Gait pattern after electromechanically-assisted gait training with the Hybrid Assistive Limb and conventional gait training in sub-acute stroke rehabilitation-A subsample from a randomized controlled trial.

Introduction: Electromechanically-assisted gait training has been introduced in stroke rehabilitation as a means to enable gait training with a large number of reproducible and symmetrical task repetitions, i.e. steps. However, few studies have evaluated its impact on gait pattern functions. This study includes persons with no independent ambulation function at the start of a 4-week neurorehabilitation period in the sub-acute phase after stroke. The primary aim of the study was to evaluate whether the addition of electromechanically-assisted gait training to conventional training resulted in better gait pattern function than conventional training alone. The secondary aim was to identify correlations between overall gait quality and standardized clinical assessments. Participants and methods: Seventeen patients with no independent ambulation function who participated in a Prospective Randomized Open Blinded End-point study in the sub-acute phase after stroke were randomized into two groups; one group (n = 7) to undergo conventional training only (CONV group) and the other group (n = 10) to undergo conventional training with additional electromechanically-assisted gait training (HAL group). All patients were assessed with 3D gait analysis and clinical assessments after the 4-week intervention period. Overall gait quality as per the Gait Profile Score (GPS), as well as kinematic, and kinetic and other spatiotemporal metrics were collected and compared between intervention groups. Correlations between biomechanical and clinical outcomes were evaluated. Results: Both the CONV and HAL groups exhibited similar gait patterns with no significant differences between groups in any kinematic, kinetic parameters or other spatiotemporal metrics. The GPS for the paretic limb had a median (IQR) of 12.9° (7.8°) and 13.4° (4.3°) for the CONV and HAL groups, respectively (p = 0.887). Overall gait quality was correlated with independence in walking, walking speed, movement function and balance. We found no added benefit in gait pattern function from the electromechanically-assisted gait training compared to the conventional training alone. Discussion: This finding raises new questions about how to best design effective and optimal post-stroke rehabilitation programs in patients with moderate to severe gait impairments to achieve both independent walking and optimal gait pattern function, and about which patients should be in focus in further studies on the efficacy of electromechanically-assisted gait training. Clinical trial registration: The study was retrospectively registered at ClinicalTrials.gov, identifier (NCT02410915) on April 2015.

The impact of visuospatial and executive function on activity performance and outcome after robotic or conventional gait training, long-term after stroke-as part of a randomized controlled trial.

INTRODUCTION: Visuospatial and executive impairments have been associated with poor activity performance sub-acute after stroke. Potential associations long-term and in relation to outcome of rehabilitation interventions need further exploration. AIMS: To explore associations between visuospatial and executive function and 1) activity performance (mobility, self-care and domestic life) and 2) outcome after 6 weeks of conventional gait training and/or robotic gait training, long term (1-10 years) after stroke. METHODS: Participants (n = 45), living with stroke affecting walking ability and who could perform the items assessing visuospatial/executive function included in the Montreal Cognitive Assessment (MoCA Vis/Ex) were included as part of a randomized controlled trial. Executive function was evaluated using ratings by significant others according to the Dysexecutive Questionnaire (DEX); activity performance using 6-minute walk test (6MWT), 10-meter walk test (10MWT), Berg balance scale, Functional Ambulation Categories, Barthel Index and Stroke Impact Scale. RESULTS: MoCA Vis/Ex was significantly associated with baseline activity performance, long-term after stroke (r = .34-.69, p < .05). In the conventional gait training group, MoCA Vis/Ex explained 34% of the variance in 6MWT after the six-week intervention (p = 0.017) and 31% (p = 0.032) at the 6 month follow up, which indicate that a higher MoCA Vis/Ex score enhanced the improvement. The robotic gait training group presented no significant associations between MoCA Vis/Ex and 6MWT indicating that visuospatial/executive function did not affect outcome. Rated executive function (DEX) presented no significant associations to activity performance or outcome after gait training. CONCLUSION: Visuospatial/executive function may significantly affect activity performance and the outcome of rehabilitation interventions for impaired mobility long-term after stroke and should be considered in the planning of such interventions. Patients with severely impaired visuospatial/executive function may benefit from robotic gait training since improvement was seen irrespective of visuospatial/executive function. These results may guide future larger studies on interventions targeting long-term walking ability and activity performance. TRIAL REGISTRATION: clinicaltrials.gov (NCT02545088) August 24, 2015.

