COVID-19: Patient Characteristics in the First Phase of Postintensive Care Rehabilitation.

OBJECTIVE: To describe clinical characteristics of patients after intensive care unit (ICU) treatment for coronavirus disease 2019 (COVID-19) who were admitted for inpatient rehabilitation. DESIGN: A cross-sectional design. SETTING: Inpatient rehabilitation care in the Netherlands. PARTICIPANTS: All post-ICU patients with COVID-19 admitted to the rehabilitation center between April 2 and May 13, 2020, were invited to participate in the study. Included were patients older than 18 years needing inpatient rehabilitation after ICU treatment for COVID-19 (N=60; mean age, 59.9y; 75% male). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The following information was collected in the first week of inpatient rehabilitation care: (1) demographics; (2) ICU stay parameters; (3) medical, physical, and functional characteristics; and (4) self-reported symptoms. RESULTS: The most important findings for rehabilitation were the following: in the first week after discharge to the rehabilitation center, 38.3% of all patients experienced exercise-induced oxygen desaturation, in 72.7% muscle weakness was present in all major muscle groups, and 21.7% had a reduced mobility in 1 or both shoulders. Furthermore 40% had dysphagia, and 39.2% reported symptoms of anxiety. CONCLUSION: Post-ICU patients with COVID-19 display physical and anxiety symptoms as reported in other post-ICU patient groups. However, this study showed some remarkable clinical characteristics of post-ICU patients with COVID-19. Rehabilitation programs need to anticipate on this. Long-term follow-up studies are necessary.

Effectiveness and feasibility of Socratic feedback to increase awareness of deficits in patients with acquired brain injury: Four single-case experimental design (SCED) studies.

OBJECTIVE: To investigate the effectiveness and feasibility of a Socratic feedback programme to improve awareness of deficits in patients with acquired brain injury (ABI). SETTING: Rehabilitation centre. PARTICIPANTS: Four patients with ABI with awareness problems. DESIGN: A series of single-case experimental design studies with random intervention starting points (A-B + maintenance design). MAIN MEASURES: Rate of trainer-feedback and self-control behaviour on everyday tasks, patient competency rating scale (PCRS), self-regulating skills interview (SRSI), hospital anxiety and depression scale. RESULTS: All patients needed less trainer feedback, the change was significant in 3 out of 4. One patient increased in overt self-corrective behaviour. SRSI performance increased in all patients (medium to strong effect size), and PCRS performance increased in two patients (medium and strong effect size). Mood and anxiety levels were elevated in one patient at the beginning of the training and decreased to normal levels at the end of the training. The feasibility of the programme was scored 9 out of 10. CONCLUSIONS: The Socratic feedback method is a promising intervention for improving awareness of deficits in patients with ABI. Controlled studies with larger populations are needed to draw more solid conclusions about the effect of this method.

Caregivers' effects of augmented cognitive-behavioural therapy for post-stroke depressive symptoms in patients: secondary analyses to a randomized controlled trial.

OBJECTIVE: To investigate the concomitant effects of two patient-directed interventions for post-stroke depressive symptoms on caregivers' well-being. DESIGN: Secondary analyses of the results of a randomized controlled trial. SUBJECTS: Fifty caregivers of stroke patients receiving outpatient rehabilitation. INTERVENTIONS: Stroke patients and their caregivers were randomly allocated to either cognitive-behavioural therapy augmented with movement or occupational therapy ( n = 23) or computerized cognitive training ( n = 27) to alleviate depressive symptoms in patients. MAIN MEASURES: Emotional burden (Involvement Evaluation Questionnaire), practical burden (Caregiver Strain Index), mental health (General Health Questionnaire) and emotional complaints (Hospital Anxiety and Depression Scale). RESULTS: Caregivers of patients who received cognitive-behavioural therapy reported significantly higher mental health levels (mean difference (MD) = 1.78, 95% confidence interval (CI) = 0.43-3.13, P = 0.01) and less worrying about patients' well-being (MD = 1.9, 95% CI = 0.56-3.24, P < 0.01). In addition, there were positive time effects on the Involvement Evaluation Questionnaire for Brain Injury, particularly the subscales Worrying, Supervision and Tension. CONCLUSION: The results suggest that augmented cognitive-behavioural therapy aimed at improving patients' emotional, behavioural and social functioning positively affects some aspects of caregivers' well-being.

