Capability beliefs on, and use of evidence-based practice among four health professional and student groups in geriatric care: A cross sectional study.

Implementation of evidence-based practice (EBP) is a complex task. This study, conducted in an acute geriatric setting, aims to compare self-reported capability beliefs on EBP between health professionals and students, and to compare the use of EBP between health professional groups. Occupational therapists, physicians, physiotherapists and registered nurses with three or more months' employment, and all students from the occupational therapy, medical, physiotherapy and nursing programs, who had conducted workplace learning at the department, were invited. Data on capability beliefs and use of EBP were collected using the Evidence-based Practice Capabilities Beliefs Scale assessing six activities of EBP: formulate questions; search databases; search other sources; appraise research reports; participate in implementation in practice; and participate in evaluation. Descriptive and inferential statistics were used. Capability beliefs on EBP: The health professionals (n = 101; response rate 80%) reported high on search other sources but less on appraise research reports. The students (n = 124; response rate 73%) reported high on all EBP activities. The health professionals reported significantly higher on search other sources than the students. The students reported significantly higher on formulate questions and appraise research reports than the health professionals. No significant differences were identified between the health professional groups or between the student groups. Use of EBP: Health professionals reported wide-ranging use from several times each month to once every six months. The physicians reported significantly more frequent use than registered nurses and occupational therapists. Health professionals supervising students reported more frequent use of appraise research reports than the non-supervising group. There is a need for improving the use of EBP, particularly among registered nurses and occupational therapists. Supervision of students might enhance the motivation among staff to increase the use of EBP and students' high EBP capability beliefs might inspire staff in this matter.

Development and validation of the Swedish national stroke register Riksstroke's questionnaires in patients at 3 and 12 months after stroke: a qualitative study.

OBJECTIVES: Because healthcare and community organisations and treatment methods are always changing, continuous changes might also be needed in questionnaires that register patient-reported outcomes (PRO) and patient-reported experiences (PRE) of healthcare interventions and community support. Thus, the aim of this study was to test the content and face validity, including the readability, of two questionnaires used by the Swedish national stroke register Riksstroke to register PRO and PRE at 3 and 12 months poststroke. DESIGN: Clinicians' and patients' knowledge and experiences of current care, rehabilitation, community support and functioning after stroke as well as comments noted regarding the content and layout of the questionnaires were retrieved in focus-groups with expert clinicians and in patient interviews analysed with content analysis. A workgroup of experts with experience in stroke care, rehabilitation and research repeatedly revised the questionnaires regarding content, layout and consistency throughout the validation process. PARTICIPANTS: The participants included allied healthcare professionals, nurses and physicians with extensive experience of working with stroke care and rehabilitation (expert clinicians) as well as patients who had suffered a stroke 3 or 12 months earlier and who were purposefully selected among those who had completed and returned the 3-month questionnaire. SETTING: Expert clinicians met at their work place in focus-groups. Patients were interviewed where they resided, that is, in their home or nursing home, including rural, town and city areas in Sweden. RESULTS: Based on clinical expertise and comments from the patients (n=47), the questionnaires were revised and then found to be valid in terms of content validity and face validity, including readability. CONCLUSIONS: The present evaluation emphasises the need for testing aspects of validity, including readability, of questionnaires addressing PRO and PRE and for the recurrent revision of such questionnaires in order to maintain their validity in a society undergoing constant change.

The Effects of "Physical Activity on Prescription" in Persons With Transient Ischemic Attack: A Randomized Controlled Study.

BACKGROUND AND PURPOSE: Transient ischemic attack (TIA) is a strong predictor of stroke, and physical inactivity is one risk factor for TIA/stroke. "Physical activity on Prescription" (PaP) can increase physical activity, but the effect of PaP after TIA has not been described. Our goal was to objectively measure the effect of PaP on physical activity and physical capacity, as well as self-rated health at 3 and 6 months after TIA. METHODS: The primary outcome was moderate to vigorous intensities of physical activity objectively assessed by accelerometry. Secondary outcomes were steps per day assessed by accelerometry, physical capacity assessed by the 6-minute walk test, and self-rated health assessed by EQ-5D VAS. RESULTS: Eighty-eight individuals with TIA were randomized to an intervention group (n = 44) that received conventional treatment and PaP or to a control group (n = 44) that received conventional treatment alone. There was a 30% dropout among the participants at 6 months. No significant differences between groups were found in physical activity at 3 and 6 months. At 6 months, participants in the intervention group were significantly more likely to have improved their physical capacity than the control group. There was no significant difference between groups in self-rated health. DISCUSSION AND CONCLUSIONS: PaP did not increase physical activity after TIA; however, there was an increase in physical capacity. The nonsignificant results for physical activity may be the result of a relatively high baseline physical activity level. The results may also indicate that prior studies suggesting that PaP increases physical activity overestimated effects because of the self-reported nature of the previous outcomes.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A134).

