Participation in everyday life of

adults following mild stroke

Noomi Katz, PhD, OTR

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Israel: Tel Aviv and Jerusalem in pictures The new and the old

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Factors contributing to

participation of adults following

mild stroke 3 month post event

Noomi Katz, Tal Adamit, Adina Maeir

Einor Ben-Assayag on behalf of the TABASCO team

Research Institute for Health and Medical Professions,

Ono Academic College, School of Occupational

Therapy, Hebrew University Jerusalem,

Tel Aviv Sourasky Medical Center, Israel

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Objectives

The aim of the study was to evaluate and provide

a profile of the status of clients that underwent

a mild stroke regarding their cognitive abilities,

affective state, daily functioning, return to

work (RTW), reintegration in the community

and quality of life.

In order to ascertain the rehabilitation needs of

this population.

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Rationale and Background

Stroke is one of the major causes of disabilities

in adults. In the last few years, it was found that

even mild stroke survivors experience residual

damages, which persist and in fact increase in

the following years.

Studies show that about a third of all

individuals after mild stroke are under the age

of 65, and 45% of the survivors having

difficulties in community participation

(Edwards et al, 2006; Wolf et al, 2009).

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Rationale and Background

Identifying factors contributing to post stroke

participation decline could potentially yield

more effective therapeutic opportunities.

Furthermore, in order to develop appropriate

rehabilitation services for this population it is

necessary to understand the factors that enable

or impede community reentry.

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Design: The TABASCO study

The study is a longitudinal, cohort study that recruits

all consecutive first ever stroke patients with mild-

moderate stroke at a major hospital in Tel Aviv.

It was designed to evaluate the association between

demographic, psychological, cognitive, brain function

and disease related factors collected during the acute

phase of the ischemic stroke and its long-term

outcomes.

Clients are followed at 3m, 6m, 12m, 18m, 24m and

will continue each year till 10 years post event

(Ben-Assayag on behalf of the TABASCO team, in press)

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Current study:

3 month post event

Within this design the current study

focused on the 3 month period after

discharge and data is gathered at the

participants' home by experienced

occupational therapists.

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Participants

All clients who fit the inclusion criteria of

first event, NIHSS≤5 defining mild stroke,

without previous neurological or psychiatric

episodes who were hospitalized at a major

medical center.

At the point of this analysis: 149

participants, 61 women and 88 men were

evaluated at 3 month post event.

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Measures

A comprehensive diagnostic, cognitive and

affective assessment battery was performed at

the hospital within the first week; further

measures at home 3 months after the event

Cognitive: MOCA, EFPT, DEX.

Affective component and quality of life: Stroke

Impact Scale (SIS) ; one factor from DEX.

Functional: FIM, Modified Rankin scale

(MRS), Occupational Questionnaire (OQ),

Return to Normal Living (RNL), SIS recovery.

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Instruments

Affective and Quality of life

SIS ; DEX

Functional

MRS

FIM

OQ

RNL

recovery))SIS

Cognitive MoCA EFPT DEX

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Participants

n %

Gender

88 59.1% Men

61 40.9% Women

Years of education

14 9.4% elementary

73 49% High

school

62 41.9% Higher

education 12

Results

Profiles of performance on all measures

Correlations between variables

Differences between subgroups of clients

who are working/not working

Multiple regression to understand what

variables predict outcomes

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Cognitive status

MoCA Mean (SD)= (4.8 )22.24 n=149

72%

28%

Below norm

Above norm

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Executive function components

Telephone task EFPT

Mean(SD) %(n) needed

Cues

N=113

(76). 22 . (13 )11.5 initiation

(83). 30 . (20 )17.7 organization

(1.46 )1.01 (48 )43.6 sequencing

(96 ).37 . (19 )17.4 judgment

(96 ).37 . (5 )4.6 completion

2.04(3.8)

