Perspectives on factors influencing quality of life in persons with long-term spinal cord injury: a qualitative study.

STUDY DESIGN: Qualitative Cohort Study. OBJECTIVES: Many people with long-term spinal cord injury (SCI) develop adaptation strategies to succeed. Understanding the factors that support their capacity to adapt and develop is important to enhance quality of life of others with SCI. This study aims to learn how these factors influence how people with SCI attain and maintain optimal quality of life as time since injury grows. SETTING: IL, USA. METHODS: A qualitative approach using one-on-one structured interviews with 16 individuals with long-term SCI was used to elicit perspectives of topics of importance. Analysis of these topics was done for the entire group, and for subgroups based on injury duration, i.e., 1-5 years, 5-15 years, and 15+ years post-injury. Deductive and inductive analyses of transcripts were performed. RESULTS: Five important themes emerged: 1. Injury, Medical Care, and Rehabilitation; 2. Built Environment and Accessibility; 3. Relationships and Support Systems; 4. Intrapersonal Thoughts and Emotions; and 5. Handling Challenges and Adversity. Topics of importance evolved over time. Most important were: 1-5 years: injury and recovery process; 5-15 years: navigating the community and how to handle difficult situations; and 15+ years: self-reflection and understanding how to handle challenges positively. CONCLUSIONS: Recognition of the factors (e.g. resilience, self-acceptance, built environment) that contribute to quality of life in people with SCI, and their prevalence over time, enables development of strategies to facilitate personal fulfillment and favorable adaptation at each stage. TRIAL REGISTRATION: This trial was posted on clinicaltrials.gov under NCT04544761.

Gait and Balance Outcome Measures Are Responsive in Severely Impaired Individuals Undergoing Inpatient Stroke Rehabilitation.

OBJECTIVE: To investigate whether gait and balance outcome measures in patients with severe gait and balance impairments at admission to inpatient rehabilitation provided additional and meaningful information beyond customary measures. Specifically, this study investigated whether individuals who obtained low scores at admission exhibited improvements that exceeded the established minimal detectable change during inpatient rehabilitation. We also investigated whether gait outcomes would capture changes in function not identified by customary measures. DESIGN: Secondary analysis of a knowledge translation project aimed at increasing the systematic collection of these outcome measures in a poststroke cohort. SETTING: Subacute inpatient rehabilitation facility. PARTICIPANTS: Individuals<2 months poststroke (N=157) with 34-43 with severe deficits including Berg Balance Scale≤5, 10-meter walk test=0 m/s, or 6-minute walk test=0 m. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Berg Balance Scale, 10-meter walk test, 6-minute walk test. RESULTS: After 1 week of rehabilitation, 41%-53% of severely impaired individuals had changes above minimal detectable changes in gait and balance outcomes, which increased to 68%-84% at discharge. Across the entire cohort, FIM locomotion scores failed to identify changes in gait function for 35% of participants after 1 week of rehabilitation. CONCLUSIONS: Routine assessment of gait and balance outcome measures in patients with severe deficits early poststroke may be beneficial. These measures were responsive after 1 week of rehabilitation and detected changes not captured by customary measures. Routine use of a standardized gait and balance assessments may provide clinicians with important information to guide clinical decision making.

Applying the Knowledge-to-Action Framework to Implement Gait and Balance Assessments in Inpatient Stroke Rehabilitation.

OBJECTIVES: The overall objectives of this project were to implement and sustain use of a gait assessment battery (GAB) that included the Berg Balance Scale, 10-meter walk test, and 6-minute walk test during inpatient stroke rehabilitation. The study objective was to assess the effect of the study intervention on clinician adherence to the recommendations and its effect on clinician perceptions and the organization. DESIGN: Pre- and post-training intervention study. SETTING: Subacute inpatient rehabilitation facility. PARTICIPANTS: Physical therapists (N=6) and physical therapist assistants (N=2). INTERVENTION: The intervention comprised a bundle of activities, including codeveloping and executing the plan with clinicians and leaders. The multicomponent implementation plan was based on the Knowledge-to-Action Framework and included implementation facilitation, implementation leadership, and a bundle of knowledge translation interventions that targeted barriers. Implementation was an iterative process in which results from one implementation phase informed planning of the next phase. MAIN OUTCOME MEASURES: Clinician administration adherence, surveys of perceptions, and organizational outcomes. RESULTS: Initial adherence to the GAB was 46% and increased to more than 85% after 6 months. These adherence levels remained consistent 48 months after implementation. Clinician perceptions of measure use were initially high (>63%), with significant improvements in knowledge and use of one measure after implementation. CONCLUSIONS: We successfully implemented the assessment battery with high levels of adherence to recommendations, likely because of using the bundle of knowledge translation activities, facilitation, and use of a framework to codevelop the plan. These changes in practice were sustainable, as determined by a 4-year follow-up.

