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Objective Individuals after stroke are less active, experience more fatigue, and perform activities at a slower pace than peers with no impairments. These problems might be caused by an increased aerobic energy expenditure during daily tasks and a decreased aerobic capacity after stroke. The aim of this study was to quantify relative aerobic load (ie, the ratio between aerobic energy expenditure and aerobic capacity) during daily-life activities after stroke. Methods Seventy-nine individuals after stroke (14 in Functional Ambulation Category [FAC] 3, 25 in FAC 4, and 40 in FAC 5) and 22 peers matched for age, sex, and body mass index performed a maximal exercise test and 5 daily-life activities at a preferred pace for 5 minutes. Aerobic energy expenditure (mL O2/kg/min) and economy (mL O2/kg/unit of distance) were derived from oxygen uptake ($\dot{\mathrm{V}}{\mathrm{O}}_2$). Relative aerobic load was defined as aerobic energy expenditure divided by peak aerobic capacity (%$\dot{\mathrm{V}}{\mathrm{O}}_2$peak) and by $\dot{\mathrm{V}}{\mathrm{o}}_2$ at the ventilatory threshold (%$\dot{\mathrm{V}}{\mathrm{o}}_2$-VT) and compared in individuals after stroke and individuals with no impairments. Results Individuals after stroke performed activities at a significantly higher relative aerobic load (39%–82% $\dot{\mathrm{V}}{\mathrm{o}}_2$peak) than peers with no impairments (38%–66% $\dot{\mathrm{V}}{\mathrm{o}}_2$peak), despite moving at a significantly slower pace. Aerobic capacity in individuals after stroke was significantly lower than that in peers with no impairments. Movement was less economical in individuals after stroke than in peers with no impairments. Conclusion Individuals after stroke experience a high relative aerobic load during cyclic daily-life activities, despite adopting a slower movement pace than peers with no impairments. Perhaps individuals after stroke limit their movement pace to operate at sustainable relative aerobic load levels at the expense of pace and economy. Impact Improving aerobic capacity through structured aerobic training in a rehabilitation program should be further investigated as a potential intervention to improve mobility and functioning after stroke.

The high prevalence and severe consequences of poor sleep following acquired brain injury emphasises the need for an effective treatment. However, treatment studies are scarce. The present study evaluates the efficacy of blended online cognitive behavioural therapy for insomnia (eCBT-I) developed specifically for people with acquired brain injury. In a multicentre prospective, open-label, blinded end-point randomised clinical trial, 52 participants with insomnia and a history of a stroke or traumatic brain injury were randomised to 6 weeks of guided eCBT-I or treatment as usual, with a 6-week follow-up. The primary outcome measure was the change in insomnia severity between baseline and after treatment, measured with the Insomnia Severity Index. Results showed that insomnia severity improved significantly more with eCBT-I than with treatment as usual compared to baseline, both at post-treatment (mean [SEM] 4.0 [1.3] insomnia severity index points stronger decrease, d = 0.96, p d = -0.78, p

Assessment of metabolic energy expenditure from indirect calorimetry is currently limited to sustained (>4 min) cyclic activities, because of steady-state requirements. This is problematic for patient populations who are unable to perform such sustained activities. Therefore, this study explores validity and reliability of a method estimating metabolic energy expenditure based on oxygen consumption (V̇O2) during short walking bouts. Twelve able-bodied adults twice performed six treadmill walking trials (1, 2 and 6 min at 4 and 5 km/h), while V̇O2 was measured. Total V̇O2 was calculated by integrating net V̇O2 over walking and recovery. Concurrent validity with steady-state V̇O2 was assessed with Pearson’s correlations. Test-retest reliability was assessed using intra-class correlation coefficients (ICC) and Bland-Altman analyses. Total V̇O2 was strongly correlated with steady-state V̇O2 (r=0.91–0.99), but consistently higher. Test-retest reliability of total V̇O2 (ICC=0.65–0.92) was lower than or comparable to steady-state V̇O2 (ICC=0.83–0.92), with lower reliability for shorter trials. Total V̇O2 discriminated between gait speeds. Total oxygen uptake provides a useful measure to estimate metabolic load of short activities from oxygen consumption. Although estimates are less reliable than steady-state measurements, they can provide insight in the yet unknown metabolic demands of daily activities for patient populations unable to perform sustained activities.

OBJECTIVE: To determine differences in participation problems between diagnostic groups and to examine diagnosis as a determinant of participation with and without statistically accounting for confounders.DESIGN: Secondary analyses of data from 8 studies.SETTING: Community, the Netherlands.PARTICIPANTS: Participants (N=1735) in diagnostic groups: stroke (n=534), subarachnoid hemorrhage (n=104), other acquired brain injury (n=163), progressive neurologic diseases (n=112), acute coronary syndrome (n=536), and spinal cord injury (n=286).INTERVENTIONS: Not applicable.MAIN OUTCOME MEASURES: Participation was measured with the Utrecht Scale for Evaluation of Rehabilitation-Participation. This measure has 3 scales: Restrictions, Satisfaction, and Frequency. In this study, scores were also computed for 3 domains across these scales: Productivity, Leisure, and Social. Scores ranged from 0 (worst) up to 100 (best). Possible confounders were age, sex, level of education, marital status, and time since onset of the condition.RESULTS: Significant differences were found in levels of participation between diagnostic groups. Individuals with acute coronary syndrome showed better participation scores in all scales and domains compared with most or all other diagnostic groups, except for the Social domain. Individuals with progressive neurologic diseases showed the lowest (worst) Restriction and Satisfaction scores, whereas those with stroke showed the lowest Frequency scores. After correcting for confounders, diagnosis explained significant proportions of the variance of participation (Frequency, 6.4%; Restrictions, 15.1%; Satisfaction, 5.1%; Productivity, 13.2%; Leisure, 13.8%; Social, 6.9%).CONCLUSIONS: Participation problems occurred in all 6 diagnostic groups within this study. Differences were found in participation between diagnostic groups, demonstrating diagnosis-specific participation profiles, including after correcting for confounders.

Acquired Brain Injury (ABI) can have lifelong consequences and accordingly, persons with ABI often receive various types of healthcare. Facilities have their own preferences towards measurement instruments used to evaluate patients, impeding data comparison across healthcare settings. In this cross-sectional study, we used the previously developed minimal dataset for persons with ABI (MDS-ABI) to uniformly document and compare characteristics and outcomes of ABI patients in three healthcare settings: (1) residential care (n = 21), (2) non-residential care (n = 80), and (3) no ABI-related care (n = 22). Overall, patients of residential care settings had the lowest functional outcome compared with patients in the remaining groups. Nonetheless, all groups showed substantial disabilities within numerous life domains, indicating that the consequences of ABI are widespread among patients within and outside of healthcare facilities. These results demonstrate the need for a broad measurement of the potential consequences of ABI. The MDS-ABI covers twelve life domains most frequently affected by ABI and therefore helps to better recognize the consequences of ABI. In research contexts, implementation of the MDS-ABI allows for direct comparison of research findings. Future directions should be aimed at further implementation of the MDS-ABI to guide clinical decision-making and assist in identifying treatment goals specific to each healthcare setting.