52.3 (57) Total

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Executive function DEX

Participants’ report difficulties: Abstract thinking – 29.5%

Planning – 19.8%

Distractibility – 24%

Poor decision-making ability – 20.6%

Family report higher percentage of

difficulties

Difference between self and family :

M(self)=13.8 (SD=11.7) ; M(family)=18.22 (SD=15.9)

t(99)=-2.72, p<.008

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Functional status

%

limitation

Mean

SD

(85)57% (1.05 )1.87 MRS

(2 )2% (9.63 )120.21 FIM total

7-42% difficulties

on different items

(8.88 )20.88 RNL

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Occupational Questionnaire

division of hours during 24 hours

3.34

5.76

4.861.86

7.88

Work

Leisure

ADL

Rest

Sleep

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Leisure & Return to Work

0

1

2

3

4

5

6

7

8

TotalActiveTVPassive

Work

Don't Work

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Participation in work

Reduced work: 62% work before the

event vs. 42% working today

0%

20%

40%

60%

80%

100%

Before EventAfter Event

Don't work

Work

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Participation in work -

only participants who worked before

From 92 individuals who worked before

event 33% didn’t return to work

33%

67%

Don't work

Work

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Comparison of cognitive & affective

only participants who worked before

t

Don’t work

N=30 work

N=62

2.54* 2.17 (2.44) .77 (1.51) EFPT

2.03* 22.48 (16.96) 14.51 (13.62) DEX

Family

*2.20 (3.16 )4.50 (2.33 )3.07 DEX

affective

-2.60* 67.68 (25.43) 81.54 (20.26) SIS

affective

*p<.05 22

Comparison of function

only participants who worked before

t

Don’t work

N=30 work

N=62

5.88** (.88) 2.33 (.72) 1.24 MRS

-3.92** (7.45 )119.50 (1.87 )124.92 FIM

3.50** (9.82) 22.10 (4.90) 16.70 RNL

-2.72** (29.10) 67.60 (15.74 )86.49 SIS

recovery

**p<.001

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Correlations

cognition with function

**p<.001

MRS FIM

total

RNL

total

-.44** .61** -.37** MOCA

.39** -.48** .34** EFPT

.27** -.35** .45** DEX self

.36** -.37** .33** DEX

other

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Correlations

cognition with QoL

SIS

ADL

SIS

Communication SIS

Memory SIS

Physical

.49** .27** .38** .36** MOCA

-.39** -.26** -.34** -.19* EFPT

-.23** -.39** -.46** -.20* DEX self

-.27** -.39** -.31** -.31** DEX

other

*p<.05 ; **p<.001 25

Correlations

cognition with QoL

SIS

Recovery

SIS

Participation SIS

Hand

function

SIS

Mobility

.41** .32** .41** .46** MOCA

-.27** -.29** -.22* -.32** EFPT

-.26** -.27** -.27** -.35** DEX self

-.17 -.25* -.33** -.31** DEX

other

*p<.05 ; **p<.001

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Correlation

function with QoL

SIS

ADL

SIS

Communication SIS

Memory SIS

Physical

-.64** -.37** -.50** -.50** MRS

.72** .36** .58** .55** FIM

-.54** -.38** -.50** -.38** RNL

*p<.05 ; **p<.001

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Correlation

function with QoL

SIS

Recovery

SIS

Participation SIS

Hand

function

SIS

Mobility

-.69** -.69** -.58** -.67** MRS

.67** .61** .57** .75** FIM

-.65** -.57** -.48** -.68** RNL

**p<.001

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Correlation

cognition & function with affective

SIS

affective

Factor emotion

DEX self

.29** -.20* MOCA

-.38** .22* EFPT

-.51** .33** MRS

.48** -.35** FIM

-.49** .46** RNL

.54** -.25** SIS Recovery

*p<.05 ; **p<.001

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Prediction of outcomes

Multiple regression

Disability (MRS)

Community reintegration (RNL)

Recovery (cognition / affective)

Recovery (function)

