Redefining a minimal rehabilitation assessment protocol for severe acquired brain injuries.

BACKGROUND: The assessment of patients with severe Acquired Brain Injury (sABI) is mandatory in every phase and setting of care, and requires a multidimensional and interdisciplinary approach, to develop the individual rehabilitation project, and monitor long-term functional outcomes. In 2001 the Italian Society of Physical and Rehabilitation Medicine (SIMFER) published the minimal assessment protocol for traumatic sABI, providing a comprehensive, standardized functional assessment based on the International Classification of Functioning, Disability and Health (ICF), 2001. In 2007, a new protocol was published, extended to all sABI patients (PMGCA). In 2019, the SIMFER appointed a working group to provide a revised, updated version: the PMGCA2020. AIM: The purpose of this study was to describe the minimal assessment protocol to be applied at every stage and setting of the care process of patients with sABI. METHODS: The working group, including one neurologist and 11 physiatrists experts in sABI rehabilitation, performed a review of the international recommendations for sABI assessment focusing on the following key words: "sABI assessment," "sABI rehabilitation," "sABI prognostic factors," "sABI rehabilitation assessment," "sABI outcome," in MEDLINE. Revision and integration proposals by each member were written and motivated, discussed and voted. RESULTS: The PMGCA2020 is addressed to sABI adult patients. It investigates the main clinical problems of sABI at any time of the rehabilitation pathway. It includes a demographic/anamnestic section, a clinical/functional assessment section and an outcome measures section following the ICF model of functioning and the model of the construction of the rehabilitation project. CONCLUSIONS: The PMGCA2020 provides an updated tool for the multidimensional rehabilitation assessment of sABI patients, at any stage of the rehabilitation pathway. Further studies will allow the validation of this minimum set of variables paving the way to an assessment standardization of patients with sABI in the rehabilitation settings. CLINICAL REHABILITATION IMPACT: This minimum set of variables, defining patient's functioning and clinical status and outcomes, at every stage and setting of the care process to provide a framework for the standardization of the clinical evaluation of patients with sABI in rehabilitation settings.

Self-Management in Stroke Survivors: Development and Implementation of the Look after Yourself (LAY) Intervention.

OBJECTIVE: Self-management is recommended in stroke rehabilitation. This report aims to describe timing, contents, and setting of delivery of a patient-centered, self-management program for stroke survivors in their early hospital rehabilitation phase: the Look After Yourself (LAY) intervention. METHODS: After extensive literature search, the LAY intervention was developed by integrating the Chronic Disease Self-Management Program, based on the self-efficacy construct of social cognitive theory, with evidence-based key elements and input from stroke survivors. RESULTS: the LAY intervention aims to implement self-management skills in stroke survivors, enabling them to be active in goal setting and problem solving using action plans and to facilitate the critical transition from hospital to community. It includes both group sessions to facilitate sharing of experiences, social comparison, vicarious learning, and increase motivation and one-to-one sessions focused on setting feasible action plans and on teaching personalized strategies to prevent falls. Standardization is ensured by manuals for facilitators and patients. CONCLUSION: The LAY intervention is the first Italian program to support early self-management in stroke rehabilitation; it has been experimented and its efficacy proven in improving self-efficacy, mental health, and activities of daily living, and detailed results have been published. The LAY intervention is described according to the TIDieR checklist.

Redefining a minimal assessment protocol for stroke rehabilitation: the new "Protocollo di Minima per l'ICtus" (PMIC2020).

The use of standardized assessment protocols is strongly recommended to identify patient's needs, outcomes, and predictors of response to specific interventions in Stroke rehabilitation. In 2008, the Italian Society of Physical and Rehabilitation Medicine (SIMFER) published the minimal protocol for the person with stroke ("Protocollo di Minima per l'ICtus" [PMIC]), in reference to the International classification of Functioning, Disability and Health. In 2019, the SIMFER appointed a working group to provide a revised, updated version in line with the most recent literature and suitable for all rehabilitation settings: the PMIC2020. Descriptive study based on the consensus of a panel of experts. The study setting includes all the rehabilitation settings. The population included is represented by stroke survivors with disability. The coordinator of the SIMFER National Stroke Section appointed the working group, including the 8 Stroke Section board members, and 4 more experts (3 physiatrists; 1 neurologist). An extensive revision of the international literature on stroke assessment recommendations was performed; each proposed change from PMIC was written and motivated, discussed and voted. The PMIC2020 is a single form, to be administered at any time of the rehabilitation pathway, including a minimum set of variables, consisting of a demographic/anamnestic section, and a clinical/functional assessment section. Newly introduced tools included measures of malnutrition (BMI<18.5); pain in verbal and non-verbal patients (Numeric Rating Scale-pain, Pain Assessment in Advanced Dementia Scale); neurological impairment (National Institute of Health-Stroke Scale); activity (Modified Barthel Index, Short Physical Performance Battery); and participation (Frenchay Activity Index). The PMIC2020 provides an updated tool for the multidimensional rehabilitation assessment of the stroke patient, at any stage of the rehabilitation pathway, aiming at a shared minimum set of variables defining patient's needs and at defined outcomes across different rehabilitation facilities and settings. The PMIC2020 identifies patient's needs, outcomes, and predictors of response to specific interventions in Stroke rehabilitation and provide ground for a highly needed Stroke Registry.