Purpose To study the longitudinal relationship between interdisciplinary vocational rehabilitation (VR) with and without additional work module on work participation of patients with chronic musculoskeletal pain and sick leave from work. Methods Retrospective longitudinal data retrieved from care as usual in seven VR centers in the Netherlands was used. The VR program without work module consisted of multi-component healthcare (physical exercise, cognitive behavioral therapy, education, relaxation). The other program with additional work module (VR+) included case management and a workplace visit. Generalized estimating equations using binary logistic was applied. The dependent variable was work participation (achieved/not achieved) on discharge and 6-months follow-up. Independent variables were type of intervention, return to work expectation, sick leave duration, working status, job strain, and job dissatisfaction. Results Data from N = 470 patients were analyzed, of which 26% received VR and 74% VR+. Both programs increased work participation at 6-months follow-up (VR 86%, VR+ 87%). The crude model showed a significant longitudinal relationship between type of intervention and work participation in favor of VR+ (OR 1.8, p = 0.01). The final model showed a non-significant relationship on discharge (OR 1.3, p = 0.51) and a significant relationship on 6-months follow-up in favor of VR+ (OR 1.7, p = 0.04). RTW expectation was a significant confounder in the final model on discharge and 6-months follow up (OR 3.1, p = 0.00). Conclusions Both programs led to increased work participation. The addition of a work module to the VR program lead to a significant increase in odds of work participation at 6-months follow-up.

Background Up to a third of stroke patients and patients with traumatic brain injury suffer from insomnia, including problems to fall asleep or stay asleep at night. Insomnia may exacerbate other brain damage-related problems, for example regarding cognitive functioning and emotional well-being; may lead to poorer quality of life; and may complicate recovery processes. Cognitive behavioral therapy for insomnia, delivered face-to-face or online, is found to be effective in the general population. However, despite the high prevalence and serious consequences of insomnia following acquired brain injury, studies on the efficacy of face-to-face cognitive behavioral treatment in this population are scarce, and this applies even more for studies on online cognitive behavioral therapy. Therefore, this study aims to evaluate the efficacy of a newly developed guided online cognitive behavioral therapy for insomnia following acquired brain injury. Methods A multicenter, prospective, randomized, open-label, blinded end point study (PROBE) will be conducted, in which 48 patients diagnosed with stroke or traumatic brain injury and insomnia will be randomly allocated to the online cognitive behavioral therapy for insomnia treatment group or the treatment as usual group. The treatment consists of 6 online cognitive behavioral therapy sessions given on a weekly basis and personalized feedback after each session, combined with 2 face-to-face sessions. Outcomes will be assessed at baseline, immediately after the intervention period and at 6-week follow-up. The primary outcome is the insomnia severity assessed with the Insomnia Severity Index. Secondary outcome measures include sleep quality, sleep features derived from the sleep diary, fatigue, anxiety and depression, subjective cognitive functioning, and societal participation. Discussion This study will provide insight on the efficacy of online cognitive behavioral therapy for insomnia following stroke and traumatic brain injury. Trial registration Netherlands Trial Register NTR7082. Registered on 12 March 2018.

Objective The objective of this study was to identify criteria to be considered when developing an exoskeleton for low-back pain patients by exploring the perceptions and expectations of potential end users. Background Psychosocial, psychological, physical load, and personality influence incidence of low-back pain. Body-worn assistive devices that passively support the user’s trunk, that is exoskeletons, can decrease mechanical loading and potentially reduce low-back pain. A user-centered approach improves patient safety and health outcomes, increases user satisfaction, and ensures usability. Still, previous studies have not taken psychological factors and the early involvement of end users into account. Method We conducted focus group studies with low-back pain patients ( n = 4) and health care professionals ( n = 8). Focus group sessions were audio-recorded, transcribed, and analyzed, using the general inductive approach. The focus group discussions included trying out an available exoskeleton. Questions were designed to elicit opinions about exoskeletons, desired design specifications, and usability. Results Important design characteristics were comfort, individual adjustability, independency in taking it on and off, and gradual adjustment of support. Patients raised concerns over loss of muscle strength. Health care professionals mentioned the risk of confirming disability of the user and increasing guarded movement in patients. Conclusion The focus groups showed that implementation of a trunk exoskeleton to reduce low-back pain requires an adequate implementation strategy, including supervision and behavioral coaching. Application For health care professionals, the optimal field of application, prevention or rehabilitation, is still under debate. Patients see potential in an exoskeleton to overcome their limitations and expect it to improve their quality of life.

The aim of this study was to assess functional performance and user satisfaction of workers with and without a history of low-back pain (LBP) when wearing a SPEXOR passive trunk exoskeleton. Twenty-four male participants, including 18 workers from load-handling professions, participated in this study. We allocated 13 individuals to a LBP group and 11 to a healthy group for subgroup analysis.

Purpose: To explore the usefulness and feasibility of a comprehensive vocational rehabilitation (C-VR) program and less comprehensive (LC-VR) program for workers on sick leave due to chronic musculoskeletal pain, from the perspective of patients, professionals, and managers.Materials and methods: Semi-structured interviews were held with patients, professionals, and managers. Using topic lists, participants were questioned about barriers to and facilitators of the usefulness and feasibility of C-VR and LC-VR. Thirty interviews were conducted with thirteen patients (n = 6 C-VR, n = 7 LC-VR), eight professionals, and nine managers. All interviews were transcribed verbatim. Data were analyzed by systematic text condensation using inductive thematic analysis.Results: Three themes emerged for usefulness ("patient factors," "content," "dosage") and six themes emerged for feasibility ("satisfaction," "intention to continue use," "perceived appropriateness," "positive/negative effects on target participants," "factors affecting implementation ease or difficulty," "adaptations"). The patients reported that both programs were feasible and generally useful. The professionals preferred working with the C-VR, although they disliked the fixed and uniform character of the program. They also mentioned that this program is too extensive for some patients, and that the latter would probably benefit from the LC-VR program. Despite their positive intentions, the managers stated that due to the Dutch healthcare system, implementation of the LC-VR program would be financially unfeasible.Conclusions: The main conclusion of this study is that it is not useful to have one VR program for all patients with CMP and reduced work participation, and that flexible and tailored-based VR are warranted.Implications for rehabilitationBoth comprehensive and less comprehensive vocational rehabilitation are deemed useful for patients with chronic musculoskeletal pain and reduced work participation. Particular patient factors, for instance information uptake, discipline, willingness to change, duration of complaints, movement anxiety, obstructing thoughts, and willingness to return to work might guide the right program for the right patient.Both comprehensive and less comprehensive vocational rehabilitation are deemed feasible in practice. However, factors such as center logistic (schemes, rooms, professionals available) and country-specific healthcare insurance and sickness compensation systems should foster the implementation of less comprehensive programs.

