INTRODUCTION: Several factors influence the return to work (RTW) after brain injury (BI). The aims of the study were to follow-up the RTW after a vocational neuropsychological programme for individuals with a brain injury and to explore factors predicting RTW. The hypothesis was that as self-awareness was already addressed in the programme, severity of injury would have a greater impact on RTW.

METHOD: Sixty-five of 72 persons (median age 27) who had attended the programme 1998-2003 were interviewed about their occupation at 1, 2, 3 and 5 years after the programme. A logistic regression was made with the variables concerning process skill, somatic problems and irritability, the digit symbol coding and pre-morbid occupation to explore predictors of RTW.

RESULTS: The main cause was TBI (44.6%). Before injury 77% were employed or studied and after the injury 80% did not have any occupation. After 5 years 40% had returned to work. The only significant variable in the regression was the pre-morbid occupation.

DISCUSSION: The study stresses the difficulty to know the key elements involved in RTW which confirms the need for rehabilitation to focus on several factors in different contexts in order to affect the outcome.

Purpose: The study explored the direction of change (decline vs. improvement) after diffuse axonal injury (DAI) in the domains of the ICF: body structure, body function, and activity.

Methods: Thirteen patients with DAI were assessed by using diffusion tensor imaging (DTI) to measure body structure, the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) to measure body function, and the Assessment of Motor and Process Skills (AMPS) to measure activity. The DTI, BNIS, and AMPS were applied at the acute phase (A1), and at 6 and 12 months post-injury (A2 and A3). Visual and statistical analyses were conducted to explore time-dependent changes in the ICF domains.

Results: Improvements were observed for most patients in all ICF domains from injury until six months. Thereafter, the results diverged, with half of the subjects showing a decline in DTI and BNIS scores between A2–A3, and all but one of the patients exhibiting identical or better A2–A3 AMPS process skill scores.

Conclusions: From 6 to 12 months post-injury, some patients underwent an ongoing degenerative process, causing a decline in cognitive function. The same decline was not observed in the activity measure, which might be explained by the use of compensatory strategies.

• Implications for rehabilitation

• In rehabilitation it is essential to be aware that in some cases with TBI, an ongoing degenerative process in the white matter can be expected, causing an adverse late effect on cognitive function.

• The cognitive decline, caused by DAI, does not necessarily mean a concurrent decrease in activity performance, possibly explained by the use of compensatory strategies. This suggests that, after the post-acute phase, rehabilitation offering strategy training may be beneficial to enhance every-day functioning.

• Strategy use requires awareness, which imply the need to assess level of awareness in order to guide rehabilitation.

OBJECTIVE: To assess the effect of three weeks of rehabilitation in the home setting for younger patients with stroke with the aim of improving activity level.

DESIGN: A randomized controlled study with blinded evaluations at discharge, three weeks, three months and one year after discharge.

SETTING: Home of the patient or the ordinary day rehabilitation clinic at the university hospital.

SUBJECTS: Fifty-eight patients (median age 53 years) consecutively discharged from inpatient rehabilitation with a first occurrence of stroke participated in training directly after discharge. Intervention: Rehabilitation was given for 9 hours/week over three weeks. The home group received individually tailored training, based on the patient's needs and desires, with a focus on activities in their natural context. Support and information were also given. The intervention in the day clinic group was aimed mainly at improved functions.

MAIN MEASURES: The main outcome was activity, assessed with the Assessment of Motor and Process Skill (AMPS). The impairment level was also evaluated. Costs were estimated.

RESULT: There were no significant differences between the groups on any of the four assessments. However, there seemed to be an earlier improvement on some measures (including AMPS) for the home group. For both groups there was a greater improvement on the activity level than on the impairment level. the costs of the home group were less than half of the costs of the day clinic group.

CONCLUSION: With the present results, both rehabilitation programmes could be recommended, however, further studies are needed to define patients who may specifically benefit from the home rehabilitation programme. Costs should be taken into consideration.

BACKGROUND: More evidence of the efficacy of caregiver interventions is needed. The aim of this study was to evaluate whether counselling in the home setting reduces the caregiver burden.

