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D van Ranst, WA Stoop, JW Meijer, HJ Otten, IG van de PortRevant, Pulmonary Rehabilitation Center "Schoondonck," Breda, the NetherlandsBackground: Pulmonary rehabilitation (PR) is an important treatment option for chronic obstructive pulmonary disease (COPD) patients and might contribute to a reduction in exacerbation and exacerbation-related hospitalization rate.Methods: In this prospective study, all COPD patients that completed a comprehensive pulmonary rehabilitation program (PRP) between June 2006 and December 2012 were included. Self-reported exacerbation and hospitalization frequency 1 year before PR was retrospectively recorded. During the year following PR, exacerbation and hospitalization frequency was recorded with questionnaires.Results: For 343 patients, complete information on exacerbation and hospitalization rate was obtained. The mean number of exacerbations decreased significantly after participating in a PRP by 1.37 exacerbations/year (95% confidence interval 1.029 to 1.717) from 4.56±3.26 exacerbations in the year preceding PR to 3.18±2.53 in the year following PR (P

Background : Impairments in arm function are a common problem in stroke survivors and have a large impact on health-related quality of life (HRQoL). Little is known about the longitudinal relationship between recovery of upper limb strength and changes in HRQoL. Objectives : This study aimed to determine to what extent changes in HRQoL are related to changes in upper limb strength after discharge from inpatient rehabilitation. Methods : 250 patients from an RCT were assessed at discharge from inpatient rehabilitation (baseline) and at 12 weeks post-discharge (follow-up). The Stroke Impact Scale was used to measure HRQoL, and the Motricity Index Arm was used to measure upper limb strength. Hierarchical regression analysis was performed to determine the predictive value of upper limb strength on HRQoL, relative to demographic and clinical characteristics. Regression analysis was used to determine the relation between upper limb strength improvement and HRQoL improvement. Results : Upper limb strength at baseline was a major predictor of HRQoL at follow-up, after accounting for demographic and clinical characteristics ( p < .05). Improvement in HRQoL was positively related to improvement in upper limb strength ( F (1, 240) = 18.351, p <.0005). Conclusions : These findings highlight the importance of upper limb strength in HRQoL, as HRQoL is associated with improvement in upper limb strength recovery. Better monitoring of recovery and treatment of upper limb strength during the outpatient rehabilitation period and beyond, i.e. outside the typical time-window of recovery in the first 3 months post-stroke, might contribute to higher quality of life for stroke survivors.

Objective: To investigate whether the 'Brains Ahead! Intervention for children and adolescents with mild traumatic brain injury' was implemented as intended. In addition, involvement in and satisfaction with the intervention among patients, caregivers and professionals delivering the intervention were studied., Design: Mixed methods, prospective study., Participants: Children with mild traumatic brain injury and their caregivers, allocated to the intervention group of the randomized controlled trial in the 'Brains Ahead!' study, and the two professionals providing the intervention., Intervention: The intervention consists of a standardized and individualized psychoeducational session with written take-home information, and follow-up telephone call(s)., Main Measures: Registration forms, evaluation questionnaires for patients and caregivers and semi-structured interviews for professionals., Data Analysis: Qualitative data were categorized based on content. Quantitative data were reported as descriptive statistics., Results: Fifty-five patients and caregivers out of 60 study-participants attended both sessions. All elements of the intervention were delivered to 53 study-participants. Evaluation questionnaires were completed by 21 of the 31 patients aged 12 years and older, and by 41 caregivers. Overall, the sessions were considered useful by 19 patients, 40 caregivers and both professionals. Reassurance, creating a better understanding and recognition of symptoms were rated as important aspects. On a scale from 1 to 10, the intervention was rated by children, caregivers and professionals with 7.6 (SD 1.2), 8.1 (SD .9) and 8.0 (SD .0), respectively., Conclusion: The 'Brains Ahead!' intervention was largely implemented as intended and the process evaluation revealed that it is considered feasible according to patients, caregivers and professionals.

Objective: To classify patients with stroke into subgroups based on their characteristics at the moment of discharge from inpatient rehabilitation in order to predict community ambulation outcome 6 months later., Design: Prospective cohort study with a baseline measurement at discharge from inpatient care and final outcome determined after 6 months., Setting: Community., Participants: A cohort of patients (N=243) with stroke, referred for outpatient physical therapy, after completing inpatient rehabilitation in The Netherlands., Interventions: Not applicable., Main Outcome Measures: A classification model was developed using Classification And Regression Tree (CART) analysis. Final outcome was determined using the community ambulation questionnaire. Potential baseline predictors included patient demographics, stroke characteristics, use of assistive devices, comfortable gait speed, balance, strength, motivation, falls efficacy, anxiety, and depression., Results: The CART model accurately predicted independent community ambulation in 181 of 193 patients with stroke, based on a comfortable gait speed at discharge of 0.5 meters per second or faster. In contrast, 27 of 50 patients with gait speeds below 0.5 meters per second were correctly predicted to become noncommunity walkers., Conclusions: We show that comfortable gait speed is a key factor in the prognosis of community ambulation outcome. The CART model may support clinicians in organizing community services at the moment of discharge from inpatient care., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

A recent review indicated that perturbation-based training (PBT) interventions are effective in reducing falls in older adults and patients with Parkinson's disease. It is unknown whether this type of intervention is effective in stroke survivors. We determined whether PBT can enhance gait stability in stroke survivors. A total of 10 chronic stroke survivors who experienced falls in the past 6 months participated in the PBT. Participants performed 10 training sessions over a 6-week period. The gait training protocol was progressive, and each training contained unexpected gait perturbations and expected gait perturbations. Evaluation of gait stability was performed by determining steady-state gait characteristics and daily-life gait characteristics. We previously developed fall prediction models for both gait assessment methods. We evaluated whether predicted fall risk was reduced after PBT according to both models. Steady-state gait characteristics significantly improved, and consequently, predicted fall risk was reduced after the PBT. However, daily-life gait characteristics did not change, and thus, predicted fall risk based on daily-life gait remained unchanged after the PBT. A PBT resulted in more stable gait on a treadmill and thus lower predicted fall risk. However, the more stable gait on the treadmill did not transfer to a more stable gait in daily life.

Purpose:: Approximately 20% of the children and adolescents after mild traumatic brain injury will not fully recover. They suffer long-term postconcussive symptoms and may experience limitations in activities and participation. Research suggests that early psychoeducational interventions may prevent long-term postconcussive symptoms. The Brains Ahead! intervention was developed to prevent long-term symptoms and, furthermore, to establish a more successful return to activities and participation after mild traumatic brain injury in children and adolescents. The intervention is currently being evaluated in a multicenter randomized controlled trial., Rationale:: Providing individualized information and personal advice in addition to standardized information about the injury and possible consequences early after the injury may enable patients and caregivers to recognize and anticipate on relevant symptoms at an early stage and to prevent problems in activities and participation., Theory Into Practice:: The Brains Ahead! intervention is a psychoeducational intervention for children and adolescents who sustained a mild traumatic brain injury and for their caregivers. The patients will receive a partially standardized and partially individualized psychoeducational session and a telephone follow-up within the first two to eight weeks after the injury.

