The Flow State Scale for Rehabilitation Tasks: A New Flow Experience Questionnaire for Stroke Patients.

IMPORTANCE: Flow can be described as a subjective state that people report when they fully engage in an activity and experience pleasure, satisfaction, and enjoyment. Flow experiences are measured to determine the extent to which patients engage in therapy activities. Several flow questionnaires are used in neurorehabilitation. However, none have been validated for patients with (sub)acute stroke. OBJECTIVE: To develop and validate a new flow questionnaire for patients with (sub)acute stroke. DESIGN: Single-center prospective cohort study. SETTING: Neurorehabilitation unit of the Neurocenter of the Luzerner Kantonsspital in Lucerne, Switzerland. PARTICIPANTS: Fifty patients with (sub)acute stroke. OUTCOMES AND MEASURES: Development of the Flow State Scale for Rehabilitation Tasks (FSSRT) and determination of the psychometric properties of the FSSRT (internal consistency, test-retest reliability, structural and construct validity) in (sub)acute stroke patients. RESULTS: The FSSRT showed good internal consistency and excellent test-retest reliability. Composed of four components-concentration, pleasure, movement control, and absorption-the FSSRT correlated significantly negatively with the Hospital Anxiety and Depression Scale, indicating good divergent validity. CONCLUSIONS AND RELEVANCE: The FSSRT is a reliable and valid questionnaire measuring flow experience in patients with (sub)acute stroke. This questionnaire can be easily used in occupational therapy as well as in physical therapy and gives therapists important information about the flow experience of patients during therapy to adjust the therapy accordingly. Plain-Language Summary: Measuring flow experience, or the extent to which patients engage in therapy activities, in the context of occupational therapy and physical therapy is a new approach. This study confirmed that the Flow State Scale for Rehabilitation Tasks questionnaire is reliable and valid for measuring the flow experience of patients after (sub)acute stroke. Occupational therapists and physical therapists can use the FSSRT to optimally adjust the therapy program and increase patient engagement during therapy.

Profiling Daily Life Performance Recovery in the Early Subacute Phase After Stroke Using a Graphical Modeling Approach.

Background Laboratory-based assessments have shown that stroke recovery is heterogeneous between patients and affected domains such as motor and language function. However, laboratory-based assessments are not ecologically valid and do not necessarily reflect patients' daily life performance. Therefore, we aimed to give an innovative view on stroke recovery by profiling daily life performance recovery across domains in patients with early subacute stroke and determine their interrelatedness, taking stroke localization into account. Methods and Results Daily life performance was observed at neurorehabilitation admission and weekly thereafter until discharge, using a scale containing 7 daily life domains. Graphical modeling was applied to investigate the conditional independence between recovery of these domains depending on stroke localization. There were 592 patients analyzed. Four clusters of interrelated domains were identified within the first 6 weeks poststroke. The first cluster included recovery in learning and applying knowledge, general tasks and demands, and domestic life. The second cluster comprised recovery in self-care and general tasks and demands. The third cluster included recovery in mobility and self-care; it incorporated interpersonal interactions and relationships in left supratentorial stroke, and learning and applying knowledge in right supratentorial stroke. The final cluster included only communication recovery. Conclusions Daily life recovery dynamics early poststroke show that although impairments in body functions are anatomically determined, their impact on performance is comparable. Second, some, but by no means all, domains show an interrelated recovery. Domains requiring cognitive abilities are especially interrelated and seem to be essential for concomitant recovery in mobility and domestic life.

Rasch validation of a new scale to measure dependency in arm use in daily life: the Upper Limb Lucerne ICF-based Multidisciplinary Observation Scale.

