Differences in the difficulty of subtasks comprising the toileting task among patients with subacute stroke: A cohort study.

INTRODUCTION: Toileting comprises multiple subtasks, and the difficulty of each is critical to determining the target and priority of intervention. The study aimed to examine the difficulty of subtasks that comprise toileting upon admission and the reacquisition of skills of subtasks during hospitalization. MATERIALS AND METHODS: This was a single-center prospective cohort study. We enrolled 101 consecutive stroke patients (mean age: 69.3 years) admitted to subacute rehabilitation wards. The independence in each of the 24 toileting subtasks was assessed using the Toileting Tasks Assessment Form (TTAF) every two or four weeks. The number of patients who were independent upon admission, as well as those who were not independent upon admission but became independent during hospitalization, was examined in each subtask. RESULTS: The most difficult subtask upon admission was "Lock the wheelchair brakes" (16.8% of patients were independent), followed by "Turn while standing (before urination/defecation)" (17.8%), "Pull the lower garments down" (18.0%), "Turn while standing (after urination/defecation)" (18.8%), "Pull the lower garments up and adjust them" (18.8%), and "Maintain a standing position (before urination/defecation)" (18.8%). The most difficult subtask for those who were not independent but became independent was "Dispose of incontinence pad/sanitary items" (19.3%), followed by "Press the nurse call button (after urination/defecation)" (28.3%), "Take the foot off the footrest and place it on the ground" (28.6%), and "Clean up after urination/defecation" (29.0%). CONCLUSIONS: The difficult subtasks upon admission and those for reacquired skills were different. The most difficult subtasks upon admission were main tasks, and the difficult subtasks in reacquiring skills were preparatory tasks.

Development of an assessment form for the performance of public transportation use in individuals with stroke.

PURPOSE: To develop a new assessment form that is assessed by therapists for the performance of public transportation use for stroke survivors through content validation. MATERIALS AND METHODS: The items for the tentative assessment form were selected using hierarchical clustering analysis on previous records of 76 field-based training sessions for public transportation use for stroke survivors. After the modification of the tentative form based on 6 months of clinical use, the final form was developed through content validation using the Delphi method by 71 therapists who had been working at the hospital for more than 2 years and had experience with training for public transportation use. RESULTS: The Public Transportation use Assessment Form (PTAF) for stroke was successfully developed through three validation processes. It consists of four categories (plan for going out, mobility, using trains, and using buses) including 15 items that cover various tasks of public transportation use. The scoring for each was as follows: 3, independent; 2, requires supervision of verbal assistance; 1, requires assistance; and N, not applicable. CONCLUSION: The PTAF, developed through content validation, could assess the ability of public transportation use, and identify specific problems for each stroke survivor in clinical setting.IMPLICATIONS FOR REHABILITATIONWe developed the Public Transportation use Assessment Form (PTAF) to assess the ability of stroke survivors to use public transportation.The PTAF could identify specific problems related to public transportation use for stroke survivors and aid in planning rehabilitation programs based on the results.The PTAF could share information about which task need support in public transportation use and could augment the hospital discharge plan.

Reliability and validity of the public transportation use assessment form for individuals after stroke.

PURPOSE: To examine the reliability and validity of the public transportation use assessment form (PTAF), which was developed for assessing the performance of tasks during public transportation use. MATERIALS AND METHODS: Fifty consecutive patients admitted after a stroke to a convalescent rehabilitation hospital and received field-based practice for public transportation use were enrolled. A physical therapist (PT) and an occupational therapist (OT) independently evaluated actual participant performance using the PTAF. Its internal consistency, inter-rater reliability, and construct validity were examined against other clinical measures related to the ability to use public transportation. RESULTS: Cronbach's coefficient alpha for the internal consistency for overall PTAF was 0.84 and 0.88 for PTs and OTs, respectively. Cohen's weighted κ coefficient for the inter-rater reliability for each item ranged from 0.61 to 0.83. Intraclass correlation coefficients for the inter-rater reliability for the mean scores of the items comprising the PTAF were 0.90 for all 14 items, 0.76 for items required for train use only, and 0.88 for items required for bus use only. The correlation coefficients for the construct validity between PTAF and clinical measures ranged from 0.38 to 0.59 (p < 0.05). CONCLUSIONS: The PTAF showed sufficient internal consistency, intra-rater reliability, and construct validity.Implications for rehabilitationThis study illustrated the inter-rater reliability of the public transportation use assessment form (PTAF), indicating that the PTAF can be used for reliable assessment independent of the rater.The PTAF showed good internal consistency, indicating that each item in the PTAF consistently assessed the ability of patients with stroke to use public transportation.The PTAF correlated with assessment tools such as walking ability, balance, motor paralysis, intelligence, and activities of daily living, indicating that it reflects the functions and abilities necessary to use public transportation.

