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.

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.

Validity of gait asymmetry estimation by using an accelerometer in individuals with hemiparetic stroke.

[Purpose] The purpose of this study was to evaluate the validity of estimating step time and length asymmetries, using an accelerometer against force plate measurements in individuals with hemiparetic stroke. [Subjects and Methods] Twenty-four individuals who previously had experienced a stroke were asked to walk without using a cane or manual assistance on a 16-m walkway. Step time and length were measured using force plates, which is the gold standard for assessing gait asymmetry. In addition to ground reaction forces, trunk acceleration was simultaneously measured using an accelerometer. To estimate step time asymmetry using accelerometer data, the time intervals between forward acceleration peaks for each leg were calculated. To estimate step length asymmetry using accelerometer data, the integration of the positive vertical accelerations following initial contact of each leg was calculated. Asymmetry was considered the affected side value divided by the unaffected side value. [Results] Significant correlations were found between the accelerometer and the force plates for step time and length asymmetries (rho=0.83 and rho=0.64, respectively). [Conclusion] An accelerometer might be useful for assessing step time and length asymmetries in individuals with hemiparetic stroke, although improvements are needed for estimating the accuracy of step length asymmetry.

Physical Therapists Use Different Motivational Strategies for Stroke Rehabilitation Tailored to an Individual's Condition: A Qualitative Study.

OBJECTIVE: Various strategies are used to motivate individuals with stroke during rehabilitation. However, how physical therapists select the motivational strategies that they use for each individual is yet to be established. Therefore, this study aimed to explore how physical therapists use different motivational strategies for individuals in stroke rehabilitation programs. METHODS: A criterion sample of 15 physical therapists who have worked in rehabilitation for over 10 years and were interested in an individual's motivation participated in one-on-one semi-structured online interviews. The interviews explored their perspectives and experiences regarding the motivational strategies used depending on each individual's condition. The collected data were analyzed with thematic analysis. RESULTS: A total of 9 themes emerged from the data upon thematic analysis and inductive coding. Participants used different strategies to encourage individuals' active participation in physical therapy depending on (1) their mental health, (2) their physical difficulties, (3) their level of cognitive function, (4) their personality, (5) their activities and participation, (6) their age, (7) their human environment, and (8) the type of rehabilitation service where the individual underwent treatment. For example, in cases where an individual lost self-confidence, participants offered practice tasks that the individual could achieve with little effort to make them experience success. The interviews also revealed (9) motivational strategies used regardless of the individual's condition. For instance, patient-centered communication was used to build rapport with individuals, irrespective of their condition. CONCLUSION: This qualitative study suggests that physical therapists use different strategies depending on the individual's mental health conditions, physical problems, level of cognitive function, personality, activities and participation, age, human environment, and the type of rehabilitation service where the individual undergoes treatment to motivate individuals with stroke during physical therapy. IMPACT: The findings of this study can provide experience-based recommendations regarding the selection of motivational strategies for stroke rehabilitation.

Comparisons of heart rate variability responses to head-up tilt with and without abdominal and lower-extremity compression in healthy young individuals: a randomized crossover study.

