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Background: After stroke, many patients experience problems with participation in daily activities. Improving participation is the main goal in stroke rehabilitation. However, the longitudinal relationship between participation and health-related quality of life (HRQoL) remains unclear.Objectives: This study aimed to examine (1) the predictive value of participation at two months on long-term HRQoL and (2) the longitudinal relationship between participation and HRQoL.Methods: In this multicenter, prospective cohort study, patients were assessed at two and 12 months after stroke. Participation was measured with the Restriction subscale of the Utrecht Scale for Evaluation of Rehabilitation - Participation. HRQoL was assessed with the three-level version of the EuroQoL five dimensions questionnaire index score.Results: This study included 291 patients. Mean age was 66.6 +/- 12.4 years, 64.3% were male and mean National Institutes of Health Stroke Scale (NIHSS) was 2.5 +/- 2.9. Multivariable linear regression, adjusted for demographic characteristics, stroke characteristics, physical and cognitive impairment, showed that a higher level of participation at two months correlated with a higher HRQoL at one year (B = .004; 95% CI =.002-.005). Patients whose participation improved had a greater increase in HRQoL, compared to patients without improvement (0.080 +/- .21 versus -.054 +/- .21; p < .001).Conclusions: The level of participation at two months post-stroke predicts HRQoL at one year. Improvement in participation during the first year after stroke is associated with improvement in HRQoL. We recommend including the assessment of participation in daily activities at follow-up visits.

Background: Many significant others of persons with serious conditions like spinal cord injury (SCI) and acquired brain injury (ABI) report high levels of psychological distress. In line with the stress-coping model, the aim of the present study was to investigate the relationship between personal resource resilience and psychological distress, and whether appraisals of threat and loss, and passive coping mediate this relationship. Methods: Significant others (n = 228) of persons with SCI or ABI completed questionnaires shortly after admission to first inpatient rehabilitation after onset of the condition. The questionnaire included measures to assess psychological distress (Hospital Anxiety and Depression Scale), resilience (Connor-Davidson Resilience Scale-10), appraisals (Appraisals of Life Events scale, threat and loss) and passive coping (Utrecht Coping List). The PROCESS tool was used to test the presence of mediation. Confounding and differences between SCI and ABI were investigated. Results: High levels of psychological distress among significant others were found (34-41%). Fifty-five percent of the variance in psychological distress was explained by the relationship between resilience and psychological distress. This relationship was mediated by appraisals of threat and loss, and passive coping. The relationship between resilience and psychological distress was similar in the SCI and ABI groups. Conclusions: The results of our study indicate that appraisals of threat and loss and passive coping are mediating factors in the relationship between resilience and psychological distress. It seems useful to investigate if interventions focussing on psychological factors like resilience, appraisal and coping are effective to prevent or reduce psychological distress among significant others of persons with SCI or ABI.

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Background and Purpose: Movement behaviors, that is, both physical activity and sedentary behavior, are independently associated with health risks. Although both behaviors have been investigated separately in people after stroke, little is known about the combined movement behavior patterns, differences in these patterns between individuals, or the factors associated with these patterns. Therefore, the objectives of this study are (1) to identify movement behavior patterns in people with first-ever stroke discharged to the home setting and (2) to explore factors associated with the identified patterns. Methods: Cross-sectional design using data from 190 people with first-ever stroke discharged to the home setting. Movement, behavior was measured over 2 weeks using an accelerometer. Ten movement behavior outcomes were calculated and compressed using principal component analysis. Movement behavior patterns were identified using a k-means clustering algorithm. Demographics, stroke, care, physical functioning, and psychological, cognitive and social factors were obtained. Differences between and factors associated with the patterns were investigated. Results: On average, the accelerometer was worn for 13.7 hours per day. The average movement behavior of the participants showed 9.3 sedentary hours, 3.8 hours of light physical activity, and 0.6 hours of moderate-vigorous physical activity. Three patterns and associated factors were identified: (1) sedentary exercisers (22.6%), with a relatively low age, few pack-years, light drinking, and high levels of physical functioning; (2) sedentary movers (45.8%), with less severe stroke symptoms, low physical functioning and high levels of self-efficacy; and (3) sedentary prolongers (31.6%), with more severe stroke symptoms, more pack-years, and low levels of self-efficacy. Conclusions: The majority of people with stroke are inactive and sedentary. Three different movement behavior patter

