Guideline adherence in speech and language therapy in stroke aftercare. A health insurance claims data analysis

Background

Impairments to comprehension and production of speech (aphasia, dysarthria) and swallowing disorders (dysphagia) are common sequelae of stroke, reducing patients’ quality of life and social participation. Treatment oriented on evidence-based guidelines seems likely to improve outcomes. Currently, little is known about guideline adherence in stroke aftercare for the above-mentioned sequelae. This study aims to analyse guideline adherence in the treatment of aphasia, dysarthria and dysphagia after stroke, based on suitable test parameters, and to determine factors that influence the implementation of recommended therapies.

Methods

Six test parameters were defined, based on systematic study of guidelines for the treatment of speech impairments and swallowing disorders (e.g. comprehensive diagnostics, early initiation and continuity). Guideline adherence in treatment was tested using claims data from four statutory health insurance companies. Multivariate logistic and linear regression analyses were performed in order to test the outcomes.

Results

4,486 stroke patients who were diagnosed with specific disorders or received speech therapy were included in the study. The median age was 78 years; the proportion of women was 55.9%. Within the first year after the stroke, 90.3% of patients were diagnosed with speech impairments and swallowing disorders. Overall, 44.1% of patients received outpatient speech and language therapy aftercare. Women were less frequently diagnosed with specific disorders (OR 0.70 [95%CI:0.55/0.88], p = 0.003) and less frequently received longer therapy sessions (OR 0.64 [95%CI:0.43/0.94], p = 0.022). Older age and longer hospitalization duration increased the likelihood of guideline recommendations being implemented and of earlier initiation of stroke aftercare measures.

Conclusions

Our observations indicate deficits in the implementation of guideline recommendations in stroke aftercare. At the same time, they underscore the need for regular monitoring of implementation measures in stroke aftercare to address group-based disparities in care.

Experiences of Physical Therapists and Professional Leaders With Implementing a Toolkit to Advance Walking Assessment Poststroke: A Realist Evaluation

OBJECTIVE

The iWalk study showed significant increase in use of the 10-Meter Walk Test (10MWT) and 6-Minute Walk Test (6MWT) poststroke following provision of a toolkit. This paper examined the influence of contextual circumstances on use of the toolkit and implementation strategy across acute care and inpatient and outpatient rehabilitation settings.

METHODS

A theory-based toolkit and implementation strategy was designed to support guideline recommendations to use standardized tools for evaluation of walking, education, and goal-setting poststroke. The toolkit comprised a mobile app, video, and educational guide outlining instructions for 3 learning sessions. After completing learning sessions, 33 physical therapists and 7 professional leaders participated in focus groups or interviews. As part of a realist evaluation, the study compared and synthesized site-specific context-mechanism-outcome descriptions across sites to refine an initial theory of how the toolkit would influence practice.

RESULTS

Analysis revealed 3 context-mechanism-outcomes: (1) No onsite facilitator? No practice change in acute care: Without an onsite facilitator, participants lacked authority to facilitate and coordinate the implementation strategy; (2) Onsite facilitation fostered integration of select practices in acute care: When onsite facilitation occurred in acute care, walk test administration and use of reference values for patient education were adopted variably with high functioning patients; (3) Onsite facilitation fostered integration of most practices in rehabilitation settings: When onsite facilitation occurred, many participants incorporated 1 or both tests to evaluate and monitor walking capacity, and reference values were applied for inpatient and outpatient education and goal setting. Participants preferentially implemented the 10MWT over the 6MWT because set-up and administration were easier and a greater proportion of patients could walk 10 m.

CONCLUSION

Findings underscore contextual factors and activities essential to eliciting change in assessment practice in stroke rehabilitation across care settings.

IMPACT

This study shows that to foster recommended walking assessment practices, an onsite facilitator should be present to enable learning sessions and toolkit use.

Exploring community-dwelling stroke survivors' experiences of receiving a nurse-led theory-based stroke self-management programme: A qualitative study

International evidence-based guidelines recommend self-management support for stroke survivors to improve their health outcomes. We developed a 4-week nurse-led stroke self-management programme (SSMP) and conducted a randomised controlled trial to assess its effects. This paper reports the findings of a qualitative study nested within the randomised controlled trial to explore stroke survivors' experiences of SSMP participation. Semi-structured interviews were conducted with all adult participants who were clinically diagnosed with a first or recurrent ischaemic or haemorrhagic stroke, residing at home, communicable in Cantonese, had a Montreal Cognitive Assessment score below the second percentile, and participated in at least 1 SSMP session. All interviews were conducted in Cantonese, lasted approximately 45 minutes, and were audio-recorded. Interview data were transcribed verbatim and analysed thematically. Sixty-four stroke survivors (mean age 66.33 years, SD 12.34) were recruited, and 59 were interviewed via phone immediately after completion of SSMP. Three themes were derived. Overall, participants were satisfied with the SSMP. Their understanding of self-management was improved, and they recognised its importance in recovery. Their confidence in self-management was also enhanced through the use of multifaceted strategies. Suggestions were made to enhance their participation experiences, including increased home visits and group sessions, making group session attendance optional and arranging them more accessibly, meeting the survivors who shared their survival experiences in the videos, and access to the videos online. This study concurred that the SSMP enhanced stroke survivors' self-efficacy in self-management. Rearrangement of the programme format and enhancements in accessibility could be further examined to enable more effective stroke self-management.

Clinical Performance Measures for Stroke Rehabilitation: Performance Measures From the American Heart Association/American Stroke Association

The American Heart Association/American Stroke Association released the adult stroke rehabilitation and recovery guidelines in 2016. A working group of stroke rehabilitation experts reviewed these guidelines and identified a subset of recommendations that were deemed suitable for creating performance measures. These 13 performance measures are reported here and contain inclusion and exclusion criteria to allow calculation of rates of compliance in a variety of settings ranging from acute hospital care to postacute care and care in the home and outpatient setting.

Effects of brain-computer interface training on upper limb function recovery in stroke patients: A protocol for systematic review and meta-analysis

BACKGROUND

In recent years, with the development of medical technology and the increase of inter-disciplinary cooperation technology, new methods in the field of artificial intelligence medicine emerge in an endless stream. Brain-computer interface (BCI), as a frontier technology of multidisciplinary integration, has been widely used in various fields. Studies have shown that BCI-assisted training can improve upper limb function in stroke patients, but its effect is still controversial and lacks evidence-based evidence, which requires further exploration and confirmation. Therefore, the main purpose of this paper is to systematically evaluate the efficacy of different BCI-assisted training on upper limb function recovery in stroke patients, to provide a reference for the application of BCI-assisted technology in stroke rehabilitation.

METHODS

We will search PubMed, Web of Science, The Cochrane Library, Chinese National Knowledge Infrastructure Database, Wanfang Data, Weipu Electronics, and other databases (from the establishment to February 2021) for full text in Chinese and English. Randomized controlled trials were collected to examine the effect of BCI-assisted training on upper limb functional recovery in stroke patients. We will consider inclusion, select high-quality articles for data extraction and analysis, and summarize the intervention effect of BCI-assisted training on the upper limb function of stroke patients. Two reviewers will screen titles, abstracts, and full texts independently according to inclusion criteria; Data extraction and risk of bias assessment were performed in the included studies. We will use a hierarchy of recommended assessment, development, and assessment methods to assess the overall certainty of the evidence and report findings accordingly. Endnote X8 will be applied in selecting the study, Review Manager 5.3 will be applied in analyzing and synthesizing.

RESULTS

The results will provide evidence for judging whether BCI is effective and safe in improving upper limb function in patients with stroke.

