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PRIMARY OBJECTIVE: To investigate the level of agreement and differences regarding the perception of family functioning between patients with acquired brain injury and their partners. Our hypothesis was that patients would report better family functioning than their partners.RESEARCH DESIGN: Cross-sectional studyMethods and Procedures: Baseline data were used from 77 patient-partner dyads (87.0% stroke) who were participating in the ongoing CARE4Patient and CARE4Carer trials. Family functioning was assessed using the General Functioning subscale of the McMaster Family Assessment Device (FAD-GF). Agreement was assessed with intraclass correlation coefficient, a Bland-Altman plot, percentages absolute agreement and weighted kappa values. Differences were tested with Wilcoxon signed-rank tests.MAIN OUTCOMES AND RESULTS: Patients and their partners differed in their perception of family functioning. Within-dyad agreement was poor regarding the overall FAD-GF scores with partners reporting significantly poorer family functioning compared to the patients (32.5% versus 18.2%). Agreement regarding the individual items ranged from slight to moderate.CONCLUSIONS: Health care professionals should assess family functioning after stroke in both patients and their partners, and any discrepancies should be discussed with both members of the patient-partner dyad.

Objective: Spontaneous recovery is an important determinant of upper extremity recovery after stroke and has been described by the 70% proportional recovery rule for the Fugl–Meyer motor upper extremity (FM-UE) scale. However, this rule is criticized for overestimating the predictability of FM-UE recovery. Our objectives were to develop a longitudinal mixture model of FM-UE recovery, identify FM-UE recovery subgroups, and internally validate the model predictions. Methods: We developed an exponential recovery function with the following parameters: subgroup assignment probability, proportional recovery coefficient r k, time constant in weeks τ k, and distribution of the initial FM-UE scores. We fitted the model to FM-UE measurements of 412 first-ever ischemic stroke patients and cross-validated endpoint predictions and FM-UE recovery cluster assignment. Results: The model distinguished 5 subgroups with different recovery parameters (r 1 = 0.09, τ 1 = 5.3, r 2 = 0.46, τ 2 = 10.1, r 3 = 0.86, τ 3 = 9.8, r 4 = 0.89, τ 4 = 2.7, r 5 = 0.93, τ 5 = 1.2). Endpoint FM-UE was predicted with a median absolute error of 4.8 (interquartile range [IQR] = 1.3–12.8) at 1 week poststroke and 4.2 (IQR = 1.3–9.8) at 2 weeks. Overall accuracy of assignment to the poor (subgroup 1), moderate (subgroups 2 and 3), and good (subgroups 4 and 5) FM-UE recovery clusters was 0.79 (95% equal-tailed interval [ETI] = 0.78–0.80) at 1 week poststroke and 0.81 (95% ETI = 0.80–0.82) at 2 weeks. Interpretation: FM-UE recovery reflects different subgroups, each with its own recovery profile. Cross-validation indicates that FM-UE endpoints and FM-UE recovery clusters can be well predicted. Results will contribute to the understanding of upper limb recovery patterns in the first 6 months after stroke. ANN NEUROL 2020;87:383–393 Ann Neurol 2020;87:383–393.

Background The evidence for rehabilitation interventions poststroke lack sufficient robustness. However, variation in treatment effects across countries have been given little attention. Objective To compare two identically protocolized trials conducted in different western countries in order to identify factors that may have caused variation in secondary trial outcomes. Methods Comparative study based on individual patient data (N = 129) from two randomized controlled trials, conducted in hospitals and rehabilitation facilities in the Netherlands (N = 66) and Australia (N = 63). Patients with stroke and their caregivers were randomly allocated to an 8-week caregiver-mediated exercises intervention (N = 63; 31 Australian and 32 Dutch) or to a control group (N = 66; 32 Australian and 34 Dutch). Patient characteristics, compliance, usual care and process measures were compared across countries. We examined if study setting significantly moderated the trial outcomes: Hospital Anxiety and Depression Scale, Fatigue Severity Scale and General Self-Efficacy Scale, measured at 8- and 12 weeks follow-up. In addition, we explored if factors that were significantly different across countries caused variation in these trial outcomes. Results Most patients suffered an ischemic stroke, were in the subacute phase and participated with their partner. Dutch patients were younger (P = 0.005) and had a lower functional status (P = 0.001). Australian patients were recruited earlier poststroke (PPPP = 0.040) among Dutch controls. No effect modification was observed and trial outcomes did not change after controlling for cross-country differences. Conclusions The present study highlighted important clinical differences across countries whilst using an identical study protocol. The observed differences could result in a different potential for recovery and variation in treatment effects across trials. We argue that we can proceed faster to evaluating interventions within international pragmatic trials.

