Determinants of access to rehabilitation professionals by individuals with stroke in the first six months after hospital discharge in Brazil: a study based on the Andersen model.

BACKGROUND: determinants of access to rehabilitation professionals after stroke in middle-income countries, where the burden of this disease is higher, are little known. OBJECTIVES: To identify the determinants of access to rehabilitation professionals by individuals with stroke at one, three, and six months after hospital discharge in Brazil and compare referral and access rates after discharge. METHODS: Longitudinal and prospective study, with individuals with primary stroke, without previous disabilities. At hospital discharge, the number of rehabilitation professionals referred by the multidisciplinary team was recorded. The possible determinants of access, according to Andersen's model, were: a) predisposing factors: age, sex, education levels, and belief that they could improve with treatment; b) need factors: stroke severity, levels of disability; c) enabling factors: socioeconomic status, disposable income for health care, and quality of care provided by rehabilitation professionals. One, three, and six months after hospital discharge, individuals were contacted to identify which rehabilitation professionals were accessed. Multiple linear regression model and Wilcoxon tests were used (α=5%). RESULTS: 201 individuals were included. Disability levels and stroke severity explained 31%, 34%, and 39% (p<0.01) of access at one, three, and six months after hospital discharge, respectively. In all periods, there was less access than that recommended at the time of hospital discharge (p<0.01). CONCLUSION: Need factors (disability levels and stroke severity) were determinants of access in all assessed periods. In addition, in all periods, the comprehensiveness of care for individuals with stroke was compromised.

Relative contributions of positive, negative, and adaptive features to limitations in upper-limb function three months after stroke.

PURPOSE: To investigate the contributions of motor impairments to limitations in upper-limb function three months after stroke. DESIGN: Cross-sectional, exploratory study. METHODS: Dependent variable was upper-limb function, measured by the Motor Assessment Scale (MAS), which scores range from 0 to 18. Independent variables included measures of strength, dexterity, spasticity, and contracture of the paretic upper limb. Multiple linear regression analysis was employed to identify which of the independent variables could explain the MAS scores (p<0.05). Analysis was performed with the whole sample and with a sub-group of participants, who had high function (MAS≥12). RESULTS: Sixty-nine individuals participated. Out of them, 63 had high upper-limb function. Regression analysis with the whole sample revealed that strength and dexterity were retained in the models. Together they explained 64% of the variance of the MAS scores (p<0.001), being strength the greater relative contributor. When the regression analysis included only participants with high upper-limb function, dexterity had a greater relative contribution, than strength. Together they explained 52 % of the variance (p< 0.001). CONCLUSIONS: Strength was the main contributor to upper-limb function in individuals three months after stroke. However, in individuals, who already had higher upper-limb function, dexterity showed to be the major contributor.

Test-retest reliability and measurement error of the modified gait efficacy scale in individuals with stroke.

PURPOSE: To investigate the test-retest reliability and measurement error of the Brazilian version of the modified Gait Efficacy scale (mGES-Brazil) in individuals who have had stroke. METHODS: The mGES-Brazil was applied on two occasions, five to seven days apart, in a research laboratory setting. Test-retest reliability and measurement error, which included the standard error of measurement (SEM), smallest detectable change (SDC), and analysis of the limits of agreement by the Bland-Altman plots, were examined. RESULTS: Fifty individuals who have had stroke (18 men), with a mean age of 64 ± 11 years, were evaluated. All individual items showed good reliability (Intra-class Correlation Coefficient - ICC2,1 > 0.90). The ICC was 0.98 (95% CI 0.97 to 0.99) and the Bland and Altman plots revealed no systematic changes in the mean test-retest scores. The SEM (SEM%) was 3 (5%), within the recommended values, while the SDC was 8 points. CONCLUSION: The mGES-Brazil demonstrated to be reliable to be applied within clinical and research contexts for the assessment of changes in walking confidence of individuals who have had stroke. Changes in mGES scores ≥8 points reflect real changes.

Deficits in motor coordination of the paretic lower limb best explained activity limitations after stroke.

Objective: To explore the relationships between selected measures of motor impairments and activities involving the lower-limbs in ambulatory people with chronic stroke. Design: Motor impairment measures included maximal isometric strength and motor coordination. Activity measures included walking speed, stair ascent/descent cadences, and the time to perform the Timed Up and Go (TUG) test. Results: Ninety individuals were included. The correlations between all motor impairment and activity measures were significant (0.18 < r < 0.52, p < 0.05). Motor coordination and strength of the knee flexor muscles explained 30% (F = 20.3; p < 0.001) of the variance in walking speed, 32% (F = 19.1; p < 0.001) of stair ascent, and 31% (F = 16.8; p < 0.001) of stair descent cadence. Regarding the TUG, only motor coordination reached significance and explained 13% (F = 13.4; p < 0.001) of the variance. Conclusion: Measures of strength and motor coordination of the paretic lower limb were significantly correlated with all activity measures. However, despite the fact that knee flexor strength explained some variance in walking speed and stair ascent/descent cadences, motor coordination was the only measure that explained the variances in all three selected activity measures. These findings are innovative for neurological rehabilitation, since this is the first study to demonstrate that deficits in motor coordination of the paretic lower limb best explained limitations in performing different lower-limb activities.

