The course of depressive symptoms in the first 12 months post-stroke and its association with unmet needs.

AIM: To describe the course of depressive symptoms during the first 12 months post-stroke and its association with unmet needs. METHODS: A prospective cohort study among stroke patients admitted to inpatient rehabilitation. Depressive symptoms were assessed 3, 6, and 12 months post-stroke using the Hospital Anxiety and Depression Scale, and categorized into three trajectories: no (all times <8), non-consistent (one or two times ≥8), or persistent (all times ≥8) depressive symptoms. Unmet needs were assessed using the Longer-Term Unmet Needs questionnaire. Multivariable logistic regression analyses were used to investigate the association between depressive symptoms and unmet needs. RESULTS: One hundred and fifty-one patients were included, of whom 95 (62.9%), 38 (25.2%), and 18 (11.9%) had no, non-consistent, or persistent depressive symptoms, respectively. Depressive symptoms three months post-stroke persisted in 43.9% and recurred in 19.5% of patients during the first 12 months post-stroke. Depressive symptoms were significantly associated with the occurrence and number of unmet needs (odds ratio 6.49; p = 0.003 and odds ratio 1.28; p = 0.005, respectively). CONCLUSIONS: Depressive symptoms three months post-stroke were likely to persist or recur during the first 12 months post-stroke. Depressive symptoms are associated with unmet needs. These results suggest that routine monitoring of depressive symptoms and unmet needs should be considered post-stroke.Implications for rehabilitationPatients with depressive symptoms three months post-stroke have a high risk of developing persistent or recurrent depressive symptoms during the first 12 months post-stroke.Unmet needs are associated with both non-consistent and persistent depressive symptoms post-stroke.These results suggest that health professionals should routinely screen for depressive symptoms and health care needs around three months post-stroke.In patients with depressive symptoms at three months post-stroke early treatment of depressive symptoms and addressing unmet needs should be considered and depressive symptoms should be routinely monitored during the first 12 months post-stroke.

Societal burden of stroke rehabilitation: Costs and health outcomes after admission to stroke rehabilitation.

OBJECTIVE: To estimate societal costs and changes in health-related quality of life in stroke patients, up to one year after start of medical specialist rehabilitation. DESIGN: Observational. PATIENTS: Consecutive patients who received medical specialist rehabilitation in the Stroke Cohort Outcomes of REhabilitation (SCORE) study. METHODS: Participants completed questionnaires on health-related quality of life (EuroQol EQ-5D-3L), absenteeism, out-of-pocket costs and healthcare use at start and end of rehabilitation and 6 and 12 months after start. Clinical characteristics and rehabilitation costs were extracted from the medical and financial records, respectively. RESULTS: From 2014 to 2016 a total of 313 stroke patients completed the study. Mean age was 59 (standard deviation (SD) 12) years, 185 (59%) were male, and 244 (78%) inpatients. Mean costs for inpatient and outpatient rehabilitation were US$70,601 and US$27,473, respectively. For inpatients, utility (an expression of quality of life) increased significantly between baseline and 6 months (EQ-5D-3L 0.66-0.73, p = 0.01; visual analogue scale 0.77-0.82, p < 0.001) and between baseline and 12 months (visual analogue scale 0.77-0.81, p < 0.001). CONCLUSION: One-year societal costs from after the start of rehabilitation in stroke patients were considerable. Future research should also include costs prior to rehabilitation. For inpatients, health-related quality of life, expressed in terms of utility, improved significantly over time.

Effect of a comprehensive eRehabilitation intervention alongside conventional stroke rehabilitation on disability and health-related quality of life: A pre-post comparison.

OBJECTIVE: To compare the effect on disability and quality of life, of conventional rehabilitation (control group) with individualized, tailored eRehabilitation intervention alongside conventional rehabilitation (Fast@home; intervention group), for people with stroke. METHODS: Pre-post design. The intervention comprised cognitive (Braingymmer®) and physical (Telerevalidatie®/Physitrack®) exercises, activity-tracking (Activ8®) and psycho-education. Assessments were made at admission (T0) and after 3 (T3) and 6 months (T6). The primary outcome concerned disability (Stroke Impact Scale; SIS). Secondary outcomes were: health-related quality of life, fatigue, self-management, participation and physical activity. Changes in scores between T0-T3, T3-T6, and T0-T6 were compared by analysis of variance and linear mixed models. RESULTS: The study included 153 and 165 people with stroke in the control and intervention groups, respectively. In the intervention group, 82 (50%) people received the intervention, of whom 54 (66%) used it. Between T3 and T6, the change in scores for the SIS subscales Communication (control group/intervention group -1.7/-0.3) and Physical strength (-5.7/3.3) were significantly greater in the total intervention group (all mean differences< minimally clinically important differences). No significant differences were found for other SIS subscales or secondary outcomes, or between T0-T3 and T0-T6. CONCLUSION: eRehabilitation alongside conventional stroke rehabilitation had a small positive effect on communication and physical strength on the longer term, compared to conventional rehabilitation only.

