Trajectories of arm recovery early after stroke: an exploratory study using latent class growth analysis.

AIM: To investigate trajectories of recovery of motor arm function after stroke during inpatient rehabilitation. MATERIALS AND METHODS: Data were available from 74 consecutively-admitted stroke survivors receiving inpatient rehabilitation from an inception cohort study. Heterogeneity of arm recovery in the first 4-weeks was investigated using latent class analysis and weekly Box and Block Test (BBT) scores. Optimal number of clusters were determined; characterised and cluster associated factors explored. RESULTS: A 4-cluster model was identified, including 19 participants with low baseline arm function and minimal recovery ('LOWstart/LOWprogress', 26%), 15 with moderate function and low recovery ('MODstart/LOWprogress', 20%), 15 with low function and high recovery ('LOWstart/HIGHprogress', 20%), and 25 with moderate function and recovery ('MODstart/MODprogress', 34%). Compared to LOWstart/LOWprogress: LOWstart/HIGHprogress presented earlier post-stroke (ß, 95%CI) (-4.81 days, -8.94 to -0.69); MODstart/MODprogress had lower modified Rankin Scale scores (-0.74, -1.15 to -0.32); and MODstart/LOWprogress, LOWstart/HIGHprogress and MODstart/MODprogress had higher admission BBT (23.58, 18.82 to 28.34; 4.85, 0.85 to 9.61; 28.02, 23.82 to 32.21), Upper Limb-Motor Assessment Scale (9.60, 7.24 to 11.97; 3.34, 0.97 to 5.70; 10.86, 8.77 to 12.94), Action Research Arm Test (31.09, 22.86 to 39.33; 12.69, 4.46 to 20.93; 38.01, 30.76 to 45.27), and Manual Muscle Test scores (10.64, 7.07 to 14.21; 6.24, 2.67 to 9.81; 11.87, 8.72 to 15.01). CONCLUSIONS: We found unique patterns of arm recovery with distinct characteristics for each cluster. Better understanding of patterns of arm recovery can guide future models and intervention development.KEY MESSAGESArm recovery early after stroke follows four distinct trajectories that relate to time post stroke, initial stroke severity and baseline level of motor arm function.Identification of recovery patterns gives insight into the uniqueness of individual's recovery.This study offers a novel approach on which to build and develop future models of arm recovery.

Assessing unmet rehabilitation needs and the feasibility of a telehealth rehabilitation consultation service for road trauma survivors recently discharged from hospital.

PURPOSE: Persistent activity limitations are common among road trauma survivors, yet access to rehabilitation in hospital and in the community remains variable. This study aimed to identify unmet rehabilitation needs following road trauma and assess the feasibility of a novel rehabilitation consultation service delivered via telehealth following hospitalization. METHODS: A pilot cohort study was conducted with survivors of road trauma who were hospitalized but did not receive formal inpatient rehabilitation. All participants received a multidisciplinary rehabilitation consultation via telehealth 1-3 weeks post-discharge, to assess rehabilitation needs and initiate treatment referrals as required. Functional and qualitative outcomes were assessed at baseline (1-7 days); one month and three months post-discharge. RESULTS: 38 participants were enrolled. All (100%) reported functional limitations at baseline; 86.5% were found to have unmet rehabilitation needs, and 75.7% were recommended rehabilitation interventions. Functional ability improved over time, but more than half the cohort continued to report activity limitations (67.6%), pain (64.7%) and/or altered mood (41.2%) for up to three months. Participants found the telehealth service to be acceptable, convenient, and helpful for recovery. CONCLUSIONS: A high proportion of mild-moderate trauma survivors report unmet rehabilitation needs following hospital discharge. Telehealth appears to be a feasible, convenient and acceptable mode of assessing these needs.Implications for rehabilitationSurvivors of road-related injuries often experience ongoing impairments and activity limitations.Among those who don't receive rehabilitation in hospital, we found a high proportion (86.5%) had unmet rehabilitation needs after discharge.A telehealth rehabilitation service was feasible to deliver and could successfully identify unmet rehabilitation needs.The piloted telehealth intervention was viewed as acceptable, convenient and beneficial by patients.

Cross-sectional survey of rehabilitation service availability for stroke and hip fracture in Australian public hospitals.