This analysis was performed on only on

n=100

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Disability (MRS)

(cognition and affective)

R²

change

F change (p) T (p) β

22. (002 ).7.01 Block 1:

(003 ).3.12 385. age

(655 ).45. 055. Years of

education

12. (038 ).3.03 Block 2:

(054 ).1.98- 284.- MoCA

(873 ).16. 024. EFPT

(858 ).18.- 023.- DEX other

14. (001 ).12.8 Block 3:

(001 ).3.58- 407.- SIS

affective 31

R²

change

F change

(p)

T (p) β

05. (263 ).1.37 Block 1:

(198 ).1.31 172. age

(219 ).1.25 164. Years of

education

15. (036 ).3.09 Block 2:

(489 ).70.- 107.- MoCa

(626 ).50. 077. EFPT

(363 ).92. 127. DEX other

20. (000 ).15.9 Block 3:

(000 ).3.98- 486.- SIS

affective

Community reintegration (RNL) (cognition and affective)

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Recovery (SIS) (cognition and affective)

R²

change

F change

(p)

T (p) β

04. (373 ).1.00 Block 1:

(334 ).97.- 13.- age

(592 ).54.- 70.- Years of

education

15. (044 ).2.90 Block 2:

(0.15 ).2.52 384. MoCa

(834 ).21. 033. EFPT

(156 ).1.44 198. DEX other

23. (000 ).18.9 Block 3:

(000 ).4.35 524. SIS

affective 33

Recovery (SIS) (Function)

R²

change

F change

(p)

T (p) β

06. (063 ).2.85 Block 1:

(113 ).1.60 13. age

(472 ).77. 05. Years of

education

48. (000 ).31.25 Block 2:

(474 ).72. 08. FIM

(000 ).4.55- 46.- MRS

(003 ).3.09 31.- RNL

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Summary of findings

Results show significant moderate correlations between

cognitive, affective and functional measures at 3 months

post onset as well as with executive function EFPT and

DEX measures, same with affective measures.

These correlations are also significant from 3 months to 6

and 12 months post onset.

Regarding RTW, more hours of work was shown to be

significantly moderately correlated with cognitive

performance, daily function, perception of recovery and

with better reintegration in the community.

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Summary of findings

Significant differences were found between

participants who RTW to those who did not on

basic functional measures (MRS, FIM, OQ, SIS

level of recovery).

Multiple regression shows significant contribution

of cognitive measures to outcomes of disability,

reintegration to community and recovery beyond

demographic variables that contribute only to

disability; Affective measure contribute

significantly beyond cognition; while recovery of

function is mainly predicted by previous functional

levels.

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Conclusions

The results show a range of difficulties

that individuals following a mild stroke

event experiencing in the community

The findings shed light on the

interactions of various demographic,

diagnostic, cognitive, affective and

functional components that play a role in

mild stroke.

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Conclusions

It further indicates the implications for return to

work and reintegration into community.

The lack of intervention provided to these

individuals, wrongly assuming for the most part

that the event did not have a lasting effect.

The findings further support the recent scientific

literature about the effects of mild neurological

events and the necessity for further investigation

of their causes.

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References

Adamit, T. (2011). Relationships between cognitive and emotional status.

Participation and quality of life among individuals following first event mils

stroke. Unpublished Thesis Occupational Therapy School, Hebrew

University, Jerusalem.

Ben-Assayag, E. et al, (In press 2011). Predictors for Post-stroke outcomes:

the TABASCO (Tel Aviv Brain Acute Stroke Cohort) study protocol.

International Journal of Stroke.

Edwards, D. et al, (2006). The impact of mild stroke on meaningful activity

and life satisfaction. Journal of Stroke and Cerebrovascular Disease, 15, 151-

157.

Wolf, T. et al, (2009). Changing face of stroke: Implications for

occupational therapy practice. American Journal of Occupational Therapy,

63, 621–625.

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Thank you from

Ono Academic College,

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Israel flowers