Stepwise Regression and Latent Profile Analyses of Locomotor Outcomes Poststroke.

BACKGROUND AND PURPOSE: Previous data suggest patient demographics and clinical presentation are primary predictors of motor recovery poststroke, with minimal contributions of physical interventions. Other studies indicate consistent associations between the amount and intensity of stepping practice with locomotor outcomes. The goal of this study was to determine the relative contributions of these combined variables to locomotor outcomes poststroke across a range of patient demographics and baseline function. METHODS: Data were pooled from 3 separate trials evaluating the efficacy of high-intensity training, low-intensity training, and conventional interventions. Demographics, clinical characteristics, and training activities from 144 participants >1-month poststroke were included in stepwise regression analyses to determine their relative contributions to locomotor outcomes. Subsequent latent profile analyses evaluated differences in classes of participants based on their responses to interventions. RESULTS: Stepwise regressions indicate primary contributions of stepping activity on locomotor outcomes, with additional influences of age, duration poststroke, and baseline function. Latent profile analyses revealed 2 main classes of outcomes, with the largest gains in those who received high-intensity training and achieved the greatest amounts of stepping practice. Regression and latent profile analyses of only high-intensity training participants indicated age, baseline function, and training activities were primary determinants of locomotor gains. Participants with the smallest gains were older (≈60 years), presented with slower gait speeds (<0.40 m/s), and performed 600 to 1000 less steps/session. CONCLUSIONS: Regression and cluster analyses reveal primary contributions of training interventions on mobility outcomes in patients >1-month poststroke. Age, duration poststroke, and baseline impairments were secondary predictors. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02507466 and NCT01789853.

Influence of skill and exercise training parameters on locomotor recovery during stroke rehabilitation.

PURPOSE OF REVIEW: Research findings from the fields of motor learning and exercise physiology suggest specific training parameters that can be manipulated during physical rehabilitation profoundly influence skilled task performance. This review details the rationale for some of these training variables and their application in selected intervention studies focused on improving walking function in patients poststroke. RECENT FINDINGS: Basic and applied studies have shown that the amount, intensity, and variability of specific task practice applied during rehabilitation interventions can affect recovery of walking poststroke. Many studies detailing the effects of conventional, therapist, and mechanically assisted interventions may incorporate some of these training parameters but minimize others, and their relative contributions may influence walking outcomes. Specific patient factors, such as the stroke acuity and degree of impairments, appear to influence the relative contributions of these training variables, and different patient subgroups may benefit from greater emphasis on specific parameters. SUMMARY: The present findings suggest these training parameters should be considered when evaluating or implementing physical interventions directed toward improving locomotor function poststroke. More work is needed to understand their optimal combinations to maximize walking outcomes in patients with different levels of impairment poststroke.

Variable Intensive Early Walking Poststroke (VIEWS): A Randomized Controlled Trial.

BACKGROUND: Converging evidence suggests that the amount of stepping practice is an important training parameter that influences locomotor recovery poststroke. More recent data suggest that stepping intensity and variability are also important, although such strategies are often discouraged early poststroke. OBJECTIVE: The present study examined the efficacy of high-intensity, variable stepping training on walking and nonwalking outcomes in individuals 1 to 6 months poststroke as compared with conventional interventions. Methods Individuals with unilateral stroke (mean duration = 101 days) were randomized to receive ≤40, 1-hour experimental or control training sessions over 10 weeks. Experimental interventions consisted only of stepping practice at high cardiovascular intensity (70%-80% heart rate reserve) in variable contexts (tasks or environments). Control interventions were determined by clinical physical therapists and supplemented using standardized conventional strategies. Blinded assessments were obtained at baseline, midtraining, and posttraining with a 2-month follow-up. Results A total of 32 individuals (15 experimental) received different training paradigms that varied in the amount, intensity, and types of tasks performed. Primary outcomes of walking speed (experimental, 0.27 ± 0.22 m/s vs control, 0.09 ± 0.09 m/s) and distances (119 ± 113 m vs 30 ± 32 m) were different between groups, with stepping amount and intensity related to these differences. Gains in temporal gait symmetry and self-reported participation scores were greater following experimental training, without differences in balance or sit-to-stand performance. Conclusion Variable intensive stepping training resulted in greater improvements in walking ability than conventional interventions early poststroke. Future studies should evaluate the relative contributions of these training parameters.

