Online awareness: a concept analysis and review of assessment approaches for adults with neurological conditions.

PURPOSE: Self-awareness is a multifaceted phenomenon that comprises two main concepts: general awareness and online awareness. The latter is an emerging concept that requires further consensus on its definition. The aim of this paper is to define the key components of online awareness and identify approaches for measuring this concept for adults with neurological conditions. MATERIALS AND METHODS: Concept analysis using Rodgers' evolutionary method was used to systematically review and summarise relevant literature. Papers were included if they provided a definition of online awareness or method for assessing online awareness for an adult neurological population. RESULTS: Fifty-six papers were included in this review, with 21 online awareness assessment approaches identified. Online awareness was described to occur within the context of task performance, with the definition framework comprising four main aspects: 1/appraisal; 2/anticipation and prediction; 3/monitoring; and 4/self-evaluation. Self-regulation is a related concept that is considered to sit outside the conceptual boundaries of online awareness. CONCLUSIONS: The findings of this analysis highlight the complexity of online awareness and its importance in rehabilitation. Psychometrically robust measures of online awareness that are inclusive of the essential elements of this concept are needed to advance practice in this area.

Online awareness or awareness of performance within the context of an activity should be included in the comprehensive assessment of self-awareness for individuals with neurological conditions.Online awareness is a task-specific phenomenon that is activated in the context of task performance, and requires assessment across a range of tasks and environments.When assessing online awareness, careful consideration is required when selecting tasks to ensure they have the right level of challenge to elicit the need to monitor performance.The heterogeneity of existing online awareness assessments highlights the need to interpret outcomes with caution.Future efforts should be directed towards development of an online awareness assessment that includes key attributes of this concept.

Cognitive Self-Efficacy in Parkinson's Disease.

Cognitive self-efficacy (CSE), one's belief in their ability to control their cognitive performance, is important for participation in daily activities and rehabilitation. This study aims to understand how Parkinson's disease (PD) affects CSE. The Cognitive Self-Efficacy Questionnaire (CSEQ) was administered to 47 non-demented PD and 52 healthy comparison (HC) participants. Groups were compared on their self-reported ability to recognize (Part 1) and manage (Part 2) cognitive symptoms and to perform cognitively complex functional activities (Part 4). Relationships between CSEQ scores and individual characteristics were assessed within PD. The PD group had lower CSEQ scores than the HC group for all Parts. Within PD, Part 2 scores were lower than Parts 1 and 4, and worse depressive symptoms and higher medication dosage correlated with lower CSE. People with PD may have low CSE, which can contribute to participation restrictions and reduced engagement in treatment. Occupational therapists should consider CSE with clients with PD.

Cognitive deficits are common in people with Parkinson's disease (PD) and affect their quality of life. In this study, the researchers looked at cognitive self-efficacy (CSE) or the belief in one's cognitive abilities and compared the CSE of healthy individuals with individuals with PD without dementia. The findings of the study suggest that non-demented individuals with PD have lower CSE as compared with healthy individuals. Furthermore, individuals with PD may have difficulty recognizing and managing their cognitive deficits such as memory deficits or distractibility. This may affect their ability to participate in everyday tasks that require complex cognition such as managing finances or shopping or engaging in therapy interventions focused on cognition. The study also found that greater depressive symptoms and higher dose of dopamine medications in non-demented individuals with PD lowered their CSE. This study recommends that rehabilitation professionals include assessments and interventions on CSE during treatment sessions.

Feasibility and Acceptability of a Remotely Delivered Executive Function Intervention That Combines Computerized Cognitive Training and Metacognitive Strategy Training in Chronic Stroke.

