Association between Oral Frailty and Dietary Variety among Community-Dwelling Older Persons: A Cross-Sectional Study.

OBJECTIVE: To examine the association between the severity of oral frailty (OF), which is one of the comprehensive oral functions evaluated, and dietary variety in community-dwelling older persons. DESIGN: Cross-sectional study. SETTING: Community-based. PARTICIPANTS: A total of 769 community-dwelling older persons aged 65 and over. INTERVENTIONS: We examined basic demographic information, functional status, cognitive status, depressive symptoms, medical history, and oral functions of the participants. MEASUREMENTS: OF was defined by 1-2 and 3 or more of 6 items of oral function evaluation in the pre-oral frailty and oral frailty groups, respectively. Dietary variety was assessed using the dietary variety score (DVS). The participants were categorized into 3 groups for evaluation: those with a low score (0-2), medium score (3-5), and high score (≥6). Ordinal logistic regression analysis was performed to examine the association between OF and DVS. RESULTS: The rate of OF in the participants was 21.6%, and its severity was significantly associated with DVS after adjusting for potential confounders (Pre-OF; adjusted odds ratio [OR] = 1.687, 95% confidence interval [CI] = 1.219-2.335, OF; adjusted OR = 2.857, 95% CI = 1.489-5.484). CONCLUSION: The severity of OF was significantly associated with DVS in community-dwelling older persons. This suggests that DVS may be useful in understanding the effects of OF on the nutritional status. Further longitudinal studies are needed to elucidate the association between OF and DVS.

Diabetic macular edema-like ocular lesions in male spontaneously diabetic torii fatty rats.

Diabetic macular edema (DME) is a major factor contributing to visual disabilities in diabetic patients, and the number of patients is increasing. Animal models play a key role in the development of novel therapies. In this study, pathophysiological analyses of ocular lesions in Spontaneously Diabetic Torii (SDT) fatty rats were performed. First, vascular endothelial growth factor (VEGF) concentrations in vitreous humor, retinal vascular permeability and retinal thickness were measured in SDT fatty rats (Experiment 1). Furthermore, the pharmacological effects of two anti-diabetic drugs, phlorizin and pioglitazone, on retinal lesions were evaluated (Experiment 2). As results, the SDT fatty rats exhibited VEGF increase in vitreous humor at 8 and 16 weeks of age, and both retinal vascular hyperpermeability and retinal thickening at 16 weeks of age. In particular, the layers between the retinal internal limiting membrane and the outer nuclear layer were thickened. Phlorizin treatment from 4 to 16 weeks of age improved hyperglycemia and normalized retinal thickness; however, the effect of pioglitazone on retinal thickness was not strong despite the normalization of hyperglycemia. These data demonstrate that the male SDT fatty rat is a useful model for developing new therapeutic approaches in DME.

Peripheral blood gene expression signature differentiates children with autism from unaffected siblings.

Autism spectrum disorder (ASD) is one of the most prevalent neurodevelopmental disorders with high heritability, yet a majority of genetic contribution to pathophysiology is not known. Siblings of individuals with ASD are at increased risk for ASD and autistic traits, but the genetic contribution for simplex families is estimated to be less when compared to multiplex families. To explore the genomic (dis-) similarity between proband and unaffected sibling in simplex families, we used genome-wide gene expression profiles of blood from 20 proband-unaffected sibling pairs and 18 unrelated control individuals. The global gene expression profiles of unaffected siblings were more similar to those from probands as they shared genetic and environmental background. A total of 189 genes were significantly differentially expressed between proband-sib pairs (nominal p < 0.01) after controlling for age, sex, and family effects. Probands and siblings were distinguished into two groups by cluster analysis with these genes. Overall, unaffected siblings were equally distant from the centroid of probands and from that of unrelated controls with the differentially expressed genes. Interestingly, five of 20 siblings had gene expression profiles that were more similar to unrelated controls than to their matched probands. In summary, we found a set of genes that distinguished probands from the unaffected siblings, and a subgroup of unaffected siblings who were more similar to probands. The pathways that characterized probands compared to siblings using peripheral blood gene expression profiles were the up-regulation of ribosomal, spliceosomal, and mitochondrial pathways, and the down-regulation of neuroreceptor-ligand, immune response and calcium signaling pathways. Further integrative study with structural genetic variations such as de novo mutations, rare variants, and copy number variations would clarify whether these transcriptomic changes are structural or environmental in origin.

