Differences in rehabilitation evaluation access for rural and socially disadvantaged stroke survivors.

BACKGROUND: Most stroke survivors have ongoing deficits and report unmet needs. Despite evidence that rehabilitation improves stroke survivors' function, access to occupational and physical therapy is limited. Describing access to care for disadvantaged communities for different levels of stroke severity will provide proportions used to create Markov economic models to demonstrate the value of rehabilitation. OBJECTIVES: The objective of this study was to explore differences in the frequency of rehabilitation evaluations via outpatient therapy and home health for Medicare Part B ischemic stroke survivors in rural and socially disadvantaged locations. METHODS: We completed a retrospective, descriptive cohort analysis using the 2018 and 2019 5% Medicare Limited Data Sets (LDS) from the Centers for Medicare and Medicaid Services using STROBE guidelines for observational studies. We extracted rehabilitation Current Procedural Terminology (CPT) codes for those who received occupational or physical therapy to examine differences in therapy evaluations for rural and socially disadvantaged populations. RESULTS: Of the 9,076 stroke survivors in this cohort, 44.2% did not receive any home health or outpatient therapy. Of these, 64.7% had a moderate or severe stroke, indicating an unmet need for therapy. Only 2.0% of stroke survivors received outpatient occupational therapy within the first year Rural and socially disadvantaged communities accessed rehabilitation evaluations at lower rates than general stroke survivors. CONCLUSIONS: These findings describe the poor access to home health and outpatient rehabilitation for stroke survivors, particularly in traditionally underserved populations. These results will influence future economic evaluations of interventions aimed at improving access to care.

Unilateral Spatial Neglect May Not Be Detected by Performance-Based Functional Neglect Assessment.

IMPORTANCE: Unilateral spatial neglect (neglect) poststroke is disabling. It is critical that people with neglect are identified so that treatment can be provided to maximize independence. However, there is some evidence to suggest that existing assessments may not adequately measure neglect. It is unclear whether assessments also fail to identify people with neglect entirely. OBJECTIVE: To determine whether there are stroke survivors who self-report neglect symptoms that are not detected by therapist-rated assessments and to compare self-report and therapist-ratings. DESIGN: Cross-sectional study. SETTING: U.S. university research center. PARTICIPANTS: Unilateral stroke survivors (N = 133). INTERVENTION: Not applicable. OUTCOMES AND MEASURES: The Catherine Bergego Scale (CBS) was administered to participants and scored by a trained occupational therapist. The parallel self-evaluation anosognosia form was also administered to participants to self-report and rate neglect symptoms. RESULTS: Forty-eight participants (36.1%) were classified as without neglect on the basis of therapist-rated total CBS scores, yet 30 (62.5%) of these 48 participants reported symptoms of neglect on the CBS self-evaluation anosognosia form. There was a significant difference (p < .001) between therapist-rated and self-rated total CBS scores. CONCLUSIONS AND RELEVANCE: Our results indicate that many stroke survivors report some level of disability associated with neglect yet do not meet the criteria to be classified as having neglect according to a commonly used therapist-rated performance-based measure. Plain-Language Summary: The findings of this study contribute to the evidence that existing assessments used by occupational therapists to measure performance-based neglect may not always detect neglect symptoms comprehensively in people poststroke. The finding also suggest that we may be missing neglect symptoms entirely. Occupational therapists should consider using various methods to assess for neglect, including patient self-report and comprehensive occupational profiles. Clinicians should also thoroughly screen all clients with stroke for neglect, regardless of lesion location.

Development of a Short Form Assessment Combining the Fugl-Meyer Assessment-Upper Extremity and the Wolf Motor Function Test for Evaluating Stroke Recovery.

