Cognitive screen and employment long-term after infratentorial stroke.

OBJECTIVES: Motor problems are well-described neurological deficits that occur commonly after an infratentorial ischemic stroke. However, the brain stem and cerebellum are also part of the neural interconnections responsible for cognition, emotions, and behavioral responses. We lack studies on long-term cognitive outcomes and patient employment after an infratentorial stroke. In the present study, we described and compared long-term poststroke cognitive outcomes and employment between patients that experienced infratentorial and supratentorial ischemic strokes. MATERIALS AND METHODS: We included consecutive patients that experienced an acute ischemic stroke at ≤58 years of age. Patients were classified according to the stroke location. At seven years poststroke, surviving participants were assessed for neurological deficits (National Institutes of Health Stroke Scale [NIHSS]), functional outcome (modified Rankin Scale [mRS]), cognitive function Barrow Neurological Institute Screen (BNIS), and employment. RESULTS: Among 141 participants, 25 (18%) had infratentorial and 116 (82%) had supratentorial strokes. At the 7-year poststroke follow-up, there was no significant difference in BNIS total scores; with a median of 43 (IQR 40.5-46) and 41 (IQR 38-46) in the infratentorial and supratentorial groups, respectively. This result indicated that cognitive dysfunction occurred frequently in both groups. Similar employment rates were observed in the infratentorial (48%) and supratentorial (55%) groups. Both groups had a median NIHSS score of 0 and a median mRS score of 2 at the 7-year follow-up. CONCLUSION: Patients who survived an infratentorial or supratentorial ischemic stroke had similar rates of long-term cognitive dysfunction and difficulties in returning and/or remaining at work.

Cognitive function in survivors of out-of-hospital cardiac arrest after target temperature management at 33°C versus 36°C.

BACKGROUND: Target temperature management is recommended as a neuroprotective strategy after out-of-hospital cardiac arrest. Potential effects of different target temperatures on cognitive impairment commonly described in survivors have not been investigated sufficiently. The primary aim of this study was to evaluate whether a target temperature of 33°C compared with 36°C was favorable for cognitive function; the secondary aim was to describe cognitive impairment in cardiac arrest survivors in general. METHODS AND RESULTS: Study sites included 652 cardiac arrest survivors originally randomized and stratified for site to temperature control at 33°C or 36°C within the Target Temperature Management trial. Survival until 180 days after the arrest was 52% (33°C, n=178/328; 36°C, n=164/324). Survivors were invited to a face-to-face follow-up, and 287 cardiac arrest survivors (33°C, n=148/36°C, n=139) were assessed with tests for memory (Rivermead Behavioural Memory Test), executive functions (Frontal Assessment Battery), and attention/mental speed (Symbol Digit Modalities Test). A control group of 119 matched patients hospitalized for acute ST-segment-elevation myocardial infarction without cardiac arrest performed the same assessments. Half of the cardiac arrest survivors had cognitive impairment, which was mostly mild. Cognitive outcome did not differ (P>0.30) between the 2 temperature groups (33°C/36°C). Compared with control subjects with ST-segment-elevation myocardial infarction, attention/mental speed was more affected among cardiac arrest patients, but results for memory and executive functioning were similar. CONCLUSIONS: Cognitive function was comparable in survivors of out-of-hospital cardiac arrest when a temperature of 33°C and 36°C was targeted. Cognitive impairment detected in cardiac arrest survivors was also common in matched control subjects with ST-segment-elevation myocardial infarction not having had a cardiac arrest. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01946932.

Individual placement and support in Sweden - a randomized controlled trial.

BACKGROUND: Currently there is no evidence on the effectiveness of Individual Placement and Support (IPS) in Sweden. AIMS: To determine the effectiveness of IPS on vocational outcomes among people with severe mental illness (SMI) in a Swedish context. A secondary aim was to evaluate a community integration effect. METHODS: A randomized controlled trial with a parallel design was used. Mental health outpatients with SMI were randomized to IPS or traditional vocational rehabilitation (TVR) services. The allocation status was assessor-blinded. The primary outcome was competitive employment. All vocational outcomes were collected continuously, and socio-demographic and clinical variables at baseline, 6 and 18 months. The trial is registered with ClinicalTrials.gov: NCT00960024. RESULTS: One hundred and twenty participants were randomized. Eighty seven per cent were assessed after 6 months, and 73% after 18 months. IPS was more effective than TVR in terms of gaining employment at 18-month follow-up (46% vs. 11%; difference 36%, 95% CI 18-54), along with the amount of working hours and weeks, longer job tenure periods and income. Cox regression analysis showed that IPS participants gained employment five times quicker than those in TVR. Ninety per cent of the IPS participants became involved in work, internships or education, i.e. activities integrated in mainstream community settings, while 24% in the TVR group achieved this. CONCLUSIONS: IPS is effective in a Swedish context in terms of gaining employment and becoming integrated within the local community. The welfare system presented obstacles for gaining competitive employment directly and it was indicated that internships delayed time to first competitive employment.

