Stroke Rehabilitation Ward Research Articles

The reliability, validity and clinical utility of the Clinical Outcomes in Routine Evaluation – ten-item version (CORE-10) in post-acute patients with stroke

Objective To explore the validity, reliability, and clinical utility of the Clinical Outcomes in Routine Evaluation – ten-item version (CORE-10: a ten-item questionnaire designed to measure psychological distress) in a stroke inpatient sample and calculate reliable and clinically significant change scores. Setting A post-acute stroke rehabilitation ward in the East of England. Participants A total of 53 patients with stroke, capable of completing the CORE-10 as part of their routine clinical assessment. Exclusion criteria included moderate to severe aphasia and/or alexia. Main measures Alongside the CORE-10, the Patient Health Questionnaire – 9, the Hospital Anxiety and Depression Scale, the Centre for Epidemiological Studies-Depression Scale, and the Beck Depression Inventory Second Edition were used as concurrent measures. Results To assess reliability, the internal consistency and test–retest reliability of the CORE-10 were calculated. The average number of days between CORE-10 test–retest administrations was 2.84 (SD = 3.12, Mdn = 1). Concurrent validity was assessed by examining correlations between the CORE-10 and comparable measures, and clinical utility was assessed using the criteria of Burton and Tyson (2015). The internal consistency (Cronbach’s alpha) for the CORE-10 was .80, and test–retest reliability interclass correlation coefficient was .81. Total score correlations between the CORE-10 and concurrent measures ranged from r = .49 to r = .89. The CORE-10 achieved the maximum score (i.e. 6/6) on criteria for clinical utility. Calculations demonstrated a reliable change index of nine points and a clinically significant change cut point of 12 on the CORE-10. Percentiles for CORE-10 total scores are reported. Conclusions This study provides preliminary support for the CORE-10 as a valid and reliable measure that has clinical utility for screening distress in inpatients with stroke.

Obesity Impairs Functional Recovery of Older Stroke Patients with Possible Sarcopenia: A Retrospective Cohort Study.

The functional prognosis of older patients with coexisting obesity and possible sarcopenia remains uncertain following acute stroke. This study aimed to determine whether coexisting obesity independently affects activities of daily living (ADL) and balance ability at discharge in older patients with possible sarcopenia admitted to a stroke rehabilitation ward. A total of 111 patients aged 65 years or older with possible sarcopenia were included, of whom 36 (32.4%) had coexisting obesity. Possible sarcopenia was diagnosed based on low handgrip strength without reduced muscle mass, while obesity was determined by body fat percentage (≥25% for men, ≥30% for women). Multivariate linear regression analysis revealed that compared to patients without obesity, patients with obesity had a higher likelihood of poorer ADL (b = -0.169; p = 0.02) and balance ability (b = -0.14; p = 0.04) performance at discharge following a 4-week period of inpatient rehabilitation. These findings suggest that obesity may be a modifiable risk factor in the rehabilitation of older patients with possible sarcopenia and should be considered in the assessment of decreased muscle strength.

An evaluation of an open group for depressed mood on a stroke rehabilitation ward: three years of clinical data

Purpose An open group intervention for stroke inpatients, based on Acceptance and Commitment Therapy, is evaluated using retrospective clinical service data. Materials and methods Participants were included unless severely unwell or unable to provide informed consent. 117 participants attended at least two sessions in a non-controlled, repeated measures design. Two session protocols were delivered on alternating weeks by an Assistant Psychologist and Trainee Psychologist, covering values, committed action, and acceptance. Participants rated their mood each session using the Depression Intensity Scale Circles (DISCs). Results Attended sessions ranged from 1 to 11 (Md: 2). Significant reductions in DISCs scores with medium effect sizes were found among those scoring above the cut-off for depression at baseline, Χ2(3) = 20.87, p < .001. The likelihood of scoring below the cut-off for depression did not change between participants’ first and last sessions, X2(1, N = 117) = 1.36, p = .24. The number of sessions attended did not predict outcome, rs(117) = .09, p = .33. Conclusions Design limitations prevented inferences of clinical effectiveness, but the group met several clinical utility criteria by providing a flexible intervention on a rehabilitation ward with competing demands. We highlight the importance of contrasting findings of clinical trials with data from clinical services.

