Riding waves to improve functioning: a quantitative evaluation of a Surf Week in individuals with chronic phase brain injury with six months follow-up.

PURPOSE: Environmental enrichment seems to enable people in the chronic phase of acquired brain injury (ABI) to experience new functional abilities and motor/coping strategies and consequently to become more adaptable which might prevent/reverse functional decline. This study describes the influence of a five-days Surf Week program on participants on physical function, self-efficacy, functional balance performance and self-perceived recovery. MATERIALS AND METHODS: A multiple-baseline single-case design was used. Adults participating in the Surf Week in chronic phase of ABI were eligible to participate. Participants completed a battery of tests monitoring physical function, self-efficacy, functional balance performance and self-perceived recovery. This battery was repeated 5 times over a 1-year period, two times pre-Surf Week, three times post-Surf Week. Visual data inspection with two non-overlap methods were used to determine if patients showed sustained improvement in outcomes post-intervention. RESULTS: A moderate to strong indication for improvements on physical function, functional balance performance and self-perceived recovery exists till six months follow-up. No indication was observed on self-efficacy till six months follow-up. CONCLUSIONS: A five-days Surf Week is a physically, cognitively and socially intensive stimulating activity that can positively challenge individuals after ABI and seems to improve physical functioning, functional balance performance and self-perceived recovery.

Surf therapy, if appropriate measures are taken, is a safe yet physically, cognitively and socially intensive stimulating intervention that capitalizes on enriched environment principles, and might address the holistic needs in this population.Surf therapy might positively influence physical function, balance and self-perceived recovery in adults with acquired brain injury in the chronic phase.Rehabilitation professionals should experience/explore with their patients with acquired brain injury challenging (group) outdoors activities such as these, aiming to meet patients' needs, interests, or values in the chronic phase of recovery, and so create successfully participation in activities that capitalizes on enriched environment principles.

Effects of Continuous Positive Airway Pressure on Cognitive and Functional Outcome of Stroke Patients with Obstructive Sleep Apnea: A Randomized Controlled Trial.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) in stroke patients is associated with worse functional and cognitive status during inpatient rehabilitation. We hypothesized that a four-week period of continuous positive airway pressure (CPAP) treatment would improve cognitive and functional outcomes. METHODS: We performed a randomized controlled trial in stroke patients admitted to a neurorehabilitation unit. Patients were assigned to rehabilitation treatment as usual (control group) or to CPAP treatment (CPAP group). Primary outcomes were cognitive status measured by neuropsychological examination, and functional status measured by two neurological scales and a measure of activities of daily living (ADL). Secondary measures included sleepiness, sleep quality, fatigue, and mood. Tests were performed at baseline and after the four-week intervention period. RESULTS: We randomly assigned 20 patients to the CPAP group and 16 patients to the control group. The average CPAP compliance was 2.5 hours per night. Patients in the CPAP group showed significantly greater improvement in the cognitive domains of attention and executive functioning than the control group. CPAP compliance was associated with greater improvement in cognitive functioning. CPAP did not result in measurable improvement on measures of neurological status or ADL, or on any of the secondary measures. CONCLUSIONS: CPAP treatment improves cognitive functioning of stroke patients with OSA. COMMENTARY: A commentary on this article appears in this issue on page 467.

Obstructive Sleep Apnea is Related to Impaired Cognitive and Functional Status after Stroke.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is a common sleep disorder in stroke patients and is associated with prolonged hospitalization, decreased functional outcome, and recurrent stroke. Research on the effect of OSA on cognitive functioning following stroke is scarce. The primary objective of this study was to compare stroke patients with and without OSA on cognitive and functional status upon admission to inpatient rehabilitation. DESIGN: Case-control study. SETTING AND PATIENTS: 147 stroke patients admitted to a neurorehabilitation unit. INTERVENTIONS: N/A. MEASUREMENTS: All patients underwent sleep examination for diagnosis of OSA. We assessed cognitive status by neuropsychological examination and functional status by two neurological scales and a measure of functional independence. RESULTS: We included 80 stroke patients with OSA and 67 stroke patients without OSA. OSA patients were older and had a higher body mass index than patients without OSA. OSA patients performed worse on tests of attention, executive functioning, visuoperception, psychomotor ability, and intelligence than those without OSA. No differences were found for vigilance, memory, and language. OSA patients had a worse neurological status, lower functional independence scores, and a longer period of hospitalization in the neurorehabilitation unit than the patients without OSA. OSA status was not associated with stroke type or classification. CONCLUSIONS: Obstructive sleep apnea (OSA) is associated with a lower cognitive and functional status in patients admitted for stroke rehabilitation. This underlines the importance of OSA as a probable prognostic factor, and calls for well-designed randomized controlled trials to study its treatability.

The effect of obstructive sleep apnea and treatment with continuous positive airway pressure on stroke rehabilitation: rationale, design and methods of the TOROS study.

BACKGROUND: Obstructive sleep apnea is a common sleep disorder in stroke patients. Obstructive sleep apnea is associated with stroke severity and poor functional outcome. Continuous positive airway pressure seems to improve functional recovery in stroke rehabilitation. To date, the effect of continuous positive airway pressure on cognitive functioning in stroke patients is not well established. The current study will investigate the effectiveness of continuous positive airway pressure on both cognitive and functional outcomes in stroke patients with obstructive sleep apnea. METHODS/DESIGN: A randomized controlled trial will be conducted on the neurorehabilitation unit of Heliomare, a rehabilitation center in the Netherlands. Seventy stroke patients with obstructive sleep apnea will be randomly allocated to an intervention or control group (n = 2×35). The intervention will consist of four weeks of continuous positive airway pressure treatment. Patients allocated to the control group will receive four weeks of treatment as usual. Outcomes will be assessed at baseline, immediately after the intervention and at two-month follow-up.In a supplementary study, these 70 patients with obstructive sleep apnea will be compared to 70 stroke patients without obstructive sleep apnea with respect to cognitive and functional status at rehabilitation admission. Additionally, the societal participation of both groups will be assessed at six months and one year after inclusion. DISCUSSION: This study will provide novel information on the effects of obstructive sleep apnea and its treatment with continuous positive airway pressure on rehabilitation outcomes after stroke. TRIAL REGISTRATION NUMBER: Dutch Trial Register NTR3412.