The Barrow Neurological Institute screen for higher cerebral functions in cognitive screening after stroke.

The objective of this study was to evaluate the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) in screening for cognitive dysfunction at long-term follow-up after stroke in young and middle-aged patients. Within the Sahlgrenska Academy Study on Ischemic Stroke Outcome, the BNIS and the Mini-Mental State Examination (MMSE) were administered to 295 consecutive surviving patients seven years after ischemic stroke. All participants were less than 70 years at index stroke. BNIS score less than 47 and an MMSE score less than 29 were chosen to indicate cognitive dysfunction. Two hundred eighty-one (95%) patients completed both tests. The 2 test scores were moderately correlated, and both tests correlated to disability as measured by the modified Rankin Scale. The distribution of the MMSE score was skewed toward the top scores, with a marked ceiling effect, whereas the BNIS score was more normally distributed. Most BNIS subscales showed mean performance around the mid of the scale without ceiling effects. Both tests identified a large proportion of the subjects as cognitive impaired, however, with a substantially larger proportion for the BNIS (89%) compared with the MMSE (65%). We conclude that the BNIS may be a useful screening instrument for cognitive dysfunction after ischemic stroke and that a large proportion of young and middle-aged ischemic stroke survivors showed signs of cognitive dysfunction long after index stroke. Further validations of BNIS against formal neuropsychological testing and studies of the determinants and consequences of long-term cognitive outcome in this patient group are warranted.

Cognitive impact of traumatic axonal injury (TAI) and return to work.

OBJECTIVE: Axonal injury (AI) after traumatic brain injury (TBI) is often overlooked as an explanation for cognitive complaints when no damage is detected by computed tomography. The purpose was to assess cognition during the 12 months following a TBI and suspected traumatic axonal injury (TAI). METHODS: The sample included 17 patients younger than 65 years old, however one died. In the acute phase and at 6 and 12 months, cognition, reaction time, psychomotor performance and finger tapping speed were assessed. Working memory and work status were added at 12 months. Acute MRI findings were recorded. RESULTS: After 1 year, all patients still showed cognitive dysfunction. A recovery had been noted at 6 months, but a cognitive decline was indicated for the majority at 12 months. The sick-listed patients had TAI located in the corpus callosum and the brainstem. They were cognitively more impaired and in more areas than the four patients who had returned to work. CONCLUSION: Cognitive screening can identify the long-term impact of TAI identified by conventional MRI, used as a routine clinical technique. For rehabilitation and for insurance-related matters, these injuries must be taken seriously, as a deterioration over time might occur. Further research is needed.

Intervention with the CO-OP Approach leads to a transfer effect over time to untrained goals for children with cerebral palsy or spina bifida.

PURPOSE: This study aims to investigate whether the treatment effects, in terms of goal attainment, transfer effects and impact on executive functions, of an intervention in children with cerebral palsy or spina bifida using the Cognitive Orientation to daily Occupational Performance (CO-OP) Approach are maintained over time, from immediately after the intervention to three months afterwards. METHOD: A three-month follow-up study, from an intervention using CO-OP. Thirty-four children (7-16 years) each identified four goals (one untrained to examine transfer) and participated in an eleven-session intervention. Assessments were performed at baseline, immediately after the intervention and at a three-month follow-up using the Canadian Occupational Performance Measure and the Performance Quality Rating Scale. Executive function and self-rated competence were assessed at the same timepoints. RESULTS: Statistically significant and clinically relevant improvements in goal achievement were demonstrated for both trained and untrained goals after the intervention and were maintained at follow-up. The clinically relevant improvement in untrained goals continued to increase until follow-up. Self-rated competence increased after the intervention and was maintained at follow-up. CONCLUSION: The CO-OP intervention was effective in achieving and maintaining the children's own goals over time. The transfer effect was confirmed by higher goal attainment for the untrained goals.