Reliability of the modified Rankin Scale in clinical practice of stroke units and rehabilitation wards.

The Modified Rankin Scale (mRS) is the most common tool to quantify post-stroke disability in everyday practice and by certified raters in clinical trials. However, interobserver variability may affect reliability of retrospective observational studies, including clinical registries. Our aim was to assess real-life consistency between neurologists and physical and rehabilitation medicine physicians using mRS to rate post-stroke disability of patients transferred directly from stroke unit (SU) to rehabilitation ward (RW). This is a retrospective analysis of 132 consecutive acute stroke patients transferred from single tertiary SU to RW located in the same hospital in Poland. Patients were assessed by one rater from each department at the day of transfer. We distinguished between physicians previously certified in using mRS for clinical trials and not-certified physicians using mRS in everyday practice. mRS at discharge from SU and on admission to RW was recorded for 105 of 132 patients. The overall agreement was 70.5% (kappa 0.55). Similar agreement was observed in the subset of 30 patients rated by certified physicians in both departments (70.0%, kappa 0.57) and in the subset of 61 patients rated by a pair of certified neurologist and not-certified rehabilitation physician (73.8%, kappa 0.58). Everyday consistency between raters from SU and RW in using mRS is modest as in previous validation studies. However, it may be considered sufficient for the purpose of observational studies or stroke registries. It emphasizes the need for easily accessible training in conventional mRS or implementation of specialized tools with predefined questions.

What underlies the difference between self-reported health and disability after stroke? A qualitative study in the UK

BackgroundLevels of self-reported health do not always correlate with levels of physical disability in stroke survivors. We aimed to explore what underlies the difference between subjective self-reported health and objectively measured disability among stroke survivors.MethodsFace to face semi-structured interviews were conducted with stroke survivors recruited from a stroke clinic or rehabilitation ward in the UK. Fifteen stroke survivors purposively sampled from the clinic who had discordant self-rated health and levels of disability i.e. reported health as ‘excellent’ or ‘good’ despite significant physical disability (eight), or as ‘fair’ or ‘poor’ despite minimal disability (seven) were compared to each other, and to a control group of 13 stroke survivors with concordant self-rated health and disability levels. Interviews were conducted 4 to 6 months after stroke and data analysed using the constant comparative method informed by Albrecht and Devlieger’s concept of ‘disability paradox’.ResultsIndividuals with ‘excellent’ or ‘good’ self-rated health reported a sense of self-reliance and control over their bodies, focussed on their physical rehabilitation and lifestyle changes and reported few bodily and post-stroke symptoms regardless of level of disability. They also frequently described a positive affect and optimism towards recovery. Some, especially those with ‘good’ self-rated health and significant disability also found meaning from their stroke, reporting a spiritual outlook including practicing daily gratitude and acceptance of limitations. Individuals with minimal disability reporting ‘fair’ or ‘poor’ self-rated health on the other hand frequently referred to their post-stroke physical symptoms and comorbidities and indicated anxiety about future recovery. These differences in psychological outlook clustered with differences in perception of relational and social context including support offered by family and healthcare professionals.ConclusionsThe disability paradox may be illuminated by patterns of individual attributes and relational dynamics observed among stroke survivors. Harnessing these wider understandings can inform new models of post-stroke care for evaluation.

Developing and implementing an exercise-based group for stroke survivors and their carers: the Carers Count group