Exploring the feasibility and usability of the experience sampling method to examine the daily lives of patients with acquired brain injury.

The experience sampling method (ESM) is a structured diary method with high ecological validity, in that it accurately captures the everyday context of individuals through repeated measurements in naturalistic environments. Our main objective was to investigate the feasibility of using ESM in individuals with acquired brain injury (ABI). A second goal was to explore the usability of ESM data on a clinical level, by illustrating the interactions between person, environment, and affect. The PsyMate device provided ABI patients (N = 17) with ten signals (beeps) per day during six consecutive days. Each beep was followed by a digital questionnaire assessing mood, location, activities, social context, and physical well-being. Results demonstrated high feasibility with a 71% response rate and a 99% completion rate of the questionnaires. There were no dropouts and the method was experienced as user-friendly. Time-lagged multilevel analysis showed that higher levels of physical activity and fatigue predicted higher levels of negative affect at the same point in time, but not at later time points. This study illustrates the potential of ESM to identify complex person-environment dynamics after ABI, while generating understandable and easy to use graphical feedback.

The immediate influence of implicit motor learning strategies on spatiotemporal gait parameters in stroke patients: a randomized within-subjects design.

OBJECTIVES:: To investigate immediate changes in walking performance associated with three implicit motor learning strategies and to explore patient experiences of each strategy. DESIGN:: Participants were randomly allocated to one of three implicit motor learning strategies. Within-group comparisons of spatiotemporal parameters at baseline and post strategy were performed. SETTING:: Laboratory setting. SUBJECTS:: A total of 56 community-dwelling post-stroke individuals. INTERVENTIONS:: Implicit learning strategies were analogy instructions, environmental constraints and action observation. Different analogy instructions and environmental constraints were used to facilitate specific gait parameters. Within action observation, only videotaped gait was shown. MAIN MEASURES:: Spatiotemporal measures (speed, step length, step width, step height) were recorded using Vicon 3D motion analysis. Patient experiences were assessed by questionnaire. RESULTS:: At a group level, three of the four analogy instructions ( n = 19) led to small but significant changes in speed ( d = 0.088 m/s), step height (affected side d = 0.006 m) and step width ( d = -0.019 m), and one environmental constraint ( n = 17) led to significant changes in step width ( d = -0.040 m). At an individual level, results showed wide variation in the magnitude of changes. Within action observation ( n = 20), no significant changes were found. Overall, participants found it easy to use the different strategies and experienced some changes in their walking performance. CONCLUSION:: Analogy instructions and environmental constraints can lead to specific, immediate changes in the walking performance and were in general experienced as feasible by the participants. However, the response of an individual patient may vary quite considerably.

Cognitive impairments and subjective cognitive complaints after survival of cardiac arrest: A prospective longitudinal cohort study.

BACKGROUND: Cardiac arrest can lead to hypoxic brain injury, which can affect cognitive functioning. OBJECTIVE: To investigate the course of objective and subjective cognitive functioning and their association during the first year after cardiac arrest. METHODS: A multi-centre prospective longitudinal cohort study with one year follow-up (measurements at two weeks, three months and one year). Cognitive functioning was measured with a neuropsychological test battery and subjective cognitive functioning with the Cognitive Failures Questionnaire. RESULTS: 141 cardiac arrest survivors participated. Two weeks post cardiac arrest 16% to 29% of survivors were cognitively impaired varying on the different tests, at three months between 9% and 23% and at one year 10%-22% remained impaired with executive functioning being affected most. Significant reduction of cognitive impairments was seen for all tests, with most recovery during the first three months after cardiac arrest. Subjective cognitive complaints were present at two weeks after cardiac arrest in 11%, 12% at three months and 14% at one year. There were no significant associations between cognitive impairments and cognitive complaints at any time point. CONCLUSIONS: Cognitive impairments are common in cardiac arrest survivors with executive functioning being mostly affected. Most recovery is seen in the first three months after cardiac arrest. After one year, a substantial number of patients remain impaired, especially in executive functioning. Because of absence of associations between impairments and complaints, cognitive testing using a sensitive test battery is important and should be part of routine follow-up after a cardiac arrest.