Introduction: Stroke survivors often fall during walking. To reduce fall risk, gait testing and training with avoidance of virtual obstacles is gaining popularity. However, it is unknown whether and how virtual obstacle crossing is associated with fall risk., Aim: The present study assessed whether obstacle crossing characteristics are reliable and assessed differences in stroke survivors who prospectively experienced falls or no falls., Method: We recruited twenty-nine community dwelling chronic stroke survivors. Participants crossed five virtual obstacles with increasing lengths. After a break, the test was repeated to assess test-retest reliability. For each obstacle length and trial, we determined; success rate, leading limb preference, pre and post obstacle distance, margins of stability, toe clearance, and crossing step length and speed. Subsequently, fall incidence was monitored using a fall calendar and monthly phone calls over a six-month period., Results: Test-retest reliability was poor, but improved with increasing obstacle-length. Twelve participants reported at least one fall. No association of fall incidence with any of the obstacle crossing characteristics was found., Discussion: Given the absence of height of the virtual obstacles, obstacle avoidance may have been relatively easy, allowing participants to cross obstacles in multiple ways, increasing variability of crossing characteristics and reducing the association with fall risk., Conclusion: These finding cast some doubt on current protocols for testing and training of obstacle avoidance in stroke rehabilitation., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: This exploratory study investigated to what extent gait characteristics and clinical physical therapy assessments predict falls in chronic stroke survivors., Design: Prospective study., Subjects: Chronic fall-prone and non-fall-prone stroke survivors., Methods: Steady-state gait characteristics were collected from 40 participants while walking on a treadmill with motion capture of spatio-temporal, variability, and stability measures. An accelerometer was used to collect daily-life gait characteristics during 7 days. Six physical and psychological assessments were administered. Fall events were determined using a "fall calendar" and monthly phone calls over a 6-month period. After data reduction through principal component analysis, the predictive capacity of each method was determined by logistic regression., Results: Thirty-eight percent of the participants were classified as fallers. Laboratory-based and daily-life gait characteristics predicted falls acceptably well, with an area under the curve of, 0.73 and 0.72, respectively, while fall predictions from clinical assessments were limited (0.64)., Conclusion: Independent of the type of gait assessment, qualitative gait characteristics are better fall predictors than clinical assessments. Clinicians should therefore consider gait analyses as an alternative for identifying fall-prone stroke survivors.

Background: Steady-state gait characteristics appear promising as predictors of falls in stroke survivors. However, assessing how stroke survivors respond to actual gait perturbations may result in better fall predictions. We hypothesize that stroke survivors who fall have a diminished ability to adequately adjust gait characteristics after gait is perturbed. This study explored whether gait characteristics of perturbed gait differ between fallers and non fallers., Method: Chronic stroke survivors were recruited by clinical therapy practices. Prospective falls were monitored over a six months follow up period. We used the Gait Real-time Analysis Interactive Lab (GRAIL, Motekforce Link B.V., Amsterdam) to assess gait. First we assessed gait characteristics during steady-state gait and second we examined gait responses after six types of gait perturbations. We assessed base of support gait characteristics and margins of stability in the forward and medio-lateral direction., Findings: Thirty eight stroke survivors complete our gait protocol. Fifteen stroke survivors experienced falls. All six gait perturbations resulted in a significant gait deviation. Forward stability was reduced in the fall group during the second step after a ipsilateral perturbation., Interpretation: Although stability was different between groups during a ipsilateral perturbation, it was caused by a secondary strategy to keep up with the belt speed, therefore, contrary to our hypothesis fallers group of stroke survivors have a preserved ability to cope with external gait perturbations as compared to non fallers. Yet, our sample size was limited and thereby, perhaps minor group differences were not revealed in the present study., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Acute lateral ankle ligamentous sprains (ALALS) are common injuries. This injury does not always have a favourable long-term outcome. Studies reporting the prognosis of ALALS after functional treatment are scarce., Objective: To determine the prognosis of functionally treated ALALS, in terms of recurrent ALALS and residual symptoms., Study Design: Retrospective cohort study., Setting: Patients were recruited from 20 family practices, nine physical therapy practices, the emergency departments of a regional hospital and a university hospital., Patients: Adult patients with an ALALS caused by an inversion trauma were invited to participate in this study 2.5-5 years after their initial injury., Independent Variables: Functional treatment of the initial ALALS., Main Outcome Measures: Acute lateral ankle ligamentous sprain recurrences and residual symptoms., Results: A total of 44 patients were included, with an average follow-up period after the initial ankle sprain of 204 weeks (range 150-274 weeks). Eight patients (18.1%) had reinjured their ankle. Explicit pain around the ankle joint at physical examination was experienced by 45.5%. Clinical symptoms of anterior ankle impingement were present in 25% (all athletes), with radiologically confirmed tibiotalar osteophyte bone formation in 82% of them., Conclusions: A large proportion of patients with ALALS experience recurrences and persistent symptoms after their initial ankle injury. The high percentage of patients with anterior ankle impingement syndromes illustrates the need for early assessment of this impairment in patients with persistent complaints., (© The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Virtual reality (VR) training is considered to be a promising novel therapy for balance and gait recovery in patients with stroke., Purpose: The aim of this study was to conduct a systematic literature review with meta-analysis to investigate whether balance or gait training using VR is more effective than conventional balance or gait training in patients with stroke., Data Sources: A literature search was carried out in the databases PubMed, Embase, MEDLINE, and Cochrane Library up to December 1, 2015., Study Selection: Randomized controlled trials that compared the effect of balance or gait training with and without VR on balance and gait ability in patients with stroke were included., Data Extraction and Synthesis: Twenty-one studies with a median PEDro score of 6.0 were included. The included studies demonstrated a significant greater effect of VR training on balance and gait recovery after stroke compared with conventional therapy as indicated with the most frequently used measures: gait speed, Berg Balance Scale, and Timed "Up & Go" Test. Virtual reality was more effective to train gait and balance than conventional training when VR interventions were added to conventional therapy and when time dose was matched., Limitations: The presence of publication bias and diversity in included studies were limitations of the study., Conclusions: The results suggest that VR training is more effective than balance or gait training without VR for improving balance or gait ability in patients with stroke. Future studies are recommended to investigate the effect of VR on participation level with an adequate follow-up period. Overall, a positive and promising effect of VR training on balance and gait ability is expected., (© 2016 American Physical Therapy Association.)

Background: Falls in stroke survivors can lead to serious injuries and medical costs. Fall risk in older adults can be predicted based on gait characteristics measured in daily life. Given the different gait patterns that stroke survivors exhibit it is unclear whether a similar fall-prediction model could be used in this group. Therefore the main purpose of this study was to examine whether fall-prediction models that have been used in older adults can also be used in a population of stroke survivors, or if modifications are needed, either in the cut-off values of such models, or in the gait characteristics of interest., Methods: This study investigated gait characteristics by assessing accelerations of the lower back measured during seven consecutive days in 31 non fall-prone stroke survivors, 25 fall-prone stroke survivors, 20 neurologically intact fall-prone older adults and 30 non fall-prone older adults. We created a binary logistic regression model to assess the ability of predicting falls for each gait characteristic. We included health status and the interaction between health status (stroke survivors versus older adults) and gait characteristic in the model., Results: We found four significant interactions between gait characteristics and health status. Furthermore we found another four gait characteristics that had similar predictive capacity in both stroke survivors and older adults., Conclusion: The interactions between gait characteristics and health status indicate that gait characteristics are differently associated with fall history between stroke survivors and older adults. Thus specific models are needed to predict fall risk in stroke survivors.