OBJECTIVE: To use Rasch methodologies to combine the items of the Fugl-Meyer Assessment-Upper Extremity (FMA-UE, motor skill) and the Wolf Motor Function Test (WMFT, motor function) onto a single measurement metric and create an FMA-UE+WMFT short form. DESIGN: Secondary analysis of preintervention data from 2 upper extremity stroke rehabilitation trials. Confirmatory factor analysis and Rasch rating scale analysis were first applied to examine the properties of the pooled item bank and then item response theory methodologies were used to develop the short form. Confirmatory factor analysis and Rasch analysis were then applied to the short form to examine the dimensionality and measurement properties. SETTING: Outpatient academic medical research center. PARTICIPANTS: Data from 167 participants who completed the FMA-UE and WMFT (rating scale score) were pooled (N=167). Participants were eligible if they had a stroke ≥3 months prior and had upper extremity (UE) hemiparesis and excluded if they had severe UE hemiparesis, severe UE spasticity, or UE pain. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The dimensionality and measurement properties of the pooled 30-item FMA-UE and the 15-item WMFT and short form were examined. RESULTS: Five items from the pool of 45 items were misfit and were removed. The 40-item pool demonstrated adequate measurement properties. A 15-item short form was then developed and met rating diagnostic scale criteria. All items on the 15-item short form met the Rasch fit criteria, and the assessment met criteria for reliability (Cronbach alpha=.94), separation (person separation = 3.7), and strata (number of strata = 5). CONCLUSIONS: Items from the FMA-UE and WMFT can be pooled to create a psychometrically sound 15-item short form.

Determining the Marginal Cost Differences of a Telehealth Versus an In-person Occupational Therapy Evaluation Session for Stroke Survivors Using Time-driven Activity-based Costing.

OBJECTIVE: To estimate the marginal cost differences and care delivery process of a telerehabilitation vs outpatient session. DESIGN: This study used a time-driven activity-based costing approach including (1) observation of rehabilitation sessions and creation of manual time stamps, (2) structured and recorded interviews with 2 occupational therapists familiar with outpatient therapy and 2 therapists familiar with telerehabilitation, (3) collection of standard wages for providers, and (4) the creation of an iterative flowchart of both an outpatient and telerehabilitation session care delivery process. SETTING: Telerehabilitation and outpatient therapy evaluation. PARTICIPANTS: Three therapists familiar with care deliver for telerehabilitation or outpatient therapy (N=3). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Marginal cost difference between telerehabilitation and outpatient therapy evaluations. RESULTS: Overall, telerehabilitation ($225.41) was more costly than outpatient therapy ($168.29) per session for a cost difference of $57.12. Primary time drivers of this finding were initial phone calls (0 minutes for OP therapists vs 35 minutes for TR) and post documentation (5 minutes for OP vs 30 minutes for TR) demands for telerehabilitation. CONCLUSIONS: Telerehabilitation is an emerging platform with the potential to reduce costs, improve health care inequities, and facilitate better patient outcomes. Improvements in documentation practices, staffing, technology, and reimbursement structuring would allow for a more successful translation.

Crafting Community-Based Participatory Research Stroke Interventions.

Stroke exerts a tremendous burden on individuals, families, communities, and health systems globally. Even more troublesome are the striking disparities faced across diverse populations. These disparities are further exacerbated by the COVID-19 pandemic. Despite efforts to advance stroke research, substantial gaps remain in understanding factors that contribute to stroke disparities, including the Social Determinants of Health. Strategically designed studies and tailored interventions are needed to bridge the inequities high-risk populations face and to meet their specific needs. Community-based participatory research offers an approach to equitably partner with community members to understand and work collaboratively to address community-specific health priorities. In this focused update, we highlight the main processes of community-based participatory research studies and share exemplars from our team's work in stroke research and from the literature. As we continue to face an increasing prevalence of stroke, compounded by the COVID-19 pandemic and ongoing implications of the Social Determinants of Health, partnering with communities to address community-driven health priorities can inform interventions targeted to overcome the disparities faced by certain populations.

Barriers and Facilitators of Stroke Recovery: Perspectives From African Americans With Stroke, Caregivers and Healthcare Professionals.

