Onset, time course and prediction of spasticity after stroke or traumatic brain injury.

OBJECTIVE: To describe spasticity from the onset of acquired brain injury, time course over the first year and factors associated with prediction of the development of spasticity. METHODS: Recent relevant literature known to the authors, along with a complementary search yielding a total of 9 articles, represented the base for this scoping review. RESULTS: Spasticity can be seen in the first week after brain injury and is more common in the upper than lower extremity. The severity of upper-limb impairment is a major factor in the development of spasticity during the first year after stroke. The prevalence of severe spasticity seems to increase during the first year. The combination of reduced arm motor function and spasticity in an early phase (4 weeks post-stroke) is an important predictor of the development of severe spasticity after 12 months. Spontaneous reduction in spasticity was seldom reported but may occur, especially in mild forms of spasticity. CONCLUSION: Signs of spasticity can often be noted within the first 4 weeks after brain injury and is more common in the upper than lower extremity. Impaired sensorimotor function is a predictor. These findings highlight the importance to follow up patients with increased risk of developing severe spasticity to be able to start adequate spasticity treatment and prevent the negative consequences of spasticity. Understanding spasticity onset and progression also provides a basis for the development of effective therapies.

Life situation 5 years after subarachnoid haemorrhage.

OBJECTIVES: Subarachnoid haemorrhage (SAH) has high mortality and morbidity among survivors. SAH mainly affects young people and may result in long-term disabilities such as decreased Health-related Quality of Life (HRQoL), mental health and cognitive function. The aim of this study was to investigate the life situation 5 years after a SAH including physical/emotional status, participation and HRQoL. MATERIALS & METHODS: In this cross-sectional descriptive study, a mail survey was sent to all persons treated at a neurosurgery unit in Gothenburg, Sweden, for non-traumatic SAH in 2009-2010, approximately 5 years post-SAH. The survey included questions regarding HRQoL; EuroQol 5-Dimensions (EQ-5D), the impact of the SAH; Stroke Impact Scale (SIS), Occupational Gaps Questionnaire and participation in society; Impact of Participation and Autonomy (IPA). RESULTS: Forty-two 5 year survivors were sent the survey, of whom 26 (62%) responded (59 years old, range 33-85). The participants had generally low HRQoL and scored low in the domain of anxiety and depression. Many reported problems with emotions, fatigue, memory and executive function, but few problems with physical condition. However, nearly all participants reported to have an acceptable level of participation and 64% were independent in their daily life. CONCLUSIONS: In this 5-year follow-up after SAH, the participants reported to have a greater number of hidden disabilities compared to physical problems, whereas most had acceptable participation in society. A yearly follow-up after a SAH could be suggested aiming to improving the cognitive and mental health.

The impact of physical function on participation in the first year post-stroke.

OBJECTIVES: Studies have investigated predictors of participation and showed that fewer depressive symptoms, physical independence, and age could predict the level of participation after stroke. Association between self-assessed functions and perceived levels of participation over time is not yet known. The aim of this study was to investigate perceptions of participation and how this related to background characteristics and self-assessed rehabilitation outcomes, at 1, 6, and 12 months post-stroke. MATERIALS AND METHODS: To capture experienced functioning and participation, a self-assessment questionnaire, the Stroke Impact Scale (SIS), was used at 1, 6, and 12 months post-stroke. Possible variables with impact on perceived participation were investigated with logistic regression: perceived physical functions, memory and thinking, emotion and communication (SIS), as well as background characteristics. In addition, directions, distributions, and strength of correlations between each independent variable and the participation domain were analyzed using scatterplots. RESULTS: Participation scores were widely distributed during the first year post-stroke. Significant associations were only found between perceived Physical score and participation during the first year post-stroke (1 month, n=92, P<.001; 6 months, n=79, P=.001; 12 months, n=78, P=.002). A moderate-to-high participation score was observed in combination with a high level of perceived emotional health and cognitive skills, at 1, 6, and 12 months. CONCLUSIONS: The findings indicate that to improve participation during the first year post-stroke, physical functioning as well as emotional and cognitive health can be important areas of concern when forming rehabilitation interventions.