METHODS: Thirty-six patients after stroke, median age 53 years, with a close family member, were selected for an evaluation of the burden of care and 35 participated. They were part of a randomized controlled trial, comparing rehabilitation in the home setting with outpatient rehabilitation. In the home setting, counselling about the stroke and its consequences was included. Assessments with the Caregiver Burden scale were made at 3 weeks, 3 months and one year after discharge.

RESULTS: The burden of the 2 groups did not differ. After the intervention, there was a tendency to a lower burden for the home setting. The burden for the home setting was then unchanged from 3 weeks to 1 year, while outpatient rehabilitation showed a reduced burden over time. For the home setting, significant correlations to activity level were seen after the intervention.

CONCLUSION: A positive effect of counselling was seen, as the home setting burden tends to be lower after the intervention, while outpatient rehabilitation seems to adjust with time. The results suggest that counselling reduces burden and the remaining burden is associated with the patient's ability.

BACKGROUND: The first aim of this study was to compare the subjective experiences of social, cognitive, and emotional problems of the patient and his/her next of kin, and explore if this related to cognitive testing. The second aim was to explore how these results reflect the patient's awareness.

METHODS: This is a subanalysis from a longitudinal study in the first year after discharge with comparisons of patient and next of kin scores on the European Brain Injury Questionnaire (EBIQ) and analyses of the relationship of their scores to an objective cognitive screening on 3 occasions. A paired t test was used to explore differences between 35 stroke patients and their next of kin on the EBIQ. Gamma analyses were made to explore the relationship between the EBIQ scores and the Barrow Neurological Institute Screening (BNIS) of higher cognitive functions, with the entire sample grouped into aware and unaware according to the BNIS item of awareness.

RESULTS: We found significant differences between the patient and next of kin assessments on all occasions, apart from at discharge. When grouped, only the group of aware patients differed significantly from their next of kin. Significant relations of the patient ratings on the EBIQ and BNIS were only found at the 1-year follow-up for the unaware group and the entire sample. Next of kin EBIQ scores did not correlate with the BNIS.

CONCLUSIONS: Neither next of kin ratings nor an objective measurement was feasible to use for evaluation of the patient's awareness of social, cognitive, and emotional problems.

Aim: To explore the feasibility to make on-road assessments routinely at 3 months follow-up for all patients with a 3 months verbal prohibition of driving after stroke, to support the physicians decision of fitness to drive.

Methods: From September 2007 to December 2009 there were 151 stroke patients from the stroke units at the hospital eligible for inclusion in the study. Fifty agreed to be assessed by the Nordic Stroke Driver Screening Assessment (NorSDSA) and on-road assessment. As base for discussion about the consequences on resource use relative to accuracy, calculations were made to explore and compare an expected yearly cost for two different assessment conditions, the NorSDSA followed by on-road assessment in uncertain cases and on-road assessment for all cases.

Findings: The yearly need for driving assessments was estimated to 500 patients. With less accuracy than only on-road assessments the NorSDSA with the stipulated cut-off produced a cost benefit of 1,700 €. The NorSDSA resulted in 32% uncertain cases and the certain cases were in 17% in disagreement with the on-road assessment, the gold standard.

Conclusion: It is conceivable and could be recommended to make on-road assessments for all patients with stroke at 3 months follow-up as accuracy is of importance both for patients and society and may save resources in the long run.

OBJECTIVE: We sought to examine the reliability and validity of the European Brain Injury Questionnaire as an evaluation tool in a stroke population by applying the Rasch methodology.

METHODS: The European Brain Injury Questionnaire was distributed to 54 patients with stroke and 36 next of kin at discharge from the rehabilitation ward and at a 1-year follow-up. Rasch analysis was used for evaluating the psychometric characteristic and the quality of the measures produced with focus on reliability and validity. The reliability was determined by the separation. The construct validity was determined by examining the hierarchy of the tasks and by evaluating the fit of individual tasks to the latent construct. Analyses of differences across occasions, and across patients and next of kin, were made to examine the stability of the instrument.

