Stroke Recovery During the COVID-19 Pandemic: A Position Paper on Recommendations for Rehabilitation.

Health care delivery shifted and adapted with the COVID-19 pandemic caused by the novel severe acute respiratory syndrome coronavirus 2. Stroke care was negatively affected across the care continuum and may lead to poor community living outcomes in those who survived a stroke during the ongoing pandemic. For instance, delays in seeking care, changes in length of stays, and shifts in discharge patterns were observed during the pandemic. Those seeking care were younger and had more severe neurologic effects from stroke. Increased strain was placed on caregivers and public health efforts, and community-wide lockdowns, albeit necessary to reduce the spread of COVID-19, had detrimental effects on treatment and recommendations to support community living outcomes. The American Congress of Rehabilitation Medicine Stroke Interdisciplinary Special Interest Group Health and Wellness Task Force convened to (1) discuss international experiences in stroke care and rehabilitation and (2) review recently published literature on stroke care and outcomes during the pandemic. Based on the findings in the literature, the task force proposes recommendations and interdisciplinary approaches at the (1) institutional and societal level; (2) health care delivery level; and (3) individual and interpersonal level spanning across the care continuum and into the community.

Smartphone and mHealth Use After Stroke: Results From a Pilot Survey.

Advances in smartphone technology have revolutionized health care providing innovative approaches to improve health and well-being. Emerging mobile health (mHealth) apps are becoming increasingly available and offer opportunities to support self-management needs in people with stroke; however, experiences with mHealth among this population are not well understood. The objective of this study is to conduct a cross-sectional survey on smartphone and mHealth app use for adults with stroke. A pilot survey of 50 adults with stroke was conducted. In all, 51% of respondents reported using their smartphone more frequently than before their stroke, and 91% reported having some degree of difficulty with its use. Respondents reported on specific challenges with app use and discussed desired content and features. Occupational therapists should familiarize themselves with valid, accessible, usable, and acceptable apps for people with stroke and consider implementing mHealth apps in self-management intervention plans to improve health, rehabilitation, and community integration outcomes in this population.

'Timing it Right': needs of African American adults with stroke and their caregivers across the care continuum.

Objective: African Americans are disproportionately affected by stroke in the United States (US). The purpose of this study is to explore experiences, wants, and needs of African Americans with stroke and their family caregivers residing in the stroke belt across the care continuum using the 'Timing It Right' (TIR) framework as a conceptual guide.Design: We conducted a series of focus groups among 20 African Americans living with stroke and 19 family caregivers. Focus groups were audio-recorded and transcribed verbatim. For this secondary analysis, we coded qualitative data using the TIR framework.Results: Participants in this sample identified pre-stroke needs in addition to the TIR phases that span across the care continuum and into community living. We identified four important contextual factors and real-world conditions that operate in the background and influence the post-stroke needs of this specific population across the TIR framework: (1) religion, faith, and church, (2) healthcare delivery, (3) community, and (4) sentinel events.Conclusions: We propose a TIR model that expands upon the original TIR framework which includes factors important for consideration when developing and delivering community-based interventions among African Americans with stroke and family caregivers in the southeastern US.

Home safety evaluation - getting it right.

PURPOSE: Comprehensive and efficient home safety assessments are needed to provide quality interventions for community living. This study explores early career and experienced home evaluator perspectives on content and usability of HESTIA, a home safety assessment app. METHOD: Four early career and five experienced practitioners rated the HESTIA app using the uMARS usability evaluation and then participated in focus groups. Data were analysed using a key concept analytic approach. RESULTS: Results include "how to do" home safety evaluations and how prompts and training help practitioners "get it right." Early practitioner participants viewed the step-wise processes of the app as necessary whereas the experienced evaluators relied on own knowledge and experiences. CONCLUSIONS: Gobet and Chassy's TempT theory provides insight into the development of expertise in practice for rehabilitation professionals. The procedural complexities of assessment and ethical responsibility to provide competent, quality service to clients with disabilities are integrated into discussion of the development of professional intuition and ethical practice as guided by HESTIA.IMPLICATIONS FOR REHABILITATIONHome safety evaluations and home modifications are essential in helping persons with disabilities to live at home.Mobile applications such as HESTIA can serve as beneficial supports in facilitating effective decision making processes for rehabilitation practitioners conducting home safety evaluations.Technology driven assessments through mobile applications (apps) can help improve proper decision making and client outcomes, as well as aid in the development of intuition in students and early-career practitioners.Decision making support systems can help practitioners uphold their ethical responsibility to provide competent and quality rehabilitative services.

Use of mHealth Technology for Patient-Reported Outcomes in Community-Dwelling Adults with Acquired Brain Injuries: A Scoping Review.