The extent of using mobility assistive devices can partly explain fatigue among persons with late effects of polio - a retrospective registry study in Sweden.

BACKGROUND: Fatigue is reported as one of the most disabling symptoms and is common among persons living with late effects of polio. Although fatigue has been studied in the context of people living with late effects of polio, there is a lack of knowledge concerning the association of fatigue and variables of importance for participation in daily life. Therefore, the aim of this study was to explore possible factors associated with fatigue among persons with late effects of polio in Sweden. METHODS: This retrospective registry study consisted of 89 persons with late effects of polio living in Sweden. Fatigue was measured with the Multidimensional Fatigue Inventory (MFI-20) scale, Swedish version. Pearson's correlation coefficient was used to analyse the correlation between the factors and fatigue, and a multiple linear regression was carried out to explore factors for fatigue. RESULTS: Fatigue statistically significantly correlated with age (r = 0.234, p < 0.05) and the use of mobility assistive devices (r = 0.255, p < 0.05). The multiple linear regression model showed that the factors age (ß = 0.304, p < 0.019) and mobility assistive devices (ß = 0.262, p < 0.017) were associated with fatigue among persons living with late effects of polio, and the model partly explained 14% of the variation of fatigue. CONCLUSIONS: Fatigue could partly be explained by the extent of using mobility assistive devices and age. Healthcare professionals should provide and demonstrate the importance of assistive devices to ensure management of fatigue in persons living with late effects of polio.

A comparison of stroke rehabilitation; data from two national cohorts.

OBJECTIVES: Inpatient rehabilitation is a commonly used complex intervention to improve a person's independence after stroke. Evaluation and comparison of the effects of routine clinical practice could provide a contribution towards optimization of stroke care. The aim of this study is to describe results of inpatient rehabilitation as a complex intervention for persons after stroke and explore possible differences between two countries. METHODS: Data from 1055 Latvian and 1748 Swedish adult patients after stroke receiving inpatient rehabilitation, during 2011-2013, were used for this retrospective cohort study. Qualitative description of systems, as well as information on basic medical and sociodemographic information, and organizational aspects were reported. Change in the Functional Independence Measure during rehabilitation was investigated. In six domains of the instrument, the shifts for three levels of dependence were analysed using ordinal regression analysis. RESULTS: The components of stroke care seem to be similar in Latvia and Sweden. However, the median time since stroke onset until the start of rehabilitation was 13 weeks in Latvia and 2 weeks in Sweden. The median length of rehabilitation was 12 and 49 days, respectively. The level of dependency at start, time since stroke onset and length of the period had an impact on the results of the rehabilitation. CONCLUSIONS: Although components of the rehabilitation are reported as being the same, characteristics and the outcome of the inpatient rehabilitation are different. Therefore, comparison of stroke rehabilitation between countries requires caution.

Stroke treated at a neurosurgical ward: a cohort study.

OBJECTIVES: Little is known about the long-term recovery of patients treated with neurosurgery after stroke. This study aimed to explore the recovery of patients with first-time stroke treated in a neurosurgical ward, including their function, the presence of disability and life situation at admission, discharge and 4 years later. METHODS: In this cohort study, 28 subjects (average age 55 years) were included. All had first-time stroke and were treated at the neurosurgical ward consecutively for 18 months. Baseline characteristics were identified, and follow-up home visits (n = 13) were performed 4 years post-stroke to explore the life situation, health status and recovery. RESULTS: At admission, the median Glasgow Coma Scale score was 8 (range 3-15). Craniectomy or craniotomy was performed on 12 of the subjects. Average hospitalization time was 58 days. Two subjects died during the hospital stay, and an additional five died before the follow-up. Significant improvement in function from discharge to follow-up was noted: four of 13 were back at work, two were in need of personal assistance and one lived in a nursing home. Follow-up questionnaires showed a relatively high level of participation and independence. CONCLUSIONS: Patients with stroke who were admitted to a neurosurgical ward had a low mortality rate during the acute treatment, and at 4 years post-stroke, the survival rate was 75%. The level of disability and dependence at discharge was high, but at 4 years post-stroke, there was both measurable and self-perceived improvement in function.