OBJECTIVE: To describe the rehabilitation services available for people with stroke and hip fracture across New South Wales/Australian Capital Territory metropolitan and rural/regional public hospitals in Australia. DESIGN: A cross-sectional study design was used. SETTING: New South Wales/Australian Capital Territory public hospital providing rehabilitation services for stroke and hip fracture. PARTICIPANTS: Delegates from 59 eligible hospitals. INTERVENTION: Information about the type, number and availability of inpatient and outpatient rehabilitation services at each hospital was collected via survey. MAIN OUTCOME MEASURES: Counts, percentages, mean (SD), median (IQR) were used to quantify the number and type of inpatient and outpatient services available. RESULTS: Across inpatient rehabilitation units, reduced availability was noted in the number of clinical disciplines available, availability of neuropsychology and social work in rural units. Across outpatient rehabilitation services, reduced availability was noted in the number of disciplines available, availability of occupational therapy, psychology, rehabilitation physicians, specialist nursing, geriatricians, and podiatry in rural services. Five rural hospitals had no access to outpatient rehabilitation. CONCLUSION: There was reduced availability of rehabilitation services and health disciplines in rural/regional settings. A follow-up study is underway investigating relationships between reduced outpatient service availability and inpatient length of stay in rural/regional versus metropolitan hospitals.

Dosage and predictors of arm practice during inpatient stroke rehabilitation: an inception cohort study.

PURPOSE: To describe the amount/type of arm practice completed by stroke survivors during inpatient rehabilitation; and establish predictors of arm practice dose achieved. MATERIALS AND METHODS: Inception cohort study including 99 consecutively admitted stroke survivors. Amount (repetitions) and type of arm practice completed during inpatient rehabilitation and possible predictors of dose were recorded. RESULTS: Average length-of-stay was 36.9 days (standard deviation (SD) = 30.0, median = 28.0, interquartile range = 39.5) and days of therapy provided was 11.1 days (SD = 13.3, median = 6.0, IQR = 12.0). Mean number of arm practice sessions completed overall was 12.8 (SD = 15.3, median = 7.0, interquartile range = 15.0), or 2.0 sessions per week (SD = 1.5, median = 1.5, interquartile range = 1.7). Mean repetitions of practice completed per therapy day was 86.1 (SD = 76.5, median = 68.5, interquartile range = 88.2). Variation in practice dose was best explained by age (-1.3 repetitions per year of age, p = 0.04) and cognitive impairment (-34.9 repetitions, p = 0.03). In participants without cognitive impairment (n = 73) variation in dose was best explained by stroke severity (modified Rankin Sale = 5, -48.4 repetitions, p = 0.01), and the inability to grasp/release (Box and Block Test = 0, +48.3 repetitions, p = 0.03). CONCLUSIONS: The amount of arm practice completed was low. Daily sessions were often not provided as recommended in clinical guidelines. Clinicians should focus on strategies to increase intensity and opportunities for arm practice.Implications for RehabilitationDose (repetitions) of arm practice varied greatly during inpatient rehabilitation.Number of arm rehabilitation sessions provided was lower than levels recommended in clinical guidelines.Therapists and researchers should focus on strategies to increase amount of therapy and opportunities for arm practice.

Prevalence of upper-limb spasticity and its impact on care among nursing home residents with prior stroke.

Purpose: Post-stroke spasticity can impair motor function and may cause pain, limb deformity, contracture, and difficulties with limb care. This study aimed to assess the prevalence and burden of post-stroke upper-limb spasticity among nursing home residents.Materials and methods: A multisite, cross-sectional study was conducted across three nursing home facilities. Participants included residents with a confirmed diagnosis of stroke, and nursing staff involved in their care. Residents were assessed using the Tardieu Scale, passive range-of-motion, Abbey Pain scale, Modified Rankin Scale and observation of limb position and skin condition. Nursing staff completed the Arm Activity Measure (ArmA).Results: 264 individuals were screened, 51 had a diagnosis of stroke (19.3%), and 23 consented to participate. 16 participants (70%) demonstrated upper-limb spasticity of at least one joint, median Tardieu score 2 [IQR 2-3]. Pain scores and nurse-rated passive ArmA were significantly higher for patients with spasticity compared to those without (p = 0.003 and p < 0.001, respectively). Greater spasticity correlated with higher pain (rs =0.44) and ArmA scores (rs =0.71).Conclusions: A high proportion (70%) of nursing home residents with stroke demonstrated upper-limb spasticity, associated with pain and passive care difficulties. These data suggest there is an unmet need for spasticity management among nursing-home residents.Implications for rehabilitationUpper-limb spasticity is prevalent among nursing home residents with prior stroke; here, observed in 70% of cases.Spasticity was associated with increased pain and more difficult passive limb care in this population.There is an unmet need for spasticity management among nursing home residents with prior stroke.Efforts should be made to improve access to multidisciplinary spasticity treatment for this vulnerable patient population.