Purpose Guidelines recommend that carers of stroke survivors should be engaged early in rehabilitation. There has been limited research implementing exercise programs that include carers. The aims of this study were to develop, facilitate, and evaluate an intervention, the Carers Count group, an exercise-based group for stroke survivors and their carers. Methods Over a 5-month period, a staged approach was used to design the intervention and implementation strategies which would maximise the chances of embedding the intervention within an inpatient stroke ward. Implementation strategies included planning, educating, restructuring, financing, and managing quality. Following development and facilitation of the intervention, outcomes were evaluated through collecting data about therapy time, surveys (n = 30) and interviews (n = 18) with participants, and a focus group with staff. Results Thirty stroke survivors and their carers participated in the Carers Count group. Analysis of time spent in therapy showed that participation led to increased dose of physiotherapy time (service outcome). Survey and interview data suggested that participation in the group was a rewarding and engaging experience for participants (client outcomes). Conclusion Using multifaceted strategies, a group designed to include carers was implemented on a stroke rehabilitation ward. The intervention provided positive outcomes in terms of increased therapy dose and satisfaction according to participant feedback. Clinical Trials registration number ANZCTR12620000708954 Implications for rehabilitation It is possible to develop modes of delivery in rehabilitation that include the carers of stroke survivors and these interventions are considered enjoyable and beneficial. Health professionals should consider interventions that are engaging and fun for stroke survivors and their carers. Health professionals should carefully plan and utilise appropriate implementation strategies when aiming to introduce a new intervention into an established health service. Health professionals should ensure stroke survivors and their carers have an understanding of recovery following stroke and how to maximise outcomes through increasing amount of practice.

224 Dance Artist and Physiotherapist Collaboration in Stroke Rehabilitation

Abstract Background Many studies have measured the benefits of dance for patients, in particular those with Parkinson's disease, with positive effects demonstrated in functional measures, wellbeing and patient experience. However, neither the value of dance when used as an adjunct to stroke rehabilitation nor the act of collaboration between dance artist and physiotherapist has previously been studied. Aim: To explore the experience and process of collaboration between the physiotherapist and dance artist when dance is used as an adjunct to conventional physiotherapy post-stroke in a geriatric medicine and stroke service in a university teaching hospital. Methods The study used a descriptive qualitative design and a convenience sample of 8 participants were recruited from the stroke rehabilitation ward. The physiotherapist advised the dance artist on specific movement goals for each session. The physiotherapist and dance artist kept individual diaries which included subjective and professional assessment of sessions. Exploratory analysis was used to discover emerging themes. Results Themes identified fell into the categories of physiotherapist learning, dance artist learning, collaborative process, language, and the therapeutic relationship. While benefits such as greater liberation of patients’ movements and higher endurance rates were recorded, what was particularly of note was the communication between the physiotherapist and the dance artist. The language used was key: physiotherapy discourse tends to be more specific to particular movements whereas the dance artist relates more to the overall movement of the individual, identifying movement patterns and habits. The dance artist uses the lens of choreological studies (the science of movement) when working with patients and this way of working was particularly beneficial. In particular the use of motif writing became an invaluable resource in terms of communication. Conclusion Within this study we questioned: what is required to create successful collaboration within a medical context? We hope that describing how this particular collaboration was successful will benefit those interested in similar collaborations.

Does feedback on daily activity level from a Smart watch during inpatient stroke rehabilitation increase physical activity levels? Study protocol for a randomized controlled trial

BackgroundPracticing activities improves recovery after stroke, but many people in hospital do little activity. Feedback on activity using an accelerometer is a potential method to increase activity in hospital inpatients. This study’s goal is to investigate the effect of feedback, enabled by a Smart watch, on daily physical activity levels during inpatient stroke rehabilitation and the short-term effects on simple functional activities, primarily mobility.Methods/designA randomized controlled trial will be undertaken within the stroke rehabilitation wards of the Second Affiliated hospital of Anhui University of Traditional Chinese Medicine, Hefei, China. The study participants will be stroke survivors who meet inclusion criteria for the study, primarily: able to participate, no more than 4 months after stroke and walking independently before stroke. Participants will all receive standard local rehabilitation and will be randomly assigned either to receive regular feedback about activity levels, relative to a daily goal tailored by the smart watch over five time periods throughout a working day, or to no feedback, but still wearing the Smart watch. The intervention will last up to 3 weeks, ending sooner if discharged. The data to be collected in all participants include measures of daily activity (Smart watch measure); mobility (Rivermead Mobility Index and 10-metre walking time); independence in personal care (Barthel Activities of Daily Living (ADL) Index); overall activities (the World Health Organization (WHO) Disability Assessment Scale, 12-item version); and quality of life (the Euro-Qol 5L5D). Data will be collected by assessors blinded to allocation of the intervention at baseline, 3 weeks or at discharge (whichever is the sooner); and a reduced data set will be collected at 12 weeks by telephone interview. The primary outcome will be change in daily accelerometer activity scores. Secondary outcomes are compliance and adherence to wearing the watch, and changes in mobility, independence in personal care activities, and health-related quality of life.DiscussionThis project is being implemented in a large city hospital with limited resources and limited research experience. There has been a pilot feasibility study using the Smart watch, which highlighted some areas needing change and these are incorporated in this protocol.Trial registrationClinicalTrials.gov, NCT02587585. Registered on 30 September 2015. Chinese Clinical Trial Registry, ChiCTR-IOR-15007179. Registered on 8 August 2015.