Introduction: About 77% of adults with stroke have upper limb impairments. Many scales are available to measure the impairment and activity level of the affected limb. However, an observational scale to assess dependency on others in upper limb performance during daily life activities instead of laboratory settings is lacking. Therefore, we developed a new 5-item Upper Limb Lucerne ICF-based Multidisciplinary Observation Scale (UL-LIMOS). As next step in the psychometric analysis, we evaluated the unidimensionality and structural validity of the UL-LIMOS with Rasch Measurement Theory and we calculated a cut-off score for independent arm use in daily life activities at discharge. Methods: This is a single-center cross-sectional study in adults with (sub) acute stroke. We applied Rasch Measurement Theory (RMT) to analyze the structural validation and unidimensionality of the UL-LIMOS. The outputs provide evidence of unidimensionality, item and person fit, overall fit, differential item functioning (DIF), principal component analysis of residuals (PCAR), person separation reliability (PSR), and residual item correlations (to identify local item dependence). Person mean location, floor and ceiling effects identify proper targeting. Results: We recruited 407 adults with (sub) acute stroke (median age 63 years, 157 women). All items and persons fit the Rasch model. The PSR of 0.90 indicates that clinicians and researchers can reliably use the scale for individual decision-making. There were small floor (2.70%) and ceiling (13.00%) effects. The average person mean location was 1.32 ± 2.99 logits. There was no DIF. PCAR eigenvalue was 2.46 with 49.23% explained variance. Paired t-tests revealed that 0.89% of person locations were significantly different, confirming unidimensionality. One pair of items (arm and hand use and fine hand use) showed residual item correlations. The ROC's AUC was 0.90, CI95% = [0.85-0.96] with cut-off score of ≥14/20, and high sensitivity (87%, CI95% = [81%-91%]), specificity (83%, CI95% = [77%-87%]) for independent arm use in daily living at discharge. Discussion: The new Rasch-based UL-LIMOS is a valid ICF-based observation performance scale at the ICF-activity level, to evaluate dependency during upper limb use in daily life in adults with stroke. Additional psychometric analyses are warranted. The UL-LIMOS would be a valuable addition to the core assessments of adults with (sub) acute stroke.

Speed up discharge planning at the acute stroke unit: A development and external validation study for the early prediction of discharge home.

Background: To reduce healthcare costs, it has become increasingly important to shorten the length of stay in acute stroke units. The goal of this study was to develop and externally validate a decision tree model applicable < 48 h poststroke for discharge home from an acute stroke unit with a short length of stay, and to assess the inappropriate home discharge rate. Methods: A prospective study including two samples of stroke patients admitted to an acute stroke unit. The outcome was discharge home (yes/no). A classification and regression tree analysis was performed in Sample 1. The model's performance was tested in Sample 2. Results: In total, 953 patients were included. The final decision tree included the patients' activities of daily living (ADL) performance <48 h poststroke, including motor function, cognition, and communication, and had an area under the curve (AUC) of 0.84 (95% confidence interval 0.76, 0.91). External validation resulted in an AUC of 0.74 (95% confidence interval 0.72, 0.77). None of the patients discharged home were re-admitted < 2 months after discharge to a hospital or admitted to a rehabilitation center for symptoms that had needed inpatient neurorehabilitation. Conclusions: The developed decision tree shows acceptable external validity in predicting discharge home in a heterogeneous sample of stroke patients, only based on the patient's actual ADL performance <48 h poststroke. Importantly, discharge was safe, i.e., no re-hospitalization was registered. The tree's application to speed up discharge planning should now be further evaluated.

Development and Validation of the Short-LIMOS for the Acute Stroke Unit-A Short Version of the Lucerne ICF-Based Multidisciplinary Observation Scale.