Users' experiences of intensive robotic-assisted gait training post-stroke - "a push forward or feeling pushed around?"

PURPOSE: Robotic-assisted gait training (RAGT) is suggested to improve walking ability after stroke. The purpose of this study was to describe experiences of robotic-assisted gait training as part of a gait training intervention among persons in the chronic phase after stroke. MATERIALS AND METHODS: Semi-structured interviews were performed with 13 participants after a 6-week intervention including treadmill gait training with the Hybrid Assistive Limb® (HAL) exoskeleton. Data were analysed using qualitative content analysis. RESULTS: Four categories emerged: (1) A rare opportunity for potential improvements describes the mindset before the start of the intervention; (2) Being pushed to the limit represents the experience of engaging in intensive gait training; (3) Walking with both resistance and constraints reveals barriers and facilitators during HAL training; (4) Reaching the end and taking the next step alone illustrates feelings of confidence or concern as the intervention ended. CONCLUSIONS: The gait training intervention including RAGT was considered demanding but appreciated. Support and concrete, individual feedback was crucial for motivation, whilst the lack of variation was a barrier. Results encourage further development of exoskeletons that are comfortable to wear and stimulate active participation by enabling smoothly synchronised movements performed during task-specific activities in different environments. IMPLICATIONS FOR REHABILITATIONWhen provided in a suitable context, the mental and physical challenges of intensive robotic-assisted gait training can be both inspiring and motivating.Support and engagement along with informative feedback from therapists are suggested crucial for motivation.Intensive task-specific gait training may preferably be performed in an enriched environment and combined with other physiotherapy treatments to stimulate engagement.

Effects of 60 Min Electrostimulation With the EXOPULSE Mollii Suit on Objective Signs of Spasticity.

Background: The EXOPULSE Mollii method is an innovative full-body suit approach for non-invasive electrical stimulation, primarily designed to reduce disabling spasticity and improve motor function through the mechanism of reciprocal inhibition. This study aimed to evaluate the effectiveness of one session of stimulation with the EXOPULSE Mollii suit at different stimulation frequencies on objective signs of spasticity and clinical measures, and the subjective perceptions of the intervention. Methods: Twenty patients in the chronic phase after stroke were enrolled in a cross-over, double-blind controlled study. Electrical stimulation delivered through EXOPULSE Mollii was applied for 60 min at two active frequencies (20 and 30 Hz) and in OFF-settings (placebo) in a randomized order, every second day. Spasticity was assessed with controlled-velocity passive muscle stretches using the NeuroFlexor hand and foot modules. Surface electromyography (EMG) for characterizing flexor carpi radialis, medial gastrocnemius, and soleus muscles activation, Modified Ashworth Scale and range of motion were used as complementary tests. Finally, a questionnaire was used to assess the participants' perceptions of using the EXOPULSE Mollii suit. Results: At group level, analyses showed no significant effect of stimulation at any frequency on NeuroFlexor neural component (NC) and EMG amplitude in the upper or lower extremities (p > 0.35). Nevertheless, the effect was highly variable at the individual level, with eight patients exhibiting reduced NC (>1 N) in the upper extremity after stimulation at 30 Hz, 5 at 20 Hz and 3 in OFF settings. All these patients presented severe spasticity at baseline, i.e., NC > 8 N. Modified Ashworth ratings of spasticity and range of motion did not change significantly after stimulation at any frequency. Finally, 75% of participants reported an overall feeling of well-being during stimulation, with 25% patients describing a muscle-relaxing effect on the affected hand and/or foot at both 20 and 30 Hz. Conclusions: The 60 min of electrical stimulation with EXOPULSE Mollii suit did not reduce spasticity consistently in the upper and lower extremities in the chronic phase after stroke. Findings suggest a need for further studies in patients with severe spasticity after stroke including repeated stimulation sessions. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04076878, identifier: NCT04076878.

