Using Self-Regulation Assessment to Explore Associations between Self-Regulation, Participation and Health-Related Quality of Life in a Rehabilitation Population.

OBJECTIVE: Self-regulation, participation and health-related quality of life are important rehabilitation outcomes. The aim of this study was to explore associations between these outcomes in a multi-diagnostic and heterogenic group of former rehabilitation patients. METHODS: This cross-sectional survey used the Self-Regulation Assessment (SeRA), Utrecht Scale for Evaluation of Rehabilitation-participation (USERParticipation) and the Patient-Reported-Outcome-Measurement-System (PROMIS) ability and PROMIS satisfaction with participation in social roles, and the EuroQol-5L-5D and PROMIS-10 Global Health. Regression analyses, controlling for demographic and condition-related factors, were performed. RESULTS: Respondents (n = 563) had a mean age of 56.5 (standard deviation (SD) 12.7) years. The largest diagnostic groups were chronic pain disorder and brain injury. In addition to demographic and condition-related factors, self-regulation subscales explained 0-15% of the variance in participation outcome scores, and 0-22% of the variance in HRQoL outcome scores. Self-regulation subscales explained up to 22% of the variance in satisfaction subscales of participation (USER-Participation and PROMIS) and the mental health subscale of the PROMIS-10. Self-regulation subscales explained up to 11% of the restriction and frequency subscales of participation (USER-Participation) and the physical health subscale of the PROMIS-10. CONCLUSION: Self-regulation is more strongly associated with outcomes such as satisfaction with participation and mental health compared with outcomes such as restrictions in participation and physical health.

To What Extent is Walking Ability Associated with Participation in People after Stroke?

OBJECTIVES: This study aims to 1) identify the relation between walking ability and participation after stroke and 2) explore whether change in walking ability is associated with change in participation over time in community living-people after stroke. MATERIALS AND METHODS: Fifty-two people after stroke were assessed at baseline and after a 6-week gait training intervention. People were included between two weeks and six months after stroke. The Utrecht Scale for Evaluation of Rehabilitation-Participation was used to measure participation. Assessment of walking ability included the six-minute walking test for walking endurance, Timed-up & Go test for functional mobility, Mini Balance Evaluation Systems Test for dynamic balance, and total duration of walking activity per day to measure walking activity. RESULTS: At baseline, six-minute walking test, Timed-up & Go test, and Mini Balance Evaluation Systems Test were univariately associated with participation (P < 0.001). Backward multiple regression analysis showed that the Mini Balance Evaluation Systems Test independently explained 55.7% of the variance in participation at baseline. Over time, only change in the six-minute walking test was positively associated with change in participation (R2 = 0.087, P = 0.040). CONCLUSIONS: Cross-sectional associations showed that walking ability, and especially dynamic balance, contributes to participation after stroke. Dynamic balance, as underlying variable for walking, was an important independently related factor to participation after stroke which needs attention during rehabilitation. Longitudinally, improvement in walking endurance was significantly associated with improvement in participation, which indicates the relevance of training walking endurance to improve participation after stroke.

Effect of Virtual Reality Gait Training on Participation in Survivors of Subacute Stroke: A Randomized Controlled Trial.

OBJECTIVE: After stroke, people experience difficulties with walking that lead to restrictions in participation in daily life. The purpose of this study was to examine the effect of virtual reality gait training (VRT) compared to non-virtual reality gait training (non-VRT) on participation in community-living people after stroke. METHODS: In this assessor-blinded, randomized controlled trial with 2 parallel groups, people were included between 2 weeks and 6 months after stroke and randomly assigned to the VRT group or non-VRT group. Participants assigned to the VRT group received training on the Gait Real-time Analysis Interactive Lab (GRAIL), and participants assigned to the non-VRT group received treadmill training and functional gait exercises without virtual reality. Both training interventions consisted of 12 30-minute sessions during 6 weeks. The primary outcome was participation measured with the restrictions subscale of the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P) 3 months postintervention. Secondary outcomes included subjective physical functioning, functional mobility, walking ability, dynamic balance, walking activity, fatigue, anxiety and depression, falls efficacy, and quality of life. RESULTS: Twenty-eight participants were randomly assigned to the VRT group and 27 to the non-VRT group, of whom 25 and 22 attended 75% or more of the training sessions, respectively. No significant differences between the groups were found over time for the USER-P restrictions subscale (1.23; 95% CI = -0.76 to 3.23) or secondary outcome measures. Patients' experiences with VRT were positive, and no serious adverse events were related to the interventions. CONCLUSIONS: The effect of VRT was not statistically different from non-VRT in improving participation in community-living people after stroke. IMPACT: Although outcomes were not statistically different, treadmill-based VRT was a safe and well-tolerated intervention that was positively rated by people after stroke. VR training might, therefore, be a valuable addition to stroke rehabilitation. LAY SUMMARY: VRT is feasible and was positively experienced by people after stroke. However, VRT was not more effective than non-VRT for improving walking ability and participation after stroke.