Introduction: At hospital stroke units, the time available to assess the patient's limitations in activities and participation is limited, although being essential for discharge planning. Till date, there is no quick-to-perform instrument available that captures the patient's actual performance during daily activities from a motor, cognitive, and communication perspective within the International Classification of Functioning, Disability and Health (ICF) framework. Therefore, the aim was to develop and validate a shortened version of the Lucerne ICF-Based Multidisciplinary Observation Scale (Short-LIMOS) that observes the patient's performance across ICF-domains and is applicable in the context of an acute stroke unit. Methods: The Short-LIMOS was developed by reducing the original 45-item LIMOS to the ten most important items using a multivariable linear regression ANOVA with data of 836 stroke patients collected during inpatient neurorehabilitation. The Short-LIMOS's reliability, validity, and responsiveness were evaluated with data of 416 stroke patients in the acute stroke unit. Results: A significant equation [F (10,825) = 232.083] with R 2 of 0.738 was found for the following ten items for the Short-LIMOS: maintaining a body position (d415), changing basic body position (d410), climbing stairs (d4551), eating (d550), dressing (d540), communicating with-receiving-written messages (reading) (d325), applying knowledge, remembering facts (d179), solving complex problems (d1751), making simple decisions (d177), and undertaking a simple task (d2100). Principal component analysis revealed a Short-LIMOS motor and a Short-LIMOS cognition/communication component. The Short-LIMOS had a high internal consistency and good test-retest reliability. A moderate construct validity was shown by the significant correlation with the Barthel Index. The Short-LIMOS had neither floor nor ceiling effects. Discussion and Conclusion: The developed Short-LIMOS was found to be reliable and valid within a population of (hyper)acute and subacute stroke patients. The added value of this multidisciplinary assessment is its comprehensiveness by capturing the patient's actual performance on the motor, cognitive, and communication domain embedded in an ICF-framework in <10 mins.

Getting into a "Flow" state: a systematic review of flow experience in neurological diseases.

BACKGROUND: Flow is a subjective psychological state that people report when they are fully involved in an activity to the point of forgetting time and their surrounding except the activity itself. Being in flow during physical/cognitive rehabilitation may have a considerable impact on functional outcome, especially when patients with neurological diseases engage in exercises using robotics, virtual/augmented reality, or serious games on tablets/computer. When developing new therapy games, measuring flow experience can indicate whether the game motivates one to train. The purpose of this study was to identify and systematically review current literature on flow experience assessed in patients with stroke, traumatic brain injury, multiple sclerosis and Parkinson's disease. Additionally, we critically appraised, compared and summarized the measurement properties of self-reported flow questionnaires used in neurorehabilitation setting. DESIGN: A systematic review using PRISMA and COSMIN guidelines. METHODS: MEDLINE Ovid, EMBASE Ovid, CINAHL EBSCO, SCOPUS were searched. Inclusion criteria were (1) peer-reviewed studies that (2) focused on the investigation of flow experience in (3) patients with neurological diseases (i.e., stroke, traumatic brain injury, multiple sclerosis and/or Parkinson's disease). A qualitative data synthesis was performed to present the measurement properties of the used flow questionnaires. RESULTS: Ten studies out of 911 records met the inclusion criteria. Seven studies measured flow in the context of serious games in patients with stroke, traumatic brain injury, multiple sclerosis and Parkinson's disease. Three studies assessed flow in other activities than gaming (song-writing intervention and activities of daily living). Six different flow questionnaires were used, all of which were originally validated in healthy people. None of the studies presented psychometric data in their respective research population. CONCLUSION: The present review indicates that flow experience is increasingly measured in the physical/cognitive rehabilitation setting in patients with neurological diseases. However, psychometric properties of used flow questionnaires are lacking. For exergame developers working in the field of physical/cognitive rehabilitation in patients with neurological diseases, a valid flow questionnaire can help to further optimize the content of the games so that optimal engagement can occur during the gameplay. Whether flow experiences can ultimately have positive effects on physical/cognitive parameters needs further study.

Can I Discharge My Stroke Patient Home After Inpatient Neurorehabilitation? LIMOS Cut-Off Scores for Stroke Patients "Living Alone" and "Living With Family".

