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Objective: To undertake an economic analysis of the Take Charge intervention as part of the Taking Charge after Stroke (TaCAS) study., Design: An open, parallel-group, randomised trial comparing active and control interventions with blinded outcome assessment., Setting: Community., Participants: Adults ( n = 400) discharged to community, non-institutional living following acute stroke., Interventions: The Take Charge intervention, a strengths based, self-directed rehabilitation intervention, in two doses (one or two sessions), and a control intervention (no Take Charge sessions)., Measures: The cost per quality-adjusted life year (QALY) saved for the period between randomisation (always post hospital discharge) and 12 months following acute stroke. QALYs were calculated from the EuroQol-5D-5L. Costs of stroke-related and non-health care were obtained by questionnaire, hospital records and the New Zealand Ministry of Health., Results: One-year post hospital discharge cost of care was mean (95% CI) $US4706 (3758-6014) for the Take Charge intervention group and $6118 (4350-8005) for control, mean (95% CI) difference $ -1412 (-3553 to +729). Health utility scores were mean (95% CI) 0.75 (0.73-0.77) for Take Charge and 0.71 (0.67-0.75) for control, mean (95% CI) difference 0.04 (0.0-0.08). Cost per QALY gained for the Take Charge intervention was $US -35,296 (=£ -25,524, € -30,019). Sensitivity analyses confirm Take Charge is cost-effective, even at a very low willingness-to-pay threshold. With a threshold of $US5000 per QALY, the probability that Take Charge is cost-effective is 99%., Conclusion: Take Charge is cost-effective and probably cost saving.

Purpose: Understanding personal experiences of real-world walking for stroke survivors could assist clinicians to tailor interventions to their clients' specific needs. We explored the research questions: "What does real-world walking mean to people after stroke and how do they think it can be better?", Method: Using an Interpretive Descriptive methodology, we purposively sampled eight stroke survivors who reported difficulty walking in the real-world. We sought diversity on key participant characteristics. Participants were interviewed using a semi-structured guide. Data were analysed with thematic analysis., Results: Many found real-world walking, particularly in the outdoors, created opportunities for freedom from dependence and a visible step by step progress, which generated hope for future recovery. Conversely, when participants did not experience sufficient progress, they expressed negative emotions. Participants strove to overcome challenges to their walking goals using everyday routines, planning skills, and confidence building experiences to motivate themselves. They also drew on, and extended, social resources highlighting the relational aspects of real-world walking., Conclusions: Walking in their real-world provided a meaningful, desirable, but challenging goal for participants that required significant emotional effort. Successful progress in real-world walking builds confidence and hope and can contribute to psychological wellbeing by providing opportunities for successful mastery and social connectedness.IMPLICATIONS FOR REHABILITATIONReal-world settings can be unpredictable which makes walking in the real-world after stroke demanding.Positive experiences of walking in the real-world can provide significant psychological benefits to stroke survivors.Many survivors need to carefully concentrate on the act of walking in outdoor settings.Pre-planning routes, confidence-building experiences and developing daily routines may help patients overcome these challenges.

Objective: To use secondary data from the Taking Charge after Stroke study to explore mechanisms for the positive effect of the Take Charge intervention on physical health, advanced activities of daily living and independence for people after acute stroke., Design: An open, parallel-group, randomised trial with two active and one control intervention and blinded outcome assessment., Setting: Community., Participants: Adults ( n  = 400) discharged to community, non-institutional living following acute stroke., Interventions: One, two, or zero sessions of the Take Charge intervention, a self-directed rehabilitation intervention which helps a person with stroke take charge of their own recovery., Measures: Twelve months after stroke: Mood (Patient Health Questionnaire-2, Mental Component Summary of the Short Form 36); 'ability to Take Charge' using a novel measure, the Autonomy-Mastery-Purpose-Connectedness (AMP-C) score; activation (Patient Activation Measure); body mass index (BMI), blood pressure (BP) and medication adherence (Medication Adherence Questionnaire)., Results: Follow-up was near-complete (388/390 (99.5%)) of survivors at 12 months. Mean age (SD) was 72.0 (12.5) years. There were no significant differences in mood, activation, 'ability to Take Charge', medication adherence, BMI or BP by randomised group at 12 months. There was a significant positive association between baseline AMP-C scores and 12-month outcome for control participants (1.73 (95%CI 0.90 to 2.56)) but not for the Take Charge groups combined (0.34 (95%CI -0.17 to 0.85))., Conclusion: The mechanism by which Take Charge is effective remains uncertain. However, our findings support a hypothesis that baseline variability in motivation, mastery and connectedness may be modified by the Take Charge intervention.