PurposeThe purpose of this study was to assess test-retest reliability, agreement, and responsiveness of questionnaires on productivity loss (iPCQ-VR) and healthcare utilization (TiCP-VR) for sick-listed workers with chronic musculoskeletal pain who were referred to vocational rehabilitation. Methods Test-retest reliability and agreement was assessed with a 2-week interval. Responsiveness was assessed at discharge after a 15-week vocational rehabilitation (VR) program. Data was obtained from six Dutch VR centers. Test-retest reliability was determined with intraclass correlation coefficient (ICC) and Cohen's kappa. Agreement was determined by Standard Error of Measurement (SEM), smallest detectable changes (on group and individual level), and percentage observed, positive and negative agreement. Responsiveness was determined with area under the curve (AUC) obtained from receiver operation characteristic (ROC). Results A sample of 52 participants on test-retest reliability and agreement, and a sample of 223 on responsiveness were included in the analysis. Productivity loss (iPCQ-VR): ICCs ranged from 0.52 to 0.90, kappa ranged from 0.42 to 0.96, and AUC ranged from 0.55 to 0.86. Healthcare utilization (TiCP-VR): ICC was 0.81, and kappa values of the single healthcare utilization items ranged from 0.11 to 1.00. Conclusions The iPCQ-VR showed good measurement properties on working status, number of hours working per week and long-term sick leave, and low measurement properties on short-term sick leave and presenteeism. The TiCP-VR showed adequate reliability on all healthcare utilization items together and medication use, but showed low measurement properties on the single healthcare utilization items.

BackgroundIndividuals post-stroke walk slower than their able-bodied peers, which limits participation. This might be attributed to neurological impairments, but could also be caused by a mismatch between aerobic capacity and aerobic load of walking.Research questionWhat is the potential impact of aerobic capacity and aerobic load of walking on walking ability post-stroke?MethodsIn a cross-sectional study, forty individuals post-stroke (more impaired N=21; preferred walking speed (PWS)2/kg/min) and energy cost (mlO2/kg/m) were derived from oxygen uptake . Relative load was defined as energy expenditure divided by peak aerobic capacity and by at ventilatory threshold . Relative load and energy cost at PWS were compared between groups with one-way ANOVA’s. The effect of speed on these parameters was modeled with GEE.ResultsBoth more and less impaired individuals post-stroke showed lower PWS than able-bodied controls (0.44[0.19-0.76] and 1.04[0.81-1.43] vs 1.36[0.89-1.53] m/s) and higher relative load at PWS (50.2±14.4 and 51.7±16.8 vs peak and 101.9±20.5 and 97.0±27.3 vs ). No differences in relative load were found between stroke groups. Energy cost at PWS of more impaired (0.30[.19-1.03] mlO2/kg/m) was higher than less-impaired (0.19[0.10-0.24] mlO2/kg/m) and able-bodied (0.15[0.13-0.18] mlO2/kg/m). For post-stroke individuals, increasing walking speed above PWS decreased energy cost, but resulted in a relative load above endurance threshold.SignificanceIndividuals post-stroke seem to reduce walking speed to prevent unsustainably high relative aerobic loads at the expense of reduced economy. When aiming to improve walking ability in individuals post-stroke, it is important to consider training aerobic capacity.

To safely and effectively train the exercise capacity of post-COVID-19 patients it is important to test for cardiopulmonary risk factors and to assess exercise limitations. The goal of this study was to describe the exercise capacity and underlying exercise limitations of mechanically ventilated post-COVID-19 patients in clinical rehabilitation.A retrospective cohort study.Twenty-four post-COVID-19patients that were mechanically ventilated at ICU and thereafter admitted for clinical rehabilitation performed a symptom-limited cardiopulmonary exercise test (CPET) with breath-by-breath gas-exchange monitoring, ECG-registration, blood pressure- and saturation monitoring. In absence of a primary cardiac or ventilatory exercise limitation patients were considered to be limited primarily by decreased peripheral muscle mass.Twenty-three patients could perform a maximal exercise test and no adverse events occurred. Cardiorespiratory fitness was very poor with a median peak oxygen uptake of 15.0 [10.1-21.4] mlO2/kg/min (57% of predicted values). However, we observed large differences within the group in both exercise capacity and exercise limitations. While 7/23 patients were primarily limited by ventilatory function, the majority (70%) was limited primarily by the decreased peripheral muscle mass.Cardiorespiratory fitness of post-COVID-19 patients in clinical rehabilitation is strongly deteriorated. The majority of patients seemed primarily limited for exercise by the decreased peripheral muscle mass.

Objective: To provide an overview of the availability of and process involved in vocational rehabilitation (VR) services for people with acquired brain injury (ABI) provided in Dutch rehabilitation institutions. Methods: A survey on the availability and characteristics of the VR intervention process for people with ABI was conducted in all Dutch rehabilitation centers and rehabilitation departments of general and academic hospitals (n = 120). Different domains of the VR intervention process were included in the questionnaire, the number (and percentage) of respondents giving a certain answer within a domain was reported. Results: Fifty-five institutions replied (response rate 46%). VR services for ABI were provided in 34 (62%) of these, of which 20 (59%) used a VR protocol. The main similarities found among different organizations providing VR services were the involvement of different disciplines, determination of the gap between job requirements and the patient’s abilities, goal-setting for VR, involvement of external partners, timing, and source of funding. The main differences found concerned start and stop criteria, and coordination of the VR process. Conclusions: Currently, at least 30% of the Dutch rehabilitation institutions offer VR services for people with ABI; there is variation in processes.

OBJECTIVE: Data collection in the field of acquired brain injury (ABI) lacks uniformity due to the broad spectrum of available measurement instruments, leading to incomparability of data and the need for patients to 'repeat their story'. To pursue uniform data collection, an ABI-specific minimal dataset (MDS-ABI) is currently under development. The current study aimed to assess the feasibility (performance according to protocol, user opinion, potential implementation barriers, and suggested improvements) of the MDS-ABI in clinical settings.METHODS: A mixed-methods approach was used in a range of healthcare sectors for persons with ABI. Clinicians of several relevant disciplines within these sectors were asked to administer the MDS-ABI to five patients. Subsequently, feasibility according to clinicians was assessed by means of a paper questionnaire about every administration and an online questionnaire about the feasibility in general. Feasibility according to patients was assessed with a paper questionnaire and think aloud interviews.RESULTS: Thirteen clinicians and 50 patients were included. In general, the MDS-ABI performed according to protocol. Both clinicians and patients were overall satisfied with the content of the MDS-ABI. The Cumulative Illness Rating Scale was regarded incomprehensible, leading to missing data. Further, clinicians indicated that the MDS-ABI would not be suitable for all ABI-patients, as some are incapable of self-report due to potential cognitive problems, communicative problems, fatigue, perceptual problems, or impaired awareness of deficits.CONCLUSION: The MDS-ABI is a promising tool for obtaining core information on ABI-patients. The MDS-ABI will be adjusted according to the suggestions. For patients who are incapable of self-report, a proxy-reported version of the self-reported part was developed.

