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A significant percentage of stroke survivors are reported to have anxiety and depression. Autogenic Relaxation Training (ART), a psychophysiological self-control therapy which aims to induce relaxation proved to be effective in reducing the anxiety and depression in some health conditions. However, there is lack of studies which evaluated the effects of ART in the rehabilitation of stroke survivors. The aim of this experimental pilot study is to evaluate the feasibility and outcomes of ART in addition to usual physiotherapy for stroke survivors. A total of 14 sub-acute stroke survivors from a teaching hospital were enrolled in this study. All participants received 20 minutes ART followed by 40 minutes usual physiotherapy once a week and they were requested to carry out the intervention at home for twice per week, for six weeks. Intervention outcomes were assessed using Hospital Anxiety and Depression Scale (HADS-A and HADS-D), Barthel Index (BI), Timed Up and Go (TUG) and EuroQol 5-Dimension 5 Levels (EQ5D5L). Changes in all outcome measures were analysed using paired t-test and Wilcoxon signed rank test, with level of significance set at p

Introduction: The occurrence of post-stroke emotional problems is significant during the early post-stroke stage and affects the recovery of functionality among the survivors. Because stroke survivors require active engagement in rehabilitation to optimize the process of neuroplasticity in the initial stage of stroke, there is a need to integrate an intervention, preferably therapists-mediated during rehabilitation, which reduce emotional problems thus improve motivation level among the survivors. One such technique is autogenic relaxation training (ART). ART has been found to reduce anxiety and depression among patients with several medical conditions. However, its usage in stroke survivors during rehabilitation has been limited to date. Therefore, this study is intended to evaluate the effectiveness of ART in addition to usual physiotherapy in improving emotional state and functional level of stroke survivors during rehabilitation. Methods: This is an assessor blinded randomized controlled trial comparing 2 intervention approaches namely ART-added physiotherapy (experimental group) and usual physiotherapy (control group). A total of 70 post-stroke patients will be recruited and allocated into either the ART-added physiotherapy or the usual physiotherapy group. The ART-added physiotherapy group will undergo a 20-minute ART session followed by 40 minutes of usual physiotherapy. While the usual physiotherapy group will receive usual physiotherapy alone for 60 minutes. All participants will be treated once a week and are required to carry out a set of home exercises for 2 times per week during the 12-week intervention. Assessment of emotional status and functional independence will be carried out at pre-intervention and week 13 of the intervention with the use of Hospital anxiety and depression scale, Barthel index, and EuroQol-5 dimensions-5 levels. All data will be analyzed using descriptive and inferential statistics. Discussion: The expected main study outcome is an enhanced evidence-based physiotherapy program that may be used by physiotherapists in the rehabilitation of stroke patients with emotional disturbances. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12619001664134 (last updated on 28/11/2019).

Despite being becoming popular and heavily used in rehabilitation, the evidence on the effectiveness of Virtual reality-based therapy (VRBT) among persons with knee osteoarthritis (OA) remains limited. The aim of this study was to determine the effects of VRBT on walking endurance and quality of life of older persons with knee OA in comparison to conventional exercise therapy. This was a randomised controlled trial involving 44 participants (mean age and standard deviation = 66.32 + 5.73 years) who received either a VRBT (experimental group, n=22) or a conventional exercise therapy (control group, n=22) for 45 minutes, twice per week for 12 weeks. The outcome of both therapies on walking endurance was measured using Six-minute Walk Test (6MWT), while quality of life was assessed using the Malay-version of Short Form-36 (SF-36). Analysis was done by ‘intention-to-treat’ approach, using Mixed Model ANOVA. A significant time-effect (p < 0.05), with large effect size between 0.54 and 1.0 were found for all outcomes following the therapies. An increase of 17% and 19% of 6MWT scores were obtained in experimental and control group, respectively. Meanwhile, the scores for the physical and mental components of the SF-36 increased by 37.8% and 19.4% in the experimental group, and 45.7% and 20.6% in the control group. However, no significant group and interaction effects were found for all outcomes. In conclusion, VRBT is comparable with c onventional exercise therapy in improving walking endurance and quality of life of persons with knee OA, and can be used as a therapy option for this population. DOI : http://dx.doi.org./10.17576/JSKM-2019-1702-13