Background and Purpose: "Take Charge" is a novel, community-based self-directed rehabilitation intervention which helps a person with stroke take charge of their own recovery. In a previous randomized controlled trial, a single Take Charge session improved independence and health-related quality of life 12 months following stroke in Māori and Pacific New Zealanders. We tested the same intervention in three doses (zero, one, or two sessions) in a larger study and in a broader non-Māori and non-Pacific population with stroke. We aimed to confirm whether the Take Charge intervention improved quality of life at 12 months after stroke in a different population and whether two sessions were more effective than one., Methods: We randomized 400 people within 16 weeks of acute stroke who had been discharged to institution-free community living at seven centers in New Zealand to a single Take Charge session (TC1, n = 132), two Take Charge sessions six weeks apart (TC2, n = 138), or a control intervention (n = 130). Take Charge is a "talking therapy" that encourages a sense of purpose, autonomy, mastery, and connectedness with others. The primary outcome was the Physical Component Summary score of the Short Form 36 at 12 months following stroke comparing any Take Charge intervention to control., Results: Of the 400 people randomized (mean age 72.2 years, 58.5% male), 10 died and two withdrew from the study. The remaining 388 (97%) people were followed up at 12 months after stroke. Twelve months following stroke, participants in either of the TC groups (i.e. TC1 + TC2) scored 2.9 (95% confidence intervals (CI) 0.95 to 4.9, p = 0.004) points higher (better) than control on the Short Form 36 Physical Component Summary. This difference remained significant when adjusted for pre-specified baseline variables. There was a dose effect with Short Form 36 Physical Component Summary scores increasing by 1.9 points (95% CI 0.8 to 3.1, p < 0.001) for each extra Take Charge session received. Exposure to the Take Charge intervention was associated with reduced odds of being dependent (modified Rankin Scale 3 to 5) at 12 months (TC1 + TC2 12% versus control 19.5%, odds ratio 0.55, 95% CI 0.31 to 0.99, p = 0.045)., Conclusions: Confirming the previous randomized controlled trial outcome, Take Charge-a low-cost, person-centered, self-directed rehabilitation intervention after stroke-improved health-related quality of life and independence., Clinical Trial Registration-Url: http://www.anzctr.org.au. Unique identifier: ACTRN12615001163594.

Understanding how people adjust following stroke is essential to optimise recovery and ensure services are responsive to people's needs. This study aimed to explore people's experiences over the first three years post-stroke and identify what helped or hindered recovery. As part of a longitudinal, qualitative descriptive study, 55 people and 27 significant others purposefully selected from a population-based stroke incidence study were interviewed 6, 12, 24 and 36 months post-stroke. Interviews were audio taped and transcribed verbatim. Participants described an ongoing process of shock, disruption, and fear, making sense of what happened, needing to fit in with what's offered, finding what works for them and evolving a new normal, whilst managing the ups and downs of life . This process needed to be re-negotiated over time, as people experienced changes in their recovery, comorbidities and/or wider circumstances. The adjustment process continued over the three years post-stroke, even for those who perceived that they were recovering well. Rehabilitation services need to support patients to make sense of their stroke, navigate the health system, address individual concerns and priorities and to know what, when and how much to challenge themselves. Rehabilitation plans need to be revised as circumstances change to facilitate adjustment following a stroke.

Background: Engagement is commonly considered important in stroke rehabilitation, with some arguing it is essential for positive patient outcomes. An emerging body of research indicates the practitioner influences engagement through their ways of relating, communicating and working with the patient. People experiencing communication disability may face particular challenges with engagement as a practitioner's communication and interactional patterns may limit their ability to engage., Aims: To understand how rehabilitation practitioners worked to engage people experiencing communication disability throughout the course of rehabilitation., Methods & Procedures: A qualitative study using the Voice Centred Relational Approach. Longitudinal observational and interview data were gathered from 28 practitioners and three people experiencing communication disability in inpatient and community stroke rehabilitation services. Data were analyzed using the Listening Guide., Outcomes & Results: Engagement was a relational practice on the part of the rehabilitation practitioner. It was underpinned by a relational philosophy and characterized by three core processes: embedding relational work throughout rehabilitation; getting to know the patient and working in ways valued by the patient; and communicating using relational dialogue and supported conversation. Practitioners wove these together with their technical, disciplinary-based work and rehabilitation tasks., Conclusions & Implications: Patient engagement was constructed through relationships and strongly influenced by the practitioners' way of thinking about and enacting practice, challenging the idea that engagement is solely an intrinsic patient state and behaviour. The findings raise questions about which aspects of rehabilitation work and communication are most valuable when working to engage people experiencing communication disability. Viewing engagement as a relational practice and understanding the different ways this is enacted may support practitioners to reflect on their understandings of engagement, their patient's engagement, their ways of working, and the frames and philosophies that surround and influence their practice., (© 2018 Royal College of Speech and Language Therapists.)