Impact of Intensive Gait Training With and Without Electromechanical Assistance in the Chronic Phase After Stroke-A Multi-Arm Randomized Controlled Trial With a 6 and 12 Months Follow Up.

Introduction: Movement related impairments and limitations in walking are common long-term after stroke. This multi-arm randomized controlled trial explored the impact of training with an electromechanically assisted gait training (EAGT) system, i.e., the Hybrid Assistive Limb® (HAL), when integrated with conventional rehabilitation focused on gait and mobility. Material and Methods: Participants, aged 18-70 years with lower extremity paresis but able to walk with manual support or supervision 1-10 years after stroke, were randomized to (A) HAL-training on a treadmill, combined with conventional rehabilitation interventions (HAL-group), or (B) conventional rehabilitation interventions only (Conventional group), 3 days/week for 6 weeks, or (C) no intervention (Control group). Participants in the Control group were interviewed weekly regarding their scheduled training. Primary outcome was endurance in walking quantified by the 6 Minute Walk Test (6MWT). A rater blinded to treatment allocation performed assessments pre- and post-intervention and at follow-ups at 6 and 12 months. Baseline assessment included the National Institute of Health Stroke Scale (NIHSS) and the Modified Ranking Scale (MRS). Secondary outcomes included the Fugl Meyer Assessment- Lower Extremity, 10 Meter Walk Test, Berg Balance Scale (BBS), Barthel Index (BI) and perceived mobility with the Stroke Impact Scale. Results: A total of 48 participants completed the intervention period. The HAL-group walked twice as far as the Conventional group during the intervention. Post-intervention, both groups exhibited improved 6 MWT results, while the Control group had declined. A significant improvement was only found in the Conventional group and when compared to the Control group (Tukey HSD p = 0.022), and not between the HAL group and Conventional group (Tukey HSD p = 0.258) or the HAL- group and the Control group (Tukey HSD p = 0.447). There was also a significant decline in the Conventional group from post-intervention to 6 months follow up (p = 0.043). The best fitting model to predict outcome included initial balance (BBS), followed by stroke severity (NIHSS), and dependence in activity and participation (BI and MRS). Conclusion: Intensive conventional gait training induced significant improvements long-term after stroke while integrating treadmill based EAGT had no additional value in this study sample. The results may support cost effective evidence-based interventions for gait training long-term after stroke and further development of EAGT. Trial registration: Published on clinicaltrials.gov (NCT02545088) August 24, 2015.

Feasibility and potential effects of using the electro-dress Mollii on spasticity and functioning in chronic stroke.

BACKGROUND: Spasticity after lesions of central motor pathways may be disabling and there is a need for new, cost-effective treatment methods. One novel approach is offered by the electro-dress Mollii®, primarily designed to enhance reciprocal inhibition of spastic muscles by multifocal, transcutaneous antagonist stimulation. METHODS: The Mollii® suit was set individually for 20 participants living with spasticity and hemiplegia after stroke and used in the home setting for 6 weeks. Usability and perceived effects were monitored by weekly telephone interviews. Outcome was assessed by use of the NeuroFlexor™ method for quantification of the neural component (NC) of resistance to passive stretch (spasticity), and the modified Ashworth scale (MAS) for total resistance, Fugl-Meyer Assessment of motor recovery for sensorimotor function in upper (FM-UE) and lower extremities (FM-LE), activity performance with the Action Research Arm Test (ARAT), Berg balance scale, 10 m and 6 min walk tests, and perceived functioning with the Stroke Impact Scale. RESULTS: Compliance was high (mean 19.25 of 21 sessions). Perceived positive effects were reported by 60% and most commonly related to decreased muscle tone (n = 9), improved gait pattern function (n = 7) and voluntary movement in the upper extremity (n = 6). On a group level, the NC decreased significantly in the wrist flexors of the affected hand (p = 0.023) and significant improvements according to FM-UE (p = 0.000) and FM-LE (p = 0.003) were seen after the intervention. No significant difference was detected with MAS or assessed activity performance, except for the ARAT (p = 0.000). FM-UE score change correlated significantly and fairly with the perceived effect in the upper extremity (r 0.498 p = 0.025) and in the corresponding analysis for the FM-LE and perceived effect in the lower extremity (r = 0.469 p = 0.037). CONCLUSION: This study indicates that the Mollii® method is feasible when used in the home setting to decrease spasticity and improve sensorimotor function. The results may guide a larger controlled study combined with rehabilitation interventions to enhance effects on activity and participation domains. TRIAL REGISTRATION: NCT04076878 . Registered 2 September 2019 - Retrospectively registered.