Objective To classify patients with stroke into subgroups based on their characteristics at the moment of discharge from inpatient rehabilitation in order to predict community ambulation outcome 6 months later. Design Prospective cohort study with a baseline measurement at discharge from inpatient care and final outcome determined after 6 months. Setting Community. Participants A cohort of patients (N=243) with stroke, referred for outpatient physical therapy, after completing inpatient rehabilitation in The Netherlands. Interventions Not applicable. Main Outcome Measures A classification model was developed using Classification And Regression Tree (CART) analysis. Final outcome was determined using the community ambulation questionnaire. Potential baseline predictors included patient demographics, stroke characteristics, use of assistive devices, comfortable gait speed, balance, strength, motivation, falls efficacy, anxiety, and depression. Results The CART model accurately predicted independent community ambulation in 181 of 193 patients with stroke, based on a comfortable gait speed at discharge of 0.5 meters per second or faster. In contrast, 27 of 50 patients with gait speeds below 0.5 meters per second were correctly predicted to become noncommunity walkers. Conclusions We show that comfortable gait speed is a key factor in the prognosis of community ambulation outcome. The CART model may support clinicians in organizing community services at the moment of discharge from inpatient care.

Oefenen met een naaste (caregiver-mediated exercises, CME) in aanvulling op de reguliere therapie is een nieuwe vorm van oefenen voor patienten met een beroerte. Deze exploratieve kwalitatieve studie, onderdeel van de CARE4STROKE trial, richt zich op de ervaring van het samen oefenen. De onderzoeksvragen waren: 1) Hoe oefenen patient en naaste samen? en 2) Waar leidt het samen oefenen toe, behalve tot meer oefenmomenten? Er vonden semigestructureerde interviews plaats met zeven patienten en zeven naasten uit de CARE4STROKE-interventiegroep. Analyse vond plaats met inductieve thematische analyse. We vonden drie manieren waarop de patient en naaste samen oefenden: 1) de controle lag bij de patient; 2) er was sprake van samenwerking; 3) de naaste nam de verantwoordelijkheid (in het verlengde van de rol als mantelzorger). De meerwaarde van het samen oefenen is in drie thema’s in te delen, namelijk: 1) actieve betrokkenheid leidt tot personalisatie, 2) voorbereiding op de thuissituatie en 3) betrokkenheid op elkaar. Geconcludeerd werd dat er verschillende rolverdeling bestaan bij het oefenen met een naaste. Het is van belang dat de fysiotherapeuten die de koppels begeleiden zich bewust zijn wat voor effect CME kan hebben op de belasting van de patient of de naaste. De meerwaarde van het samen oefenen reikt verder dan een intensivering van de therapie. Door de actieve betrokkenheid kan samen oefenen leiden tot een individualisering van het behandelplan en een betere voorbereiding op ontslag naar huis.

Background: Stroke affects the neuronal networks of the non-infarcted hemisphere. The central motor conduction time (CMCT) induced by transcranial magnetic stimulation (TMS) could be used to determine the conduction time of the corticospinal tract of the non-infarcted hemisphere after a stroke. Objectives: Our primary aim was to demonstrate the existence of prolonged CMCT in the non-infarcted hemisphere, measured within the first 48 h when compared to normative data, and secondly, if the severity of motor impairment of the affected upper limb was significantly associated with prolonged CMCTs in the non-infarcted hemisphere when measured within the first 2 weeks post stroke. Methods: CMCT in the non-infarcted hemisphere was measured in 50 patients within 48 h and at 11 days after a first-ever ischemic stroke. Patients lacking significant spontaneous motor recovery, so-called non-recoverers, were defined as those who started below 18 points on the FM-UE and showed less than 6 points (10%) improvement within 6 months. Results: CMCT in the non-infarcted hemisphere was prolonged in 30/50 (60%) patients within 48 h and still in 24/49 (49%) patients at 11 days. Sustained prolonged CMCT in the non-infarcted hemisphere was significantly more frequent in non-recoverers following FM-UE. Conclusions: The current study suggests that CMCT in the non-infarcted hemisphere is significantly prolonged in 60% of severely affected, ischemic stroke patients when measured within the first 48 h post stroke. The likelihood of CMCT is significantly higher in non-recoverers when compared to those that show spontaneous motor recovery early post stroke.