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.

Background: Intensity refers to the amount of effort or rate of work undertaken during exercise. People receiving rehabilitation after stroke frequently do not reach the moderate to high intensity exercise recommended to maximise gains., Objective: To explore the factors that influence the acceptability of, and engagement with, a high intensity group-based exercise programme for people with stroke., Methods: This qualitative descriptive study included 14 people with stroke who had completed a 12-week, high intensity group-based exercise rehabilitation programme. Semi-structured interviews were used to explore the acceptability of high intensity exercise and the barriers and facilitators to engagement. Interviews were recorded, transcribed and analysed using qualitative content analysis., Results: The participants found high intensity exercise rehabilitation acceptable despite describing the exercise intensity as hard and reporting post-exercise fatigue. Participants accepted the fatigue as a normal response to exercise, and it did not appear to negatively influence engagement. The ease with which an individual engaged in high intensity exercise rehabilitation appeared to be mediated by inter-related factors, including: seeing progress, sourcing motivation, working hard, the people involved and the fit with the person and their life. Participants directly related the intensity of their effort to the gains that they made., Conclusions: In this study, people with stroke viewed training at higher intensities as a facilitator, not a barrier, to engagement in exercise rehabilitation. The findings may challenge assumptions about the influence of exercise intensity on engagement.

Background and Purpose: Stroke recurrence rates are high (20%-25%) and have not declined over past 3 decades. This study tested effectiveness of motivational interviewing (MI) for reducing stroke recurrence, measured by improving adherence to recommended medication and lifestyle changes compared with usual care., Methods: Single-blind, prospective phase III randomized controlled trial of 386 people with stroke assigned to either MI treatment (4 sessions at 28 days, 3, 6, and 9 months post stroke) or usual care; with outcomes assessed at 28 days, 3, 6, 9, and 12 months post stroke. Primary outcomes were change in systolic blood pressure and low-density lipoprotein cholesterol levels as indicators of adherence at 12 months. Secondary outcomes included self-reported adherence, new stroke, or coronary heart disease events (both fatal and nonfatal); quality of life (Short Form-36); and mood (Hospital Anxiety and Depression Scale)., Results: MI did not significantly change measures of blood pressure (mean difference in change, -0.2.35 [95% confidence interval, -6.16 to 1.47]) or cholesterol (mean difference in change, -0.0.12 [95% confidence interval, -0.30 to 0.06]). However, it had positive effects on self-reported medication adherence at 6 months (1.979; 95% confidence interval, 0.98-3.98; P=0.0557) and 9 months (4.295; 95% confidence interval, 1.56-11.84; P=0.0049) post stroke. Improvement across other measures was also observed, but the differences between MI and usual care groups were not statistically significant., Conclusions: MI improved self-reported medication adherence. All other effects were nonsignificant, though in the direction of a treatment effect. Further study is required to determine whether MI leads to improvement in other important areas of functioning (eg, caregiver burden)., Clinical Trial Registration: URL: http://www.anzctr.org.au. Unique identifier: ACTRN-12610000715077., (© 2015 American Heart Association, Inc.)