Contains fulltext : 193508.pdf (publisher's version ) (Open Access), Acquired brain injury patients often report navigation impairments. A cognitive rehabilitation therapy has been designed in the form of a serious game. The aim of the serious game is to aid patients in the development of compensatory navigation strategies by providing exercises in 3D virtual environments on their home computers. The objective of this study was to assess the usability of three critical gaming attributes: movement control in 3D virtual environments, instruction modality and feedback timing. Thirty acquired brain injury patients performed three tasks in which objective measures of usability were obtained. Mouse controlled movement was compared to keyboard controlled movement in a navigation task. Text-based instructions were compared to video-based instructions in a knowledge acquisition task. The effect of feedback timing on performance and motivation was examined in a navigation training game. Subjective usability ratings of all design options were assessed using questionnaires. Results showed that mouse controlled interaction in 3D environments is more effective than keyboard controlled interaction. Patients clearly preferred video-based instructions over text-based instructions, even though video-based instructions were not more effective in context of knowledge acquisition and comprehension. No effect of feedback timing was found on performance and motivation in games designed to train navigation abilities. Overall appreciation of the serious game was positive. The results provide valuable insights in the design choices that facilitate the transfer of skills from serious games to real-life situations.

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Contains fulltext : 157232.pdf (publisher's version ) (Open Access)

Item does not contain fulltext, PURPOSE: Although physical activity and exercise for stroke patients is highly recommended for fast recovery, patients in hospitals and rehabilitation centres are insufficiently encouraged to be physically active. In this study, we investigated the impact of knowledge brokers (KBs), enterprising nurses and therapists, on health professionals' (HP) performance to encourage stroke inpatients to be physically active. METHOD: This multicenter intervention study used a pre-post test design. Two or three KBs were trained in each stroke unit of 12 hospitals and 10 rehabilitation centres in The Netherlands. Questionnaires were completed by patients and HPs before and after the KB-intervention. The primary outcome was encouragement given by HPs to their patients to be physically active, as reported by patients and HPs. RESULTS: After the KB-intervention, many more patients (48%; N=217) reported at least some encouragement by HPs to be physically active than before (26%; N=243, p<0.000). HPs (N=288) on an average reported encouraging patients more often after the intervention, but this difference was significant only for occupational therapists and KBs. CONCLUSIONS: Based on patient's reports of HP behaviour, the KB-intervention appears effective since more patients felt encouraged to be physically active after the intervention compared to before. Replication of this study in an experimental design is needed to allow causal inferences. Implications for rehabilitation We advise rehabilitation teams to make use of knowledge brokers (KBs), since the KB-intervention was shown to increase the encouragement felt by stroke patients to be physically active. It seems worthwhile to involve physicians, nurses and patients' families more frequently in efforts to encourage stroke patients to be physically active.

Item does not contain fulltext, OBJECTIVE: To estimate the relative contribution of psychological factors next to sociodemographic and premorbid/stroke-related factors to the risk of developing symptoms of depression and anxiety after stroke. DESIGN: Multicenter, longitudinal cohort study. SETTING: Patients after stroke from 6 general hospitals. PARTICIPANTS: Patients (N=331) were included at stroke onset and followed up 2 and 12 months after stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Sociodemographic and premorbid/stroke-related information was recorded during hospital admission, whereas psychological characteristics were determined with postal questionnaires 2 months poststroke. Symptoms of depression and anxiety were assessed with the Hospital Anxiety and Depression Scale (HADS) 2 and 12 months poststroke. Multivariable logistic analysis was performed to analyze the influence of sociodemographic, premorbid/stroke-related, and psychological characteristics on depressive symptoms (depression subscale of HADS >7) and symptoms of anxiety (anxiety subscale of HADS >7) 1 year after stroke. RESULTS: Early depression, stroke severity, posterior cerebral artery stroke, and neuroticism independently explained the variance of depressive symptoms 1 year poststroke (discriminative power, 83%; adjusted R(2) value, 36%). Neuroticism and early anxiety independently explained the variance of symptoms of anxiety 1 year poststroke (discriminative power, 88%; adjusted R(2) value, 44%). Based on these predictive models, nomograms were constructed to visually reflect the individual contribution of each risk factor to the development of long-term mood disorders after stroke. CONCLUSIONS: Psychological characteristics are important risk factors for poststroke symptoms of depression and anxiety.