Background. Spontaneous recovery early after stroke is most evident during a time-sensitive window of heightened neuroplasticity, known as spontaneous neurobiological recovery. It is unknown whether poststroke upper-limb motor and somatosensory impairment both reflect spontaneous neurobiological recovery or if somatosensory impairment and/or recovery influences motor recovery. Methods. Motor (Fugl-Meyer upper-extremity [FM-UE]) and somatosensory impairments (Erasmus modification of the Nottingham Sensory Assessment [EmNSA-UE]) were measured in 215 patients within 3 weeks and at 5, 12, and 26 weeks after a first-ever ischemic stroke. The longitudinal association between FM-UE and EmNSA-UE was examined in patients with motor and somatosensory impairments (FM-UE ≤ 60 and EmNSA-UE ≤ 37) at baseline. Results. A total of 94 patients were included in the longitudinal analysis. EmNSA-UE increased significantly up to 12 weeks poststroke. The longitudinal association between motor and somatosensory impairment disappeared when correcting for progress of time and was not significantly different for patients with severe baseline somatosensory impairment. Patients with a FM-UE score ≥18 at 26 weeks (n = 55) showed a significant positive association between motor and somatosensory impairments, irrespective of progress of time. Conclusions. Progress of time, as a reflection of spontaneous neurobiological recovery, is an important factor that drives recovery of upper-limb motor as well as somatosensory impairments in the first 12 weeks poststroke. Severe somatosensory impairment at baseline does not directly compromise motor recovery. The study rather suggests that spontaneous recovery of somatosensory impairment is a prerequisite for full motor recovery of the upper paretic limb.

Objective Recovery of the paretic arm post-stroke can be assessed using observational and self-reported measures. The aim of this study was to determine whether the correspondence (match) or non-correspondence (mismatch) between observational and self-reported improvements in upper limb capacity are significantly different at 0-3 months compared with 3-6 months post-stroke. Methods A total of 159 patients with ischaemic stroke with upper limb paresis were included in the study. Recovery of arm capacity was measured with observational (Action Research Arm Test; ARAT) and self-reported measures (Motor Activity Log Quality of Movement; MAL-QOM and Stroke Impact Scale Hand; SIS-Hand) at 0-3 and 3-6 months post-stroke. The proportion of matches was defined (contingency tables and Fisher's exact test) and compared across the different time-windows using McNemar's test. Results The proportion of matches was not significantly different at 0-3 months compared with 3-6 months post-stroke for the ARAT vs MAL-QOM and SIS-Hand (all p > 0.05). In case of mismatches, patients' self-reports were more often pessimistic (86%) in the first 3 months post-stroke compared with the subsequent 3 months (39%). Conclusion The match between observational and self-reported measures of upper limb capacity is not dependent on the timing of assessment post-stroke. Assessment of both observational and self-reported measures may help to recognize possible over- or under-estimation of improvement in upper limb capacity post-stroke.

BACKGROUND: Stroke rehabilitation aims to reduce impairments and promote activity and participation among patients. A major challenge for stroke rehabilitation research is to develop interventions that can reduce patients' neurological impairments. Until now, there has been no breakthrough in this research field. To move stroke rehabilitation forward, we need more knowledge about underlying mechanisms that drive spontaneous (i.e., reactive) neurobiological recovery after stroke and factors that can be used to optimize its prediction early after stroke onset.OBJECTIVE: The aim of the present invited review was therefore to elaborate on the time window of reactive neurobiological recovery, the proportional recovery rule and its generalizability to other neurological impairments, as well as to discuss the consequences for designing stroke recovery and rehabilitation trials.METHODS: In this narrative review, we offer suggestions to optimize the research designs of future stroke rehabilitation and recovery trials post stroke, in order to overcome the current prognostic heterogeneity introduced by variations in the potential for reactive neurobiological recovery.FINDINGS AND CONCLUSIONS: There is an urgent need for high-quality, explanatory trials in the first three months post stroke. These trials should preferably stratify patients based on their initial potential for reactive neurobiological recovery, measure recovery repeatedly at fixed times post stroke, and differentiate in their outcomes between behavioural restitution and compensation of functions.