Background: Insufficient data exist on population-based trends in morbidity and mortality to determine the success of prevention strategies and improvements in health care delivery in stroke. The aim of this study was to determine trends in incidence and outcome (1-year mortality, 28-day case-fatality) in relation to management and risk factors for stroke in the multi-ethnic population of Auckland, New Zealand (NZ) over 30-years., Methods: Four stroke incidence population-based register studies were undertaken in adult residents (aged ≥15 years) of Auckland NZ in 1981-1982, 1991-1992, 2002-2003 and 2011-2012. All used standard World Health Organization (WHO) diagnostic criteria and multiple overlapping sources of case-ascertainment for hospitalised and non-hospitalised, fatal and non-fatal, new stroke events. Ethnicity was consistently self-identified into four major groups. Crude and age-adjusted (WHO world population standard) annual incidence and mortality with corresponding 95% confidence intervals (CI) were calculated per 100,000 people, assuming a Poisson distribution., Results: 5400 new stroke patients were registered in four 12 month recruitment phases over the 30-year study period; 79% were NZ/European, 6% Māori, 8% Pacific people, and 7% were of Asian or other origin. Overall stroke incidence and 1-year mortality decreased by 23% (95% CI 5%-31%) and 62% (95% CI 36%-86%), respectively, from 1981 to 2012. Whilst stroke incidence and mortality declined across all groups in NZ from 1991, Māori and Pacific groups had the slowest rate of decline and continue to experience stroke at a significantly younger age (mean ages 60 and 62 years, respectively) compared with NZ/Europeans (mean age 75 years). There was also a decline in 28-day stroke case fatality (overall by 14%, 95% CI 11%-17%) across all ethnic groups from 1981 to 2012. However, there were significant increases in the frequencies of pre-morbid hypertension, myocardial infarction, and diabetes mellitus, but a reduction in frequency of current smoking among stroke patients., Conclusions: In this unique temporal series of studies spanning 30 years, stroke incidence, early case-fatality and 1-year mortality have declined, but ethnic disparities in risk and outcome for stroke persisted suggesting that primary stroke prevention remains crucial to reducing the burden of this disease.

Purpose: Goal setting and patient-centredness are considered fundamental concepts in rehabilitation. However, the best way to involve patients in setting goals remains unclear. The purpose of this study was to explore patient experiences of goal setting in post-acute stroke rehabilitation to further understanding of its application to practice., Method: Thematic analysis was used to analyse interview transcripts from 10 stroke survivors, recruited from 4 rehabilitation units as part of a pilot study investigating the effects of a structured means of eliciting patient-centred goals in post-acute stroke rehabilitation., Results: Three key themes emerged: (1) "A Day by Day Momentum", comprising subordinate themes of "Unpredictability" and "Natural Progression" in which daily progress forwards was seen as an integral part of rehabilitation; (2) "Battle versus Alliance" in which issues of struggle versus support influenced participants' advancement; and (3) "The Special Things", consisting of subordinate themes of "What Makes Me 'Me'" and "Symbolic Achievements" concerning issues defining individuals and their rehabilitation experiences., Conclusions: Patients' discourse around goal setting can differ from the discourse conventionally used by clinicians when describing "best practice" in rehabilitation goal setting. Understanding patients' non-conventional views of goals may assist in supporting and motivating them, thus providing drive for their rehabilitation., Implications for Rehabilitation: Stroke patients think about goals very differently from health professionals. Individual patients have diverse ideas about goals within the context of the uncertainty of stroke, their life as a whole and recovery after formal rehabilitation is completed. To meet these diverse needs, health professionals need to communicate fully with patients to gain an understanding of their experiences of stroke and wider views on goals.

Rationale: Recurrent stroke is prevalent in both developed and developing countries, contributing significantly to disability and death. Recurrent stroke rates can be reduced by adequate risk factor management. However, adherence to prescribed medications and lifestyle changes recommended by physicians at discharge after stroke is poor, leading to a large number of preventable recurrent strokes. Using behavior change methods such as Motivational Interviewing early after stroke occurrence has the potential to prevent recurrent stroke., Aims And/or Hypothesis: The overall aim of the study is to determine the effectiveness of motivational interviewing in improving adherence to medication and lifestyle changes recommended by treating physicians at and after hospital discharge in stroke patients 12 months poststroke to reduce risk factors for recurrent stroke., Design: Recruitment of 430 first-ever stroke participants will occur in the Auckland and Waikato regions. Randomization will be to intervention or usual care groups. Participants randomized to intervention will receive four motivational interviews and five follow-up assessments over 12 months. Nonintervention participants will be assessed at the same time points., Study Outcomes: Primary outcome measures are changes in systolic blood pressure and low-density lipoprotein levels 12 months poststroke. Secondary outcomes include self-reported adherence and barriers to prescribed medications, new cardiovascular events (including stroke), changes in quality of life, and mood., Discussion: The results of the motivational interviewing in stroke trial will add to our understanding of whether motivational interviewing may be potentially beneficial in the management of stroke and other diseases where similar lifestyle factors or medication adherence are relevant., (© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.)