Relationship between Functional Independence Measure (FIM) score on admission and influence of inhibitive factors in a comprehensive inpatient stroke rehabilitation ward

Relationship between Functional Independence Measure (FIM) score on admission and influence of inhibitive factors in a comprehensive inpatient stroke rehabilitation ward

Effect of Core Stability Training on Trunk Function, Standing Balance, and Mobility in Stroke Patients

Background. Trunk function is important for standing balance, mobility, and functional outcome after stroke, but few studies have evaluated the effects of exercises aimed at improving core stability in stroke patients. Objective. To investigate the effectiveness of core stability training on trunk function, standing balance, and mobility in stroke patients. Methods. An assessor-blinded, randomized controlled trial was undertaken in a stroke rehabilitation ward, with 32 participants randomly assigned to an experimental group or a control group (n = 16 each). The experimental group received 400 minutes of core stability training in place of conventional programs within total training time, while the control group received only conventional programs. Primary outcome measures were evaluated using the Trunk Impairment Scale (TIS), which reflects trunk function. Secondary outcome measures were evaluated by pelvic tilt active range of motion in the sagittal plane, the Balance Evaluation Systems Test–brief version (Brief-BESTest), Functional Reach test, Timed Up-and-Go test (TUG), and Functional Ambulation Categories (FAC). A general linear repeated-measures model was used to analyze the results. Results. A treatment effect was found for the experimental group on the dynamic balance subscale and total score of the TIS (P = .002 and P < .001, respectively), pelvic tilt active range of motion (P < .001), Brief-BESTest (P < .001), TUG (P = .008), and FAC (P = .022). Conclusions. Core stability training has beneficial effects on trunk function, standing balance, and mobility in stroke patients. Our findings might provide support for introducing core stability training in stroke rehabilitation.

Starting out - Standards set in our code were with me every day of my first placement.

After spending 11 weeks on a stroke rehabilitation ward, I have now finished my first clinical placement. I never thought I could learn so much in such a short time.

Effectiveness of a fall-risk reduction programme for inpatient rehabilitation after stroke

Purpose: To evaluate effectiveness of fall-risk-assessment-based fall prevention for stroke rehabilitation inpatients.Method: A consecutive series of 232 patients admitted for the first time to a subacute stroke-rehabilitation ward during 2010–2011 was studied in detail. The Assessment Sheet for Fall Prediction in Stroke Inpatients (ASFPSI by Nakagawa et al.) was used to assess fall-risk upon admission. Association of ASFPSI score and patient characteristics with actual falls was statistically tested. Yearly incidence of falls per 1000 hospital days (HD) was retrospectively audited for the 2006–2014 period to evaluate effectiveness of fall-risk reduction measures.Results: The observed incidence of falls over the detailed-study-period was 3.0/1000 HD; 39% of the fallers fell during the first week after admission. ASFPSI score was not significantly associated with falls. Longer hospital stay, left body-side affected and non-extreme FIM score (55–101) were associated with higher odds of fall. Introduction of fall-risk reduction measures followed by compulsory fall-risk assessment lead to incidence of falls dropping from 7.1/1000 HD in 2006 to 2.8/1000 HD in 2011 and remaining at that level until 2014.Conclusions: The fall-risk-assessment-based measures appear to have led to decreasing falls risk among post-stroke rehabilitation inpatients classified as being at high risk of falls. The fall prevention programme as a whole was successful. Patients with non-extreme level of functional independence should receive enhanced fall prevention.Implications for RehabilitationRecognising the fall risk upon the patient's admission is essential for preventing falls in rehabilitation wards.Assessing the fall risk is a team tasks and combines information from various sources.Assessing fall risk in stroke patients using the assessment sheet by Nakagawa et al. immediately upon admission systematically draws attention to the risk of falls in each individual patient.