BACKGROUND: The added prognostic value of transcranial magnetic stimulation (TMS)-induced motor-evoked potentials (MEPs) to clinical modeling for the upper limb is still unknown early poststroke.OBJECTIVE: To determine the added prognostic value of TMS of the adductor digiti minimi (TMS-ADM) to the clinical model based on voluntary shoulder abduction (SA) and finger extension (FE) during the first 48 hours and at 11 days after stroke.METHODS: This was a prospective cohort study with 3 logistic regression models, developed to predict upper-limb function at 6 months poststroke. The first model showed the predictive value of SA and FE measured within 48 hours and at 11 days poststroke. The second model included TMS-ADM, whereas the third model combined clinical and TMS-ADM information. Differences between derived models were tested with receiver operating characteristic curve analyses.RESULTS: A total of 51 patients with severe, first-ever ischemic stroke were included. Within 48 hours, no significant added value of TMS-ADM to clinical modeling was found ( P = .369). Both models suffered from a relatively low negative predictive value within 48 hours poststroke. TMS-ADM combined with SA and FE (SAFE) showed significantly more accuracy than TMS-ADM alone at 11 days poststroke ( P = .039).CONCLUSION: TMS-ADM showed no added value to clinical modeling when measured within first 48 hours poststroke, whereas optimal prediction is achieved by SAFE combined with TMS-ADM at 11 days poststroke. Our findings suggest that accuracy of predicting upper-limb motor function by TMS-ADM is mainly determined by the time of assessment early after stroke onset.

ObjectivePeer support facilitates patients and caregivers in adjusting to long-term disabilities. This study aimed to determine which patient characteristics are related to need for peer support during rehabilitation after acquired brain injury (ABI) and investigate factors that explain whether peer support is perceived as meaningful or not.DesignA prospective cohort study over a period of 17 months following patients with ABI during inpatient rehabilitation in the Netherlands. Multivariable logistic modelling was applied to identify patient and intervention characteristics that were related to (1) need for peer support and (2) whether or not peer support was perceived as meaningful. Additional information on duration and subjects of conversation was reported.SettingPeer support was provided during inpatient rehabilitation.Participants120 patients with ABI ≥18 years were included and assessed at admission, 94 patients were assessed at discharge. Seventy-three percent (n=88) expressed a need for peer support and at discharge 76.6% (n=72) perceived contact as meaningful.ResultsNon-Western and single patients perceived a significantly higher need for peer support. Patients younger than 60 and those with time between ABI and discharge of >3 months perceived their contact significantly more meaningful.ConclusionsResults provide more insight into characteristics of patients with ABI who may benefit from peer support during inpatient rehabilitation. Optimal dosage, length of contact, rehabilitation phase and strategy for the provision of peer support should be investigated as well as the effects for ABI survivors on outcomes such as coping, self-efficacy, depression and health-related quality of life.

Background and purposeWe designed an 8-week caregiver-mediated exercise program with e-health support after stroke (CARE4STROKE) in addition to usual care with the aim to improve functional outcome and to facilitate early supported discharge by increasing the intensity of task specific training.MethodsAn observer-blinded randomized controlled trial in which 66 stroke patient-caregiver couples were included during inpatient rehabilitation. Patients allocated to the CARE4STROKE program trained an additional amount of 150 minutes a week with a caregiver and were compared to a control group that received usual care alone. Primary outcomes: self-reported mobility domain of the Stroke Impact Scale 3.0 (SIS) and length of stay (LOS). Secondary outcomes: motor impairment, strength, walking ability, balance, mobility and (Extended) Activities of Daily Living of patients, caregiver strain of caregivers, and mood, self-efficacy, fatigue and quality of life of both patients and caregivers. Outcomes were assessed at baseline, 8 and 12 weeks after randomization.ResultsNo significant between-group differences were found regarding SIS-mobility after 8 (β 6.21, SD 5.16; P = 0.229) and 12 weeks (β 0.14, SD 2.87; P = 0.961), and LOS (P = 0.818). Significant effects in favor of the intervention group were found for patient's anxiety (β 2.01, SD 0.88; P = 0.023) and caregiver's depression (β 2.33, SD 0.77; P = 0.003) post intervention. Decreased anxiety in patients remained significant at the 12-week follow-up (β 1.01, SD 0.40; P = 0.009).ConclusionsThis proof-of concept trial did not find significant effects on both primary outcomes mobility and LOS as well as the secondary functional outcomes. Treatment contrast in terms of total exercise time may have been insufficient to achieve these effects. However, caregiver-mediated exercises showed a favorable impact on secondary outcome measures of mood for both patient and caregiver.Clinical trial registrationNTR4300, URL- http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4300.