Background: Qualitative data can add value and understanding to more traditional epidemiological studies. This study was designed to complement the quantitative data from the incidence study the Auckland Regional Community Stroke Study or ARCOS-IV by using qualitative methods to uncover the richer detail of life as a stroke survivor, thereby extending our understanding of the impact of stroke., Aims: The aims of the study were to identify how the experience of recovery and adaptation changes over time after stroke; and to elicit the strategies people with stroke and their whānau/family use and find helpful in living life after stroke. The aim of this paper is to describe the methodology and also the challenges and advantages of embedding qualitative research into a large epidemiological study., Methods: Longitudinal study utilizing a Qualitative Description design in a subset of those taking part in the incidence study. Participants will be interviewed at 6, 12, 24, and 36 months after stroke. Semistructured interviews will explore three key areas: (1) issues of importance to people following a stroke and their whānau/family; (2) the perceived impact on people's sense of recovery, adaptation, and hopes; and (3) key strategies that people with stroke and their whānau/family use and find most helpful in living life after stroke. Thematic analysis will be conducted using iterative constant comparative methods., Conclusions: This methodology paper demonstrates the application of mixed methods in epidemiology. It also considers some of the practical and methodological issues that have emerged and may provide a useful framework for other qualitative projects in population-based studies., (© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.)

Background: Stroke is a leading cause of death and disability worldwide. Stroke burden is immense as it leads to premature deaths, leaves survivors with ongoing disabilities, and has a major financial impact on the individual, their families, and the community. Reliable, high-quality evidence is needed on stroke risk factors, incidence, and outcomes to provide information on how best to reduce this burden. Population-based studies are regarded as the 'gold-standard' of measuring disease burden but are not common due to the logistical and financial challenges they present. The Auckland Regional Community Stroke Studies are among a few in the world that have been carried out at a population level and at regular intervals., Aim: The aim of the fourth Auckland Regional Community Stroke Studies IV is to examine the current measures of stroke incidence, prevalence, and outcomes as well the trends over four decades. This article describes the methodology of the Auckland Regional Community Stroke Studies IV with stroke and transient ischemic attacks cases registered over a 12-month period from March 1, 2011 to February 29, 2012., Conclusions: The methodology described may be used as a guide in order to design similar population-based stroke incidence and outcome studies in other countries and populations, thus facilitating the collection of most consistent and accurate stroke epidemiological data., (© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.)

Aim: Health outcomes research for Maori has been hampered by the lack of adequately validated instruments that directly address outcomes of importance to Maori, framed by a Maori perspective of health. Hua Oranga is an outcome instrument developed for Maori with mental illness that uses a holistic view of Maori health to determine improvements in physical, mental, spiritual and family domains of health. Basic psychometric work for Hua Oranga is lacking. We sought to explore the psychometric properties of the instrument and compare its responsiveness alongside other, more established tools in an intervention study involving Maori and Pacific people following acute stroke., Methods: Randomised 2x2 controlled trial of Maori and Pacific people following acute stroke with two interventions aimed at facilitating self-directed rehabilitation, and with follow-up at 12 months after randomisation. Primary outcome measures were the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the Short Form 36 (SF36) at 12 months. Hua Oranga was used as a secondary outcome measure for participants at 12 months and for carers and whanau (extended family). Psychometric properties of Hua Oranga were explored using plots and correlation coefficients, principal factors analysis and scree plots., Results: 172 participants were randomised, of whom 139 (80.8%) completed follow-up. Of these, 135 (97%) completed the Hua Oranga and 117 (84.2%) completed the PCS and MCS of the SF36. Eighty-nine carers completed the Hua Oranga. Total Hua Oranga scores and PCS improved significantly for one intervention group but not the other. Total Hua Oranga scores for carers improved significantly for both interventions. Total Hua Oranga score correlated moderately with the PCS (correlation coefficient 0.55, p<0.001). Factor analysis suggested that Hua Oranga measures two and not four factors; one 'physical-mental' and one 'spiritual-family'., Conclusion: The Hua Oranga instrument, developed for Maori people with mental illness, showed good responsiveness and adequate psychometric properties in Maori and Pacific people after stroke. Its simplicity, relative brevity, minimal cost and adequate psychometric properties should favour its use in future studies with both Maori and Pacific people. Suggestions are made for refinements to the measure. These should be tested in a new population before Hua Oranga is recommended for general use in a clinical setting.

Stroke is a major cause of death and disability in many countries. Early access to the most appropriate medical treatment can improve health outcomes. Despite this, only 30-60% of people who experience a stroke seek medical help within the recommended 3-hour timeframe. This study used open-ended interviews to explore patients' views on factors that influenced their decision to seek help at the time of stroke. Twenty participants were recruited from five centres: three hospitals, a community-based stroke support service and a primary healthcare service focused on providing health care for Maori. A qualitative methodology drawing on Grounded Theory informed data collection and analysis. Four main themes influenced the decision to seek help: making sense of symptoms, maintaining a sense of normality, presence and influence of another person and perception of medical services. Participants appeared to go through a process of recognition, interpretation and negotiation during their decision-making. Each of the four themes seemed to influence this process, either assisting or delaying help-seeking behaviour. The more time spent going through this process (or repeating each step), the longer the delay appeared to be. Our key findings which add to current help-seeking literature, include: (1) people tended to prioritise everyday commitments and responsibilities over their own health; (2) at times the presence and influence of another person contributed to delays in seeking help; and (3) people had different personal thresholds for when they perceived themselves to be 'sick enough' to seek medical help.