Perceived barriers and facilitators for gait-related participation in people after stroke: From a patients' perspective.

Background: An important focus of post-stroke physical therapy is to improve walking and walking capacity. However, many people after stroke experience difficulties with gait-related participation, which includes more than walking capacity alone. Gait-related participation involves walking with a participation goal and requires to deal with changes in the environment during walking and perform dual tasks, for example.Objective: To explore barriers and facilitators for gait-related participation from the perspective of people after stroke. This knowledge can contribute to the development of effective interventions to improve gait-related participation.Methods: Semi-structured interviews were conducted to investigate how people after stroke experience gait-related participation. Audio-recorded interviews were transcribed, anonymized, and analyzed thematically. Barriers and facilitators were categorized according to the International Classification of Functioning, Disability and Health (ICF) framework.Results: Twenty-one people after stroke participated. Median age was 65 years, median time since stroke 16 weeks. Barriers were reported in movement-related functions, cognitive functions, mobility, personal factors, and environmental factors. Facilitators were found on participation level and in personal and environmental factors, such as motivation and family support.Conclusion: People after stroke who were physically able to walk independently still described multiple barriers to gait-related participation in all components of the ICF framework.

Virtual reality gait training versus non-virtual reality gait training for improving participation in subacute stroke survivors: study protocol of the ViRTAS randomized controlled trial.

BACKGROUND: A stroke often results in gait impairments, activity limitations and restricted participation in daily life. Virtual reality (VR) has shown to be beneficial for improving gait ability after stroke. Previous studies regarding VR focused mainly on improvements in functional outcomes. As participation in daily life is an important goal for rehabilitation after stroke, it is of importance to investigate if VR gait training improves participation. The primary aim of this study is to examine the effect of VR gait training on participation in community-living people after stroke. METHODS/DESIGN: The ViRTAS study comprises a single-blinded, randomized controlled trial with two parallel groups. Fifty people between 2 weeks and 6 months after stroke, who experience constraints with walking in daily life, are randomly assigned to the virtual reality gait training (VRT) group or the non-virtual reality gait training (non-VRT) group. Both training interventions consist of 12 30-min sessions in an outpatient rehabilitation clinic during 6 weeks. Assessments are performed at baseline, post intervention and 3 months post intervention. The primary outcome is participation measured with the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P). Secondary outcomes are subjective physical functioning, functional mobility, walking ability, walking activity, fatigue, anxiety and depression, falls efficacy and quality of life. DISCUSSION: The results of the study provide insight into the effect of VR gait training on participation after stroke. TRIAL REGISTRATION: Netherlands National Trial Register, Identifier NTR6215 . Registered on 3 February 2017.

Effect of Virtual Reality Training on Balance and Gait Ability in Patients With Stroke: Systematic Review and Meta-Analysis.

BACKGROUND: Virtual reality (VR) training is considered to be a promising novel therapy for balance and gait recovery in patients with stroke. PURPOSE: The aim of this study was to conduct a systematic literature review with meta-analysis to investigate whether balance or gait training using VR is more effective than conventional balance or gait training in patients with stroke. DATA SOURCES: A literature search was carried out in the databases PubMed, Embase, MEDLINE, and Cochrane Library up to December 1, 2015. STUDY SELECTION: Randomized controlled trials that compared the effect of balance or gait training with and without VR on balance and gait ability in patients with stroke were included. DATA EXTRACTION AND SYNTHESIS: Twenty-one studies with a median PEDro score of 6.0 were included. The included studies demonstrated a significant greater effect of VR training on balance and gait recovery after stroke compared with conventional therapy as indicated with the most frequently used measures: gait speed, Berg Balance Scale, and Timed "Up & Go" Test. Virtual reality was more effective to train gait and balance than conventional training when VR interventions were added to conventional therapy and when time dose was matched. LIMITATIONS: The presence of publication bias and diversity in included studies were limitations of the study. CONCLUSIONS: The results suggest that VR training is more effective than balance or gait training without VR for improving balance or gait ability in patients with stroke. Future studies are recommended to investigate the effect of VR on participation level with an adequate follow-up period. Overall, a positive and promising effect of VR training on balance and gait ability is expected.