Enhancing patient-provider communication for long-term post-stroke spasticity management.

Stroke is a major public health concern, with estimated 16 million people worldwide experiencing first-time strokes each year, a number that is expected to rise. Two-thirds of those experiencing a stroke are younger than 70 years of age. Stroke is a leading cause of disability in adults as a result of major sequelae that include spasticity, cognitive impairment, paresis, and depression. Disabling spasticity, defined as spasticity severe enough to require intervention, occurs in 4% of stroke survivors within 1 year of first-time stroke. The aim of this report is to focus instead on a discussion of patient-provider communication, and its role in post-stroke spasticity (PSS) rehabilitation within the context of patient-centered health care. A discussion based on a review of the literature, mainly since 2000. Problems within communication are identified and suggestion to enhance communication are proposed thus improving patient-centered goal setting/goal achievement for the effective management of spasticity rehabilitation. These are as follows: (i) involving family members, (ii) educating patients and family members on stroke and rehabilitation, and (iii) establishing a common definition for long-term goals. Increased communication among physicians, patients, and payers may bridge some of the gaps and increase the effectiveness of PSS rehabilitation and management.

More outcomes than trials: a call for consistent data collection across stroke rehabilitation trials.

Stroke survivors experience complex combinations of impairments, activity limitations, and participation restrictions. The essential components of stroke rehabilitation remain elusive. Determining efficacy in randomized controlled trials (RCTs) is challenging; there is no commonly agreed primary outcome measure for rehabilitation trials. Clinical guidelines depend on proof of efficacy in RCTs and meta-analyses. However, diverse trial aims, differing methods, inconsistent data collection, and use of multiple assessment tools hinder comparability across trials. Consistent data collection in acute stroke trials has facilitated meta-analyses to inform trial design and clinical practice. With few exceptions, inconsistent data collection has hindered similar progress in stroke rehabilitation research. There is an urgent need for the routine collection of a core dataset of common variables in rehabilitation trials. The European Stroke Organisation Outcomes Working Group, the National Institutes of Neurological Disorders and Stroke Common Data Elements project, and the Collaborative Stroke Audit and Research project have called for consistency in data collection in stroke trials. Standardizing data collection can decrease study start up times, facilitate data sharing, and inform clinical guidelines. Although achieving consensus on which outcome measures to use in stroke rehabilitation trials is a considerable task, perhaps a feasible starting point is to achieve consistency in the collection of data on demography, stroke severity, and stroke onset to inclusion times. Longer term goals could include the development of a consensus process to establish the core dataset. This should be endorsed by researchers, funders, and journal editors in order to facilitate sustainable change.

Unlocking the locked in; a need for team approach in rehabilitation of survivors with locked-in syndrome.

OBJECTIVES: A stroke that affects the medulla oblongata and/or pons can result in tetra pareses and paralysis of the lower cranial nerves while other parts of the brain remain intact, thus locking the person in. The incidence and prevalence is not known. The aim of this article is to communicate the need for and benefits of a comprehensive rehabilitation and a standardized way of approaching the locked-in person. MATERIAL AND METHODS: To illustrate the rehabilitation process, we present four cases to highlight the needs of the person and what is required of the team. RESULTS: Communication at arrival: three persons communicated through eye movement, one by weak voice. At follow-up (1-6 years later): computer assisted communication was used by two persons, a letter board by one and 'ordinary communication' by one. CONCLUSIONS: There is a need for follow-up not only to re-assess skills and needs partly owing to new technologies but also to see whether the person needs more assistance to adapt to the alternative means of communication or whether the carers of the person need extra information about communication. We conclude that the low incidence of the syndrome necessitates a skilled team in which different professionals can together assess the person. This probably requires some centralization.

The Swedish version of the Haemophilia Activity List.