The purpose of our scoping review was to describe the current use of mHealth technology for long-term assessment of patient-reported outcomes in community-dwelling individuals with acquired brain injury (ABI). Following PRISMA guidelines, we conducted a scoping review of literature meeting these criteria: (1) civilians or military veterans, all ages; (2) self-reported or caregiver-reported outcomes assessed via mobile device in the community (not exclusively clinic/hospital); (3) published in English; (4) published in 2015-2019. We searched Ovid MEDLINE(R) < 1946 to 16 August 2019, MEDLINE InProcess, EPub, Embase, and PsycINFO databases for articles. Thirteen manuscripts representing 12 distinct studies were organized by type of ABI [traumatic brain injury (TBI) and stroke] to extract outcomes, mHealth technology used, design, and inclusion of ecological momentary assessment (EMA). Outcomes included post-concussive, depressive, and affective symptoms, fatigue, daily activities, stroke risk factors, and cognitive exertion. Overall, collecting patient-reported outcomes via mHealth was feasible and acceptable in the chronic ABI population. Studies consistently showed advantage for using EMA despite variability in EMA timing/schedules. To ensure best clinical measurement, research on post-ABI outcomes should consider EMA designs (versus single time-point assessments) that provide the best timing schedules for their respective aims and outcomes and that leverage mHealth for data collection.

America's housing affordability crisis: Perpetuating disparities among people with disability.

America's housing affordability crisis has had various indirect costs on health and safety among people living with disability. The skyrocketing housing prices have exponentially increased with the onset of the COVID-19 pandemic leaving many people at risk for eviction after federal and local moratoriums providing protection during the pandemic expire. Americans with disabilities have been particularly affected by the affordability crisis and it is expected that this major public health problem will only grow as government-provided protections and supports wane. It is critical that both government and various housing organizations consider ways to support affordability, quality, and accessibility in this particularly hard-hit population.

Inconsistent Classification of Mild Stroke and Implications on Health Services Delivery.

OBJECTIVE: To conduct a scoping review on classifications of mild stroke based on stroke severity assessments and/or clinical signs and symptoms reported in the literature. DATA SOURCES: Electronic searches of PubMed, PsycINFO (Ovid), and Cumulative Index to Nursing and Allied Health (CINAHL-EBSCO) databases included keyword combinations of mild stroke, minor stroke, mini stroke, mild cerebrovascular, minor cerebrovascular, transient ischemic attack, or TIA. STUDY SELECTION: Inclusion criteria were limited to articles published between January 2003 and February 2018. Inclusion criteria included studies (1) with a definition of either mild or minor stroke, (2) written in English, and (3) with participants aged 18 years and older. Animal studies, reviews, dissertations, blogs, editorials, commentaries, case reports, newsletters, drug trials, and presentation abstracts were excluded. DATA EXTRACTION: Five reviewers independently screened titles and abstracts for inclusion and exclusion criteria. Two reviewers independently screened each full-text article for eligibility. The 5 reviewers checked the quality of the included full-text articles for accuracy. Data were extracted by 2 reviewers and verified by a third reviewer. DATA SYNTHESIS: Sixty-two studies were included in the final review. Ten unique definitions of mild stroke using stroke severity assessments were discovered, and 10 different cutoff points were used. The National Institutes of Health Stroke Scale was the most widely used measure to classify stroke severity. Synthesis also revealed variations in classification of mild stroke across publication years, time since stroke, settings, and medical factors including imaging, medical indicators, and clinical signs and symptoms. CONCLUSIONS: Inconsistencies in the classification of mild stroke are evident with varying use of stroke severity assessments, measurement cutoff scores, imaging tools, and clinical or functional outcomes. Continued work is necessary to develop a consensus definition of mild stroke, which directly affects treatment receipt, referral for services, and health service delivery.

In-home contextual reality: a qualitative analysis using the Multiple Errands Test Home Version (MET-Home).

Adults with stroke frequently experience executive dysfunction. Despite the range of assessments that examine the effects of executive dysfunction on daily tasks, there remains a paucity of literature that examines the influence of the environment on performance in the community. The MET-Home is an ecologically valid assessment for examining post-stroke executive dysfunction in the home environment. This qualitative study explores the relationship between the environment and MET-Home performance among home-dwelling adults with stroke and matched controls. Using a descriptive qualitative approach, we analysed video, interview, and observation notes from a MET-Home validation study. An overarching theme of interplay between everyday task performance and the home environment produced further themes: naturalistically emerging supports and barriers and environment as strategy. Within naturalistically emerging supports and barriers, five contextual sub-themes were discovered: physical environment, social environment, temporal context, virtual context, and personal context. Within environment as strategy, we identified four sub-themes: reducing distractions, using everyday technologies, planning in context, and seeking social support. These findings extend the conceptualisation of how we evaluate executive dysfunction in the context of the community to also consider the inherent influence of the environment.

