Clinical impact of non-lying time on hospital-associated functional decline in older patients undergoing transcatheter aortic valve implantation.

The purposes of the present study were: (1) to investigate the relationship between hospital-associated functional decline (HAFD) and non-lying time and (2) to clarify the optimal cut-off value for non-lying time associated with HAFD in older patients undergoing transcatheter aortic valve implantation (TAVI). From January 2021 to December 2022, patients admitted to a university hospital who underwent trans-femoral TAVI were consecutively recruited. We measured short physical performance battery (SPPB) pre and post-TAVI, and non-lying time from post-operative days 3-5. HAFD was defined as at least 1 point decrease in SPPB during pre and post-TAVI. Among 75 patients (47 female, mean age of 84.5 years) enrolled, 14 patients were classified as having HAFD. Non-lying time was significantly shorter in the HAFD group than in the non-HAFD group (371 min vs. 539 min, P < 0.001). Receiver-operating characteristic analysis determined an optimal cut-off value of 477 min for differentiating the patients more likely to experience HAFD (sensitivity, 75%; specificity, 92%; area under the curve, 0.798). The non-lying time could be one of the associated factors of HAFD in older patients with TAVI. Non-lying time of about 480 min (8 h) during hospitalization may be an initial target for preventing HAFD.

Determinants of Gait Parameters in Patients With Severe Hip Osteoarthritis.

OBJECTIVE: To investigate the characteristics and symptoms of patients with hip osteoarthritis that are associated with spatiotemporal gait parameters, including their variability and asymmetry. DESIGN: A retrospective, cross-sectional study. SETTING: University hospital. PARTICIPANTS: The study analyzed the gait analysis data of 155 patients (N=155) with hip osteoarthritis who were admitted to a university hospital for total hip replacement and were able to walk on a treadmill without a handrail. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The dependent variables were gait parameters during treadmill walking. These included gait speed, stride length, cadence, coefficient of variation of stride length and stride time, swing time symmetry index, and step symmetry index. Single and multiple regression analyses were conducted using independent variables of the characteristics and symptoms of the patients, including age, sex, height, pain, leg-length discrepancy, and muscle strength of the affected and normal sides measured with a hand-held dynamometer (iliopsoas, gluteus medius, and quadriceps). RESULTS: In the analysis, gait speed and stride were the dependent variables, whereas age, height, and muscle strength on the affected side were the significant independent variables (P<.05). Additionally, pain demonstrated a marginal association with gait speed (P=.053). Only the leg-length discrepancy correlated with cadence. When the coefficient of variation of the stride length was the dependent variable, age and muscle strength on the affected side were significant. For the swing time symmetry index, only the muscle strength on the affected side was significant. Furthermore, the step symmetry index only correlated with leg-length discrepancy. The muscle strength on the affected side was the only significant independent variable for the coefficient of variation of the stride time. CONCLUSIONS: The results revealed that each of the frequent clinical symptoms of hip osteoarthritis, such as pain, muscle weakness, and leg-length discrepancy, can explain different aspects of gait performance.

Prediction of Pharyngeal 3D Volume Using 2D Lateral Area Measurements During Swallowing.

This study evaluated the validity of pharyngeal 2D area measurements acquired from the lateral view for predicting the actual 3D volume in healthy adults during swallowing. Seventy-five healthy adults (39 females, 36 males; mean age 51.3 years) were examined using 320-row area detector computed tomography (320-ADCT). All participants swallowed a 10 mL honey-thick barium bolus upon command while seated in a 45° semi-reclining position. Multi-planar reconstruction images and dynamic 3D-CT images were obtained using Aquilion ONE software. Pharyngeal 2D area and 3D volume measurements were taken before swallowing and at the frame depicting maximum pharyngeal constriction. Pharyngeal volume before swallowing (PVhold) was accurately predicted by 2D area (R2 = 0.816). Adding height and sex to the model increased R2 to 0.836. Regarding pharyngeal volume during maximum constriction (PVmax), 2D area also exhibited acceptable predictive power (R2 = 0.777). However, analysis of statistical residuals and outliers revealed a greater tendency for prediction errors when there is less complete constriction of the pharynx as well as asymmetry in bolus flow or movement. Findings highlight the importance of routinely incorporating anterior-posterior views during VFSS exams. Future work is needed to determine clinical utility of pharyngeal volume measurements derived from 320-ADCT.