RESULTS: The reliability was good as the instrument met the criteria for separation. Two items at discharge and 5 items at 1-year follow-up were misfits. If not more than 5% of the items fail to fit the Rasch model the instrument can be considered unidimensional, which in this case only concerned the 1-year follow-up. The instrument was stable over time and across patients and next of kin.

CONCLUSION: With some alterations the European Brain Injury Questionnaire seems to be a useful instrument in clinical practice and research, and a help to capture the social, emotional, and cognitive impacts of a stroke.

BACKGROUND: In recent years a number of costs of stroke studies have been conducted based on incidence or prevalence and estimating costs at a given time. As there still is a need for a deeper understanding of factors influencing these costs the aim of this study was to calculate the direct and indirect costs in a younger (<65) sample of stroke patients and to explore factors affecting the costs.

METHODS: Fifty-eight patients included in a study of home rehabilitation and followed for 1 year after discharge from the rehabilitation unit, were interviewed about their use of health care services, assistance, medications and assistive devices. Costs (defined as the cost for society) were calculated. A linear regression of cost and variables of functioning, ability, community integration and health-related quality of life was done.

RESULTS: Inpatient care contributed substantially to the direct cost with a mean length of stay of 92 days. Rehabilitation during the first year constituted of an average of 28 days in day clinics, 38 physiotherapy sessions and 20 occupational therapy sessions. The total direct mean cost was 80 020 euro and the indirect cost 35 129 euro. The direct costs were influenced by the process skill (the ability to plan and perform a given task and to adapt when needed) and presence of aphasia. Indirect costs for informal care giving increased for patients with a lower health-related quality of life as well as a low score on home integration.

CONCLUSION: Costs are high in this group of young (< 65 years) stroke patients compared to other studies, partly due to the length of the stay and partly to loss of productivity.

Background: Working memory (WM) problems influence most activities of daily living. The aim was to evaluate if computerized working memory training after brain injury has a significant effect on functioning in daily life. Method: Outpatients with WM deficits, aged 22-63 years, were randomized to either intervention group (IG, n = 20) or control group (CG, n = 18) and received 5 weeks standard rehabilitation. The IG also received WM training with the Cogmed QM training program. Assessments were made before (A1), immediately (A2) and 3 months (A3) after intervention. After follow-up, the CG was offered the computerized training and assessed after this (A4; n = 8). Assessments included the WAIS-III Digit span reversed, Fatigue Impact Scale (FIS), Assessment of Motor and Process Skills (AMPS), Rivermead Behavioural Memory Test-II (RBMT-II) and a WM questionnaire. Results: The IG improved on digit span and FIS, A1-A2, and significantly more than the CG on the WM questionnaire, A1-A3. Both groups improved in AMPS motor skill and the AMPS process skill score tended towards significant improvement in the IG, from A1-A3. After training (A3-A4), the CG improved in digit span and RBMT-II. Conclusion: The WM training seems to have a generalized effect on functional activity and lessens fatigue.

The purpose of this project was to investigate the effects of Virtual Reality technology and haptics for stroke rehabilitation. Twenty-nine stroke subjects, 17 women, and 12 men aged 44-85 years, participated in three different studies. All participants responded favorable to the use of the VR activity station. A change of attitude took place after the subjects were exposed to playing computer games. The general experience with the VR application approach suggests that this treatment concept is promising in stroke rehabilitation, with a wide range of applicability.

Virtual reality (VR) technology is altering the health care environment and is changing the options that are available to therapists. This study describes how a haptic device was used as a cinematic assessment utility. Three chronic stroke inpatients at Sahlgrenska University Hospital with left hemisphere damage were assessed. The patients were administered by the box and block manual dexterity test. For comparisons, a reference group was added to the study. Several parameters, including time, speed, and movement of the right upper extremity, were extracted and evaluated. The results indicate that the system shows potential as an assessment device. The feasibility study setup is working well, as is the assessment method. Further research, testing, refinement of the exercises, and use of VR and haptics within neurological rehabilitation are suggested.