Presence and Characteristics of Behavioral and Psychological Symptoms in Subacute Stroke Patients with Cognitive Impairment.

This retrospective cross-sectional study is aimed at investigating the prevalence and characteristics of behavioral and psychological symptoms (BPS) in subacute stroke patients with cognitive impairment. The Neuropsychiatric Inventory-Questionnaire (NPI-Q) was used to assess BPS. A total of 358 consecutive patients with first-ever stroke admitted to rehabilitation wards and with Mini-Mental State Examination (MMSE) scores < 24 on admission were included. BPS was defined as a total NPI-Q Severity or Distress score ≥ 1. Differences between the severity and presence of BPS among patients with severe cognitive impairment (MMSE scores 0-17) and those with mild cognitive impairment (MMSE scores 18-23) were analyzed using the Mann-Whitney U test and chi-squared test, respectively. Eighty-one patients (mean (standard deviation) age, 73.5 (13.1) years) were enrolled for analysis. BPS were observed in 69.1% and 74.1% of patients when assessed with NPI-Q Severity and NPI-Q Distress, respectively. The most frequently observed BPS was apathy, followed by depression (approximately 44% and 40%, respectively). The severity and frequency of delusions, euphoria, apathy, and disinhibition were significantly higher in the severe cognitive impairment group than in the mild cognitive impairment group. However, the severity, distress, and frequency of depression were not dependent on the severity of cognitive impairment. The presence of BPS, especially apathy and depression, in subacute stroke patients with cognitive impairment is high. The severity and frequency of some BPS are higher in patients with severe cognitive impairment than in those with mild cognitive impairment. However, depression is highly prevalent among the patients regardless of the severity of cognitive impairment.

Effects of Alternating Bilateral Training Between Non-Paretic and Paretic Upper Limbs in Patients with Hemiparetic Stroke: A Pilot Randomized Controlled Trial.

OBJECTIVE: To examine whether alternating training with both the non-paretic and paretic sides (alternating bilateral training), expecting trial-to-trial inter-limb transfer of training effects from the nonparetic to the paretic side, improves upper-limb motor performance in post-stroke patients, compared with unilateral training involving only the paretic side. DESIGN: An assessor-blinded pilot randomized controlled trial. SUBJECTS: Twenty-four right-handed post-stroke patients with hemiparesis. METHODS: Participants were randomly allocated to either an alternating bilateral training group or a unilateral training group (n = 12/group). Participants underwent dexterity training of the paretic arm using the Nine-Hole Peg Test, completing 10 trials/day for 7 consecutive days. The alternating bilateral training group additionally performed alternating trials with the non-paretic limb. Performance change, assessed 1 day and 1 week after the 7-day training period, was compared between groups. RESULTS: Although the improvement was comparable in both groups at both post-training time-points, a sub-analysis in which those with left hemiparesis and those with right hemiparesis were analyzed separately revealed potential benefits of the alternating bilateral training, specifically for those with left hemiparesis. CONCLUSION: Alternating bilateral training may augment training effects and improve upper-limb motor function in patients with left hemiparesis.

Difficulty of the subtasks comprising bed-wheelchair transfer in patients with subacute strokes: A cohort study.

OBJECTIVE: Bed-wheelchair transfer comprises multiple subtasks; hence, it is important to know the difficulty of each subtask to identify and prioritize subtasks that must be practiced. This study aimed to investigate the difficulty of the subtasks that comprise bed-wheelchair transfer upon admission and reacquiring subtask skills during hospitalization. MATERIALS AND METHODS: This was a single-center prospective cohort study. We enrolled 137 consecutive stroke patients (mean age: 69.8 years) admitted to subacute rehabilitation wards who used wheelchairs upon admission. The degree of independence in each of the 25 subtasks that comprised transferring was assessed using the Bed-wheelchair transfer Tasks Assessment Form every 2 weeks. The number of patients who were independent in the subtasks upon admission and those who were not but became independent during hospitalization were examined. RESULTS: The most difficult subtask for independent patients upon admission was "Manipulate the handrail for the bed" (18.3%), followed by "Ready the wheelchair for transfer" (19.3%), "Maneuver the wheelchair toward the appropriate place for transfer to the bed" (20.6%), "Wear shoes/brace" (24.8%), and "Turn while standing" (25.5%). The most difficult subtask for those who were not independent but became independent was "Ready the wheelchair for transfer" (32.1%), followed by "Manipulate the handrail for the bed" (32.9%), "Press the nurse call button" (36.4%), "Press the nurse call button (wheelchair-to-bed)" (36.7%), and "Lock the wheelchair brakes" (37.3%). CONCLUSIONS: Subtasks related to preparation for transfer were difficult upon admission, and this tendency became more pronounced during the skill acquisition process.