Although exercise is proven as an effective strategy to combat post-stroke complications and the risk of stroke recurrence, many stroke survivors fail to engage in this activity following rehabilitation. In this study, we assessed the feasibility and usefulness of a low-frequency group exercise to determine its suitability as an approach to facilitate exercise engagement among stroke survivors. Forty-one stroke survivors, mean (SD) age 59.34 (10.02) years, mean time post-stroke 17.13 (17.58) months, completed a 90 minute, once per week, group exercise supervised by therapists for 12 weeks. The exercise outcomes were measured using standardized clinical tests. We observed improvement in the group&rsquo, s physical performance, balance score by 3 units (Z = &minus, 3.88, p &lt, 0.001), speed of repetitive sit to stand by 3.4 s (Z = &minus, 4.69, p &lt, 0.001), and walking speed by 8.22 m/min (Z = &minus, 3.25, p &lt, 0.001). Scores of seven out of 14 Berg&rsquo, s balance scale items increased significantly, indicating better balance ability among the survivors. In conclusion, a 12-week, once per week group exercise session seems feasible and sufficient to improve the physical performance of community dwelling stroke survivors. This exercise arrangement may be offered to stroke survivors to facilitate exercise practice following rehabilitation.

Virtual reality (VR) games has the potential to improve patient outcomes in stroke rehabilitation. However, there is limited information on VR games as an adjunct to standard physiotherapy in improving upper limb function. This study involved 36 participants in both experimental (n = 18) and control (n = 18) groups with a mean age (SD) of 57 (8.20) and 63 (10.54) years, respectively. Outcome measures were the Fugl-Meyer assessment for upper extremities (FMA-UE), Wolf motor function test (WMFT), intrinsic motivation inventory (IMI), Lawton of instrumental activities of daily living (IADL), and stroke impact scale (SIS) assessed at pre-post intervention. The experimental group had 0.5 h of upper limb (UL) VR games with 1.5 h of standard physiotherapy, and the control group received 2 h of standard physiotherapy. The intervention for both groups was performed once a week for eight consecutive weeks. The results showed a significant time&ndash, group interaction effect for IMI (p = 0.001), Lawton IADL (p = 0.01) and SIS domain of communication (p = 0.03). A significant time effect was found in FMA-UE (p = 0.001), WMFT (p = 0.001), Lawton IADL (p = 0.01), and SIS domains, strength, ADL and stroke recovery (p &lt, 0.05). These results indicated an improvement in UL motor ability, sensory function, instrumental ADL, and quality of life in both groups after eight weeks of intervention. However, no significant (p &gt, 0.05) group effect on all the outcome measures was demonstrated. Thus, replacing a portion of standard physiotherapy time with VR games was equally effective in improving UL function and general health compared to receiving only standard physiotherapy among stroke survivors.

The benefits of engaging informal carers or family in the delivery of therapy intervention for people with stroke have not been well researched.To assess the effectiveness of a home-based carer-assisted in comparison to hospital-based therapist-delivered therapy for community-dwelling stroke survivors.An assessor blinded randomised controlled trial was conducted on 91 stroke survivors (mean age 58.9±10.6 years, median time post-onset 13.0 months, 76.5% males) who had completed individual rehabilitation. The control group received hospital-based group therapy delivered by physiotherapists as out-patients and the test group was assigned to a home-based carer-assisted therapy. Targeted primary outcomes were physical functions (mobility, balance, lower limb strength and gait speed). A secondary outcome index was health-related quality of life. An intention-to-treat analysis was used to evaluate outcomes at week 12 of intervention.Both therapy groups improved significantly in all the functional measures; mobility (p 0.01), balance (p 0.01), lower limb strength (p 0.01), gait speed (p 0.05), and in the quality of life score (p 0.05) at trial completion. No statistical differences were found between the two groups in any outcome indices (all p 0.05).The home-based carer-assisted therapy is as effective as the hospital-based therapist-delivered training in improving post-stroke functions and quality of life.