Can a prediction model combining self-reported symptoms, sociodemographic and clinical features serve as a reliable first screening method for sleep apnea syndrome in patients with stroke?

OBJECTIVE: To determine whether a prediction model combining self-reported symptoms, sociodemographic and clinical parameters could serve as a reliable first screening method in a step-by-step diagnostic approach to sleep apnea syndrome (SAS) in stroke rehabilitation. DESIGN: Retrospective study. SETTING: Rehabilitation center. PARTICIPANTS: Consecutive sample of patients with stroke (N=620) admitted between May 2007 and July 2012. Of these, 533 patients underwent SAS screening. In total, 438 patients met the inclusion and exclusion criteria. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We administered an SAS questionnaire consisting of self-reported symptoms and sociodemographic and clinical parameters. We performed nocturnal oximetry to determine the oxygen desaturation index (ODI). We classified patients with an ODI ≥15 as having a high likelihood of SAS. We built a prediction model using backward multivariate logistic regression and evaluated diagnostic accuracy using receiver operating characteristic analysis. We calculated sensitivity, specificity, and predictive values for different probability cutoffs. RESULTS: Thirty-one percent of patients had a high likelihood of SAS. The prediction model consisted of the following variables: sex, age, body mass index, and self-reported apneas and falling asleep during daytime. The diagnostic accuracy was .76. Using a low probability cutoff (0.1), the model was very sensitive (95%) but not specific (21%). At a high cutoff (0.6), the specificity increased to 97%, but the sensitivity dropped to 24%. A cutoff of 0.3 yielded almost equal sensitivity and specificity of 72% and 69%, respectively. Depending on the cutoff, positive predictive values ranged from 35% to 75%. CONCLUSIONS: The prediction model shows acceptable diagnostic accuracy for a high likelihood of SAS. Therefore, we conclude that the prediction model can serve as a reasonable first screening method in a stepped diagnostic approach to SAS in stroke rehabilitation.

Does clinical rehabilitation impose sufficient cardiorespiratory strain to improve aerobic fitness?

OBJECTIVE: To investigate the cardiorespiratory strain experienced by patients over a day and during different types of rehabilitation therapies during a clinical rehabilitation programme. In addition, to investigate the use of the Borg scale as an instrument to monitor exercise intensity. DESIGN: An observational, cross-sectional study. SETTING: Rehabilitation centre in the Netherlands. PARTICIPANTS: Eleven people after stroke (age range 20-71 years), 9 people with a lower limb amputation (age range 21-66 years) and 11 people with a spinal cord injury (age range 28-65 years). All participants were inpatients undergoing clinical rehabilitation. MAIN OUTCOME MEASURES: Frequency distribution of percentage heart rate reserve (%HRR) and length of time heart rate (HR) > 40%HRR over one day, and mean %HRR, length of time HR > 40%HRR and HR > 70%HRR during different types of rehabilitation therapies were compared with the American College of Sports Medicine guidelines for achieving an aerobic training effect. The correlation coefficient between the Borg scale score and %HRR was assessed. RESULTS: Patients' mean HR was 114 min/day (standard deviation 92) > 40%HRR, of which 1 h was spent in therapy. In 5 out of 10 rehabilitation therapies (fitness, hydrotherapy, walking group, wheelchair group and cycling/handbike group) a mean HR > 40%HRR was reached and more than half of the time was spent > 40%HRR. A moderate correlation (R = 0.56) was found between Borg scale score and %HRR. All outcome measures showed large variation between and within patients. CONCLUSION: In general, patients in a clinical rehabilitation programme experience adequate cardiorespiratory strain to potentially induce an aerobic training effect. The large variation in cardiorespiratory strain, however, necessitates individual monitoring to ensure proper exercise intensity. The Borg scale was shown to be of limited value for this monitoring, and therefore the use of HR monitors during rehabilitation should be considered.

Diagnostic accuracy of nocturnal oximetry for detection of sleep apnea syndrome in stroke rehabilitation.

BACKGROUND AND PURPOSE: Sleep apnea syndrome (SAS) is a common sleep disorder in stroke patients and is associated with decreased recovery and increased risk of recurrent stroke and mortality. The standard diagnostic test for SAS is poly(somno)graphy, but this is often not feasible in stroke rehabilitation settings. This study investigated the diagnostic value of nocturnal oximetry for screening SAS in stroke rehabilitation. METHODS: Fifty-six stroke patients underwent nocturnal polygraphy and oximetry. Sensitivity, specificity, and positive and negative predictive values for the oxygen desaturation index were calculated. Patient and sleep characteristics were used to develop a predictive model of apnea-hypopnea index. RESULTS: Forty-six percent of the stroke patients had SAS. The majority of SAS patients was male, older, and had a higher body mass index than patients without SAS. Sensitivity, specificity, and positive and negative predictive values for the oxygen desaturation index ≥15 were, respectively, 77%, 100%, 100%, and 83%. Oxygen desaturation index predicted 87% of the variance in the apnea-hypopnea index. Patient characteristics did not add significantly to the prediction model. CONCLUSIONS: Nocturnal oximetry is an accurate diagnostic screening instrument for the detection of SAS in stroke patients.