CONCLUSION

Our study will provide reliable evidence for the effect of BCI technology on the improvement of upper limb function in stroke patients.

PROSPERO REGISTRATION NUMBER

CRD42021250378.

Quality measurement of out-patient neuropsychological therapy after stroke in Germany: definition of indicators and retrospective pilot study

BACKGROUND

In contrast to the hospital setting, today little work has been directed to the definition, measurement, and improvement of the quality of out-patient medical and therapeutic care. We developed a set of indicators to measure the quality of out-patient neuropsychological therapy after stroke.

METHODS

The indicators cover core and interdisciplinary aspects of out-patient neuropsychological work such as mediation of patients into social care in case of need. Selection of the quality-indicators was done together with a consensus group of out-patient therapists and supported by evidence, validity, reliability as well as estimated relevance and variability with the quality of care. The set of indicators was further tested in a retrospective cohort study. Anonymous data of 104 patients were collected from out-patient clinical records of five clinics between November 2017 and April 2018. Associations between process and outcome quality were estimated exploitatively.

RESULTS

Results allowed for the identification of areas with greater variability in the quality of process care and indicated that attention training as recommended by current guidelines had the lowest overall rate for meeting the quality-aim (met in 44% of the cases). This was followed by time < 1 month until the start of therapy (63% met) and mediation into social care in case of need (65% met). We further observed that overall quality and involving relatives in the therapy was associated with higher rates of professional reintegration (p-value = 0.03). However, the need for mediation into social care was associated with a reduced chance for successful professional reintegration (p-value = 0.009).

CONCLUSION

In conclusion, we describe a first set of quality indicators which cover different aspects of out-patient neuropsychological therapy and sufficient variability with care. First data further suggests that meeting the specified quality aims may indeed have relevant effects on outcomes.

Accurate prediction of clinical stroke scales and improved biomarkers of motor impairment from robotic measurements

Objective

One of the greatest challenges in clinical trial design is dealing with the subjectivity and variability introduced by human raters when measuring clinical end-points. We hypothesized that robotic measures that capture the kinematics of human movements collected longitudinally in patients after stroke would bear a significant relationship to the ordinal clinical scales and potentially lead to the development of more sensitive motor biomarkers that could improve the efficiency and cost of clinical trials.

Materials and methods

We used clinical scales and a robotic assay to measure arm movement in 208 patients 7, 14, 21, 30 and 90 days after acute ischemic stroke at two separate clinical sites. The robots are low impedance and low friction interactive devices that precisely measure speed, position and force, so that even a hemiparetic patient can generate a complete measurement profile. These profiles were used to develop predictive models of the clinical assessments employing a combination of artificial ant colonies and neural network ensembles.

Results

The resulting models replicated commonly used clinical scales to a cross-validated R² of 0.73, 0.75, 0.63 and 0.60 for the Fugl-Meyer, Motor Power, NIH stroke and modified Rankin scales, respectively. Moreover, when suitably scaled and combined, the robotic measures demonstrated a significant increase in effect size from day 7 to 90 over historical data (1.47 versus 0.67).

Discussion and conclusion

These results suggest that it is possible to derive surrogate biomarkers that can significantly reduce the sample size required to power future stroke clinical trials.

Reliability of transcallosal inhibition measurements for the lower limb motor cortex in stroke

Transcallosal inhibition (TCI) is a measure of between-hemisphere inhibitory control that can be evaluated with the ipsilateral silent period (iSP) transcranial magnetic stimulation (TMS) paradigm. The study of iSP for the lower extremity has been limited possibly due to the close orientation of the lower extremity motor representations. Change in TCI can provide insights into pathophysiological mechanisms underlying the asymmetry in corticomotor excitability in stroke. Here, we describe a method for iSP quantification and report reliability of iSP parameters for the tibialis anterior (TA) muscle in stroke. 26 individuals with stroke attended three sessions where single pulse TMS was used to measure TCI from the lesioned to non-lesioned hemisphere. A double cone coil was used for stimulating the ipsilateral motor cortex while the participant maintained an isometric contraction of the non-paretic TA. Absolute and relative reliability were computed for iSP latency, duration and area. iSP latency showed the lowest measurement error (absolute reliability) and iSP latency, duration and area showed good relative reliability (intraclass correlation coefficients > 0.6). This study suggests that iSP parameters for the tibialis anterior are reliable and attempts to provide a guideline for evaluating TCI for the lower extremity in stroke and other clinical populations.

[Movement technology in the rehabilitation after stroke: hype or hope?]

Application of movement technology in the rehabilitation of neurological disorders has gained a firm position within a short time span, but the effectiveness of many technological innovations is still poorly supported by evidence. Should this burst of movement technology be considered a hype or is it offering realistic hope? This perspective focuses on motor rehabilitation after unilateral stroke and addresses the value of rehabilitation robots, virtual-reality training, peripheral neurostimulation, and brain stimulation. Current rehabilitation robots offer added value compared to conventional training, but only early after stroke for patients who are not yet able to walk independently. The effects of peripheral neurostimulation or brain stimulation are still hard to prove or relatively small. Virtual-reality training seems to be most promising for regaining motor skills, particularly when adjusted to individual capacities. Overall, functional benefits of movement technology in the rehabilitation of neurological disorders keep the middle between hype and hope.

Stroke rehabilitation in low-income and middle-income countries: a call to action

The WHO Rehabilitation 2030 agenda recognises the importance of rehabilitation in the value chain of quality health care. Developing and delivering cost-effective, equitable-access rehabilitation services to the right people at the right time is a challenge for health services globally. These challenges are amplified in low-income and middle-income countries (LMICs), in which the unmet need for rehabilitation and recovery treatments is high. In this Series paper, we outline what is happening more broadly as part of the WHO Rehabilitation 2030 agenda, then focus on the specific challenges to development and implementation of effective stroke rehabilitation services in LMICs. We use stroke rehabilitation clinical practice guidelines from both high-income countries and LMICs to highlight opportunities for rapid uptake of evidence-based practice. Finally, we call on educators and the stroke rehabilitation clinical, research, and not-for-profit communities to work in partnership for greater effect and to accelerate progress.

The acupuncture-related therapy for post-stroke urinary incontinence: A protocol for systematic review and network meta-analysis

BACKGROUND

With the rising incidences stroke, the Post-Stroke Urinary Incontinence (PSUI) has become one of the common clinical sequelae. PSUI not only lowers the quality of life of patients, but also impacts tremendously to mental health. As a treasure of Chinese medicine, acupuncture and its related therapies have been widely accepted in clinical treatment of PSUI. Recently, there have been many clinical studies on the treatment of PSUI with acupuncture and related therapies, but the best way to treat PSUI is controversial. Therefore, the purpose of this paper is to provide an optimal ranking regarding acupuncture and its related therapies for PSUI.

METHODS

The five domestic and foreign databases including PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang Database will be systematically searched. The time range of the literature search is from the date of establishment to August 31, 2020. The main evaluation outcome was the number of patients after treatment, and the frequency of urinary incontinence. The secondary evaluation outcome was International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), Barthel Activities of Daily Living Index (Barthel ADL Index) and the incidence rate of adverse events. The methodological quality of the article will evaluated by Cochrane Collaboration's Tool and the quality of evidence will evaluated through Grading of Recommendations Assessment, Development and Evaluation (GRADE) instrument. The Network Meta-Analysis (NMA) will be completed using Stata statistical software.

RESULTS

The final results of this study will be published in a peer-reviewed journal.

CONCLUSION

This network meta-analysis will compare the efficacy and safety of different acupuncture therapies in the treatment of PSUI and summarize the best treatment options, which will help patients and doctors to choose effective acupuncture methods in time.