Insomnia symptoms following acquired brain injury are serious and common, associated with cognitive and emotional complaints. This systematic review aims to summarize and appraise the current knowledge regarding the efficacy of non-pharmacological treatments for insomnia after traumatic brain injury and stroke in adults. A systematic search in the electronic databases of Medline, PsycINFO and Embase was conducted on January 15, 2019. The search strategy included traumatic brain injury or stroke and a combination of keywords and Boolean operators to represent the concept of insomnia. Articles were restricted to those in English and study populations of human adults. A total of 4341 studies were found, of which 16 were included, representing seven different non-pharmacological treatments. While the quality and quantity of the studies does not allow for firm conclusions, the outcomes suggest that cognitive behavioural therapy improves insomnia and sleep quality. The results highlight the need for larger studies of better methodological quality on non-pharmacological interventions for insomnia following brain injury.

Background: In the Dutch International Spinal Cord Injury (SCI) Data Sets project, we translated all International SCI Data Sets available in 2012 and created a Dutch SCI Database (NDD). Objective: To describe the number of included patients and completeness of the NDD, and to use the NDD to provide a profile of people with traumatic SCI (T-SCI) and non-traumatic SCI (NT-SCI) in the Netherlands. Methods: The NDD includes patients admitted for their first inpatient rehabilitation after onset of SCI to 1 of the 8 rehabilitation centers with a specialty in SCI rehabilitation in the Netherlands. Data of patients admitted in 2015 were analyzed. Results: Data for 424 patients were available at admission; for 310 of these patients (73.1%), discharge data were available. No significant differences were found between patients with and without data at discharge. Data were nearly complete (>90%) for lower urinary tract, bowel, pain, and skin. Data on sexual function has the lowest completion rate. Complete neurological and functional data were available for 41.7% and 38%, respectively. Most patients were male (63.4%), had NT-SCI (65.5%), and had incomplete SCI (58.4% D). Patients with T-SCI differed from patients with NT-SCI on most characteristics, and they stayed considerably longer in the rehabilitation center (112 days vs 65 days, p < .001). Place of discharge was not different between both groups. Conclusion: With the NDD, we collect important data on the majority of Dutch SCI patients, although much work needs to be done to improve the completeness of the data collection.

Dit literatuuronderzoek geeft een overzicht van de huidige beschikbare kennis op het gebied van terugkeer naar werk na een beroerte met betrekking tot de beoordeling van functionele mogelijkheden, prognostische factoren, interventies en het patientenperspectief. Richtlijnen, protocollen en wetenschappelijke literatuur (uit 2005-2016) zijn meegenomen in het onderzoek. Er is geen meetinstrument gevonden dat geschikt is voor het in kaart brengen van het geheel aan functionele mogelijkheden. Er is onvoldoende kwalitatief goed bewijs om prognostische factoren aan te wijzen op basis waarvan terugkeer naar werk voorspeld kan worden. De individuele situatie van de patient/werknemer speelt een belangrijke rol. Verschillende interventies lijken een positieve invloed te hebben op terugkeer naar werk. Het is echter niet mogelijk een specifieke interventie aan te bevelen. Mensen met een beroerte ervaren dat vooral de (werk)omgeving, motivatie, gevolgen van de beroerte en informatie over beroerte en de (mogelijke) gevolgen voor werk van invloed zijn op terugkeer naar werk.

In dit Opiniestuk wordt de stelling besproken dat er onvoldoende bewijs is om op basis van prognostische factoren kort na het ontstaan van niet-aangeboren hersenletsel (NAH) te voorspellen of iemand terug kan keren naar werk en dat daarom een jobcoachtraject of een ander begeleid traject op de werkvloer geindiceerd is. Aan de hand van kennis uit de literatuur en de revalidatiepraktijk wordt op deze stelling ingegaan. Ter discussie staat: 1) welke factoren zijn volgens de literatuur prognostisch voor terugkeer naar werk na NAH, en 2) welke factoren bepalen in de praktijk of iemand terug kan keren naar werk?

Aim To investigate the relation between muscle endurance and subjectively reported fatigue, walking capacity, and participation in mildly affected adolescents with cerebral palsy (CP) and peers with typical development. Method In this case–control study, knee extensor muscle endurance was estimated from individual load–endurance curves as the load corresponding to a 15-repetition maximum in 17 adolescents with spastic CP (six males, 11 females; age 12–19y) and 18 adolescents with typical development (eight males, 10 females; age 13–19y). Questionnaires were used to assess subjectively reported fatigue (Pediatric Quality of Life Inventory Multidimensional Fatigue Scale) and participation (Life-Habits questionnaire). Walking capacity was assessed using the 6-minute walk test. Relations were determined using multiple regression analyses. Results Muscle endurance related significantly to subjectively reported fatigue and walking capacity in adolescents with CP, while no relations were found for adolescents with typical development (subjectively reported fatigue: regression coefficient β [95% confidence intervals] for CP=23.72 [6.26 to 41.18], for controls=2.72 [−10.26 to 15.69]; walking capacity β for CP=125m [−87 to 337], for controls=2m [−86 to 89]). The 15-repetition maximum did not relate to participation in adolescents with CP. Interpretation Subjectively reported fatigue and reduced walking capacity in adolescents with CP are partly caused by lower muscle endurance of knee extensors. Training of muscle endurance might contribute to reducing the experience of fatigue and improving walking capacity. Reduced muscle endurance seems to have no effect on participation.

Objective: This study aimed to assess if external focus instructions result in greater improvements in motor skill and automaticity compared to internal focus instructions in stroke patients. Design: Double-blind randomized controlled trial. Setting: Inpatient stroke rehabilitation unit. Subjects: A total of 63 stroke patients (Meanage = 59.6 ± 10.7 years; Meandays since stroke = 28.5 ± 16.6; MedianFunctional Ambulation Categories = 4). Interventions: Patients were randomly assigned to an internal ( N = 31) or external ( N = 32) focus instruction group. Both groups practiced a balance board stabilization task, three times per week, for three weeks. Balance performance was assessed at baseline, and after one and three weeks of practice. Main measures: Primary outcome was the threshold stiffness (Nm/rad) at which patients could stay balanced. Secondary outcomes were patients’ sway (root-mean-square error in degrees) at the baseline threshold stiffness under single- and dual-task conditions, and their performance on the Timed Up and Go Test and Utrecht Scale for Evaluation of Rehabilitation. Results: Both groups achieved similar improvements in threshold stiffness (∆= 27.1 ± 21.1 Nm/rad), and single- (∆= 1.8 ± 2.3° root-mean-square error) and dual-task sway (∆= 1.7 ± 2.1° root-mean-square error) after three weeks of practice. No differences were found in improvements in clinical tests of balance and mobility. Patients with comparatively good balance and sensory function, and low attention capacity showed greatest improvements with external focus instructions. Conclusion: External focus instructions did not result in greater improvement in balance skill in stroke patients compared to internal focus instructions. Results suggest that tailoring instructions to the individual stroke patient may result in optimal improvements in motor skill.