Prediction of Oral Intake at Discharge with Early Assessment of Swallowing Function within 24 h after Admission: A Retrospective Cohort Study.

Dysphagia is one of the most common symptoms of stroke and can lead to other complications such as pneumonia, dehydration, and malnutrition. This retrospective cohort study evaluated the predictive value of a comprehensive swallowing assessment tool, the Mann Assessment of Swallowing Ability (MASA), in the acute phase of stroke for oral intake status at discharge. Among 1,133 consecutive patients with acute stroke, 512 patients whose swallowing function was assessed using the MASA within 24 h of admission were included. Data including demographic information, stroke severity, MASA, Oral Health Assessment Tool, body mass index, and serum albumin level were collected. Predictive factors for oral intake were analyzed using a multiple logistic regression model, and the receiver operating characteristic (ROC) curve analysis was used to determine the cutoff values of the MASA score for determining oral intake at discharge. Oral intake at discharge was established in 69.1% of the cohort (354/512). The multiple logistic regression analysis identified a higher MASA score, younger age, and higher serum albumin level as significant predictors of oral intake at discharge. The cutoff value of the MASA score for oral intake was 136.5 points, with an area under the ROC curve of 0.87. These findings suggest that the MASA is a valid tool for predicting oral intake in patients with dysphagia during the acute phase of stroke.

Effects of robot-assisted gait training using the Welwalk on gait independence for individuals with hemiparetic stroke: an assessor-blinded, multicenter randomized controlled trial.

BACKGROUND: Gait disorder remains a major challenge for individuals with stroke, affecting their quality of life and increasing the risk of secondary complications. Robot-assisted gait training (RAGT) has emerged as a promising approach for improving gait independence in individuals with stroke. This study aimed to evaluate the effect of RAGT in individuals with subacute hemiparetic stroke using a one-leg assisted gait robot called Welwalk WW-1000. METHODS: An assessor-blinded, multicenter randomized controlled trial was conducted in the convalescent rehabilitation wards of eight hospitals in Japan. Participants with first-ever hemiparetic stroke who could not walk at pre-intervention assessment were randomized to either the Welwalk group, which underwent RAGT with conventional physical therapy, or the control group, which underwent conventional physical therapy alone. Both groups received 80 min of physical therapy per day, 7 days per week, while the Welwalk group received 40 min of RAGT per day, 6 days per week, as part of their physical therapy. The primary outcome was gait independence, as assessed using the Functional Independence Measure Walk Score. RESULTS: A total of 91 participants were enrolled, 85 of whom completed the intervention. As a result, 91 participants, as a full analysis set, and 85, as a per-protocol set, were analyzed. The primary outcome, the cumulative incidence of gait-independent events, was not significantly different between the groups. Subgroup analysis revealed that the interaction between the intervention group and stroke type did not yield significant differences in either the full analysis or per-protocol set. However, although not statistically significant, a discernible trend toward improvement with Welwalk was observed in cases of cerebral infarction for the full analysis and per-protocol sets (HR 4.167 [95%CI 0.914-18.995], p = 0.065, HR 4.443 [95%CI 0.973-20.279], p = 0.054, respectively). CONCLUSIONS: The combination of RAGT using Welwalk and conventional physical therapy was not significantly more effective than conventional physical therapy alone in promoting gait independence in individuals with subacute hemiparetic stroke, although a trend toward earlier gait independence was observed in individuals with cerebral infarction. TRIAL REGISTRATION: This study was registered with the Japan Registry of Clinical Trials ( https://jrct.niph.go.jp ; jRCT 042180078) on March 3, 2019.

Location of the upper oesophageal sphincter during swallowing: Analysis using swallowing CT.