Feasibility of Focused Stepping Practice During Inpatient Rehabilitation Poststroke and Potential Contributions to Mobility Outcomes.

BACKGROUND: Optimal physical therapy strategies to maximize locomotor function in patients early poststroke are not well established. Emerging data indicate that substantial amounts of task-specific stepping practice may improve locomotor function, although stepping practice provided during inpatient rehabilitation is limited (<300 steps/session). OBJECTIVE: The purpose of this investigation was to determine the feasibility of providing focused stepping training to patients early poststroke and its potential association with walking and other mobility outcomes. METHODS: Daily stepping was recorded on 201 patients <6 months poststroke (80% < 1 month) during inpatient rehabilitation following implementation of a focused training program to maximize stepping practice during clinical physical therapy sessions. Primary outcomes included distance and physical assistance required during a 6-minute walk test (6MWT) and balance using the Berg Balance Scale (BBS). Retrospective data analysis included multiple regression techniques to evaluate the contributions of demographics, training activities, and baseline motor function to primary outcomes at discharge. RESULTS: Median stepping activity recorded from patients was 1516 steps/d, which is 5 to 6 times greater than that typically observed. The number of steps per day was positively correlated with both discharge 6MWT and BBS and improvements from baseline (changes; r = 0.40-0.87), independently contributing 10% to 31% of the total variance. Stepping activity also predicted level of assistance at discharge and discharge location (home vs other facility). CONCLUSION: Providing focused, repeated stepping training was feasible early poststroke during inpatient rehabilitation and was related to mobility outcomes. Further research is required to evaluate the effectiveness of these training strategies on short- or long-term mobility outcomes as compared with conventional interventions.

Employment after stroke: report of a state of the science symposium.

For many stroke survivors, returning to work becomes an important emotional and functional milestone in signaling recovery. It can also provide needed financial support and reduce the burden placed on society in the form of government assistance. The complex nature of the return-to-work process involves many factors that may support or interfere with reintegration into the workforce. For the purpose of examining this important topic more closely, the Rehabilitation Research & Training Center on Enhancing the Functional and Employment Outcomes of Individuals Who Experience a Stroke held a State of the Science Symposium on employment after stroke on November 7, 2011, which was supported by the US Department of Education, National Institute on Disability and Rehabilitation Research. Six questions were posed to the symposium members, who developed research and policy recommendations to address the issues facing stroke survivors seeking to return to work.

Nutritional intake, body mass index, and activity in postacute traumatic brain injury: a preliminary study.

PURPOSE: In the United States, traumatic brain injury (TBI) remains a serious health problem contributing to lifelong disability. Little has been written about nutrition problems experienced postrehabilitation discharge. Our objective was to describe the nutrition and weight management characteristics of TBI survivors after discharge from rehabilitation and to identify characteristics of individuals at risk for weight control issues. METHOD/DESIGN: Twenty-six TBI survivors admitted to a freestanding rehabilitation hospital were followed for 1 year postdischarge. Data on height, weight, disability rating, diet and activity were collected at admission, 3, 6, 9 and 12 months after discharge. FINDINGS: Approximately 30% of the participants showed an increasing body mass index from discharge to 1-year follow up. Two patients had more complete long-term data and are highlighted. CONCLUSION/CLINICAL RELEVANCE: The case studies provide insight into the need for rehabilitation nurses to provide nutrition education to TBI survivors that will accommodate changes in lifestyle and activity after discharge.

Examination of selected clinical factors and medication use as risk factors for pneumonia during stroke rehabilitation: a case-control study.