Background: Approximately 20 % of children and adolescents who have sustained mild traumatic brain injuries may experience long-term consequences, including cognitive problems, post-traumatic stress symptoms and reduced load-bearing capacity. The underestimation and belated recognition of these long-term consequences may lead to chronic and disruptive problems, such as participation problems in school and in social relationships. The aim of this study is to examine the level of activities and participation of children and adolescents up to 6 months after a mild traumatic brain injury and to identify possible outcome predictors. Another aim is to investigate the effectiveness of an early psychoeducational intervention and compare the results with those obtained with usual care., Methods/design: This paper presents the Brains Ahead! study design, a randomised controlled trial nested within a multicentre, longitudinal, prospective cohort study. The eligible participants include children and adolescents between 6 and 18 years of age who have experienced a mild traumatic brain injury within the last 2 weeks. The cohort study will include 500 children and adolescents with a mild traumatic brain injury and their caregivers. A subset of 140 participants and their caregivers will be included in the randomised controlled trial. Participants in the randomised controlled trial will be randomly assigned to either the psychoeducational intervention group or the usual care control group. The psychoeducational intervention involves one face-to-face contact and one phone contact with the interventionist, during which the consequences of mild traumatic brain injury and advice for coping with these consequences to prevent long-term problems will be discussed. Information will be provided both verbally and in a booklet. The primary outcome domain is activities and participation, which will be evaluated using the Child and Adolescent Scale of Participation. Participants are evaluated 2 weeks, 3 months and 6 months after the mild traumatic brain injury., Discussion: The results of this study will provide insight into which children with mild traumatic brain injury are at risk for long-term participation problems and may benefit from a psychoeducational intervention., Trial Registration: Netherlands Trial Register identifier NTR5153 . Registered on 17 Apr 2015.

Objective: To systematically review the use of cardiopulmonary exercise testing in people who have survived a stroke. The following questions are addressed: (i) What are the testing procedures used? (ii) What are the patient, safety and outcomes characteristics in the cardiopulmonary exercise testing procedures? (iii) Which criteria are used to determine maximum oxygen uptake (VO2peak/max) in the cardiopulmonary exercise testing procedures?, Methods: Systematic review of studies of cardiopulmonary exercise testing in stroke survivors. PubMed, EMBASE, and CINAHL were searched from inception until January 2014. MeSH headings and keywords used were: oxygen capacity, oxygen consumption, oxygen uptake, peak VO2, max VO2, aerobic fitness, physical fitness, aerobic capacity, physical endurance and stroke. Search and selection were performed independently by 2 reviewers. Sixty studies were scrutinized, including 2,104 stroke survivors., Results: Protocols included treadmill (n = 21), bicycle (n = 33), stepper (n = 3) and arm (n = 1) ergometry. Five studies reported 11 adverse events (1%). Secondary outcomes were reported in few studies, which hampered interpretation of the patient's effort, and hence the value of the VO2peak., Conclusion: Most studies did not adhere, or insufficiently adhered, to the existing cardiopulmonary exercise testing guidelines for exercise testing. Thus, the results of cardiopulmonary exercise testing protocols in stroke patients cannot be compared.

Objectives: To compare the incidence and characteristics of injuries between Dutch amateur and professional male soccer players during one entire competition season., Design: A prospective two-cohort design., Methods: During the 2009-2010 season, 456 Dutch male amateur soccer players and 217 professional players were prospectively followed. Information on injuries and individual exposure to all soccer activities were recorded in both cohorts. Injuries were recorded using the time-loss definition., Results: In total, 424 injuries were recorded among 274 of the amateur players (60.1% injured players) and 286 injuries were sustained by 136 (62.7% injured players) of the professional players (p=0.52). Compared to the professionals, the injury incidence during training sessions was higher among amateurs (p=0.01), but the injury incidence among professionals was higher during matches (p<0.001). Professional players also had a higher incidence of minimal injuries (p<0.001), whereas the incidence of moderate and severe injuries was higher for amateurs (all p<0.001). Lastly, professional players sustained more overuse injuries (p=0.02), whereas amateurs reported more recurrent injuries (p<0.001)., Conclusions: The above-mentioned differences in injury rates between amateur and professional players in the Netherlands might be explained by the difference in the level at which they play, since factors like the availability of medical support and/or the team size may influence the injury risk and characteristics., (Copyright © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Objective: To describe characteristics of outdoor soccer injury and recovery among Dutch soccer players., Design: Prospective cohort study., Setting: The 2009-2010 competitive season (33 weeks)., Participants: Four hundred fifty-six Dutch male soccer players of 23 amateur teams., Main Outcome Measures: Coaches recorded individual exposure to all soccer activities. Paramedics or sports trainers collected information on the occurrence (e.g., location, type, circumstances) and consequences (eg, absenteeism, medical treatment) of injuries., Results: In total, 424 time-loss injuries were sustained by 60% (n = 274) of the players, with 23% (n = 105) having more than 1 injury. This corresponds to an overall density of 9.6 (8.7-10.5) injuries per 1000 player hours; 3.9 (3.3-4.7) in training sessions and 20.4 (18.1-23.1) in soccer matches. Almost 30% (n = 123) of the injuries lasted for more than 1 month, 14% (n = 58) were reinjuries (causing longer absence than new injuries), and 54% (n = 230) of the injuries were given medical treatment. The most common diagnoses were muscle/tendon (38%) or joint/ligament injuries (23%) of the lower extremities. After regaining the ability to fully take part in soccer training or matches, 27.4% of the players (n = 116) still reported complaints., Conclusions: Two recommendations based on the above-mentioned results are (1) prevention should primarily focus on these most common diagnoses and (2) players resuming soccer activities after an injury should be given special attention to resolve the remaining complaints and to prevent reinjuries.

Study Design: Systematic literature review., Objective: To summarize the evidence for physical therapist-guided quadriceps-strengthening exercises as a treatment for patellofemoral pain syndrome., Background: Although quadriceps strengthening is often included in the plan of care for patellofemoral pain syndrome, a systematic review published in 2003 found only limited evidence that exercise was more effective than no exercise for this common condition., Methods: The PubMed, Embase/MEDLINE, and Cochrane Central Register of Controlled Trials databases, from inception to January 9, 2014, were searched for randomized controlled trials comparing the use of quadriceps-strengthening exercises to interventions consisting of advice/information or a placebo. Outcomes of interest were pain measures and function, as measured with self-report questionnaires. The methodological quality of the randomized controlled trials was assessed with the Physiotherapy Evidence Database scale. Results were summarized using a best-evidence synthesis and graphically illustrated using forest plots without meta-analysis., Results: Seven studies were included in the literature review. These studies reported strong evidence that isolated quadriceps strengthening is more effective in reducing pain and improving function than advice and information alone. In addition, compared to advice and information or placebo, there was strong evidence that quadriceps-strengthening exercises combined with other interventions may be more effective in reducing pain immediately postintervention and after 12 months, but not in improving function., Conclusion: The literature provides strong evidence for the use of quadriceps-strengthening exercises, with or without other interventions, for the treatment of patellofemoral pain syndrome.

Introduction: Community-dwelling stroke survivors tend to become less physically active over time. There is no 'gold standard' to measure walking activity in this population. Assessment of walking activity generally involves subjective or observer-rated instruments. Objective measuring with an activity monitor, however, gives more insight into actual walking activity. Although several activity monitors have been used in stroke patients, none of these include feedback about the actual walking activity. FESTA (FEedback to Stimulate Activity) determines number of steps, number of walking bouts, covered distance and ambulatory activity profiles over time and also provides feedback about the walking activity to the user and the therapist., Aim: To examine the criterion validity and test-retest-reliability of the FESTA as a measure of walking activity in patients with chronic stroke. To target the properties of the measurement device itself and thus exclude effects of behavioral variability as much as possible evaluation was performed in standardized activities., Methods: Community-dwelling individuals with chronic stroke were tested twice with a test-retest interval varying from two days to two weeks. They performed a six-minute walk test and a standardized treadmill test at different speeds on both testing days. Walking activity was expressed in gait parameters: steps, mean-step-length and walking distance. Output data of the FESTA on the treadmill was compared with video analysis as the criterion measurement. Intraclass Correlations Coefficients (ICCs) and Mean Relative Root Squared Error (MRRSE) were calculated., Results: Thirty-three patients were tested to determine criterion validity, 27 patients of this group were tested twice for test-retest reliability. ICC values for validity and reliability were high, ranging from .841 to .972., Conclusion: This study demonstrated good criterion validity and test-retest-reliability of FESTA for measuring specific gait parameters in chronic stroke patients. FESTA is a valid and reliable tool for capturing walking activity measurements in stroke, and has applicability to both clinical practice and research.