Early head-up mobilisation versus standard care for patients with severe acquired brain injury: A systematic review with meta-analysis and Trial Sequential Analysis

BACKGROUND

There is increasing focus on earlier rehabilitation in patients with traumatic or hypoxic brain injury or stroke. This systematic review evaluates the benefits and harms of early head-up mobilisation versus standard care in patients with severe acquired brain injury.

METHODS

We searched Medline, CENTRAL, EMBASE, four other databases and 13 selected clinical trial registries until April 2020. Eligible randomised clinical trials compared early head-up mobilisation versus standard care in patients with severe acquired brain injury and were analysed conducting random- and fixed-effects meta-analyses and Trial Sequential Analysis (TSA). Certainty of evidence was assessed by GRADE.

MAIN RESULTS

We identified four randomised clinical trials (total n = 385 patients) with severe acquired brain injury (stroke 86% and traumatic brain injury 13%). Two trials were at low risk and two at high risk of bias. We found no evidence of a difference between early mobilisation vs. standard care on mortality or poor functional outcome at end of the intervention (relative risk (RR) 1.19, 95% CI 0.93 to 1.53; I2 0%; very low certainty) or at maximal follow-up (RR 1.03, 95% CI 0.89 to 1.21; I2 0%; very low certainty). We found evidence against an effect on quality of life at maximal follow-up. The proportion of patients with at least one serious adverse event did not differ at end of intervention or at maximal follow-up. For most comparisons, TSA suggested that further trials are needed.

CONCLUSIONS

We found no evidence of a difference between early mobilisation versus standard care for patients with severe acquired brain injury. Early mobilisation appeared not to exert a major impact on quality of life. This systematic review highlights the insufficient evidence in patients with severe brain injury, and no firm conclusions can be drawn from these data.

TRIAL REGISTRATION

Protocol uploaded to PROSPERO: April 2018 (revised October 2018, CRD42018088790).

Combining Items From 3 Federally Mandated Assessments Using Rasch Measurement to Reliably Measure Cognition Across Postacute Care Settings

OBJECTIVE

To combine items from the Functional Independence Measure, Minimum Data Set (MDS) 2.0, and the Outcome and Assessment Information Set (OASIS)-B to reliably measure cognition across postacute care settings and facilitate future studies of patient cognitive recovery.

DESIGN

Rasch analysis of data from a prospective, observational cohort study.

SETTING

Postacute care inclusive of inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies.

PARTICIPANTS

Patients (N=147) receiving rehabilitation services.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional Independence Measure, MDS 2.0, and the OASIS-B.

RESULTS

Six cognition items demonstrated good construct validity with no misfitting items, unidimensionality, good precision (person separation reliability, 0.95), and an item hierarchy that reflected a clinically meaningful continuum of cognitive challenge.

CONCLUSIONS

This is the first attempt to combine the cognition items from the 3 historically, federally mandated assessments to create a common metric for cognition. These 6 items could be adopted as standardized patient assessment data elements to improve cognitive assessment across postacute care settings.

Measuring stroke outcomes for 74 501 patients using linked administrative data: System-wide estimates and validation of 'home-time' as a surrogate measure of functional status

AIMS

Administrative data offer cost-effective, whole-of-population stroke surveillance yet the lack of validated measures of functional status is a shortcoming. The number of days spent living at home after stroke ('home-time') is a patient-centred outcome that can be objectively ascertained from administrative data. Population-based validation against both severity and outcome measures and for all subtypes is lacking. We aimed to report representative 'home-time' estimates and validate 'home-time' as a surrogate measure of functional status after stroke.

METHODS

Stroke hospitalisations from a state-wide census in New South Wales, Australia, from January 1, 2005 to March 31, 2014 were linked to prehospital data, poststroke admissions and deaths. We correlated 90-day 'home-time' with Glasgow Coma Scale (GCS) scores, measured upon a patient's initial contact with paramedics and Functional Independence Measure (FIM) scores, measured upon entry to rehabilitation after the acute hospital stroke admission. Negative binomial regressions identified predictors of 'home-time'.

RESULTS

Patients with stroke (N = 74 501) spent a median of 53 days living at home 90 days after the event. Median 'home-time' was 60 days after ischaemic stroke, 49 days after subarachnoid haemorrhage and 0 days after intracerebral haemorrhage. GCS and FIM scores significantly correlated with 'home-time' (P < .001). Women spent significantly less time at home compared with men after stroke, although being married increased 'home-time' after ischaemic stroke and subarachnoid haemorrhage.

CONCLUSIONS

These findings underscore the immediate and adverse impact of stroke. 'Home-time' measured using administrative data is a robust, replicable and valid patient-centred outcome enabling inexpensive population-based surveillance and system-wide quality assessment.

Evidence-based practice guideline on integrative medicine for stroke 2019

OBJECTIVE

Stroke is the leading cause of death and disability in China. Chinese medicine integrated with conventional medicine is now widely used in the prevention and treatment of stroke. A clinical practice guideline for the application of integrative medicine in stroke is urgently needed.

METHODS

This guideline was developed following the methodology and procedures recommended in the World Health Organization Handbook for Guideline Development and the Guideline Development Handbook for Diagnosis and Therapy of Integrative Medicine. The quality of evidence and strength of recommendations were evaluated using the GRADE approach. The guideline followed the RIGHT statement and AGREE II was consulted to ensure its quality.

RESULTS

A multidisciplinary working team was established. Eleven research questions from 15 clinical questions were identified by questionnaire surveys, face-to-face meetings, and analyzed by the working team. Fourteen recommendations regarding integrative medicine for ischemic stroke, hemorrhagic stroke, and complications of stroke were formulated from systematic reviews of the benefits, harms, cost-effectiveness, quality of evidence, the values and preferences of patients and their family members, feedback on proposed recommendations from medical practitioners from a variety of disciplines, and a face-to-face consensus meeting.

CONCLUSIONS

This guideline focuses on clinical treatments that are specific to integrative medicine for stroke and can be used at all levels in medical institutions and rehabilitation facilities. The end-users of the guideline are most likely to be medical practitioners, including Chinese herbal medicine specialists, acupuncturists, integrative medicine practitioners, physicians, physical therapists, and clinical pharmacists.

Experiences of Occupational Performance in Survivors of Stroke Attending Peer Support Groups

BACKGROUND.

Survivors of stroke often experience environmental isolation and decreased occupational performance after discharge from the hospital. Peer groups benefit psychological, social, and cognitive functioning, though few studies have examined their influence on occupational performance of survivors of stroke.

PURPOSE.

This study explores the experiences of occupational performance in survivors of stroke attending an outpatient peer support group.

METHOD.

An interpretive qualitative study using semi-structured interviews was conducted with seven survivors of stroke attending an outpatient peer support group. Data was thematically analyzed.

FINDINGS.

Four themes related to the experience of peer support on occupational performance emerged: finding hope to return to meaningful occupation, a place for belonging, problem-solving occupational concerns, and finding purpose beyond oneself.

IMPLICATIONS.

This research adds to the existing literature that peer support groups help survivors of stroke reengage in meaningful occupations, manage their stroke experience, and move positively through recovery.

The significant gap between international standards and stroke management practices at Queen Elizabeth Central Hospital (Malawi): An audit report

Background

The Queen Elizabeth Central Hospital (QECH) is preparing to set up the first stroke unit in Blantyre, Malawi. We conducted this audit to assess current stroke management practices and outcomes at QECH and identify priority areas for intervention.

Methods

From April to June 2018, we prospectively enrolled patients with acute stroke and collected data on clinical presentation, cardiovascular risk factors, investigations and interventions, in-hospital outcomes, and follow-up plans after discharge. The American Heart Association/American Stroke Association (AHA/ASA) guidelines were used as the standard of care for comparison.