There has been increasing interest in the patient's perspective on outcome of treatment. The Haemophilia Activity List (HAL) has been developed as a disease-specific questionnaire for haemophilia patients and is a validated self-report measure of function developed according to WHO's International Classification of Functioning, Disability and Health. To validate HAL in Sweden. The Dutch and English versions of HAL were translated into Swedish using 'the forward-backward translation' method and merged into a final Swedish version. Validation was performed against the Swedish version of the questionnaires Arthritis Impact Measurement 2 (AIMS 2) and Impact on Participation and Autonomy (IPA). Two hundred and twenty-five patients with severe and moderate forms of haemophilia A and B from three centres were invited to participate in the study. Spearman's rank correlation test was used for validation, and internal consistency of the HAL was calculated with Cronbach's alpha. Eighty-four patients (39%) (18-80 years old) filled out the questionnaires. The internal consistency of the Swedish version of HAL was high, with Cronbach's alpha being 0.98-0.71. Function of the legs had the highest consistency and transportation had the lowest. The correlation was excellent between the HAL sum score and AIMS 2 physical (r = 0.84, P < 0.01), IPA autonomy indoors (r = 0.83, P < 0.01) and autonomy outdoors (r = 0.89, P < 0.01). The Swedish version of HAL has both internal consistency and convergent validity and may complement other functional tests to gather information on the patient's self-perceived ability.

Functioning of the upper extremity in persons with late polio.

BACKGROUND: There are a number of people living with late effects of polio, but the extent of engagement with the upper extremity is unclear. The objective is to describe the polio involvement in persons attending the polio clinic and to assess the perceived problems in self-reported arm/hand function. MATERIAL AND METHODS: A 1-year sample of consecutively examined community-dwelling people at the polio clinic. Electromyography and muscle strength were assessed as part of the clinical examination. A questionnaire regarding perceived problems in different activities involving arm/hand function was sent out prior to appointment and brought to the clinic. RESULTS: A total of 186 persons were seen, and the majority was women (65%). The average age at examination was 60 years (SD 14), and the acute polio illness had occurred at 5 years of age (SD 7). Post-polio syndrome was present in 96%. Polio involvement in the upper extremities was seen in the majority, and this was often clinically unstable. Perceptions of problems in arm/hand activities did not always correlate with having had polio in the upper extremity or with mode of mobility. However, the grip force correlated significantly with the number of perceived problems. Bi-manual activities were more often perceived problematic. CONCLUSIONS: Polio involvement in the upper extremity is very common. There were no obvious correlations with the objective findings of polio and perceived problems. The polio survivors' adaptation requires more questions and assessments from the professional team to identify those with a possible need for intervention.

Return to work after acquired brain injury: facilitators and hindrances observed in a sub-acute rehabilitation setting.

OBJECTIVES: There is great variability in the rate of return to work for persons who have suffered from brain injury. The aims of this study was: 1) to describe employment status of persons with stroke or traumatic brain injury, one year after the incident and 2) to investigate the impact of injury/stroke severity, length of stay, the ability to perform activities of daily living and cognitive function on return to work. PARTICIPANTS AND METHODS: Information was collected from 72 persons; 48 with a diagnosis of stroke and 24 with a traumatic brain injury. All patients had attended to a Rehabilitation Centre with inpatient and outpatient facilities. Data of the above mentioned variables was gathered retrospectively and information about employment status was retrieved from the medical records. RESULTS: After one year, 13 persons (approximately 18%), 5 with a stroke and 8 with a traumatic brain injury (one with mild brain injury, 9 with moderate and 3 persons with severe injuries) had returned to work. They had significantly shorter length of stay at the rehabilitation hospital and were younger than those that did not return to work. Somewhat better results at the neuropsychological screening were seen among those that returned to work, although with a significant difference only in the subscale assessing affect. Some persons with severe injury returned to work, while a majority of those with mild brain injury did not. CONCLUSION: Traumatic brain injury, younger age and less need of rehabilitation were associated with a higher rate of returning to work. Patients with stroke were older and seem to need more support in order to be successful in work return. It is of importance to reach primary rehabilitation goals, such as being ADL independent, as this was also favourable for work return. The impact of injury severity seemed complex and should to be further explored. Persons with mild brain injury should be followed-up with respect to work return. An important cognitive factor was ability to perceive and express affective responses, reflecting the need of social skills in today's work-life.