Role of genetic factors (CETP gene Taq I B polymorphism and Apo A-I gene Msp I polymorphism) in serum HDL-C levels in women.

BACKGROUND AND AIM: Plasma high density lipoprotein cholesterol (HDL-C) levels are determined by a variety of environmental and genetic factors. The cholesteryl ester transfer protein (CETP) and apolipoprotein A-I (Apo A-I) are considered to be associated with HDL-C metabolism. The aim of this study was to investigate the relationship between the CETP gene Taq I B and Apo A-I gene Msp I polymorphisms and plasma lipid levels taking into account environmental factors, and to determine the combined effects of these polymorphisms on HDL-C levels in Japanese women. METHODS AND RESULTS: The study involved 270 Japanese women aged 30-69 years. We found a significant association between the CETP genotypes and HDL-C levels (p=0.0020), which were also associated with the Apo A-I gene (M1) polymorphism. Stepwise multiple regression analysis revealed that both the CETP Taq I B and Apo A-I gene (M1) genotypes were independent predictive variables. The strength of the association between the Apo A-I (M1) subgroup and HDL-C levels was reduced in the subjects with a high Body Mass Index (BMI). The combination of genotypes provided more detailed information about HDL-C levels. The "high risk" combination of the M1+ (M1+/+) and B1B1 genotypes was associated with the lowest HDL-C level (1.52+/-0.36 mmol/L), and the "low risk" combination of the M1- (M1+/- or M1-/-) and B2B2 genotypes was associated with the highest HDL-C levels (2.06+/-0.34 mmol/L). CONCLUSIONS: Our results suggest that the combination of the two polymorphisms influences HDL-C levels in women, and that the association between genetic factors and HDL-C levels is altered by environmental factors. They may also help to detect individuals with low HDL-C levels at high risk for coronary artery syndrome.

Changes in postural sway during a period of sustained wakefulness in male adults.

Nocturnal variations in postural sway during a period of sustained wakefulness were studied in seven healthy male adults. Postural sways with the subject's eyes open and with them closed were measured every hour from 22:00 to 04:00 h the following day. Parameters of postural sway [rectangle area (RA), root mean square of length in the anterior-posterior direction (RMSL-y), and medium-frequency-band (0.2-1.0 Hz) power of postural sway in the lateral (MF-x) and anterior-posterior (MF-y) directions] showed significant nocturnal variations. RA, RMSL-y, MF-x and MF-y increased after midnight and reached peaks at 04:00 h. Moreover, changes in RA and MF-y depended on visual conditions. The increases in RA and MF-y were larger with the eyes closed than with them open. These postural sway parameters showed positive correlations with subjectively rated sleepiness and negative correlations with electroencephalographic alpha activity. The results suggest that changes in postural sway during the night are influenced by the increase in sleepiness.

NeuroD/beta2 gene G-->A polymorphism may affect onset pattern of type 1 diabetes in Japanese.

OBJECTIVE: The majority of type 1 diabetes is considered to be autoimmune with, for the most part, abrupt development. However, type 1 diabetes with slow onset, or the so-called slowly progressive type 1 diabetes or latent autoimmune diabetes in adults, has been recently recognized and is considered to be autoimmune-related. Although some investigators tried to explain the difference in onset pattern by the genetic background, including HLA type, it has not been established thus far. We hypothesized that the difference in onset pattern may relate to regeneration or differentiation of pancreatic beta-cells, and we therefore focused on the NeuroD/BETA2 gene, which encodes a transcription factor for the insulin gene and beta-cell differentiation. RESEARCH DESIGN AND METHODS: We examined the NeuroD/BETA2 gene polymorphism in 105 Japanese type 1 diabetic patients and in 122 nondiabetic Japanese subjects in a case-control study, and we stratified the patients according to their onset pattern and islet-associated autoantibody positivity. RESULTS: Regardless of the existence of islet-associated autoantibody, we found a significant difference in A allele frequency between type 1 diabetic patients with acute-onset type and control subjects. However, no difference was found between type 1 slow-onset diabetic patients and control subjects. CONCLUSIONS: These results support our hypothesis that NeuroD/BETA2 may affect the ability of regeneration of beta-cells, leading to a difference in the onset pattern and clinical course of type 1 diabetes.