Unrecognised psychopathology in patients with difficult asthma: major mental and personality disorders.

BACKGROUND: Difficult asthma is a severe subgroup of asthma in which the main feature is uncontrollability of symptoms. Psychopathology is suggested to be prominent in patients with difficult asthma and considered important in its treatment; however, the evidence is scarce. AIMS: To describe psychopathology in difficult asthma, both major mental and personality disorders, based on diagnostic interviews. METHOD: This study was conducted in a specialised asthma care centre. A total of 51 patients with difficult asthma were diagnosed at the start of the treatment programme using two structured clinical interviews for both major mental (SCID-I) and personality disorders (SCID-II) according to DSM-IV-TR. RESULTS: About 55% of the patients with difficult asthma had a psychiatric disorder of which 89% was undiagnosed and untreated before being interviewed. About 49% had a minimum of one major mental disorder of which the cluster of anxiety disorders was the most common cluster of major mental disorders, followed by somatoform disorders. About 20% were diagnosed with a personality disorder. Of the 10 patients with a personality disorder, 9 had an obsessive-compulsive personality disorder. CONCLUSIONS: This study demonstrates that more than half of patients with difficult asthma had a psychiatric disorder of which 89% was unrecognised. This study highlights the importance of offering patients with difficult asthma a psychiatric diagnostic interview and/or a psychiatric consultation as part of their routine medical examination and provision of appropriate psychiatric treatment. Moreover, it highlights the urgency of further research into the role of psychopathology in the development of difficult asthma. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Psychopathology in difficult asthma.

OBJECTIVE: Within the asthma population, difficult asthma (DA) is a severe condition in which patients present with frequent exacerbations, hospitalizations and emergency room visits. The identification and treatment of psychopathology is included in the management of DA. Psychopathology is supposed to predispose patients to DA or vice versa; psychopathology may develop as a consequence of DA. We reviewed the available literature on empirical findings regarding psychopathology in adult patients with DA. METHODS: Studies in English language journals using MEDLINE, Cochrane and PsycINFO databases, were retrieved by an electronic search published from 1990 till July 2014. RESULTS: Literature on psychopathology in DA is scarce. The search identified 16 articles of which only 6 articles were specifically about psychopathology in adult patients with DA. Almost half of the patients with DA had evidence of psychopathology at both syndrome and symptom level. Moreover, psychopathology appeared to be related to frequent exacerbations in patients with DA. CONCLUSIONS: This literature review suggests a high prevalence of psychopathology of patients with DA, although it remains unclear whether psychopathology occurs more often in DA compared to "stable asthma". More research is needed on a possible role of psychopathology on clinical signs and symptoms in DA.

[Give general practitioner a central role during the chronic phase after stroke]. / Stel huisarts centraal in chronische fase na beroerte.

In February 2014 an update of a systematic review was published on the effectiveness of physical therapy after stroke. This review shows that the quality and quantity of the scientific basis for physical therapy interventions in rehabilitation after stroke have increased significantly, which confirms the relevance of physical therapy in multidisciplinary stroke care. As far as physical therapy is concerned, implementation of the results of this review and organisation or reorganisation of care so that it is accessible to all patients is a major challenge. We propose that the general practitioner should be given a central role in the care of patients during the chronic phase after stroke.

Tolerance and effectiveness of a new dynamic hand-wrist orthosis in chronic stroke patients.