OBJECTIVE: This exploratory study assessed the possible effectiveness of hemiparetic upper extremity training in subjects with chronic stroke with computer instrumentation (haptic force feedback) and 3-dimensional visualization applied to computer games, as well as to evaluate concurrent computer-assisted assessment of the kinematics of movements and test whether any improvement detected in the computer environment was reflected in activities of daily living (ADLs).

METHODS: A single-subject repeated-measures experimental design (AB) was used. After baseline testing, 5 patients were assigned to the therapy 3 times a week for 45 min for 5 weeks. Velocity, time needed to reach, and hand path ratio (reflecting superfluous movements) were the outcome measures, along with the Assessment of Motor and Process Skills and the Box and Block test. The follow-up phase (C) occurred 12 weeks later.

RESULTS: Improvements were noted in velocity, time, and hand path ratio. One patient showed improvement in occupational performance in ADLs.

CONCLUSIONS: The application of this strategy of using virtual reality (VR) technologies may be useful in assessing and training stroke patients. The results of this study must be reproduced in further studies. The VR systems can be placed in homes or other nonclinical settings.

OBJECTIVES: To examine the recovery of cognitive function, activities of daily living (ADL) ability and vocational situation after stroke.

MATERIALS AND METHODS: Subjects below 65 years of age were included. Cognitive function and personal and instrumental ADL were assessed at discharge and at 1 year. Pre-stroke vocational situation was recorded at baseline and at 1 and 3 years after discharge.

RESULTS: Fifty-eight patients participated. During the first year after discharge, cognitive function and ADL ability improved. At 1 year after discharge, 83% still had cognitive dysfunction, 20% were dependent in ADL and few had returned to work. Only 20% returned to gainful employment 3 years later.

CONCLUSIONS: There was a recovery of cognition and ADL function after stroke but few persons returned to work. Good neurological status was found to be a significant factor and recovery of cognitive function a near-significant factor for return to work.

Introduction: Stroke not only affects the stroke survivor, it also significantly affects their families. Given the important supportive role that relatives of stroke survivor have, they should receive information that helps them plan and cope with the new situation. The objective of the study was to explore how relatives to stroke survivors perceived the information provided by the stroke unit.

Methods: This qualitative study was based on extensive semi-structured interviews with an inductive approach. A heterogeneous convenience sample of relatives to stroke survivor (n=14) was selected. Qualitative content analysis served to analyze the transcribed interview texts.

Results: The content analysis yielded four categories, each with 2-3 subcategories. The overall theme was "to be acknowledged or not": it encompassed the underlying meaning and the relationships between the categories. The four categories were as follows: shifting information needs; striving for information; lacking of continuity and structure; and taking part and being acknowledged.

Conclusions: The study highlighted that the relatives of stroke survivors have a strong need for information and showed that the relatives experienced that they did not always feel satisfactorily informed and supported by the healthcare professionals in the stroke unit. A challenge for the healthcare professionals was to be able to give the right information at the right time and in the appropriate way. The study also showed that when the relatives were acknowledged and invited to participate in the rehabilitation process, they were less anxious of the discharge.

OBJECTIVE: The aim of this work was to explore the extent to which social, cognitive, emotional and physical aspects influence participation after a traumatic brain injury (TBI).

DESIGN/SUBJECTS: An explorative study of the patient perspective of participation 4 years after TBI. The cohort consisted of all patients (age range 18-65 years), presenting in 1999-2000, admitted to the hospital (n = 129). Sixty-three patients responded; 46 males and 17 females, mean age 41 (range 19-60) years.

METHODS: Four years after the injury, the European Brain Injury Questionnaire (EBIQ), EuroQol-5D, Swedish Stroke Register Questionnaire and Impact on Participation and Autonomy (IPA) questionnaire were sent to the sample. Data were analysed with logistic regression.

RESULTS: On the EBIQ, 40% of the sample reported problems in most questions. According to IPA, between 20% and 40% did not perceive that they had a good participation. The analyses gave 5 predictors reflecting emotional and social aspects, which could explain up to 70% of the variation in participation.