Changes in the ability to participate in and satisfaction with social roles and activities in patients in outpatient rehabilitation.

BACKGROUND: One of the main aims of rehabilitation is to improve participation. Patient-Reported Outcomes Measurement Information System (PROMIS®) item banks 'Ability to Participate in Social roles and Activities, (PROMIS-APS) and 'Satisfaction with Social Roles and Activities' (PROMIS-SPS) are promising options to measure participation, but the literature on PROMIS measures of (satisfaction with) participation across diagnoses in rehabilitation is limited. Therefore, the objective of this study was to describe levels of and changes in participation, as assessed with the PROMIS-APS and the PROMIS-SPS short forms, of patients in outpatient rehabilitation. METHODS: This study had quantitative, observational design with assessments at admission and discharge. Consecutive patients treated between April and August 2018 receiving outpatient multidisciplinary rehabilitation were the population of this study. The following diagnosis categories were included: brain injury (e.g. stroke), spinal cord and nerve injury, neuromuscular disorder (e.g. lateral sclerosis), amputation, musculoskeletal condition (e.g. osteoarthritis) or heart or lung disease (e.g. myocardial infarction, chronic obstructive pulmonary disease). The main patient-reported outcomes (PRO) of this study were the short form of the PROMIS-APS (8 items, Dutch general population reference score 50.6 [SD 9.5]), and PROMIS-SPS (8 items, Dutch general population reference score 47.5 [SD 8.3]. RESULTS: Of the 1279 patients invited, 777 (61%) completed the online forms at admission. Of those, 329 patients were invited at discharge, with 209 (64%) completing the forms. The mean (SD) T-scores of the PROMIS-APS and PROMIS-SPS were lower at admission (42.7 [SD 7.4]; (41.4 [SD 7.7]) and discharge (43.6 [SD 7.2]; (43.7 [SD 7.8]) than the Dutch general population. The change scores of the PROMIS-APS and PROMIS-SPS were 1.2 (95% CI 0.4-1.9; p = 0.004; effect size 0.16), and 2.4 (95% CI 1.6-3.2; p < 0.0001; effect size 0.31), respectively. In all diagnostic subgroups with > 30 paired measurements statistically significant improvements of PROMIS-APS, PROMIS-SPS or both were seen. CONCLUSIONS: Patients undergoing outpatient rehabilitation had, both at admission and discharge, considerably lower PROMIS-APS and PROMIS-SPS T-scores short forms than the general Dutch population, and showed small T-score improvements at discharge.

Out-of-hospital cardiac arrest survivors need both cardiological and neurological rehabilitation!

PURPOSE OF REVIEW: Most survivors of out-of-hospital cardiac arrest (OHCA) suffer from cardiologic symptoms and approximately half of them experience cognitive problems because of hypoxic brain damage. Symptoms of anxiety and depression are also common. This review aims to give an overview of recent literature on rehabilitation treatment aiming at improvement of quality of life after OHCA. RECENT FINDINGS: Existing cognitive screening tools are now validated for OHCA survivors. OHCA patients with cognitive deficits may have lower exercise capacity. Cardiac rehabilitation seems to be well tolerated for OHCA survivors, with outcomes comparable to myocardial infarction patients. Many caregivers suffer from posttraumatic stress disorder and emotional stress. Interventions for them are available. Implementation of integrated programs covering both cognitive and cardiac rehabilitation is hampered by lack of knowledge and organizational barriers. SUMMARY: OHCA survivors should be routinely screened for cognitive and emotional problems. When patients with mild cognitive deficits participate in cardiac rehabilitation, their program should be adjusted to their cognitive abilities. For patients with severe cognitive or emotional problems, individualized rehabilitation seems favorable. Integrated rehabilitation treatment between cardiac and cognitive rehabilitation departments is recommended. Attention should be paid to the burden of caregivers.