PURPOSE: To evaluate tolerance of a new dynamic hand-wrist orthosis and effectiveness on the prevention of progressive wrist contracture and spasticity after stroke. METHOD: Chronic stroke patients (N = 6) with upper limb spasticity, who had not been able to endure a static orthosis, were provided with a custom-made dynamic orthosis. Tolerance of the orthosis was evaluated by the daily wearing time, and self-reported pain and spasticity. Effectiveness was measured by contracture of wrist and finger flexor muscles, upper limb spasticity and use of spasticity treatment. Outcome measures were collected at time of fitting of the dynamic orthosis (baseline) and after three and six months. RESULTS: Five patients could endure the dynamic orthosis without discomfort for 6 hours daily during the 6-month period. Self-reported spasticity and pain decreased significantly (p < 0.05) compared to wearing the static orthosis. In comparison to baseline, the maximum passive wrist extension increased significantly from -29° to -12° (p < 0.05). Although, no significant change in spasticity was measured, the use of Botulinum Toxin injections decreased for two patients. CONCLUSIONS: The majority of the included chronic stroke patients tolerated the new dynamic orthosis for at least 6 hours daily and the use significantly reduced wrist contractures in a 6-month period.

Evaluation of change in fatigue, self-efficacy and health-related quality of life, after a group educational intervention programme for persons with neuromuscular diseases or multiple sclerosis: a pilot study.

PURPOSE: An intervention for persons with neuromuscular diseases (NMD) or multiple sclerosis (MS) who experienced severe fatigue was developed which aimed at educating participants in maintaining a balance between capacity and load in their daily activities. This pilot study evaluated the results of this intervention. METHODS: Persons with NMD or MS who experienced severe fatigue were included. Outcome measures were: fatigue (Fatigue Severity Scale), health-related quality of life (HRQoL; SF-36) and self-efficacy (ALCOS-16). Changes in scores between the start of the intervention (T0) and 3 months post-intervention (T1) were tested with the Wilcoxon tests in the complete group and in subgroups (gender, education, high/low self-efficacy). RESULTS: Forty-three persons participated. Significant improvements of HRQoL were found for the domains role-physical, mental health and general health perceptions. Subgroup analyses showed more improvement in males (fatigue, role-physical, vitality, bodily pain, general health perceptions), participants with lower education (role-physical, vitality) and participants with low self-efficacy at T0 (self-efficacy, mental health, general health perceptions) than in females, participants with higher education and participants with higher initial self-efficacy. CONCLUSION: This pilot-study provides preliminary evidence for the effectiveness of a group educational intervention in improving HRQoL without increasing fatigue in persons with NMD and MS.

Short-term effects and long-term use of a hybrid orthosis for neuromuscular electrical stimulation of the upper extremity in patients after chronic stroke.

OBJECTIVE: To associate the short-term effects of the Handmaster orthosis on disabling symptoms of the affected upper extremity with long-term Handmaster orthosis use after stroke. DESIGN: Historic cohort study. PATIENTS: Patients with chronic stroke. METHODS: The Modified Ashworth Scale (0-5) for wrist (primary outcome) and elbow flexor hypertonia, visual analogue scale (0-10) for pain, oedema score (0-3), and passive range of wrist flexion and extension (pROM, degrees) were assessed prior to Handmaster orthosis prescription (T0), after 6 weeks try-out (T1) and a subsequent 4 weeks withhold period (T2). Long-term use was evaluated using a questionnaire. Non-parametric analyses and predictive values were used for statistical analyses. RESULTS: Of the 110 included patients 78.2% were long-term Handmaster orthosis users. Long-term users showed significant short-term (T0-T1) improvements on all impairment scores and a significant relapse of wrist and elbow Modified Ashworth Scale (T1-T2). Non-users showed significant short-term effects on elbow Modified Ashworth Scale and visual analogue scale only. Positive predictive values of short-term effects for long-term use varied between 75% and 100%, with 85% (95% confidence interval (CI) 0.72-0.93) for wrist Modified Ashworth Scale. Negative predictive values were low (11-27%). CONCLUSION: Short-term Handmaster orthosis effects were generally beneficial for hypertonia, pain, oedema, and pROM, especially in long-term users. Short-term beneficial effects were highly predictive for long-term use, but not for non-use.

Acute deterioration of bulbar function after botulinum toxin treatment for sialorrhoea in amyotrophic lateral sclerosis.

