BackgroundFatigue is the most frequent symptom reported by patients with chronic illnesses. As a subjective experience, fatigue is commonly assessed with patient-reported outcome measures (PROMs). Currently, there are more than 40 generic and disease-specific PROMs for assessing fatigue in use today. The interpretation of changes in PROM scores may be enhanced by estimates of the so-called minimal important difference (MID). MIDs are not fixed attributes of PROMs but rather vary in relation to estimation method, clinical and demographic characteristics of the study group, etc. The purpose of this paper is to compile published MIDs for fatigue PROMs, spanning diagnostic/patient groups and estimation methods, and to provide information relevant for appraising their appropriateness for use in specific clinical trials and in monitoring fatigue in defined patient groups in routine clinical practice.MethodsA systematic search of three databases (Scopus, CINAHL and Cochrane) for studies published between January 2000 to April 2015 using fatigue and variations of the term MID, e.g. MCID, MIC, etc. Two authors screened search hits and extracted data independently. Data regarding MIDs, anchors used and study designs were compiled in tables.ResultsIncluded studies (n = 41) reported 60 studies or substudies estimating MID for 28 fatigue scales, subscales or single item measures in a variety of diagnostic groups and study designs. All studies used anchor-based methods, 21/60 measures also included distribution-based methods and 17/60 used triangulation of methods. Both similarities and dissimilarities were seen within the MIDs.ConclusionsMagnitudes of published MIDs for fatigue PROMs vary considerably. Information about the derivation of fatigue MIDs is needed to evaluate their applicability and suitability for use in clinical practice and research.

The Fugl-Meyer Assessment of Upper Extremity (FMA-UE) is one of the most used and recommended assessment scales of sensorimotor function in stroke. This study investigated the reliability of the scale when different therapists assessed the patient's performance at the same test session and when the assessment was performed by the same therapist but on 2 different occasions. Sixty individuals with stroke at the Central Military Hospital of Colombia were included. The results showed that the agreement in each individual movement (FMA-UE includes 33 movements/items) was 79% or above. Disagreements in scorings between raters were noted for 4 single items. These disagreements were probably caused by the spontaneous recovery that occurred in the early subacute phase after stroke. The item, subscale and total score level reliabilities were high and the scale can be recommended for use in general, including in Spanish-speaking countries. It is important, however, that standardized testing procedures are followed. Objective: The Fugl-Meyer Assessment of Upper Extremity (FMA-UE) is recommended for evaluation of sensorimotor impairment post stroke, but the itemlevel reliability of the scale is unknown. This study aims to determine intra-and inter-rater reliability of the FMA-UE at item-, subscale-and total score level in patients with early subacute stroke. Design: Intra/inter-rater reliability. Subjects: Sixty consecutively included patients with stroke (mean age 65.9 years) admitted to Central Military Hospital of Colombia, Bogota. Methods: Two physiotherapists scored FMA-UE independently on 2 consecutive days within 10 days post stroke. A rank-based statistical method for paired ordinal data was used to assess the level of agreement, systematic and random disagreements. Results: Systematic disagreements either in position or concentration were detected in 4 items of the shoulder section. The item level intra-and inter-rater agreement was high (79-100%). The 70% agreement was also reached for the subscales and the total score when 1-3-point difference was accepted. Conclusion: The FMA-UE is reliable both within and between raters in patients with stroke in the early subacute phase. A wider international use of FMA-UE will allow comparison of stroke recovery between regions and countries and thereby potentially improve the quality of care and rehabilitation in persons with stroke worldwide.