Objectives: To assess the effect of environment and a secondary task on gait parameters in community ambulant stroke survivors and to assess the contribution of clinical symptoms to gait performance., Design: A 2x3 randomized factorial design with 2 main factors: task (no task, motor task, cognitive task) and environment (clinic, suburban street, shopping mall)., Setting: Subjects were assessed in 1 of 3 settings: 2 in the community (a suburban street and shopping mall) and 1 clinical environment., Participants: Twenty-seven people with stroke (mean age, 61+/-11.6y; mean time since stroke onset, 45.8+/-34.2mo), living at home, were recruited from community stroke groups and from a local rehabilitation unit. Selection criteria included the following: ability to give informed consent, unilateral first ever or recurrent stroke at least 6 months previously, walking independently in the community, a gait speed between 24 and 50 m/min, Mini-Mental State Examination score of 24 or higher, and no severe comorbidity., Interventions: Not applicable., Main Outcome Measures: Gait speed (in m/min), cadence, and step length were assessed by using an accelerometer with adjustable thresholds. Clinical measures hypothesized to influence gait parameters in community environments were also assessed including fatigue, anxiety and depression, and attentional deficit., Results: Twenty-seven people with a mean baseline gait speed of 42.2+/-5.9 m/min were randomly allocated to 1 of 9 conditions in which the setting and distraction were manipulated. Analysis of variance showed a significant main effect for environment (P = .046) but not for task (P = .37). The interaction between task and environment was not significant (P = .73). Adjusting for baseline gait speed, people walked on average 8.8m/min faster in the clinic (95% confidence interval, 0.3-17.3m/min) than in the mall. Scores for fatigue, anxiety and depression, and attentional deficit were higher than normative values but did not influence gait performance., Conclusions: This study suggests that people with chronic stroke cope well with the challenges of varied environments and can maintain their gait speed while performing a secondary task. Despite moderate levels of gait impairment, gait automaticity may be restored over time to a functional level.

Objective: To describe the underlying dimensions for a range of functional measures across 3 neurologic diseases at different time points., Design: Multiple cohort study., Setting: Combination of public hospital wards and community., Participants: Patients (N=308) from 3 cohorts: paralytic poliomyelitis (n=38), mean of 25 years previously, assessed once; acute stroke admitted to hospital and followed up for 12 months postdischarge (n=181); and traumatic brain injury (TBI), admitted to hospital and followed up for 12 months postdischarge (n=89)., Interventions: Not applicable., Main Outcome Measures: The Barthel Index, FIM instrument, Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical component score (PCS) and mental component score (MCS), Community Integration Questionnaire (CIQ), and the London Handicap Score (LHS). Measures were compared at 2 time points: pre-event status for stroke, TBI and the polio cohort, and 12-month postdischarge status for stroke and TBI., Results: The different measures generally correlated highly within disease states at each time point. Principal components analysis revealed 2 underlying dimensions, a physical dimension onto which loaded the Barthel Index, FIM, PCS, and LHS and a cognitive/emotional dimension onto which loaded the MCS and, for subjects with polio, the CIQ. These 2 dimensions accounted for 69% of the variance in measures at the pre-event time point and 85% of the variance at the 12-month time point., Conclusions: These data suggest 2 basic underlying dimensions across a wide range of measures in 3 different neurologic conditions even at different time points. Most of the variation in the measures can be captured using the 2 component summary scores (PCS, MCS) of the SF-36.