Diurnal variations in alpha power density and subjective sleepiness while performing repeated vigilance tasks.

OBJECTIVE: Diurnal variations in EEG activity and subjectively rated sleepiness while performing repeated vigilance tasks were examined. METHODS: Nine diurnally active healthy males underwent repeated vigilance tasks at 08:00, 11:00, 14:00, 17:00 and 20:00 h. An electroencephalogram (EEG) was taken while the subjects performed the tasks with their eyes open. The alpha power spectra (8.6-13.3 Hz) of EEG was integrated. Subjectively rated sleepiness, reaction time and oral temperature were also measured. RESULTS: Significant diurnal variations were found for alpha power, subjectively rated sleepiness and oral temperature. The alpha power was significantly smaller at 08:00 than at 11:00, 14:00, 17:00 and 20:00 h. The subjectively rated sleepiness was significantly larger at 08:00 than at 11:00, 17:00 and 20:00 h. The diurnal variation in alpha power did not correspond to that in subjectively rated sleepiness. On the other hand, repeated vigilance tasks increased the alpha power, subjectively rated sleepiness and reaction time at each time of day. The increase in alpha power was significantly greater at 14:00 than at 08:00 and 20:00 h. CONCLUSIONS: The diurnal variation was found in alpha power while performing vigilance tasks. Furthermore, the increase in alpha power with repetition of the task depended on the time of day.

Quantitative EEG data and comprehensive ADL (Activities of Daily Living) evaluation of stroke survivors residing in the community.

The purpose of this study was to investigate the hypothesis that EEG values match other comprehensive activities of daily living (ADL) evaluations between stroke survivors and normal controls. Various functions related to ADL were examined by means of ADL assessments (Measurement of Competence in the Elderly Living at Home, Barthel Index, Stroke Impairment Assessment Set, time needed to walk 10 metres) and biosocial synchronization (the questionnaire on biosocial rhythms of daily living). EEG was undertaken using a computer-assisted portable EEG recorder. The power spectra were computed using a fast Fourier transformation analysis (FFT). The absolute and relative powers (percent of the total EEG power) of 5 frequency bands (delta, theta, alpha 1, alpha 2 and beta) and the peak frequency were analyzed. In comparing stroke survivors and the independent elderly, the latter had higher scores than the former in assessments of various functions related to ADL. The absolute and relative power of the delta band were lower in normal controls, and the relative power of the alpha (2) band and the peak frequency were higher than those of stroke survivors. Among the correlations between EEG and ADL assessments, the absolute and relative power of the alpha (2) band correlated significantly with ADL assessments of stroke survivors with right hemiplegia. The peak frequency was significantly increased in cases with high ADL scores. In conclusion, significant correlations were identified between the quantitative EEG data of stroke survivors in the chronic stage, living in the community, and ADL-related functions. Computer-assisted portable EEG recording is a potentially useful screening tool for objectively evaluating the functional levels of stroke survivors in field work.

[A case of gastric cancer with liver metastases successfully treated with combination therapy of systemic and hepatic arterial infusion chemotherapy].

A 67-year-old man was admitted to our hospital because of advanced gastric cancer associated with metastases to the liver, the lymph nodes along the lesser curvature and the infradiaphragmatic lymph nodes. As we considered the primary lesion and the liver metastases to be unresectable, we treated him with combination therapy of systemic and hepatic arterial infusion chemotherapy. The regimen of systemic chemotherapy consisted of cisplatin (CDDP) and UFT. Hepatic arterial infusion chemotherapy included 5-fluorouracil (5-FU), doxorubicin (DXR) and mitomycin C (MMC). We repeated this therapy six times. The size of the primary lesion and the lymph node metastases decreased significantly after the chemotherapy. The size of the liver metastases did not change, but they appeared to necrotize. The patient maintained a good quality of life during the therapy. He finally died of peritonitis carcinomatosa 18 months after the diagnosis. This case indicated that combination therapy of systemic and hepatic arterial infusion chemotherapy was effective in cases of unresectable gastric cancer associated with liver metastases.

Postural sway during cane use by patients with stroke.