Introduction: Abdominal and lower-extremity compression techniques can help reduce orthostatic heart rate increases. However, the effects of body compression on the cardiac autonomic systems, which control heart rate, remain unclear. The primary objective of this study was to compare heart rate variability, a reflection of cardiac autonomic regulation, during a head-up tilt test with and without abdominal and lower-extremity compression in healthy young individuals. The secondary objective was to conduct a subgroup analysis, considering participant sex, and compare heart rate and heart rate variability responses to head-up tilt with and without compression therapy. Methods: In a randomized crossover design, 39 healthy volunteers (20 females, aged 20.9 ± 1.2 years) underwent two head-up tilt tests with and without abdominal and lower-extremity compression. Heart rate and heart rate variability parameters were measured during the head-up tilt tests, including the Stress Index, root mean square of successive differences between adjacent R-R intervals, low- and high-frequency components, and low-to-high frequency ratio. Results: Abdominal and lower-extremity compression reduced the orthostatic increase in heart rate (p < 0.001). The tilt-induced changes in heart rate variability parameters, except for the low-frequency component, were smaller in the compression condition than in the no-compression condition (p < 0.001). These results were consistent regardless of sex. Additionally, multiple regression analysis with potentially confounding variables revealed that the compression-induced reduction in Stress Index during the head-up tilt position was a significant independent variable for the compression-induced reduction in heart rate in the head-up tilt position (coefficient = 0.411, p = 0.025). Conclusion: Comparative analyses revealed that abdominal and lower-extremity compression has a notable impact on the compensatory sympathetic activation and vagal withdrawal typically observed during orthostasis, resulting in a reduction of the increase in heart rate. Furthermore, this decrease in heart rate was primarily attributed to the attenuation of cardiac sympathetic activity associated with compression. Our findings could contribute to the appropriate application of compression therapy for preventing orthostatic tachycardia. This study is registered with UMIN000045179.

Blood pressure reduction cut-points for orthostatic hypotension in stroke survivors using a sit-up test: a multicentre cross-sectional study.

OBJECTIVE: The sit-up test is used to assess orthostatic hypotension in stroke survivors who cannot stand independently without using a tilt table. However, no study has identified the optimal cut-points for orthostatic hypotension using the test. Therefore, this study aimed to examine the decrease in SBP and DBP during the sit-up test to detect orthostatic hypotension in individuals with stroke. METHODS: Thirty-eight individuals with stroke, recruited from three convalescent rehabilitation hospitals, underwent the sit-up and head-up tilt tests. Systolic and diastolic orthostatic hypotension was defined as a decrease of at least 20 and 10 mmHg in the SBP and DBP, respectively, during the head-up tilt test. The receiver operator characteristic curve with the Youden Index was used to identify the optimal cut-points. RESULTS: Eight and three participants showed systolic and diastolic orthostatic hypotension, respectively. The optimal cut-points for orthostatic hypotension using the sit-up test were a decrease of 10 mmHg in SBP [sensitivity = 87.5% (95% confidence interval: 47.4-99.7), specificity = 96.7% (82.8-99.9)] and 5 mmHg in DBP [sensitivity = 100.0% (29.2-100.0), specificity = 88.6% (73.3-96.8)]. CONCLUSION: Compared with the conventional cut-points, smaller cut-points of a decrease in SBP and DBP may be better to identify orthostatic hypotension in individuals with stroke using the sit-up test. The findings of this study may provide valuable information for the clinical application of the sit-up test.

A multicenter explanatory survey of patients' and clinicians' perceptions of motivational factors in rehabilitation.

BACKGROUND: Patient motivation is an important determinant of rehabilitation outcomes. Differences in patients' and clinicians' perceptions of motivational factors can potentially hinder patient-centered care. Therefore, we aimed to compare patients' and clinicians' perceptions of the most important factors in motivating patients for rehabilitation. METHODS: This multicenter explanatory survey research was conducted from January to March 2022. In 13 hospitals with an intensive inpatient rehabilitation ward, 479 patients with neurological or orthopedic disorders undergoing inpatient rehabilitation and 401 clinicians, including physicians, physical therapists, occupational therapists, and speech-language-hearing therapists, were purposively selected using inclusion criteria. The participants were asked to choose the most important factor motivating patients for rehabilitation from a list of potential motivational factors. RESULTS: Here we show that realization of recovery, goal setting, and practice related to the patient's experience and lifestyle are the three factors most frequently selected as most important by patients and clinicians. Only five factors are rated as most important by 5% of clinicians, whereas nine factors are selected by 5% of patients. Of these nine motivational factors, medical information (p < 0.001; phi = -0.14; 95% confidence interval = -0.20 to -0.07) and control of task difficulty (p = 0.011; phi = -0.09; 95% confidence interval = -0.16 to -0.02) are selected by a significantly higher proportion of patients than clinicians. CONCLUSIONS: These results suggest that when determining motivational strategies, rehabilitation clinicians should consider individual patient preferences in addition to using the core motivational factors supported by both parties.