Item does not contain fulltext, OBJECTIVES: (1) To assess real-time patterns of fatigue; (2) to assess the association between a real-time fatigue score and 3 commonly used questionnaires (Checklist Individual Strength [CIS] fatigue subscale, Modified Fatigue Impact Scale (MFIS), and Fatigue Severity Scale [FSS]); and (3) to establish factors that confound the association between the real-time fatigue score and the conventional fatigue questionnaires in patients with multiple sclerosis (MS). DESIGN: Cross-sectional study. SETTING: MS-specialized outpatient facility. PARTICIPANTS: Ambulant patients with MS (N=165) experiencing severe self-reported fatigue. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A real-time fatigue score was assessed by sending participants 4 text messages on a particular day (How fatigued do you feel at this moment?; score range, 0-10). Latent class growth mixed modeling was used to determine diurnal patterns of fatigue. Regression analyses were used to assess the association between the mean real-time fatigue score and the CIS fatigue subscale, MFIS, and FSS. Significant associations were tested for candidate confounders (eg, disease severity, work status, sleepiness). RESULTS: Four significantly different fatigue profiles were identified by the real-time fatigue score, namely a stable high (n=79), increasing (n=57), stable low (n=16), and decreasing (n=13). The conventional questionnaires correlated poorly (r<.300) with the real-time fatigue score. The Epworth Sleepiness Scale significantly reduced the regression coefficient between the real-time fatigue score and conventional questionnaires, ranging from 15.4% to 35%. CONCLUSIONS: Perceived fatigue showed 4 different diurnal patterns in patients with MS. Severity of sleepiness is an important confounder to take into account in the assessment of fatigue.

Item does not contain fulltext, Background and Objective Favorable prognosis of the upper limb depends on preservation or return of voluntary finger extension (FE) early after stroke. The present study aimed to determine the effects of modified constraint-induced movement therapy (mCIMT) and electromyography-triggered neuromuscular stimulation (EMG-NMS) on upper limb capacity early poststroke. Methods A total of 159 ischemic stroke patients were included: 58 patients with a favorable prognosis (>10 degrees of FE) were randomly allocated to 3 weeks of mCIMT or usual care only; 101 patients with an unfavorable prognosis were allocated to 3-week EMG-NMS or usual care only. Both interventions started within 14 days poststroke, lasted up until 5 weeks, focused at preservation or return of FE. Results Upper limb capacity was measured with the Action Research Arm Test (ARAT), assessed weekly within the first 5 weeks poststroke and at postassessments at 8, 12, and 26 weeks. Clinically relevant differences in ARAT in favor of mCIMT were found after 5, 8, and 12 weeks poststroke (respectively, 6, 7, and 7 points; P < .05), but not after 26 weeks. We did not find statistically significant differences between mCIMT and usual care on impairment measures, such as the Fugl-Meyer assessment of the arm (FMA-UE). EMG-NMS did not result in significant differences. Conclusions Three weeks of early mCIMT is superior to usual care in terms of regaining upper limb capacity in patients with a favorable prognosis; 3 weeks of EMG-NMS in patients with an unfavorable prognosis is not beneficial. Despite meaningful improvements in upper limb capacity, no evidence was found that the time-dependent neurological improvements early poststroke are significantly influenced by either mCIMT or EMG-NMS.

Contains fulltext : 143349.pdf (publisher's version ) (Closed access), Objectives: Prior research suggests that dampening neural activity of the intact, presumably overactive hemisphere, combined with increasing neural activity in the damaged hemisphere, might restore cortical interhemispheric balance and reduce neglect. In the present study we repeatedly applied a relatively new technique, transcranial direct current stimulation (tDCS), to the posterior parietal cortex to modulate spontaneous neural activity levels in a polarity dependent fashion to find evidence for improvements in severe hemispatial neglect in chronic patients. Methods: Eighty-nine patients were initially identified from our databases as having neglect, after thoroughly screening databases, consulting medical practitioners and baseline testing, only five met our inclusion criteria and agreed to participate. Sixty-five patients were excluded as they did not meet safety criteria for tDCS (epilepsy, metal implants), suffered from other medical conditions (i.e., heart disease, epilepsy, current psychiatric disorder) or displayed only mild neglect at baseline testing. Five patients with severe chronic hemispatial neglect were enrolled in a double-blind, placebo-controlled treatment program. TDCS or placebo was applied for 20 minutes over the left (cathodal) and right (anodal) posterior parietal cortex at an intensity of 2 mA on five consecutive days. Treatment conditions were separated by a four week wash-out period. Baseline corrected change in performance on the conventional subtests of the Behavioral Inattention Test (BIT) was our primary endpoint. Results: No treatment-related effects were observed for the BIT change scores and performance on individual subtests. Moreover, patients' performance somewhat improved only during the stimulation period (day one vs day five, irrespective of whether it was placebo or tDCS), but not thirty days later, indicating a practice effect. Discussion: The present study does not provide evidence that tDCS to the posterior parietal cort