Effect of body-part specificity and meaning in gesture imitation in left hemisphere stroke patients.

Previous studies showed that imitation of finger and hand/arm gestures could be differentially impaired after brain damage. However, so far, the interaction between gesture meaning and body part in imitation deficits has not been fully assessed. In the present study, we aimed at filling this gap by testing 36 unilateral left brain-damaged patients with and without apraxia (20 apraxics), and 29 healthy controls on an imitation task of either finger or hand/arm meaningful (MF) gestures and meaningless (ML) movements, using a large sample of stimuli and controlling for the composition of the experimental list. Left-brain damaged patients imitated ML finger worse than hand/arm movements, whereas they did not show the same difference in MF gesture imitation. In addition, apraxic patients imitated finger movements worse than hand/arm movements. Furthermore, apraxic patients' imitation performance was equally affected irrespective of the action meaning, whereas non-apraxic patients showed better imitation performance on MF gestures. Results suggest that MF gestures are processed as a whole, as imitation of these gestures relies on the stored motor programs in long-term memory, independently of the body part involved. In contrast, ML movements seem to be processed through direct visuo-motor transformations, with left-brain damage specifically disrupting imitation performance of the more cognitive demanding finger movements.

The Look After Yourself (LAY) intervention to improve self-management in stroke survivors: Results from a quasi-experimental study.

OBJECTIVE: To test the efficacy of a self-management intervention for stroke survivors vs. usual care. METHODS: Using a quasi-experimental study, participants were recruited from three public Italian hospitals. Questionnaires assessing self-efficacy (SSEQ), quality of life (SF-12), physical performance (SPPB), depression (GDS) and activities of daily living (MBI) were administered at baseline, discharge and two months after discharge. Mixed models with a propensity score were used between experimental group (EG) and control group (CG). Logistic models were used to compare the use of health services. RESULTS: Eighty-two stroke survivors were enrolled in the EG and 103 in the CG. Self-efficacy in self-management improved in the EG compared to the CG during hospitalization. Improvements from baseline to discharge were found in the EG in the mental component of SF-12 and in MBI. The EG were 8.9 times more likely to contact general practitioners after discharge and 2.9 times to do regular exercise than CG. Notably, EG with higher education benefitted more from the intervention. CONCLUSION: The intervention was efficacious in improving self-efficacy, mental health and activities of daily living. PRACTICE IMPLICATIONS: Structured educational interventions based on problem-solving and individual goal setting may improve self-management skills in stroke survivors.

Self-management and self-efficacy in stroke survivors: validation of the Italian version of the Stroke Self-Efficacy Questionnaire.

BACKGROUND: Self-efficacy is an important mediator of the adaptation process after stroke. However, few studies have attempted to measure self-efficacy in a stroke population. The most recently developed scale is the Stroke Self-Efficacy Questionnaire that measures self-efficacy ratings in specific domains of functioning relevant for a stroke survivor. AIM: The aim of this study was to validate the Italian version of Stroke Self-efficacy Questionnaire in stroke survivors. DESIGN: Cross-sectional study. SETTING: Three Physical Medicine and Rehabilitation Units located in public hospitals. POPULATION: 149 adult patients recruited after their first stroke. METHODS: Patients were assessed using the Self-efficacy in stroke survivors questionnaire, the Modified Barthel Index, the Geriatric Depression Scale and the Short Form Health Survey. RESULTS: Patients (38.3% female, mean age 69.3 years) completed the Self-efficacy in stroke survivors questionnaire with the help of an interviewer. Using confirmatory factor analysis two factors were identified (activity and self-management). The factor score 'activity' was significantly associated with the Modified Barthel Index and with the physical component of the Short Form Health Survey, but uncorrelated with the mental component of the Short Form Health Survey and with the Geriatric Depression Scale, supporting the convergent/discriminant validity of the instrument. The 'self-management' factor was weakly associated with the Modified Barthel Index, the physical and mental components of the Short Form Health Survey and uncorrelated with the Geriatric Depression Scale, suggesting that it measures a different construct. When we categorized patients according to their walking status, we found that the walking group had significantly higher scores on the activity factor than the non-walking group, while no significant differences were found concerning the self-management factor. CONCLUSIONS: The findings supported the validity of the Italian version of the Stroke Self-efficacy questionnaire . It measures two dimensions of self-efficacy, activity and self-management, strongly related to independence and recovery after stroke and therefore it represents a useful tool to assess self-efficacy. CLINICAL REHABILITATION IMPACT: The Italian version of the Stroke Self-efficacy questionnaire is a valid and reliable measure of self-efficacy. Clinicians can use this instrument to target rehabilitation interventions according to patients' individual confidence in their functional and self-management capacity and in order to set realistic goals.