Can in-reach multidisciplinary rehabilitation in the acute ward improve outcomes for critical care survivors? A pilot randomized controlled trial.

OBJECTIVES: To assess the feasibility of in-reach rehabilitation for critical care survivors following discharge from the intensive care unit. To determine whether additional in-reach rehabilitation reduces hospital length-of-stay and improves outcomes in critical care survivors, compared with usual therapy. PARTICIPANTS: A total of 66 consecutively-admitted critical care survivors with an intensive care unit stay ≥ 5 days were enrolled in the study. Of these, 62 were included in the analyses. METHODS: Pilot randomized control trial with blinded assessment at 6 and 12 months. The intervention group (n = 29) received in-reach rehabilitation in addition to usual ward therapy. The usual-care group (n = 33) received usual ward therapy. The primary outcome assessed was length-of-stay. Secondary outcomes included mobility, functional independence, psychological status and quality-of-life. RESULTS: The intervention group received more physiotherapy and occupational therapy sessions per week than the usual-care group (median = 8.2 vs 4.9, p < 0.001). Total length-of-stay was variable; while median values differed between the intervention and usual care groups (median 31 vs 41 days), this was not significant and the pilot study was not adequately powered (p = 0.57). No significant differences were observed in the secondary outcomes at hospital discharge, 6- or 12-month follow-ups. CONCLUSION: Provision of intensive early rehabilitation to intensive care unit survivors on the acute ward is feasible. A further trial is needed to draw conclusions on how this intervention affects length-of-stay and functional outcomes.

Responsiveness of five measures of arm function in acute stroke rehabilitation.

OBJECTIVE: To determine the responsiveness of five arm function measures in people receiving acute inpatient stroke rehabilitation. DESIGN: Inception cohort study. SETTING: Comprehensive stroke unit providing early rehabilitation. SUBJECTS: A total of 64 consecutively admitted stroke survivors with moderately severe disability (Modified Rankin Scale score median (interquartile range (IQR)): 4.0 (1.0)). MAIN MEASURES: Responsiveness was analyzed by calculating effect size, standardized response mean and median-based effect size. Floor/ceiling effects were calculated as the percentage of participants scoring the lowest/highest possible scores. RESULTS: Average length of stay and number of therapy days were 34 (SD = 27.9) and 12 (SD = 13.1), respectively. Box and Block Test and Functional Independence Measure-Self-Care showed the highest responsiveness with values in the moderate-large range (effect size = 1.09, standardized response mean = 1.07 and median-based effect size = 0.76; effect size = 0.94, standardized response mean = 1.04 and median-based effect size = 1.0). Responsiveness of Action Research Arm Test and Upper Limb-Motor Assessment Scale were moderate (effect size = 0.58, standardized response mean = 0.69 and median-based effect size = 0.59; effect size = 0.62, standardized response mean = 0.75 and median-based effect size = 0.67). For Manual Muscle Test, responsiveness was in the small-moderate range (effect size = 0.42, standardized response mean = 0.59 and median-based effect size = 0.5). Box and Block Test showed the largest floor effect on admission (28%), and Action Research Arm Test and Manual Muscle Test showed the largest ceiling effect on discharge (31%). CONCLUSION: These five measures varied in their ability to detect change with responsiveness ranging from the small to large range. Box and Block Test and Functional Independence Measure-Self-Care showed a greater ability to detect change; both demonstrated moderate-large responsiveness.

External validation of approaches to prediction of falls during hospital rehabilitation stays and development of a new simpler tool.