OBJECTIVE: To describe illness cognitions two months and two years post stroke and to investigate changes in illness cognitions over time. We also examined the associations between illness cognitions and life satisfaction at two months and two years post stroke and investigated if changes in illness cognitions predicted life satisfaction two years post stroke, taking demographic and stroke-related factors and emotional symptoms into account. METHODS: Prospective cohort study in which 287 patients were assessed at two months and two years post stroke. The illness cognitions helplessness (maladaptive), acceptance (adaptive) and perceiving benefits (adaptive) were measured with the Illness Cognition Questionnaire. Life satisfaction was assessed with two life satisfaction questions. Correlational and regression analyses were performed. RESULTS: Patients experienced both maladaptive and adaptive illness cognitions two months and two years post stroke. Only acceptance increased significantly from two months to two years post stroke (p

Objective: To investigate the effectiveness of a self-management intervention aimed at proactive coping for stroke patients and partners, compared with an education intervention. Design: Multicentre randomized controlled trial. Participants: The study included 113 stroke patients (mean age 57.0 years (standard deviation (SD) 9.0), mean 18.8 months after stroke (SD 28.4)) and 57 partners (mean age 59.2 years (SD 8.3)). Methods: Participants were randomized to a self-management intervention, or an education intervention, both 10 weeks' duration, outpatient, stroke-specific, and group-based. Main patient inclusion criteria were symptomatic stroke (>= 6 weeks previously) and reporting >= 2 restrictions on the Restriction subscale of the Utrecht Scale for Evaluation of Rehabilitation Participation. Measurements were performed immediately after intervention, and at 3 and 9 months follow-up. Primary patient and partner outcomes were proactive coping and participation restrictions. Analyses were based on linear mixed modelling. Results: A significant effect was found only in partners' increased proactive coping at T2 (compared with education intervention). Beneficial trends were found for the self-management intervention in partners' self-efficacy and patients' health-related quality of life, mood complaints and participation restriction. Conclusion: Little convincing evidence was found favouring our self-management intervention over the education intervention; therefore, the self-management intervention should not be implemented yet in clinical practice. Further research is needed to explore beneficial trends.

Item does not contain fulltext, OBJECTIVE: To determine visual training effects on measures of daily life activities in cerebral blindness patients. METHOD: The study design was an explorative pre-post test design of patients in the chronic phase of stroke (not greater-than8 months) with visual field defects. Twelve hemianopic patients were trained by using visual restorative training, which is aimed at reducing the visual field defect. Goal attainment scaling (GAS) was applied to assess whether the functional impact of visual field defects on daily life activities was reduced after defects were reduced. RESULTS: Visual field defect reduction was observed in all 12 patients to varying degrees. GAS score improvements were observed in 9 patients. In 5 of these 9 patients, all goals were attained or over-attained; in 2 of these patients, some goals were attained and other goals were not attained; and in 2 patients, goals were not attained. As a group, patients significantly improved their GAS scores (t test, P <.005). The correlation between GAS and defect reduction was not significant (Pearson's r = 0.37, P not greater-than .01). It is likely that this was due to the fact that the set goals were not tuned to the part of the visual field where defect reduction could be expected. This, in turn, may have led to slightly underestimated results. CONCLUSIONS: Visual restorative function training does not only lead to visual field enlargement, as assessed with dynamic Goldmann perimetry, but it may also lead to a subjective improvement of daily visual functioning as evaluated by means of GAS.

Aim The aim of this study is to compare the amount of energy expenditure during lying, sitting, standing, wheelchair propulsion and walking of stroke survivors with the energy expenditure of ≤1.5 Metabolic Equivalent of Task (MET) within the definition of sedentary behavior used in healthy adults. Methods Energy expenditure of stroke survivors was measured by indirect calorimetry (Metamax II) during lying, supported and unsupported sitting, standing, wheelchair propulsion and walking. Measurements were performed with aids used in daily life. Calculations were done for the total group as well as categorised by the Functional Ambulation Categories (FAC). Results Supported and unsupported sitting showed a lower MET value than 1.5 for the total group and all FAC levels. Only the group FAC 0 showed a higher MET value during standing (i.e. 1.60 METs). The total group (n=27) showed higher levels than 1.5 METs when propelling a wheelchair and walking, respectively 1.91 and 2.55. These increases were also the case when differentiated by ambulation level. Conclusion The energy expenditure for individuals with stroke to maintain their balance while sitting is not high enough to classify as non-sedentary. Moreover, also for standing, except for individuals classified at FAC 0, there is currently no evidence that qualifies standing as true non-sedentary time. Because standing is not a part of the definition of sedentary behavior for healthy adults, the definition seems only partly applicable to stroke survivors. Clinical Relevance This study gives insight concerning the amount of energy expenditure of stroke survivors during postures and activities, which may lead to better tailored care and advises during and after rehabilitation in terms of sedentary behavior and low intensity activities. Independent wheelchair propulsion seems to be a light activity which can be used in the clinical practise to encourage stroke survivors to be more active.