Results

Fifty patients with acute stroke were enrolled (46% women, 54% men). The mean age was 63.1 years (95% CI: 59.7-66.6). The diagnosis of stroke was based on the World Health Organization criteria. The diagnosis was made within 24 hours of admission in 19 patients (38%). Acute revascularisation therapy was not available. Forty-eight patients (96%) had their vital signs checked at baseline and <10% had their vital signs checked more than three times within the first 24 hours. Essential blood tests including random blood sugar (RBS), full blood count (FBC), urea/creatinine, and lipid profiles were performed in 72%, 68%, 48%, and 4%, respectively. An electrocardiogram was performed on 34 patients (68%). Blood pressure on admission was >140/90 mmHg in 34 patients (68%), including 4 with values >220/120 mmHg. Nine patients had an RBS >10 mmol/L and four received insulin. Prophylaxis for deep venous thrombosis was offered to 12 patients (24%). Aspiration pneumonia was reported in 16 patients (32%) and was the most common hospital complication. The mean duration of hospitalisation was 10.4 days (95% CI: 5.6-15.2), and case fatality was 18%. The modified Rankin scale at discharge was ≤2 in 32% of patients. Only four patients (8%) were transferred to a rehabilitation centre. At the time of discharge, only 32% of patients received education on stroke.

Conclusion

Acute stroke care is less than optimal in this setting. Simple interventions such as reducing the delay in making a stroke diagnosis, early swallow assessments, and closer monitoring of vital signs could make a significant difference in stroke outcome. Furthermore, treating cardiovascular risk factors and setting up health education programmes to improve secondary prevention represent key priorities.

Moving Stroke Rehabilitation Research Evidence into Clinical Practice: Consensus-Based Core Recommendations From the Stroke Recovery and Rehabilitation Roundtable

Moving research evidence to practice can take years, if not decades, which denies stroke patients and families from receiving the best care. We present the results of an international consensus process prioritizing what research evidence to implement into stroke rehabilitation practice to have maximal impact. An international 10-member Knowledge Translation Working Group collaborated over a six-month period via videoconferences and a two-day face-to-face meeting. The process was informed from surveys received from 112 consumers/family members and 502 health care providers in over 28 countries, as well as from an international advisory of 20 representatives from 13 countries. From this consensus process, five of the nine identified priorities relate to service delivery (interdisciplinary care, screening and assessment, clinical practice guidelines, intensity, family support) and are generally feasible to implement or improve upon today. Readily available website resources are identified to help health care providers harness the necessary means to implement existing knowledge and solutions to improve service delivery. The remaining four priorities relate to system issues (access to services, transitions in care) and resources (equipment/technology, staffing) and are acknowledged to be more difficult to implement. We recommend that health care providers, managers, and organizations determine whether the priorities we identified are gaps in their local practice, and if so, consider implementation solutions to address them to improve the quality of lives of people living with stroke.

Asymmetric Dual Arm Approach For Post Stroke Recovery Of Motor Functions Utilizing The EXO-UL8 Exoskeleton System: A Pilot Study

In a dual arm therapeutic regime aiming to rehabilitate motor functions post stroke, both the affected arm (paretic) and the unaffected (non-paretic) arm are involved. In this context, the leading idea is that motor functions of the affected arm during a reaching task may be improved if the unaffected arm has already reached the target. As part of this pilot study, one chronic post-stroke patient with weakness and spasticity on his right arm conducted reaching tasks to virtual targets arranged in a $5\times 3$ matrix located parallel to his frontal plane, in two different configurations: (1) affected arm only (without assistance from the exoskeleton); (2) unaffected arm first followed by the affected arm (2a) without, and (2b) with assistance. A force field attracting the wrist of the affected arm to the target was used in the assistive mode. The data post-processing and analysis included task completion time, reachable task space, joint range of motion, human-robot interaction force/torque and power exchange at multiple sensors along the arm - visualized in a series of interaction maps. The data validated the robotic system's basic functionality in facilitating post-stroke unilateral and asymmetric bilateral training. Future work would be expanded to clinical trials with more subjects to be recruited and additional features to be implemented.

Effectiveness of a multifactorial context-enhancing functional therapy to promote functional arm use and recovery of stroke survivors: study protocol for a clinical trial

INTRODUCTION

After a stroke, 55% of survivors do not regain the ability to completely use their arm in daily life functioning. Currently, evidence-based guidelines recommend functional training for improving the affected hand after stroke. However, promoting an optimal quantity and quality of functional training is influenced by personal and environmental contextual factors. Studies that comprehensively target multiple factors regulating arm use are limited. This study compares the effects of functional training to multifactorial context-enhancing functional training program for improving functional arm use and recovery after stroke.

METHODS AND ANALYSIS

This is a protocol for an observer-blinded, two parallel groups, randomised controlled trial. A total of 126 community-dwelling subacute and chronic stroke survivors will be included in the study. A tailor-made multifactorial context-enhancing intervention-incorporating education, environmental enrichment and behaviour change techniques to reinforce functional training will be provided to the experimental group. The functional training group will be provided with functional exercises. The intervention will be delivered for 2 months. The primary outcomes of functional arm use and recovery will be measured using Motor Activity Log, Goal Attainment Scale and Rating of Everyday Arm-use in the Community and Home scale. The secondary outcomes of arm motor impairment and function will be measured using Fugl-Meyer upper limb score, Action Research Arm Test, ABILHAND questionnaire and Stroke Impact Scale. These will be measured at three points in time: before, after 2 months and after 1-month follow-up. The outcome measures will be analysed using one-way analysis of variance and regression analysis will be performed to identify factors limiting optimal task practice.

ETHICS AND DISSEMINATION

The study has been approved by the Institutional Ethics Committee of Kasturba Hospital, Manipal, India. Participants will sign a written informed consent prior to participation. The results will be published on completion of the trial and communicated to community-dwelling stroke survivors.

TRIAL REGISTRATION NUMBER

CTRI/2017/10/010108.

Assessment of the quality and content of clinical practice guidelines for post-stroke rehabilitation of aphasia

OBJECTIVES

The purpose of this study was to evaluate the quality of guidelines for rehabilitation of post-stroke aphasia using the Appraisal of Guidelines for Research and Evaluation (AGREE-II) instrument and identify consistency of different guidelines.

METHODS

A systematic search was undertaken from inception to October 2018. Two reviewers independently screened all titles and abstracts, and assessed eligible guidelines using the AGREE-II. Agreement among reviewers was measured by using intra-class correlation coefficient (ICC).

RESULTS

From 5008 records screened, 8 guidelines met the inclusion criteria. The quality of guidelines was heterogeneous. Three guidelines were rated high (6.5) across; the highest rated domain was "scope and purpose' (median score 95.8%); the lowest rated domain was "rigor of development' (median score 67.2%). An overall high degree of agreement among reviewers to each domain was observed (ICC ranged from 0.60 to 0.99). The speech language therapy was recommended in 3 guidelines. Four guidelines described group treatment was beneficial for the continuum of care. However, other therapies for aphasia varied in the level of detail across guidelines.

CONCLUSIONS

Our study indicated the quality of guidelines for post-stroke aphasia needed to be improved. Moreover, the treatment recommendations of aphasia existed discrepancy among the included guidelines. Therefore, it is suggested to pay more attention on the rigor of methodology and applicability during the process of the formulation of guideline. Future research should focus on the effectiveness, intensity, and duration of treatment measures.

