also seen when individual improvement and subjective improvement are considered. Measured with the Barthel Index for instance, 71% of the patients improved.

CONCLUSIONS

These results suggest that the programme seems to be successful in teaching patients compensatory strategies that enable them to function more independently, despite the lasting presence of apraxia.

From cognition to biomechanics and back: the end-state comfort effect and the middle-is-faster effect

Consistent preferences for particular types of movement suggest criteria for movement selection. These can be important when, as is usually the case, infinitely many movements allow a task to be achieved. The experiments reported here were designed to identify the source of a strong preference observed in earlier object-manipulation studies. In those earlier studies, subjects usually grabbed objects to be moved from one location to another in a way that afforded a comfortable final posture rather than a comfortable initial posture (the end-state comfort effect). The comfortable final state usually allowed the forearm to be at or near the middle of its range of motion on the pronation-supination dimension. The hypothesis tested here was that the end-state comfort effect stemmed from an expectation that movements can be made more quickly in the middle of the pronation-supination range than at either extreme. To test this hypothesis, we asked subjects, in the first experiment, to perform a handle rotation task that demanded little or no precision and so no need to make rapid to-and-fro homing-in movements near the end of the rotation. Half the subjects did not show the end-state comfort effect, in contrast to all previous studies, where all subjects showed the effect. An incidental finding of the first experiment was that handle rotations that ended at or near the end of the range of motion took longer than handle rotations that ended at or near the middle of the range of motion. To test the latter result more carefully, we asked subjects, in Experiments 2 and 3, to oscillate the forearm as quickly as possible, either in the supination part of the forearm rotation range, in the middle part of the range, or in the pronation part of the range. As predicted, oscillation frequencies were highest in midrange, and this was true for both hands. The results as a whole have implications for the relation between cognitive psychology and biomechanics, and for human factors.