BACKGROUND: Upper oesophageal sphincter (UES) serves as an important anatomical and functional landmark during swallowing. However, the precise UES location before and during swallowing has not been well established. OBJECTIVE: This study aimed to determine upper oesophageal sphincter (UES) location and displacement during swallowing accounting for sex, age, and height in healthy adults using 320-row area detector computed tomography (320-ADCT). METHODS: Ninety-four healthy adults (43 males; 22-90 years) underwent 320-ADCT scanning while swallowing one trial of 10 mL honey thick barium. UES location at bolus hold and at maximum displacement and vertical displacement during swallowing were identified using the coordinates and the section classification of vertebrae (VERT scale). The differences and correlations of UES location and distance in terms of sex, age, and height were analysed using Mann-Whitney U test and Spearman's correlation coefficient. RESULTS: UES locations at bolus hold and at maximum displacement were significantly lower and UES vertical displacement was significantly larger in males than in females (p < .001). UES location at bolus hold became lower with increasing age (r = -.312, p = .002), but the negative correlation was low at maximum displacement (r = -.230, p = .026), resulting in larger vertical distance with ageing. UES locations showed high negative correlation at bolus hold with height (r = -.715, p < .001), and showed moderate negative correlation at maximum displacement with height (r = -.555, p < .001), although this effect was unclear when analysed by sex. CONCLUSION: Males showed lower UES location and larger displacement than females. The impact of age was evident with lower location before swallowing and larger displacement during swallowing. Differences observed by sex were not completely explained by using the VERT scale to adjust for height.

Direction-dependent differences in the quality and quantity of horizontal reaching in people after stroke.

Arm reaching is often impaired in individuals with stroke. Nonetheless, how aiming directions influence reaching performance and how such differences change with motor recovery over time remain unclear. Here, we elucidated kinematic parameters of reaching toward various directions in people with poststroke hemiparesis in the subacute phase. A total of 13 and 15 participants with mild and moderate-to-severe hemiparesis, respectively, performed horizontal reaching in eight directions with their more-affected and less-affected sides using an exoskeleton robotic device at the time of admission to and discharge from the rehabilitation ward of the hospital. The movement time, path length, and number of velocity peaks were computed for the mild group (participants able to reach toward all eight directions). In addition, the total amount of displacement (i.e., movement quantity) toward two simplified directions (mediolateral or anteroposterior) was evaluated for the moderate-to-severe group (participants who showed difficulty in completing the reaching task). Motor recovery was evaluated using the Fugl-Meyer assessment. The mild group showed worse values of movement parameters during reaching in the anteroposterior direction, irrespective of the side of the arm or motor recovery achieved. The moderate-to-severe group exhibited less movement toward the anteroposterior direction than toward the mediolateral direction at admission; however, this direction-dependent bias in movement quantity decreased, with the movement expanding toward the anteroposterior direction with motor recovery at discharge. These results suggest that direction-dependent differences in the quality and quantity of reaching performance exist in people after stroke, regardless of the presence or severity of hemiparesis. This highlights the need to consider the task work area when designing rehabilitative training.NEW & NOTEWORTHY Arm reaching, a fundamental function required for the upper extremities, is often impaired after stroke due to muscle weakness and abnormal synergies. Nonetheless, how aiming directions influence performance remains unclear. Here, we report that direction-dependent differences in the quality and quantity of reaching performance exist, surprisingly regardless of the presence or severity of hemiparesis. This result highlights the need to consider the task work area when designing rehabilitative training.

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.

Shock-absorbing effect of flooring-adopted mechanical metamaterial technology and its influence on the gait and balance of older adults.

OBJECTIVE: To elucidate the performance of a shock-absorbing floor material with a mechanical metamaterial (MM-flooring) structure and its effect on the gait and balance of older adults. METHODS: The drop-weight impact was applied to evaluate the shock-absorbing performance. The falling weight was adjusted equivalent to the energy exerted on the femur of an older woman when she falls, which was evaluated on the MM-flooring and six other flooring materials.Nineteen healthy people over the age of 65 years participated in the gait and balance evaluations. The timed up and go and two-step tests were adopted as gait performance tests, and the sway-during-quiet-balance test with force plates and the functional reach test (FRT) were adopted as balance tests. All the participants underwent these tests on the MM-flooring, shock-absorbing mat and rigid flooring. RESULTS: The shock-absorbing performance test revealed that MM-flooring has sufficient shock-absorbing performance, and suggesting that it may reduce the probability of fractures in the older people when they fall. The results of the gait performance test showed that the participants demonstrated the same gait performance on the MM-flooring and the rigid floor. In the quiet standing test, MM-flooring did not affect the balance function of the participants to the same extent as the rigid floor, compared with the shock-absorbing mat. In the FRT, no significant differences were found for any of the flooring conditions. CONCLUSIONS: MM-flooring has the potential to prevent fractures attributed to falls and does not affect the gait or balance of older adults.

Effects of Balance Exercise Assist Robot training for patients with hemiparetic stroke: a randomized controlled trial.