Introduction The aim of this study was to explore test-retest reliability, agreement, and responsiveness of questionnaires on productivity loss (iPCQ-VR) and healthcare utilisation (TiCP-VR) for sick workers with chronic musculoskeletal pain who were referred to vocational rehabilitation. Methods Test-retest reliability and agreement was assessed with a two-week interval. Responsiveness was assessed at discharge after a 15 week vocational rehabilitation (VR) program. Data was obtained from six VR centres in the Netherlands. Test-retest reliability was calculateed with intraclass correlation coefficient (ICC) and Cohen’s kappa. Agreement was calculated by Standard Error of Measurement, Smallest detectable changes (on group and individual level), and percentage observed, positive and negative agreement. Responsiveness was calculated with area under the curve (AUC) obtained from receiver operation characteristic (ROC). Results A sample of 52 participants on test-retest reliability and agreement and a sample of 223 on responsiveness were included in the study. Of the iPCQ-VR, ICCs ranged from 0.52 to 0.90, kappa ranged from 0.42 to 0.96, and AUC ranged from 0.55–0.86. The ICC of total healthcare utilisation of the TiCP-VR was 0.81 and kappa values of the single healthcare utilisation items ranged from 0.11 to 1. Discussion The iPCQ-VR showed good clinimetric properties on working status, number of hours working per week and long term sick leave, and low measurement properties on short term sick leave and presenteeism. The TiCP-VR showed adequate reliability on all healthcare utilisation items together and medication use, but showed low clinimetric properties on the single healthcare utilisation items.

Study Objectives: Obstructive sleep apnea (OSA) is a common sleep disorder in stroke patients and is associated with prolonged hospitalization, decreased functional outcome, and recurrent stroke. Research on the effect of OSA on cognitive functioning following stroke is scarce. The primary objective of this study was to compare stroke patients with and without OSA on cognitive and functional status upon admission to inpatient rehabilitation.Design: Case-control study.Setting and Patients: 147 stroke patients admitted to a neurorehabilitation unit.Interventions: N/A.Measurements: All patients underwent sleep examination for diagnosis of OSA. We assessed cognitive status by neuropsychological examination and functional status by two neurological scales and a measure of functional independence.Results: We included 80 stroke patients with OSA and 67 stroke patients without OSA. OSA patients were older and had a higher body mass index than patients without OSA. OSA patients performed worse on tests of attention, executive functioning, visuoperception, psychomotor ability, and intelligence than those without OSA. No differences were found for vigilance, memory, and language. OSA patients had a worse neurological status, lower functional independence scores, and a longer period of hospitalization in the neurorehabilitation unit than the patients without OSA. OSA status was not associated with stroke type or classification.Conclusions: Obstructive sleep apnea (OSA) is associated with a lower cognitive and functional status in patients admitted for stroke rehabilitation. This underlines the importance of OSA as a probable prognostic factor, and calls for well-designed randomized controlled trials to study its treatability.

© 2017 Informa UK Limited, trading as Taylor & Francis GroupPurpose: People without neurological impairments show superior motor learning when they focus on movement effects (external focus) rather than on movement execution itself (internal focus). Despite its potential for neurorehabilitation, it remains unclear to what extent external focus strategies are currently incorporated in rehabilitation post-stroke. Therefore, we observed how physical therapists use attentional focus when treating gait of rehabilitating patients with stroke. Methods: Twenty physical therapist-patient couples from six rehabilitation centers participated. Per couple, one regular gait-training session was video-recorded. Therapists’ statements were classified using a standardized scoring method to determine the relative proportion of internally and externally focused instructions/feedback. Also, we explored associations between therapists’ use of external/internal focus strategies and patients’ focus preference, length of stay, mobility, and cognition. Results: Therapists’ instructions were generally more external while feedback was more internal. Therapists used relatively more externally focused statements for patients with a longer length of stay (B = −0.239, p = 0.013) and for patients who had a stronger internal focus preference (B = −0.930, p = 0.035). Conclusions: Physical therapists used more external focus instructions, but more internally focused feedback. Also, they seem to adapt their attentional focus use to patients’ focus preference and rehabilitation phase. Future research may determine how these factors influence the effectiveness of different attentional foci for motor learning post-stroke. IMPLICATIONS FOR REHABILITATIONPhysical therapists use a balanced mix of internal focus and external focus instructions and feedback when treating gait of stroke patients.Therapists predominantly used an external focus for patients in later rehabilitation phases, and for patients with stronger internal focus preferences, possibly in an attempt to stimulate more automatic control of movement in these patients.Future research should further explore how a patients’ focus preference and rehabilitation phase influence the effectiveness of different focus strategies.Awaiting further research, we recommend that therapists use both attentional focus strategies, and explore per patient which focus works best on a trial-and-error basis.

The aim of this study was to identify predictors, available at admission, of physical independence at discharge from inpatient rehabilitation. Secondary aims were to identify predictors of functional gain and length of stay (LOS). We included 1310 adult stroke patients who were admitted for inpatient rehabilitation in five Dutch rehabilitation centres. Data on the Utrecht Scale for Evaluation of Clinical Rehabilitation at admission and discharge (physical and cognitive independence, mood, pain and fatigue), age, sex and in a subsample stroke characteristics as well were collected. A prediction model was created using random coefficient analysis. None of the stroke characteristics were independently associated with physical independence or functional gain at discharge, or LOS. Higher physical and cognitive independence scores and severe pain at admission were predictors of higher physical independence scores at discharge. Furthermore, lower physical independence scores, higher cognitive independence scores, less pain at admission and younger age predicted more functional gain. Finally, lower physical and cognitive independence scores at admission and younger age predicted longer LOS. Physical independence at admission was the most robust predictor for rehabilitation outcome in a Dutch rehabilitation setting. To a lesser extent, age, cognitive independence and pain predicted rehabilitation outcome after stroke. Treatment of cognition and pain should be taken into account during rehabilitation. Further work needs to be carried out to establish whether focusing on these factors improves outcome after rehabilitation. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

