Background Cognitive impairments occur frequently after stroke and contribute to significant disability. Strategy training shows promise but has not been examined in the acute phase of recovery. Objective We conducted a single-blind randomized pilot study estimating the effect of strategy training, relative to reflective listening (attention control), for reducing disability and executive cognitive impairments. Methods Thirty participants with acute stroke who were enrolled in inpatient rehabilitation and had cognitive impairments were randomized to receive strategy training (n=15, 10 sessions as adjunct to usual inpatient rehabilitation) or reflective listening (n=15, same dose). The Functional Independence Measure assessed disability at baseline, rehabilitation discharge, 3 and 6 months. The Color Word Interference Test of the Delis-Kaplan Executive Function System assessed selected executive cognitive impairments (inhibition, flexibility) at baseline, 3 and 6 months. Results Changes in Functional Independence Measure scores for the two groups over 6 months showed significant effects of group (F1,27=9.25, p=0.005), time (F3.74=96.00, p<0.001), and group*time interactions (F3,74=4.37, p<0.007) after controlling for baseline differences in stroke severity (F1,27=6.74, p=0.015). Color Word Interference Inhibition scores showed significant effects of group (F1,26=6.50, p=0.017), and time (F2,34=4.74, p=0.015), but the group*time interaction was not significant (F2,34=2.55, p=0.093). Color Word Interference Cognitive Flexibility scores showed significant effects of group (F1,26=23.41, p<0.001), and time (F2,34=12.77, p<0.001), and group*time interactions (F2,34=7.83, p<0.002). Interaction effects suggested greater improvements were associated with strategy training. Conclusions Strategy training shows promise for addressing disability in the first 6 months after stroke. Lessons from this pilot study may inform future clinical trials.

Objective To examine the feasibility of a strategy training clinical trial in a small group of adults with stroke-related cognitive impairments in inpatient rehabilitation, and to explore the impact of strategy training on disability. Design Non-randomized two-group intervention pilot study Setting Two inpatient rehabilitation units within an academic health center Participants Individuals with a primary diagnosis of acute stroke, who were admitted to inpatient rehabilitation and demonstrated cognitive impairments were included. Individuals with severe aphasia; dementia; major depressive disorder, bipolar, or psychotic disorder; recent drug or alcohol abuse; and anticipated length of stay less than 5 days were excluded. Intervention Participants received strategy training or an attention control session in addition to usual rehabilitation care. Sessions in both groups were 30–40 minutes daily, 5 days per week, for the duration of inpatient rehabilitation. Main Outcome Measures We assessed feasibility through participants’ recruitment and retention; research intervention session number and duration; participants’ comprehension and engagement; intervention fidelity; and participants’ satisfaction. We assessed disability at study admission, inpatient rehabilitation discharge, 3 and 6 months using the Functional Independence Measure. Results Participants in both groups (5 per group) received the assigned intervention (>92% planned sessions; >94% fidelity) and completed follow-up testing. Strategy training participants in this small sample demonstrated significantly less disability at 6 months [M(SE)=117 (3)] than attention control participants [M(SE)=96 (14); t8=7.87, p=.02]. Conclusions It is feasible and acceptable to administer both intervention protocols as an adjunct to acute inpatient rehabilitation, and strategy training shows promise for reducing disability.

Objective To examine the effects of direct skill training and guided training for promoting independence after stroke. Design Single-blind randomized pilot study. Setting Inpatient rehabilitation facility. Participants Forty-three participants in inpatient rehabilitation with acute stroke and cognitive impairments. Interventions Participants were randomized to receive direct skill training (n=22, 10 sessions as adjunct to usual inpatient rehabilitation) or guided training (n=21, same dose). Main Outcome Measure The Functional Independence Measure assessed independence at baseline, rehabilitation discharge, and months 3, 6, and 12. Results Linear mixed models (random intercept, other effects fixed) revealed a significant intervention by time interaction (F4,150=5.11, p<0.001), a significant main effect of time (F4,150=49.25, p<0.001), and a significant effect of stroke severity (F1,150=34.46, p<.001). There was no main effect of intervention (F1,150=0.07, p=0.79). Change in Functional Independence Measures scores was greater for the DIRECT group at rehabilitation discharge (effect size of between group differences, d=0.28) and greater for the GUIDE group at months 3 (d=0.16), 6 (d=0.39), and 12 (d=0.53). The difference between groups in mean 12 month change scores was 10.57 points. Conclusions Guided training, provided in addition to usual care, offered a small advantage in the recovery of independence, relative to direct skill training. Future studies examining guided training in combination with other potentially potent intervention elements may further advise best practices in rehabilitation for individuals with cognitive impairments after acute stroke.

OBJECTIVE. We determined whether various assessment tools detect neglect differently by administering a battery of assessments to people with stroke. METHOD. We conducted a case series study and administered five neglect assessments (paper-and-pencil, functional, virtual reality) to participants poststroke. RESULTS. Twelve participants (6 men, 6 women) with stroke completed the assessment battery, which required approximately 2 hr to administer (over one to two sessions). All participants demonstrated neglect on three or more assessments. Functional assessments and the virtual reality assessment detected neglect more frequently than the paper-and-pencil assessments. Participants performed differently on the paper-and-pencil assessments and functional assessments. CONCLUSION. Because neglect is complex, detection may depend largely on the assessment administered.