OBJECTIVE: To quantitatively evaluate the effects of body support with a cane on postural sway by measuring gravity-center sway of patients with stroke who reside at home. DESIGN: The subjects were 41 patients with stroke and 36 healthy independent elderly people. Each subject stood in the standard Romberg position on a gravicorder under two conditions: without support and with a cane. RESULTS: In both groups, the largest area of gravity-center sway occurred when the subjects stood without support. The area of gravity-center sway of the patients with stroke was significantly greater than that of the healthy independent elderly. In the patients with stroke group, the percentage decrease in the standing position with the cane was 58.0% in the men and 53.9% in the women, as opposed to 67.7% in the men and 67.8% in the women in the group of healthy independent elderly. CONCLUSION: The authors quantitatively evaluated the effects of body support with a cane on postural sway of patients with stroke. The effect of body support with cane on postural sway of patients with stroke was more effective than that of healthy independent elderly.

Circadian rhythm abnormalities of wrist activity of institutionalized dependent elderly persons with dementia.

BACKGROUND: The study objective was to clarify the descriptive characteristics of circadian rhythm abnormalities of wrist activity of the institutionalized elderly with dementia. METHODS: We studied 82 elderly persons with dementia who were institutionalized in a long-term medical care facility. The ambulatory continuous monitoring of their wrist activity was conducted for 7 days at 1-minute intervals. The time series data were analyzed using the double-plotted chronogram, spectral analysis was performed using the fast Fourier transformation and periodogram analysis was performed as well. RESULTS: The frequency of circadian rhythm abnormalities of wrist activity rhythm in elderly persons with dementia was 57.3% (47 out of 82). The abnormalities were classified into four categories: severely impaired circadian rhythm type with no boundary between day and night, free-running rhythm type, decreased circadian amplitude type, and accentuation of ultradian rhythm type. CONCLUSION: This four-category classification system provides a scientific approach for studying the mechanisms of circadian activity rhythm abnormalities of elderly persons with dementia.

Dietary short-chain fructooligosaccharides increase calbindin-D9k levels only in the large intestine in rats independent of dietary calcium deficiency or serum 1,25 dihydroxy vitamin D levels.

Dietary short-chain fructooligosaccharides (Sc-FOS) increase mucosal calbindin-D9k (CaBP) levels in the large intestine whereas levels in the small intestine are decreased in rats. In the present study, we investigated the mechanism by which Sc-FOS induce this increase in CaBP in the large intestine by measuring intestinal CaBP levels in rats fed normal and calcium-deficient diets. Dietary groups included a calcium-containing (0.5%) diet with or without Sc-FOS (100 g/kg diet) and a calcium-deficient (abt. 0.01%) diet with or without Sc-FOS (100 g/kg diet). The rats were fed these diets for 10 days following which they were killed and the intestine removed for collection of the entire mucosa which was divided into four segments, i.e., proximal and distal segments of the small intestine, the cecum and the colorectum. Mucosal CaBP and plasma calcium (Ca), 1,25-dihydroxycholecalciferol (1,25(OH)2D3), 25-hydroxycholecalciferol (25(OH)D3), parathyroid hormone (PTH) and calcitonin levels were measured. Feeding of calcium deficient diet resulted in an increase in CaBP levels in the small intestine, but did not influence levels in the large intestine. Moreover, a significant positive correlation between plasma 1,25(OH)2D3 and CaBP levels in the case of both small intestinal segments (proximal, r = 0.77012, p < 0.00007; distal, r = 0.75056, p < 0.00014) was observed, but not in the case of the large intestinal segments. Sc-FOS increased CaBP levels in the large intestine. These results suggest that the large intestinal CaBP levels do not change in response to dietary calcium conditions and are not regulated by circulating 1,25(OH)2D3 indicating that the effect of Sc-FOS on CaBP levels in the large intestine is independent of the action of 1,25(OH)2D3.

Physical performance tests after stroke: reliability and validity.