A randomized controlled study incorporating an electromechanical gait machine, the Hybrid Assistive Limb, in gait training of patients with severe limitations in walking in the subacute phase after stroke.

Early onset, intensive and repetitive, gait training may improve outcome after stroke but for patients with severe limitations in walking, rehabilitation is a challenge. The Hybrid Assistive Limb (HAL) is a gait machine that captures voluntary actions and support gait motions. Previous studies of HAL indicate beneficial effects on walking, but these results need to be confirmed in blinded, randomized controlled studies. This study aimed to explore effects of incorporating gait training with HAL as part of an inpatient rehabilitation program after stroke. Thirty-two subacute stroke patients with severe limitations in walking were randomized to incorporated HAL training (4 days/week for 4 weeks) or conventional gait training only. Blinded assessments were carried out at baseline, after the intervention, and at 6 months post stroke. The primary outcome was walking independence according to the Functional Ambulation Categories. Secondary outcomes were the Fugl-Meyer Assessment, 2-Minute Walk Test, Berg Balance Scale, and the Barthel Index. No significant between-group differences were found regarding any primary or secondary outcomes. At 6 months, two thirds of all patients were independent in walking. Prediction of independent walking at 6 months was not influenced by treatment group, but by age (OR 0.848, CI 0.719-0.998, p = 0.048). This study found no difference between groups for any outcomes despite the extra resources required for the HAL training, but highlights the substantial improvements in walking seen when evidence-based rehabilitation is provided to patients, with severe limitations in walking in the subacute stage after stroke. In future studies potential subgroups of patients who will benefit the most from electromechanically-assisted gait training should be explored.

Factors affecting the usability of an assistive soft robotic glove after stroke or multiple sclerosis.

OBJECTIVE: To explore the usability and effects of an assistive soft robotic glove in the home setting after stroke or multiple sclerosis. DESIGN: A mixed methods design. METHODS: Participants with stroke (n = 10) or multiple sclerosis (n = 10) were clinically assessed, and instructed to use the glove in activities of daily living for 6 weeks. They reported their experience of using the glove via weekly telephone interviews and one semi-structured interview. RESULTS: The soft robotic glove was used by participants in a wide variety of activities of daily living. Perceived beneficial effects while using the glove were a sustained and a strong grip. Disadvantages of using the glove were a lack of assistance in hand opening function and the glove not being usable for fine hand use. The glove was found to be useful by two-thirds of participants who completed the study, mainly by participants with moderate limitations in hand activity and an overall level of functioning that allowed participation in everyday life activities. CONCLUSION: This study identified a subgroup of participants, who found the glove useful in activities requiring a strong and prolonged grip but not fine hand use, and highlights aspects for consideration in the further development of soft hand robotics for sustained use in a larger population living with a central nervous system lesion.

Self-perceived functioning and disability after randomized conventional and electromechanically-assisted gait training in subacute stroke: A 6 months follow-up.

BACKGROUND: Few previous studies have assessed self-perceived functioning, disability and recovery after electromechanically-assisted gait training (EAGT). OBJECTIVE: To compare self-perceived functioning, disability and recovery after EAGT and after conventional gait training in the subacute stage after stroke, using the Stroke Impact Scale (SIS), and factors associated with self-perceived recovery, assessed at 6 months after stroke. METHODS: Patients were randomized into two groups performing a 4-week intervention period of incorporated EAGT using the Hybrid Assistive Limb (HAL) or conventional physiotherapy only. RESULTS: There were no significant differences in self-perceived strength, ADL, mobility, participation and percentage of recovery between intervention groups (p > 0.05). Self-perceived mobility was associated with improvements in objectively assessed walking speed/endurance and balance (R2 0.717, p = 0.002), and self-perceived recovery with self-perceived activities of daily living (ADL) ability (R2 0.34, p = 0.001). CONCLUSIONS: This study indicates that EAGT and conventional gait training in the subacute stage after stroke have no differential impact on self-perceived functioning, disability and recovery at 6 months after stroke. Further, the study highlights the importance of interventions targeting ADL and self-care independence during stroke rehabilitation to enhance self-perceived recovery and clinical aspects to be targeted to enhance perceived mobility.