Background During upper extremity (UE) stroke rehabilitation it is critical to match patient-ability to task-difficulty to promote neural reorganization and UE skill re-learning. However, there are few methods to do so. A Fugl-Meyer Upper Extremity Assessment (FMA-UE) “keyform,” derived from Rasch Analysis informed and progressed an UE rehabilitation program. Objective Test the feasibility of the keyform method for systematically planning and progressing rehabilitation. We hypothesized that optimally-challenging task-practice will maximize UE motor skill reacquisition. Methods Inclusion criteria: ischemic stroke >3 mo., voluntarily shoulder flexion ≥30° and simultaneous elbow extension ≥20°. The keyform method defined initial targets (goals) and progressed therapy after every 3rd session. Therapy targets were practiced within the context of client-selected functional tasks not in isolation. Feasibility was defined by subject pain/fatigue, UE motor function (Wolf Motor Function Test, WMFT) and movement patterns (kinematics). Assessments were administered pre- and post-treatment and compared with paired t-tests. Task-difficulty and patient-ability measures were calculated with Rasch analysis and compared with paired t-tests (p<0.05). Results Ten subjects (59.70±9.96 yrs., 24.1±30.54 mo. post-stroke) participated in 9 sessions, 200 movement repetitions/session in <2 hrs without pain or fatigue. Subjects gained UE motor function (WMFT: Pre 22.23±24.26 seconds, Post 15.46±22.12 seconds, p=0.01), improved shoulder-elbow coordination (index of curvature: Pre 1.30±0.15, Post 1.21±0.11, p=0.01) and exhibited reduced trunk compensatory movement (trunk displacement: Pre 133.97±74.15 mm, Post 108.08±64.73 mm, p=0.02). Task-difficulty and patient-ability measures were not statistically different throughout the program (Person-ability measures of 1.01±0.05, 1.64±0.45 and 2.22±0.65 logits and item difficulty measures of 0.93±0.37, 1.70±0.20, and 2.06±0.24 logits at the 3 testing time points respectively, p>0.05). Conclusion The FMA-UE keyform is a feasible method to assure that the difficulty of tasks practiced were well matched to initial and evolving levels of UE motor ability.

Rasch keyforms can help interpret clinical assessment scores. The Action Research Arm Test (ARAT) is a commonly used assessment, yet no keyform currently exists. The aim is to provide a keyform for the ARAT and demonstrate how a clinician can use the keyform to design optimally challenging rehabilitation sessions. Secondary analysis of ARAT data ( n = 122) using confirmatory factor and Rasch analyses were used to examine the measurement properties and generate a keyform. The item standardized factor loadings were >0.40 (range = 0.82-0.96) and R values were >.60 (range = .65-.96). All items exhibited adequate infit statistics with point measure correlations >.60 (range = .72-.97). Person reliability was .98, and person separation was 7.07. Item-difficulty measures ranged from -2.78 logits to 2.64 logits. The ARAT has strong measurement properties, and a keyform was provided. We showed how the keyform can be utilized by clinicians to interpret scores, set goals, and plan treatment.

The Behavioral Assessment Screening Tool (BAST) measures neurobehavioral symptoms in adults with traumatic brain injury (TBI). Exploratory Factor Analyses established five subscales: Negative Affect, Fatigue, Executive Function, Impulsivity, and Substance Abuse. In the current study, we assessed all the subscales except Substance Abuse using Rasch analysis following the Rasch Reporting Guidelines in Rehabilitation Research (RULER) framework. RULER identifies unidimensionality and fit statistics, item hierarchies, targeting, and symptom severity strata as areas of interest for Rasch analysis. The BAST displayed good unidimensionality with only one item from the Impulsivity scale exhibiting potential item misfit (MnSQ 1.40). However, removing this item resulted in a lower average domain measure (1.42 to -1.49) and higher standard error (0.34 to 0.43) so the item was retained. Items for each of the four subscales also ranged in difficulty (i.e. endorsement of symptom frequency) with more severe symptoms being endorsed in the Fatigue subscale and more mild symptoms being endorsed in the Impulsivity subscale. Though Negative Affect and Executive Function displayed appropriate targeting, the Fatigue and Impulsivity Subscales had larger average domain values (1.35 and -1.42) meaning that more items may need to be added to these subscales to capture differences across a wider range of symptom severity. The BAST displayed excellent reliability via item and person separation indices and distinct strata for each of the four subscales. Future work should use Rasch analysis in a larger, more representative sample, include more items for the Fatigue and Impulsivity subscale, and include the Substance Abuse subscale.

OBJECTIVE. We examined the feasibility, tolerability, and preliminary efficacy of repetitive task-specific practice for people with unilateral spatial neglect (USN). METHOD.People with USN ³6 mo poststroke participated in a single-group, repeated-measures study.Attendance, total repetitions, and satisfaction indicated feasibility and pain indicated tolerability. Paired t tests and effect sizes were used to estimate changes in upper-extremity use (Motor Activity Log), function (Action Research Arm Test), and attention (Catherine Bergego Scale). CONCLUSION. Repetitive task-specific practice is feasible and tolerable for people with USN. Improvements in upper-extremity use, function, and attention may be attainable. RESULTS.