Effectiveness of adaptive physical activity combined with therapeutic patient education in stroke survivors at twelve months: a non-randomized parallel group study.

BACKGROUND: Adaptive physical activity (APA) is a community-based exercise program for chronic stroke survivors that proved to be effective in improving physical functioning and psychological well-being in the short term. AIM: The aim of the present paper is to determine the effectiveness at twelve months of an intervention of APA combined with therapeutic patient education (TPE) in stroke survivors. DESIGN: This study is a non-randomized parallel group study comparing APA-TPE intervention with treatment as usual (TAU). SETTING: Patients were recruited after discharge from two Physical Medicine and Rehabilitation Units, 3 to 18 months after the stroke event. The APA-TPE intervention was conducted in local gymnasiums. POPULATION: The study population includes consecutive adult stroke survivors with mild to moderate hemiparesis who were able to walk 25 m independently and had no need of physical therapy. METHODS: The experimental group (N.=126) underwent 16 biweekly sessions of APA and 3 TPE sessions and controls (N.=103) underwent TAU. Twelve-month outcomes included the Modified Barthel Index, the Caregiver Strain Index, SF-12 health-related quality of life, medical complications and health services use. RESULTS: At twelve months, the ability to perform daily living activities, assessed using Modified Barthel Index, was decreased in the TAU group and improved in the APA-TPE group. The physical and mental components of quality of life were significantly improved in both groups. The risk of fractures (OR=0.09, 95% CI 0.01-0.79) and recourse to rehabilitation treatments (OR=0.24, 95% CI 0.08-0.77) were lower in the APA-TPE compared with the TAU group. No difference was found between groups concerning the caregiver burden. CONCLUSION: APA-TPE is an effective intervention to maintain and improve activities of daily living, reduce falls and recourse to rehabilitation treatments at twelve months. CLINICAL REHABILITATION IMPACT: Structured physical activity programs that can be performed also at home, when combined with therapeutic education focused on benefits of physical activity, will encourage stroke survivors to continue exercising. Therefore, it fulfills an essential requirement to the maintenance of lasting health benefits and the prevention of physical and psychological deterioration.

Impact of adapted physical activity and therapeutic patient education on functioning and quality of life in patients with postacute strokes.

OBJECTIVE: The aim of this study was to assess whether the combination of Adapted Physical Activity (APA) and Therapeutic Patient Education (TPE) improves function and quality of life in survivors of strokes. METHODS: This nonrandomized controlled study enrolled patients with mild to moderate hemiparesis referred to 2 physical medicine and rehabilitation units in Emilia-Romagna, Italy, 3 to 18 months after a single unilateral mild to moderate stroke. The experimental group (n = 126) received 16 APA sessions and 3 sessions of TPE, and the control group (n = 103) received usual care; 86.9% completed treatment. The main outcome measure was a 4-month change in gait endurance (that corresponds to 2 months after intervention in the experimental group), and secondary outcomes included the Short Physical Performance Battery, Berg Balance Scale, Barthel Index, Geriatric Depression Scale, 12-item Short-Form Health Survey, and Caregiver Strain Index. Changes in scores at 4 months were compared between groups using analysis of variance and controlling for group imbalance by means of the propensity score. RESULTS: Gait endurance, physical performance, balance, and the physical component of the quality of life score increased significantly at 4 months in the APA group and remained stable in the control group. The propensity-adjusted between-group change was significant for these scores at P < .01. CONCLUSIONS: Our results confirm that it is feasible and potentially effective to implement APA programs for elderly patients with complex clinical conditions as early as 3 months after a stroke and suggest that, when combined with TPE, the effects of a postrehabilitation APA program are relatively enduring.

Survey of the reporting characteristics of systematic reviews in rehabilitation.