Development and validation of the Swedish national stroke register Riksstroke's questionnaires in patients at 3 and 12 months after stroke: a qualitative study.

OBJECTIVES: Because healthcare and community organisations and treatment methods are always changing, continuous changes might also be needed in questionnaires that register patient-reported outcomes (PRO) and patient-reported experiences (PRE) of healthcare interventions and community support. Thus, the aim of this study was to test the content and face validity, including the readability, of two questionnaires used by the Swedish national stroke register Riksstroke to register PRO and PRE at 3 and 12 months poststroke. DESIGN: Clinicians' and patients' knowledge and experiences of current care, rehabilitation, community support and functioning after stroke as well as comments noted regarding the content and layout of the questionnaires were retrieved in focus-groups with expert clinicians and in patient interviews analysed with content analysis. A workgroup of experts with experience in stroke care, rehabilitation and research repeatedly revised the questionnaires regarding content, layout and consistency throughout the validation process. PARTICIPANTS: The participants included allied healthcare professionals, nurses and physicians with extensive experience of working with stroke care and rehabilitation (expert clinicians) as well as patients who had suffered a stroke 3 or 12 months earlier and who were purposefully selected among those who had completed and returned the 3-month questionnaire. SETTING: Expert clinicians met at their work place in focus-groups. Patients were interviewed where they resided, that is, in their home or nursing home, including rural, town and city areas in Sweden. RESULTS: Based on clinical expertise and comments from the patients (n=47), the questionnaires were revised and then found to be valid in terms of content validity and face validity, including readability. CONCLUSIONS: The present evaluation emphasises the need for testing aspects of validity, including readability, of questionnaires addressing PRO and PRE and for the recurrent revision of such questionnaires in order to maintain their validity in a society undergoing constant change.

An interactive distance solution for stroke rehabilitation in the home setting - A feasibility study.

BACKGROUND: In this study an interactive distance solution (called the DISKO tool) was developed to enable home-based motor training after stroke. OBJECTIVES: The overall aim was to explore the feasibility and safety of using the DISKO-tool, customized for interactive stroke rehabilitation in the home setting, in different rehabilitation phases after stroke. METHODS: Fifteen patients in three different stages in the continuum of rehabilitation after stroke participated in a home-based training program using the DISKO-tool. The program included 15 training sessions with recurrent follow-ups by the integrated application for video communication with a physiotherapist. Safety and feasibility were assessed from patients, physiotherapists, and a technician using logbooks, interviews, and a questionnaire. Qualitative content analysis and descriptive statistics were used in the analysis. RESULTS: Fourteen out of 15 patients finalized the training period with a mean of 19.5 minutes spent on training at each session. The DISKO-tool was found to be useful and safe by patients and physiotherapists. CONCLUSIONS: This study demonstrates the feasibility and safety of the DISKO-tool and provides guidance in further development and testing of interactive distance technology for home rehabilitation, to be used by health care professionals and patients in different phases of rehabilitation after stroke.

Developing Leadership in Managers to Facilitate the Implementation of National Guideline Recommendations: A Process Evaluation of Feasibility and Usefulness.

BACKGROUND: Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers' leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention's potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation. METHODS: Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a four-month leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention. RESULTS: Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation. CONCLUSION: Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers' behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations.

Assessing feasibility and acceptability of study procedures: getting ready for implementation of national stroke guidelines in out-patient health care.