Young individuals with stroke: a cross sectional study of long-term disability associated with self-rated global health.

BACKGROUND: Perceived disability after stroke may persist long-term even among young individuals with mild stroke and may be related to age-related expectations of health and recovery. Thus, in order to appreciate the magnitude of perceived disability in a younger stroke population studies are needed to explore perceived health-related differences between young individuals with stroke and a matched general population. Further, to provide long-term measures by health care, relevant to the same young individuals with stroke, their perceived long-term functioning and disability associated with health need to be explored. METHODS: The generic questionnaire EQ-5D was used to compare ratings of global health and disability between young individuals living in the community up to 6 years after stroke (n = 150) and an age and geographically matched general population (n = 2661). Stroke related medical data were retrieved from medical records and the study specific questionnaire, the MYS-questionnaire, was used to assess self-rated disability associated with global health. RESULTS: Among the young individuals 79% had suffered a mild stroke, 45% rated a low global health compared to 15% of the matched general population and a higher proportion rated problems in mobility, self-care, usual activities and anxiety/depression. Among the young individuals with stroke, limitations and restrictions in leisure activities, work, reading as well as low level of physical activity, utilizing personal care provider or personal assistance and tiredness were negatively associated with self-rated global health (R square 0.60). CONCLUSION: The negative effects of stroke, on self-rated global health among young individuals living in the community, appear to be substantial, multi factorial and long-standing which call for interdisciplinary research collaborations and team measures by health care long-term.

Differences between younger and older individuals in their use of care and rehabilitation but not in self-perceived global recovery 1year after stroke.

BACKGROUND: Although priorities in Swedish stroke care should be based on the ethical principles of equal care and greatest support to those in greatest need, being of working age (younger) or retired (older) might influence expectations on recovery and the provision of care and rehabilitation. METHOD: Information regarding the use of care and rehabilitation during the 1st year after stroke was retrieved from the Stockholm County Council database and the medical data was taken from the medical records. The Barthel Index was used for self-ratings of dependence pre-stroke, and the Stroke Impact Scale was used to assess self-perceived disability and a global rating of recovery at 12 months. One hundred and ninety-two individuals were included. RESULTS: Results showed that the younger group received more care and rehabilitation than the older group. In the older group, comorbid conditions and pre-stroke dependence, estimated in accordance with the Barthel Index, were more common. The older group reported larger impact on self-perceived disability regarding strength, mobility, self-care and domestic life, while self-perceived global recovery did not differ between the groups. CONCLUSION: Younger individuals received more care and rehabilitation, which indicates structural inequality in the provision of health care resources. However, as no difference in self-perceived global recovery was found between the groups; the disparity in the provision of health care may also be a consequence of greatest support being given to those in greatest need. By demonstrating the necessity of involving self-rated assessments of stroke impact at different points in time and in different age groups, the results of this study add to previous knowledge of age-related differences in the provision of health care and stroke outcome. Furthermore, this suggests a way to approach evaluation of equality in the provision of health care.

Spasticity after stroke: an overview of prevalence, test instruments, and treatments.

The objective of this study was to present an overview of the prevalence of spasticity after stroke as well as of test instruments and treatments. Recent studies show that spasticity occurs in 20%-30% of all stroke victims and in less than half of those with pareses. Although spasticity may occur in paretic patients after stroke, muscle weakness is more likely to be the reason for the pareses. Spasticity after stroke is more common in the upper than the lower limbs, and it seems to be more common among younger than older people. To determine the nature of passive stretch, electromyographic equipment is needed. However, the Modified Ashworth Scale, which measures the sum of the biomechanical and neural components in passive stretch, is the most common instrument used to grade spasticity after stroke. Treatment of spasticity with physiotherapy is recommended, although its beneficial effect is uncertain. The treatment of spasticity with botulinum toxin in combination with physiotherapy is suggested to improve functioning in patients with severe spasticity. A task-specific approach rather than a neurodevelopmental approach in assessing and treating a patient with spasticity after stroke seems to be preferred.

Adult norms of the perceptual threshold of touch (PTT) in the hands and feet in relation to age, gender, and right and left side using transcutaneous electrical nerve stimulation.