Executive dysfunction after stroke is associated with limitations in daily activities and disability. Existing interventions for executive dysfunction show inconsistent transfer to everyday activities and require frequent clinic visits that can be difficult for patients with chronic mobility challenges to access. To address this barrier, we developed a telehealth-based executive function intervention that combines computerized cognitive training and metacognitive strategy. The goal of this study was to describe intervention development and to provide preliminary evidence of feasibility and acceptability in three individuals who completed the treatment protocol. The three study participants were living in the community and had experienced a stroke >6 months prior. We assessed satisfaction (Client Satisfaction Questionnaire-8 [CSQ-8]), credibility (Credibility and Expectancy Questionnaire), and feasibility (percent of sessions completed). All three subjects rated the treatment in the highest satisfaction category on the CSQ-8, found the treatment to be credible, and expected improvement. Participants completed a median of 96% of computerized cognitive training sessions and 100% of telehealth-delivered metacognitive strategy training sessions. Individuals with chronic stroke may find a remotely delivered intervention that combines computerized cognitive training and metacognitive strategy training to be feasible and acceptable. Further evaluation with larger samples in controlled trials is warranted.

Using machine learning to modify and enhance the daily living questionnaire.

The Daily Living Questionnaire (DLQ) constitutes one of a number of functional cognitive measures, commonly employed in a range of medical and rehabilitation settings. One of the drawbacks of the DLQ is its length which poses an obstacle to conducting efficient and widespread screening of the public and which incurs inaccuracies due to the length and fatigue of the subjects. Objective: This study aims to use Machine Learning (ML) to modify and abridge the DLQ without compromising its fidelity and accuracy. Method: Participants were interviewed in two separate research studies conducted in the United States of America and Israel, and one unified file was created for ML analysis. An ML-based Computerized Adaptive Testing (ML-CAT) algorithm was applied to the DLQ database to create an adaptive testing instrument-with a shortened test form adapted to individual test scores. Results: The ML-CAT approach was shown to reduce the number of tests required on average by 25% per individual when predicting each of the seven DLQ output scores independently and reduce by over 50% when predicting all seven scores concurrently using a single model. These results maintained an accuracy of 95% (5% error) across subject scores. The study pinpoints which DLQ items are more informative in predicting DLQ scores. Conclusions: Applying the ML-CAT model can thus serve to modify, refine and even abridge the current DLQ, thereby enabling wider community screening while also enhancing clinical and research utility.

Cognitive impairment predicts engagement in inpatient stroke rehabilitation.

Patient engagement during inpatient rehabilitation is an important component of rehabilitation therapy, as lower levels of engagement are associated with poorer outcomes. Cognitive deficits may impact patient engagement during inpatient stroke rehabilitation. Here, we assess whether patient performance on the cognitive tasks of the 30-min National Institute of Neurologic Disorders and Stroke - Canadian Stroke Network (NINDS-CSN) screening battery predicts engagement in inpatient stroke rehabilitation. Prospective data from 110 participants completing inpatient stroke rehabilitation at an academic medical center were utilized for the present analyses. Cognitive functioning was assessed at inpatient stroke rehabilitation admission using the NINDS-CSN cognitive battery. Patient engagement was evaluated at discharge from an inpatient rehabilitation unit using the Hopkins Rehabilitation Engagement Rating Scale. The results demonstrate that the NINDS-CSN cognitive battery, specifically subtests measuring executive functioning, attention and processing speed, predicts patient engagement in inpatient stroke rehabilitation. Cognitively impaired patients undergoing rehabilitation may benefit from modifications and interventions to increase engagement and improve functional outcomes.

The Weekly Calendar Planning Activity to Assess Functional Cognition in Parkinson Disease.

The Weekly Calendar Planning Activity (WCPA) may improve understanding of functional cognition in people with Parkinson disease (PwPD) without dementia. We aimed to determine if WCPA performance (a) discriminates between PwPD with and without cognitive impairment and healthy controls and (b) correlates with other indicators of cognition and daily function. This was a cross-sectional study. Parkinson disease (PD) participants without dementia were divided into normal cognition (PD-NC, n = 25) and possible mild cognitive impairment (PD-MCI, n = 21) groups. Their WCPA performance was compared with that of a normative sample (n = 196) and correlated with neuropsychological test performance and self-reported cognition and participation. Both the PD-MCI and PD-NC groups had impaired WCPA performance. WCPA performance correlated with executive function, processing speed, and self-reported cognition and participation. The WCPA can detect functional cognitive deficits in PwPD without dementia and can inform occupational therapy interventions to support functional cognition, occupational performance, and participation in this population.