The children's self-defined goals were achieved after the Cognitive Orientation to daily Occupational Performance (CO-OP) intervention and remained so at the three-month follow-up.The CO-OP Approach is useful for children with cerebral palsy or spina bifida.A transfer effect was demonstrated for untrained goals by both subjective and objective assessments.Using children's self-defined goals is effective.

The Cognitive Orientation to daily Occupational Performance (CO-OP) Approach is superior to ordinary treatment for achievement of goals and transfer effects in children with cerebral palsy and spina bifida - a randomized controlled trial.

PURPOSE: Children with cerebral palsy (CP) or spina bifida (SB) often have executive dysfunction affecting activity performance. With the Cognitive Orientation to daily Occupational Performance (CO-OP) Approach, children find their own way to perform activities, using problem-solving strategies and meta-cognitive thinking. The present study aimed to investigate the effectiveness of the CO-OP Approach in children with CP or SB, compared with conventional rehabilitation, in achieving self-identified activity goals, and to explore any generalization and transfer effects. METHOD: Randomized controlled trial, CO-OP versus treatment as usual, 38 children (7-16 years) participated. Each child identified four goals (to study generalization and transfer, one remained untrained). Primary outcomes: Canadian Occupational Performance Measure (COPM) and Performance Quality Rating Scale (PQRS). Secondary outcomes assessed executive functions and self-rated everyday-life competence. RESULTS: Self-rated goal attainment (COPM) was significantly greater for both trained and untrained goals in the CO-OP group compared with the control group. The rating of observed performance (PQRS) was significantly higher for trained goals in the CO-OP group. The CO-OP group experienced fewer problems in everyday life after treatment. Executive functions did not differ significantly between groups. CONCLUSION: CO-OP is more effective than ordinary treatment in achieving both trained and untrained goals.IMPLICATIONS FOR REHABILITATIONCO-OP enables children with CP (MACS levels I-III) or SB without intellectual disabilities to reach self-identified goals.CO-OP shows transfer effects to new activities and situations, which may enhance children's self-efficacy.CO-OP is an important complement to conventional rehabilitation services for children with CP and SB.

"With CO-OP I'm the boss" - experiences of the cognitive orientation to daily occupational performance approach as reported by young adults with cerebral palsy or spina bifida.

Purpose: Restrictions to activity and participation in persons with cerebral palsy or spina bifida are often due to both motor and executive dysfunction. Hence methods focusing solely on motor issues are not enough to enhance participation. The Cognitive Orientation to daily Occupational Performance ApproachTM is a performance-based approach offering clients opportunities to create their own strategies to learn skills. The aim of the present study was to explore and describe experiences of the Cognitive Orientation to daily Occupational Performance Approach as reported by young adults with cerebral palsy or spina bifida.Methods: Qualitative content analysis was used. Semi-structured individual interviews were conducted with the 10 participants aged 16-28, post-intervention and at 6-months follow-up.Results: The participants described how the Cognitive Orientation to daily Occupational Performance Approach enhanced their self-efficacy. Four categories describing the participants' experiences emerged: "CO-OP is a different way of learning", "CO-OP sometimes puts a strain on me", "CO-OP supports my way of thinking and doing" and "CO-OP boosts me".Conclusion: The young adults expressed that the Cognitive Orientation to daily Occupational Performance intervention, although sometimes challenging, was worth the effort because it provided them with an opportunity to master everyday-life problems by using meta-cognitive thinking, which enhanced their self-efficacy.Implications for rehabilitationThe Cognitive Orientation to daily Occupational Performance Approach™ - was perceived to provide opportunities to master everyday-life problems by using meta-cognitive thinking.The Cognitive Orientation to daily Occupational Performance Approach boosted the persons feeling of self-efficacy.The Cognitive Orientation to daily Occupational Performance Approach is person-centred and supports the person's own way of learning.

Potential benefits of the cognitive orientation to daily occupational performance approach in young adults with spina bifida or cerebral palsy: a feasibility study.

