Return to work and health-related quality of life up to 1 year in patients hospitalized for COVID-19: the CO-FLOW study.

BACKGROUND: Currently, evidence about the long-term consequences of COVID-19 on return to work and health-related quality of life (HRQoL) is limited. We evaluated return to work and its associations with baseline characteristics and physical and mental recovery over time in patients up to 1 year after hospitalization for COVID-19. Secondly, we aimed to evaluate the association between return to work and health-related quality of life (HRQoL). METHODS: CO-FLOW, a multicenter prospective cohort study, enrolled adult participants hospitalized for COVID-19, aged ≥ 18 years within 6 months after hospital discharge. Return to work and HRQoL were collected at 3, 6, and 12 months after hospital discharge using the iMTA Productivity Cost Questionnaire and the 36-Item Short Form Health Survey, respectively. Data were collected between July 1, 2020, and September 1, 2022. Generalized estimating equations with repeated measurements were used to assess outcomes over time. RESULTS: In the CO-FLOW study, 371 participants were employed pre-hospitalization. At 3, 6, and 12 months post-discharge, 50% (170/342), 29% (92/317), and 15% (44/295) of participants had not returned to work, and 21% (71/342), 21% (65/317), and 16% (48/295) only partially, respectively. ICU admission (adjusted odds ratio (95% confidence interval): 0.17 (0.10 to 0.30), p < 0.001), persistent fatigue (0.93 (0.90 to 0.97), p < 0.001), female sex (0.57 (0.36 to 0.90), p = 0.017), and older age (0.96 (0.93 to 0.98), p < 0.001) were independently associated with no return to work. ICU patients required a longer time to return to work than non-ICU patients. Patients who did not return or partially returned to work reported lower scores on all domains of HRQoL than those who fully returned. CONCLUSIONS: One year after hospitalization for COVID-19, only 69% of patients fully returned to work, whereas 15% did not return and 16% partially returned to work. No or partial return to work was associated with reduced HRQoL. This study suggests that long-term vocational support might be needed to facilitate return to work. TRIAL REGISTRATION: World Health Organization International Clinical Trials Registry Platform NL8710.

Requirements for home-based upper extremity rehabilitation using wearable motion sensors for stroke patients: a user-centred approach.

PURPOSE: Telerehabilitation systems have the potential to enable therapists to monitor and assist stroke patients in achieving high-intensity upper extremity exercise in the home environment. We adopted an iterative user-centred approach, including multiple data sources and meetings with end-users and stakeholders to define the user requirements for home-based upper extremity rehabilitation using wearable motion sensors for subacute stroke patients. METHODS: We performed a requirement analysis consisting of the following steps: 1) context & groundwork; 2) eliciting requirements; 3) modelling & analysis; 4) agreeing requirements. During these steps, a pragmatic literature search, interviews and focus groups with stroke patients, physiotherapists and occupational therapists were performed. The results were systematically analysed and prioritised into "must-haves", "should-haves", and "could-haves". RESULTS: We formulated 33 functional requirements: eighteen must-have requirements related to blended care (2), exercise principles (7), exercise delivery (3), exercise evaluation (4), and usability (2); ten should-haves; and five could-haves. Six movement components, including twelve exercises and five combination exercises, are required. For each exercise, appropriate exercise measures were defined. CONCLUSION: This study provides an overview of functional requirements, required exercises, and required exercise measures for home-based upper extremity rehabilitation using wearable motion sensors for stroke patients, which can be used to develop home-based upper extremity rehabilitation interventions. Moreover, the comprehensive and systematic requirement analysis used in this study can be applied by other researchers and developers when extracting requirements for designing a system or intervention in a medical context.

This study provides an extensive overview of user requirements for home-based upper extremity rehabilitation using wearable motion sensors in stroke patients.These requirements can be used as a basis for developing home-based UE telerehabilitation interventions.Including these requirements may facilitate the clinical implementation of such telerehabilitation systems.The comprehensive and systematic approach used in this sudy can be applied by other researchers and developers when extracting requirements for designing a system or intervention in a medical context.

Cognitive function and participation in children and youth with mild traumatic brain injury two years after injury.