BACKGROUND: Robot-assisted rehabilitation for patients with stroke is promising. However, it is unclear whether additional balance training using a balance-focused robot combined with conventional rehabilitation programs supplements the balance function in patients with stroke. The purpose of this study was to compare the effects of Balance Exercise Assist Robot (BEAR) training combined with conventional inpatient rehabilitation training to those of conventional inpatient rehabilitation only in patients with hemiparetic stroke. We also aimed to determine whether BEAR training was superior to intensive balance training. METHODS: This assessor-blinded randomized controlled trial included 60 patients with first-ever hemiparetic stroke, admitted to rehabilitation wards between December 2016 and February 2019. Patients were randomly assigned to one of three groups, robotic balance training and conventional inpatient rehabilitation (BEAR group), intensive balance training and conventional inpatient rehabilitation (IBT group), or conventional inpatient rehabilitation-only (CR group). The intervention duration was 2 weeks, with assessments conducted pre- and post-intervention, and at 2 weeks follow-up. The primary outcome measure was a change in the Mini-Balance Evaluation Systems Test (Mini-BESTest) score from baseline. RESULTS: In total, 57 patients completed the intervention, and 48 patients were evaluated at the follow-up. Significant improvements in Mini-BESTest score were observed in the BEAR and IBT groups compared with in the CR group post-intervention and after the 2-week follow-up period (P < 0.05). CONCLUSIONS: The addition of balance exercises using the BEAR alongside conventional inpatient rehabilitation improved balance in patients with subacute stroke. TRIAL REGISTRATION: https://www.umin.ac.jp/ctr ; Unique Identifier: UMIN000025129. Registered on 2 December 2016.

Effects of head flexion posture in patients with dysphagia.

BACKGROUND: The chin-down posture is often used as a compensatory manoeuvre for patients with dysphagia. This posture presumably involves flexion of the head and/or neck, but this is not clearly defined. OBJECTIVE: This study aimed to assess the effects of head flexion posture in a retrospective study of videofluoroscopic examination of swallowing (VF). METHODS: A total of 73 patients who underwent VF both with and without head flexion posture in the lateral projection were included in the analysis. The head and neck angles at the initiation of the swallowing reflex, penetration-aspiration scale (PAS), nasopharyngeal closure time, stage transition duration, duration of laryngeal closure, time from swallowing reflex to laryngeal closure and to the opening of upper oesophageal sphincter (UES), duration of UES opening, location of the bolus leading edge at swallowing reflex, and bolus transition time were evaluated. RESULTS: The head flexion angle increased (p < 0.001), but the neck flexion angle did not change in the head flexion posture. Moreover, PAS improved (p < 0.001), aspiration was reduced (p < 0.001), the time between the swallowing reflex and the onset of laryngeal closure was shortened (p = 0.006), and the leading edge of the bolus at swallowing reflex became shallower (p = 0.004) in the head flexion posture. Other parameters did not significantly change. CONCLUSION: The head flexion posture resulted in earlier laryngeal closure and a shallower position of the leading bolus edge at swallowing reflex, resulting in PAS improvement and decreased aspiration.

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.

Stroke Patients with Nearly Independent Transfer Ability are at High Risk of Falling.

OBJECTIVES: To examine the relationship between patients' transfer ability and fall risk in stroke patients during hospitalization. MATERIALS AND METHODS: We retrospectively enrolled 237 stroke patients who were transferred to a convalescent rehabilitation ward from acute wards in the same hospital. Using incident reports, we investigated their fall rates and activity status at the falls according to their transfer abilities, which were assessed with Functional Independence Measure (FIM) transfer scores. The bi-weekly time trend of fall rates in all patients and in three subgroups based on FIM transfer scores of 1-3, 4-5, and 6-7, and activity status at the falls, were investigated. In addition, changes of patients' transfer ability on admission, at the first fall, and at discharge were investigated among falling patients. RESULTS: The fall rate was the greatest in patients with a FIM transfer score of 4 (14.3 times/1000 person-days). The majority of falls for patients with a FIM transfer score of 1 occurred at the activity status of "on the bed" and "sitting", while three quarters of patients with a FIM score of 7 had falls during "standing" and "walking". No longitudinal trend in fall rates was found overall; however, the fall rate trends differed depending on the FIM transfer score. The majority of the patients who fell required full assistance for transfers upon admission but required no assistance at discharge. CONCLUSIONS: Fall risk differed among patients with various transfer abilities; the greatest risk was in those who needed minimal assistance for transfers.