Introduction: Stroke survivors are commonly at risk of functional decline following discharge from rehabilitation, which increase their susceptibility to falls, dependency in activities of daily living and emotional disturbances. To combat these, continued therapy is important. Home-based therapy (HBT) has been shown to be useful in maintaining functional performance and quality of life of chronic stroke survivors. However, evidence on its effectiveness remains limited, while no studies are available to date which report the benefit of HBT on stroke survivors self-efficacy and emotional status. Therefore, this study aims to assess the effectiveness of post-discharge HBT in comparison to usual practice on functional outcome (mobility and gait speed), self-efficacy and anxiety level among stroke survivors. Methods: This is an assessor-blinded randomized control trial comparing 2 types of intervention which are HBT (experimental group) and usual practice (UP) (control group). Based on sample size calculation using GPower, a total number of 42 participants will be recruited and allocated into either the HBT or the UP group. Participants in HBT group will receive a set of structured exercise therapy consisting of progressive strengthening, balance and task-related exercises. While participants in UP group will receive a usual “intervention” practised by rehabilitation professional prior to discharging stroke patients from their care. Both groups are advised to perform the given interventions for 3 times per week for 12 weeks under the supervision of their caregiver. Outcomes of interventions will be measured using timed up and go test (for mobility), ten-meter walk test (for gait speed), stroke self-efficacy questionnaire (for self-efficacy) and hospital anxiety and depression scale (for anxiety level). All data will be analyzed using descriptive and inferential statistics. Discussion: This study will provide the information on the effectiveness of HBT in comparison to UP among stroke population who are discharged from rehabilitation. Findings from the study will enable rehabilitation professionals to design effective discharge care plan for stroke survivors in combating functional decline when no longer receiving hospital-based therapy. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12619001182189 (last updated 22/11/2019).

Although nutritional screening and dietary monitoring in clinical settings are important, studies on related user satisfaction and cost benefit are still lacking. This study aimed to: (1) elucidate the cost of implementing a newly developed dietary monitoring tool, the Pictorial Dietary Assessment Tool (PDAT); and (2) investigate the accuracy of estimation and satisfaction of healthcare staff after the use of the PDAT. A cross-over intervention study was conducted among 132 hospitalized patients with diabetes. Cost and time for the implementation of PDAT in comparison to modified Comstock was estimated using the activity-based costing approach. Accuracy was expressed as the percentages of energy and protein obtained by both methods, which were within 15% and 30%, respectively, of those obtained by the food weighing. Satisfaction of healthcare staff was measured using a standardized questionnaire. Time to complete the food intake recording of patients using PDAT (2.31 ± 0.70 min) was shorter than when modified Comstock (3.53 ± 1.27 min) was used (p < 0.001). Overall cost per patient was slightly higher for PDAT (United States Dollar 0.27 ± 0.02) than for modified Comstock (USD 0.26 ± 0.04 (p < 0.05)). The accuracy of energy intake estimated by modified Comstock was 10% lower than that of PDAT. There was poorer accuracy of protein intake estimated by modified Comstock (71%) (p < 0.05). Mean user satisfaction of healthcare staff was significantly higher for PDAT than that for modified Comstock (p < 0.05). PDAT requires a shorter time to be completed and was rated better than modified Comstock.