BACKGROUND: 10-20% of children and youth with mild traumatic brain injury (mTBI) suffer from long-term cognitive impairments with, supposedly, a negative impact on most domains of functioning. OBJECTIVES: To describe cognitive functioning and participation in children and youth two-years post-mTBI and to determine associated risk factors. METHODS: Cross-sectional study among 73 patients (aged 6-22 years), hospital diagnosed with mTBI. Linear regression modelling was used to investigate the effect of potential predictors on cognitive functioning as measured with a neuropsychological assessment (NPA), two-years post-injury. Extent of participation was assessed using the Child and Adolescent Scale of Participation and correlation analysis was conducted to examine its association with level of cognitive functioning. RESULTS: 7-15% of all participants had impaired cognitive functions, especially in the domains of processing speed, inhibitory control, cognitive flexibility, visuospatial constructional ability and visuospatial memory. Lower level of education and pre-injury cognitive problems were predictive for a lower level of long-term cognitive functioning. Slower inhibition speed, impaired visuospatial and verbal working memory were associated with reduced participation. DISCUSSION AND CONCLUSIONS: Persisting cognitive problems two years after mTBI were mostly related to the lower level of education and to pre-injury cognitive problems. Although participation of the patients was reported by parents to be relatively high, slower inhibition speed, impaired visuospatial and verbal working memory were associated with reduced participation.

Cerebellar Cathodal Transcranial Direct Stimulation and Performance on a Verb Generation Task: A Replication Study.

The role of the cerebellum in cognitive processing is increasingly recognized but still poorly understood. A recent study in this field applied cerebellar Transcranial Direct Current Stimulation (c-tDCS) to the right cerebellum to investigate the role of prefrontal-cerebellar loops in language aspects of cognition. Results showed that the improvement in participants' verbal response times on a verb generation task was facilitated immediately after cathodal c-tDCS, compared to anodal or sham c-tDCS. The primary aim of the present study is to replicate these findings and additionally to investigate possible longer term effects. A crossover within-subject design was used, comparing cathodal and sham c-tDCS. The experiment consisted of two visits with an interval of one week. Our results show no direct contribution of cathodal c-tDCS over the cerebellum to language task performance. However, one week later, the group receiving cathodal c-tDCS in the first visit show less improvement and increased variability in their verbal response times during the second visit, compared to the group receiving sham c-tDCS in the first visit. These findings suggest a potential negative effect of c-tDCS and warrant further investigation into long term effects of c-tDCS before undertaking clinical studies with poststroke patients with aphasia.

The effect of hypopituitarism on fatigue after subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Aneurysmal subarachnoid hemorrhage (SAH) survivors often complain of fatigue, which is disabling. Fatigue is also a common symptom of pituitary dysfunction (PD), in particular in patients with growth hormone deficiency (GHD). A possible association between fatigue after SAH and long-term pituitary deficiency in SAH survivors has not yet been established. METHODS: A single center observational study was conducted amongst 84 aneurysmal SAH survivors to study the relationship between PD and fatigue over time after SAH, using mixed model analysis. Fatigue was measured with the Fatigue Severity Scale and its relationships with other clinical variables were studied. RESULTS: Three-quarters of respondents (76%) have pathological fatigue directly after SAH and almost two-thirds (60%) of patients still have pathological levels of fatigue after 14 months. The severity of SAH measured with a World Federation of Neurosurgical Societies (WFNS) score higher than 1 (P = 0.008) was associated with long-term fatigue. There is no statistically significant effect of PD (P = 0.8) or GHD (P = 0.23) on fatigue in SAH survivors over time. CONCLUSIONS: Fatigue is a common symptom amongst SAH survivors. WFNS is a usable clinical determinant of fatigue in SAH survivors. Neither PD nor GHD has a significant effect on long-term fatigue after SAH.

Pituitary dysfunction after aneurysmal subarachnoid haemorrhage: course and clinical predictors­the HIPS study.