Background and purposeEarly supported discharge (ESD) has been shown to be efficient and safe as part of the stroke care pathway. The best results have been seen with a multidisciplinary team and after mild to moderate stroke. However, how very early supported discharge (VESD) works has not been studied.The aim of this study was to investigate whether VESD for stroke patients in need of ongoing individualized rehabilitation affects the level of anxiety and overall disability for the patient compared with ordinary discharge routine.MethodsA randomized controlled trial was performed with intention to treat analyses comparing VESD and ordinary discharge from hospital. All patients admitted at the stroke care unit at Sahlgrenska University Hospital of Gothenburg between August 2011 and April 2016 were screened. Inclusion occurred on day 4 using a block randomization of 20 and with a blinded assessor. Assessments were made 5 days post-stroke and 3 and 12 months post-stroke. Patients in the VESD group underwent continued rehabilitation in their homes with a multidisciplinary team from the stroke care unit for a maximum of 1 month. The patients in the control group had support as usual after discharge when needed such as home care service and outpatient rehabilitation.The primary outcome was anxiety as assessed by the Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A). The secondary outcome was the patients’ degree of overall disability, measured by the modified Rankin Scale (mRS).ResultsNo significant differences were found between the groups regarding anxiety at three or 12 months post-stroke (p = 0.811). The overall disability was significantly lower in the VESD group 3 months post-stroke (p = 0.004), compared to the control group. However, there was no significant difference between the groups 1 year post-stroke.ConclusionsThe VESD does not affects the level of anxiety compared to ordinary rehabilitation. The VESD leads to a faster improvement of overall disability compared to ordinary rehabilitation. We suggest considering coordinated VESD for patients with mild to moderate stroke in addition to ordinary rehabilitation as part of the service from a stroke unit.Trial registrationClinical Trials.gov: NCT01622205. Registered 19 June 2012 (retrospectively registered).

BackgroundStroke is the disease with the highest costs for hospital care and also after discharge. Early supported discharge (ESD) has shown to be efficient and safe and the best results with well-organised discharge teams and patients with less severe strokes.The aim is to investigate if very early supported discharge (VESD) for stroke patients in need for on-going individualised rehabilitation at home is useful for the patient and cost effective.Methods/designA randomized controlled trial comparing VESD with ordinary discharge. Inclusion criteria: confirmed stroke, >18 years of age, living within 30 min from the stroke unit, on day 2 0–16 points on the National institute of health stroke scale (NIHSS) and 50–100 points on the Barthel Index (BI), with BI 100 then the patient can be included if the Montreal Cognitive Assessment is < 26. Exclusion criteria are: NIHSS >16, BI < 50, life expectancy < 1 year, inability to speak or to communicate in Swedish. The inclusion occurs on day 4 and in block randomization of 20 and with blinded assessor.Primary outcome: levels of anxiety and depression. Secondary outcomes: independence, security, level of function, quality of health, needs of support in activities of daily living and caregiver burden.Power calculation is based on the level of anxiety and with a power of 80%, p-value 0.05 (2 sided test) 44 persons per group are needed. Data is gathered on co-morbidity, re-entry to hospital, mortality and a health economic analysis. Interviews will be accomplished with a strategic sample of 15 patients in the intervention group before discharge, within two weeks after homecoming and 3 months later. Interviews are also planned with 15 relatives in the intervention group 3 months after discharge.DiscussionThe ESD studies in the Cochrane review present hospital stays of a length that no longer exist in Sweden. There is not yet, to our knowledge, any study of early supported discharge with present length of hospital stay. Thus it is not clear if home rehabilitation nowadays without risks, is cost effective, or with the same patient usefulness as earlier studies.Trial registrationClinicalTrials.gov NCT01622205

Objective: To examine the intra-and inter-rater reliability of the Action Research Arm Test (ARAT) at the item level after stroke. Design: An intra-rater and inter-rater reliability study. Subjects: Thirty-five participants (median age 62 years, median time post-stroke 22 months) with impaired upper extremity function after stroke were included in the study. Methods: Two physiotherapists simultaneously, but independently, assessed the participants' performance in all 19 items of the ARAT twice in 1 day. A rank-based statistical method for paired ordinal data, including calculation of percentage agreement (PA), systematic disagreements (relative position (RP), relative concentration (RC)) and individual variability (relative rank variance (RV)) was used. Results: Satisfactory intra-rater and inter-rater agreement was noted for all items except item 19, which was just below satisfactory level. Within and between raters, small but nonnegligible systematic disagreements were found for items 11, 14 and 19 and for items 1, 4, 17 and 19, respectively. There was no disagreement due to random variance within or between raters. Conclusion: The ARAT is a highly reliable observational rating scale at the item level after stroke. Awareness regarding the small systematic disagreements demonstrated in some items is, however, recommended when using ARAT.