Rehabilitation is the interventions needed to restore the abilities required for daily life following illness or injury. Patients and clinicians who provide these interventions may have different ideas about what encourages patients to engage in rehabilitation. It is important to understand what motivates patients and any differences in opinion between patients and clinicians. We asked patients and clinicians about the most important motivational factors. All agreed that realizing recovery is possible, setting goals or targets for the stages of recovery, and targeting interventions relevant to the patient's experience and lifestyle were the most important motivational factors. The patients also found access to medical information and being able to control the difficulty of tasks required during rehabilitation motivating. These findings could help clinicians provide rehabilitation care that is more specifically tailored to each patient's needs and preferences.

Comparison of the sit-up test and head-up tilt test for assessing blood pressure and hemodynamic responses in healthy young individuals.

OBJECTIVE: The sit-up test is used to assess orthostatic hypotension, without the use of a tilt table, in populations who are unable to stand. The primary objective of this study was to determine the differences in blood pressure and hemodynamic responses between the sit-up and head-up tilt tests. The secondary objective was to determine the hemodynamic responses related to changes in blood pressure during each test. METHODS: Nineteen healthy volunteers (nine males, aged 24.3 ± 2.4 years) underwent the sit-up and head-up tilt tests. Systolic and diastolic blood pressure, heart rate, stroke volume, cardiac output, and total peripheral resistance were measured. RESULTS: The increase in systolic blood pressure (15 ± 9 vs. 8 ± 8 mmHg) was greater, while the increase in heart rate (8 ± 5 vs. 12 ± 8 bpm) and reduction in stroke volume (-17 ± 10 vs. -21 ± 10 ml) were smaller during the sit-up test than during the head-up tilt test (P < 0.05). Additionally, the increases in blood pressure variables were significantly associated with the increase in total peripheral resistance (P < 0.05), but not with changes in other hemodynamic variables in both tests. CONCLUSION: Although the magnitudes of changes in systolic blood pressure, heart rate, and stroke volume differed between the tests, the hemodynamic variable related to changes in blood pressure was the same for both tests. These results may contribute to the clinical application of the sit-up test for identifying the presence and hemodynamic mechanisms of orthostatic hypotension.

A Single Bout of Constant-Load Exercise Test for Estimating the Time Constant of Oxygen Uptake Kinetics in Individuals With Stroke.

OBJECTIVE: To examine the relationship between the time constant of oxygen uptake kinetics during the onset of exercise (τVO2) estimated from a single exercise bout and that obtained from three averaged exercise bouts in individuals with stroke. METHODS: Twenty participants with stroke performed three bouts of a constant-load pedaling exercise at approximately 80% of the workload corresponding to the ventilatory threshold to estimate τVO2. The VO2 data from the first trial of three bouts were used to estimate τVO2 for a single bout. Additionally, data collected from three bouts were ensemble-averaged to obtain τVO2 for three averaged bouts as the criterion. RESULTS: There was a very high correlation between τVO2 for a single bout (34.8±14.0 seconds) and τVO2 for three averaged bouts (38.5±13.4 seconds) (r=0.926, p<0.001). However, τVO2 for a single bout was smaller than that for three averaged bouts (p=0.006). CONCLUSION: τVO2 for a single bout could reflect the relative difference in τVO2 for three averaged bouts among individuals with stroke. However, it should be noted that τVO2 for a single bout may be underestimated compared to τVO2 for three averaged bouts.

Cardiorespiratory responses to exercise related to post-stroke fatigue severity.