OBJECTIVE: We describe the occurrence and course of anterior pituitary dysfunction (PD) after aneurysmal subarachnoid haemorrhage (SAH), and identify clinical determinants for PD in patients with recent SAH. METHODS: We prospectively collected demographic and clinical parameters of consecutive survivors of SAH and measured fasting state endocrine function at baseline, 6 and 14 months. We included dynamic tests for growth-hormone function. We used logistic regression analysis to compare demographic and clinical characteristics of patients with SAH with and without PD. RESULTS: 84 patients with a mean age of 55.8 (±11.9) were included. Thirty-three patients (39%) had PD in one or more axes at baseline, 22 (26%) after 6 months and 6 (7%) after 14 months. Gonadotropin deficiency in 29 (34%) patients and growth hormone deficiency (GHD) in 26 (31%) patients were the most common deficiencies. PD persisted until 14 months in 6 (8%) patients: GHD in 5 (6%) patients and gonadotropin deficiency in 4 (5%). Occurrence of a SAH-related complication was associated with PD at baseline (OR 2.6, CI 2.2 to 3.0). Hydrocephalus was an independent predictor of PD 6 months after SAH (OR 3.3 CI 2.7 to 3.8). PD was associated with a lower score on health-related quality of life at baseline (p=0.06), but not at 6 and 14 months. CONCLUSIONS: Almost 40% of SAH survivors have PD. In a small but substantial proportion of patients GHD or gonadotropin deficiency persists over time. Hydrocephalus is independently associated with PD 6 months after SAH. TRIAL REGISTRATION NUMBER: NTR 2085.

Diagnostic value of a ghrelin test for the diagnosis of GH deficiency after subarachnoid hemorrhage.

OBJECTIVE: To determine the diagnostic value of a ghrelin test in the diagnosis of GH deficiency (GHD) shortly after aneurysmal subarachnoid hemorrhage (SAH). DESIGN: Prospective single-center observational cohort study. METHODS: A ghrelin test was assessed after the acute phase of SAH and a GH-releasing hormone (GHRH)-arginine test 6 months post SAH. Primary outcome was the diagnostic value of a ghrelin test compared with the GHRH-arginine test in the diagnosis of GHD. The secondary outcome was to assess the safety of the ghrelin test, including patients' comfort, adverse events, and idiosyncratic reactions. RESULTS: Forty-three survivors of SAH were included (15 males, 35%, mean age 56. 6 ± 11.7). Six out of 43 (14%) SAH survivors were diagnosed with GHD by GHRH-arginine test. In GHD subjects, median GH peak during ghrelin test was significantly lower than that of non-GHD subjects (5.4 vs 16.6, P=0.002). Receiver operating characteristics analysis showed an area under the curve of 0.869. A cutoff limit of a GH peak of 15 µg/l corresponded with a sensitivity of 100% and a false-positive rate of 40%. No adverse events or idiosyncratic reactions were observed in subjects undergoing a ghrelin test, except for one subject who reported flushing shortly after ghrelin infusion. CONCLUSION: Owing to its convenience, validity, and safety, the ghrelin test might be a valuable GH provocative test, especially in the early phase of SAH.

Metamemory and memory test performance in stroke patients.

Memory Self-Efficacy (MSE) has been shown to be related to memory performance and social participation in a healthy elderly population. This relation is unclear in stroke. As about 30% of all stroke survivors report memory complaints, there is an urgent need for effective treatment strategies. Before implementing MSE as a potential target in memory training, it should be examined whether the association between MSE and memory performance demonstrated in healthy elderly people also applies in stroke patients. This study therefore explored the predictive value of MSE on two kinds of memory tests in stroke patients; adjusted and unadjusted for age, gender, education and location of stroke. In 57 stroke patients, the Metamemory in Adulthood Questionnaire (MIA), an everyday memory test (RBMT) and a more traditional memory test (AVLT) were completed. The results show that MSE significantly predicts memory test performance on both memory tests (RBMT: beta = .34; p = .01 AVLT: beta = .28; p = .04). When adjusted for gender, age, education and location of stroke, the predictive value of MSE remained significant for the AVLT (RBMT: beta = .23; p = .07; AVLT: beta = .23; p = .05). The results support the hypothesis that MSE predicts test performance in stroke patients and, by consequence, enables improving memory performance in post-acute memory rehabilitation after stroke.