CONCLUSION: It is not easy to find single predictors, as there seems to be a close interaction between several aspects. Motor deficits appear to have smaller significance for participation in this late state, while emotional and social factors play a major role.

PURPOSE: The aim of this study was to describe if and when a sample of traumatic brain injury (TBI) patients could finish their time of sick leave during a 4-year follow up and to explore which factors that influenced the time for sick leave.

MATERIALS AND METHODS: All persons, 1999-2002, between 18 and 64 years of age (250 in total), admitted to the emergency room and diagnosed according to ICD 10 as S062 and S063, were included. Demographic data were gathered from medical charts and data concerning sick leave 1 year before trauma and 4 years after trauma, were collected from the Swedish social insurance system. To explore predictors of sick leave, two logistic regressions were performed.

RESULTS: The sample (mean age 39.68) consisted of 78% men. More than half of the accidents were due to fall. In the sample, 28 % was on sick leave on the day of trauma and 96 % of these were still on sick leave 4 years after trauma, compared with 39 % in the group not on sick leave on the day of TBI. Sick leave at the day for trauma was found to be a predictor for sick leave 4 years after trauma for the whole group (p = 0.000) together with Glasgow Coma Scale (GCS) (p = 0.002) and length of stay (p = 0.049). In the logistic regression with only the group not on sick leave, the only significant variable was GCS (p = 0.003).

CONCLUSION: The findings support the necessity to consider premorbid and social factors in the TBI rehabilitation.

BACKGROUND AND PURPOSE: Early 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.

METHODS: A 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).

RESULTS: No 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.

CONCLUSIONS: The 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 REGISTRATION: Clinical Trials.gov: NCT01622205. Registered 19 June 2012 (retrospectively registered).

PURPOSE: The aim of this study is to explore differences between male and female patients entering a rehabilitation program at a pain clinic in order to gain a greater understanding of different approaches to be used in rehabilitation.

METHOD: 1371 patients referred to a specialty pain rehabilitation clinic, completed sociodemographic and pain related questionnaires. They rated their pain acceptance (CPAQ-8), their kinesiophobia (TSK), the impact of pain in their life (MPI), anxiety and depression levels (HAD) and quality of life scales: the SF-36, LiSat-11, and the EQ-5D. Because of the large sample size of the study, the significance level was set at the p ≤.01.

RESULTS: Analysis by t-test showed that when both sexes experience the same pain severity, women report significantly higher activity level, pain acceptance and social support while men report higher kinesiophobia, mood disturbances and lower activity level.

CONCLUSION: Pain acceptance (CPAQ-8) and kinesiophobia (TSK) showed the clearest differences between men and women. Pain acceptance and kinesiophobia are behaviorally defined and have the potential to be changed.

BACKGROUND: Stroke 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/DESIGN: A 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.

DISCUSSION: The 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 REGISTRATION: ClinicalTrials.gov NCT01622205.

Objective: To study if computerized working memory (WM) training, in the sub-acute phase after acquired brain injury, in patients with impaired WM, improves WM, cognition and psychological health. Research design: A randomized study (n = 47) with an intervention group (IG) and a control group (CG), mean age 47.7 years. The WAIS-III NI, Digit span, Arithmetic, Letter-Number Sequences (Working Memory sub-scale), Spatial span, the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) and the self-rating scales DEX and HADS were administered at baseline and at follow-ups at 6 and 18 weeks. Both groups underwent integrated rehabilitation. The IG also trained with the computerized WM training program, Cogmed QM, which was offered to the CG and followed up after the study completion. Results: Both groups improved after their WM training in Working Memory, BNIS and in Digit span, particularly the reversed section. Both the BNIS and the Digit span differed significantly between the IG and CG due to the greater improvement in the IG after their WM training. Psychological health improved as both groups reported less depressive symptoms and the CG also less anxiety, after the training. Conclusion: Results indicated that computerized WM training can improve working memory, cognition and psychological health.