Hamstring injuries are common injuries in soccer players. In view of the high incidence and the serious consequences, identifying risk factors related to hamstring injuries is essential. The aim of this systematic review was therefore to identify risk factors for hamstring injuries in male adult soccer players. PubMed, Embase/Medline, Cumulative Index to Nursing and Allied Health Literature, and SPORTDiscus were systematically searched, and prospective studies investigating risk factors for hamstring injuries in adult male soccer players were included. The methodological quality of the included articles was assessed using a standardized set of predefined criteria. Seven of the 11 studies identified, involving a total of 1775 players and 344 hamstring injuries, met the inclusion criteria. All but one of the included studies met at least five of nine methodological criteria, causing them to be qualified as 'high quality'. The included studies used univariate as well as multivariate analyses to identify risk factors for hamstring injury. The results from the multivariate analyses suggest that previous hamstring injury is most strongly related to hamstring injury. Conflicting evidence is found for age and hamstring length or flexibility as risk factors for the occurrence of hamstring injuries., (© 2012 John Wiley & Sons A/S.)

Background: Inspiratory muscle training (IMT) before cardiac surgery has proved to be a promising intervention to reduce postoperative pneumonia in a randomized controlled trial setting. Effects of IMT in routine care have not been reported., Objective: The purpose of this study was to investigate the effect of IMT before cardiac surgery on postoperative pneumonia in routine care at a Dutch university medical center using propensity scoring., Design: This was an observational cohort study., Methods: All candidates for cardiac surgery were preoperatively stratified by a physical therapist for low risk or high risk for postoperative pulmonary complications. Patients at high risk either engaged in an unsupervised IMT program (20 minutes a day) at home for at least 2 weeks before surgery (group 1) or received usual care (no IMT) (group 2). Results in terms of outcome measures were adjusted with propensity scores to reduce bias caused by nonrandom treatment assignment., Results: The results showed that of the 94 patients at high risk in group 1, 1 patient (1.1%) developed a postoperative pneumonia. In group 2, 8 out of the 252 patients at high risk (3.2%) developed this pulmonary complication (adjusted odds ratio=0.34, 95% confidence interval=0.04-3.38). No significant differences were found regarding median (25th-75th percentile) ventilation time (7 [5-9] hours versus 7 [5-10] hours), length of stay in the intensive care unit (23 [21-24] hours versus 23 [21-25] hours), or total postoperative length of stay (7 [6-11] days versus 7 [5-9] days)., Limitations: The most important limitations of this study were confounding, incomplete data collection, and a low incidence of the primary outcome., Conclusions: Propensity scoring is believed to be a valuable tool of great potential interest to researchers in the field of observational studies. Whether IMT in routine care resulted in less postoperative pneumonia cannot be concluded.

Background: The incidence of soccer (football) injuries is among the highest in sports. Despite this high rate, insufficient evidence is available on the efficacy of preventive training programmes on injury incidence., Objective: To systematically study the evidence on preventive exercise-based training programmes to reduce the incidence of injuries in soccer., Data Sources: The databases EMBASE/MEDLINE, PubMed, CINAHL, Cochrane Central Register of controlled trials, PEDro and SPORTDiscus™ were searched for relevant articles, from inception until 20 December 2011. The methodological quality of the included studies was assessed using the PEDro scale., Study Selection: The inclusion criteria for this review were (1) randomized controlled trials or controlled clinical trials; (2) primary outcome of the study is the number of soccer injuries and/or injury incidence; (3) intervention focusing on a preventive training programme, including a set of exercises aimed at improving strength, coordination, flexibility or agility; and (4) study sample of soccer players (no restrictions as to level of play, age or sex). The exclusion criteria were: (1) the article was not available as full text; (2) the article was not published in English, German or Dutch; and (3) the trial and/or training programme relates only to specific injuries and/or specific joints. To compare the effects of the different interventions, we calculated the incidence risk ratio (IRR) for each study., Results: Six studies involving a total of 6,099 participants met the inclusion criteria. The results of the included studies were contradictory. Two of the six studies (one of high and one of moderate quality) reported a statistical significant reduction in terms of their primary outcome, i.e. injuries overall. Four of the six studies described an overall preventive effect (IRR<1), although the effect of one study was not statistically significant. The three studies that described a significant preventive effect were of high, moderate and low quality., Conclusions: Conflicting evidence has been found for the effectiveness of exercise-based programmes to prevent soccer injuries. Some reasons for the contradictory findings could be different study samples (in terms of sex and soccer type) in the included studies, differences between the intervention programmes implemented (in terms of content, training frequency and duration) and compliance with the programme. High-quality studies investigating the best type and intensity of exercises in a generic training programme are needed to reduce the incidence of injuries in soccer effectively.

Purpose: To evaluate tolerance of a new dynamic hand-wrist orthosis and effectiveness on the prevention of progressive wrist contracture and spasticity after stroke., Method: Chronic stroke patients (N = 6) with upper limb spasticity, who had not been able to endure a static orthosis, were provided with a custom-made dynamic orthosis. Tolerance of the orthosis was evaluated by the daily wearing time, and self-reported pain and spasticity. Effectiveness was measured by contracture of wrist and finger flexor muscles, upper limb spasticity and use of spasticity treatment. Outcome measures were collected at time of fitting of the dynamic orthosis (baseline) and after three and six months., Results: Five patients could endure the dynamic orthosis without discomfort for 6 hours daily during the 6-month period. Self-reported spasticity and pain decreased significantly (p < 0.05) compared to wearing the static orthosis. In comparison to baseline, the maximum passive wrist extension increased significantly from -29° to -12° (p < 0.05). Although, no significant change in spasticity was measured, the use of Botulinum Toxin injections decreased for two patients., Conclusions: The majority of the included chronic stroke patients tolerated the new dynamic orthosis for at least 6 hours daily and the use significantly reduced wrist contractures in a 6-month period.

Background: The incidence rate of soccer injuries is among the highest in sports, particularly for adult male soccer players., Purpose: To investigate the effect of the 'The11' injury prevention programme on injury incidence and injury severity in adult male amateur soccer players., Study Design: Cluster-randomised controlled trial., Methods: Teams from two high-level amateur soccer competitions were randomly assigned to an intervention (n=11 teams, 223 players) or control group (n=12 teams, 233 players). The intervention group was instructed to perform The11 in each practice session during one soccer season. The11 focuses on core stability, eccentric training of thigh muscles, proprioceptive training, dynamic stabilisation and plyometrics with straight leg alignment. All participants of the control group continued their practice sessions as usual., Results: In total, 427 injuries were recorded, affecting 274 of 456 players (60.1%). Compliance with the intervention programme was good (team compliance=73%, player compliance=71%). Contrary to the hypothesis, injury incidences were almost equal between the two study groups: 9.6 per 1000 sports hours (8.4-11.0) for the intervention group and 9.7 (8.5-11.1) for the control group. No significant differences were found in injury severity, but a significant difference was observed in the location of the injuries: players in the intervention group sustained significantly less knee injuries., Conclusions: This study did not find significant differences in the overall injury incidence or injury severity between the intervention and control group of adult male soccer players. More research is recommended, focusing on injury aetiology and risk factors in adult male amateur soccer players.