Association between apolipoprotein-epsilon4 and long-term outcome after traumatic brain injury.

OBJECTIVES: To investigate the effect of carrying the apolipoprotein epsilon 4 (APOE-in4) allele on global functional outcome, on activity limitations and participation restrictions, and on community integration at 3, 6, 12, 18, 24 and 36 months after traumatic brain injury. METHOD: The Glasgow Outcome Scale (GOS), the Sickness Impact Profile-68 (SIP-68) and the Community Integration Questionnaire (CIQ) were assessed in 79 moderate and severe traumatic brain injury patients at 3, 6, 12, 18, 24 and 36 months post injury. Repeated measures analyses of variance were performed with APOE-in4 status and time of measurement as independent variables and the GOS, SIP-68 and CIQ as dependent variables. Analyses were adjusted for baseline age, gender and Glasgow Coma Scale. RESULTS: Patients with the APOE-in4 allele had a significantly better global functional outcome on the GOS than patients without the APOE-in4 allele. No significant associations were found between APOE-in4 status and the SIP-68 and CIQ. DISCUSSION: In contrast to other studies, we found that carrying the APOE-in4 allele had a protective influence on outcome. Multiple mechanisms, and in some cases competitive mechanisms, may explain the variable relation between the APOE-in4 allele and outcome after traumatic brain injury.

Traumatic brain injury rehabilitation in the Netherlands: dilemmas and challenges.

Traumatic brain injury (TBI) is the number one cause of mortality and morbidity in young adults in modern Western societies. This article discusses TBI rehabilitation in the Netherlands. Facts and figures on rehabilitation as well as on the epidemiology of TBI and its silent epidemic in the Netherlands are presented. The Dutch healthcare system is described, and strengths and weaknesses of TBI rehabilitation are discussed.

Being restricted in participation after a traumatic brain injury is negatively associated by passive coping style of the caregiver.

PURPOSE: To examine whether the caregivers' coping style is associated with the functional outcome of the traumatic brain injury (TBI) patient 1 year post-injury. METHOD: A cross-sectional study among patients with a TBI, including their primary caregivers. The study included 51 patients aged 17-64 years with a moderate-to-severe TBI and 51 caregivers (23 parents and 28 partners) aged 23-67 years. The coping preferences of the caregivers were assessed at minimum 6 and maximum 12 months post-injury, by filling out the Utrecht Coping List (UCL) and were related to limitations in activity, as measured with the Frenchay Activities Index and with restrictions in participation as measured with the Sickness Impact Profile-68 of TBI patients 1 year post-injury. The patients were interviewed at their homes; the caregivers received and returned the UCL by mail. RESULTS: The patients' age and the caregivers' coping style are independently associated with restrictions in participation 1 year post-injury. CONCLUSIONS: A passive coping style of the primary caregiver is negatively associated with the patient's functional outcome in terms of participation in society.

Traumatic brain injury: classification of initial severity and determination of functional outcome.

PURPOSE: The aim of the present manuscript is to review current methods for classifying initial severity and final outcome in traumatic brain injury (TBI) and to suggest a direction and form of further research. METHOD: The literature on valid and reliable measurements used in TBI-research for classifying initial severity and final outcome was reviewed. RESULTS: Classifying initial severity in patients with head injury according to clinical condition or CT-parameters is valid. Classifying outcome according to measurement tools of disability showed adequate validity and reliability. CONCLUSIONS: Future research in TBI outcome, particularly in rehabilitation medicine, should focus on determinants of outcome, identifying those patients who will have the greatest chance of benefiting from intensive rehabilitation programmes. More research is needed to determine the long-term functional outcome in TBI, the long-term socio-economic costs, and the influence of behavioural problems on family cohesion. Finally, validation of outcome measures is required in the TBI-population; the relative value of various outcome measures needs to be determined, and the usefulness and applicability of measures for health related quality of life in TBI should be established.

Complex regional pain syndrome type I treated with topical capsaicin: a case report.