BACKGROUND: Systematic reviews (SRs) have become increasingly important for informing clinical practice; however, little is known about the reporting characteristics and the quality of the SRs relevant to the practice of rehabilitation health professionals. OBJECTIVE: The purpose of this study was to examine the reporting quality of a representative sample of published SRs on rehabilitation, focusing on the descriptive, reporting, and bias-related characteristics. METHODS: A cross-sectional study was conducted by searching MEDLINE for aggregative and configurative SRs indexed in 2011 that focused on rehabilitation as restorative of functional limitations. Two reviewers independently screened and selected the SRs and extracted data using a 38-item data collection form derived from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The data were analyzed descriptively. RESULTS: Eighty-eight SRs published in 59 journals were sampled. The median compliance with the PRISMA items was 17 (63%) out of 27 items (interquartile ratio=13-22 [48%-82%]). Two thirds of the SRs (n=66) focused on interventions for which efficacy is best addressed through a randomized controlled trial (RCT) design, and almost all of these SRs included RCTs (63/66 [95%]). More than two thirds of the SRs assessed the quality of primary studies (74/88 [84%]). Twenty-eight reviews (28/88 [32%]) meta-analyzed the results for at least one outcome. One half of the SRs reported positive statistically significant findings (46%), whereas a detrimental result was present only in one review. CONCLUSIONS: This sample of SRs in the rehabilitation field showed heterogeneous characteristics and a moderate quality of reporting. Poor control of potential source of bias might be improved if more widely agreed-upon evidence-based reporting guidelines will be actively endorsed and adhered to by authors and journals.

Family burden after severe brain injury: the Italian experience with families and volunteer associations.

BACKGROUND: As part of the development of the Italian National Consensus Conference investigating the period from the hospital rehabilitation of patients with severe brain injury to their return to the community, a working group was appointed to identify the needs of brain injury patients and their families in Italy. METHODS: Two postal self-administered survey questionnaires were carried out: one targeted families of patients with severe brain injury to evaluate their objective and subjective burdens and needs; the other focused on the viewpoints of volunteer associations helping people with severe brain injury. Issues explored were quality of discharge from hospital (information received, family participation, etc.), needs of the family (work, financial resources, spare time, relationships with friends and other relatives), and the viewpoint of volunteer associations. RESULTS: A total of 234 families (54% of sample) of patients (69% male, mean age 41 years) with severe brain injury returned the questionnaire. Most said they had been involved and informed in the hospital discharge process; about 17% had not been involved at all and only about one-third of families received satisfactory support during the discharge phase. Few families received any help from community social services (10%). Almost two-thirds of families had experienced financial difficulties and, in many cases, one family member had to change his/her work situation. Families' social relationships, travelling, hobbies, and spare time were significantly reduced. The 57 volunteer associations who returned the survey (84% response rate) confirmed that their members had experienced the same difficulties. CONCLUSIONS: Considering the difficulties and problems documented by these two surveys, more research is needed on effective interventions to support patients with severe brain injury and their families, particularly during the discharge phase from hospital to home and community life.

Sensory stimulation of brain-injured individuals in coma or vegetative state: results of a Cochrane systematic review.

OBJECTIVES: To assess the effectiveness of sensory stimulation programmes in patients in coma or vegetative state. DESIGN: Systematic review of randomized control trials (RCT) and nonrandomized controlled clinical trials (CCT) comparing any type of stimulation programmes with standard rehabilitation in patients in coma or vegetative state. The Injuries Group specialized register, the Cochrane Controlled trial register, EMBASE, MEDLINE, CINAHL, PSYCHLIT from 1966 to January 2002 were searched without language restriction. Reference lists of articles were scanned and experts in the area contacted to find other relevant studies. Abstracts and papers found were initially screened by one reviewer. Three reviewers independently identified relevant studies, extracted data and assessed study quality, resolving disagreement by consensus. OUTCOME MEASURES: Duration of unconsciousness (including coma and vegetative state) defined as the time between trauma and objective recovery of the ability to respond to verbal commands; level of consciousness, as measured by the Glasgow Coma Scale (GCS); level of cognitive functioning (LCF); functional outcomes, as measured by Glasgow Outcome Scale (GOS) or by Disability Rating Scale; negative effects (e.g. increased intracranial pressure). RESULTS: Three studies (one RCT and two CCTs) with 68 traumatic brain-injured patients in total, most of whom were road accident victims, met the inclusion criteria. The overall methodological quality was poor and studies differed widely in terms of study design and conduct. Moreover, due to the diversity in reporting of outcome measures, a quantitative metanalysis was not possible. None of the three studies provided useful and valid results on outcomes of clinical relevance for coma patients. CONCLUSIONS: This systematic review indicates that there is no reliable evidence to support the effectiveness of multisensory stimulation programmes in patients in coma or the vegetative state.