Objective: To describe practice variation in the structure of stroke rehabilitation in 4 specialized multidisciplinary rehabilitation centres in the Netherlands. Design and methods: A multidisciplinary expert group formulated a set of 23 elements concerning the structure of inpatient and outpatient stroke rehabilitation, categorized into 4 domains: admission-related (n = 7), treatment-related (n = 10), client involvement-related (n = 2), and facilities-related (n = 4). In a cross-sectional study in 4 rehabilitation centres data on the presence and content of these elements were abstracted from treatment programmes and protocols. In a structured expert meeting consensus was reached on the presence of practice variation per element. Results: Practice variation was observed in 22 of the 23 structure elements. The element "strategies for patient involvement" appeared similar in all rehabilitation centres, whereas differences were found in the elements regarding admission, exclusion and discharge criteria, patient subgroups, care pathways, team meetings, clinical assessments, maximum time to admission, aftercare and return to work modules, health professionals, treatment facilities, and care-giver involvement. Conclusion: Practice variation was found in a wide range of aspects of the structure of stroke rehabilitation.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) in stroke patients is associated with worse functional and cognitive status during inpatient rehabilitation. We hypothesized that a four-week period of continuous positive airway pressure (CPAP) treatment would improve cognitive and functional outcomes.METHODS: We performed a randomized controlled trial in stroke patients admitted to a neurorehabilitation unit. Patients were assigned to rehabilitation treatment as usual (control group) or to CPAP treatment (CPAP group). Primary outcomes were cognitive status measured by neuropsychological examination, and functional status measured by two neurological scales and a measure of activities of daily living (ADL). Secondary measures included sleepiness, sleep quality, fatigue, and mood. Tests were performed at baseline and after the four-week intervention period.RESULTS: We randomly assigned 20 patients to the CPAP group and 16 patients to the control group. The average CPAP compliance was 2.5 hours per night. Patients in the CPAP group showed significantly greater improvement in the cognitive domains of attention and executive functioning than the control group. CPAP compliance was associated with greater improvement in cognitive functioning. CPAP did not result in measurable improvement on measures of neurological status or ADL, or on any of the secondary measures.CONCLUSIONS: CPAP treatment improves cognitive functioning of stroke patients with OSA.COMMENTARY: A commentary on this article appears in this issue on page 467.

Jaarlijks worden circa 20.000 werkenden in ziekenhuizen geregistreerd met niet-progressief niet-aangeboren hersenletsel (NAH). Slechts 40% van hen keert binnen 2 jaar terug naar werk. Om het proces rondom werkhervatting bij NAH en de samenwerking tussen betrokken disciplines te stroomlijnen, is de richtlijn ‘NAH en Arbeidsparticipatie’ ontwikkeld door een multidisciplinaire werkgroep van vertegenwoordigers van relevante beroeps- en patientenverenigingen. Een zestal uitgangsvragen vormde de basis voor systematisch literatuuronderzoek en kwalitatief onderzoek.

TBV 20 / nr 5 / mei 2012 Terugkeer naar werk na niet-aangeboren hersenletsel (NAH) is niet vanzelfsprekend. Uit onderzoek is gebleken dat slechts 40% van de mensen met NAH binnen 2 jaar terugkeert naar werk. In de 3B-richtlijn NAH en arbeidsparticipatie die eerder in dit tijdschrift beschreven is, wordt gesteld dat vroege interventie en multidisciplinaire samenwerking belangrijk is bij het behoud van arbeidsparticipatie van mensen met NAH. Een belangrijke rol is hierbij weggelegd voor de revalidatiearts en de bedrijfsarts. Een van de werkwijzen die voldoet aan deze aanbevelingen is de arbeidsgerelateerde revalidatie (AGR) waarmee gewerkt wordt in revalidatiecentrum Heliomare te Wijk aan Zee. A R B E I D S G E R E L AT E E R D E R E VA L I DAT I E Arbeidsgerelateerde revalidatie is een werkwijze waarmee arbeid structureel en in een vroeg stadium van de revalidatie na NAH aan de orde komt. Het maakt deel uit van de reguliere revalidatiebehandeling en zorgt ervoor dat (terugkeer naar) werk vanaf dag 1 van de revalidatie in beeld is. De ketenpartners, zoals de werkgever en de bedrijfsarts, worden nadrukkelijk bij de AGR betrokken. Met de revalidant, het revalidatiebehandelteam, de werkgever, de bedrijfsarts en eventuele andere ketenpartners als partijen betrokken bij de AGRbehandeling, is het belangrijk dat een persoon het overzicht houdt en het proces coordineert. Deze taak wordt uitgevoerd door de re-integratiecoordinator. Deze is verantwoordelijk voor het overleg met en tussen de verschillende betrokkenen, voor de formulierenstroom en voor het stellen van behandeldoelen gericht op arbeid. AGR bestaat uit vier fasen die elkaar opvolgen in de tijd. Deze fasen worden in dit artikel besproken en toegelicht aan de hand van een casus. Hierbij zal met name aandacht besteed worden aan de rol van de bedrijfsarts.

Objectives: To describe the number of people with spinal cord injury who returned to work (RTW) 1 yr after discharge from inpatient rehabilitation and to investigate whether RTW can be predicted from wheelchair capacity at discharge from inpatient rehabilitation, after correction for confounders. Design: Prospective cohort study in which 118 subjects with spinal cord injury (age 18-65 yrs) of eight Dutch rehabilitation centers participated. Main outcome measure was RTW for at least 1 hr/wk. The outcome variables of wheelchair capacity were peak oxygen uptake, peak aerobic power output, and wheelchair skill scores (ability, performance time, and physical strain). Possible confounders were age, gender, lesion level, and lesion completeness. Where necessary, corrections were made for education level. Results: Thirty-three percent of the subjects RTW. Peak aerobic power output (persons with a 10-W higher peak aerobic power output were 1.37 times more likely to RTW), ability score (persons with a one-point higher ability score were 2.22 times more likely to RTW), and performance time (an increase, or worsening, of 1 sec on the performance time gave an odds ratio of 0.87, so persons with lower, or better, performance time scores were more likely to RTW) were significant predictors of RTW after correction for confounders and education level. Conclusions: RTW was successful in 33% of the subjects. Wheelchair capacity was independently related to RTW. Therefore, it is recommended to train wheelchair capacity in the context of RTW. American Journal of Physical Medicine & Rehabilitation Copyright © 2008 by Lippincott Williams & Wilkins.