There is a lack of standardized and quantifiable measures of touch function, for clinical work. Furthermore, it is not possible to make accurate diagnostic judgments of touch function before normative values are estimated. The objectives of this study were to establish adult norms of the perceptual threshold of touch (PTT) for the hands and feet according to age and gender and to determine the effect of right/left side, handedness, height, weight, and body mass index (BMI) on the PTT. The PTT was assessed by using a high-frequency transcutaneous electrical nerve stimulator (Hf/TENS) with self-adhesive skin electrodes in 346 adults. The PTT was identified as the level registered in mA at which the participants perceived a tingling sensation. The PTT for all participants was a median of 3.75 mA (range 2.50-7.25) in the hands and a median of 10.00 (range 5.00-30.00) in the feet. With increasing age an increase of the PTT was found. Men reported higher PTT than women. The right hand had higher PTT than the left. Handedness, height, weight, and BMI did not affect the PTT. Adult norms of the PTT in the hands for age, gender, and right/left side are presented for four age groups. The present study's estimate of the PTT in the hands could be used as adult norms. Adult norms for the feet could not be estimated because the PTT values in the feet showed a great variance.

Long-term health states relevant to young persons with stroke living in the community in southern Stockholm - a study of self-rated disability and predicting factors.

PURPOSE: The purpose was to explore self-rated long-term disability and to analyze whether initial stroke-related, personal and environmental factors can predict disability in a population-based sample of community-dwelling young (<65 years) persons suffering a stroke in 2000-2006. METHOD: Data on initial stroke-related, personal and environmental factors were retrieved from medical records. A study-specific posted questionnaire was used. RESULTS: Of the 158 young persons with stroke, 78% had suffered a mild stroke. Tiredness was the most commonly reported mental impairment (86%) followed by impaired memory (67%). A majority reported limitations/restrictions in returning to leisure activities (58%) and work (52%). Stroke-related, personal and environmental factors failed to predict self-reported mental and physical impairments, but predicted activity limitations/participation restrictions with an acceptable power of accuracy (0.70-0.73) but a low sensitivity (0.28-0.59). CONCLUSIONS: A majority of these young persons were diagnosed with a mild stroke but experienced long-term mental impairments and activity limitations/participation restrictions that could not be predicted by initial stroke-related, personal and environmental factors solely. Therefore, regular long-term assessments irrespective of initial stroke severity are warranted in order to identify disabilities and improve the state of health among young persons with stroke when needed.

Limited fine hand use after stroke and its association with other disabilities.

OBJECTIVE: To describe the recovery of fine hand use and the associations between fine hand use and, respectively, somatosensory functions, grip strength, upper extremity movements and self-care, in the first week and at 3 and 18 months after stroke, and to describe whether these associations change over time. DESIGN: Prospective observational study. PATIENTS: Sixty-six consecutive patients with stroke. METHODS: The following parameters were assessed in the first week, and at 3 and 18 months after stroke: fine hand use, grip strength (not assessed in the first week), touch, proprioceptive and upper extremity movement functions; and self-care. RESULTS: Seventy percent of all patients had limited fine hand use in the first week, 41% at 3 months and 45% at 18 months after stroke. The associations between fine hand use and the other functioning were moderate to high, but decreased over time for fine hand use and, respectively, somatosensory functions, upper extremity movements and self-care. CONCLUSION: Limited fine hand use is common after acute stroke. Our results suggest that, with time after stroke, upper extremity movements and self-care become less dependent on fine hand use and fine hand use becomes less dependent on touch function, although no ultimate conclusions can be drawn on causality.

Determinants of mobility and self-care in older people with stroke: importance of somatosensory and perceptual functions.

BACKGROUND AND PURPOSE: Somatosensory as well as mental impairments are easily overlooked after acute stroke. Furthermore, their associations with activity limitations are not fully understood. The purpose of this study was to examine this association and whether the assessment of somatosensory functions will provide information on perceptual functions after acute stroke. SUBJECTS AND METHODS: In 115 subjects who were > or =65 years of age, the following parameters were assessed 5 days after stroke: somatosensory (touch and proprioceptive), perceptual, and cognitive functions; depressive symptoms; mobility; and self-care. RESULTS: Multivariate analyses showed that normal proprioceptive function was significantly associated with better mobility. Normal perceptual and touch functions were significantly associated with better self-care. Subjects with normal proprioceptive function were 8.6 times as likely to have normal perceptual function as subjects with proprioceptive impairment. DISCUSSION AND CONCLUSION: Somatosensory and perceptual functions were significantly associated with subjects' activity levels. Normal proprioceptive function also might indicate normal perceptual function.