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.

Development, Reliability, and Validity of the Multiple Errands Test Home Version (MET-Home) in Adults With Stroke.

OBJECTIVE: Our objective was to perform initial psychometric analysis of the Multiple Errands Test Home Version (MET-Home), which was designed to assess the influence of poststroke executive dysfunction on in-home task performance. METHOD: We examined the reliability and validity of the MET-Home in adults with stroke (n = 23) and individually matched control participants (n = 23). All participants completed a series of assessments during a single in-home visit. RESULTS: Notable differences in MET-Home subscores were discovered between participants with stroke and control participants. Participants with stroke omitted more tasks, broke more rules, passed by tasks more often, and were less efficient than matched control participants. The MET-Home demonstrated evidence of adequate internal consistency, excellent interrater reliability, and significant moderate associations with several tests. CONCLUSION: This preliminary study suggests that the MET-Home differentiates between adults with stroke and matched control participants. The MET-Home provides evidence of initial reliability and validity among adults with stroke.

Classification of Mild Stroke: A Mapping Review.

Persons with mild stroke experience motor and cognitive impairments that negatively affect their health and quality of life. To address these deficits, it is essential for clinicians and researchers to precisely identify mild stroke survivors. Despite the fact that half of all strokes are categorized as mild, no standards exist on what constitutes a "mild" stroke. The purpose of this study is to summarize the current classification of mild stroke using a mapping review approach. Strategies to categorize "mild stroke" severity were explored in 188 papers indexed in the PubMed database. The results indicate that there was substantial variability in the procedures and scoring criteria used to determine mild stroke. To identify persons with mild stroke, researchers have largely applied assessment instruments developed to inform acute stroke care (eg, National Institutes of Health Stroke Scale, Modified Rankin Scale, Barthel Index). Unfortunately, these approaches demonstrate floor effects and fail to detect the long-term disabling impairments that often limit the outcomes of mild stroke survivors. Additional research is warranted to suggest an evidence-based mild stroke categorization strategy that enhances diagnosis, treatment, and referral decisions to the benefit of mild stroke survivors.

Racial and ethnic disparities in stroke outcomes: a scoping review of post-stroke disability assessment tools.

Purpose: To identify how post-stroke disability outcomes are assessed in studies that examine racial/ethnic disparities and to map the identified assessment content to the International Classification of Functioning, Disability, and Health (ICF) across the time course of stroke recovery. Methods: We conducted a scoping review of the literature. Articles published between January 2001 and July 2017 were identified through Scopus, PubMed, CINAHL, and PsycINFO according to predefined inclusion and exclusion criteria. Results: We identified 1791 articles through database and hand-searching strategies. Of the articles, 194 met inclusion criteria for full-text review, and 41 met inclusion criteria for study inclusion. The included studies used a variety of outcome measures encompassing domains within the ICF: body functions, activities, participation, and contextual factors across the time course of stroke recovery. We discovered disproportionate representation among racial/ethnic groups in the post-stroke disability disparities literature. Conclusions: A wide variety of assessments are used to examine disparities in post-stroke disability across the time course of stroke recovery. Several studies have identified disparities through a variety of assessments; however, substantial problems abound from the assessments used including inconsistent use of assessments, lacking evidence on the validity of assessments among racial/ethnic groups, and inadequate representation among all racial/ethnic populations comprising the US. Implications for Rehabilitation An enhanced understanding of racial/ethnic disparities in post-stroke disability outcomes is inherently important among rehabilitation practitioners who frequently engage with racial/ethnic minority populations across the time course of stroke recovery. Clinicians should carefully consider the psychometric properties of assessment tools to counter potential racial bias. Clinicians should be aware that many assessments used in stroke rehabilitation lack cultural sensitivity and could result in inaccurate assessment findings.

Racial and ethnic differences in post-stroke subjective cognitive decline exist.

BACKGROUND: Racial and ethnic minorities consistently demonstrate disparate post-stroke outcomes. However, there is a paucity of literature related to whether this disparity exists specifically in post-stroke cognitive decline. OBJECTIVE: To determine if racial and ethnic disparities exist in post-stroke subjective cognitive decline (SCD) among non-Hispanic Blacks (Blacks), American Indians or Alaska Natives (AI/ANs), Hispanics, and non-Hispanic Whites (Whites) in the United States using data from the Behavioral Risk Factor Surveillance System (BRFSS). METHODS: A retrospective analysis was completed using the 2016 BRFSS data in adults who self-reported stroke and SCD. Descriptive statistics were completed for baseline comparisons using chi squared tests for categorical variables. A binary logistic regression controlling for baseline differences was completed to examine racial and ethnic differences in SCD. RESULTS: Significant differences in SCD were identified across all racial and ethnic groups. When compared to Whites, Blacks, AI/ANs, and Hispanics more frequently reported worsening confusion or memory loss that interfered with day-to-day activities and the ability to work, volunteer, and engage in social activities outside of the home. AI/ANs who reported SCD were more likely than Whites to have help available. Hispanic persons with SCD or their family members were most likely to discuss SCD with a healthcare provider. CONCLUSION: Although persons from all racial and ethnic groups in this study experienced some degree of SCD, Blacks, AI/ANs, and Hispanics most frequently reported worsening confusion or memory loss impacting engagement in day-to-day activities and the ability to work, volunteer, and engage in social activities outside of the home.