The purpose of this study was to evaluate (1) the feasibility of an early vocational rehabilitation (EVR) protocol in the standard rehabilitation process, (2) promoting factors and barriers encountered with the EVR protocol, and (3) perceived effectiveness of the protocol in facilitating return to work (RTW) following acquired brain injury (ABI). A pre- and post-process evaluation was performed in a Dutch rehabilitation center. Dependent variables were feasibility (defined by the usability on process level and fulfillment of usability expectations), promoting factors and barriers, and perceived effectiveness of the protocol. Usability (defined by 13 performance and timing goals) was evaluated with existing forms and registrations. Fulfillment of usability expectations, perceived promoting factors and barriers, and perceived effectiveness were investigated with questionnaires. Data of 23 patients were available for process evaluation. Nine rehabilitation professionals, 10 patients with ABI, nine employers, and six occupational physicians completed the questionnaires. Two-thirds of the performance goals and one-fourth of the timing goals were reached. All respondents cited the structured protocol as a promoting factor. Thirty-two of the thirty-four participants perceived the protocol as being suitable facilitating RTW after ABI. The EVR protocol provides a structured strategy to focus on RTW during standard rehabilitation. It is now possible to implement and test the protocol in other rehabilitation settings. The early vocational rehabilitation (EVR) facilitates an interdisciplinary and systematic focus on return to work during rehabilitation of people with acquired brain injury. The feasibility of the EVR protocol has been tested. The EVR protocol is ready for implementation and wider testing in other rehabilitation settings

Background and Purpose— Sleep apnea syndrome (SAS) is a common sleep disorder in stroke patients and is associated with decreased recovery and increased risk of recurrent stroke and mortality. The standard diagnostic test for SAS is poly(somno)graphy, but this is often not feasible in stroke rehabilitation settings. This study investigated the diagnostic value of nocturnal oximetry for screening SAS in stroke rehabilitation. Methods— Fifty-six stroke patients underwent nocturnal polygraphy and oximetry. Sensitivity, specificity, and positive and negative predictive values for the oxygen desaturation index were calculated. Patient and sleep characteristics were used to develop a predictive model of apnea–hypopnea index. Results— Forty-six percent of the stroke patients had SAS. The majority of SAS patients was male, older, and had a higher body mass index than patients without SAS. Sensitivity, specificity, and positive and negative predictive values for the oxygen desaturation index ≥15 were, respectively, 77%, 100%, 100%, and 83%. Oxygen desaturation index predicted 87% of the variance in the apnea–hypopnea index. Patient characteristics did not add significantly to the prediction model. Conclusion— Nocturnal oximetry is an accurate diagnostic screening instrument for the detection of SAS in stroke patients.

OBJECTIVE: To determine whether a prediction model combining self-reported symptoms, sociodemographic and clinical parameters could serve as a reliable first screening method in a step-by-step diagnostic approach to sleep apnea syndrome (SAS) in stroke rehabilitation.DESIGN: Retrospective study.SETTING: Rehabilitation center.PARTICIPANTS: Consecutive sample of patients with stroke (N=620) admitted between May 2007 and July 2012. Of these, 533 patients underwent SAS screening. In total, 438 patients met the inclusion and exclusion criteria.INTERVENTIONS: Not applicable.MAIN OUTCOME MEASURES: We administered an SAS questionnaire consisting of self-reported symptoms and sociodemographic and clinical parameters. We performed nocturnal oximetry to determine the oxygen desaturation index (ODI). We classified patients with an ODI ≥15 as having a high likelihood of SAS. We built a prediction model using backward multivariate logistic regression and evaluated diagnostic accuracy using receiver operating characteristic analysis. We calculated sensitivity, specificity, and predictive values for different probability cutoffs.RESULTS: Thirty-one percent of patients had a high likelihood of SAS. The prediction model consisted of the following variables: sex, age, body mass index, and self-reported apneas and falling asleep during daytime. The diagnostic accuracy was .76. Using a low probability cutoff (0.1), the model was very sensitive (95%) but not specific (21%). At a high cutoff (0.6), the specificity increased to 97%, but the sensitivity dropped to 24%. A cutoff of 0.3 yielded almost equal sensitivity and specificity of 72% and 69%, respectively. Depending on the cutoff, positive predictive values ranged from 35% to 75%.CONCLUSIONS: The prediction model shows acceptable diagnostic accuracy for a high likelihood of SAS. Therefore, we conclude that the prediction model can serve as a reasonable first screening method in a stepped diagnostic approach to SAS in stroke rehabilitation.

As a result of an ageing work force and the continuing economic crisis, the coming decades will demand a long-term active role on the part of the Dutch in participating in paid and voluntary work as well as volunteer aid. This will provide a significant stimulus for so-called work-related healthcare: care that incorporates prevention and treatment of work-related symptoms and diseases, thereby enabling timely and sustainable work participation. Both patients and an increasing number of doctors are willing to contribute to this system of integrated care. The division of financial resources in the Dutch healthcare sector impedes the existing opportunities in providing work-related care, resulting in less care being given and reduced efficiency of the care. The extra costs for introducing structural attention to work in healthcare are estimated at 2-3 Euros per employee.

This study evaluates the criterion, content, and construct validity of the Rehabilitation Activities Profile (RAP) in patients with stroke. This instrument is constructed for screening, monitoring, and prognosis purposes to assist clinical rehabilitation. It consists of 21 activities, covering the domains communication, mobility, personal care, occupation, and relationships. Disabilities and perceived problems are assessed in parallel on two four-point severity scales. The disability sum scores of the first four RAP domains were used in the analyses presented in this article. An inception cohort of stroke patients was studied during 26 weeks. Patients that were still hospitalized on the 14th day after stroke were included. The functional assessments took place 2, 3, 4, 8, 12, and 26 weeks after stroke. The patients were visited at the hospital, at home, nursing home, or rehabilitation center. 125 patients were included in the study. After 26 weeks, 105 patients were still alive; 18 patients had died, and 2 patients were lost to follow-up. The RAP, Barthel Index (BI) and Frenchay Activities Index (FAI). The domain "mobility+personal care" correlated highly with the BI score (r: 0.87 to 0.90). The domain "occupation" correlated with the FAI score before the stroke and 26 weeks after stroke (r: 0.72, 0.73, respectively). The disability sum score of the domain "mobility+personal care" allowed a prediction of the living arrangement 26 weeks after stroke (receiver operator characteristic area surface: 0.90). The same domain showed significant differences (p < 0.05) in the 8-week disability sum score for most living arrangements. Exceptions were rehabilitation center versus intermediate care in a nursing home (p = 0.23) and acute care hospital versus chronic care in a nursing home (p = 0.45). Hypotheses on subgroup differences in mean scores in the domains "communication" and "mobility+personal care" could be confirmed (the discerned subgroups were: gender, having a partner, motor deficit of upper or lower extremity, urinary incontinence, higher cortical deficits, conjugate deviation of the eye, coma, hemianopsia). The disability sum scores of the RAP can be used as discriminative, evaluative, and predictive indexes