Brain training improves recovery after stroke but waiting list improves equally: A multicenter randomized controlled trial of a computer-based cognitive flexibility training.

BACKGROUND: Brain training is currently widely used in an attempt to improve cognitive functioning. Computer-based training can be performed at home and could therefore be an effective add-on to available rehabilitation programs aimed at improving cognitive functioning. Several studies have reported cognitive improvements after computer training, but most lacked proper active and passive control conditions. OBJECTIVE: Our aim was to investigate whether computer-based cognitive flexibility training improves executive functioning after stroke. We also conducted within-group analyses similar to those used in previous studies, to assess inferences about transfer effects when comparisons to proper control groups are missing. METHODS: We conducted a randomized controlled, double blind trial. Adults (30-80 years old) who had suffered a stroke within the last 5 years were assigned to either an intervention group (n = 38), active control group (i.e., mock training; n = 35), or waiting list control group (n = 24). The intervention and mock training consisted of 58 half-hour sessions within a 12-week period. Cognitive functioning was assessed using several paper-and-pencil and computerized neuropsychological tasks before the training, immediately after training, and 4 weeks after training completion. RESULTS AND CONCLUSIONS: Both training groups improved on training tasks, and all groups improved on several transfer tasks (three executive functioning tasks, attention, reasoning, and psychomotor speed). Improvements remained 4 weeks after training completion. However, the amount of improvement in executive and general cognitive functioning in the intervention group was similar to that of both control groups (active control and waiting list). Therefore, this improvement was likely due to training-unspecific effects. Our results stress the importance to include both active and passive control conditions in the study design and analyses. Results from studies without proper control conditions should be interpreted with care.

The impact of cardiac arrest on the long-term wellbeing and caregiver burden of family caregivers: a prospective cohort study.

OBJECTIVE: The purpose was to gain insight in the functioning of caregivers of cardiac arrest survivors at 12 months after a cardiac arrest. Secondly, the course of the wellbeing of the caregivers during the first year was studied. Finally, factors that are associated with a higher care burden at 12 months after the cardiac arrest were investigated. SUBJECTS: A total of 195 family caregivers of cardiac arrest survivors were included. MAIN MEASURES: Quality of life (SF-36, EuroQol-VAS), caregiver strain (CSI) and emotional functioning (HADS, IES) were measured at two weeks, three months and one year after the cardiac arrest. Thereby, the caregiver was asked to fill out the cognitive failure questionnaire (CFQ) to evaluate their view on the cognitive status of the patient. RESULTS: Caregiver strain was high in 16 (15%) of the caregivers at 12 months. Anxiety was present in 33 (25%) caregivers and depression in 18 (14%) caregivers at 12 months. The repeated measures MANOVA showed that during the first year the following variables improved significantly: SF-36 domains social and mental health, role physical, role emotional and vitality, caregiver strain, HADS and IES ( P<0.001). At 12 months caregiver strain correlated significantly (explained variance 63%, P=0.03) with caregiver HADS ( P=0.01), EuroQol-VAS ( P=0.02), and the CFQ ( P<0.001), all measured at 12 months after the cardiac arrest. CONCLUSIONS: Overall wellbeing of the caregivers improves during the first year up to normal levels, but caregivers with emotional problems or perceived cognitive problems at 12 months are at risk for developing a higher care burden.

