Block 2.

5 – Scenario for assignment Prognostic Research:

Cerebral Vascular Accident (CVA)

A Cerebral Vascular Accident or CVA, is an acute interruption of blood supply to the brain,
causing neurological symptoms. In case of CVA these symptoms last for more than 24 hours
or lead within this timeframe to death. Brain tissue is damaged through lack of oxygen and
glucoses or the direct pressure caused by the bleeding. Depending on the circumstances
brain tissue can survive oxygen shortages sometimes for hours. In these cases there is a
loss of functions but these could return after normal blood supply is restored. After a CVA
many people recover well or have relatively few residual symptoms. A part of the patients
is confronted with enduring limitations (Kennisnetwerk CVA Nederland, 2011). Many
factors (biological, psychological or social) are of influence on the course of CVA.
A CVA can be divided in ischemic strokes and hemorrhagic strokes. Ischemic strokes
are far more common than hemorrhagic strokes, namely 85 percent versus 15 percent. The
incidence of CVA is approximately 40.000 per year. The incidence of CVA recorded by
general practitioners is over 2 per 1.000 people yearly. Among people aged 65 or older this
is 14 per 1000 per year. Given the greying of the population an increase of the incidence is
anticipated. In 2009 approximately 9.000 people deceased from CVA. Estimates concerning
the number of people suffering a CVA vary; in 2007 the prevalence was about 200.000.
Only 10 percent of the people suffered only one CVA, on average people suffering a CVA
have more than 4 diagnoses all together (Kennisnetwerk CVA Nederland, 2011).
After a CVA immediate recognizable sensorimotor and speech or swallowing
disorders may occur. Also neurological function disorders and mood disorders, in particular
depression occur frequently. These influence rehabilitation motivation, the course of
recovery and the regaining of daily activities and the participation. In almost half of people
also emotional and behavioral changes occur after CVA (Kennisnetwerk CVA Nederland,
2011).
 In every phase (acute, rehabilitation and chronic) after the CVA patients can
experience problems resuming their lives. During the acute and sub-acute phase in the
hospital care is directed at the medical treatment of the CVA, the prevention of
complications and assessment of the consequences for daily life. To support resumption of
daily life, advice is given concerning the best treatment trajectory. A part of the clients
continues the treatment trajectory during the rehabilitation phase in a clinical or policlinical
treatment trajectory. This care is offered by the hospital (policlinical), the rehabilitation
center (clinical and policlinical rehabilitation), elderly care facilities (clinical geriatric
rehabilitation, day care, home care) as well as first line practices

Translation of Steultjens, E.M.J., Cup, E.H.C., Zajec, J., Van Hees, S., (2013) Ergotherapierichtlijn
CVA. Nijmegen/Utrecht. Hogeschool van Arnhem en Nijmegen/Ergotherapie Nederland.

Assignment: Approach the course of CVA from the perspective that is assigned to your group
(see below):

The patient / family perspective: the perspective of patients with CVA, or the perspective of their
family / caregivers.

Based on the perspective that was assigned to you, what prognostic research question would
you come up with and in what study design would you ideally investigate this prognostic
research question? Describe this in a paper with a maximum of 1000 words (excluding the
diagram/flowchart). The paper should contain the following elements:
- the research question you are addressing;
- the perspective from which the research question will be addressed (this perspective
will be assigned to the different groups, e.g. the perspective of the patient, doctor,
employer) and the setting in which the study will be performed (the setting follows from
the perspective, e.g. a specialised clinic);
- the study design (including the motivation for the chosen study design);
- the in- and exclusion criteria for selecting the appropriate patients, including the
moment during the course of the disease from which the patients are followed over
time;
- definition of primary and secondary outcome measures; also explain the measurement
instruments that will be used to measure these outcomes (and prognostic factors) and
the intervals at which they will be measured – consider the adequate scale,
measurement instrument, and motivation for choosing particular measurement
instruments;
- duration and frequency of follow-up;
- definition of prognostic factors;
- ways to prevent/counteract loss-to-follow-up;
- illustration of the study design in a flowchart/diagram;
- used literature (add a reference list).

Submitting your paper

Please write your names on the front page (the front page can be downloaded from eleum), so
that it is clear for the tutor who have contributed to the assignment. Also on the front page,
each student has to give his/her signature stating that he/she has contributed in an adequate
way to the assignment. If a signature is missing, it is assumed that this student did not
contribute and no grade will be given to him/her.

Deadline for submission of the paper is:

Wednesday 4 June 2013 13.00 hours

The paper needs to be submitted as hard-copy at the department of Epidemiology (deb1, 2nd
floor, room A2.14) and via Safe Assign (BA ITM> Epidemiology> Year 2> Prognostic research
(block 2.5) > Hand in prognostic research)
Note! Papers submitted after the deadline will be considered as “not received” and will not
be graded.