Aims and Objectives: To study how patients with acute stroke spend their day and to determine whether activity levels of patients with acute stroke in a Dutch university hospital increase after the implementation of interventions to stimulate activity., Background: Previous studies suggest that patients with acute stroke are prone to inactivity. Early mobilisation and increasing levels of activities are part of several guidelines for patients with stroke. However, implementing interventions to increase activity levels is difficult owing to time and money constrains., Design: This study used a descriptive pre/postdesign., Methods: Outcomes is assessed on three levels: location, other people involved and activity, and it is determined by direct non-participant observation. An intervention was implemented to stimulate activity levels of the patients. This intervention consisted of (1) increasing the group therapy session and (2) providing a therapy guide that includes exercises patients can do by themselves or together with nurses, therapists or their family to stimulate the patients to be more active., Results: In total, 66 patients have been observed: 35 during the first and 31 during the second observation periods. Compared with the first observation period, patients in the second observation period spent less time in their room and spent less time lying in bed (49 vs. 29%). They did spend more time sitting in bed (13% vs. 20%) and sitting supported (14% vs. 24%)., Conclusion: Simple interventions can lead to less inactivity in patients with acute stroke. Nurses should be highly involved in implementing and stimulating these interventions. Also, family can play an important role in reducing inactivity in patients after stroke., Relevance to Clinical Practice: Nurses can play an important role in increasing activity levels of patients by using simple interventions., (© 2012 Blackwell Publishing Ltd.)

Objective: To analyse the effect of task oriented circuit training compared with usual physiotherapy in terms of self reported walking competency for patients with stroke discharged from a rehabilitation centre to their own home., Design: Randomised controlled trial with follow-up to 24 weeks., Setting: Multicentre trial in nine outpatient rehabilitation centres in the Netherlands, Participants: Patients with stroke who were able to walk a minimum of 10 m without physical assistance and were discharged from inpatient rehabilitation to an outpatient rehabilitation clinic. Patients were randomly allocated to circuit training or usual physiotherapy, after stratification by rehabilitation centre, with an online randomisation procedure., Intervention: Patients in the intervention group received circuit training in 90 minute sessions twice a week for 12 weeks. The training included eight different workstations in a gym and was intended to improve performance in tasks relating to walking competency. The control group received usual outpatient physiotherapy., Main Outcome Measures: The primary outcome was the mobility domain of the stroke impact scale (SIS, version 3.0). Secondary outcomes were standing balance, self reported abilities, gait speed, walking distance, stair climbing, instrumental activities of daily living, fatigue, anxiety, and depression. Differences between groups were analysed according to the intention to treat principle. All outcomes were assessed by blinded observers in a repeated measurement design lasting 24 weeks., Results: 126 patients were included in the circuit training group and 124 in the usual care group (control), with data from 125 and 117, respectively, available for analysis. One patient from the circuit training group and seven from the control group dropped out. Circuit training was a safe intervention, and no serious adverse events were reported. There were no significant differences between groups for the stroke impact scale mobility domain (β=0.05 (SE 0.68), P=0.943) at 12 weeks. Circuit training was associated with significantly higher scores in terms of gait speed (0.09 m/s (SE 0.02), P<0.001), walking distance (20.0 m (SE 7.4), P=0.007), and modified stairs test (-1.6 s (SE 0.7), P=0.015). There were no significant differences between groups for the other secondary outcomes, except for the leisure domain of the Nottingham extended activities of daily living and the memory and thinking domain of the stroke impact scale. With the exception of gait speed (-0.04 m/s (SE 0.02), P=0.040), there were no significant differences between groups at follow-up., Conclusion: Task oriented circuit training can safely replace usual physiotherapy for patients with stroke who are discharged from inpatient rehabilitation to the community and need further training in gait and gait related activities as an outpatient., Trial Registration: Dutch Trial Register (NTR1534).

Objective: To determine the construct validity, test-retest reliability, and measurement error of the shuttle walk test (SWT) for patients after stroke., Design: Clinimetric study., Setting: Three rehabilitation centers in the Netherlands., Participants: A sample of patients after stroke (N=75; mean age ± SD, 58.8±9.8y) who are capable of walking without physical assistance. Patients were excluded if they had sustained a subarachnoid hemorrhage or a stroke in the cerebellum or brainstem, or had any other conditions that limited their walking capacity more than the current stroke, or had sensory aphasia., Interventions: Not applicable., Main Outcome Measures: Construct validity (6-minute walk test [6MWT]) and test-retest reliability of the SWT were assessed. Measurement error was determined with the standard error of measurement (SEM), limits of agreement, and smallest detectable differences (SDDs)., Results: Construct validity was confirmed by high significant correlations (r(p)≥.65, P<.01) between the SWT and 6MWT. Difference scores were significantly higher in favor of the SWT for high-speed walkers (≥0.8m/s). In the small group (n=12) of low-speed walkers (<0.8m/s), no significant correlations and differences between both tests were found except for walking distance in favor of the 6MWT. Test-retest reliability was good (intraclass correlation coefficient model 2,1 [ICC(2,1)]=.961 [.936-.977]). SEM was 6.0%, and the SDDs for individual and group were 302.0m (37%) and 38.7m (5%), respectively., Conclusions: The SWT is a valid and reliable measure and therefore a feasible instrument to determine functional walking capacity of patients after stroke, especially in high-speed walkers., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: To provide an overview of walking tests including their measurement properties that have been used in stroke survivors., Method: Electronic databases were searched using specific search strategies. Retrieved studies were selected by using specified inclusion criteria. A modified consensus-based standards for the selection of health status measurement instruments (COSMIN) checklist was applied for methodological quality assessment of the included studies. A quality assessment for statistical outcomes was used to assess measurement properties of the walking tests. Tests that were included were categorized according to the framework of the international classification of functioning, disability and health (ICF)., Results: Thirty-two studies, evaluating 23 walking tests, were included. The tests assessed walking using the outcome measures of walking speed, walking distance, functional ambulation and walking on different surfaces. The methodological design and statistical methods of most studies evaluating reliability and criterion validity were sufficient, and found the outcome measures to be reliable and valid. However, data on measurement error, minimal important difference and minimal important change were lacking and responsiveness was correctly evaluated in one study only., Conclusions: Many walking tests have been clinimetrically evaluated in stroke survivors. Most walking tests were found to be reliable and valid.

Background. Several studies have examined determinants related to post-stroke fatigue. However, it is unclear which determinants can predict an increase in poststroke fatigue over time. Aim. This prospective cohort study aimed to identify determinants which predict an increase in post-stroke fatigue. Methods. A total of 250 patients with stroke were examined at inpatient rehabilitation discharge (T0) and 24 weeks later (T1). Fatigue was measured using the Fatigue Severity Scale (FSS). An increase in post-stroke fatigue was defined as an increase in the FSS score beyond the 95% limits of the standard error of measurement of the FSS (i.e., 1.41 points) between T0 and T1. Candidate determinants included personal factors, stroke characteristics, physical, cognitive, and emotional functions, and activities and participation and were assessed at T0. Factors predicting an increase in fatigue were identified using forward multivariate logistic regression analysis. Results. The only independent predictor of an increase in post-stroke fatigue was FSS (OR 0.50; 0.38-0.64, P < 0.001). The model including FSS at baseline correctly predicted 7.9% of the patients who showed increased fatigue at T1. Conclusion. The prognostic model to predict an increase in fatigue after stroke has limited predictive value, but baseline fatigue is the most important independent predictor. Overall, fatigue levels remained stable over time.