Changes in ability, perceived difficulty and use of assistive devices in everyday life: a 4-year follow-up study in people with late effects of polio.

BACKGROUND: There are numbers of persons living in the community with late effects of polio, of which many develop new symptoms, but the course of progression is unclear. OBJECTIVES: To assess changes after 4 years in ability and perceived difficulty in persons with late effects of polio. MATERIAL AND METHODS: Community dwelling persons from a polio clinic. Information was gathered by questionnaire and interview on demographics, age at polio onset, affected body parts, health problems, the use of assistive devices, housing condition and activities of daily living (ADL) function as well as perceived difficulties. RESULTS: There were no significant increase in frequency of ADL dependency but perceived difficulties increased significantly and more used mobility devices. CONCLUSIONS: Over 4 years, more persons perceived difficulties and the use of assistive devices increased. This is might reflect adaptation and acknowledgement of problems previously ignored. Time is a factor in integrating knowledge and adaptation.

Agreement in activities of daily living performance after stroke in a postal questionnaire and interview of community-living persons.

OBJECTIVE: To compare assessments of activities of daily living (ADL) made in a postal questionnaire and an interview. DESIGN: Comparative study of a convenience sample. SUBJECTS: Results in 36 persons with stroke >10 years previously. METHODS: Data on ADL were gathered in a self-administered postal questionnaire followed by a semi-structured interview (within 1-2 weeks) using items in the Functional Independence Measure, combined with instrumental items, Instrumental Activity Measure or the ADL taxonomy (personal and instrumental items). RESULTS: There was generally moderate to good agreement between the postal questionnaire and the interview. Other dependence identified was reported during the interviews. Although the operational descriptions of the items varied between the ADL indices, they primarily identified ADL independence in the same persons. CONCLUSION: The use of a self administrated postal ADL questionnaire was feasible for studying ADL performance. However, in some persons, interviews may be needed to complement the results.

Two years after cardiac arrest; cognitive status, ADL function and living situation.

PURPOSE: To describe cognitive function, activities of daily living (ADL), housing and return to work after cardiac arrest (CA) and examine the prognostic value of early assessments. METHOD: Two years after CA 22 persons were assessed with the Barrow Neurological Screen for Higher Cerebral Functions (BNIS) and the Functional Independence Measure (FIM). Data on early assessments of neurological status (The National Institute of Health Stroke Scale, NIHSS), mental status (the Mini Mental State Examination, MMSE) and ADL ability (FIM) were retrieved. RESULTS: Sixty-four per cent were living in their own home, 36% lived in sheltered accommodation and 29% of those of working age had returned to work. Cognitive dysfunction was noted in 95% according to neuropsychological screen. Four persons living in own homes were in need of assistance in social-cognitive ADL. All those in sheltered accommodation needed help in ADL; one was independent in motor functions. This need for assistance was reflected at initial assessments by a higher degree of neurological deficits, cognitive dysfunctions and dependency in ADL activities. CONCLUSION: The majority had persistent cognitive dysfunctions. Persons in sheltered accommodation were dependent for ADL. Early evaluation is important for understanding and planning for future need for assistance and care, having realistic goals.

Recovery after stroke: cognition, ADL function and return to work.

OBJECTIVES: To examine the recovery of cognitive function, activities of daily living (ADL) ability and vocational situation after stroke. MATERIALS AND METHODS: Subjects below 65 years of age were included. Cognitive function and personal and instrumental ADL were assessed at discharge and at 1 year. Pre-stroke vocational situation was recorded at baseline and at 1 and 3 years after discharge. RESULTS: Fifty-eight patients participated. During the first year after discharge, cognitive function and ADL ability improved. At 1 year after discharge, 83% still had cognitive dysfunction, 20% were dependent in ADL and few had returned to work. Only 20% returned to gainful employment 3 years later. CONCLUSIONS: There was a recovery of cognition and ADL function after stroke but few persons returned to work. Good neurological status was found to be a significant factor and recovery of cognitive function a near-significant factor for return to work.