Lack of intersectoral collaboration within public health sectors compound efforts to promote effective multidisciplinary post stroke care after discharge following acute phase. A coordinated, primary care-led care pathway to manage post stroke patients residing at home in the community was designed by an expert panel of specialist stroke care providers to help overcome fragmented post stroke care in areas where access is limited or lacking. Expert panel discussions comprising Family Medicine Specialists, Neurologists, Rehabilitation Physicians and Therapists, and Nurse Managers from Ministry of Health and acadaemia were conducted. In Phase One, experts chartered current care processes in public healthcare facilities, from acute stroke till discharge and also patients who presented late with stroke symptoms to public primary care health centres. In Phase Two, modified Delphi technique was employed to obtain consensus on recommendations, based on current evidence and best care practices. Care algorithms were designed around existing work schedules at public health centres. Indication for patients eligible for monitoring by primary care at public health centres were identified. Gaps in transfer of care occurred either at post discharge from acute care or primary care patients diagnosed at or beyond subacute phase at health centres. Essential information required during transfer of care from tertiary care to primary care providers was identified. Care algorithms including appropriate tools were summarised to guide primary care teams to identify patients requiring further multidisciplinary interventions. Shared care approaches with Specialist Stroke care team were outlined. Components of the iCaPPS were developed simultaneously: (i) iCaPPS-Rehab© for rehabilitation of stroke patients at community level (ii) iCaPPS-Swallow© guided the primary care team to screen and manage stroke related swallowing problems. Coordinated post stroke care monitoring service for patients at community level is achievable using the iCaPPS and its components as a guide. The iCaPPS may be used for post stroke care monitoring of patients in similar fragmented healthcare delivery systems or areas with limited access to specialist stroke care services. No.: ACTRN12616001322426 (Registration Date: 21st September 2016).

Background: This study aimed to evaluate the provision of rehabilitation to and the functional recovery of stroke survivors receiving acute care in a tertiary hospital. Methods: Analyses of medical records of stroke patients who were admitted to a main teaching hospital between the years 2006-2009. Variables studied were the demographics, clinical profiles, rehabilitation profiles and the patients' functional recovery at discharge, as measured on a modified Rankin Scale (mRS). Findings: Records of 557 patients; mean age 64 years, 53.7% females were analysed. Mean length of stay was 6.8 days SD=5.8 during which, 62.7% received daily rehabilitation. Mean time from stroke diagnosis to rehabilitation was 3.0 days SD=2.0; 51.0% of cases were seen after 48 hours of hospital admission. Rehabilitation was provided mainly by physiotherapy services to 71.6%, 64.7% and 52.5% of severe, moderate and mild cases, respectively. Mean mRS was 3.5, SD=0.9 and 53.0% had not regained any level of walking ability prior to discharge. Age and severity level significantly predicted mRS at discharge (F6,536=12.26, P Conclusions: Provision of rehabilitation to acute stroke survivors in a tertiary hospital was sub-optimal. Establishment of dedicated stroke rehabilitation services is recommended to enable better functional gain in post-stroke survivors.

Background Provision of post stroke care in developing countries is hampered by discoordination of services and limited access to specialised care. Albeit shortcomings, primary care continues to provide post-stroke services in less than favourable circumstances. This paper aimed to review provision of post-stroke care and related problems among Family Medicine Specialists managing public primary health care services. Methods A semi-structured questionnaire was distributed to 121 Family Physicians servicing public funded health centres in a pilot survey focused on improving post stroke care provision at community level. The questionnaire assessed respondents background and practice details i.e. estimated stroke care burden, current service provision and opinion on service improvement. Means and frequencies described quantitative data. For qualitative data, constant comparison method was used until saturation of themes was reached. Results Response rate of 48.8% was obtained. For every 100 patients seen at public healthcentres each month, 2 patients have stroke. Median number of stroke patients seen per month is 5 (IQR 2-10). 57.6% of respondents estimated total stroke patients treated per year at each centre was less than 40 patients. 72.4% lacked a standard care plan although 96.6% agreed one was needed. Patients seen were: discharged from tertiary care (88.1%), shared care plan with specialists (67.8%) and patients who developed stroke during follow up at primary care (64.4%). Follow-ups were done at 8-12 weekly intervals (60.3%) with 3.4% on ‘as needed’ basis. Referrals ranked in order of frequency were to physiotherapy services, dietitian and speech and language pathologists in public facilities. The FMS’ perceived 4 important ‘needs’ in managing stroke patients at primary care level; access to rehabilitation services, coordinated care between tertiary centres and primary care using multidisciplinary care approach, a standardized guideline and family and caregiver support. Conclusions Post discharge stroke care guidelines and access to rehabilitation services at primary care is needed for post stroke patients residing at home in the community.