Background: Intensity of practice and task and context specificity are key factorsfor improving functional outcome in stroke survivors. Novel methods are needed toaugment intensity of practice with minimal use of resources and costs. Caregivermediatedexercises (CMEs) focused on mobility, in which a caregiver acts as an exercisecoach and can increase the intensity of practice. There is preliminary evidencethat CME can improve functional outcome, reduce length of stay, and allow early supporteddischarge, without an increase in caregiver burden. In the CARE4STROKEprogramme (C4S), CME therapy and e‐health support are combined to promote asmoother transition from the inpatient setting to the home environment, with activerehabilitation continuing in the community.The objective of this paper is to describe the content of the C4S intervention in detailand explain implementation of this intervention in practice using the Template forIntervention Description and Replication checklist.Methods: Content, timing and intensity of the programme, participant screeningand selection, and intervention procedures were described using the Template forIntervention Description and Replication checklist. Mobility exercises and use of avideo application on tablet/smartphone are explained. The role of the caregiver asprovider of the intervention is illustrated.Discussion: C4S prescribes an additional exercise dose of 1,200 min and may be a promisingnovel and effective method to augment the pallet of therapeutic options for strokerehabilitation. Important aspects for successful implementation are availability and suitabilityof a caregiver. Suggestions for additional use of e‐health technology are described.Implications for physiotherapy practice: The presented description of C4S givesphysical therapists practical guidelines to facilitate implementation of the CMEintervention.

Background. During upper limb motor recovery after stroke, the greatest improvements occur typically in the first 5 weeks poststroke. It is unclear what patients learn during this early phase of recovery. Objective. To investigate the hypothesis that, early poststroke, patients learn to master the degrees of freedom in the paretic upper limb as reflected by dissociated shoulder and elbow movements during reach-to-grasp. Methods. Thirty-one patients with a first-ever ischemic stroke were included. Repeated 3-dimensional kinematic measurements were conducted at 14, 25, 38, 57, 92, and 189 days poststroke. Trunk, shoulder, elbow, and wrist rotations were measured during a reach-to-grasp task. Using principal component analysis the longitudinal changes in dissociated upper limb movements during reach-to-grasp were investigated. Twelve healthy subjects were included for comparison. Results. The main coordination pattern during reach-to-grasp in patients with stroke and healthy subjects consisted mostly of horizontal shoulder adduction and elbow extension. The standard deviation of this main pattern increased over time, with the largest increase in the first 5 weeks poststroke ( F = 5.5, P < .001), but remained smaller than in healthy individuals. The standard deviation increased by 0.46° per day between 14 and 38 days and tapered off to 0.05° per day between 38 and 189 days poststroke. Conclusions. Our results suggest that restitution of motor control by dissociation of shoulder and elbow movements occurs mainly early poststroke. However, compared with healthy adults, most patients did not achieve fully dissociated upper limb movements at 26 weeks poststroke, suggesting that upper limb motor control after stroke remains adaptive.

Constraint-induced movement therapy (CIMT) is a commonly used rehabilitation intervention to improve upper limb function after stroke. CIMT was originally developed for patients with a chronic upper limb paresis. Although there are indications that exercise interventions should start as early as possible after stroke, only a few randomized controlled trials have been published on either CIMT or modified forms of CIMT (mCIMT) during the acute phase after stroke. The implementation of (m)CIMT in published studies is very heterogeneous in terms of content, timing and intensity of therapy. Moreover, mCIMT studies often fail to provide a detailed description of the protocol applied. The purpose of the present paper is therefore to describe the essential elements of the mCIMT protocol as developed for the EXplaining PLastICITy after stroke (EXPLICIT-stroke) study. The EXPLICIT-stroke mCIMT protocol emphasizes restoring body functions, while preventing the development of compensatory movement strategies. More specifically, the intervention aims to improve active wrist -and finger extension, which is assumed to be a key factor for upper limb function. The intervention starts within 2 weeks after stroke onset. The protocol retains two of the three key elements of the original CIMT protocol, that is, repetitive training and the constraining element. Repetitive task training is applied for 1 hour per working day, and the patients wear a mitt for at least 3 hours per day for three consecutive weeks.