Revisiting the dynamic comprehensive model of self-awareness: a scoping review and thematic analysis of its impact 20 years later.

This study aimed to (1) describe the scope of research related to the Dynamic Comprehensive Model of Awareness (DCMA) (Toglia & Kirk, 2000); (2) identify themes and support for key model postulates; and (3) suggest future research directions related to this model. Using PRISMA scoping guidelines, 366 articles were reviewed, and 54 articles met our inclusion criteria. Selected studies were clustered into three themes: (1) the relationship between general and online self-awareness (50%); (2) interventions based on the model (41%); and (3) factors contributing to self-awareness (9%). Most studies were conducted with participants with acquired brain injury (BI) and traumatic BI (68%), most used a cross-sectional design (50%), and most intervention studies utilized a single-subject design (18%), followed by an experimental design (9%). This review provides evidence for the wide application of the DCMA across varying ages and populations. The need for a multidimensional assessment approach is recognized; however, stronger evidence that supports a uniform assessment of online self-awareness is needed. The intervention studies frequently described the importance of direct experience in developing self-awareness; however, few studies compared how intervention methods to influence general versus online self-awareness, or how cognitive capacity, self-efficacy, psychological factors, and context, influence the development of self-awareness.

Online awareness of performance on a functional cognitive assessment in individuals with stroke: A case-control study.

Unawareness is a significant barrier to cognitive rehabilitation following acquired brain injury. Little is known about online awareness of cognitively-based instrumental activities of daily living (C-IADL) after stroke, particularly C-IADLs that emphasize executive functions. Our goal was to evaluate in stroke patients (1) online awareness during and immediately after a C-IADL task that emphasizes executive functions and (2) the association between awareness and performance on the C-IADL task. Seventy-seven stroke patients on an acute inpatient rehabilitation unit and 77 control participants completed the 10-item Weekly Calendar Planning Activity (WCPA-10), a standardized C-IADL task that requires working memory, planning, shifting, and inhibition. Trained examiners observed the use of a self-checking strategy and self-recognition of errors during the task. Immediately after the task, participants estimated their accuracy, and rated their own performance, which was compared with objective accuracy. Relative to the control group, stroke patients overestimated their accuracy, less often recognized errors, and less frequently used a self-checking strategy. Overestimation was associated with worse overall performance on the WCPA-10. Findings suggest that poor online awareness of C-IADL performance is common in stroke patients undergoing acute inpatient rehabilitation. Increasing awareness through metacognitive interventions should be a core focus of early post-stroke cognitive rehabilitation.

Feasibility and acceptability of the multicontext approach for individuals with acquired brain injury in acute inpatient rehabilitation: A single case series.

The Multicontext (MC) approach, a metacognitive intervention designed to improve awareness, strategy use, and executive functioning, may be beneficial for individuals with acquired brain injury (ABI) undergoing acute inpatient rehabilitation. The goal of this study was to provide evidence of feasibility and acceptability of the MC approach and to explore clinical outcomes. A case series of eight individuals with acquired brain injury and at least mild executive functioning impairment were recruited from an acute inpatient rehabilitation unit. The MC approach - involving guided questioning and patient self-generation of strategies practiced across everyday functional cognitive tasks - was implemented within routine occupational therapy. Occupational therapists implemented the MC approach with high adherence to the treatment protocol. Therapists' perceived challenges were the time constraints of inpatient rehabilitation as well as client factors. Participants rated the MC approach as highly satisfying and engaging. They described subjective improvements in their ability to use executive functioning strategies. The MC approach was associated with improvement in awareness, strategy use, and executive functioning at the conclusion of treatment. The MC approach may be a beneficial intervention for individuals with acquired brain injury and executive dysfunction undergoing acute inpatient rehabilitation. Further evaluation with larger samples in controlled trials is warranted.Trial registration: ClinicalTrials.gov identifier: NCT04363645..

Spatial exploration strategy training for spatial neglect: A pilot study.