Objective: To examine the reproducibility, responsiveness and concurrent validity of the six-minute walk test (6MWT) when tested outdoors in patients' own neighbourhoods using a global positioning system (GPS) or a measuring wheel., Methods: A total of 27 chronic stroke patients, discharged to their own homes, were tested twice, within 5 consecutive days. The 6MWT was conducted using a GPS and an measuring wheel simultaneously to determine walking distance. Reproducibility was determined as test-retest reliability and agreement, using the intraclass correlation coefficient, standard error of measurement and Bland & Altman plots. Responsiveness was expressed as the smallest real difference and visualized in Bland & Altman plots. Pearson's correlation coefficient (r) was used to study concurrent validity between the GPS and measuring wheel., Results: Intraclass correlation coefficiens were 0.96 for the GPS and 0.98 for the measuring wheel, and standard error of measurement scores were 11.9 m for the measuring wheel and 18.1 m for the GPS, resulting in smallest real differences of 33.0 m and 50.2 m, respectively. Concurrent validity was strong (r = 0.99)., Conclusion: These results indicate that the outdoor 6MWT using a GPS or measuring wheel is reproducible, responsive and concurrently valid. This suggests that therapists working in the community can use the outdoor 6MWT as a reliable, responsive and valid test.

Background: Amyotrophic lateral sclerosis (ALS) is a fatal progressive neurodegenerative disorder affecting motor neurons in the spinal cord, brainstem and motor cortex, leading to muscle weakness. Muscle weakness may result in the avoidance of physical activity, which exacerbates disuse weakness and cardiovascular deconditioning. The impact of the grave prognosis may result in depressive symptoms and hopelessness. Since there is no cure for ALS, optimal treatment is based on symptom management and preservation of quality of life (QoL), provided in a multidisciplinary setting. Two distinctly different therapeutic interventions may be effective to improve or preserve daily functioning and QoL at the highest achievable level: aerobic exercise therapy (AET) to maintain or enhance functional capacity and cognitive behavioural therapy (CBT) to improve coping style and cognitions in patients with ALS. However, evidence to support either approach is still insufficient, and the underlying mechanisms of the approaches remain poorly understood. The primary aim of the FACTS-2-ALS trial is to study the effects of AET and CBT, in addition to usual care, compared to usual care alone, on functioning and QoL in patients with ALS., Methods/design: A multicentre, single-blinded, randomized controlled trial with a postponed information model will be conducted. A sample of 120 patients with ALS (1 month post diagnosis) will be recruited from 3 university hospitals and 1 rehabilitation centre. Patients will be randomized to one of three groups i.e. (1) AET + usual care, (2) CBT + usual care, (3) Usual care. AET consists of a 16-week aerobic exercise programme, on 3 days a week. CBT consists of individual psychological support of patients in 5 to 10 sessions over a 16-week period. QoL, functioning and secondary outcome measures will be assessed at baseline, immediately post intervention and at 3- and 6-months follow-up., Discussion: The FACTS-2-ALS study is the first theory-based randomized controlled trial to evaluate the effects, and the maintenance of effects, of AET and CBT on functioning and QoL in patients with ALS. The results of this study are expected to generate new evidence for the effect of multidisciplinary care of persons with ALS., Trial Registration: Dutch Trial Register NTR1616.

Hypothesis: A multi-modal treatment program (MMT) is more effective than exercise therapy (ET) for the treatment of long-standing adductor-related groin pain., Study Design: Single blinded, prospective, randomised controlled trial., Patients: Athletes with pain at the proximal insertion of the adductor muscles on palpation and resisted adduction for at least two months., Interventions: ET: a home-based ET and a structured return to running program with instruction on three occasions from a sports physical therapist. MMT: Heat, Van den Akker manual therapy followed by stretching and a return to running program., Primary Outcome: time to return to full sports participation., Secondary Outcome Measures: objective outcome score and the visual analogue pain score during sports activities. Outcome was assessed at 0, 6, 16 and 24 weeks., Results: Athletes who received MMT returned to sports quicker (12.8 weeks, SD 6.0) than athletes in the ET group (17.3 weeks, SD 4.4. p = 0.043). Only 50-55% of athletes in both groups made a full return to sports. There was no difference between the groups in objective outcome (p = 0.72) or VAS during sports (p = 0.12)., Conclusions: The multi-modal program resulted in a significantly quicker return to sports than ET plus return to running but neither treatment was very effective., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objective: To summarize the current evidence on the effects of preoperative exercise therapy in patients awaiting invasive surgery on postoperative complication rate and length of hospital stay., Data Sources: A primary search of relevant key terms was conducted in the electronic databases of PubMed, EMBASE, PEDro and CINAHL., Review Methods: Studies were included if they were controlled trials evaluating the effects of preoperative exercise therapy on postoperative complication rate and length of hospital stay. The methodological quality of included studies was independently assessed by two reviewers using the PEDro scale. Statistical pooling was performed when studies were comparable in terms of patient population and outcome measures. Results were separately described if pooling was not possible., Results: Twelve studies of patients undergoing joint replacement, cardiac or abdominal surgery were included. The PEDro scores ranged from 4 to 8 points. Preoperative exercise therapy consisting of inspiratory muscle training or exercise training prior to cardiac or abdominal surgery led to a shorter hospital stay and reduced postoperative complication rates. By contrast, length of hospital stay and complication rates of patients after joint replacement surgery were not significantly affected by preoperative exercise therapy consisting of strength and/or mobility training., Conclusion: Preoperative exercise therapy can be effective for reducing postoperative complication rates and length of hospital stay after cardiac or abdominal surgery. More research on the utility of preoperative exercise therapy and its long-term effects is needed as well as insight in the benefits of using risk models.

Background and Aims: Approximately 16% of all sports injuries in the Netherlands are caused by outdoor soccer. A cluster-randomised controlled trial has been designed to investigate the effectiveness and cost-effectiveness of an injury prevention programme ('The11') for male amateur soccer players. The injury prevention programme The11, developed with the support of the World Football Association FIFA, aims to reduce the impact of intrinsic injury risk factors in soccer., Methods: Teams playing at first-class amateur level in two districts in the Netherlands are participating in the study. Teams in the intervention group were instructed to apply The11 during each practice session throughout the 2009-10 season. All participants of the control group continued their practice sessions as usual. All soccer-related injuries and related costs for each team were systematically reported online by a member of the medical staff. Player exposure to practice sessions and matches was reported weekly by the coaches. Also the use of The11 during the season after the intervention season will be monitored., Discussion: Our hypothesis is that integrating the The11 exercises in the warm-up for each practice session is effective in terms of injury incidence, injury severity, healthcare use, and its associated costs and/or absenteeism. Prevention of soccer injuries is expected to be beneficial to adult soccer players, soccer clubs, the Royal Dutch Football Association (KNVB), health insurance companies and society.