Background Post-stroke care after hospital discharge suffers from lack of intersectoral collaboration within the public health sectors. Hence, primary care remains the only option in managing stroke patients in underserved areas in Malaysia. This study aimed to identify the areas, which can be better coordinated to deliver optimal poststroke care in community setting. A seamless transfer of care model known as integrated Care Pathway for Post Stroke patients (iCaPPS) was designed to address this issue.

Context: Poststroke care in developing countries is inundated with poor concordance and scarce specialist stroke care providers. A primary care‑driven health service is an option to ensure optimal care to poststroke patients residing at home in the community. Aims: We assessed outcomes of a pilot long‑term stroke care clinic which combined secondary prevention and rehabilitation at community level. Settings and Design: A prospective observational study of stroke patients treated between 2008 and 2010 at a primary care teaching facility. Subjects and Methods: Analysis of patients was done at initial contact and at 1‑year post treatment. Clinical outcomes included stroke risk factor(s) control, depression according to Patient Health Questionnaire (PHQ9), and level of independence using Barthel Index (BI). Statistical Analysis Used: Differences in means between baseline and post treatment were compared using paired t‑tests or Wilcoxon‑signed rank test. Significance level was set at 0.05. Results: Ninety‑one patients were analyzed. Their mean age was 62.9 [standard deviation (SD) 10.9] years, mean stroke episodes were 1.30 (SD 0.5). The median interval between acute stroke and first contact with the clinic 4.0 (interquartile range 9.0) months. Mean systolic blood pressure decreased by 9.7 mmHg (t = 2.79, P = 0.007), while mean diastolic blood pressure remained unchanged at 80mmHg (z = 1.87, P = 0.06). Neurorehabilitation treatment was given to 84.6% of the patients. Median BI increased from 81 (range: 2−100) to 90.5 (range: 27−100) (Z = 2.34, P = 0.01). Median PHQ9 scores decreased from 4.0 (range: 0−22) to 3.0 (range: 0−19) though the change was not significant (Z= −0.744, P = 0.457). Conclusions: Primary care‑driven long‑term stroke care services yield favorable outcomes for blood pressure control and functional level.

Background Evidence indicates that the continuation of therapy among community-dwelling stroke survivors improves physical function. Community rehabilitation programmes often face limitations in terms of resources. It is imperative to include new motivational interventions to encourage some level of non-clinician management. The aim of this study was to determine whether there were any changes in physical function and activities of daily living when substituting a portion of the standard physiotherapy time with virtual reality games among community-dwelling stroke survivors. Methods In this controlled trial, the experimental group received 30 minutes of virtual reality balance games in addition to 90 minutes of standard physiotherapy. The control group continued with their two hours of routine standard physiotherapy. Both groups received 12 therapy sessions: two-hour sessions twice per week for six continuous weeks. Changes in physical function, activities of daily living and balance ability were assessed using the Timed Up and Go test, 30-second Sit to Stand test, Timed Ten-Metre Walk test, Six-Minute Walk test and the Barthel Index, and static balance was assessed using a probalance board. Results Twenty-eight participants completed post-intervention assessments. The results showed a significant within-subject effect on the Timed Up and Go test: F (1, 26) = 5.83, p = 0.02; and the 30-second Sit to Stand test; F (1, 26) = 13.50, p = 0.001. The between-subject effect was not significant (p > 0.05) for any of the outcome measurements. Conclusion Substituting a portion of the standard physiotherapy time with virtual reality games was equally effective in maintaining physical function outcomes and activities of daily living among community-dwelling stroke survivors. Trial Registration Australia and New Zealand Clinical Trials Register, ACTRN12613000478718