Patients' thoughts on their falls in a rehabilitation hospital: a qualitative study of patients with stroke.

BACKGROUND: Patients with stroke in rehabilitation wards are at an increased risk of falling. Although patients' participation in establishing medical safety is considered crucial, there is limited evidence on their perspectives of falls. This study aims to comprehensively elucidate the subjective falling experience of patients with stroke who have been admitted to rehabilitation wards. METHODS: Twenty-three consecutive patients with stroke (44 to 90 years) who experienced a fall during hospitalisation were interviewed within 1 week after the fall, and thematic analysis was used to analyse the data. RESULTS: Five themes surrounding fall events were extracted from the narratives: 'Psychological background before the action', 'Support for the action', 'Direct causes of the fall', 'Patients' awareness after the fall', and 'Changes in attitudes and behaviours after the fall'. 'Psychological background before the action' comprised hastiness or hesitation to call for help. Participants often took an action based on 'Support for the action' derived from their past experiences of moving safely, their confidence, and/or motivation to challenge themselves to move. 'Direct causes of the fall' consisted of unfamiliar actions, training fatigue, the surrounding environment, reduced physical function due to paralysis, lack of attention, overconfidence in their ability, and insufficient prediction of falls. 'Patients' awareness after the fall' consisted of re-affirming difficult movements, the need for rehabilitation, a reduced ability to move, an increased risk of falling, the need for attention while moving, a fear of falling, and a lack of lessons learned from falling. Finally, patients demonstrated 'Changes in attitudes and behaviours after the fall' such as embodying a positive attitude to cope with the risk of falling or behavioural changes to reduce the risk of falling. CONCLUSIONS: Comprehensive information on patients' perspectives before and after the fall was elucidated, uncovering many aspects including the psychological background for why patients engaged in risky behaviours resulting in falls, presence of positive thinking, and behaviour after the fall. By incorporating the patients' views on fall incidences and their assessment, we can develop appropriate prevention strategies against falls.

Vitality index is a predictor of the improvement in the functional independence measure score in subacute stroke patients with cognitive impairment.

OBJECTIVES: To investigate the effect of motivation on improvements in the Functional Independence Measure (FIM) scores in subacute stroke patients with cognitive impairment. METHODS: This retrospective cohort study included 358 consecutive subacute stroke patients with first-ever stroke and Mini-Mental State Examination score ≤23 at admission. We determined motivation and rehabilitation outcome using the vitality index and FIM-motor gain, respectively. Stepwise multiple regression analysis was performed to identify the factors at admission related to FIM-motor gain. RESULTS: Of 80 participants enrolled in this study (mean age: 74.2 ± 11.3 years). The median (interquartile range) vitality index at admission and FIM-motor gain were 7 (4) and 23 (22) points, respectively. Stepwise multiple regression analysis revealed that age (B, -0.43; 95% confidence interval [CI], -0.65-(-0.21); ß, -0.31; P <.001), duration from stroke onset to admission (B, -0.18; 95% CI, -0.33-(-0.04); ß, -0.20; P =.014) and Stroke Impairment Assessment Set-motor function (B, 1.27; 95% CI, 0.92-1.61; ß, 0.78; P <.001), FIM-motor (B, -0.80; 95% CI, -1.01-(-0.60); ß, -0.95; P <.001), and vitality index (B, 3.79; 95% CI, 2.37-5.21; ß, 0.50; P <.001) scores at admission were significantly associated with the FIM-motor gain. DISCUSSION: The vitality index was significantly associated with FIM improvement in subacute stroke patients with cognitive impairment.

Reliability and Validity of a New Toileting Assessment Form for Patients with Hemiparetic Stroke.