BACKGROUND: Even though Swedish national guidelines for stroke care (SNGSC) have been accessible for nearly a decade access to stroke rehabilitation in out-patient health care vary considerably. In order to aid future interventions studies for implementation of SNGSC, this study assessed the feasibility and acceptability of study procedures including analysis of the context in out-patient health care settings. METHODS: The feasibility and acceptability of recruitment, observations and interviews with managers, staff and patients were assessed, as well as the feasibility of surveying health care records. RESULTS: To identify patients from the the hospitals was feasible but not from out-patient care where a need to relieve clinical staff of the recruitment process was identified. Assessing adherence to guidelines and standardized evaluations of patient outcomes through health care records was found to be feasible and suitable assessment tools to evaluate patient outcome were identified. Interviews were found to be a feasible and acceptable tool to survey the context of the health care setting. CONCLUSION: In this feasibility study a variety of qualitative and quantitative data collection procedures and measures were tested. The results indicate what can be used as a set of feasible and acceptable data collection procedures and suitable measures for studying implementation of stroke guidelines in an out-patient health care context.

Users perspectives on interactive distance technology enabling home-based motor training for stroke patients.

The aim of this work has been to develop a technical support enabling home-based motor training after stroke. The basis for the work plan has been to develop an interactive technical solution supporting three different groups of stroke patients: (1) patients with stroke discharged from hospital with support from neuro team; (2) patients with stroke whose support from neuro team will be phased out and (3) patients living with impaired motor functions long-term. The technology has been developed in close collaboration with end-users using a method earlier evaluated and described [12]. This paper describes the main functions of the developed technology. Further, results from early user-tests with end-users, performed to identify needs for improvements to be carried out during further technical development. The developed technology will be tested further in a pilot study of the safety and, usefulness of the technology when applied as a support for motor training in three different phases of the post-stroke rehabilitation process.

Clinical application of the Hybrid Assistive Limb (HAL) for gait training-a systematic review.

OBJECTIVE: The aim of this study was to review the literature on clinical applications of the Hybrid Assistive Limb system for gait training. METHODS: A systematic literature search was conducted using Web of Science, PubMed, CINAHL and clinicaltrials.gov and additional search was made using reference lists in identified reports. Abstracts were screened, relevant articles were reviewed and subject to quality assessment. RESULTS: Out of 37 studies, 7 studies fulfilled inclusion criteria. Six studies were single group studies and 1 was an explorative randomized controlled trial. In total, these studies involved 140 participants of whom 118 completed the interventions and 107 used HAL for gait training. Five studies concerned gait training after stroke, 1 after spinal cord injury (SCI) and 1 study after stroke, SCI or other diseases affecting walking ability. Minor and transient side effects occurred but no serious adverse events were reported in the studies. Beneficial effects on gait function variables and independence in walking were observed. CONCLUSIONS: The accumulated findings demonstrate that the HAL system is feasible when used for gait training of patients with lower extremity paresis in a professional setting. Beneficial effects on gait function and independence in walking were observed but data do not allow conclusions. Further controlled studies are recommended.

Young individuals with stroke: a cross sectional study of long-term disability associated with self-rated global health.

BACKGROUND: Perceived disability after stroke may persist long-term even among young individuals with mild stroke and may be related to age-related expectations of health and recovery. Thus, in order to appreciate the magnitude of perceived disability in a younger stroke population studies are needed to explore perceived health-related differences between young individuals with stroke and a matched general population. Further, to provide long-term measures by health care, relevant to the same young individuals with stroke, their perceived long-term functioning and disability associated with health need to be explored. METHODS: The generic questionnaire EQ-5D was used to compare ratings of global health and disability between young individuals living in the community up to 6 years after stroke (n = 150) and an age and geographically matched general population (n = 2661). Stroke related medical data were retrieved from medical records and the study specific questionnaire, the MYS-questionnaire, was used to assess self-rated disability associated with global health. RESULTS: Among the young individuals 79% had suffered a mild stroke, 45% rated a low global health compared to 15% of the matched general population and a higher proportion rated problems in mobility, self-care, usual activities and anxiety/depression. Among the young individuals with stroke, limitations and restrictions in leisure activities, work, reading as well as low level of physical activity, utilizing personal care provider or personal assistance and tiredness were negatively associated with self-rated global health (R square 0.60). CONCLUSION: The negative effects of stroke, on self-rated global health among young individuals living in the community, appear to be substantial, multi factorial and long-standing which call for interdisciplinary research collaborations and team measures by health care long-term.