OBJECTIVE: To assess the association of selected clinical factors and specific medication use (proton pump inhibitors, H2 receptor antagonists [H2 blockers], and angiotensin-converting enzyme inhibitors) with presence of pneumonia in patients with stroke undergoing acute inpatient rehabilitation. DESIGN: Matched case-control study in a freestanding urban academic inpatient acute rehabilitation hospital. Participants were 72 stroke survivors, consisting of 36 patients who developed pneumonia during rehabilitation hospitalization individually matched in order of decreasing priority on age, sex, stroke side, depth, and severity with 36 patients with stroke not developing pneumonia. Potential risk factors, including severe dysphagia, dietary interventions, presence of tracheostomy or feeding tube, and specific medications, were assessed for association with pneumonia during rehabilitation using separate univariate and multivariate analyses. Functional change was assessed using the functional independence measure. RESULTS: Although pneumonia was associated with proton pump inhibitors or H2 blockers (odds ratio, 3.3; 95% confidence interval, 1.0-13.7), any feeding tube (odds ratio: 5.0; 95% confidence interval, 1.4-27.0), severe dysphagia (odds ratio: 15.0; 95% confidence interval, 2.3-631), and tracheostomy (odds ratio: 10; 95% confidence interval, 1.4-434.0) on univariate evaluation, none of these individual factors was significantly associated with pneumonia in a multivariate model. Risk factors were found to be highly related to each other. Odds of pneumonia did not significantly decrease with angiotensin-converting enzyme inhibitors (odds ratio: 0.9; 95% confidence interval, 0.2-3.0). Patients with pneumonia had a significantly lower functional independence measure score at discharge. CONCLUSIONS: A reduction in pneumonia was not found with the use of angiotensin-converting enzyme inhibitors. Although tracheostomies, feeding tubes, proton pump inhibitor or H2 blocker use, and the presence of dysphagia were identified as risk factors for pneumonia on univariate analyses, none of these factors demonstrated an independent association with pneumonia on multivariate analyses. It may be more that the underlying impairment, rather than the assessed interventions, may confer greater risk of pneumonia in the poststroke patient.

Community skill performance and its association with the ability to perform everyday tasks by stroke survivors one year following rehabilitation discharge.

BACKGROUND: Stroke survivors experience functional loss in basic activities of daily living (ADLs) and in everyday community activities or instrumental activities of daily living (IADLs). Historically there has been a greater focus by rehabilitation professionals on basic ADLs than on IADLs. PURPOSE: The purpose of this study was to describe the relationship between the ability to perform ADLs and community activities in a large group of stroke patients measured 1 year following rehabilitation discharge. METHOD: A structured survey was administered by telephone. Outcome measures were the Frenchay Activities Index (FAI), a measure of IADL, and the FIM, a measure of disability. RESULTS: Visual inspection of the relationship between FAI scores and FIM scores revealed that the data largely followed a curvilinear pattern. Curve estimation regression models were used to determine the line of best fit. A cubic function was found to give a good fit with an R2 of 0.644. The three activities in which stroke patients most frequently engaged were social outings, walking outside for more than 15 minutes, and local shopping. The three activities in which stroke patients engaged the least were gainful work, gardening outside, and household/car maintenance. CONCLUSION: A score of approximately 80 or greater on the FIM was associated with a substantially increased level of participation in home and community activities.

Outcomes in two post-acute non-inpatient rehabilitation settings.

BACKGROUND: Although several attempts have been made to look into the "black box" of inpatient rehabilitation, little is known about therapy effectiveness in outpatient settings. METHOD: This study described the characteristics of 167 persons with stroke referred to one of two outpatient settings-a comprehensive rehabilitation program or a single modality outpatient clinic within one system of care; the services provided in each setting; and the relationship of patient and therapy characteristics to rehabilitation outcomes. RESULTS: Differences were found in the characteristics of persons referred to each setting and the amount and intensity of therapy provided. The amount of therapy provided was positively related to initial status (greater need results in more therapy), but better outcomes appeared to be more strongly related to the match between the need and amount of therapy provided than to the amount provided (more therapy does not necessarily result in better outcomes).

Delay in transfer to inpatient stroke rehabilitation: the role of acute hospital medical complications and stroke characteristics.