Purpose: People with cerebral palsy (CP) or spina bifida (SB) often struggle to perform everyday-life activities. Both groups frequently also have difficulties in creating and using strategies effectively when performing tasks. The cognitive orientation to daily occupational performance (CO-OP) Approach combines the learning of cognitive strategies with task-specific approaches through a client-centred procedure. The aim of this study was to investigate whether the CO-OP Approach is feasible for and potentially beneficial to adolescents and young adults with CP or SB in Sweden by analysing four areas of feasibility (acceptability, efficacy, adaptation, and expansion).Methods: Exploratory multiple-case study using mixed methods. Ten persons aged 16-28, five with each condition, participated in an intervention period. Assessments were performed on three occasions: baseline, post-intervention, and six-month follow-up.Results: The result demonstrates that the CO-OP Approach has the potential to enable adolescents and young adults with either condition to achieve personal goals and to enhance their planning skills and their ability to use strategies when performing activities. This approach is also compatible with the core values of habilitation in Sweden and was found by the participants to be highly meaningful and useful.Conclusions: The CO-OP Approach is feasible for adolescents and young adults with SB or CP in Sweden.Implications for rehabilitationThe Cognitive Orientation to daily Occupational Performance• is a feasible approach for adolescents and young adults with spina bifida and with cerebral palsy.• is a promising approach when it comes to enabling the achievement of personal goals.• might have potential to enhance executive functioning through strategy use.• is in line with the fundamental core values of disability rights of inclusion, empowerment, and participation.

Return to Work and Participation in Society After Out-of-Hospital Cardiac Arrest.

BACKGROUND: The aim of this study was to describe out-of-hospital cardiac arrest (OHCA) survivors' ability to participate in activities of everyday life and society, including return to work. The specific aim was to evaluate potential effects of cognitive impairment. METHODS AND RESULTS: Two hundred eighty-seven OHCA survivors included in the TTM trial (Target Temperature Management) and 119 matched control patients with ST-segment-elevation myocardial infarction participated in a follow-up 180 days post-event that included assessments of participation, return to work, emotional problems, and cognitive impairment. On the Mayo-Portland Adaptability Inventory-4 Participation Index, OHCA survivors (n=270) reported more restricted participation In everyday life and in society (47% versus 30%; P<0.001) compared with ST-segment-elevation myocardial infarction controls (n=118). Furthermore, 27% (n=36) of pre-event working OHCA survivors (n=135) compared with 7% (n=3) of pre-event working ST-segment-elevation myocardial infarction controls (n=45) were on sick leave (odds ratio, 4.9; 95% confidence interval, 1.4-16.8; P=0.01). Among the OHCA survivors assumed to return to work (n=135), those with cognitive impairment (n=55) were 3× more likely (odds ratio, 3.3; 95% confidence interval, 1.2-9.3; P=0.02) to be on sick leave compared with those without cognitive impairment (n=40; 36%, n=20, versus 15%, n=6). For OHCA survivors, the variables that were found most predictive for a lower participation were depression, restricted mobility, memory impairment, novel problem-solving difficulties, fatigue, and slower processing speed. CONCLUSIONS: OHCA survivors reported a more restricted societal participation 6 months post-arrest, and their return to work was lower compared with ST-segment-elevation myocardial infarction controls. Cognitive impairment was significantly associated with lower participation, together with the closely related symptoms of fatigue, depression, and restricted mobility. These predictive variables may be used during follow-up to identify OHCA survivors at risk of a less successful recovery that may benefit from further support and rehabilitation. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01946932.

Application and validation of the barrow neurological institute screen for higher cerebral functions in a control population and in patient groups commonly seen in neurorehabilitation.

OBJECTIVE: To determine whether the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) can differentiate brain-dysfunctional patients from controls. DESIGN: A case-control study. SUBJECTS: A total of 92 controls and 120 patients from a neuro-rehabilitation clinic with a diagnosis of: right and left hemisphere stroke, traumatic brain injury, Parkinson's disease or anoxic brain damage. METHODS: The BNIS has a maximum total score of 50 points, < 47 indicates cognitive dysfunction. Group comparisons and exploration of variables influencing the BNIS total score were made. RESULTS: A significant difference was found between the control group and the total patient group for the BNIS total score and for the subscales (p < 0.0005). Sensitivity was 88% and specificity 78%. Presence of disease and educational level had the greatest influence on the results of the BNIS. Patients with Parkinson's disease were shown to be the least cognitively affected and those with anoxic brain damage the most affected. CONCLUSION: The BNIS has potential value as a screening instrument for cognitive functions and is sufficiently sensitive to differentiate brain-dysfunctional patients from a control population. It appears to be applicable in a neurological rehabilitation setting, and can be used early in the process, giving a baseline cognitive functional level.

Cognitive functioning and employment among people with schizophrenia in vocational rehabilitation.