Background and Purpose It is largely unknown how adaptive motor control of the paretic upper limb contributes to functional recovery after stroke. This paucity of knowledge emphasizes the need for longitudinal 3-dimensional (3D) kinematic studies with frequent measurements to establish changes in coordination after stroke. A portable 3D kinematic setup would facilitate the frequent follow-up of people poststroke. This case report shows how longitudinal kinematic changes of the upper limb can be measured at a patient's home using a portable 3D kinematic system in the first 6 months poststroke. Case Description The outcomes of the upper-limb section of the Fugl-Meyer Motor Assessment (FMA), the Action Research Arm Test (ARAT), and 3D kinematic analyses were obtained from a 41-year-old man with a left hemispheric stroke. Three-dimensional kinematic data of the paretic upper limb were collected during a reach-to-grasp task using a portable motion tracker in 5 measurements during the first 6 months after stroke. Data from an individual who was healthy were used for comparison. Outcomes The FMA and ARAT scores showed nonlinear recovery profiles, accompanied by significant changes in kinematic outcomes over time poststroke. Specifically, elbow extension increased, forward trunk motion decreased, peak hand speed increased, peak hand opening increased, and peak hand opening occurred sooner after peak hand speed. Discussion This case report illustrates the feasibility of frequently repeated, on-site 3D kinematic measurements of the paretic upper limb. Early after stroke, task performance was mainly driven by adaptive motor control, whereas adaptations were mostly reduced at 26 weeks poststroke. The presented approach allows the investigation of what is changing in coordination and how these changes are related to the nonlinear pattern of improvements in body functions and activities after stroke.

Constraint-induced movement therapy is a commonly used intervention to improve upper limb function after stroke. However, the effectiveness of constraint-induced movement therapy and its optimal dosage during acute or sub-acute stroke is still under debate. To examine the literature on the effects of constraint-induced movement therapy in acute or sub-acute stroke. A literature search was performed to identify randomized, controlled trials; studies with the same outcome measure were pooled by calculating the mean difference. Separate quantitative analyses for high-intensity and low-intensity constraint-induced movement therapy were applied when possible. Five randomized, controlled trials were included, comprising 106 participants. The meta-analysis demonstrated significant mean differences in favor of constraint-induced movement therapy for the Fugl-Meyer arm, the Action Research Arm Test, the Motor Activity Log, Quality of Movement and the Grooved Pegboard Test. Nonsignificant mean difference in favor of constraint-induced movement therapy were found for the Motor Activity Log, Amount of Use. Separate analyses for high-intensity and low-intensity constraint-induced movement therapy resulted in significant favorable mean differences for low-intensity constraint-induced movement therapy for all outcome measures, in contrast to high-intensity constraint-induced movement therapy. This meta-analysis demonstrates a trend toward positive effects of high-intensity and low-intensity constraint-induced movement therapy in acute or sub-acute stroke, but also suggests that low-intensity constraint-induced movement therapy may be more beneficial during this period than high-intensity constraint-induced movement therapy. However, these results were based on a small number of studies. Therefore, more trials are needed applying different doses of therapy early after stroke and a better understanding is needed about the different time windows in which underlying mechanisms of recovery operate. © 2011 The Authors. International Journal of Stroke © 2011 World Stroke Organization.

Background and Purpose— The aim of the present study was to determine if outcome in terms of upper limb function at 6 months after stroke can be predicted in hospital stroke units using clinical parameters measured within 72 hours after stroke. In addition, the effect of the timing of assessment after stroke on the accuracy of prediction was investigated by measurements on days 5 and 9. Methods— Candidate determinants were measured in 188 stroke patients within 72 hours and at 5 and 9 days after stroke. Logistic regression analysis was used for model development to predict upper limb function at 6 months measured with the action research arm test (ARAT). Results— Patients with an upper limb motor deficit who exhibit some voluntary extension of the fingers and some abduction of the hemiplegic shoulder on day 2 have a probability of 0.98 to regain some dexterity at 6 months, whereas the probability was 0.25 for those without this voluntary motor activity. Sixty percent of patients with some early finger extension achieved full recovery at 6 months in terms of action research arm test score. Retesting the model on days 5 and 9 resulted in a gradual decline in probability from 0.25 to 0.14 for those without voluntary motor activity of shoulder abduction and finger extension, whereas the probability remained 0.98 for those with this motor activity. Conclusions— Based on 2 simple bedside tests, finger extension and shoulder abduction, functional recovery of the hemiplegic arm at 6 months can be predicted early in a hospital stroke unit within 72 hours after stroke onset.

