Self-reported quality of life following stroke: a systematic review of instruments with a focus on their psychometric properties.

PURPOSE: To evaluate the psychometric properties of common health-related quality-of-life instruments used post stroke and provide recommendations for research and clinical use with this diagnostic group. METHODS: A systematic review of the psychometric properties of the five most commonly used quality-of-life measurement tools (EQ-5D, SF-36, SF-6D, AQoL, SS-QOL) was conducted. Electronic searches were performed in MEDLINE, CINAHL, and EMBASE on November 27th 2019. Two authors screened papers against the inclusion criteria and where consensus was not reached, a third author was consulted. Included papers were appraised using the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist and findings synthesized to make recommendations. RESULTS: A total of n = 50,908 papers were screened and n = 45 papers reporting on 40 separate evaluations of psychometric properties met inclusion criteria (EQ-5D = 19, SF-36 = 16, SF-6D = 4, AQoL = 2, SS-QOL = 4). Studies reported varied psychometric quality of instruments, and results show that psychometric properties of quality-of-life instruments for the stroke population have not been well established. The strongest evidence was identified for the use of the EQ-5D as a quality-of-life assessment for adult stroke survivors. CONCLUSIONS: This systematic evaluation of the psychometric properties of self-reported quality-of-life instruments used with adults after stroke suggests that validity across tools should not be assumed. Clinicians and researchers alike may use findings to help identify the most valid and reliable measurement instrument for understanding the impact of stroke on patient-reported quality of life.

Designing an intervention process that embeds work-focussed interventions within inpatient rehabilitation: An intervention mapping approach.

INTRODUCTION: Returning to work is a goal for many people after brain injury. The failure to return to work after injury brings both economic and personal (quality of life) costs to those living with stroke or brain injury, their families, and society. This study explored the barriers to providing work-focused interventions during hospital-based rehabilitation and co-created solutions with rehabilitation providers to increase the provision of work-focused intervention during inpatient rehabilitation. METHODS: This study used an Intervention Mapping approach (a six-step protocol that guides the design of complex interventions) based on an action research methodology. Focus group data, in addition to best evidence from systematic reviews, practice guidelines and key articles were combined with theoretical models for changing behaviour and clinician experience. This was then systematically operationalised into an intervention process using consensus among clinicians. The process was further refined through piloting and feedback from key stakeholders, and group consensus on the final process. RESULTS: A detailed five phase return to work intervention process for inpatient rehabilitation was developed. The key features of the process include; having one key allied health clinician to coordinate the process, choosing assessments based on pre-injury work demands, emphasising the importance of core work skills and considering the most appropriate service for referral at the conclusion of rehabilitation. CONCLUSION: We used a systematic approach, guided by the intervention mapping approach and behaviour change theory to tailor existing workfocused interventions to the inpatient setting.

A professional development program increased the intensity of practice undertaken in an inpatient, upper limb rehabilitation class: A pre-post study.

BACKGROUND/AIM: Increasing the intensity of practice is associated with improved upper limb outcomes, yet observed intensity levels during rehabilitation are low. The purpose of this study was to investigate: whether a professional development program would increase the intensity of practice undertaken in an inpatient, upper limb rehabilitation class; and whether any increase would be maintained six months after the cessation of the program. METHOD: A pre-post study was conducted within an existing inpatient, upper limb rehabilitation class in a metropolitan hospital. Staff received a professional development program which included: a two day theoretical, practical and clinical training workshop covering evidence-based practice for upper limb rehabilitation after stroke; and three 1-hour meetings to revise evidence-based practice and discuss implementation of strategies. Intensity of practice, as measured by the proportion of practice time per class (%) and the number of repetitions per practice time (repetitions/min) observed during the 60-minute classes during one week, was recorded at baseline, end of program (12 months) and six months later (18 months). RESULTS: Twenty-two (100%) staff attended at least one professional development program session; outcomes were measured across n = 15 classes (n = 30 patients). Between baseline and 12 months, the mean proportion of practice time per class increased by 52% (95% confidence interval (CI) 33-70; P < 0.001) and the mean number of repetitions per practice time increased by 5.1 repetitions/min (95% CI 1.7-8.4; P < 0.01). Between baseline and 18 months, the mean proportion of practice time per class increased by 53% (95% CI 36-69; P < 0.001) and the mean number of repetitions per practice time increased by 3.9 repetitions/min (95% CI 1.9-5.9; P < 0.001). CONCLUSION: Providing professional development was associated with increased intensity of practice in an inpatient, upper limb rehabilitation class. The increase was maintained six months later.