How to improve eRehabilitation programs in stroke care? A focus group study to identify requirements of end-users

BACKGROUND

A user-centered design approach for eHealth interventions improves their effectiveness in stroke rehabilitation. Nevertheless, insight into requirements of end-users (patients/informal caregivers and/or health professionals) for eRehabilitation is lacking. The aim of this study was to identify end-user requirements for a comprehensive eHealth program in stroke rehabilitation.

METHODS

Eight focus groups were conducted to identify user requirements; six with patients/informal caregivers and two with health professionals involved in stroke rehabilitation (rehabilitation physicians, physiotherapists, occupational therapists, psychologists, team coordinators, speech therapist). The focus groups were audiotaped and transcribed in full. Direct content analysis was used to identify the end-user requirements for stroke eHealth interventions concerning three categories: accessibility, usability and content.

RESULTS

In total, 45 requirements for the accessibility, usability and content of a stroke eRehabilitation program emerged from the focus groups. Most requirements concerned content (27 requirements), followed by usability (12 requirements) and accessibility (6 requirements). Patients/informal caregivers and health professionals each identified 37 requirements, respectively, with 29 of them overlapping.

CONCLUSIONS

Requirements between stroke patients/informal caregivers and health professionals differed on several aspects. Therefore, involving the perspectives of all end users in the design process of stroke eRehabilitation programs is needed to achieve a user-centered design.

TRIAL REGISTRATION

The study was approved by the Medical Ethical Review Board of the Leiden University Medical Center [P15.281].

Test-retest reliability of the Mini Nutritional Assessment and its relationship with quality of life in patients with stroke

BACKGROUND & OBJECTIVE

Malnutrition is one of commonly issues in patients with stroke. The Mini Nutritional Assessment (MNA) is a widely used measure for assessing nutritional status in patients with stroke. A nutritional measure with acceptable test-retest reliability allows clinicians to consistently assess patients' nutritional status. Knowledge of the relationship between nutritional status and quality of life (QOL) could guide clinicians to improve QOL in patients with stroke more effectively. This study aimed to examine test-retest reliability of the MNA and its relationship with QOL in patients with stroke.

METHODS

Fifty-nine patients participated in the test-retest reliability study and the correlation between the MNA and WHO Quality of Life-BREF (WHOQOL-BREF) study. A repeated-assessments design (1 week apart) was used to examine the test-retest reliability of the MNA.

RESULTS

The intraclass correlation coefficient for the MNA was 0.91. The minimal detectable change and percentage of minimal detectable change for the MNA were 2.1 and 8.2%, respectively. The MNA was positively associated with the QOL (r = 0.32; p = 0.013). The result of linear regression analysis shows that after controlling for age, sex and activities of daily living functions, only the MNA was significantly associated with the WHOQOL-BREF (r2 = 0.104; p = 0.008).

CONCLUSIONS

The MNA has satisfactory test-retest reliability that is useful for repeatedly assessing the nutritional status of patients with stroke. The MDC of the MNA has acceptable random measurement error which is useful for determining whether the change score of a patient is outside the range of random measurement error. Future studies that recruit stroke patients in the acute stage is needed to further examine the relationship between the nutritional status and QOL.

The Methodological Quality of Short-Term/Working Memory Treatments in Poststroke Aphasia: A Systematic Review

Purpose The aims of this systematic review are to provide a critical overview of short-term memory (STM) and working memory (WM) treatments in stroke aphasia and to systematically evaluate the internal and external validity of STM/WM treatments. Method A systematic search was conducted in February 2014 and then updated in December 2016 using 13 electronic databases. We provided descriptive characteristics of the included studies and assessed their methodological quality using the Risk of Bias in N-of-1 Trials quantitative scale ( Tate et al., 2015 ), which was completed by 2 independent raters. Results The systematic search and inclusion/exclusion procedure yielded 17 single-case or case-series studies with 37 participants for inclusion. Nine studies targeted auditory STM consisting of repetition and/or recognition tasks, whereas 8 targeted attention and WM, such as attention process training including n-back tasks with shapes and clock faces as well as mental math tasks. In terms of their methodological quality, quality scores on the Risk of Bias in N-of-1 Trials scale ranged from 4 to 17 ( M = 9.5) on a 0-30 scale, indicating a high risk of bias in the reviewed studies. Effects of treatment were most frequently assessed on STM, WM, and spoken language comprehension. Transfer effects on communication and memory in activities of daily living were tested in only 5 studies. Conclusions Methodological limitations of the reviewed studies make it difficult, at present, to draw firm conclusions about the effects of STM/WM treatments in poststroke aphasia. Further studies with more rigorous methodology and stronger experimental control are needed to determine the beneficial effects of this type of intervention. To understand the underlying mechanisms of STM/WM treatment effects and how they relate to language functioning, a careful choice of outcome measures and specific hypotheses about potential improvements on these measures are required. Future studies need to include outcome measures of memory functioning in everyday life and psychosocial functioning more generally to demonstrate the ecological validity of STM and WM treatments.

Association Between Performance on an Interdisciplinary Stroke Assessment Battery and Falls in Patients With Acute Stroke in an Inpatient Rehabilitation Facility: A Retrospective Cohort Study

OBJECTIVE

To explore the association between demographic factors and functional performance measures of patients with acute stroke in an inpatient rehabilitation facility (IRF) and falls during the IRF stay and to quantify the diagnostic accuracy of functional outcome measures in identifying fallers.

DESIGN

Retrospective cohort study.

SETTING

Inpatient rehabilitation facility.

PARTICIPANTS

Individuals with acute stroke admitted to hospital-based IRF (N=139).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Odds ratios were used to examine the relationship between fall frequency and functional outcome measures (National Institute of Stroke Scale, neglect [Item #11], Berg Balance Scale, Stroke Rehabilitation Assessment of Movement mobility and Stroke Rehabilitation Assessment of Movement lower extremity subscales [STREAM-LE], Montreal Cognitive Assessment, Dynamic Gait Index, and Stroke Impact Scale). Receiver operator characteristic analysis with area under the curve, sensitivity, specificity, and diagnostic odds ratio were used to assess the diagnostic accuracy of each functional outcome measure to distinguish patients who fell vs those who did not fall in the IRF.

RESULTS

A total of 23 patients (16.2%) fell during the IRF hospitalization. Patients who did and did not fall did not differ in terms of age, sex, stroke type, or stroke location. Only the STREAM-LE was associated with falls (odds ratio, 0.93; 95% CI, 0.86-0.99). Area under the curve was 0.67 (95% CI, 0.51-0.82). With a positivity cutoff point of 12, sensitivity and specificity were 73.3% (95% CI, 54.6%-92.2%) and 50.0% (95% CI, 39.9%-59.2%), respectively. The diagnostic odds ratio was 3.4.

CONCLUSIONS

The STREAM-LE score at admission to IRF may identify patients with acute stroke who are more likely to fall during their stay. However, the search for measures with greater diagnostic accuracy should continue.

Understanding the Experience of Early Supported Discharge from the Perspective of Patients with Stroke and Their Carers and Health Care Providers: A Qualitative Review

A systematic review of qualitative studies that examined the experience of early supported discharge (ESD) from the perspective of patients with stroke and their caregivers and health care providers revealed an emphasis on psychosocial aspects-the patient-provider relationship, the value of the home environment, and the ability to tailor treatment to meet patient-oriented goals. Patients, caregivers, and providers stressed the importance of clear and systematic communication throughout the ESD process to support transitions, prevent duplication of services, foster trust in relationships, and ensure that patients and caregivers have the knowledge and skills required to manage a chronic condition long term.

Does training in a top-down approach influence recorded goals and treatment plans?

BACKGROUND.