Physical deconditioning after stroke may induce post-stroke fatigue. However, research on this association is limited. Our primary objective was to investigate the associations of post-stroke fatigue severity with oxygen uptake ([Formula: see text]O2) at peak exercise and the time constant of [Formula: see text]O2 kinetics (τ[Formula: see text]O2) at exercise onset. The secondary objective was to examine the associations between fatigue and cardiorespiratory variables potentially affecting [Formula: see text]O2 during exercise. Twenty-three inpatients from a subacute rehabilitation ward were enrolled in this study. The median (interquartile range) Fatigue Severity Scale (FSS) score, as a measure of fatigue, was 32 (range 27-42) points. The FSS score was not associated with [Formula: see text]O2 at peak exercise during a symptom-limited graded exercise test (rho = - 0.264; p = 0.224), whereas it was significantly associated with τ[Formula: see text]O2 during a submaximal constant-load exercise test (rho = 0.530; p = 0.009). A higher FSS score also significantly correlated with a longer time constant of cardiac output (CO) kinetics (rho = 0.476; p = 0.022). Our findings suggest that severe post-stroke fatigue is associated with delayed increases in [Formula: see text]O2 and CO at the onset of exercise. Our findings can contribute to the development of an appropriate rehabilitation programme for individuals with post-stroke fatigue.

Cardiorespiratory mechanisms underlying the impaired oxygen uptake kinetics at exercise onset after stroke.

BACKGROUND: Oxygen uptake (V˙O2) kinetics at the onset of exercise is slower in patients with stroke than in healthy adults. However, little is known about the cardiorespiratory mechanisms underlying the impaired V˙O2 kinetics. OBJECTIVES: This study aimed to investigate the relative effect of impaired oxygen delivery and utilisation on V˙O2 kinetics at the onset of submaximal exercise in patients with stroke by comparing the time constants of cardiac output (τCO) and V˙O2 (τV˙O2). In addition, we aimed to examine the association between the kinetics of cardiorespiratory variables and functional outcomes. METHODS: We included 21 patients with stroke (15 males, mean [SD] age 58.7 [9.5] years, mean days post-stroke 67.9 [30.9]). A submaximal constant-load exercise test was performed to measure τV˙O2, τCO, and the time constant of arterialvenous oxygen difference (τAVO2diff). The ratio of τCO to τV˙O2 was calculated to assess the matching of oxygen delivery and consumption. Fugl-Meyer lower-extremity motor scores, comfortable gait speeds, and Functional Independence Measure motor scores were used as functional variables. RESULTS: Mean (SD) τAVO2diff was markedly shorter than τV˙O2 and τCO (26.1 [7.1] vs. 38.7 [10.2] and 46.6 [23.2 s], P<0.05), with no significant difference between τV˙O2 and τCO (P=0.444). The greater ratio of τCO to τV˙O2 was related to poorer motor function (rho=-0.484, P=0.026) and slower comfortable gait speed (r=-0.482, P=0.027). CONCLUSIONS: An increase in CO was slower than that in AVO2diff in patients with stroke. Therefore, V˙O2 kinetics in patients with stroke appears to be affected by a delayed increase in CO rather than AVO2diff. Furthermore, these patients with motor and gait impairments may have a poor matching of oxygen delivery and consumption during exercise onset.

Motivational Strategies for Stroke Rehabilitation: A Descriptive Cross-Sectional Study.

Background: The addition of motivational strategies to a rehabilitation program is thought to enhance patient adherence and improve outcomes. However, little is known about how rehabilitation professionals motivate stroke patients during rehabilitation. The primary objective of this study was to provide a comprehensive and quantitative list of motivational strategies for stroke rehabilitation. In addition, we aimed to examine (1) whether professionals with more clinical experience used a higher number of motivational strategies, (2) the purpose for using each strategy, and (3) the information considered when choosing strategies. Methods: This descriptive, cross-sectional study was conducted using a web survey with a convenience sample of 407 rehabilitation professionals including physicians, nurses, physical therapists, occupational therapists, and speech-language-hearing therapists. Results: We received data for 362 participants. Fifteen strategies were found to be used by more than 75% of the respondents to motivate their patients. Almost all of the respondents reported that they actively listened to and praised their patients to increase patient adherence to rehabilitation programs. Respondents with more clinical experience tended to use a higher number of motivational strategies (rho = 0.208, p < 0.001). For 11 of the 15 strategies selected by more than 75% of the respondents, the highest percentage of respondents reported that they used the strategies to make rehabilitation worthwhile for their patients. The majority of respondents reported that they decided which motivational strategy to use by considering comprehensive information regarding the patient health condition, environmental factors, and personal factors. Conclusions: The comprehensive list of motivational strategies obtained may be useful for increasing patient adherence to rehabilitation, especially for professionals with less clinical experience. Furthermore, our findings regarding the purpose for using each strategy and the information considered when choose strategies might help rehabilitation professionals to optimally utilize the motivational strategy list.