Sacred Work? Exploring Spirituality with Therapists Working with Stroke Patients with Aphasia

Speech and language therapists (SLT), occupational therapists (OT) and physiotherapists (PT) on stroke rehabilitation wards have long worked in an holistic way, with the client at the centre of their interventions. However, if we consider our clients to be tripartite beings, comprising body, mind and spirit, do we, in fact, give credence to the spiritual dimension? Are there particular considerations in this regard when we consider those patients who present with communication difficulties following a stroke? Are we able to facilitate expressions of spiritual distress/need in our clients with aphasia who have difficulty verbalizing their thoughts and, if so, is it our role to do so? As part of a larger study exploring stories of spirituality with people with aphasia, I interviewed members of the multidisciplinary team on an acute stroke ward. I wanted to explore their understanding of their professional role vis-à-vis spirituality. This article focuses on some of the themes which emerged in the interviews with the therapists on the stroke ward: an OT, SLT and PT. Using a hermeneutic phenomenological approach, I encouraged them to talk about their interventions with people with aphasia, their definition of spirituality, and whether they considered facilitation of expressions of spirituality in their clients with aphasia as part of their therapeutic remit. Although, of course, this represents a very small sample of therapists, nevertheless some interesting themes have begun to emerge, which I hope will contribute to further dialogue.

Exploring stroke survivor experience of participation in an enriched environment: a qualitative study

Background: Data highlight the importance of undertaking intense and frequent repetition of activities within stroke rehabilitation to maximise recovery. An enriched environment (EE) provides a medium in which these activities can be performed and enhanced recovery achieved. An EE has been shown to promote neuroplasticity in animal models of stroke, facilitating enhanced recovery of motor and cognitive function. However, the benefit of enriching the environment of stroke survivors remains unknown. Aim: To qualitatively explore stroke survivors’ experience of implementation of exposure to an EE within a typical stroke rehabilitation setting, in order to identify facilitators and barriers to participation. Methods: Semi-structured interviews with 10 stroke survivors (7 females and 3 males, mean age of 70.5 years) exposed to an EE for a 2-week period following exposure to routine rehabilitation within a stroke rehabilitation ward. An inductive thematic approach was utilised to collect and analyse data. Results: Qualitative themes emerged concerning the environmental enrichment paradigm including: (1) “It got me moving” – perceived benefits of participation in an EE; (2) “You can be bored or you can be busy.” – Attenuating factors influencing participation in an EE; (3) “I don’t like to make the staff busier” – limitations to use of the EE. Conclusions: This study provides preliminary support for the implementation of an EE within a typical stroke rehabilitation setting from a patient perspective. Reported benefits included (1) increased motor, cognitive and sensory stimulation, (2) increased social interaction, (3) alleviation of degree of boredom and (4) increased feelings of personal control. However, participants also identified a number of barriers affecting implementation of the EE. We have previously published findings on perceptions of nursing staff working with stroke survivors in this enriched rehabilitation environment who identified that patients benefited from having better access to physical, cognitive and social activities. Together, results contribute to valuable evidence for future implementation of an EE in stroke rehabilitation settings.Implications for RehabilitationStroke survivor access to an enriched environment (EE):Results identified that participation in both individual and communal forms of environment enrichment within the stroke rehabilitation ward resulted in increased access to activities providing increased opportunities for enhanced motor, cognitive and sensory stimulation.Increased access to and participation in activities of the environmental enrichment (individual and communal) interrupted the ongoing cycle of boredom and inactivity experienced by many participants.This study provides preliminary support for the implementation of an EE within a typical stroke rehabilitation setting from a patient perspective.

Predictors of oral health-related quality of life in patients following stroke.