Five stroke rehabilitation teams were supported in the implementation of Cognitive Orientation to daily Occupational Performance (CO-OP) as part of a knowledge translation (KT) project called CO-OP KT. Medical record auditors noted there was occasionally a disconnect between client goals and treatment plans, revealing a need to better understand the characteristics of each and their relationship to each other.

PURPOSE.

This study aimed to examine the characteristics of goals and treatment plans in occupational therapy before and after CO-OP KT.

METHOD.

A descriptive secondary analysis of medical record data was employed.

FINDINGS.

Post intervention, there was a change in goal specificity (p = .04) and therapist-client goal alignment (p = .05). Occupation-based goals were often paired with a bottom-up, impairment-based treatment. Top-down treatments, when present, lacked the same detail given to bottom-up plans.

IMPLICATIONS.

CO-OP KT seemed to lead to more specific goals, but matching top-down treatment plans were not found.

Counselling training for speech-language therapists working with people affected by post-stroke aphasia: a systematic review

BACKGROUND

Speech-language therapists use counselling to address the psychological well-being of people affected by post-stroke aphasia. Speech-language therapists report low counselling knowledge, skill and confidence for working in post-stroke aphasia which may be related to a lack of counselling training specific to the needs of this client group.

AIMS

To identify current training in counselling for speech-language therapists to address psychological well-being in people affected by post-stroke aphasia. Specifically, the intent was to establish the objectives, content, amount, teaching methods and outcomes of counselling training provided to speech-language therapists working with people affected by post-stroke aphasia.

METHODS & PROCEDURES

Eleven databases were searched from inception to January 2018 using terms relating to counselling, psychological well-being, speech-language therapy, stroke, aphasia and training. Studies using any research methodology and design were included. Nine studies were critically appraised and synthesized as a systematic review using the Search, AppraisaL, Synthesis and Analysis (SALSA) framework.

MAIN CONTRIBUTION

Information on counselling training came from the UK, United States and Australia. Student speech-language therapists received training in goal-setting and generic counselling skills. After qualification, speech-language therapists received counselling training from mental health professionals within stroke workplaces, from external providers and further education. A range of teaching techniques and counselling approaches were described. Self-report and themes from qualitative data were the primary measures of counselling training outcomes. Moderate correlations were reported between counselling training and levels of speech-language therapists' knowledge, comfort, confidence and preparedness to counsel people affected by post-stroke aphasia.

CONCLUSIONS

Research in counselling training for speech-language therapists working in post-stroke aphasia is limited, with a small number of primarily low-quality studies available. Training in generic counselling skills and brief psychological approaches with support from mental health professionals in the stroke workplace enabled speech-language therapists to feel knowledgeable, skilled and confident to address the psychological well-being of people affected by post-stroke aphasia. Evidence about the effectiveness of counselling training on speech-language therapists' confidence and competence in practice and on client outcomes in psychological well-being in post-stroke aphasia is required.

The new frontiers of rehabilitation medicine in people with chronic disabling illnesses

Because of the demographic shift and the increased proportion of patients surviving acute critical illnesses, the number of people living with severely disabling chronic diseases and, consequently, the demand for rehabilitation are expected to increase sharply over time. As underscored by the World Health Organization, there is substantial evidence that the provision of inpatient rehabilitation in specialized rehabilitation units to people with complex needs is effective in fostering functional recovery, improving health-related quality of life, increasing independence, reducing institutionalization rate, and improving prognosis. Recent studies in the real world setting reinforce the evidence that patients with ischemic heart disease or stroke benefit from rehabilitation in terms of improved prognosis. In addition, there is evidence of the effectiveness of rehabilitation for the prevention of functional deterioration in patients with complex and/or severe chronic diseases. Given this evidence of effectiveness, rehabilitation should be regarded as an essential part of the continuum of care. Nonetheless, rehabilitation still is underdeveloped and underused. Efforts should be devoted to foster healthcare professional awareness of the benefits of rehabilitation and to increase referral and participation.

Utility-weighted modified Rankin Scale: Still too crude to be a truly patient-centric primary outcome measure?

BACKGROUND

The utility-weighted modified Rankin Scale (UW-mRS) is an outcome measure recently proposed to improve statistical efficiency and interpretability of the mRS. Statistical properties of the UW-mRS have been well investigated, but construct validity has yet to be established.

AIMS

To investigate the construct validity of the UW-mRS as a primary outcome measure by assessing variability in utility values within and between mRS categories, over time post-stroke, and by different derivation methods.

METHODS

UW-mRS was derived using assessment of quality of life (AQoL-4D) and mRS scores at 3 and 12 months (n = 2030) from a large randomized controlled trial, A Very Early Rehabilitation Trial (AVERT). Receiver operator characteristic (ROC) analysis of AQoL-4D was conducted to differentiate between sequential mRS categories. Intraclass correlation was used to explore variability in utility values over time post-stroke, UW-mRS values, and derivation methods from multiple studies.

RESULTS

UW-mRS values for mRS categories 0-6 at three months were 0.80, 0.78, 0.63, 0.37, 0.11, 0.03, and 0. Based on AQoL-4D utility values, areas under the ROC curve varied from 0.54 to 0.87. Time post-stroke explained 42%-56% of variability in AQoL-4D utility values in patients with no change in mRS between 3 and 12 months. The choice of the derivation method contributed to 25% of the variability in UW-mRS values.

CONCLUSIONS

The high variability in utility values between and within mRS categories, over time post-stroke, and using different derivation methods is not adequately reflected in the UW-mRS. These threats to construct validity warrant caution when using UW-mRS as a primary outcome measure.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12606000185561).

The Improvement of Walking Ability Following Stroke

BACKGROUND

Gait velocity and maximum walking distance are central parameters for measuring the success of rehabilitation of gait after a stroke. The goal of this study was to provide an overview of current evidence on the rehabilitation of gait after a stroke.

METHODS

A systematic review of randomized, controlled trials was carried out using network meta-analysis. The primary endpoint was gait velocity; secondary end- points were the ability to walk, maximum walking distance, and gait stability. The following interventions were analyzed: no gait training, conventional gait training (reference category), training on a treadmill with or without body weight support, training on a treadmill with or without a speed paradigm, and electromechanically assisted gait training with end-effector or exoskeleton apparatus.

RESULTS

The systematic search yielded 40 567 hits. 95 randomized, controlled trials involving a total of 4458 post-stroke patients were included in the meta-analysis. With respect to the primary endpoint of gait velocity, gait training assisted by end- effector apparatus led to significant improvement (mean difference [MD] = 0.16 m/s; 95% confidence interval [0.04; 0.28]). None of the other interventions improved gait velocity to any significant extent. With respect to one of the secondary endpoints, maximum walking distance, both gait training assisted by end-effector apparatus and treadmill training with body weight support led to significant improvement (MD = 47 m, [4; 90], and MD = 38 m, [4; 72], respectively). A network meta-analysis could not be performed with respect to the ability to walk (a different secondary endpoint) because of substantial inconsistencies in the data. The interventions did not differ significantly with respect to safety.

CONCLUSION

In comparison to conventional gait rehabilitation, gait training assisted by end-effector apparatus leads to a statistically significant and clinically relevant improvement in gait velocity and maximum walking distance after stroke, while treadmill training with body weight support leads to a statistically significant and clinically relevant improvement in maximum walking distance.

A mixed-methods study to explore opinions of research translation held by researchers working in a Centre of Research Excellence in Australia

OBJECTIVE

There is a growing need for researchers to demonstrate impact, which is reliant on successful research translation. The Australian National Health and Medical Research Council funded a Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery (CRE-Stroke) to enhance collaborations between researchers conducting different types of stroke rehabilitation research. The purpose of this study was to explore opinions about research translation held by CRE-Stroke researchers conducting preclinical and clinical research, in terms of scope, importance, responsibility and perceived skills and knowledge.