Association between oral health status and oral food intake level in subacute stroke patients admitted to a convalescent rehabilitation unit.

BACKGROUND: Stroke patients often suffer from dysphagia during their recovery. We hypothesised that subacute stroke patients with dysphagia had more deteriorated oral health status including muscle strength and motor function. OBJECTIVE: Quantitatively investigate oral health status and identify associations with oral feeding status in stroke patients admitted to a convalescent rehabilitation unit. METHODS: We prospectively recruited 187 stroke patients admitted to a convalescent rehabilitation unit. Oral feeding status was examined using the Functional Oral Intake Scale (FOIS), and the cohort was divided into three groups based on FOIS score as non-oral feeding (FOIS-123; 22 patients), dysphagic diet (FOIS-45; 74 patients), and regular diet (FOIS-67; 91 patients) groups. Activities of daily living (ADL) were assessed with the Functional Independence Measure (FIM). Oral health status was measured quantitatively in six oral function parameters and Oral Health Assessment Tool (OHAT), and differences according to the FOIS, age and FIM were statistically tested. RESULTS: In bivariate analysis, two parameters, tongue pressure and tongue-lip motor functions were significantly higher in the regular diet group than in the other groups (P < .01). Gross OHAT score was also significantly better in the regular diet group than in the other groups (P < .01). These significant associations mostly remained in the multiple model after adjusting for age and FIM. CONCLUSION: This study suggests that, amongst oral health status, tongue strength and motor function, as well as OHAT score, may have strong associations with oral feeding status in subacute stroke patients at convalescent rehabilitation units regardless of ADL levels.

Development of a clinical tool for rating the body function categories of the ICF generic-30/rehabilitation set in Japanese rehabilitation practice and examination of its interrater reliability.

BACKGROUND: The International Classification of Functioning, Disability, and Health (ICF) Generic-30 (Rehabilitation) Set is a tool used to assess the functioning of a clinical population in rehabilitation. The ICF Generic-30 consists of nine ICF categories from the component "body functions" and 21 from the component "activities and participation". This study aimed to develop a rating reference guide for the nine body function categories of the ICF Generic-30 Set using a predefined, structured process and to examine the interrater reliability of the ratings using the rating reference guide. METHODS: The development of the first version of the rating reference guide involved the following steps: (1) a trial of rating patients by several raters; (2) cognitive interviews with each rater to analyze the thought process involved in each rating; (3) the drafting of the rating reference guide by a multidisciplinary panel; and (4) a review by ICF specialists to confirm consistency with the ICF. Subsequently, we conducted a first field test to gain insight into the use of the guide in practice. The reference guide was modified based on the raters' feedback in the field test, and an inter-rater reliability test was conducted thereafter. Interrater agreement was evaluated using weighted kappa statistics with linear weights. RESULTS: The first version of the rating reference guide was successfully developed and tested. The weighted kappa coefficient in the field testing ranged from 0.25 to 0.92. The interrater reliability testing of the rating reference guide modified based on the field test results yielded an improved weighted kappa coefficient ranging from 0.53 to 0.78. Relative improvements in the weighted kappa coefficients were observed in seven out of the nine categories. Consequently, seven out of nine categories were found to have a weighted kappa coefficient of 0.61 or higher. CONCLUSIONS: In this study, we developed and modified a rating reference guide for the body function categories of the ICF Generic-30 Set. The interrater reliability test using the final version of the rating reference guide showed moderate to substantial interrater agreement, which encouraged the use of the ICF in rehabilitation practice.

Impact of heart failure severity on bone mineral density among older patients with heart failure.

The study aimed to identify factors related to bone mineral density (BMD) among older patients with heart failure (HF). A total of 70 consecutive patients with HF aged 65 years or older who were admitted to an acute hospital due to worsening condition were enrolled before discharge. BMD of the femoral neck was evaluated using the DEXA method. Physical function, as well as echocardiographic and laboratory findings including biomarker of HF severity were collected. Bivariate and multiple regression analyses were employed to determine the association between BMD and the clinical variables. Bivariate analysis determined that age, grip strength, walking speed, serum albumin, and N-terminal pro B-type natriuretic peptide (NT-proBNP) were significantly correlated with BMD (P < 0.01), whereas other clinical parameters were not. The multiple regression analysis identified NT-proBNP as an independent related factor for BMD after adjusting with confounding clinical variables. NT-proBNP was independently related to BMD among older patients with HF. Our results suggest the inclusion of bone fracture prevention strategies in disease management programs, especially for older patients with HF.