Background: Discharge planning of stroke patients during inpatient neurorehabilitation is often difficult since it depends both on the patient's ability to perform activities of daily living (ADL) and the social context. The aim of this study was to define ADL cut-off scores using the Lucerne ICF-based multidisciplinary observation scale (LIMOS) that allow the clinicians to decide whether stroke patients who "live alone" and "live with a family" can be discharged home or must enter a nursing home. Additionally, we investigated whether age and gender factors influence these cut-off scores. Methods: A single-center retrospective cohort study was conducted to establish cut-off discharge scores for the LIMOS. Receiver-operating-characteristics curves were calculated for both patient groups "living alone" and "living with family" to illustrate the prognostic potential of the LIMOS total score with respect to their discharge goals (home alone or nursing home; home with family or nursing home). A logistic regression model was used to determine the (age- and gender-adjusted) odds ratios of being released home if the LIMOS total score was above the cut-off. A single-center prospective cohort study was then conducted to verify the adequacy of the cut-off values for the LIMOS total score. Results: A total of 687 stroke inpatients were included in both studies. For the group "living alone" a LIMOS total score above 158 indicated good diagnostic accuracy in predicting discharge home (sensitivity 93.6%; specificity 95.4%). A LIMOS total cut-off score above 130 points was found for the group "living with family" (sensitivity 92.0%; specificity 88.6%). The LIMOS total score odds ratios, adjusted for age and gender, were 292.5 [95% CI: (52.0-1645.5)] for the group "living alone" and were 89.4 [95% CI: (32.3-247.7)] for the group "living with family." Conclusion: Stroke survivors living alone needed a higher ADL level to return home than those living with a family. A LIMOS total score above 158 points allows a clinician to discharge a patient that lives alone, whereas a lower LIMOS score above 130 points can be sufficient in a patient that lives with a family. Neither age nor gender played a significant role.

Comprehensive ADL Outcome Measurement after Stroke: Rasch Validation of the Lucerne ICF-Based Multidisciplinary Observation Scale (LIMOS).

OBJECTIVE: To establish Rasch validation of the Lucerne International Classification of Functioning, Disability and Health (ICF)-based Multidisciplinary Observation Scale (LIMOS) in stroke. LIMOS measures the level of assistance in daily life activities related to motor function, communication, cognition, and domestic life. Rasch Measurement Theory (RMT) transforms an ordinal scale into an interval scale and thus the Rasch-based LIMOS scale captures a more accurate improvement of functional outcomes via Rasch-transformed scores. DESIGN: Cross-sectional study design. SETTING: Neurorehabilitation center, Luzerne, Switzerland. PARTICIPANTS: We recruited participants with stroke (N=407; age=63.2±16.0y; n=157 women) through consecutive sampling. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants were assessed with LIMOS at admission and discharge of rehabilitation. We used RMT to evaluate overall model fit, response dependency, floor and ceiling effect, reliability, and differential item functioning (DIF) for sex, age, type, and time of stroke on the 4 LIMOS subscales using the Rasch Unidimensional Measurement Model (RUMM) 2030 program. RESULTS: The Rasch-based LIMOS subscales fit the Rasch model after reducing and rescoring items: motor (from 20 to 18 items), communication (5 items), cognition (from 15 to 13 items), and domestic life (5 items). There was no floor or ceiling effect. Some artificial DIF was identified. Scoring at discharge was dependent on the scoring responses at admission, which means that without applying a correction factor to the discharge scores, there was an underestimation of change in scores between admission and discharge, ranging from 0.24 to 0.97 logits (10.79%-49.24%) on the different subscales. CONCLUSIONS: The Rasch-based LIMOS scale is recommended to measure functional outcome in people with acute or chronic stages of ischemic or hemorrhagic stroke.

Spatial Neglect Predicts Upper Limb Use in the Activities of Daily Living.

BACKGROUND AND PURPOSE: Motor tests performed at stroke onset have been shown to predict the recovery of upper limb motor impairment. Less is known about upper limb recovery at the level of functional activity or of participation and how spatial neglect may influence the integration of the upper limb in the activities of daily living (ADL). Our objective was to investigate whether the initial severity of spatial neglect may predict upper limb use in ADL. METHODS: Eighty-two patients with a right-hemispheric stroke (RHS) were prospectively included in the study. They were assessed twice in the acute/subacute and in the subacute/chronic phases (mean time interval of 45 days) after stroke. The Catherine Bergego Scale (CBS) was used to quantify the influence of spatial neglect on the ADL. Contralesional upper limb use in the ADL was evaluated with the Lucerne international classification of function, disability and health-based Multidisciplinary Observation Scale. Hand strength was measured using the Jamar, dexterity with the Nine Hole Peg test, and tactile perception using the stereognosis subtest of the Nottingham Sensory Assessment. Cognitive functions were assessed with the Montreal Cognitive Assessment. RESULTS: Regression analyses revealed that spatial neglect is an independent and a significant predictor of upper limb outcome. A CBS score of ≤5 at the time of admission to neurorehabilitation care was highly predictive for good upper limb use in the ADL 45 days later. CONCLUSIONS: This study demonstrates that spatial neglect severity, as observed in the ADL, is a significant and an independent predictor of upper limb outcome. Neglect therapy is thus needed to further improve contralesional upper limb use in the ADL in RHS patients.