This report describes the case of a multitrauma patient who underwent an amputation of the left arm and had a complicated left crural fracture with a delayed union. He was treated in an inpatient setting for preprosthetic training for a myoelectric prosthesis and to regain walking abilities. After consolidation of the crural fracture, complex regional pain syndrome type I (CRPS I) developed in the left foreleg, which hindered mobilization. Topical capsaicin .075% was prescribed and a stress-loading mobilization schema was instituted. No other treatment modalities directed at CRPS I were added. After 6 weeks, no signs or symptoms of CRPS I were present and capsaicin was discontinued. Capsaicin is a well-accepted and documented treatment modality in neuropathic pain states such as postherpetic neuralgia. However, it has rarely been described in CRPS I. Capsaicin is discussed within the framework of recent insights in the neurobiology of nociception, and it is concluded that it may provide a theory-driven treatment for CRPS I, especially in the acute stage, that facilitates physical therapy and prevents peripheral and spinal sensitization.

Struck by stroke: a pilot study exploring quality of life and coping patterns in younger patients and spouses.

So far, research on quality of life after stroke has focused mainly on elderly patients. This study is targeted at younger stroke patients and their partners, aiming to evaluate stroke impact, as related to coping strategy. For our pilot study, eight patients who had suffered a stroke and four partners completed the Impact of Event Scale questionnaire. The mean age was 47.6 years in patients and 44.5 years in partners. The patients' level of activities of daily life was assessed using the Barthel Index. They were then interviewed to obtain information with respect to stroke impact and coping. The Schedule for the Evaluation of Individual Quality of Life procedure was carried out to measure quality of life, and stroke impact was quantified using Visual Analogue Scales. On average, patients scored 19.25 on the Barthel Index. Quality of life had deteriorated by 20.1% in patients, whereas partners did not show a decline in quality of life. However, well-being was inversely correlated among patients and partners. Accommodative coping was positively correlated with quality of life in both patients and partners. Conversely, assimilation was negatively related to quality of life in patients.

Systematic review of aetiology and treatment of post-stroke hand oedema and shoulder-hand syndrome.

Studies on the aetiology and treatment of post-stroke hand oedema and shoulder-hand syndrome (SHS) published from January 1973 until August 1998 were identified. Eleven studies were included with at least some control for confounding. These were evaluated on 11 methodological criteria and by standardized effect sizes. There were five aetiological studies: four cohort studies and one study consisting of two case series using a within-subjects design. The matters investigated included lymph scintigraphy in hand oedema, bone scintigraphy, putative risk factors and the existence of autonomic dysregulation and peripheral nerve lesions in SHS. There were six therapeutic studies: one randomized controlled trial, one non-randomized controlled trial, one cohort study and three case series, of which two studies used a within-subjects design. These studies investigated continuous passive motion and neuromuscular stimulation in hand oedema as well as oral corticosteroids, intramuscular calcitonin and trauma prevention in SHS. A great diversity of pathophysiological and therapeutic insight was found. Based on systematic analysis of the literature, the following conclusions seem justified: (i) the shoulder is involved in only half of the cases with painful swelling of wrist and hand, suggesting a "wrist-hand syndrome" between simple hand oedema and SHS; (ii) hand oedema is not lymphoedema; (iii) SHS usually coincides with increased arterial blood flow; (iv) trauma causes aseptic joint inflammations in SHS; (v) no specific treatment has yet proven its advantage over other physical methods for reducing hand oedema; and (vi) oral corticosteroids are the most effective treatment for SHS.

Reflex sympathetic dystrophy: is the immune system involved?