Cross-diagnostic validity in a generic instrument: an example from the Functional Independence Measure in Scandinavia.

BACKGROUND: To analyse the cross-diagnostic validity of the Functional Independence Measure (FIM) motor items in patients with spinal cord injury, stroke and traumatic brain injury and the comparability of summed scores between these diagnoses. METHODS: Data from 471 patients on FIM motor items at admission (stroke 157, spinal cord injury 157 and traumatic brain injury 157), age range 11-90 years and 70 % male in nine rehabilitation facilities in Scandinavia, were fitted to the Rasch model. A detailed analysis of scoring functions of the seven categories of the FIM motor items was made prior to testing fit to the model. Categories were re-scored where necessary. Fit to the model was assessed initially within diagnosis and then in the pooled data. Analysis of Differential Item Functioning (DIF) was undertaken in the pooled data for the FIM motor scale. Comparability of sum scores between diagnoses was tested by Test Equating. RESULTS: The present seven category scoring system for the FIM motor items was found to be invalid, necessitating extensive rescoring. Despite rescoring, the item-trait interaction fit statistic was significant and two individual items showed misfit to the model, Eating and Bladder management. DIF was also found for Spinal Cord Injury, compared with the other two diagnoses. After adjustment, it was possible to make appropriate comparisons of sum scores between the three diagnoses. CONCLUSION: The seven-category response function is a problem for the FIM instrument, and a reduction of responses might increase the validity of the instrument. Likewise, the removal of items that do not fit the underlying trait would improve the validity of the scale in these groups. Cross-diagnostic DIF is also a problem but for clinical use sum scores on group data in a generic instrument such as the FIM can be compared with appropriate adjustments. Thus, when planning interventions (group or individual), developing rehabilitation programs or comparing patient achievements in individual items, cross-diagnostic DIF must be taken into account.

Postural control in persons with late effects of polio.

BACKGROUND: Persons who have suffered from acute poliomyelitis may decades later experience reduction of balance and gait capacity due to muscle weakness, fatigue and/or pain. This may affect the activity level in daily life of these persons. AIMS OF THE STUDY: The aim of this study was to describe observer assessed and subjectively perceived postural control in persons with late effects of polio and to evaluate the correlation between postural control and gait velocity for this population. METHOD: 50 persons (mean age 59.8 yrs) with diagnosed polio disease and without other causes of mobility disorders were included. Balance was tested with the Timed Up and Go test (TUG), the Functional Reach test (FR) and the Falls Efficacy Scale (FES) (Swedish Version). Gait velocity over 30 m was measured for convenient and maximal velocity. RESULTS: The subjects had reduced balance (TUG mean 9.0 sec, FR mean 23.5 cm) and perceived balance problems in ADL items (FES(S) median 119.5, normal value 130). They also showed reduced gait velocity compared to healthy persons of the same age (mean 1.01 m/s compared to 1.30 m/s, convenient speed). Correlations were demonstrated between the reduced balance and decreased convenient and maximal gait velocity (TUG/gait velocity: r = -0.7 (convenient), r = -0.8 (maximal), p

Outcome after severe brain damage, what makes the difference?

OBJECTIVE: To assess and compare the consequences for outcome in terms of the dimensions of activity and participation for two groups: group A, which received early formalized rehabilitation, and group B, which received late or no formalized rehabilitation. RESEARCH DESIGN: A cross-sectional study. PROCEDURE: Twenty-six patients (A: n = 14 and B: n = 12) with severe brain damage were included. The participants were assessed a mean of 26.6 months (SD 7.1, median 25, range 14-41) after the incident using the structured form for the Swedish Neuro database, the Glasgow Outcome Scale (GOS), the Extended Glasgow Outcome Scale (GOSE) and the Functional Independence Measure (FIM). RESULTS: The study reveals a better outcome for group A. No patient remained in a vegetative state in group A as compared with three in group B. In group A, 50% were independent as compared with 17% in group B. The frequency of return to work was 43% in group A, but no patient in group B had returned to work.