Efficacy of Interventions to Improve Respiratory Function After Stroke.

BACKGROUND: The aim of this study was to systematically review all current interventions that have been utilized to improve respiratory function and activity after stroke. METHODS: Specific searches were conducted. The experimental intervention had to be planned, structured, repetitive, purposive, and delivered with the aim of improving respiratory function. Outcomes included respiratory strength (maximum inspiratory pressure [PImax], maximum expiratory pressure [PEmax]) and endurance, lung function (FVC, FEV1, and peak expiratory flow [PEF]), dyspnea, and activity. The quality of the randomized trials was assessed by the PEDro scale using scores from the Physiotherapy Evidence Database (www.pedro.org.au), and risk of bias was assessed in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: The 17 included trials had a mean PEDro score of 5.7 (range 4-8) and involved 616 participants. Meta-analyses showed that respiratory muscle training significantly improved all outcomes of interest: PImax (weighted mean difference 11 cm H2O, 95% CI 7-15, I2 = 0%), PEmax (8 cm H2O, 95% CI 2-15, I2 = 65%), FVC (0.25 L, 95% CI 0.12-0.37, I2 = 29%), FEV1 (0.24 L, 95% CI 0.17-0.30, I2 = 0%), PEF (0.51 L/s, 95% CI 0.10-0.92, I2 = 0%), dyspnea (standardized mean difference -1.6 points, 95% CI -2.2 to -0.9; I2 = 0%), and activity (standardized mean difference 0.78, 95% CI 0.22-1.35, I2 = 0%). Meta-analyses found no significant results for the effects of breathing exercises on lung function. For the remaining interventions (ie, aerobic and postural exercises) and the addition of electrical stimulation, meta-analyses could not be performed. CONCLUSIONS: This systematic review reports 5 possible interventions used to improve respiratory function after stroke. Respiratory muscle training proved to be effective for improving inspiratory and expiratory strength, lung function, and dyspnea, and benefits were carried over to activity. However, there is still no evidence to accept or refute the efficacy of aerobic, breathing, and postural exercises, or the addition of electrical stimulation in respiratory function.

Respiratory muscle training increases respiratory muscle strength and reduces respiratory complications after stroke: a systematic review.

QUESTION: After stroke, does respiratory muscle training increase respiratory muscle strength and/or endurance? Are any benefits carried over to activity and/or participation? Does it reduce respiratory complications? DESIGN: Systematic review of randomised or quasi-randomised trials. PARTICIPANTS: Adults with respiratory muscle weakness following stroke. INTERVENTION: Respiratory muscle training aimed at increasing inspiratory and/or expiratory muscle strength. OUTCOME MEASURES: Five outcomes were of interest: respiratory muscle strength, respiratory muscle endurance, activity, participation and respiratory complications. RESULTS: Five trials involving 263 participants were included. The mean PEDro score was 6.4 (range 3 to 8), showing moderate methodological quality. Random-effects meta-analyses showed that respiratory muscle training increased maximal inspiratory pressure by 7 cmH2O (95% CI 1 to 14) and maximal expiratory pressure by 13 cmH2O (95% CI 1 to 25); it also decreased the risk of respiratory complications (RR 0.38, 95% CI 0.15 to 0.96) compared with no/sham respiratory intervention. Whether these effects carry over to activity and participation remains uncertain. CONCLUSION: This systematic review provided evidence that respiratory muscle training is effective after stroke. Meta-analyses based on five trials indicated that 30minutes of respiratory muscle training, five times per week, for 5 weeks can be expected to increase respiratory muscle strength in very weak individuals after stroke. In addition, respiratory muscle training is expected to reduce the risk of respiratory complications after stroke. Further studies are warranted to investigate whether the benefits are carried over to activity and participation. REGISTRATION: PROSPERO (CRD42015020683). [Menezes KKP, Nascimento LR, Ada L, Polese JC, Avelino PR, Teixeira-Salmela LF (2016) Respiratory muscle training increases respiratory muscle strength and reduces respiratory complications after stroke: a systematic review.Journal of Physiotherapy62: 138-144].