OBJECTIVE: Evaluation of immune system function in patients with reflex sympathetic dystrophy (RSD). DESIGN: Survey on blood samples obtained from RSD patients and from a randomly selected control group. The lymphocyte populations (T, B, NK cells), and the activated T cells (CD25, and HLA-Dr-positive CD4 and CD8 cells) were analyzed by flow cytometry with dual-color direct immunofluorescence after whole-blood lysis. Clinical chemistry parameters were analyzed in additional serum samples. SETTING: Tertiary care center (outpatient rehabilitation clinic). SUBJECTS: Thirteen patients (nine women) with RSD and a control group of 21 healthy individuals. MAIN OUTCOME MEASURES: The results of the flow cytometry analysis of RSD patients were related to those of the control subjects. Means were analyzed, and confidence intervals for differences of the means were calculated. The means of the clinical chemical analysis were related to local reference values. RESULTS: The flow cytometry analysis did not differ between RSD patients and healthy controls. Although in some patients an individual parameter of clinical chemical analysis differed from its reference value, all of the mean values were within reference limits. Stratification on medications with immunomodulatory effects and on probability of a definite diagnosis of RSD had no influence on the results. CONCLUSION: No association between immunologic indices and RSD was found. This finding is relevant, because recent theories stress that it is not the sympathetic nervous system but a local inflammatory reaction that is fundamental in the pathogenesis of RSD. The results of this study do not support this theory.

Axillary brachial plexus blockade for the reflex sympathetic dystrophy syndrome.

The reflex sympathetic dystrophy syndrome (RSD) is a neurogenic pain syndrome that is characterized by pain, vasomotor and dystrohic changes and often motor impairments. Although the exact pathogenesis of RSD is unknown, for long the sympathetic nervous system was thought to play a dominant role and pharmacological and surgical sympathectomies have been a mainstay in treatment procedures. However, there is growing evidence of a pivotal role of C- and A delta-fibres in the aetiology of RSD. These fibres subserve a dual sensory-effector function. Besides the initiation of afferent impulses, they release neuropeptide mediators that cause a peripheral neurogenic inflammatory reaction and central neuroplastic reactions. Brachial plexus blockade (BPB) with local anaesthetic drugs interferes with the conduction of action potentials along both sympathetic efferents and the somatosensory C- and A delta-afferents and therefore seems a potential treatment modality in RSD. The aim of this study was to draw attention on this regional anaesthetic technique that is not commonly used in RSD. In this study six patients with severe RSD of an upper extremity in varying stages were treated with BPB in the multidisciplinary setting of an out-patient rehabilitation clinic with a follow-up of 12 to 21 months. The study was not placebo controlled. Three patients responded well. In these cases the treatment interval varied from 3 to 6 months, one case had RSD stage 1 and the two others stage 2. Three patients showed poor response. In one of these patients the initial effect was good but due to an infection at the insertion site of the catheter BPB had to be discontinued. The other two poor-responders had treatment intervals of 7 and 25 months and both had stage 3 RSD. We conclude that there is theoretical and clinical support to further evaluate the effect of BPB as a treatment modality in the early stages of RSD.

Identification of static and dynamic postural instability following traumatic brain injury.

OBJECTIVE: Quantitative evaluation of static and dynamic aspects of postural instability as a long-term consequence of traumatic brain injury (TBI). DESIGN: Experimental two-group design. SETTING: Outpatient rehabilitation department. PATIENTS AND OTHER PARTICIPANTS: From a consecutive sample of TBI patients at least 6 months after trauma, 20 subjects were selected who complained of reduced gross motor skills but showed no sensorimotor impairments in a standard neurological examination (11 men, 9 women; mean age 36.2 +/- 10.7 years). Thirteen patients had sustained mild, 2 moderate, and 5 severe TBI. Twenty healthy controls were matched for age and gender. INTERVENTION: None. MAIN OUTCOME MEASURES: A dual-plate force platform recorded the amplitude and velocity of the center-of-pressure fluctuations in the anteroposterior (AP) and lateral (LAT) sway directions during quiet standing. Also, the speed and fluency of weight shifting using visual feedback was registered. Both balance tasks were combined with an arithmetic task, whereas quiet standing was also tested with visual deprivation. RESULTS: Compared to controls, TBI patients showed an increase of over 50% in AP and LAT sway, and a weight-shifting speed 20% lower. Dual-task interference was never significant. Visual deprivation was most detrimental for the TBI patients, particularly for LAT sway control. CONCLUSION: A long-term overall reduction in both static and dynamic control of posture can be present after TBI, even in patients without clear neurological deficits. Force-plate recordings can identify such (latent) balance problems. Visual deprivation during quiet standing appears a simple, sensitive test for postural instability related to sensory integration deficits.