Objectives: We sought to determine the relationship between self-reported ratings of health-related quality of life (HRQoL) by people with 3 chronic and disabling conditions and population estimates of those health states and to model factors that might explain the disagreement between these 2 ratings., Research Design: A cross-sectional postal survey was sent in which each participant completed a set of questionnaires addressing HRQoL. Data from self-valuation on a visual analog scale (VAS) was compared with a population-based VAS-equivalent valuation, using the EQ-5D instrument. Different ways of scaling the 2 VAS scores were also explored. Data were analyzed using descriptive statistics and analysis of covariance., Subjects: A community sample of 1036 people took part in the study (rheumatoid arthritis n = 142, stroke n = 585, multiple sclerosis n = 309). MEASUREMENT INSTRUMENT: The EQ-5D health state profile and accompanying visual analog scale were used., Results: Self-ratings were significantly different than the population-based ratings, and agreement was poor, both on the original scale of the data and by analyses of rescaled data. On the original scales the mean difference was 0.13 (95% confidence interval 0.117-0.143). Diagnosis, health state severity, and its square explained 35.3% of the variation in the differences between self and population ratings with a curvilinear relationship suggesting that the differences increased as the health state worsened, but at a decreasing rate as health state severity increased., Conclusions: This study provides evidence that EQ-5D population valuation estimates of treatment benefit for people with disabling and chronic conditions may well be inaccurate representations of the degree of change actually experienced by the individual with the condition. The varying magnitude of difference between the 2 forms of valuation has important implications for interpreting shifts in health status valuation following interventions for these populations.

Purpose: This study aimed to explore the applicability of a previously derived model of what mattered most to people with arthritis across a number of different disabling conditions., Method: A qualitative study using interviews with 30 participants from three out-patient groups (rheumatoid arthritis, stroke and chronic pain) was conducted. Participants were asked to identify and discuss the most important consequences of living with their condition. Narratives were explored for similarities and differences within and across conditions., Results: While diagnostically related differences were clearly evident, particularly in categories within the Intrinsic, Extrinsic and Future Issues themes, a marked level of similarity in view was apparent in two themes, Taking Charge and Perceptions of Normality., Conclusions: The study identified a shared perspective about a number of issues, but also detailed where there were differences. We suggest explicit consideration of the themes highlighted in this research, and a deeper understanding of the inter-relatedness of seemingly separate issues will help health professionals and researchers re-think ways of working with people who have disabling conditions, and identify different factors to address in measuring the success of rehabilitation.

Objective: To determine whether health valuations, such as those used in economic evaluation, are affected by duration of a health condition. People with disabling health conditions tend to value health more highly than members of the general population, and one explanation for this is that over time their experience of living with a disabling illness changes the way in which they value health. If this is so, a relationship between the duration of an individual's disabling health condition and the valuation they assign to their health-state might reasonably be expected., Design: A postal survey using the EuroQoL (EQ-5D) instrument to collect descriptions and valuations for health from people who reported a diagnosis of either stroke or multiple sclerosis. Contact with participants was made through national support organizations and questionnaires were returned by mail., Results: Eight hundred and ninety-four people completed the survey. One hundred (11 %) had one health-state indicating moderate problems in all five dimensions of the EQ-5D descriptive profile. For people with this health-state, analysis of covariance showed no relationship between valuation of health-state and time from onset of illness (F = 0.38, p = 0.54). This finding applied irrespective of the diagnosis, and for some other less frequently reported health-states., Conclusion: Clinical experience suggests that over time people adapt to long-term disability. However we found no evidence to support the proposition that higher health-state valuations by people with disabling conditions are explained by the actual duration of their condition.

Aims: We sought to explore resource use both in hospital and the community twelve months after hospital discharge for patients of different ethnicity admitted to hospital with acute stroke., Methods: Resource utilisation data were collected for consecutive patients admitted to each of three general hospitals in the Wellington region over a nine month period. Patients were interviewed, where possible, at three, six and twelve months after hospital discharge. Ethnicity was determined by self report., Results: Non-Europeans had longer hospital stays than Europeans (median 36 days vs 18 days, p = 0.01). Contact with rehabilitation professionals in the community was low for all groups with no significant differences between Europeans and non-Europeans. For the entire cohort, spending on institutional care was around ten times higher than spending on community rehabilitation in the first twelve months following stroke., Conclusions: Differences in hospital stay after stroke may reflect problems of access to inpatient rehabilitation services for younger people and not relate directly to the ethnicity of the patient. With the projected increasing proportion of Maori and Pacific people in the population, combined with the aging of that population, health policy-makers need to consider the implications of differences in resource utilisation for different ethnic groups in New Zealand. How to manage all the available resources for people with stroke to maximise outcome remains an important issue for health funders.