Objective: The Utrecht Scale for Evaluation of Rehabilitation (USER) is a measure of functional independence that covers physical functioning (mobility, self-care), cognitive functioning and additional domains of pain, fatigue and mood. USER is implemented in the Netherlands as a generic rehabilitation outcome measure. This article reports the development and psychometric characteristics of USER., Design: (1) Inter-rater reliability study and (2) responsiveness study with measurements at admission and at discharge from clinical rehabilitation., Setting: Three rehabilitation facilities in the Netherlands., Patients: Rehabilitation inpatients (N = 319)., Interventions: Not applicable., Main Outcome Measures: Effect size (ES) and standardized response mean (SRM) of USER scales were compared to those of the Barthel Index, Functional Independence Measure (FIM) and to relevant scales of the SF-36., Results: Inter-rater reliability of USER was satisfactory to good. Strong correlations were found between the physical and cognitive functioning scores of USER, the Barthel Index and FIM (0.84-0.94). Correlations between USER pain, fatigue and mood scores and SF-36 scores were also strong (0.58-0.84). Responsiveness of USER physical functioning (1.0-1.2) was very good and slightly better than responsiveness of the Barthel Index (0.9-1.1) and the FIM motor score (0.8-1.1). Responsiveness of the USER cognitive score was below standard (0.2-0.3), but better than responsiveness of the FIM cognitive scores (0.1-0.2)., Conclusions: USER is a reliable, valid and responsive measure of functional independence that can be used as an alternative for the FIM. The pain, fatigue and mood scores were adapted after this study and need additional validation.

Background: Most patients who suffer a stroke experience reduced walking competency and health-related quality of life (HRQoL). A key factor in effective stroke rehabilitation is intensive, task-specific training. Recent studies suggest that intensive, patient-tailored training can be organized as a circuit with a series of task-oriented workstations. Primary aim of the FIT-Stroke trial is to evaluate the effects and cost-effectiveness of a structured, progressive task-oriented circuit class training (CCT) programme, compared to usual physiotherapeutic care during outpatient rehabilitation in a rehabilitation centre. The task-oriented CCT will be applied in groups of 4 to 6 patients. Outcome will be defined in terms of gait and gait-related ADLs after stroke. The trial will also investigate the generalizability of treatment effects of task-oriented CCT in terms of perceived fatigue, anxiety, depression and perceived HRQoL., Methods/design: The multicentre single-blinded randomized trial will include 220 stroke patients discharged to the community from inpatient rehabilitation, who are able to communicate and walk at least 10 m without physical, hands-on assistance. After discharge from inpatient rehabilitation, patients in the experimental group will receive task-oriented CCT two times a week for 12 weeks at the physiotherapy department of the rehabilitation centre. Control group patients will receive usual individual, face-to-face, physiotherapy. Costs will be evaluated by having each patient keep a cost diary for the first 24 weeks after randomisation. Primary outcomes are the mobility part of the Stroke Impact Scale (SIS-3.0) and the EuroQol. Secondary outcomes are the other domains of SIS-3.0, lower limb muscle strength, walking endurance, gait speed, balance, confidence not to fall, instrumental ADL, fatigue, anxiety, depression and HRQoL., Discussion: Based on assumptions about the effect of intensity of practice and specificity of treatment effects, FIT-Stroke will address two key aims. The first aim is to investigate the effects of task-oriented CCT on walking competency and HRQoL compared to usual face-to-face physiotherapy. The second aim is to reveal the cost-effectiveness of task-oriented CCT in the first 6 months post stroke. Both aims were recently recommended as priorities by the American Hearth Association and Stroke Council.

Purpose: To investigate the prevalence of unmet demands concerning autonomy and participation and to identify risk factors related to these unmet demands in patients with chronic stroke., Method: A cross-sectional study of 147 patients three years after stroke. We assessed perceived unmet care demands in relation to problems of participation and autonomy measured by the Impact on Participation and Autonomy Questionnaire (IPAQ). Socio-demographic and health characteristics were analysed as potential risk factors for the prevalence of unmet demands, using multivariate regression analysis., Results: A total of 33% of the patients perceived at least one unmet demand in one of the IPAQ subdomains. Risk factors significantly related to the presence of unmet demands were younger age, motor impairment, fatigue and depressive symptoms. Findings indicate that the model including these factors was fairly accurate in identifying patients having unmet demands and those not having unmet demands., Conclusions: Unmet care demands were present in a substantial proportion of the stroke patients. The risk factors identified are helpful for clinicians and health care providers to recognize patients who are at risk of perceiving unmet care demands and to optimize care to patients with chronic stroke.

Objective: To examine the reproducibility and responsiveness of two often-used instruments for caregiver burden: the Caregiver Strain Index and the Caregiver Reaction Assessment., Design: Repeated administration of self-report questionnaires three years post stroke., Subjects: Convenience sample of partners of stroke patients., Methods: Weighted kappa and percentage agreement at item level and intraclass correlations (ICCs) for subscale and total scores. Responsiveness was expressed as smallest detectable difference (SDD) and standard error of measurement (SEM)., Results: Reproducibility of the total Caregiver Strain Index score (N = 26) was very good (0.93; 95% confidence interval 0.84-0.97). For the Caregiver Reaction Assessment (N = 21), the subscales disrupted schedule, financial problems and health problems showed sufficient reproducibility (ICC 0.79-0.86), but the ICCs of the subscales lack of family support (0.67) and self-esteem (0.58) were insufficient. Relating the SDD and SEM to the standard deviation and maximum scale range, responsiveness appears moderate for the Caregiver Strain Index and unsatisfactory for the Caregiver Reaction Assessment., Conclusion: The Caregiver Strain Index showed good reproducibility and moderate responsiveness. The Caregiver Reaction Assessment showed insufficient reproducibility and responsiveness.

Objective: To investigate the long-term effects on children of parental stroke, with respect to care-giving tasks, children's behavioural problems and stress, and to study the relationship between stress and child, patient and partner characteristics., Subjects: A total of 44 children (age range 10-21 years) were assessed 3 years after parental stroke., Main Measures: Behavioural problems were assessed with the Child Behaviour Check List and the Youth Self-Report. Stress was measured using the Dutch Stress Questionnaire for Children., Results: Most children (66%) assisted their parent in self-care or mobility. Some of the children (31%) experienced behavioural problems. The results showed that 37.5% of younger children show externalizing problems on the Child Behaviour Check List. Stress was significantly related to female gender of the child, and to depression, limitations in extended activities of daily living and life satisfaction of the patient., Conclusion: Most children do well 3 years after parental stroke. However, some children of patients after stroke have behavioural problems and need attention in clinical practice.

To determine the effectiveness of training programs that focus on lower-limb strengthening, cardiorespiratory fitness, or gait-oriented tasks in improving gait, gait-related activities, and health-related quality of life after stroke. Randomized controlled trials (RCTs) were searched for in the databases of Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, Physiotherapy Evidence Database (PEDro), EMBASE, Database of the Dutch Institute of Allied Health Care, and CINAHL. Databases were systematically searched by two independent researchers. The following inclusion criteria were applied: (1) participants were people with stroke, older than 18 yrs; (2) one of the outcomes focused on gait-related activities; (3) the studies evaluated the effectiveness of therapy programs focusing on lower-limb strengthening, cardiorespiratory fitness, or gait-oriented training; and (4) the study was published in English, German, or Dutch. Studies were collected up to November 2005, and their methodological quality was assessed using the PEDro scale. Studies were pooled and summarized effect sizes were calculated. Best-evidence synthesis was applied if pooling was impossible. Twenty-one RCTs were included, of which five focused on lower-limb strengthening, two on cardiorespiratory fitness training (e.g., cycling exercises), and 14 on gait-oriented training. Median PEDro score was 7. Meta-analysis showed a significant medium effect of gait-oriented training interventions on both gait speed and walking distance, whereas a small, nonsignificant effect size was found on balance. Cardiorespiratory fitness programs had a nonsignificant medium effect size on gait speed. No significant effects were found for programs targeting lower-limb strengthening. In the best-evidence synthesis, strong evidence was found to support cardiorespiratory training for stair-climbing performance. Although functional mobility was positively affected, no evidence was found that activities of daily living, instrumental activities of daily living, or health-related quality of life were significantly affected by gait-oriented training. This review shows that gait-oriented training is effective in improving walking competency after stroke.