The Responsiveness of the Lucerne ICF-Based Multidisciplinary Observation Scale: A Comparison with the Functional Independence Measure and the Barthel Index.

BACKGROUND: Good responsive functional outcome measures are important to measure change in stroke patients. The aim of study was to compare the internal and external responsiveness, floor and ceiling effects of the motor, cognition, and communication subscales of the Lucerne ICF-based Multidisciplinary Observation Scale (LIMOS) with the motor and cognition subscales of the Functional Independence Measure (FIM), and the Barthel Index (BI), in a large cohort of stroke patients. METHODS: One hundred eighteen stroke patients participated in this study. Admission and discharge score distributions of the LIMOS motor, LIMOS cognition and communication, FIM motor and FIM cognition, and BI were analyzed based on skewness and kurtosis. Floor and ceiling effects of the scales were determined. Internal responsiveness was assessed with t-tests, effect sizes (ESs), and standardized response means (SRMs). External responsiveness was investigated with linear regression analyses. RESULTS: The LIMOS motor and LIMOS cognition and communication subscales were more responsive, expressed by higher ESs (ES = 0.65, SRM = 1.17 and ES = 0.52, SRM = 1.17, respectively) as compared with FIM motor (ES = 0.54, SRM = 0.96) and FIM cognition (ES = 0.41, SRM = 0.88) and the BI (ES = 0.41, SRM = 0.65). The LIMOS subscales showed neither floor nor ceiling effects at admission and discharge (all <15%). In contrast, ceiling effects were found for the FIM motor (16%), FIM cognition (15%) at discharge and the BI at admission (22%) and discharge (43%). LIMOS motor and LIMOS cognition and communication subscales significantly correlated (p < 0.0001) with a change in the FIM motor and FIM cognition subscales, suggesting good external responsiveness. CONCLUSION: We found that the LIMOS motor and LIMOS cognition and communication, which are ICF-based multidisciplinary standardized observation scales, might have the potential to better detect changes in functional outcome of stroke patients, compared with the FIM motor and FIM cognition and the BI.

Validation of the new Lucerne ICF based Multidisciplinary Observation Scale (LIMOS) for stroke patients.

BACKGROUND: Valid and multidisciplinary assessment of a stroke patient's ability to perform activities of daily living is very important to define individual goals and to plan targeted rehabilitation. Until today, there is no observation scale that relies on International Classification of Functioning, Disability and Health (ICF). The aim of the present study was to develop and evaluate the reliability and validity of a new multidisciplinary observation scale for stroke patients, shortly called LIMOS, which is based on ICF. METHODS: In a first phase, LIMOS was defined, using a Delphi approach, by an expert panel and a pilot testing was conducted in a small group of stroke patients (n =10) to investigate feasibility and practicability. In a second phase, LIMOS was assessed for its reliability (internal consistency and test-retest reliability) and validity in a large cohort of stroke patients (n = 102). For convergent validity, the correlation between total scores of the LIMOS and the Functional Independence Measure (FIM) was assessed. RESULTS: LIMOS consisted of seven ICF chapters incorporating 45 domains. A high internal consistency (=0.98) of LIMOS was found. Furthermore, good test-retest reliability at item and subscale level was found. Principal component analysis revealed that among the seven ICF chapters, four components could be found: (1) interpersonal activities, mobility and self-care, (2) communication, (3) knowledge and general tasks, and (4) domestic life. Significant associations were found between LIMOS and the FIM indicating good convergent validity. CONCLUSIONS: The new LIMOS is a reliable and valid observation scale for stroke patients based on ICF, which can be used by a multidisciplinary team working in a neurorehabilitation setting.