Extra upper limb practice after stroke: a feasibility study.

BACKGROUND: There is a need to provide a large amount of extra practice on top of usual rehabilitation to adults after stroke. The purpose of this study was to determine if it is feasible to add extra upper limb practice to usual inpatient rehabilitation and whether it is likely to improve upper limb activity and grip strength. METHOD: A prospective, single-group, pre- and post-test study was carried out. Twenty adults with upper limb activity limitations who had some movement in the upper limb completed an extra hour of upper limb practice, 6 days per week for 4 weeks. Feasibility was measured by examining recruitment, intervention (adherence, efficiency, acceptability, safety) and measurement. Clinical outcomes were upper limb activity (Box and Block Test, Nine-Hole Peg Test) and grip strength (dynamometry) measured at baseline (week 0) and end of intervention (week 4). RESULTS: Of the 212 people who were screened, 42 (20%) were eligible and 20 (9%) were enrolled. Of the 20 participants, 12 (60%) completed the 4-week program; 7 (35%) were discharged early, and 1 (5%) withdrew. Participants attended 342 (85%) of the possible 403 sessions and practiced for 324 (95%) of the total 342 h. In terms of safety, there were no study-related adverse events. Participants increased 0.29 blocks/s (95% CI 0.19 to 0.39) on the Box and Block Test, 0.20 pegs/s (95% CI 0.10 to 0.30) on the Nine-Hole Peg Test, and 4.4 kg (95% CI 2.9 to 5.9) in grip strength, from baseline to end of intervention. CONCLUSIONS: It appears feasible for adults who are undergoing inpatient rehabilitation and have some upper limb movement after stroke to undertake an hour of extra upper limb practice. The magnitude of the clinical outcomes suggests that further investigation is warranted and this study provides useful information for the design of a phase II randomized trial. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry (ACTRN12615000665538).

Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review.

QUESTIONS: In people receiving rehabilitation aimed at reducing activity limitations of the lower and/or upper limb after stroke, does adding extra rehabilitation (of the same content as the usual rehabilitation) improve activity? What is the amount of extra rehabilitation that needs to be provided to achieve a beneficial effect? DESIGN: Systematic review with meta-analysis of randomised trials. PARTICIPANTS: Adults aged 18 years or older that had a diagnosis of stroke. INTERVENTION: Extra rehabilitation with the same content as usual rehabilitation aimed at reducing activity limitations of the lower and/or upper limb. OUTCOME MEASURES: Activity measured as lower or upper limb ability. RESULTS: A total of 14 studies, comprising 15 comparisons, met the inclusion criteria. Pooling data from all the included studies showed that extra rehabilitation improved activity immediately after the intervention period (SMD=0.39, 95% CI 0.07 to 0.71, I(2)=66%). When only studies with a large increase in rehabilitation (> 100%) were included, the effect was greater (SMD 0.59, 95% CI 0.23 to 0.94, I(2)=44%). There was a trend towards a positive relationship (r=0.53, p=0.09) between extra rehabilitation and improved activity. The turning point on the ROC curve of false versus true benefit (AUC=0.88, p=0.04) indicated that at least an extra 240% of rehabilitation was needed for significant likelihood that extra rehabilitation would improve activity. CONCLUSION: Increasing the amount of usual rehabilitation aimed at reducing activity limitations improves activity in people after stroke. The amount of extra rehabilitation that needs to be provided to achieve a beneficial effect is large. TRIAL REGISTRATION: PROSPERO CRD42012003221. [Schneider EJ, Lannin NA, Ada L, Schmidt J (2016) Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review.Journal of Physiotherapy62: 182-187].