Spatial neglect is a syndrome due to impaired neural networks critical for spatial attention and related cognitive and motor functions. Affected individuals also have impaired self-awareness of their own neglect symptoms. The present randomized controlled study was the first proof-of-concept pilot examining the multi-context treatment approach using a protocol of spatial exploration strategy training in one brief session (20-30 minutes). The therapist provided supportive feedback and semi-structured guidance to promote strategy learning and self-discovery of omission errors. 40 patients with left-sided neglect after right brain stroke were included. The results showed that the treatment reduced lateralized bias toward the ipsilesional side of space but did not improve overall detection performance. Impaired general self-awareness of daily-life spatial difficulties was found independent of treatment outcome. This implies that judgment regarding responsiveness to treatment should not be made based on an awareness interview or the severity of neglect symptoms. Lastly, the treatment showed the potential of improving online contextual self-awareness of spatial abilities. A collaborative and interactive approach that focuses on helping the patient self-discover, monitor and self-manage their errors, appears to have a potential for decreasing neglect symptoms. Future studies are required to examine additional aspects of the multi-context treatment approach.

Detecting change in community participation with the Enfranchisement scale of the community participation indicators.

OBJECTIVE: This study determined the sensitivity to change of the Enfranchisement scale of the Community Participation Indicators in people with stroke. DATA SOURCES: We analyzed data from two studies of participants with stroke: an intervention study and an observational study. MAIN MEASURES: The Enfranchisement Scale contains two subscales: the Importance subscale (feeling valued by and contributing to the community; range: 14-70) and the Control subscale (choice and control: range: 13-64). DATA ANALYSIS: Assessments were administered 6 months apart. We calculated minimum detectable change and minimal clinically important difference. RESULTS: The Control subscale analysis included 121 participants with a mean age of 61.2 and mild-moderate disability (Functional Independence Measure, mean = 97.9, SD = 24.7). On the Control subscale, participants had a mean baseline score of 51.4 (SD = 10.4), and little mean change (1.3) but with large variation in change scores (SD = 11.5). We found a minimum detectable change of 9 and a minimum clinically important difference of 6. The Importance subscale analysis included 116 participants with a mean age of 60.7 and mild-moderate disability (Functional Independence Measure, mean = 98.9, SD = 24.5). On the Importance subscale, participants had a mean baseline score of 44.1 (SD = 12.7), and again demonstrated little mean change (1.08) but with large variation in change scores (SD = 12.6). We found a minimum detectable change of 11 and a minimum clinically important difference 7. CONCLUSIONS: The Control subscale required 9 points of change, and the Importance subscale required 11 points of change, to achieve statistically and clinically meaningful changes, suggesting adequate sensitivity to change.

Discharge Rehabilitation Measures Predict Activity Limitations in Patients With Stroke 6 Months After Inpatient Rehabilitation.

OBJECTIVE: The aim of this study was to identify rehabilitation measures at discharge from acute inpatient stroke rehabilitation that predict activity limitations at 6 mos postdischarge. DESIGN: This is a retrospective analysis of a prospective, longitudinal, observational cohort study. It was conducted in an acute inpatient rehabilitation unit at an urban, academic medical center. Activity limitations in patients ( N = 141) with stroke of mild-moderate severity were assessed with the activity measure for post-acute care at inpatient stroke rehabilitation discharge and 6-mo follow-up. Rehabilitation measures at discharge were investigated as predictors for activity limitations at 6 mos. RESULTS: Measures of balance (Berg Balance Scale), functional limitations in motor-based activities (functional independence measure-motor subscore), and motor impairment (motricity index), in addition to discharge activities measure for post-acute care scores, strongly predicted activity limitations in basic mobility and daily activities at 6 mos (51% and 41% variance explained, respectively). Functional limitations in cognition (functional independence measure-cognitive subscore) and executive function impairment (Trail Making Test-part B), in addition to the discharge activities measure for post-acute care score, modestly predicted limitations in cognitively based daily activities at 6 mos (12% of variance). CONCLUSIONS: Standardized rehabilitation measures at inpatient stroke rehabilitation discharge can predict future activity limitations, which may improve prediction of outcome post-stroke and aid in postdischarge treatment planning.