OBJECTIVE: To evaluate the reliability and validity of the modified physical performance tests for stroke survivors who live in a community. DESIGN: The subjects included 40 stroke survivors and 40 apparently healthy independent elderly persons. The physical performance tests for the stroke survivors comprised two physical capacity evaluation tasks that represented physical abilities necessary to perform the main activities of daily living, e.g., standing-up ability (time needed to stand up from bed rest) and walking ability (time needed to walk 10 m). RESULTS: Regarding the reliability of tests, significant correlations were confirmed between test and retest of physical performance tests with both short and long intervals in individuals after stroke. Regarding the validity of tests, the authors studied the significant correlations between the maximum isometric strength of the quardriceps muscle and the time needed to walk 10 m, centimeters reached while sitting and reaching, and the time needed to stand up from bed rest. CONCLUSIONS: The authors confirmed that there were significant correlations between the instrumental activity of daily living and the time needed to stand up from bed rest, along with the time needed to walk 10 m for the stroke survivors. These physical performance tests are useful guides for evaluating a level of activity of daily living and physical frailty of stroke survivors living in a community.

Diurnal variation in the P300 component of human cognitive event-related potential.

Diurnal variation in the P300 component of the human cognitive event-related potential (ERP) was examined. The P300 component is considered to be a measure of neuroelectric activity related to cognitive functions such as attention allocation and information processing. Nine diurnally active healthy male subjects whose sleep-wake rhythms were synchronized prior to the experiment were studied. The P300 components oral temperature, heart rate, left- and right-hand grip strength, reaction time, subjectively rated sleepiness, attention level, and fatigue were measured at 08:00, 11:00, 14:00, 17:00, and 20:00. Significant diurnal variations in P300 latency, P300 amplitude, oral temperature, heart rate, left- and right-hand grip strength, subjectively rated sleepiness, and attention level were observed. The P300 latency at 08:00 was significantly longer than at 11:00, 17:00, and 20:00, while the P300 amplitude at 08:00 was significantly greater than at 17:00 and 20:00. The P300 latency was correlated positively with subjectively rated sleepiness and negatively correlated with subjectively rated attention level. These results suggest the existence of diurnal variation in human cognitive functions.

Examination of lacZ mutant induction in the liver and testis of Muta Mouse following injection of halogenated aliphatic hydrocarbons classified as human carcinogens.

Possible induction of lacZ mutation was examined in the liver and testis of Muta Mouse following the administration of carcinogenic halogenated compounds, namely 1,2-dichloroethane (DCE), 1,2-dibromoethane (DBE), carbon tetrachloride, or 1,2-dibromo-3-chloropropane (DBCP). Slight increases were observed on the mutant frequency in the testis DNA isolated from the mice 14 days after treatment with DBCP at 40 mg/kg or with DBE at 60 mg/kg but not in the liver. Further investigation was necessary to confirm the mutation induction by these chemicals in the testis including experiments with longer sampling intervals. No increase was detected in the frequency following DCE administration of single doses of up to 150 mg/kg or of consecutive injections of up to 280 mg/kg. Marginal but biologically insignificant responses were observed in the liver from the carbon tetrachloride exposed mice. The present results suggest that these carcinogenic chemicals are less efficient for induction of gene mutation in the liver of Muta Mouse.

Time-of-day effects of ethanol consumption on EEG topography and cognitive event-related potential in adult males.

Time-of-day effects of ethanol consumption on EEG topography and cognitive event-related potential in adult males were studied. Ethanol (0.5 g/kg) or control drink was orally administered to nine healthy males at 10:00 and 18:00. The alpha 2 amplitude was significantly lower than that of the control at 0.5, 2.5 and 4.5 hours after ethanol consumption in the morning. These effects were observed in the left hemisphere and were only found after consumption in the morning. The subjectively rated attention was significantly lower than that of the control at 0.5 and 2.5 hours after ethanol consumption in the morning and at 0.5 hours after ethanol consumption in the evening. In contrast, the search speed of serial search task and P300 amplitude was significantly lower than that of the control at 2.5 hours after ethanol consumption in the evening. These results demonstrate that effects of ethanol are dependent on time-of-day of consumption. Ethanol consumption significantly lowered the alpha 2 amplitude when consumed in the morning, and lowered P300 amplitude when consumed in the evening.

Reliability and validity of the questionnaire to determine the biosocial rhythms of daily living in the disabled elderly.