Poststroke Fatigue at Admission is Associated With Independence Levels of Activities of Daily Living at Discharge From Subacute Rehabilitation Wards.

OBJECTIVE: To determine whether poststroke fatigue at admission is associated with the degree of independence in activities of daily living in patients with stroke at discharge from subacute rehabilitation wards. DESIGN: Retrospective cohort study. SETTING: Subacute rehabilitation hospital. PARTICIPANTS: A consecutive sample of patients (N=156) with stroke who were admitted to a subacute rehabilitation ward between December 2012 and November 2013 were enrolled in the study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Poststroke fatigue was assessed using the Fatigue Severity Scale within 2 weeks of admission. Poststroke fatigue was defined as the mean score of 4 points or more from among 9 items in the Fatigue Severity Scale. Functional outcome was assessed by using FIM motor items. RESULTS: Fifty-six (35.9%) of the 156 participants had poststroke fatigue at admission. The scores of the FIM motor items at admission and discharge were significantly lower in the fatigue group than in the nonfatigue group (P<.05). Multiple regression analysis with potentially confounding variables revealed that poststroke fatigue was a significant independent factor for discharge FIM motor items score (P<.05). CONCLUSION: Poststroke fatigue at admission was significantly associated with functional outcome at discharge from subacute rehabilitation wards. Our findings emphasize that rehabilitation professionals need to manage poststroke fatigue in addition to providing the interventions to improve daily activities in patients with subacute stroke.

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.

Quantitative Evaluation of Facial Expression in a Patient With Minimally Conscious State After Severe Traumatic Brain Injury.

OBJECTIVE: To investigate whether automatic facial expression analysis can quantify differences in the intensity of facial responses depending on the affective stimuli in a patient with minimally conscious state (MCS). METHODS: We filmed the facial responses of a patient with MCS during the delivery of three 1-minute auditory stimuli: audio clips of comedy movies, a nurse hilariously talking, and recitation of a novel (comedy, nurse, and recitation conditions, respectively). These measures were repeated at least 13 times for each condition on different days for approximately 10 months. The intensity of being "happy" was estimated from the smiling face using a software called FaceReader. The intensity among 5 conditions including those at 2 resting conditions (pre- and poststimuli) was compared using the Kruskal-Wallis test and the Dunn-Bonferroni test for multiple comparisons. RESULTS: Significantly higher values were found in the intensity of being "happy" in the comedy and nurse conditions versus other conditions, with no significant differences between the recitation and pre- or poststimulus conditions. These findings indicate that the automated facial expression analysis can quantify differences in context-dependent facial responses in the patient recruited in this study. CONCLUSIONS: This case study demonstrates the feasibility of using automated facial expression analysis to quantitatively evaluate the differences in facial expressions and their corresponding emotions in a single patient with MCS.

Motivational Strategies for Stroke Rehabilitation: A Delphi Study.

OBJECTIVES: The primary objective was to provide a list of effective motivational strategies based on consensus among rehabilitation experts, generated using the Delphi technique. The secondary objective was to identify the types of information that are important when selecting motivational strategies. DESIGN: Delphi study. SETTING: On-site survey at academic conferences and web-based survey. PARTICIPANTS: Rehabilitation experts (N=198) including physicians, physical therapists, occupational therapists, and speech-language-hearing therapists who had worked in stroke rehabilitation for at least 5 years. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Panelists were asked to rate the effectiveness of motivational strategies and to rate the importance of different types of information using a 5-point Likert scale. Consensus was defined as having been reached for items with an interquartile range of 1 or less. RESULTS: A total of 116 experts (58.6%) completed the third round of the Delphi survey. Consensus was reached on all of the 26 presented strategies. Seven strategies, such as control of task difficulty and goal setting, were considered to be very effective in increasing patient motivation. In addition, all 11 of the presented types of information regarding patient health status, environmental factors, and personal factors were deemed very important or important in determining which motivational strategies to use. CONCLUSIONS: We generated a list of effective motivational strategies for stroke rehabilitation based on expert consensus. Our results suggest that experts consider a comprehensive range of patient information when choosing motivational strategies. These findings represent a group of consensus-based recommendations for increasing patient adherence to stroke rehabilitation programs, which may be beneficial to many medical professionals working in stroke rehabilitation.