The 3s Spreadsheet Test version 2 for assessing egocentric viewer-centered and allocentric stimulus-centered spatial neglect.

The present study established the norms of the 3 s Spreadsheet Test version 2 (3S-v2 Test) with 186 healthy adults, compared performance of 23 individuals with spatial neglect after right brain stroke to the norms, and examined the extent that allocentric neglect is independent from egocentric neglect. The task required in the 3S-v2 Test is to cross out the target digit "3" in a spreadsheet that contained 10 columns and 14 rows of digit strings, including 120 target digits and 720 non-target digits. Each target is categorized with respect to its location on the page (egocentric viewer-centered) and its position within the digit string (allocentric stimulus-centered). Patients completed the 3S-v2 Test, the Apples Test, and Scene Copying Test (a five-object figure copying test). Based on the neglect classification criteria of these three tests, 18 patients (78.3%) were identified with both forms of neglect, three patients (13.0%) had isolated egocentric neglect, and two (8.7%) had isolated allocentric neglect. Among patients who were determined as having allocentric neglect by a given test, we found no significant correlation between severity of allocentric neglect and stimulus location in the egocentric reference frame. Based on the present findings, we suggest that including the 3S-v2 Test, a functionally relevant task and different from the currently available tests, may increase the comprehensiveness of neglect assessment. In addition, allocentric neglect symptoms are independent of egocentric locations.

Awareness of Performance on a Functional Cognitive Performance-Based Assessment Across the Adult Lifespan.

As people age, their cognitive skills and ability to complete complex instrumental activities of daily living often decline in subtle ways. Older adults who are aware of these slight cognitive and functional changes spontaneously adapt and implement strategies to maximize performance. On the other hand, older adults with limited self-awareness are less likely to adjust performance or initiate compensatory strategies as they may not recognize the need to do so. This places them at higher risk of functional decline and loss of independence. Research on awareness of functional performance in healthy adults is, however, limited, and there is a paucity of assessment tools available to address questions of awareness and strategy use in functional tasks. We used the Weekly Calendar Planning Activity (WCPA) - a performance-based assessment of functional cognition including measures of awareness and strategy use - to investigate differences in performance, awareness, and strategy use across the adult lifespan. The WCPA requires examinees to schedule appointments into a weekly calendar while following rules designed to increase task demands. Healthy adults (n=342) from ages 18-92 were observed for strategy use and error recognition, while a post-test interview probed participants' reported strategy use and estimation of accuracy. The discrepancy between participant estimation and actual accuracy provided a measure of online awareness of performance where a larger estimation discrepancy indicated over-estimation of performance. Performance on the WCPA declined across the adult lifespan. Older adults were less likely to use self-monitoring strategies and used less effective strategies overall. Overestimation was associated with use of fewer strategies and lower accuracy in all age groups. Importantly, twice as many older adults overestimated compared to younger adults. Furthermore, the subset of older adults who had good awareness of performance was more likely to use effective strategies, to recognize errors, and achieved accuracy on par with their younger counterparts. Our results emphasize the importance of examining self-awareness of performance and analyzing the strategies used to perform a complex functional task. This information can provide a foundation for early detection of functional decline in aging and for designing interventions to maximize functional independence in aging.

Young individuals with stroke in rehabilitation: a cohort study.

Stroke in younger populations is a public health crisis and the prevalence is rising. Little is known about the progress of younger individuals with stroke in rehabilitation. Characterization of the course and speed of recovery is needed so that rehabilitation professionals can set goals and make decisions. This was a cohort study with data extracted from electronic medical records. Participants were 408 individuals diagnosed with stroke who participated in inpatient rehabilitation in an urban, academic medical center in the USA. The main predictor was age which was categorized as (18-44, 45-64, 65-74 and 75+). Outcomes included baseline-adjusted discharge functional independence measure (FIM) scores and FIM efficiency. In linear regression models for FIM scores, the reference category was the youngest age group. The oldest group was discharged with significantly lower FIM total (B = -8.84), mobility (B = -4.13), self-care (B = -4.07) and cognitive (B = -1.57) scores than the youngest group after controlling for covariates. The 45-64 group also finished with significantly lower FIM total (B = -6.17), mobility (B = -2.61) and self-care (B = -3.01) scores than youngest group. FIM efficiencies were similar for all ages in each of the FIM scales. Younger individuals with stroke make slightly greater functional gains compared to older individuals with stroke, but other factors, such as admission scores, are more important and the rates of recovery may be similar.