Objective: To determine the optimal cutoff scores for the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) with regard to predicting no, poor, limited, notable, or full upper-limb capacity according to frequently used cutoff points for the Action Research Arm Test (ARAT) at 6 months poststroke.Design: Prospective.Setting: Rehabilitation center.Participants: Patients (N=460) with a first-ever ischemic stroke at 6 months poststroke.Interventions: Not applicable.Main Outcome Measures: Based on the ARAT classification of poor to full upper-limb capacity, receiver operating characteristic curves were used to calculate the area under the curve, optimal cutoff points for the FMA-UE were determined, and a weighted kappa was used to assess the agreement.Results: FMA-UE scores of 0 through 22 represent no upper-limb capacity (ARAT 0-10); scores of 23 through 31 represent poor capacity (ARAT 11-21); scores of 32 through 47 represent limited capacity (ARAT 22-42); scores of 48 through 52 represent notable capacity (ARAT 43-54); and scores of 53 through 66 represent full upper-limb capacity (ARAT 55-57). Overall, areas under the curve ranged from .916 (95% confidence interval [CI], .890-.943) to .988 (95% CI, .978-.998; PConclusions: There is considerable overlap in the area under the curve between the ARAT and FMA-UE. FMA-UE scores >31 points correspond to no to poor arm-hand capacity (ie, 31 correspond to limited to full arm-hand capacity (ie, >= 22 points) on the ARAT. (C) 2015 by the American Congress of Rehabilitation Medicine

Several systematic reviews have shown that additional exercise therapy has a positive effect on functional outcome after stroke. However, there is an urgent need for resource-efficient methods to augment rehabilitation services without increasing health care costs. Asking informal caregivers to do exercises with their loved ones, combined with e-health services may be a cost-effective method to promote early supported discharge with increased functional outcome. The primary aim of the CARE4STROKE study is to evaluate the effects and cost-effectiveness of a caregiver-mediated exercises program combined with e-health services after stroke in terms of self-reported mobility and length of stay. An observer-blinded randomized controlled trial, in which 66 stroke-patients admitted to a hospital stroke unit, rehabilitation center or nursing home are randomly assigned to either 8 weeks of the CARE4STROKE program in addition to usual care (i.e., experimental group) or 8 weeks of usual care alone (i.e., control group). The CARE4STROKE program is compiled in consultation with a trained physical therapist. A tablet computer is used to present video-based exercises for gait and gait-related activities in which a caregiver acts as an exercise coach. Primary outcomes are the mobility domain of the Stroke Impact Scale and length of stay. Secondary outcomes are the other domains of the Stroke Impact Scale, motor impairment, strength, walking ability, balance, mobility, (Extended) Activities of Daily Living, psychosocial functioning, self-efficacy, fatigue, health-related quality of life of the patient as well as the experienced strain, psychosocial functioning and quality of life of the caregiver. An economic evaluation will be conducted from the societal and health care perspective. The main aspects of the CARE4STROKE program are 1) increasing intensity of training by doing exercises with a caregiver in addition to usual care and 2) e-health support. We hypothesize this program leads to better functional outcome and early supported discharge, resulting in reduced costs. The study is registered in the Dutch trial register as NTR4300 , registered 2 December 2013.

Een beroerte is een van de belangrijkste oorzaken van chronische invaliditeit bij volwassenen. Als gevolg van de vergrijzing zal naar verwachting het aantal patienten met een beroerte in de toekomst toenemen, wat grote sociaal-economische gevolgen heeft (Truelsen, Ekman & Boysen, 2005). Vanwege de verwachte toename van het aantal patienten en de impact van een beroerte voor de individuele patient is het belangrijk om de kwaliteit en doelmatigheid van de zorg verder te verbeteren. De laatste jaren is er een trend zichtbaar van steeds kortere opnames op zogenoemde stroke-units in het ziekenhuis. Al tijdens de eerste dagen na de beroerte moeten daarom keuzes worden gemaakt over het beste revalidatietraject voor de patient. Deze keuzes worden in belangrijke mate bepaald door de functionele prognose. Kennis over de functionele prognose draagt bij aan het formuleren van realistischeen haalbare doelstellingen in de zorg, een adequaat verwijsbeleid en de mogelijkheid om al vroeg te kunnen anticiperen op eventuele aanpassingen en/of hulpmiddelen die in een latere fase nodig zijn. Als lid van het multidisciplinaire team op de stroke-unit behoort het tot de taken van de fysiotherapeut om een inschatting te maken van de functionele prognose voor de motorische functies en mede op basis daarvan een adequaat advies te geven aan het multidisciplinaire team.