To describe the factors experienced by adults with moderate-to-severe acquired brain injury (ABI) as either limiting or facilitating during the process of return to work (RTW) in order to give an advice about the vocational rehabilitation process. A qualitative study was performed. Twelve adults who were working before acquiring traumatic or non-traumatic brain injury (2-3 years earlier) participated. The experiences were gathered by semi-structured interviews. The International Classification of Functioning, Disability and Health was used as a theoretical framework for the interviews and the analysis. The most common limiting factor was tiredness. The most common facilitating factors were the will to RTW, the ongoing recovery and the knowledge and support of the employer, colleagues, occupational physician and occupational specialist. Different aspects were experienced as being important during the process of RTW after ABI. These aspects should be kept in mind during the process of RTW to make the outcome as successful as possible. It is advised to pay special attention to the recovery opportunities of an individual, to inform the employer, colleagues, occupation physician and the occupational specialist about ABI, and to support people with ABI for long time periods. An important role can be played by the rehabilitation centre

Accelerometry can be used to objectively assess the walking ability of people with a lower-limb prosthesis inside and outside the laboratory setting. In this study, the validity of the DynaPort GaitMonitor software (McRoberts, The Hague, the Netherlands) for assessing spatiotemporal parameters of amputee gait was evaluated. Fourteen subjects with a lower-limb prosthesis walked on a straight level walkway at a self-selected walking speed over three different distances. During walking, we measured pelvis acceleration using a triaxial accelerometer (DynaPort MiniMod). Mean spatiotemporal parameters were derived from these signals using the DynaPort GaitMonitor software. Similar parameters were simultaneously determined from video. Overall, the number of steps, mean step time, step length, and walking speed were detected accurately by the GaitMonitor software. No systematic deviation was found, and the accuracy of the different parameters was within 6.5%. However, step times measured separately for both the intact and prosthetic legs differed considerably between the GaitMonitor and the video. Step time was systematically underestimated by the GaitMonitor for the intact leg and overestimated for the prosthetic leg. We concluded that the DynaPort GaitMonitor is a valid instrument for assessing mean spatiotemporal parameters in amputee gait, although systematic errors in prosthetic and intact heel strike detection prevent a reliable analysis of walking symmetry.

The aim of this study was to investigate whether balance control during a static upright standing task with and without balance perturbations elicits a significant and meaningful metabolic energy demand and to test whether this energy demand correlates with conventional posturography measures for balance control. Ten healthy subjects were assessed in four 4-min upright standing conditions on a force platform while energy consumption was measured using open circuit respirometry. In the reference condition subjects stood upright in parallel stance without balance perturbation (PS). In the other conditions balance was perturbed by placing the subjects in tandem stance (TS), in tandem stance blind folded (TSBF) and in tandem stance on a balance board (TSBB). Gross and net energy consumption was assessed and various conventional posturography measures were derived from the excursion of the center of pressure (CoP) of the ground reaction force. Energy consumption was substantially affected by all balance perturbations, compared to the reference condition. The highest increase in energy consumption was found for the TSBF condition (increase of 0.86 J kg(-1) s(-1) or 60% of PS). Significant correlations were found between energy consumption and posturography measures. The strongest correlation was found between gross energy consumption and the CoP path and normalized Cop path along the anterior-posterior axis (resp. r = 0.57 and r = 0.66, p

Accelerometry can be used to objectively assess the walking ability of people with a lower-limb prosthesis inside and outside the laboratory setting. In this study, the validity of the DynaPort GaitMonitor software (McRoberts, The Hague, the Netherlands) for assessing spatiotemporal parameters of amputee gait was evaluated. Fourteen subjects with a lower-limb prosthesis walked on a straight level walkway at a self-selected walking speed over three different distances. During walking, we measured pelvis acceleration using a triaxial accelerometer (DynaPort MiniMod). Mean spatiotemporal parameters were derived from these signals using the DynaPort GaitMonitor software. Similar parameters were simultaneously determined from video. Overall, the number of steps, mean step time, step length, and walking speed were detected accurately by the GaitMonitor software. No systematic deviation was found, and the accuracy of the different parameters was within 6.5%. However, step times measured separately for both the intact and prosthetic legs differed considerably between the GaitMonitor and the video. Step time was systematically underestimated by the GaitMonitor for the intact leg and overestimated for the prosthetic leg. We concluded that the DynaPort GaitMonitor is a valid instrument for assessing mean spatiotemporal parameters in amputee gait, although systematic errors in prosthetic and intact heel strike detection prevent a reliable analysis of walking symmetry.

Background Obstructive sleep apnea is a common sleep disorder in stroke patients. Obstructive sleep apnea is associated with stroke severity and poor functional outcome. Continuous positive airway pressure seems to improve functional recovery in stroke rehabilitation. To date, the effect of continuous positive airway pressure on cognitive functioning in stroke patients is not well established. The current study will investigate the effectiveness of continuous positive airway pressure on both cognitive and functional outcomes in stroke patients with obstructive sleep apnea. Methods/Design A randomized controlled trial will be conducted on the neurorehabilitation unit of Heliomare, a rehabilitation center in the Netherlands. Seventy stroke patients with obstructive sleep apnea will be randomly allocated to an intervention or control group (n = 2×35). The intervention will consist of four weeks of continuous positive airway pressure treatment. Patients allocated to the control group will receive four weeks of treatment as usual. Outcomes will be assessed at baseline, immediately after the intervention and at two-month follow-up. In a supplementary study, these 70 patients with obstructive sleep apnea will be compared to 70 stroke patients without obstructive sleep apnea with respect to cognitive and functional status at rehabilitation admission. Additionally, the societal participation of both groups will be assessed at six months and one year after inclusion. Discussion This study will provide novel information on the effects of obstructive sleep apnea and its treatment with continuous positive airway pressure on rehabilitation outcomes after stroke. Trial registration Trial registration number: Dutch Trial Register NTR3412

Background Although vocational rehabilitation is a widely advocated intervention for workers on sick leave due to subacute or chronic nonspecific musculoskeletal pain, the optimal dosage of effective and cost-effective vocational rehabilitation remains unknown. The objective of this paper is to describe the design of a non-inferiority trial evaluating the effectiveness and cost-effectiveness of 40-h multidisciplinary vocational rehabilitation compared with 100-h multidisciplinary vocational rehabilitation on work participation for workers on sick leave due to subacute or chronic musculoskeletal pain. Methods/Design A non-inferiority study design will be applied. The study population consists of workers who are on part-time or full-time sick leave due to subacute or chronic nonspecific musculoskeletal pain. Two multidisciplinary vocational rehabilitation programs following the bio-psychosocial approach will be evaluated in this study: 40-h vocational rehabilitation and 100-h vocational rehabilitation, both delivered over a maximum of 15 weeks. The 100-h vocational rehabilitation comprises five modules: work participation coordination, graded activity, cognitive behavioral therapy, group education, and relaxation. The 40-h vocational rehabilitation comprises work participation coordination and a well-reasoned choice from the other four modules. Four rehabilitation centers will participate in this study, each delivering both interventions. Patients will be randomized into one of the interventions, stratified for the duration of sick leave (