BACKGROUND: Acquiring toileting independence is an important target of stroke rehabilitation. In planning an intervention for acquiring toileting independence, developing an assessment for individual subtasks that comprise toileting would assist in identifying specific tasks that prevent independence in patients and would facilitate interventions to improve toileting independence. OBJECTIVE: To examine the reliability and validity of a newly developed toileting assessment form, the Toileting Tasks Assessment Form (TTAF), for assessing toileting subtasks in hemiparetic stroke. DESIGN: Validation and test-retest study. SETTING: Subacute rehabilitation wards in Japan. PARTICIPANTS: Eighty-two therapists verified the form's content validity; 30 stroke patients who were using a wheelchair participated in the validation and test-retest study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The content validity of the assessment form was initially assessed based on a questionnaire. Subsequently, four occupational therapists used the form to evaluate video-recorded toileting performances simulated by participants with hemiparetic stroke. Two assessors evaluated each video-recorded performance once and repeated the evaluation of the same performance at 2 weeks later. The interrater reliability, intrarater reliability, internal consistency, and concurrent validity of the form were examined. RESULTS: Fleiss' κ coefficient for interrater reliability for each form item was 0.61 or more. Cohen's κ coefficient for intrarater reliability for each item was 0.60 or more. Cronbach's coefficient alpha ranged from 0.94 to 0.95. Spearman's rank correlation coefficients for the mean score on the form and the Functional Independence Measure (FIM) score for "toileting" ranged from 0.88 to 0.93 (P < .001). Spearman's rank correlation coefficients for the mean score on the form and the FIM score for "toilet transfer" ranged from 0.91 to 0.93 (P < .001). CONCLUSIONS: The TTAF demonstrated good reliability and validity. Further multicenter studies involving patients at different stroke phases are required to verify the reliability and validity of TTAF and confirm the generalizability of these findings.

Reliability and Validity of a New Transfer Assessment Form for Stroke Patients.

INTRODUCTION: Transferring is a basic skill that is essential for mobility independence and indispensable for expanding activities of daily living of stroke patients using a wheelchair. Therefore, transfer independence is an important issue that greatly affects daily life in the hospital and at home. To offer an effective intervention to acquire a skill, developing an assessment for individual subtasks that comprise transferring would assist the identification of specific tasks that prevent independence in patients and facilitate interventions to improve transferring independence. OBJECTIVE: To examine the reliability and validity of a newly developed transfer assessment form, the Bed-wheelchair transfer Tasks Assessment Form (BTAF), for stroke patients to evaluate subtasks required for transferring. DESIGN: Validation and test-retest studies. SETTING: Subacute rehabilitation wards in Japan. PARTICIPANTS: A total of 82 therapists for verifying content validity; 30 patients for validation and test-retest study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The content validity was initially assessed based on a questionnaire. Subsequently, four occupational therapists used the form to evaluate the video-recorded transferring performances of stroke participants. Two assessors evaluated each performance once and then 2 weeks later. The inter-rater reliability, intra-rater reliability, internal consistency, and concurrent validity were examined. RESULTS: Fleiss's κ coefficient for inter-rater reliability for each item of the form was 0.66 or more. Cohen's κ coefficient for intra-rater reliability for each item was 0.73 or more. Cronbach's coefficient alpha ranged from 0.90 to 0.93. Spearman's rank correlation coefficients between the mean scores of our form and scores of the functional independence measure item "transfer to bed/chair/wheelchair" ranged from 0.53 to 0.78 (P < .01). CONCLUSIONS: The form demonstrated good reliability and validity. Its usefulness and efficacy should be further investigated in stroke patients to facilitate rehabilitation.

New portable voice guidance device for the manual wheelchair transfer: a pilot study in patients with hemiplegia.

PURPOSE: Older and/or cognitively impaired patients require verbal guidance to prevent accidents during wheelchair operation, thus increasing the burden on caregivers. This study aimed to develop a new portable voice guidance device for manual wheelchairs and examine its clinical usefulness. METHOD: We developed a portable voice guidance device to monitor the statuses of wheelchair brakes and footrests and automatically provide voice guidance for operation. The device comprises a microcomputer, four magnets and magnetic sensors, speaker and battery. Device operation was assessed during the transfer from a wheelchair to bed six times per day over three days for a total of 90 transfers in five stroke patients (mean age: 79.6 years) who required verbal guidance to direct wheelchair operation. Device usability was also assessed using a questionnaire. RESULTS: The device performed perfectly during all attempted transfers (100%). To ensure safety, the assessor needed to add verbal guidance during 33 of 90 attempted transfers (36.6%). Overall, the device usability was favourable. However, some assessors were unsatisfied with the volume of the device voice, guidance timing and burden reduction. CONCLUSIONS: Our device could facilitate wheelchair operation and might potentially be used to reduce fall risk in stroke patients and the burden on caregivers. Implications for Rehabilitation The acquisition of transfer independence is an important step in the rehabilitation of patients with mobility issues. Many patients require supervision and guidance regarding the operation of brakes and footrests on manual wheelchairs. This newly developed voice guidance device for manual wheelchair transfers worked well in patients with hemiplegia and might be helpful to reduce the fall risks and the burden of care.