The questionnaire to determine the biosocial rhythms of daily living in the disabled elderly was newly developed. This questionnaire was aimed to evaluate a state of synchronization of biological rhythms in the disabled elderly. Eighteen items of the questionnaire relating to the synchronization of biological rhythms were finally selected by the test-retest method that was conducted for 68 disabled elderly living in a community with a duration of one year. The factor analysis showed that the questionnaire consisted of five factors: outdoor activities, ultradian rhythms, subjective evaluation of health status, social support, and sleep habits. The cumulative contribution rate of five factors was 53.2%. Reliability of the questionnaire was confirmed by a calculation of the Equal-length Spearman-Brown coefficients ranging from 0.60 to 0.80. Regarding the construct validity of the questionnaire, results of factor analysis showed five factors that were consistent with the synchronizers known in chronobiology. The total score of the questionnaire was significantly correlated to Barthel Index score and the competence score, suggesting that it partly reflects the activities of daily living of the disabled elderly. We conclude that a new questionnaire to determine the biosocial rhythm of daily living in the disabled elderly is useful to evaluate the biosocial synchronization of the disabled elderly because of its high reliability and validity.

Induction of lacZ mutation by 7,12-dimethylbenz[a]anthracene in various tissues of transgenic mice.

The induction of gene mutations was examined in MutaMouse after an intraperitoneal injection of 7, 8-dimethylbenz[a]anthracene (DMBA) at 20 mg/kg in a collaborative study participated by four laboratories. Although the DMBA dose used was lower than the level that has been reported to induce micronucleated erythrocytes maximally in several mouse strains, a killing effect appeared after day 9 of the post-treatment interval. Mutations in lacZ transgene were detected by the positive selection assay following in vitro packaging of phage lambda from the genomic DNA of the transgenic animals that survived. The mutant induction was evaluated in the bone marrow, liver, skin, colon, kidney, thymus, and testis 7 to 28 days after the treatment. In the bone marrow, the mutant frequency reached a maximum, approximately a 30-fold increase, 14 days after the treatment and the increased frequency persisted at least up to day 28 of the post-treatment. Induction of mutants was detected in the liver, colon, thymus, and skin to lesser extents. Marginal responses were obtained in the kidney and testis. The slight increases in the mutant frequencies in the kidney and testis observed in some laboratories were within laboratory-to-laboratory or animal-to-animal variations. In contrast to the gene mutation induction in the bone marrow, the frequency of micronucleated reticulocytes increased transiently 3 days after the treatment and returned to a control level before day 8 of the post-treatment. It was suggested that DMBA induced gene mutation is fixed in stem cells depending on cell proliferation while DNA damages responsible for chromosome breakage are not transmitted to progeny cells.

Evaluation of complex activities in daily living of elderly Japanese with visual impairment.

This study was conducted to determine whether elderly subjects with visual impairment differ in the performance of complex activities in daily living from those without visual impairment. The study subjects were residents in two homes for the aged in Japan, and consisted of 37 elderly people with visual impairment, and 42 elderly people, serving as controls; ages ranged from 64 to 95 years. Complex activities of the subjects were ascertained by interview using a 46-item questionnaire. The visually impaired elderly had lower performance levels for telephone use (p = 0.007), shopping (p = 0.049), cleaning up one's room (p = 0.001), and utilization of medical facilities (p = 0.001) in instrumental ADL (IADL); for interest in TV or radio (p = 0.004) and religious faith (p = 0.042) in "enriching activities"; and for visiting behaviors (p < 0.05) in "social role". The performances of complex activities by the elderly with visual impairment were diminished in specific categories, but not overall, and this may be attributable to poor mobility and/or more passive attitudes in their daily activities.

Sleep-wake rhythm and physical fitness in relation to activities of daily living in stroke survivors residing at home.

To clarify the relationship between sleep-wake rhythm, physical fitness, and competence level of elderly stroke survivors living at home, thirty-seven stroke survivors living at home (65.4 ± 7.3 years) voluntarily participated in a cross-sectional study with an interview survey and measurement of physical fitness. All subjects lived in a community and received community home health care services. Sleep-wake rhythm and competence were evaluated by the questionnaire method. Physical fitness in relation to daily living activities was measured by both die time needed to walk 10 meters and that needed to stand up from bed rest position. There was a significant positive correlation between rising time and the 10 meter walking time. Regarding rising time and the competence score, there was a significant negative correlation. Stroke survivors who actively participated in community activities arose earlier than those who had a negative attitude toward participation in community activities. The sleep-wake rhydim, especially rising time, and the participation in community activities were related to the high competence level of stroke survivors living at home. Strengthening the synchronization of the sleep-wake rhythm and increasing the social network may serve as useful procedures to improve the competence of stroke survivors living at home.