INTRODUCTION AND GOAL: Stroke is a serious health condition that disproportionally affects African-Americans relative to non-Hispanic whites. In the absence of clearly defined reasons for racial disparities in stroke recovery and subsequent stroke outcomes, a critical first step in mitigating poor stroke outcomes is to explore potential barriers and facilitators of poststroke recovery in African-American adults with stroke. The purpose of this study was to qualitatively explore poststroke recovery across the care continuum from the perspective of African-American adults with stroke, caregivers of African-American adults with stroke, and health care professionals with expertise in stroke care. MATERIALS AND METHODS: This qualitative descriptive study included in-depth key informant interviews with health care providers (n = 10) and focus groups with persons with stroke (n = 20 persons) and their family members or caregivers (n = 19 persons). Data were analyzed using thematic analysis according to the Social Ecological Model, using both inductive and deductive approaches. FINDINGS: Persons with stroke and their caregivers identified social support, resources, and knowledge as the most salient factors associated with stroke recovery. Perceived barriers to recovery included: (1) physical and cognitive deficits, mood; (2) medication issues; (3) lack of support and resources; (4) stigma, culture, and faith. Health care providers identified knowledge/information, care coordination, and resources in the community as key to facilitating stroke recovery outcomes. CONCLUSIONS: Key findings from this study can be incorporated into interventions designed to improve poststroke recovery outcomes and potentially reduce the current racial-ethnic disparity gap.

Interpreting Action Research Arm Test Assessment Scores to Plan Treatment.

Rasch keyforms can help interpret clinical assessment scores. The Action Research Arm Test (ARAT) is a commonly used assessment, yet no keyform currently exists. The aim is to provide a keyform for the ARAT and demonstrate how a clinician can use the keyform to design optimally challenging rehabilitation sessions. Secondary analysis of ARAT data ( n = 122) using confirmatory factor and Rasch analyses were used to examine the measurement properties and generate a keyform. The item standardized factor loadings were >0.40 (range = 0.82-0.96) and R2 values were >.60 (range = .65-.96). All items exhibited adequate infit statistics with point measure correlations >.60 (range = .72-.97). Person reliability was .98, and person separation was 7.07. Item-difficulty measures ranged from -2.78 logits to 2.64 logits. The ARAT has strong measurement properties, and a keyform was provided. We showed how the keyform can be utilized by clinicians to interpret scores, set goals, and plan treatment.

Rasch analysis of a new hierarchical scoring system for evaluating hand function on the motor assessment scale for stroke.

Objectives. (1) To develop two independent measurement scales for use as items assessing hand movements and hand activities within the Motor Assessment Scale (MAS), an existing instrument used for clinical assessment of motor performance in stroke survivors; (2) To examine the psychometric properties of these new measurement scales. Design. Scale development, followed by a multicenter observational study. Setting. Inpatient and outpatient occupational therapy programs in eight hospital and rehabilitation facilities in the United States and Canada. Participants. Patients (N = 332) receiving stroke rehabilitation following left (52%) or right (48%) cerebrovascular accident; mean age 64.2 years (sd 15); median 1 month since stroke onset. Intervention. Not applicable. Main Outcome Measures. Data were tested for unidimensionality and reliability, and behavioral criteria were ordered according to difficulty level with Rasch analysis. Results. The new scales assessing hand movements and hand activities met Rasch expectations of unidimensionality and reliability. Conclusion. Following a multistep process of test development, analysis, and refinement, we have redesigned the two scales that comprise the hand function items on the MAS. The hand movement scale contains an empirically validated 10-behavior hierarchy and the hand activities item contains an empirically validated 8-behavior hierarchy.

Examination of the factor structure of the Disabilities of the Arm, Shoulder, and Hand questionnaire.