Results Data of 748 stroke patients were retrieved for analysis. The average length of hospital stay was 6.4 (SD: 3.1) days. The mean cost of medical care was RM 3696.40 (SD: 1842.10) per stroke patient per admission. Human resources made up the highest cost component (RM 1343.90, SD: 669.8) or 36% of the total cost of care, followed by medications (RM 867.30, SD: 432.40) and laboratory tests (RM 337.90, SD: 168.40). The cost increased by 15% when patient suffered from moderately severe stroke and further increased by 52% in the highest level of severity compared to mild stroke (p < 0.05). No significant differences were found when comparing costs between the sub-groups of age, gender and stroke sub-types. Conclusion There is a substantial cost involved in the care of inpatient stroke in this study. Further research involving other health care settings are required to better estimate the financial impact of stroke to this country.

Materials and methods This was a cross-sectional study of 91 stroke patients; mean age 58.9±10.6 years, 79% male, median stroke duration 13 months who have completed intensive individual rehabilitation at the Universiti Kebangsaan Malaysia Medical Centre in the years 2010 and 2011. Rehabilitation outcome was measured with the use of standardised tools; Rivermead Mobility Scale (RMI), Berg’s Balance Scale (BBS), Sit to Stand Test (STS) for lower limb strength and Timed 10 metre walk test for walking speed. Post-rehabilitation disability level and quality of life were also assessed on a Modified Rankin Scale (mRS) and Euro-Qol 5 Dimensions-Visual analogue Scale (EQ5D-VAS), respectively. All data were analysed descriptively using SPSS version 18.

Background The importance of long term rehabilitation for people with stroke is increasingly evident, yet it is not known whether such services can be materialised in countries with limited community resources. In this study, we explored the perception of rehabilitation professionals and people with stroke towards long term stroke rehabilitation services and potential approaches to enable provision of these services. Views from providers and users are important in ensuring whatever strategies developed for long term stroke rehabilitations are feasible and acceptable. Methods Focus group discussions were conducted involving 15 rehabilitation professionals and eight long term stroke survivors. All recorded conversations were transcribed verbatim and analysed using the principles of qualitative research. Results Both groups agreed that people with stroke may benefit from more rehabilitation compared to the amount of rehabilitation services presently provided. Views regarding the unavailability of long term rehabilitation services due to multi-factorial barriers were recognised. The groups also highlighted the urgent need for the establishment of community-based stroke rehabilitation centres. Family-assisted home therapy was viewed as a potential approach to continued rehabilitation for long term stroke survivors, given careful planning to overcome several family-related issues. Conclusions Barriers to the provision of long term stroke rehabilitation services are multi-factorial. Establishment of community-based stroke rehabilitation centres and training family members to conduct home-based therapy are two potential strategies to enable the continuation of rehabilitation for long term stroke survivors.

Materials and methods A single-blinded randomised controlled trial was conducted on 91 stroke patients. In all, 76.5% males with mean age of 58.9±10.6 years and median stroke duration of 13.0 months (range 6-84) completed intensive rehabilitation at a tertiary hospital. The control group received outpatient group exercise led by therapists while the experimental group was assigned to a home-based familyassisted task-oriented training. Primary outcomes were mobility (Rivermead Mobility Scale), balance (Berg’s Balance Scale), lower limb strength (5-Times-Sit-to-Stand Test) and gait speed. Secondary outcome was healthrelated quality of life as measured using EQ5D-Visual analogue Scale. All assessments were carried out at baseline and at week twelve of intervention. An intention-totreat analysis was used to evaluate outcome of the interventions.