Cardiorespiratory factors related to the increase in oxygen consumption during exercise in individuals with stroke.

BACKGROUND: Understanding the cardiorespiratory factors related to the increase in oxygen consumption ([Formula: see text]) during exercise is essential for improving cardiorespiratory fitness in individuals with stroke. However, cardiorespiratory factors related to the increase in [Formula: see text] during exercise in these individuals have not been examined using multivariate analysis. This study aimed to identify cardiorespiratory factors related to the increase in [Formula: see text] during a graded exercise in terms of respiratory function, cardiac function, and the ability of skeletal muscles to extract oxygen. METHODS: Eighteen individuals with stroke (aged 60.1 ± 9.4 years, 67.1 ± 30.8 days poststroke) underwent a graded exercise test for the assessment of cardiorespiratory response to exercise. The increases in [Formula: see text] from rest to first threshold and that from rest to peak exercise were measured as a dependent variable. The increases in respiratory rate, tidal volume, minute ventilation, heart rate, stroke volume, cardiac output, and arterial-venous oxygen difference from rest to first threshold and those from rest to peak exercise were measured as the independent variables. RESULTS: From rest to first threshold, the increases in arterial-venous oxygen difference (ß = 0.711) and cardiac output (ß = 0.572) were significant independent variables for the increase in [Formula: see text] (adjusted R2 = 0.877 p < 0.001). Similarly, from rest to peak exercise, the increases in arterial-venous oxygen difference (ß = 0.665) and cardiac output (ß = 0.636) were significant factors related to the increase in [Formula: see text] (adjusted R2 = 0.923, p < 0.001). CONCLUSION: Our results suggest that the ability of skeletal muscle to extract oxygen is a major cardiorespiratory factor related to the increase in [Formula: see text] during exercise testing in individuals with stroke. For improved cardiorespiratory fitness in individuals with stroke, the amount of functional muscle mass during exercise may need to be increased.

Unilateral Arm Crank Exercise Test for Assessing Cardiorespiratory Fitness in Individuals with Hemiparetic Stroke.

Cardiorespiratory fitness assessment with leg cycle exercise testing may be influenced by motor impairments in the paretic lower extremity. Hence, this study examined the usefulness of a unilateral arm crank exercise test to assess cardiorespiratory fitness in individuals with stroke, including sixteen individuals with hemiparetic stroke (mean ± SD age, 56.4 ± 7.5 years) and 12 age- and sex-matched healthy controls. Participants performed the unilateral arm crank and leg cycle exercise tests to measure oxygen consumption ([Formula: see text]O2) and heart rate at peak exercise. The [Formula: see text]O2 at peak exercise during the unilateral arm crank exercise test was significantly lower in the stroke group than in the control group (p < 0.001). In the stroke group, the heart rate at peak exercise during the unilateral arm crank exercise test did not significantly correlate with the Brunnstrom recovery stages of the lower extremity (p = 0.137), whereas there was a significant correlation during the leg cycle exercise test (rho = 0.775, p < 0.001). The unilateral arm crank exercise test can detect the deterioration of cardiorespiratory fitness independently of lower extremity motor impairment severity in individuals with hemiparetic stroke. This study is registered with UMIN000014733.