Purpose: The aim of the study was to identify factors that are significantly related to depression in chronic stroke patients., Methods: Prospective cohort study of stroke patients admitted for rehabilitation. A total of 165 first ever stroke patients over 18 years of age were assessed at one and three years post stroke. Depression was determined by the Centre for Epidemiologic Studies Depression Scale (CES-D). Patients with scores >/=16 were classified as depressed. Bivariate and multivariate logistic regression analyses were used to identify prognostic factors for depression., Results: At three years post stroke, 19% of the patients were depressed. Bivariate analysis showed significant associations between post-stroke depression and type of stroke, fatigue, motor function of the leg and arm, activities of daily living (ADL) independency and instrumental ADL. Multivariate logistic regression analysis showed that depression was predicted by one-year instrumental ADL and fatigue. Sensitivity of the model was 63%, while specificity was 85%., Conclusions: The present prospective cohort study showed that depression three years after stroke can be predicted by instrumental ADL and fatigue one year post stroke. Recognition of prognostic factors in patients at risk may help clinicians to apply interventions aimed at preventing depression in chronic stroke.

Purpose: To examine the content of outcome measures that are frequently used in stroke rehabilitation and focus on activities and participation, by linking them to the International Classification of Functioning, Disability and Health (ICF). Method. Constructs of the following instruments were linked to the ICF: Barthel Index, Berg Balance Scale, Chedoke McMaster Stroke Assessment Scale, Euroqol-5D, Functional Independence Measure, Frenchay Activities Index, Nottingham Health Profile, Rankin Scale, Rivermead Motor Assessment, Rivermead Mobility Index, Stroke Adapted Sickness Impact Profile 30, Medical Outcomes Study Short Form 36, Stroke Impact Scale, Stroke Specific Quality of Life Scale and Timed Up and Go test. Results. It proved possible to link most constructs to the ICF. Most constructs fitted into the activities and participation component, with mobility being the category most frequently covered in the instruments. Although instruments were selected on the basis of their focus on activities and participation, 27% of the constructs addressed categories of body functions. Approximately 10% of the constructs could not be linked., Conclusions: The ICF is a useful tool to examine and compare contents of instruments in stroke rehabilitation. This content comparison should enable clinicians and researchers to choose the measure that best matches the area of their interest.

Background: To determine the longitudinal association of poststroke fatigue with activities of daily living (ADL), instrumental ADL (IADL) and perceived health-related quality of life (HRQoL) and to establish whether this relationship is confounded by other determinants., Methods: A prospective cohort study of stroke patients consecutively admitted for inpatient rehabilitation was conducted. ADL, IADL and HRQoL were assessed in 223 patients at 6, 12 and 36 months after stroke. Fatigue was determined by the Fatigue Severity Scale. Random coefficient analysis was used to analyze the impact of fatigue on ADL, IADL and HRQoL. The association between fatigue and outcome was corrected for potential confounders, i.e. age, gender, comorbidity, executive function, severity of paresis and depression. The covariate was considered to be a confounder if the regression coefficient of fatigue on outcome changed by >15%., Results: Fatigue was significantly related to IADL and HRQoL but not to ADL. The relation between fatigue and IADL was confounded by depression and motor impairment. Depression biased the relation between fatigue and HRQoL, but fatigue remained independently related to HRQoL., Conclusions: Fatigue is longitudinally spuriously associated with IADL and independently with HRQoL. These findings suggest that in examining the impact of poststroke fatigue on outcome, one should control for confounders such as depression., (Copyright 2007 S. Karger AG, Basel.)

Objective: To develop a prognostic model to predict mobility outcome one year post-stroke., Design: Prospective cohort study in patients with a first-ever stroke admitted for inpatient rehabilitation., Patients: A total of 217 patients with stroke (mean age 58 years) following inpatient rehabilitation in 4 rehabilitation centres across the Netherlands., Methods: Mobility was measured using the Rivermead Mobility Index at one year poststroke. Included independent variables were: patient and stroke characteristics, functional status, urinary incontinence, sitting balance, motor and cognitive function. Univariate and multivariate linear regression analyses were performed in a model-developing set (n=174) and the model was validated in cross-validation set (n=43)., Results: Total Rivermead Mobility Index score at one year post-stroke was predicted by functional status, sitting balance, time between stroke onset and measurement, and age. The derived model predicted 48% of the variance, while validation in the cross-validation set resulted in an adjusted R(2) of 0.47., Conclusion: The present prospective study shows that outcome of mobility one year after stroke can be predicted validly by including functional status, sitting balance, moment of admission to the rehabilitation centre after stroke onset and age.

Objectives: To investigate the development of mobility status during the second year after stroke in patients who had had inpatient rehabilitation, and to evaluate risk factors for mobility decline., Design: Evaluation of change in Rivermead Mobility Index (RMI) score over the second year after stroke in an inception cohort of first-ever stroke patients eligible for inpatient rehabilitation. Logistic regression techniques were used to predict decline. Independent variables were measured with standardized instruments 1 year after stroke., Setting: Home or institution, after discharge from rehabilitation center., Participants: Patients (N=148) with single first-ever stroke (supratentorial), age more than 18 years., Interventions: Not applicable., Main Outcome Measures: Decline of 2 or more points on the RMI and the percentages and odds ratios (ORs) for decline., Results: The mean RMI score did not significantly change over time. Mobility declined in 12% of the patients. Mobility decline was found more often in patients with depression (25%) than without (7%), with right-sided weakness (17% vs 8%), with ischemic stroke (13% vs 8%), with aphasia (22% vs 11%), with cognitive dysfunction (17% vs 11%), with comorbidity interfering with locomotion (25% vs 12%), with poor social functioning (15% vs 10%), and with mobility disability (16% vs 8%). Statistical significance was found only for depression (OR=4.2; 95% confidence interval, 1.3-13.2)., Conclusions: Most patients maintained the level of mobility they achieved during inpatient rehabilitation over the second year after stroke. Only 12% had a decline in mobility, and depression was the only statistically significant predictor for decline.

Background and Purpose: The aim of the present study was to identify clinical determinants able to predict which individuals are susceptible to deterioration of mobility from 1 to 3 years after stroke., Methods: Prospective cohort study of stroke patients consecutively admitted for inpatient rehabilitation. A total of 205 relatively young, first-ever stroke patients were assessed at 1 and 3 years after stroke. Mobility status was determined by the Rivermead Mobility Index (RMI), and decline was defined as a deterioration of > or =2 points on the RMI. Univariate and multivariate logistic regression analyses were performed to identify prognostic factors for mobility decline. The discriminating ability of the model was determined using a receiver operating characteristic curve., Results: A decline in mobility status was found in 21% of the patients. Inactivity and the presence of cognitive problems, fatigue, and depression at 1 year after stroke were significant predictors of mobility decline. The multivariate model showed a good fit (Hosmer-Lemeshow test P>0.05), and discriminating ability was good (area under the curve 0.79)., Conclusions: Mobility decline is an essential concern in chronic stroke patients, especially because it might lead to activities of daily living dependence and affects social reintegration. Early recognition of prognostic factors in patients at risk may guide clinicians to apply interventions aimed to prevent deterioration of mobility status in chronic stroke.