Objectives: To explore the influence of socio-demographic and clinical oral health factors on oral health-related quality of life (OHRQoL) in patients after stroke, and to monitor OHRQoL outcomes following the provision of an in-hospital oral health intervention programme. Design: OHRQoL was measured before and after randomization and provision of oral health promotion interventions in a prospective clinical trial. Subjects: Eighty-one patients admitted to a stroke rehabilitation ward. Methods: OHRQoL was assessed using the Oral Health Impact Profile-14 (OHIP-14) and Oral Health Transition Scale upon admission and 3 weeks later following provision of an oral health promotion programme. Potential factors were examined for their association with OHRQoL outcomes. Results: Lack of a regular daily brushing habit was significantly associated with 6 of 8 transition scale items (p < 0.01) at baseline, while significant improvements in OHRQoL were observed over the course of the clinical trial for all patients as a whole (p < 0.05). Conclusion: OHRQoL is compromised following stroke and may be influenced by the lack of a regular daily brushing habit during hospitalization. The early re-establishment of an oral hygiene protocol is a priority in stroke rehabilitation wards in order to improve clinical oral health and OHRQoL.

Evaluating a novel approach to enhancing dysphagia management: workplace‐based, blended e‐learning

To evaluate the learning effect and resource use cost of workplace-based, blended e-learning about dysphagia for stroke rehabilitation nurses. Dysphagia is a potentially life-threatening problem that compromises quality of life. In many countries, nurses play a crucial role in supporting the management of patients with swallowing problems, yet the literature reports a need for training. A single-group, pre- and post-study with mixed methods. Each blended e-learning session comprised a needs analysis, e-learning programmes, practical skills about modifying fluids and action planning to transfer learning into practice. Participants were the population of registered nurses (n = 22) and healthcare assistants (n = 10) on a stroke rehabilitation ward in a large, teaching hospital in England between August 2010-March 2011. Data collection comprised observation (34 hours), questionnaires administered at four time points to examine change in attitude, knowledge and practice, and estimating the resource use cost for the service. Nonparametric tests and content analysis were used to analyse the data. All participants achieved a nationally recognised level of competence. The learning effect was evident on the post- and follow-up measures, with some items of dysphagia knowledge and attitude achieving significance at the p ≤ 0·05 level. The most common self-reported changes in practice related to medicines management, thickening fluids and oral hygiene. The resource use cost was estimated at £2688 for 108 hours training. Workplace-based, blended e-learning was an acceptable, cost effective way of delivering essential clinical knowledge and skills about dysphagia. Dysphagia should be viewed as a patient safety issue because of the risks of malnutrition, dehydration and aspiration pneumonia. As such, it is pertinent to many members of the interdisciplinary team. Consideration should be given to including dysphagia management in initial education and continuing professional development programmes.

Classification of falls in stroke rehabilitation – not all falls are the same

Objective: To develop a practical taxonomy of falls and to determine whether these different fall groups have different outcomes. Design: Descriptive study examining patient characteristics at the time of each fall and iterative development of falls taxonomy. Setting: An inpatient stroke rehabilitation ward. Methods: All falls over 21 months were reviewed retrospectively. Case notes were reviewed and each patient’s level of functioning at the time of fall, together with admission profile and discharge outcomes, were collected. Outcomes for fallers (as opposed to falls) were compared using the predominant fall type. Results: There were 241 falls in 122 patients and most falls occurred around the bed (196 (81%) falls). Toileting-related falls occurred in 54 patients (22.4%). The taxonomy proposes seven main fall types. One fall type (‘I’m giving it a go’) appeared quite different and was associated with better functioning at time of fall and better outcomes. Other fall types were related to high dependency needs, visuospatial difficulties or delirium. Medication-related falls were uncommon in this cohort. Conclusions: The falls taxonomy developed showed four main types of falls with different, but overlapping, patient characteristics at time of fall with different outcomes. Different fall-prevention strategies may be required for each group.