A pilot study of sensory feedback by transcutaneous electrical nerve stimulation to improve manipulation deficit caused by severe sensory loss after stroke.

BACKGROUND: Sensory disturbance is common following stroke and can exacerbate functional deficits, even in patients with relatively good motor function. In particular, loss of appropriate sensory feedback in severe sensory loss impairs manipulation capability. We hypothesized that task-oriented training with sensory feedback assistance would improve manipulation capability even without sensory pathway recovery. METHODS: We developed a system that provides sensory feedback by transcutaneous electrical nerve stimulation (SENS) for patients with sensory loss, and investigated the feasibility of the system in a stroke patient with severe sensory impairment and mild motor deficit. The electrical current was modulated by the force exerted by the fingertips so as to allow the patient to identify the intensity. The patient had severe sensory loss due to a right thalamic hemorrhage suffered 27 months prior to participation in the study. The patient first practiced a cylindrical grasp task with SENS for 1 hour daily over 29 days. Pressure information from the affected thumb was fed back to the unaffected shoulder. The same patient practiced a tip pinch task with SENS for 1 hour daily over 4 days. Pressure information from the affected thumb and index finger was fed back to the unaffected and affected shoulders, respectively. We assessed the feasibility of SENS and examined the improvement of manipulation capability after training with SENS. RESULTS: The fluctuation in fingertip force during the cylindrical grasp task gradually decreased as the training progressed. The patient was able to maintain a stable grip force after training, even without SENS. Pressure exerted by the tip pinch of the affected hand was unstable before intervention with SENS compared with that of the unaffected hand. However, they were similar to each other immediately after SENS was initiated, suggesting that the somatosensory information improved tip pinch performance. The patient's manipulation capability assessed by the Box and Block Test score improved through SENS intervention and was partly maintained after SENS was removed, until at least 7 months after the intervention. The sensory test score, however, showed no recovery after intervention. CONCLUSIONS: We conclude that the proposed system would be useful in the rehabilitation of patients with sensory loss.

A pilot study of contralateral homonymous muscle activity simulated electrical stimulation in chronic hemiplegia.

OBJECTIVE: For the recovery of hemiparetic hand function, a therapy was developed called contralateral homonymous muscle activity stimulated electrical stimulation (CHASE), which combines electrical stimulation and bilateral movements, and its feasibility was studied in three chronic stroke patients with severe hand hemiparesis. METHODS: Patients with a subcortical lesion were asked to extend their wrist and fingers bilaterally while an electromyogram (EMG) was recorded from the extensor carpi radialis (ECR) muscle in the unaffected hand. Electric stimulation was applied to the homonymous wrist and finger extensors of the affected side. The intensity of the electrical stimulation was computed based on the EMG and scaled so that the movements of the paretic hand looked similar to those of the unaffected side. The patients received 30-minutes of therapy per day for 2 weeks. RESULTS: Improvement in the active range of motion of wrist extension was observed for all patients. There was a decrease in the scores of modified Ashworth scale in the flexors. Fugl-Meyer assessment scores of motor function of the upper extremities improved in two of the patients. CONCLUSIONS: The results suggest a positive outcome can be obtained using the CHASE system for upper extremity rehabilitation of patients with severe hemiplegia.

A sensory feedback system utilizing cutaneous electrical stimulation for stroke patients with sensory loss.

Sensory disturbance is very common following stroke and may exacerbate a patient's functional impairment, even if the patient has good motor function. For instance, patients with sensory disturbances will often grip an object with excessive or underestimated pinch pressure, because they do not receive the appropriate sensory feedback and must rely only on visual feedback. In this study, we developed a sensory feedback system that used cutaneous electrical stimulation for patients with sensory loss. In the system, electrical stimulation is modulated by the strength of pinch pressure and the patients are able to identify their fingertip pinch pressure. To evaluate the efficacy of the system, a clinical case study was conducted in a stroke patient with severe sensory loss. The fluctuation in force control during grasping was gradually decreased as the training progressed and the patient was able to maintain a stable pinch pressure during grasping even without the system following 2 months of intervention. We conclude that the system described in this study may be a useful contribution towards the rehabilitation of patients with sensory loss.