BACKGROUND: An increased delay between stroke onset and transfer to rehabilitation has been associated with poorer outcomes after stroke rehabilitation. PURPOSE: The purpose of this study was to examine the relationships between selected clinical factors and the interval from stroke onset to rehabilitation admission. METHOD: A cohort of 2,457 patients consecutively admitted for inpatient stroke rehabilitation was studied. Patient demographic data, stroke characteristics, stroke onset to rehabilitation admission interval (ORAI), and medical complications that occurred during the acute post-stroke hospitalization were documented. Univariate and multiple regression analyses were used to determine relationships between patient demographic data, stroke characteristics, and acute medical complications with ORAI. RESULTS: The average ORAI was 17.2 days, with a median of 12 days. Stroke characteristics and acute medical complications were the two groups of factors that were most strongly associated with longer ORAIs. These two groups each explained approximately 15.5% and 17.3% of the variance in the model, respectively. The most significant individual factors included the presence of an enteral feeding tube, a hemorrhagic stroke, a cortical stroke, pneumonia, urinary tract infection, and younger age at stroke onset. CONCLUSION: Although some medical problems associated with longer ORAI are functions of the severity of the stroke and patient characteristics, attention to preventable medical complications may be associated with a more rapid transition to the inpatient rehabilitation setting.

The effectiveness of anticoagulant and antiplatelet agents in preventing venous thromboembolism during stroke rehabilitation: a historical cohort study.

OBJECTIVE: To determine the effectiveness of anticoagulant and antiplatelet agents in preventing venous thromboembolism (VTE) during stroke rehabilitation. DESIGN: Historical cohort study. SETTING: Acute inpatient rehabilitation hospital. PARTICIPANTS: Consecutive patients (N=1506) with ischemic and hemorrhagic stroke admitted for rehabilitation. INTERVENTIONS: Documented use of anticoagulants (warfarin or anticoagulant doses of heparin), heparin in prophylactic doses, and antiplatelet agents. MAIN OUTCOME MEASURE: Occurrence of deep vein thrombosis detected by ultrasound or venography or pulmonary embolism detected by ventilation perfusion scan, spiral computed tomography, or pulmonary angiography. RESULTS: Fifty-eight VTE events occurred (3.9% incidence or 1.36 events per 1000 patient days), with higher risk in patients with severe stroke. Only therapeutic anticoagulation had a statistically significant protective effect for VTE risk in univariate analysis (odds ratio [OR]=.44; 95% confidence interval [CI],.20-.98). After adjusting for multiple medication use and other factors, including age, stroke onset to admission interval, length of rehabilitation stay, cause of stroke, and admission National Institutes of Health Stroke Scale score, therapeutic anticoagulation gave strong protection against VTE (OR=.37; 95% CI,.15-.88), followed by heparin (OR=.48; 95% CI,.23-.98) but not by antiplatelet agents (OR=.79; 95% CI,.40-1.57). No medications were associated with significant bleeding complications. CONCLUSIONS: Use of therapeutic anticoagulants or prophylactic heparin prevented VTE in stroke patients during inpatient rehabilitation.

Seven-year trends in stroke rehabilitation: patient characteristics, medical complications, and functional outcomes.

Studies of stroke trends have focused primarily on incidence, mortality, and hospitalization rates. There has been little evaluation of changes over time in the common patient characteristics, medical comorbidities, and functional outcomes of patients. The present study evaluated changes during a 7-year period. We found that while demographic variables, stroke severity, and most stroke characteristics remained relatively stable, disability levels at admission and discharge decreased and frequencies of both medical tube usage and many secondary medical complications increased over time. These changes have important implications for the clinical management of stroke patients in rehabilitation and for the organization and financing of stroke rehabilitation programs.

Reconceptualizing poststroke activity level using the Frenchay Activities Index.

Modifications of the Frenchay Activities Index were implemented in a study of postacute stroke rehabilitation outcomes. These modifications incorporated the prestroke activity levels and postrehabilitation goals and assessments of activity importance of 136 persons with stroke who received services in either a single modality or comprehensive outpatient rehabilitation setting. Prestroke activity levels were assessed retrospectively at admission to postacute rehabilitation, and current activity levels were assessed at discharge and 3 months post discharge. Prestroke activity levels were used to determine postrehabilitation goal attainment. Results showed that activities for which goals were less likely to be attained were more strenuous in nature, and activities for which goals were more likely to be attained were more sedentary in nature. The importance persons placed on specific activities was used to tailor the estimates of overall activity levels to reflect their importance to each person. Results showed that adjusting for importance decreased the estimate of prestroke activity level but had little effect on poststroke activity level. Incorporation of these modifications represents a reconceptualization of poststroke activity levels that clinicians can use to guide their selection of postacute rehabilitation therapy goals.