OBJECTIVE: The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is a global scale evaluating the impact of upper-extremity disorders. We sought to validate or challenge the unidimensional factor structure of the DASH. METHOD: Secondary analysis was performed on data collected from outpatient clinics. Factor analysis was performed in two steps, exploratory factor analysis (EFA) followed by confirmatory factor analysis (CFA). To provide further support for unidimensionality, fit statistics were calculated using the Andrich Rasch rating-scale model. RESULTS: EFA revealed three potential factors (eigenvalues = 18.40, 1.56, and 1.54). CFA was performed fitting a three-factor model. Tucker-Lewis Index (.99) and standardized root mean square residual (.05) values indicated good fit. Comparative fit index (.89) and root mean square error of approximation (.13) did not. When divided into three constructs, only one item misfit. CONCLUSION: More research is needed to determine situations in which division of the DASH may enhance interpretability.

Translating measurement findings into rehabilitation practice: an example using Fugl-Meyer Assessment-Upper Extremity with patients following stroke.

Standardized assessments are critical for advancing clinical rehabilitation, yet assessment scores often provide little information for rehabilitation treatment planning. A keyform recovery map is an innovative way for a therapist to record patient responses to standardized assessment items. The form enables a therapist to view the specific items that a patient can or cannot perform. This information can assist a therapist in tailoring treatments to a patient's individual ability level. We demonstrate how a keyform recovery map can be used to inform clinical treatment planning for individuals with stroke-related upper-limb motor impairment. A keyform map of poststroke upper-limb recovery defined by items of the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) was generated by a previously published Rasch analysis. Three individuals with stroke enrolled in a separate research study were randomly selected from each of the three impairment strata of the FMA-UE. Their performance on each item was displayed on the FMA-UE keyform. The forms directly connected qualitative descriptions of patients' motor ability to assessment measures, thereby suggesting appropriate shorter and longer term rehabilitation goals. This study demonstrates how measurement theory can be used to translate a standardized assessment into a useful, evidence-based tool for making clinical practice decisions.

Longitudinal stability of the Fugl-Meyer Assessment of the upper extremity.

OBJECTIVE: To investigate the longitudinal stability of the Fugl-Meyer Assessment (FMA) of the upper-extremity item difficulties by using Rasch analysis. DESIGN: Secondary analysis of existing data from a cohort longitudinal study of stroke recovery. SETTING: University research center. PARTICIPANTS: A total of 377 people, ages 69.2+/-11.2 years, to whom the assessment was administered at 2 weeks and 6 months poststroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Differential item function analysis performed by using the Winsteps software program examined whether the item difficulty hierarchical order of a modified 30-item FMA for the upper extremity (reflex items removed) was invariant across 2 testing occasions. RESULTS: Only 2 items (shoulder flexion to 180 degrees, movement with normal speed) showed large differences in test-retest item difficulty calibration. Item instability had no practical consequences on the longitudinal measurement of person ability. CONCLUSIONS: The 30-item assessment shows a longitudinally stable item difficulty order and is valid for measuring volitional arm motor ability over time.

Dimensionality and construct validity of the Fugl-Meyer Assessment of the upper extremity.

OBJECTIVE: To investigate the dimensionality and construct validity of the Fugl-Meyer Assessment of the upper extremity by using Rasch analysis. DESIGN: Secondary analysis of pooled data from 2 existing datasets: a randomized therapeutic exercise clinical trial and a cohort longitudinal study of stroke recovery. SETTING: University research center. PARTICIPANTS: A total of 512 subjects, ages 69.8+/-11.1 years, who were 0 to 145 days poststroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Dimensionality was examined with principal components analysis and Rasch item-fit statistics. The Rasch-derived item hierarchy was examined for consistency with the expected course of poststroke upper-extremity recovery suggested by the reflex-hierarchical conceptual model underlying the assessment. RESULTS: Factor loadings and item infit statistics suggested that the 3 reflex items were empirically disconnected from other assessment items. The reflex items were removed. The modified 30-item assessment showed a unidimensional structure. The Rasch-item-difficulty order was not consistent with the expected item order. CONCLUSIONS: The items testing resting-state reflexes may threaten the assessment's dimensionality. With reflex items removed, the assessment is a unidimensional measure of volitional movement. The Rasch-generated item-difficulty order challenges the hierarchical structure implied by the instrument's underlying conceptual framework.