Augmented Cognitive Behavioral Therapy for Poststroke Depressive Symptoms: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effectiveness of individually tailored cognitive behavioral therapy (CBT) for reducing depressive symptoms with or without anxiety poststroke. DESIGN: Multicenter, assessor-blinded, randomized controlled trial. SETTING: Ambulatory rehabilitation setting. PARTICIPANTS: Patients who had a Hospital Anxiety and Depression Scale-depression subscale (HADS-D) score >7 at least 3 months poststroke (N=61). INTERVENTIONS: Participants were randomly allocated to either augmented CBT or computerized cognitive training (CCT). The CBT intervention was based on the principles of recognizing, registering, and altering negative thoughts and cognitions. CBT was augmented with goal-directed real-life activity training given by an occupational or movement therapist. MAIN OUTCOME MEASURES: HADS-D was the primary outcome, and measures of participation and quality of life were secondary outcomes. Outcome measurements were performed at baseline, immediately posttreatment, and at 4- and 8-month follow-up. Analysis was performed with linear mixed models using group (CBT vs CCT) as the between-subjects factor and time (4 assessments) as the within-subjects factor. RESULTS: Mixed model analyses showed a significant and persistent time effect for HADS-D (mean difference, -4.6; 95% confidence interval, -5.7 to -3.6; P<.001) and for participation and quality of life in both groups. There was no significant group × time effect for any of the outcome measures. CONCLUSIONS: Our augmented CBT intervention was not superior to CCT for the treatment of mood disorders after stroke. Future studies should determine whether both interventions are better than natural history.

Risk Factors for Symptoms of Depression and Anxiety One Year Poststroke: A Longitudinal Study.

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

Screening Poststroke Fatigue; Feasibility and Validation of an Instrument for the Screening of Poststroke Fatigue throughout the Rehabilitation Process.

OBJECTIVE: Our objective is to investigate the feasibility and validity of a new instrument to screen for determinants of poststroke fatigue during the rehabilitation process. DESIGN AND SETTING: This prospective cohort study was conducted within the stroke department of a rehabilitation center. PARTICIPANTS: The participants in the study were postacute adult stroke patients. The Detection List Fatigue (DLF)was administered 2 weeks after the start of the rehabilitation program and again 6 weeks later. MAIN OUTCOME MEASURES: To determine the construct validity, the Hospital Anxiety and Depression Scale, the Checklist Individual Strength subscale fatigue, and the Fatigue Severity Scale--7-item version were administered. A fatigue rating scale was used to measure the patients' fatigue experience. Frequency analyses of the number of patients reporting poststroke fatigue determinants according to the DLF were performed. RESULTS: One hundred seven patients (mean age 60 years) without severe communication difficulties were included in the study. The DLF was easy to understand and quick to administer. The DLF showed good internal consistency (Cronbach's alpha: .79 and .87), high convergent validity (rs = .85 and rs = .79), and good divergent validity (rs = .31 and rs = .45). The majority of the patients (88.4%-90.2%) experienced at least 2 poststroke fatigue (PSF) determinants,of which "sleeping problem" was most frequently reported. CONCLUSIONS: The DLF is a feasible and valid instrument for the screening of PSF determinants throughout the rehabilitation process in stroke patients. Future studies should investigate whether the use of the list in determining a treatment plan prevents the development of PSF.

Multidisciplinary Views on Applying Explicit and Implicit Motor Learning in Practice: An International Survey.