Spasticity and its association with functioning and health-related quality of life 18 months after stroke.

BACKGROUND: There is no consensus concerning the presence of spasticity or the relationship between spasticity and functioning and spasticity and health-related quality of life (HRQL) in the stable phase after stroke. OBJECTIVE: The aim of the present study was to describe, 18 months after stroke, the frequency of spasticity and its association with functioning and HRQL. METHODS: In a cohort of 66 consecutive patients with first-ever stroke, studied prospectively, the following parameters were assessed 18 months after stroke: spasticity, by the Modified Ashworth Scale (0-4 points with 1+ as the modification), muscle stiffness, by self-report, abnormal tendon reflexes, by physical examination, motor performance, by the Lindmark Motor Assessment Scale, mobility, by the Rivermead Mobility Index, activities of daily living, by the Barthel Index, and HRQL, by the Swedish Short Form 36 Health Survey Questionnaire (SF-36). RESULTS: Of 66 patients studied, 38 were hemiparetic; of these, 13 displayed spasticity, 12 had increased tendon reflexes, and 7 reported muscle stiffness 18 months after stroke. Weak (r < 0.5) to moderate (r = 0.5-0.75) correlations were seen between spasticity and functioning scores. Correlations between spasticity and HRQL were generally weak (r < 0.5). Hemiparetic patients without spasticity had significantly better functioning scores and significantly better HRQL on 1 of the 8 SF-36 health scales (physical functioning) than patients with spasticity. CONCLUSIONS: Few patients displayed spasticity 18 months after stroke. Spasticity might contribute to impairment of movement function and to limitation of activity, but seems to have a less pronounced effect on HRQL.

Hemiplegic limb synergies in stroke patients.

OBJECTIVE: To describe the extent to which the voluntary movements of hemiparetic stroke patients are restricted to the hemiplegic limb synergies (which are marked by the inability to master individual joint movements) described by Brunnström. The study also aimed to describe the extent to which the synergies are related to functioning. DESIGN: In a prospective observational study design, 64 consecutive hemiparetic stroke patients were assessed with Brunnström's hemiplegic limb synergies, the modified Ashworth scale for spasticity, the Rivermead mobility index, and the Barthel ADL index. RESULTS: Three months after stroke, 8 of the 64 patients were moving completely or partly within the synergies. All patients whose movements were restricted to the synergies also exhibited spasticity. Hemiparetic patients whose movements were restricted to the synergies had significantly worse functioning scores than hemiparetic patients whose movements were not restricted to the synergies although severe disabilities were seen in both groups. CONCLUSIONS: Three months after stroke, the voluntary movements of only 13% of hemiparetic stroke patients were restricted to the synergies. The synergies were associated with spasticity and activity limitations. The use of the synergies might only be suitable for a small fraction of hemiparetic patients-namely, those displaying spasticity.

Spasticity after stroke: its occurrence and association with motor impairments and activity limitations.

BACKGROUND AND PURPOSE: There is no consensus concerning the number of patients developing spasticity or the relationship between spasticity and disabilities after acute stroke. The aim of the present study was to describe the extent to which spasticity occurs and is associated with disabilities (motor impairments and activity limitations). METHODS: Ninety-five patients with first-ever stroke were examined initially (mean, 5.4 days) and 3 months after stroke with the Modified Ashworth Scale for spasticity; self-reported muscle stiffness; tendon reflexes; Birgitta Lindmark motor performance; Nine Hole Peg Test for manual dexterity; Rivermead Mobility Index; Get-Up and Go test; and Barthel Index. RESULTS: Of the 95 patients studied, 64 were hemiparetic, 18 were spastic, 6 reported muscle stiffness, and 18 had increased tendon reflexes 3 months after stroke. Patients who were nonspastic (n=77) had statistically significantly better motor and activity scores than spastic patients (n=18). However, the correlations between muscle tone and disability scores were low, and severe disabilities were seen in almost the same number of nonspastic as spastic patients. CONCLUSIONS: Although spasticity seems to contribute to disabilities after stroke, spasticity was present in only 19% of the patients investigated 3 months after stroke. Severe disabilities were seen in almost the same number of nonspastic as spastic patients. These findings indicate that the focus on spasticity in stroke rehabilitation is out of step with its clinical importance. Careful and continual evaluation to establish the cause of the patient's disabilities is essential before a decision is made on the most proper rehabilitation approach.