OBJECTIVES: To test the external validity of 4 approaches to fall prediction in a rehabilitation setting (Predict_FIRST, Ontario Modified STRATIFY (OMS), physiotherapists' judgement of fall risk (PT_Risk), and falls in the past year (Past_Falls)), and to develop and test the validity of a simpler tool for fall prediction in rehabilitation (Predict_CM2). PARTICIPANTS: A total of 300 consecutively-admitted rehabilitation inpatients. METHODS: Prospective inception cohort study. Falls during the rehabilitation stay were monitored. Potential predictors were extracted from medical records. RESULTS: Forty-one patients (14%) fell during their rehabilitation stay. The external validity, area under the receiver operating characteristic curve (AUC), for predicting future fallers was: 0.71 (95% confidence interval (95% CI): 0.61-0.81) for OMS (Total_Score); 0.66 (95% CI: 0.57-0.74) for Predict_FIRST; 0.65 (95% CI 0.57-0.73) for PT_Risk; and 0.52 for Past_Falls (95% CI: 0.46-0.60). A simple 3-item tool (Predict_CM2) was developed from the most predictive individual items (impaired mobility/transfer ability, impaired cognition, and male sex). The accuracy of Predict_CM2 was 0.73 (95% CI: 0.66-0.81), comparable to OMS (Total_Score) (p = 0.52), significantly better than Predict_FIRST (p = 0.04), and Past_Falls (p < 0.001), and approaching significantly better than PT_Risk (p = 0.09). CONCLUSION: Predict_CM2 is a simpler screening tool with similar accuracy for predicting fallers in rehabilitation to OMS (Total_Score) and better accuracy than Predict_FIRST or Past_Falls. External validation of Predict_CM2 is required.

Use of audit, feedback and education increased guideline implementation in a multidisciplinary stroke unit.

BACKGROUND: The audit-feedback cycle is a behaviour change intervention used to reduce evidence-practice gaps. In this study, repeat audits, feedback, education and training were used to change practice and increase compliance with Australian guideline recommendations for stroke rehabilitation. OBJECTIVE: To increase the proportion of patients with stroke receiving best practice screening, assessment and treatment. METHODS: A before-and-after study design was used. Data were collected from medical records (n=15 files per audit). Four audits were conducted between 2009 and 2013. Consecutive files of patients with stroke admitted to the stroke unit were selected and audited retrospectively. Staff behaviour change interventions included four cycles of audit feedback, and education to assist staff with change. The primary outcome measure was the proportion of eligible patients receiving best practice against target behaviours, based on audit data. RESULTS: Between the first and fourth audit (2009 and 2013), 20 of the 27 areas targeted (74%) met or exceeded the minimum target of 10% change. Practice areas that showed the most change included sensation screening (+75%) and rehabilitation (+100%); neglect screening (+92%) and assessment (100%). Some target behaviours showed a drop in compliance such as anxiety and depression screening (-27%) or little or no overall improvement such as patient education about stroke (6% change). CONCLUSIONS: Audit feedback and education increased the proportion of inpatients with stroke receiving best practice rehabilitation in some, but not all practice areas. An ongoing process of quality improvement is needed to help sustain these improvements.

Barriers and enablers to implementing multiple stroke guideline recommendations: a qualitative study.

BACKGROUND: Translating evidence into practice is an important final step in the process of evidence-based practice. Medical record audits can be used to examine how well practice compares with published evidence, and identify evidence-practice gaps. After providing audit feedback to professionals, local barriers to practice change can be identified and targetted with focussed behaviour change interventions. This study aimed to identify barriers and enablers to implementing multiple stroke guideline recommendations at one Australian stroke unit. METHODS: A qualitative methodology was used. A sample of 28 allied health, nursing and medical professionals participated in a group or individual interview. These interviews occurred after staff had received audit feedback and identified areas for practice change. Questions focused on barriers and enablers to implementing guideline recommendations about management of: upper limb sensory impairments, mobility including sitting balance; vision; anxiety and depression; neglect; swallowing; communication; education for stroke survivors and carers; advice about return to work and driving. Qualitative data were analysed for themes using theoretical domains described by Michie and colleagues (2005). RESULTS: Six group and two individual interviews were conducted, involving six disciplines. Barriers were different across disciplines. The six key barriers identified were: (1) Beliefs about capabilities of individual professionals and their discipline, and about patient capabilities (2) Beliefs about the consequences, positive and negative, of implementing the recommendations (3) Memory of, and attention to, best practices (4) Knowledge and skills required to implement best practice; (5) Intention and motivation to implement best practice, and (6) Resources. Some barriers were also enablers to change. For example, occupational therapists required new knowledge and skills (a barrier), to better manage sensation and neglect impairments while physiotherapists generally knew how to implement best-practice mobility rehabilitation (an enabler). CONCLUSIONS: Findings add to current knowledge about barriers to change and implementation of multiple guideline recommendations. Major challenges included sexuality education and depression screening. Limited knowledge and skills was a common barrier. Knowledge about specific interventions was needed before implementation could commence, and to maintain treatment fidelity. The provision of detailed online intervention protocols and manuals may help clinicians to overcome the knowledge barrier.