BACKGROUND: A variety of options and techniques for causing implicit and explicit motor learning have been described in the literature. The aim of the current paper was to provide clearer guidance for practitioners on how to apply motor learning in practice by exploring experts' opinions and experiences, using the distinction between implicit and explicit motor learning as a conceptual departure point. METHODS: A survey was designed to collect and aggregate informed opinions and experiences from 40 international respondents who had demonstrable expertise related to motor learning in practice and/or research. The survey was administered through an online survey tool and addressed potential options and learning strategies for applying implicit and explicit motor learning. Responses were analysed in terms of consensus (≥ 70%) and trends (≥ 50%). A summary figure was developed to illustrate a taxonomy of the different learning strategies and options indicated by the experts in the survey. RESULTS: Answers of experts were widely distributed. No consensus was found regarding the application of implicit and explicit motor learning. Some trends were identified: Explicit motor learning can be promoted by using instructions and various types of feedback, but when promoting implicit motor learning, instructions and feedback should be restricted. Further, for implicit motor learning, an external focus of attention should be considered, as well as practicing the entire skill. Experts agreed on three factors that influence motor learning choices: the learner's abilities, the type of task, and the stage of motor learning (94.5%; n = 34/36). Most experts agreed with the summary figure (64.7%; n = 22/34). CONCLUSION: The results provide an overview of possible ways to cause implicit or explicit motor learning, signposting examples from practice and factors that influence day-to-day motor learning decisions.

Can the Montreal Cognitive Assessment predict discharge destination in a stroke population in the hospital?

BACKGROUND: To decide on an appropriate discharge destination for stroke survivors from hospital, factors such as activities of daily living and age are often taken into account as predictors. Cognition has been found to support the decision whether to send a patient home or to a dependent living situation. The Montreal Cognitive Assessment (MOCA) has been proven to be a suitable cognitive screening instrument in the acute phase after stroke. However, its predictive value in the determination of discharge destination is unknown. The aim of the present study was to examine whether cognitive functioning, as measured with the MOCA, in the acute phase after stroke could predict discharge destination. METHODS: The study involved 211 patients with a first-ever cerebral stroke within the first week after stroke. Demographic and stroke-specific data, cognitive functioning (MOCA), and level of functional disability (Barthel Index [BI]) were collected. Multivariate logistic regression analyses were used to predict discharge destination (dependent versus independent living situation). RESULTS: Both age (B = -.05; P < .01) and BI score (B = .33; P < .001) were found to be significantly related to discharge destination with explained variance of 43%. Adding MOCA score as a predictor variable to the model resulted in a nonsignificant improvement of the model, explaining 44% of the variance. CONCLUSIONS: Cognitive functioning, as measured by a single screening instrument such as the MOCA, in the acute phase after stroke is not predictive for discharge destination.

An augmented cognitive behavioural therapy for treating post-stroke depression: description of a treatment protocol.

AIM: Currently, no evidence-based treatment is available for mood problems after stroke. We present a new psychological intervention designed to reduce depressive complaints after stroke. METHOD OF PROTOCOL DEVELOPMENT: This intervention was based on cognitive behavioural therapy principles and was shown feasible in a pilot study. In order to meet the specific needs of stroke patients (concerning both sensori-motor, cognitive, and behavioural problems), we incorporated motivational interviewing, grief resolution, and psycho-education. We emphasised for each session to take into account the cognitive deficits of the patients (i.e. be concrete, accessible, structured, specific, and repeat information). Moreover, we augmented the psychologist-administered therapy with the contribution of an occupational or movement therapist aimed at facilitating patients' goal-setting and attainment. The intervention consisted of 12 one-hour sessions with a psychologist and three or four one-hour sessions with an occupational or movement therapist. Currently, the effectiveness of the intervention is evaluated in a randomised controlled trial. DISCUSSION: The proposed psychological treatment protocol is innovative, as it applies cognitive behavioural therapy in a stroke-specific manner; moreover, it supports goal attainment by incorporating occupational or movement therapy sessions.

Using a Delphi technique to seek consensus regarding definitions, descriptions and classification of terms related to implicit and explicit forms of motor learning.