Patients' outcome expectations and their fulfilment in multidisciplinary stroke rehabilitation.

BACKGROUND: Patients' expectations of the outcomes of rehabilitation may influence the outcomes and satisfaction with treatment. OBJECTIVES: For stroke patients in multidisciplinary rehabilitation, we aimed to explore patients' outcome expectations and their fulfilment as well as determinants. METHODS: The Stroke Cohort Outcomes of REhabilitation (SCORE) study included consecutive stroke patients admitted to an inpatient rehabilitation facility after hospitalisation. Outcome expectations were assessed at the start of rehabilitation (admission) by using the three-item Expectancy scale (sum score range 3-27) of the Credibility/Expectancy Questionnaire (CEQ). After rehabilitation, patients answered the same questions formulated in the past tense to assess fulfilment of expectations. Baseline patient characteristics were recorded and health-related quality of life (EQ-5D) was measured at baseline and after rehabilitation. The number of patients with expectations unfulfilled or fulfilled or exceeded was computed by subtracting the admission and discharge CEQ Expectancy scores. Multivariable regression analysis was used to determine the factors associated with outcome expectations and their fulfilment, estimating odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: We included 165 patients (96 males [58.2%], mean (SD) age 60.2 years [12.7]) who completed the CEQ Expectancy instrument at admission (median score 21.6, interquartile range [IQR] 17.0-24.0); 79 completed it both at admission (median score 20.6, IQR 16.6-24.4) and follow-up (median score 20.0, IQR 16.4-22.8). For 40 (50.6%) patients, expectations of therapy were fulfilled or exceeded. No patient characteristic at admission was associated with baseline CEQ Expectancy score. Odds of expectation fulfilment were associated with low expectations at admission (OR 0.70, 95% CI 0.60-0.83) and improved EQ-5D score (OR 1.35, 95% CI 1.04-0.75). CONCLUSIONS: In half of the stroke patients in multidisciplinary rehabilitation, expectations were fulfilled or exceeded, most likely in patients with low expectations at admission and with improved health-related quality of life. More research into the role of health professionals regarding the measurement, shaping and management of outcome expectations is needed.

The Longer-term Unmet Needs after Stroke Questionnaire: Cross-Cultural Adaptation, Reliability, and Concurrent Validity in a Dutch Population.

BACKGROUND: Unmet needs are common after stroke. We aimed to translate the 22-item Longer-term Unmet Needs after Stroke (LUNS) Questionnaire and validate it in a Dutch stroke population. METHODS: The LUNS was translated and cross-culturally adapted according to international guidelines. After field testing, the Dutch version was administered twice to a hospital-based cohort 5-8 years after stroke. Participants were also asked to complete the Frenchay Activity Index (FAI) and Short Form (SF)-12. To explore acceptability, the response and completion rates as well as number of missing items were computed. For concurrent validity, the differences in health status (FAI, SF-12) between groups who did and did not report an unmet need were calculated per item. To determine the 14-day test-retest reliability, the percentage of agreement between the first and the second administration was calculated for each item. RESULTS: Seventy-eight of 145 patients (53.8%) returned the initial Dutch LUNS (average age 68.3 [standard deviation 14.0] years, 59.0% male); 66 of these patients (84.6%) fully completed it. Of all items, 3.3% were missing. Among completers, the median number of unmet needs was 3.5 (2.0-5.0; 1.0-14.0). For 15 of 22 items, there was a significant association with the FAI or SF-12 Mental or Physical Component Summary scales. The percentage of agreement ranged from 69.8% to 98.1% per item. CONCLUSIONS: Among the 53.8% who completed the survey, the LUNS was concluded to be feasible, reliable, and valid; two-thirds of its items were related to activities and quality of life. Its usefulness and acceptability when administered in routine practice require further study.

Short-Term and Long-Term Outcomes of a Vocational Rehabilitation Program for Patients with Acquired Brain Injury in The Netherlands.