Impaired Performance on a Cognitively-Based Instrumental Activities of Daily Living Task, the 10-Item Weekly Calendar Planning Activity, in Individuals With Stroke Undergoing Acute Inpatient Rehabilitation.

Performance-based, functionally relevant, and standardized measures of cognitive-instrumental activities of daily living (C-IADL) can complement neuropsychological tests of cognitive impairment and provide valuable clinical information to inform rehabilitation planning. Existing measures have been validated in the outpatient setting. Here, we sought to evaluate a 10-item, short-form of a C-IADL measure, Weekly Calendar Planning Activity (WCPA-10), in inpatients with stroke undergoing acute rehabilitation. The specific goal was to determine if the WCPA-10 could differentiate between stroke patients undergoing acute inpatient rehabilitation and healthy control individuals. We also explored whether the WCPA-10 would identify C-IADL limitations in stroke patients screened as having intact cognition. Seventy-seven stroke inpatients undergoing rehabilitation and 77 healthy control participants completed the WCPA-10, which involves entering a list of simulated, fictional appointments into a weekly schedule while keeping track of and adhering to multiple task rules and ignoring built-in obstacles and distractions. Compared to the control group, stroke patients had significantly worse accuracy, made more errors, used fewer cognitive strategies, followed fewer rules, took more time to complete the task, and were less efficient. 83% of stroke patients were less accurate than predicted by their age, and 64% used less strategies than their age prediction. Among 28 participants who screened as having "normal" cognitive function on the Montreal Cognitive Assessment, the majority had deficits on the WCPA-10. Our results provide initial support for use of a brief C-IADL assessment, WCPA-10, for individuals with stroke undergoing inpatient rehabilitation. They indicate that stroke patients have deficits in C-IADL accuracy, efficiency, and strategy use at this stage of stroke recovery. Results highlight the need to use performance based, functional cognitive assessments, even for those who perform well on cognitive screening tools.

Cognitive impairment and functional change in COVID-19 patients undergoing inpatient rehabilitation.

Cognitive impairment is increasingly recognized as a sequela of COVID-19. It is unknown how cognition changes and relates to functional gain during inpatient rehabilitation. We administered the Montreal Cognitive Assessment (MoCA) at admission to 77 patients undergoing inpatient rehabilitation for COVID-19 in a large US academic medical center. Forty-five patients were administered the MoCA at discharge. Functional gain was assessed by change in the quality indicator for self-care (QI-SC). In the full sample, 80.5% of patients exhibited cognitive impairment on admission, which was associated with prior delirium. Among 45 patients with retest data, there were significant improvements in MoCA and QI-SC. QI-SC score gain was higher in patients who made clinically meaningful changes on the MoCA, an association that persisted after accounting for age and delirium history. Cognitive impairment is frequent among COVID-19 patients, but improves over time and is associated with functional gain during inpatient rehabilitation.

Using Multicontext Approach to Improve Instrumental Activities of Daily Living Performance after a Stroke: A Case Report.

Cognitive deficits constitute one of the greatest challenges for independence achievement after a stroke. This paper provides an in depth view of the application of the Multicontext approach within routine Occupational Therapy care for a 41-year-old who demonstrated limited participation in activities of daily living as a consequence of executive function impairments and limited self-awareness. Results indicated improved online self-awareness, strategy use and functional performance, however, no changes were observed on a standard Awareness Questionnaire. This suggests that awareness within activities may be more important in contributing to effective strategy use and functional performance compared to verbal acknowledgment in an interview. Results also support the feasibility of the Multicontext approach within inpatient settings in Argentina.

Changes in the Activity Measure for Post-Acute Care Domains in Persons With Stroke During the First Year After Discharge From Inpatient Rehabilitation.