Background/Aims: Self-management models have recently been applied to stroke, but the most effective components are yet to be determined. To inform the ongoing refinement of stroke self-management programmes, this study explored challenges at 6 months after stroke. Methods: A total of 53 stroke survivors and 26 significant others were interviewed 6 months after stroke. Results were analysed qualitatively using thematic analysis. Findings: Stroke was experienced as a shocking and frightening event regardless of severity, and participants struggled to manage the consequences of their stroke. The stroke experience occurred within the context of more than one chronic condition and with competing demands of everyday life. Participants struggled to formulate a model of causation for their stroke, yet this appeared a necessary basis for action. Conclusions: The findings suggest that health care targeted at enhancing self-management, including self-management programmes, may benefit from encompassing a specific focus on participants' beliefs as an important foundation for recovery after stroke. [ABSTRACT FROM AUTHOR]

Purpose: People with stroke or Parkinson’s disease (PD) live with reduced mood, social participation and quality of life (QOL). Communication difficulties affect 90% of people with PD (dysarthria) and over 33% of people with stroke (aphasia). These consequences are disabling in many ways. However, as singing is typically still possible, its therapeutic use is of increasing interest. This article explores the experiences of and factors influencing participation in choral singing therapy (CST) by people with stroke or PD and their significant others.Method: Participants (eight people with stroke, six with PD) were recruited from a community music therapy choir running CST. Significant others (seven for stroke, two for PD) were also recruited. Supported communication methods were used as needed to undertake semi-structured interviews (totalN = 23).Results: Thematic analysis indicated participants had many unmet needs associated with their condition, which motivated them to explore self-management options. CST participation was described as an enjoyable social activity, and participation was perceived as improving mood, language, breathing and voice.Conclusions: Choral singing was perceived by people with stroke and PD to help them self-manage some of the consequences of their condition, including social isolation, low mood and communication difficulties.Implications for RehabilitationChoral singing therapy (CST) is sought out by people with stroke and PD to help self-manage symptoms of their condition.Participation is perceived as an enjoyable activity which improves mood, voice and language symptoms.CST may enable access to specialist music therapy and speech language therapy protocols within community frameworks. [ABSTRACT FROM AUTHOR]

Objective: Few community interventions following stroke enhance activity, participation or quality of life. We tested two novel community interventions designed to promote self-directed rehabilitation following stroke.Design: This was a randomized, controlled parallel group 2×2 trial.Setting: Community.Participants: Maori and Pacific New Zealanders, >15 years old, randomized within three months of a new stroke.Interventions: A DVD of four inspirational stories by Maori and Pacific people with stroke and a ‘Take Charge Session’ – a single structured risk factor and activities of daily living assessment, designed to facilitate self-directed rehabilitation.Main measures: Primary outcomes were Health-related Quality of Life (Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the Short Form 36 (SF-36)) 12 months from randomization. Secondary outcomes were Barthel Index, Frenchay Activities Index, Carer Strain Index and modified Rankin score.Results: One hundred and seventy-two people were randomized with 139 (80.8%) followed up at 12 months post randomization. The effect of the Take Charge Session on SF-36 PCS at 12 months was 6.0 (95% confidence interval (CI) 2.0 to 10.0) and of the DVD was 0.9 (95% CI −3.1 to 4.9). Participants allocated to the Take Charge Session were less likely to have a modified Rankin score of >2 (odds ratio (OR) 0.42, 95% CI 0.2 to 0.89) and their carers had lower (better) Carer Strain Index scores (−1.5, 95% CI −2.8 to −0.1).Conclusion: A simple, low-cost intervention in the community phase of stroke recovery aiming to promote self-directed rehabilitation improved outcomes. [ABSTRACT FROM PUBLISHER]

Objective: To determine the feasibility, the cluster design effect and the variance and minimal clinical importance difference in the primary outcome in a pilot study of a structured approach to goal-setting.Design: A cluster randomized controlled trial.Setting: Inpatient rehabilitation facilities.Subjects: People who were admitted to inpatient rehabilitation following stroke who had sufficient cognition to engage in structured goal-setting and complete the primary outcome measure.Interventions: Structured goal elicitation using the Canadian Occupational Performance Measure.Main measures: Quality of life at 12 weeks using the Schedule for Individualised Quality of Life (SEIQOL-DW), Functional Independence Measure, Short Form 36 and Patient Perception of Rehabilitation (measuring satisfaction with rehabilitation). Assessors were blinded to the intervention.Results: Four rehabilitation services and 41 patients were randomized. We found high values of the intraclass correlation for the outcome measures (ranging from 0.03 to 0.40) and high variance of the SEIQOL-DW (SD 19.6) in relation to the minimally importance difference of 2.1, leading to impractically large sample size requirements for a cluster randomized design.Conclusions: A cluster randomized design is not a practical means of avoiding contamination effects in studies of inpatient rehabilitation goal-setting. Other techniques for coping with contamination effects are necessary. [ABSTRACT FROM AUTHOR]