Purpose To describe short-term and long-term work status after a vocational rehabilitation (VR) program in patients with acquired brain injury (ABI) in the Netherlands. Methods Patients with ABI who participated in a VR program between 2007 and 2010 were included in this study. The 4-month VR program included a multidisciplinary assessment, three meetings with all stakeholders and reintegration with coaching on the job. Short-term results at the end of the VR program were based on data extracted from medical records. Long-term results were determined at 3-6 years (mean 4.4 years) after the program based on patient-reported data. Outcome measures included return to work, hours at work and task adjustments. Results Fifty-eight patients were included [mean age 48 (SD 9.4) years; n = 33 male; all working before ABI]. After the intervention, 50 patients (86%) had returned to work, working on average 60% of their former hours. Working tasks were adjusted in 48 patients. At long-term follow-up 28 patients had paid work, working on average 5.3 h more than immediately after the VR program. Conclusions Directly after the intervention 86% of the patients had returned to work. After 3-6 years, 64% of these patients were still working in a paid job.

Out-of-hospital cardiac arrest survivors with cognitive impairments have lower exercise capacity.

BACKGROUND: Hypoxic brain injury is described in up to 40% of survivors after out-of-hospital cardiac arrest (OHCA). Besides cognitive impairments, lack of circulation may also affect exercise capacity. It is not known if exercise capacity of patients with cognitive impairments differs from other OHCA survivors. METHODS: This retrospective cohort study included patients ≥18 years with myocardial infarction (MI) as cause of OHCA admitted for cardiac rehabilitation between February 2011 and April 2014. Data in socio-demographic, OHCA and medical interventions were retrieved. Cognitive functioning was determined with the Mini-Mental State Examination, Cognitive Failures Questionnaire and the Informant Questionnaire on Cognitive Decline in the Elderly. Exercise capacity (VO2peak), workload (Watts) and blood pressure (mmHg) were measured at maximum cardiopulmonary exercise. Heart rate (bpm) was measured at rest and maximum exercise and Metabolic Equivalents of Tasks (MET) were calculated. RESULTS: 65 patients after OHCA caused by MI were included (85% male, median age 60years). Of 53 patients Cardio Pulmonary Exercise Test data was available of which nine patients showed cognitive impairments. Significant differences (p<0.05) in exercise capacity were found between patients with and without cognitive impairments: VO2peak (median 14.5 vs 19.7ml/kg/min), workload (median 130.0 vs 143.5W) and MET's (median 4.1 vs 5.6). CONCLUSION: Based on this small study, there seems to be a correlation between cognitive impairments and lower exercise capacity in patients referred for rehabilitation after OHCA caused by MI. It seems sensible for rehabilitation programs to take the lower exercise capacity of patients with cognitive impairments into account.

Rehabilitation after Cardiac Arrest: Integration of Neurologic and Cardiac Rehabilitation.

Cognitive impairments are common after resuscitation. Severe cognitive impairments are easily recognized. Mild cognitive impairments are much more difficult to spot. Given the influence of cognitive problems in daily functioning, it is important to identify cognitive impairments at an early stage. Also, emotional problems, mainly depression and fear, are common in this group of patients. To optimize the care for patients after an out-of-hospital cardiac arrest, rehabilitation should focus on the physical approach through cardiac rehabilitation and on brain injury and associated cognitive impairments. The goal of rehabilitation after a cardiac arrest is to provide excellent patient-centered cardiac and cognitive rehabilitation to all patients and their spouses to achieve optimal participation in society, with minimal burden for spouses and society. To achieve this, cardiac and cognitive rehabilitation need to be coordinated in an integrated care path.

Practice variation in the structure of stroke rehabilitation in four rehabilitation centres in the Netherlands.

OBJECTIVE: To describe practice variation in the structure of stroke rehabilitation in 4 specialized multidisciplinary rehabilitation centres in the Netherlands. DESIGN AND METHODS: A multidisciplinary expert group formulated a set of 23 elements concerning the structure of inpatient and outpatient stroke rehabilitation, categorized into 4 domains: admission-related (n = 7), treatment-related (n = 10), client involvement-related (n = 2), and facilities-related (n = 4). In a cross-sectional study in 4 rehabilitation centres data on the presence and content of these elements were abstracted from treatment programmes and protocols. In a structured expert meeting consensus was reached on the presence of practice variation per element. RESULTS: Practice variation was observed in 22 of the 23 structure elements. The element "strategies for patient involvement" appeared similar in all rehabilitation centres, whereas differences were found in the elements regarding admission, exclusion and discharge criteria, patient subgroups, care pathways, team meetings, clinical assessments, maximum time to admission, aftercare and return to work modules, health professionals, treatment facilities, and care-giver involvement. CONCLUSION: Practice variation was found in a wide range of aspects of the structure of stroke rehabilitation.