Interdisciplinary Approaches to Facilitate Return to Driving and Return to Work in Mild Stroke: A Position Paper.

Adults with mild stroke face substantial challenges resuming valued roles in the community. The term "mild" provides false representation of the lived experience for many adults with mild stroke who may continue to experience persistent challenges and unmet needs. Rehabilitation practitioners can identify and consequently intervene to facilitate improved independence, participation, and quality of life by facilitating function and reducing the burden of lost abilities among adults with mild stroke. The Health and Wellness Task Force identified 2 important, and often interdependent, goals that frequently arise among adults living with mild stroke that must be addressed to facilitate improved community reintegration: (1) return to driving and (2) return to work. Adults with mild stroke may not be receiving adequate rehabilitative services to facilitate community reintegration for several reasons but primarily because current practice models are not designed to meet such needs of this specific population. Thus, the Health and Wellness Task Force convened to review current literature and practice trends to (1) identify opportunities based on the evidence of assessment and interventions, for return to driving and return to work; and (2) identify gaps in the literature that must be addressed to take advantage of the opportunities. Based on findings, the task force proposes a new interdisciplinary practice model for adults with mild stroke who are too often discharged from the hospital to the community without needed services to enable successful return to driving and work.

Sex Differences in Patient-Reported Poststroke Disability.

BACKGROUND: Recent studies have shown that stroke has a differential impact in women compared to men. Women are more likely to survive strokes than men, yet they experience more severe strokes resulting in greater poststroke disability. However, few studies have characterized sex differences in functional ability after stroke. This study examined sex differences in long-term disability among stroke survivors. METHODS: This was a retrospective analysis of the 2015 National Health Interview Survey. Respondents were asked to rate their ability to perform 11 functional tasks. Univariate comparisons were completed to evaluate sex differences in performance, and multinomial logistic regression was used to determine the odds of reporting functional limitations. RESULTS: Five hundred fourteen men and 641 women stroke survivors completed the survey (mean age: 66.9 years). Approximately 75% of the sample reported having hypertension, 61% high cholesterol, 33% diabetes, 24% heart disease, 21% heart attack, and 16% chronic obstructive pulmonary disease. In the predictive models, men were less likely to report "very difficult/can't do at all" in walking » mile (odds ratios [OR] = 0.68, 95% CI 0.51-0.90), climbing 10 steps (OR = 0.65, 95% CI 0.49-0.85), standing 2 hours (OR = 0.66, 95% CI 0.50-0.87), stooping (OR = 0.51, 95% CI 0.39-0.68), reaching overhead (OR = 0.69, 95% CI 0.49-0.97), carrying 10 pounds (OR = 0.45, 95% CI 0.34-0.59), and pushing large objects (OR = 0.37, 95% CI 0.28-0.5) compared to women. CONCLUSIONS: The functional outcomes of men stroke survivors were significantly greater than women. The specific factors that contribute to sex differences in stroke-related outcomes are not entirely clear. Future research is needed to better understand these differences to ensure that equity of care is received.

Embedding technology into inter-professional best practices in home safety evaluation.

PURPOSE: To explore inter-professional home evaluators' perspectives and needs for building useful and acceptable decision-support tools for the field of home modifications. METHOD: Twenty semi-structured interviews were conducted with a range of home modification professionals from different regions of the United States. The interview transcripts were analyzed with a qualitative, descriptive, perspective approach. RESULTS: Technology supports current best practice and has potential to inform decision making through features that could enhance home evaluation processes, quality, efficiency and inter-professional communication. CONCLUSIONS: Technological advances with app design have created numerous opportunities for the field of home modifications. Integrating technology and inter-professional best practices will improve home safety evaluation and intervention development to meet client-centred and societal needs. Implications for rehabilitation Understanding home evaluators technology needs for home safety evaluations contributes to the development of app-based assessments. Integrating inter-professional perspectives of best practice and technological needs in an app for home assessments improves processes. Novice and expert home evaluators would benefit from decision support systems embedded in app-based assessments. Adoption of app-based assessment would improve efficiency while remaining client-centred.