What is the nursing team involvement in maintaining and promoting the mobility of older adults in hospital? A grounded theory study

Aims of the paperTo present a grounded theory of the nursing team involvement in the process of maintaining and promoting the mobility of hospitalised older adults. BackgroundBeing able to mobilise is an important determinant of quality of life in late adulthood. However, advancing age is often accompanied by worsening mobility, which may deteriorate further as a result of illness and particularly hospitalisation. Targeted in-patient rehabilitation interventions may have the capacity to maintain and promote older adults’ mobility. Some authors suggest that the nursing team may have a central role in such activities. ObjectivesThe study set out to describe the involvement of the nursing team in the process of maintaining and promoting the mobility of hospitalised older adults. It also sought to understand how members of the nursing team viewed their work in relation to physiotherapists and in relation to hospital policy on patient handling. DesignGrounded theory provided the philosophical and structural underpinning to the study. SettingsData collection centred on three clinical settings which included a general rehabilitation ward, a regional spinal injuries unit and stroke rehabilitation ward. ParticipantsSemi-structured interviews with 39 rehabilitation staff and 61h of non-participant observation comprised the data set. FindingsThe nursing team involvement in patients’ mobility maintenance and rehabilitation was explained by the core category ‘care to keep safe.’ This category identified how the nursing team focused primarily on preventing patient problems rather than focusing on rehabilitation goals. A number of contextual factors in the workplace meant that the nursing team found it difficult to engage in activities to support mobility maintenance and rehabilitation. ConclusionsSignificant changes in the micro and macro context for rehabilitation practice are needed to enable the nursing team to engage more fully in the processes of mobility rehabilitation. Nurse-led initiatives which allow the nursing team to take an active role in implementing intentional strategies to maintain and promote mobility should be implemented and trialled for effectiveness.

Can Surface Neuromuscular Electrical Stimulation of the Wrist and Hand Combined With Routine Therapy Facilitate Recovery of Arm Function in Patients With Stroke?

Rosewilliam S, Malhotra S, Roffe C, Jones P, Pandyan AD. Can surface neuromuscular electrical stimulation of the wrist and hand combined with routine therapy facilitate recovery of arm function in patients with stroke? ObjectiveTo investigate whether treatment with surface neuromuscular electrical stimulation to the wrist extensors improves recovery of arm function in severely disabled patients with stroke. DesignSingle blinded randomized controlled trial. SettingAcute stroke unit and stroke rehabilitation wards of a university hospital. ParticipantsPatients with no upper limb function (Action Research Arm Test [ARAT] score 0) (N=90; mean age ± SD, 74±11y; 49% men) were recruited to the study within 6 weeks of stroke. Only 67 participants were alive at the end of the study and data from 66 of these people were analyzed. InterventionsParticipants were randomized to surface neuromuscular electrical stimulation using surface electrical stimulators for 30 minutes, twice in a working day for 6 weeks in addition to standardized upper limb therapy or just standardized upper limb therapy. Main Outcome MeasureThe primary outcome measure was the ARAT score. Assessments were made at baseline and at 6, 12, 24, and 36 weeks after recruitment. ResultsThere were statistically significant improvements in measures of wrist extensor (mean difference 0.5; 95% confidence interval [CI], 0.0–1.0) and grip strength (mean difference 0.9; 95% CI, 0.1–1.7) over the treatment period. Arm function (ARAT score) was not significantly different between the groups over the treatment period at 6 weeks (mean difference 1.9; 95% CI, −2.9 to 6.8) or over the study period at 36 weeks (mean difference 6.4; 95% CI, −1.8 to 14.7), and the rate of recovery was not significantly different (mean difference 0.7; 95% CI, −0.2 to 1.6). ConclusionsIn patients with severe stroke, with no functional arm movement, electrical stimulation of wrist extensors improves muscle strength for wrist extension and grip, and larger studies are required to study its influence on arm function.

Atrial fibrillation predicts cognitive impairment in patients with ischemic stroke.

Atrial fibrillation (AF) is considered as a risk factor for cognitive impairment. This retrospective chart review study was conducted in a patient stroke rehabilitation ward of a university-affiliated referral hospital. The participants were 707 patients admitted for a standard rehabilitation course after an ischemic stroke. Cognitive status was assessed by the Mini-Mental State Examination (MMSE), and scores lower than 24 points were considered as suggestive of cognitive impairment. Atrial fibrillation, age, gender, diabetes, and dementia emerged as the only statistically significant parameters differing between those with MMSE score lower than 24 or higher. In a multiple logistic regression analysis, AF (odds ratio 1.6, 95% confidence interval 1.03-2.47, P = .03) was associated with an increased risk of cognitive impairment. Our findings suggest that atrial fibrillation upon admission is independently associated with lower MMSE scores in patients with ischemic stroke.