BACKGROUND: Motor learning is central to domains such as sports and rehabilitation; however, often terminologies are insufficiently uniform to allow effective sharing of experience or translation of knowledge. A study using a Delphi technique was conducted to ascertain level of agreement between experts from different motor learning domains (i.e., therapists, coaches, researchers) with respect to definitions and descriptions of a fundamental conceptual distinction within motor learning, namely implicit and explicit motor learning. METHODS: A Delphi technique was embedded in multiple rounds of a survey designed to collect and aggregate informed opinions of 49 international respondents with expertise related to motor learning. The survey was administered via an online survey program and accompanied by feedback after each round. Consensus was considered to be reached if ≥70% of the experts agreed on a topic. RESULTS: Consensus was reached with respect to definitions of implicit and explicit motor learning, and seven common primary intervention strategies were identified in the context of implicit and explicit motor learning. Consensus was not reached with respect to whether the strategies promote implicit or explicit forms of learning. DISCUSSION: The definitions and descriptions agreed upon may aid translation and transfer of knowledge between domains in the field of motor learning. Empirical and clinical research is required to confirm the accuracy of the definitions and to explore the feasibility of the strategies that were identified in research, everyday practice and education.

Treatment of unawareness of deficits in patients with acquired brain injury: a systematic review.

OBJECTIVE: To review and evaluate the effectiveness and methodological quality of available treatment methods for unawareness of deficits after acquired brain injury (ABI). METHODS: Systematic literature search for treatment studies for unawareness of deficits after ABI. Information concerning study content and reported effectiveness was extracted. Quality of the study reports and methods were evaluated. RESULTS: A total of 471 articles were identified; 25 met inclusion criteria. 16 were uncontrolled or single-case studies. Nine were of higher quality: 2 randomized controlled trials, 5 single case experimental designs, 1 single-case design with pre- and posttreatment measurement, and 1 quasi-experimental controlled design. Overall, interventions consisted of multiple components including education and multimodal feedback on performance. Five of the 9 high-quality studies reported a positive effect of the intervention on unawareness in patients with some knowledge of their impairments. Effect sizes ranged from questionable to large. CONCLUSION: Patients with ABI may improve their awareness of their disabilities and possibly attain a level at which they personally experience problems when they occur. At present, because of lack of evidence, no recommendation can be made for treatment approaches for persons with severe impairment of self-awareness in the chronic phase of ABI. We recommended developing and evaluating theory-driven interventions specifically focused on disentangling the components of treatment that are successful in improving awareness. High-quality intervention studies are urgently needed using controlled designs (eg, single-case experimental designs, randomized controlled trials) based on a theoretic perspective with a detailed description of the content of the intervention and suitable outcome measures.

Terminology, taxonomy, and facilitation of motor learning in clinical practice: protocol of a delphi study.

BACKGROUND: Facilitating motor learning in patients during clinical practice is complex, especially in people with cognitive impairments. General principles of motor learning are available for therapists to use in their practice. However, the translation of evidence from the different fields of motor learning for use in clinical practice is problematic due to lack of uniformity in definition and taxonomy of terms related to motor learning. OBJECTIVE: The objective of this paper was to describe the design of a Delphi technique to reach consensus on definitions, descriptions, and taxonomy used within motor learning and to explore experts' opinions and experiences on the application of motor learning in practice. METHODS: A heterogeneous sample of at least 30 international experts on motor learning will be recruited. Their opinions regarding several central topics on motor learning using a Delphi technique will be collected in 3 sequential rounds. The questionnaires in the 3 rounds will be developed based on the literature and answers of experts from earlier rounds. Consensus will be reached when at least 70% of the experts agree on a certain topic. Free text comments and answers from open questions on opinions and experiences will be described and clustered into themes. RESULTS: This study is currently ongoing. It is financially supported by Stichting Alliantie Innovatie (Innovation Alliance Foundation), RAAK-international (Registration number: 2011-3-33int). CONCLUSIONS: The results of this study will enable us to summarize and categorize expert knowledge and experiences in a format that should be more accessible for therapists to use in support of their clinical practice. Unresolved aspects will direct future research.

The effectiveness of an augmented cognitive behavioural intervention for post-stroke depression with or without anxiety (PSDA): the Restore4Stroke-PSDA trial.