BACKGROUND: Employment is central to recovery in schizophrenia, but little attention has been paid to its relationship with cognitive functioning. OBJECTIVE: This cross-sectional study adds to the knowledge base of relationships between cognitive functioning and gaining competitive employment, work hours per week, and monthly income among people with schizophrenia in vocational rehabilitation. It also examines which area of cognitive function may be decisive for gaining employment. METHODS: Thirty-nine vocational rehabilitation participants were administered a cognitive battery based on MATRICS Consensus Cognitive Battery. Socio-demographic, clinical, and vocational data were gathered and analyzed with nonparametric statistics. RESULTS: Individuals with competitive employment differed from those without competitive employment in attention and psychomotor speed, delayed verbal recall, immediate visual recall, and planning, reasoning, and problem-solving. Higher scores in immediate and delayed verbal recall and planning, reasoning, and problem-solving correlated with more work hours per week and higher income. Immediate visual recall was related to higher income. Higher scores in planning, reasoning, and problem-solving was an indicator of competitive employment (OR = 1.48). CONCLUSIONS: Higher order cognitive functioning of planning, reasoning, and problem-solving may have a central role in gaining employment. The findings should be considered in compensation for or improving cognitive functions for vocational rehabilitation participants.

The first year after successful cardiac resuscitation: function, activity, participation and quality of life.

AIM: To assess cognitive function, activities of daily living (ADL) and living situation longitudinally up to 1 year after cardiac arrest. SETTING: University hospital. MATERIALS: The study continued for 3 years and consecutive patients (18-75 years of age) who survived resuscitation were included. METHOD: A longitudinal study with examinations using the National Institute of Health Stroke Scale for assessing brain damage, along with the Mini Mental State Examination. To assess ADL, we used the Functional Independence Measure and the Instrumental Activity Measure. Life satisfaction was assessed, together with health-related quality of life. Social status and vocational status were recorded. RESULTS: Mortality was high during the first 90 days (31%). After discharge, not much improvement was seen in cognitive function. This was reflected in reduced dependency in ADL. Work capacity at 1 year was only 13%. The health related quality of life showed great improvement during the first year, being almost the same as for Swedish reference values. CONCLUSIONS: Most of the improvement resulting in the independence of ADL occurred during the first 45 days. It is important to give the next of kin information about the patient's progress and need for assistance in order to enable them to plan for the future before discharge.

Support and process in individual placement and support: a multiple case study.

OBJECTIVE: This multiple case study investigated support and process in the Individual Placement and Support (IPS) approach from individual client, longitudinal, and Person-Environment-Occupation (PEO) model perspectives. PARTICIPANTS: Five IPS-participants, or cases, with severe mental illness (SMI) who worked a minimum of 4 hours a week entered the study. METHODS: A multiple data collection method was used over a period of 12 months and included IPS-vocational profiles and plans as well as various instruments and questionnaires concerning socio-demographics, work performance, limitations, and accommodations. Both within- and across-case analyses were performed. RESULTS: The IPS-process concerned job search support, job-matches (PEO-match), and adjustment of the PEO-match by providing accommodations by on- and off-worksite support. All participants had limitations concerning social interactions and handling symptoms/tolerating stress. Several accommodations were made for the same limitations, mostly directed towards the social environment. Prior work experience, disclosure, and not being in an acute phase of illness seemed important to the support provided. CONCLUSIONS: This study has visualised the support and process in IPS and provided a theoretical framework, the PEO-model, to detect limitations and provide IPS-support. The organization of IPS-support and methods of providing it to individuals may be important for job tenure and employment success.

Reclaiming the worker role: perceptions of people with mental illness participating in IPS.

OBJECTIVE: People with severe mental illness are often successful in gaining work when participating in the evidence-based Individual Placement and Support (IPS) approach. Little evidence exists on how starting work is perceived by IPS participants. This qualitative study aimed to explore how IPS participants perceived working and the work environment to impact on their work performance. METHODS: Nineteen participants starting work in mainstream work settings were interviewed. Questions from the Work Environment Impact Scale were used and data was analysed by content analysis. The participants strove to fit in by coping with environmental demands and adapting to their worker role. RESULTS: Work was perceived as having a positive impact on their daily life, although starting work was perceived as a challenge and the mental illness affected work performance. Personal strategies were needed in order to cope. They perceived both supportive and demanding factors in their work environments, such as the employer's support and the social atmosphere among colleagues. CONCLUSION: The study showed that it is vital to focus on the individual's own strategies for adapting to the worker role when designing the support, as well as to develop collaborative relationships with employers and to optimize the match between the individual and the demands of the work environment.