DESIGN

Mixed-methods study, comprising a paper-based survey and semistructured interviews. Interview data were inductively coded and thematically analysed. Survey and interview data were compared and synthesised.

PARTICIPANTS

55 (7 preclinical, 48 clinical) researchers attending a CRE-Stroke research forum completed a paper-based survey. Semistructured interviews with 22 CRE-Stroke (5 preclinical, 17 clinical) researchers were conducted.

RESULTS

Research translation was described as translating to other research and translating to clinical practice and policy. Most researchers (n=54, 98%) reported that research translation was important, particularly in terms of generating research impact, but the most common sign of project completion reported by researchers (n=7, 100% preclinical; n=37, 77% clinical) was publication. Most researchers (preclinical n=4, 57%; clinical n=37, 77%) reported having responsibility for translating research, but less than half reported having the necessary skills (n=1, 14% preclinical; n=17, 35% clinical) and knowledge (n=3, 43% preclinical; n=19, 40% clinical). Differing opinions about who should be responsible for translating findings to clinical practice were expressed.

CONCLUSIONS

Stroke rehabilitation researchers appear confident to translate their research via the traditional mechanism of publications. To optimise impact, clarity is needed regarding who is best placed to translate research findings to clinical practice and policy. Education and skills development to apply broader translation processes are needed to maximise the use of research at all stages.

Development of elbow spasticity model for objective training of spasticity assessment of patients post stroke

Reliable assessment is essential for the management of spasticity, one of the most frequent complication of various neurological diseases. For the spasticity assessment, several clinical tools have been developed and widely used in clinics. The most popular one is modified Ashworth scale (MAS). It has a simple protocol, but is subjective and qualitative. To improve its reliability, quantitative measurement and consistent training would be needed. This study presents an elbow spasticity simulator which mimics spastic response of adult post stroke survivors. First, spastic responses (i.e. resistance and joint motion) from patients with a stroke were measured during conventional MAS assessment. Each grade of MAS was quantified by using three parameters representing three characteristics of the spasticity. Based on the parameters, haptic models of MAS were developed for implementing repeatable and consistent haptic training of novice clinicians. Two experienced clinicians participated in preliminary evaluation of the models.

Systematic review of clinical practice guidelines to identify recommendations for rehabilitation after stroke and other acquired brain injuries

OBJECTIVES

Rehabilitation clinical practice guidelines (CPGs) contain recommendation statements aimed at optimising care for adults with stroke and other brain injury. The aim of this study was to determine the quality, scope and consistency of CPG recommendations for rehabilitation covering the acquired brain injury populations.

DESIGN

Systematic review.

INTERVENTIONS

Included CPGs contained recommendations for inpatient rehabilitation or community rehabilitation for adults with an acquired brain injury diagnosis (stroke, traumatic or other non-progressive acquired brain impairments). Electronic databases (n=2), guideline organisations (n=4) and websites of professional societies (n=17) were searched up to November 2017. Two independent reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, and textual syntheses were used to appraise and compare recommendations.

RESULTS

From 427 papers screened, 20 guidelines met the inclusion criteria. Only three guidelines were rated high (>75%) across all domains of AGREE-II; highest rated domains were 'scope and purpose' (85.1, SD 18.3) and 'clarity' (76.2%, SD 20.5). Recommendations for assessment and for motor therapies were most commonly reported, however, varied in the level of detail across guidelines.

CONCLUSION

Rehabilitation CPGs were consistent in scope, suggesting little difference in rehabilitation approaches between vascular and traumatic brain injury. There was, however, variability in included studies and methodological quality.

PROSPERO REGISTRATION NUMBER

CRD42016026936.

The Impact of Stroke Nurse Navigation on Patient Compliance Postdischarge

PURPOSE

The purpose of this study was to describe the impact a stroke nurse navigation program has on concurrent chart reviews and patient compliance postdischarge.

DESIGN

Phase I: Concurrent chart review of The Joint Commission Primary Stroke Center core measures for ischemic stroke patients. Phase II: Longitudinal study of 100 ischemic stroke patients discharged to home.

METHODS

Telephone surveys were conducted at prescribed intervals posthospital discharge (Phase II). Surveys focused on medication compliance, follow-up medical appointment compliance, and neurovascular emergency department (ED) visits/readmissions.

FINDINGS

Phase I trends included increased stroke performance measures compliance. Phase II favorable trends included increased medication compliance (>98%), increased follow-up appointments (100%), decreased rate of neurovascular ED visits/rehospitalizations (3%), and improvement in activities of daily living and quality of life measures through 12 months postdischarge.

CONCLUSIONS

Stroke nurse navigation increased conformity of stroke performance measures and stroke patient discharge compliance through 12 months postdischarge.

Validation of the efficiency of a robotic rehabilitation training system for recovery of severe plegie hand motor function after a stroke

We have developed a rehabilitation training system called the Useful and Ultimate Rehabilitation System PARKO (UR System PARKO) to promote the recovery of motor function of the severe chronic plegic hand of stroke patients. This system was equipped with two functions to realize two conditions: (1) fixing of all fingers to a hyperextended position and (2) extending the elbow joint while applying resistance load to the fingertips. A clinical test was conducted with two patients to determine the therapeutic effect of the UR System PARKO for severe plegic hand. In both patients, the active ranges of motion of finger extension improved after training with the UR System PARKO. Moreover, the Modified Ashworth scale scores of finger extension increased. Thus, training reduced the spastic paralysis. These results suggest the effectiveness of training with the UR System PARKO for recovery of motor function as reflected in the finger extension of the severe plegic hand.

Customized therapy using distributions of reaching errors

While there has been recent success with robotic therapy approaches, individual differences in motor impairments motivate the need for customized therapy. Our latest work with healthy participants considered the likelihood of one's error to construct a customized force field training environment, which we termed an error field. We believe error statistics could characterize individual motor impairments for stroke survivors. Here we present preliminary results from a pilot study testing this therapy technique on individuals following stroke. We tracked the changes in error for three stroke survivors across multiple days using error field training, and found that participants' errors reduced for all target directions across sessions. We also used a modeling approach to test whether the changes in error reflected the specific mathematical structure of the intervention. These results provide encouraging preliminary evidence that error field training can be valuable for both characterizing deficits and custom-tailoring therapy.

Robots testing robots: ALAN-Arm, a humanoid arm for the testing of robotic rehabilitation systems

Robotics is increasing in popularity as a method of providing rich, personalized and cost-effective physiotherapy to individuals with some degree of upper limb paralysis, such as those who have suffered a stroke. These robotic rehabilitation systems are often high powered, and exoskeletal systems can attach to the person in a restrictive manner. Therefore, ensuring the mechanical safety of these devices before they come in contact with individuals is a priority. Additionally, rehabilitation systems may use novel sensor systems to measure current arm position. Used to capture and assess patient movements, these first need to be verified for accuracy by an external system. We present the ALAN-Arm, a humanoid robotic arm designed to be used for both accuracy benchmarking and safety testing of robotic rehabilitation systems. The system can be attached to a rehabilitation device and then replay generated or human movement trajectories, as well as autonomously play rehabilitation games or activities. Tests of the ALAN-Arm indicated it could recreate the path of a generated slow movement path with a maximum error of 14.2mm (mean = 5.8mm) and perform cyclic movements up to 0.6Hz with low gain (<1.5dB). Replaying human data trajectories showed the ability to largely preserve human movement characteristics with slightly higher path length and lower normalised jerk.