BACKGROUND: Post-Stroke Depression with or without Anxiety (PSDA) is a common disorder in the chronic phase of stroke. Neuropsychiatric problems, such as PSDA, have a negative impact on social reintegration and quality of life. Currently, there is no evidence-based treatment available for reducing PSDA symptoms. In the recent literature on depression in the general population it has been shown that depression complaints can diminish by cognitive behavioural therapy (CBT). In the current study, the effectiveness of augmented, activation-based and individually tailored CBT on the reduction of depression and anxiety will be investigated in patients with PSDA. Additionally, the effects on various secondary outcome measures, such as quality of life, goal attainment and societal participation will be evaluated. This study is embedded in a consortium of 4 interrelated studies on quality of life after stroke (Restore4Stroke). METHODS/DESIGN: A multi-centre, assessor-blind, randomized controlled trial is conducted. A sample of 106 PSDA patients, as assessed with the Hospital Anxiety and Depression Scale (HADS depression subscale >7), will be recruited and randomly allocated to either an experimental or a control group. The experimental intervention consists of an augmented CBT intervention. The intervention is based on CBT principles of recognizing, registering, and altering negative thoughts and cognitions so that mood, and emotional symptoms are improved. CBT is augmented with direct in-vivo activation offered by occupational or movement therapists. Patients in the control group will receive a computerized cognitive training intervention. Outcomes will be assessed at baseline, immediately post intervention, and at 6 and 12 months follow up. DISCUSSION: This study is the first randomized clinical trial that evaluates the (maintenance of) effects of augmented CBT on post-stroke depression with or without anxiety symptoms. Together with three other projects, the Restore4Stroke PSDA trial will provide novel information about the (treatment of) emotional problems and quality of life after stroke. TRIAL REGISTRATION NUMBER: Dutch Trial Register NTR2999.

Development and validity of the Brain Injury Alert (BI Alert) screening tool for cognitive, emotional and social problems after paediatric acquired brain injury.

PURPOSE: Validation of a new screening tool, viz., the Brain Injury Alert (BI Alert) for identification of cognitive and emotional problems after traumatic brain injury (TBI) in children. METHODS: Parents and teachers of children with TBI as well as controls were interviewed using the BI Alert. Validity was determined using reference instruments (CBCL and TRF; neuropsychological functioning). RESULTS: The BI Alert was feasible; Required assessment time: 15 minutes. Parents and teachers of children with TBI (n = 42) reported significantly more problems compared to controls (n = 29). Internal consistency (α = 0.68 for parents and 0.82 for teachers) and inter-rater reliability (r > 0.66) were good. Test-re-test reliability was reasonable (r > 0.46). Correlations with CBCL were statistically significant for the parents (r range from 0.36-0.66) and TRF emotion for the teachers (r = 0.62). The correlations with the TRF cognition and school were statistically significant for the teachers (r range from 0.43-0.63). There were only low correlations with the neuropsychological tests. CONCLUSIONS: The BI Alert is a useful, feasible and valid instrument for the cognitive screening of children with TBI by health professionals in primary care.

Motor imagery in patients with a right hemisphere stroke and unilateral neglect.

INTRODUCTION: In the last decade new treatments based on mental imagery have been developed for patients with stroke. Whether this therapy works for patients with neglect is currently unclear. OBJECTIVE: To investigate whether patients with a right hemisphere stoke complicated with unilateral neglect were less capable of performing motor imagery as compared to patients with a right hemisphere stroke without unilateral neglect. METHODS: In a patient-control study, 20 patients with a right hemisphere stroke were included. Twelve patients were diagnosed on admission with neglect and eight without neglect. The ability to perform motor imagery was tested using mental rotation tasks, based on either a visual (CMIA 'Hand Rotation' test) or a verbal (Questionnaire d'Imagerie Mentale: Rotation des Mains) instruction. In both tasks subjects were instructed to generate a mental image of their hand. RESULTS: Patients with neglect scored significantly less (p=0.02) as compared to patients without neglect on the visual mental rotation task, but not on the mental rotation task with verbal instruction. CONCLUSION: Patients with a right-hemisphere stroke and neglect seem less capable of performing visual mental rotation tasks in comparison to patients with a stroke without neglect.