OBJECTIVE: To describe functional changes after inpatient stroke rehabilitation using the Activity Measure for Post-Acute Care (AM-PAC), an assessment measure sensitive to change and with a low risk of ceiling effect. DESIGN: Retrospective, longitudinal cohort study. SETTING: Inpatient rehabilitation unit of an urban academic medical center. PARTICIPANTS: Among 433 patients with stroke admitted from 2012-2016, a total of 269 (62%) were included in our database and 89 of 269 patients (33.1%) discharged from inpatient stroke rehabilitation had complete data. Patients with and without complete data were very similar. The group had a mean age of 68.0±14.2 years, National Institutes of Health Stroke Score of 8.0±8.0, and rehabilitation length of stay of 14.7±7.4 days, with 84% having an ischemic stroke and 22.5% having a recurrent stroke. INTERVENTION: None. MAIN OUTCOME MEASURES: Changes in function across the first year after discharge (DC) were measured in a variety of ways. Continuous mean scores for the basic mobility (BM), daily activity (DA), and applied cognitive domains of the AM-PAC were calculated at and compared between inpatient DC and 6 (6M) and 12 months (12M) post DC. Categorical changes among individuals were classified as "improved," "unchanged," or "declined" between the 3 time points based on the minimal detectable change, (estimated) minimal clinically important difference, and a change ≥1 AM-PAC functional stage (FS). RESULTS: For the continuous analyses, the Friedman test was significant for all domains (P≤.002), with Wilcoxon signed-rank test significant for all domains from DC to 6M (all P<.001) but with no change in BM and DA between 6M and 12M (P>.60) and a decline in applied cognition (P=.002). Despite group improvements from DC to 6M, for categorical changes at an individual level 10%-20% declined and 50%-70% were unchanged. Despite insignificant group differences from 6M-12M, 15%-25% improved and 20%-30% declined in the BM and DA domains. CONCLUSIONS: Despite group gains from DC to 6M and an apparent "plateau" after 6M post stroke, there was substantial heterogeneity at an individual level. Our results underscore the need to consider individual-level outcomes when evaluating progress or outcomes in stroke rehabilitation.

Standardized Outcome Measures in Stroke Rehabilitation and Falls After Discharge: A Cohort Study.

INTRODUCTION: Individuals with stroke discharged from inpatient rehabilitation units (IRUs) are at increased risk for falls. In IRUs, standardized outcome measures (SOMs) have been used to predict falls, but the results have been mixed. OBJECTIVE: To examine the relationship between SOMs and the risk of falls in individuals with stroke within 6 months of discharge from an IRU. DESIGN: Prospective cohort study with 6-month follow-up. SETTING: IRU that was part of a large, urban academic medical center. PARTICIPANTS: Individuals with stroke who underwent rehabilitation. MAIN OUTCOME MEASURES: Self-reported falls within 6 months of discharge. RESULTS: The study included 105 participants who were discharged to their homes after inpatient rehabilitation and who responded to a 6-month follow-up (57% response rate) phone call. Twenty-nine participants (28%) reported falling. Significant odds ratios (ORs), adjusted for age, sex, and stroke severity, were found for the following measures: Berg Balance Scale (OR 0.95, 95% confidence interval [CI] 0.92-0.99), Activity Measure for Post-Acute Care basic mobility (OR 0.89, 95% CI 0.81-0.97), Motricity Index (OR 0.96, 95% CI 0.94-0.98), Functional Independence Measure mobility subscale (OR 0.89, 95% CI 0.80-0.98), and Trunk Control Test (OR 0.97, 95% CI 0.95-0.99). Areas under the curve ranged from .64 to .71. In samples of 82 to 90 patients who could complete the tests, gait speed, the Functional Reach Test, the 6-minute Walk Test, and Timed Up and Go did not result in significant ORs. CONCLUSIONS: At discharge, SOMs were associated with the odds of falls within 6 months. The multifactorial nature of falls will continue to make prediction challenging but SOMs can be helpful. Lower extremity strength deserves more attention as a risk factor.