Utilization of kinematical redundancy of a rehabilitation robot to produce compliant motions under limitation on actuator performance

This paper addresses the mechanical structure and control method of a redundant drive robot (RDR) to produce compliant motions, and show how the design parameters of the RDR can effect the produced motions and the mechanical and performance limitations of the actuators of the RDR. The structure and control method of the RDR can have been proper to produce compliant motions, but the effect of the design parameters of the RDR to the mechanical and performance limitations have not been clear. Therefore, the feasibility of producing compliant motions in the case of the prototype of the RDR is confirmed by conducting simulations and experiments, and then the design parameters of the RDR to the mechanical and performance limitations are verified by conducting simulations.

Stroke Transitions of Care

This quality improvement project focused on improving patient education and patient satisfaction, and reducing all-cause 30-day readmissions. A 72-hour discharge follow-up telephone call was completed in patients discharged home with diagnosis of stroke.

Transitional Stroke Clinic Lowers 30-Day Readmissions

Wake Forest Baptist Medical Center’s transitional stroke clinic, developed to provide standardized care for stroke patients discharged to home, resulted in a 48% lower risk of 30-day readmissions among patients who made just one visit to the clinic. The clinic is run by nurse practitioners who see patients within 14 days of discharge and assess them for medical, cognitive, and psychosocial needs, conduct medication reconciliation, and screen for caregiver burnout. Patients attend the clinic in addition to going to their regular follow-up visits with the neurology clinic, their primary care providers, and therapy sessions. The model also includes follow-up phone calls by an RN within two days of discharge to ensure patients have filled their prescriptions and know how to take their medication, if any equipment has arrived, and to continue the education started in the hospital.

Considerations for the Selection of Time-Limited Walk Tests Poststroke: A Systematic Review of Test Protocols and Measurement Properties

BACKGROUND AND PURPOSE

Systematic reviews of research evidence describing the quality and methods for administering standardized outcome measures are essential to developing recommendations for their clinical application. The purpose of this systematic review was to synthesize the research literature describing test protocols and measurement properties of time-limited walk tests in people poststroke.

METHODS

Following an electronic search of 7 bibliographic data-bases, 2 authors independently screened titles and abstracts. One author identified eligible articles, and performed quality appraisal and data extraction.

RESULTS

Of 12 180 records identified, 43 articles were included. Among 5 walk tests described, the 6-minute walk test (6MWT) was most frequently evaluated (n = 36). Only 5 articles included participants in the acute phase (<1 month) poststroke. Within tests, protocols varied. Walkway length and walking aid, but not turning direction, influenced 6MWT performance. Intraclass correlation coefficients for reliability were 0.68 to 0.71 (12MWT) and 0.80 to 1.00 (2-, 3-, 5- and 6MWT). Minimal detectable change values at the 90% confidence level were 11.4 m (2MWT), 24.4 m (5MWT), and 27.7 to 52.1 m (6MWT; n = 6). Moderate-to-strong correlations (≥0.5) between 6MWT distance and balance, motor function, walking speed, mobility, and stair capacity were consistently observed (n = 33). Moderate-to-strong correlations between 5MWT performance and walking speed/independence (n = 1), and between 12MWT performance and balance, motor function, and walking speed (n = 1) were reported.

DISCUSSION AND CONCLUSIONS

Strong evidence of the reliability and construct validity of using the 6MWT poststroke exists; studies in the acute phase are lacking. Because protocol variations influence performance, a standardized 6MWT protocol poststroke for use across the care continuum is needed.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A150).

[Auditing as a tool for ongoing improvement in the Stroke Care Plan of the Region of Aragon]

INTRODUCTION

The Aragon Stroke Care Plan (PAIA) was created in 2008 within the framework of the Spanish National Health System. Monitoring hospital care of strokes by means of periodic audits was defined as one of its lines of work.

AIM

To determine the quality of the hospital care process for stroke patients in Aragon by using quality indicators.

MATERIALS AND METHODS

Three audits were carried out (in the years 2008, 2010 and 2012) following the same methodology, based on the retrospective review of a representative sample of admissions due to stroke in each of the general hospitals belonging to the Aragonese Health Service. Information was collected on 48 indicators selected according to their scientific evidence or clinical relevance.

RESULTS

Altogether 1011 cases were studied (331 in the first audit, and 340 in the second and the third). Thirty-one indicators showed a significant improvement (some of the most notable being the indicators of quality of the medical record, neurological assessment, initial preventive measures and, especially relevant, performing the swallowing test), two underwent a decline in their condition (related with rehabilitation treatment) and 15 did not register any significant variation.

CONCLUSIONS

The implementation of the PAIA has given rise to a notable improvement in most of the quality indicators evaluated, which reflects an ongoing improvement in hospital stroke care. The progressive generalisation of specialised care and the creation of stroke units are some of the determining factors.

Interventions to improve real-world walking after stroke: a systematic review and meta-analysis

OBJECTIVE

This study aimed to determine the effectiveness of current interventions to improve real-world walking for people with stroke and specifically whether benefits are sustained.

DATA SOURCES

EBSCO Megafile, AMED, Cochrane, Scopus, PEDRO, OTSeeker and Psychbite databases were searched to identify relevant studies.

REVIEW METHODS

Proximity searching with keywords such as ambulat*, walk*, gait, mobility*, activit* was used. Randomized controlled trials that used measures of real-world walking were included. Two reviewers independently assessed methodological quality using the Cochrane Risk of Bias Tool and extracted the data.

RESULTS

Nine studies fitting the inclusion criteria were identified, most of high quality. A positive effect overall was found indicating a small effect of interventions on real-world walking (SMD 0.29 (0.17, 0.41)). Five studies provided follow-up data at >3-6 months, which demonstrated sustained benefits (SMD 0.32 (0.16, 0.48)). Subgroup analysis revealed studies using exercise alone were not effective (SMD 0.19 (-0.11, 0.49)), but those incorporating behavioural change techniques (SMD 0.27 (0.12, 0.41)) were.

CONCLUSIONS

A small but significant effect was found for current interventions and benefits can be sustained. Interventions that include behaviour change techniques appear more effective at improving real-world walking habits than exercise alone.

Health, function and disability in stroke patients in the community

BACKGROUND

Stroke patients commonly have impairments associated with reduction in functionality. Among these impairments, the motor impairments are the most prevalent. The functional profile of these patients living in the community who are users of the primary health-care services in Brazil has not yet been established.

OBJECTIVE

To describe the functional profile of stroke patients who are users of the primary health-care services in Brazil, looking at one health-care unit in the city of Belo Horizonte, Brazil.

METHOD

From medical records and home visits, data were collected regarding health status, assistance received following the stroke, personal and environmental contextual factors, function and disability, organized according to the conceptual framework of the International Classification of Functioning, Disability and Health (ICF). Test and instruments commonly applied in the assessment of stroke patients were used.

RESULTS

Demographic data from all stroke patients who were users of the health-care unit (n=44, age: 69.23±13.12 years and 67±66.52 months since the stroke) participated of this study. Most subjects presented with disabilities, as changes in emotional function, muscle strength, and mobility, risks of falling during functional activities, negative self-perception of quality of life, and perception of the environment factors were perceived as obstacles. The majority of the patients used the health-care unit to renew drug prescriptions, and did not receive any information on stroke from health professionals, even though patients believed it was important for patients to receive information and to provide clarifications.

CONCLUSION

Stroke patients who used primary health-care services in Brazil have chronic disabilities and health needs that require continuous health attention from rehabilitation professionals. All of these health needs should be considered by health professionals to provide better management as part of the integral care of stroke patients, as recommended by the clinical practice guidelines for stroke rehabilitation.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).