Differences between younger and older individuals in their use of care and rehabilitation but not in self-perceived global recovery 1year after stroke.

BACKGROUND: Although priorities in Swedish stroke care should be based on the ethical principles of equal care and greatest support to those in greatest need, being of working age (younger) or retired (older) might influence expectations on recovery and the provision of care and rehabilitation. METHOD: Information regarding the use of care and rehabilitation during the 1st year after stroke was retrieved from the Stockholm County Council database and the medical data was taken from the medical records. The Barthel Index was used for self-ratings of dependence pre-stroke, and the Stroke Impact Scale was used to assess self-perceived disability and a global rating of recovery at 12 months. One hundred and ninety-two individuals were included. RESULTS: Results showed that the younger group received more care and rehabilitation than the older group. In the older group, comorbid conditions and pre-stroke dependence, estimated in accordance with the Barthel Index, were more common. The older group reported larger impact on self-perceived disability regarding strength, mobility, self-care and domestic life, while self-perceived global recovery did not differ between the groups. CONCLUSION: Younger individuals received more care and rehabilitation, which indicates structural inequality in the provision of health care resources. However, as no difference in self-perceived global recovery was found between the groups; the disparity in the provision of health care may also be a consequence of greatest support being given to those in greatest need. By demonstrating the necessity of involving self-rated assessments of stroke impact at different points in time and in different age groups, the results of this study add to previous knowledge of age-related differences in the provision of health care and stroke outcome. Furthermore, this suggests a way to approach evaluation of equality in the provision of health care.

Long-term health states relevant to young persons with stroke living in the community in southern Stockholm - a study of self-rated disability and predicting factors.

PURPOSE: The purpose was to explore self-rated long-term disability and to analyze whether initial stroke-related, personal and environmental factors can predict disability in a population-based sample of community-dwelling young (<65 years) persons suffering a stroke in 2000-2006. METHOD: Data on initial stroke-related, personal and environmental factors were retrieved from medical records. A study-specific posted questionnaire was used. RESULTS: Of the 158 young persons with stroke, 78% had suffered a mild stroke. Tiredness was the most commonly reported mental impairment (86%) followed by impaired memory (67%). A majority reported limitations/restrictions in returning to leisure activities (58%) and work (52%). Stroke-related, personal and environmental factors failed to predict self-reported mental and physical impairments, but predicted activity limitations/participation restrictions with an acceptable power of accuracy (0.70-0.73) but a low sensitivity (0.28-0.59). CONCLUSIONS: A majority of these young persons were diagnosed with a mild stroke but experienced long-term mental impairments and activity limitations/participation restrictions that could not be predicted by initial stroke-related, personal and environmental factors solely. Therefore, regular long-term assessments irrespective of initial stroke severity are warranted in order to identify disabilities and improve the state of health among young persons with stroke when needed.

Development, validity and reliability of a postal questionnaire assessing health states relevant to young persons with stroke in Sweden.

PURPOSE: The aim was to develop and test a postal questionnaire, the Swedish MYS questionnaire, for validity and reliability in order to survey health states relevant to young persons with stroke. METHOD: The questionnaire was designed with the International Classification of Functioning, Disability and Health as a frame and tested for content validity, face validity and readability by a group of experts including an occupational therapist, a physician, a physiotherapist, a psychologist, a speech and language therapist, a welfare officer and a selected sample of young persons with stroke (n = 15). To test the questionnaire for reliability in terms of stability a test-retest was performed on a selected sample of young persons (n = 20) with stroke. RESULTS: The questionnaire was found to be valid in terms of content validity, face validity and readability and finally consisted of 59 questions encompassing health states relevant to young persons with stroke. The questionnaire was stable in the test-retest (κ; 0.40-1.0) except for two questions and one alternative answer. CONCLUSION: The Swedish MYS questionnaire is a valid and reliable questionnaire that can be used in postal surveys of young persons with stroke except for two questions and one answering alternative, which need to be tested further.