Transcutaneous botulinum toxin injection in the salivary glands was introduced in 2000 as a new treatment for sialorrhoea in amyotrophic lateral sclerosis (ALS). We describe an ALS patient who developed serious complications of botulinum toxin treatment for sialorrhoea, and we review the relevant literature. A 64-yr-old woman with bulbar ALS for 6 mos was treated for disabling sialorrhoea. She had moderate dysphagia, but she was able to swallow. The submandibular and parotid glands were injected transcutaneously, under ultrasound guidance, with botulinum toxin (Dysport), 80 U on each side. Four days later, her bulbar function rapidly deteriorated, resulting in complete aphagia and anarthria on the fifth day. A PEG catheter was placed. Although according to the literature this treatment can be made safer by cautiously increasing the dosage and injecting the parotid glands first, BTX should not be the first-line treatment of sialorrhoea in ALS; comparative studies of BTX, amitryptiline, scopolamine, and radiation should be performed first.

Back to basics in diagnosing diabetic polyneuropathy with the tuning fork!

OBJECTIVE: Several national and international scoring systems are used to diagnose diabetic polyneuropathy (PNP). The variety in these scores and the lack of data on validity and predictive value has led to a comparison and validation of the scores with clinical standards for PNP to determine the most powerful measurement for screening. RESEARCH DESIGN AND METHODS: Three matched groups were selected: 24 diabetic patients with neuropathic foot ulcers, 24 diabetic patients without PNP or ulcers, and 21 control subjects without diabetes. In all participants the scores from the International Consensus on the Diabetic Foot (ICDF) and the Dutch Nederlandse Diabetes Federatie-Centraal Beleids Orgaan (NDF/CBO) were tested. The Diabetic Neuropathy Symptom score, the Diabetic Neuropathy Examination score, Heart Rate Variability, the Nerve Conduction Sum score, and a San Antonio Consensus sum score were obtained as clinical standards. Reproducibility was tested in a separate study (13 patients). RESULTS: The construct validity and discriminative power of the ICDF and NDF/CBO scores were comparable, although monofilaments (NDF/CBO) scored lower. The predictive value was good for all scores, with the best results being obtained for the tuning fork (NDF/CBO). Reproducibility of the NDF/CBO scores (monofilaments and tuning fork) was high. CONCLUSIONS: The characteristics of the scores of tests recommended by ICDF and NDF/CBO are comparable. The single use of the 128-Hz tuning fork produces results similar to the extended scores of the ICDF and much better than those of monofilaments on validation and for predictive value. For screening we therefore advise the use of the tuning fork alone.

Clinical diagnosis of diabetic polyneuropathy with the diabetic neuropathy symptom and diabetic neuropathy examination scores.

OBJECTIVE: To evaluate the discriminative power of the Diabetic Neuropathy Symptom (DNS) and Diabetic Neuropathy Examination (DNE) scores for diagnosing diabetic polyneuropathy (PNP), as well as their relation with cardiovascular autonomic function testing (cAFT) and electro-diagnostic studies (EDS). RESEARCH DESIGN AND METHODS: Three groups (matched for age and sex) were selected: 24 diabetic patients with neuropathic foot ulcers (DU), 24 diabetic patients without clinical neuropathy or ulcers (DC), and 21 control subjects without diabetes (C). In all participants, the DNS and DNE scores were assessed and cAFT (heart rate variability [HRV], baroreflex sensitivity [BRS]), and EDS were performed (Nerve Conduction Sum [NCS] score; muscle fiber conduction velocity: fastest/slowest ratio [F/S ratio]). RESULTS: Both the DNS and the DNE scores discriminated between the DU and DC groups significantly (P < 0.001). The DNE score even discriminated between DC and C (P < 0.05). Spearman's correlation coefficients between both DNS and DNE scores and cAFT (HRV -0.42 and -0.44; BRS -0.30 and -0.29, respectively) and EDS (NCS 0.51 and 0.62; F/S ratio 0.44 and 0.62, respectively) were high. Odds ratios were calculated for both DNS and DNE scores with cAFT (HRV 4.4 and 5.7; BRS 20.7 and 14.2, respectively) and EDS (NCS 5.6 and 16.8; F/S ratio 7.2 and 18.8, respectively). CONCLUSIONS: The DNS and DNE scores are able to discriminate between patients with and without PNP and are strongly related to cAFT and EDS. This further confirms the strength of the DNS and DNE scores in diagnosing diabetic PNP in daily clinical practice.