Item does not contain fulltext OBJECTIVE: To describe recovery of upper limb capacity after stroke during inpatient rehabilitation based on the Stroke Upper Limb Capacity Scale (SULCS). DESIGN: Prospective observational study. SETTING: Inpatient department of a rehabilitation center. PARTICIPANTS: Patients with stroke (N=299) admitted to a specialized stroke rehabilitation center. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Upper limb capacity was assessed at the start and end of the rehabilitation phase with the SULCS (range, 0-10). The following demographic and clinical characteristics were registered: age, sex, side of stroke, stroke type, time since stroke, and length of stay in the rehabilitation center. RESULTS: On admission, 125 patients had no hand capacity (SULCS score, 0-3), 58 had basic hand capacity (SULCS score, 4-7), and 116 had advanced hand capacity (SULCS score, 8-10). Of the patients without initial hand capacity, 41% regained some hand capacity (SULCS score, >/=4) at discharge. Of these, patients with SULCS scores of 2 and 3 had 29 and 97 times greater chance of regaining some hand capacity compared with patients with an initial SULCS score of 0, respectively. Of the patients with initial basic hand capacity, 78% regained advanced hand capacity at discharge. The SULCS score on admission explained 51% of the SULCS score variance at discharge, while time since stroke was negatively associated with upper limb recovery, explaining an additional 7% of the SULCS score variance at discharge. CONCLUSIONS: Even patients with minimal proximal shoulder and elbow control of the upper paretic limb on admission in a rehabilitation center have a fair chance of regaining some hand capacity in the long-term after stroke, whereas patients without such proximal arm control have a much poorer prognosis for regaining hand capacity. 6 p.

Background Early prediction of outcome after stroke is becoming increasingly important, as most patients are discharged from hospital stroke units within several days after stroke. Objectives The primary purposes of this study were: (1) to determine the accuracy of physical therapists' predictions at hospital stroke units regarding upper-limb (UL) function, (2) to develop a computational prediction model (CPM), and (3) to compare the accuracy of physical therapists' and the CPM's predictions. Secondary objectives were to explore the impact of timing on the accuracy of the physical therapists' and CPM's predictions and to investigate the direction of the difference between predicted and observed outcomes. Finally, this study investigated whether the accuracy of physical therapists' predictions was affected by their experience in stroke rehabilitation. Design A prospective cohort study was conducted. Methods Physical therapists made predictions at 2 time points—within 72 hours after stroke onset (T72h) and at discharge from the hospital stroke unit (Tdischarge)—about UL function after 6 months in 3 categories, derived from the Action Research Arm Test. At the same time, clinical variables were measured to derive a CPM. The accuracy of the physical therapists' and CPM's predictions was evaluated by calculating Spearman rank correlation coefficients (rs) between predicted and observed outcomes. Results One hundred thirty-one patients and 20 physical therapists participated in the study. For the T72h assessment, the rs value between predicted and observed outcomes was .63 for the physical therapists' predictions and .75 for the CPM's predictions. For the Tdischarge assessment, the rs value for the physical therapists' predictions improved to .75, and the rs value for the CPM's predictions improved slightly to .76. Limitations Physical therapists administered a test battery every 3 days, which may have enhanced the accuracy of prediction. Conclusions The accuracy of the physical therapists' predictions at T72h was lower than that of the CPM's predictions. At Tdischarge, the physical therapists' and CPM's predictions are about equally accurate.

Response: We thank Corea et al for their letter in response to our paper.1 To address the comments stated in the letter, we will tackle the raised concerns on a point-by-point basis. First, we acknowledge that besides the National Institutes of Health Stroke Scale (NIHSS), it is useful to consider other valid neurological scales for neurological assessment such as the Canadian Neurological Scale. However, we would like to emphasize that the NIHSS is used as a standard measurement instrument by most physicians2 and nurses3 in stroke units. The reason for selecting NIHSS is the excellent clinimetric properties in terms of reliability, validity, and feasibility. Recently the American Heart Association recommended the bedside NIHSS assessment as the …

Objective: To investigate the concurrent validity between the Action Research Arm Test (ARAT) and the Wolf Motor Function Test (WMFT) and to compare their reproducibility, internal consistency and floor and ceiling effects in the same sample of stroke patients. Methods: Forty patients participated in this study. Concurrent validity was determined with Spearman's rank correlation coefficients. Reproducibility was assessed with intraclass correlation coefficients (ICCs) and Bland-Altman plots, internal consistency by means of Cronbach's alphas, and floor and ceiling effects were considered to be present if more than 20% of patients fell outside a preliminary set lower and upper boundary. Results: Spearman's rank correlation coefficients ranged from 0.70 to 0.86. ICCs for inter-rater and intra-rater reliability ranged from 0.92 to 0.97. Bland-Altman plots showed a less stable way of scoring for the WMFT, compared with the ARAT. Cronbach's alpha was>0.98 for both scales. No floor and ceiling effects were found. Conclusion: The present study showed good clinimetric properties for both assessments. The high concurrent validity suggests that ARAT and WMFT have significant overlap with regard to the underlying construct that is being measured. © 2010 Foundation of Rehabilitation Information.