Behavioral self-management strategies for practice and exercise should be included in neurologic rehabilitation trials and care

"Exercise… to Me, It's Freedom": Motivation, Support, and Self-Management to Keep Physically Active with Parkinson's Disease: A Qualitative Study

The benefits of exercise have been widely explored among people with Parkinson's (PwP). Exercise can improve non-motor (fatigue, pain, sleep, etc.) and motor features (balance, muscle strength, gait speed, etc.), maintain function, as well as prevent disease progression. Although the benefits are well known, PwP continue to show difficulty adhering to physical activity and exercise. This study aims to explore motivation to exercise, support, and self-management needs among people with Parkinson's, their family members, and physiotherapists. Purposeful and maximum-variation sampling methods (age, sex, geographical setting, and disease severity) were employed. PwP and family members were recruited through physiotherapy services and local support groups. Twelve semi-structured interviews with PwP and two group interviews, one with family members (n = 4) and one with physiotherapists (n = 5), were conducted. Interview guides were informed by patient-public input and a recent systematic review. Interviews were recorded, transcribed, and analysed using thematic analysis informed by the Grounded Theory methodology. Four common themes emerged: (1) The value of an intrinsic connection with exercise, for which there are challenges. A greater connection to exercise led to long-term adherence. (2) Adapting exercise to the needs and preferences of a person is essential. Preferred exercises and environments were mixed, with differences emerging between sexes. (3) Physiotherapists' aim to only maintain physical function led to frustration. Limited self-management opportunities, stigma, and dehumanisation were discussed. (4) Non-motor symptoms, stigma, fear, and determination as well as apathy, pain, and low mood were discussed. Exercise provided physical, emotional, and social rewards. Supports are necessary; however, challenges arise when PwP's motivations are mismatched to family members' and physiotherapists' goals. Co-created goals, tailored to their preferences, and exercise plans with supported self-management are recommended.

Digital Technology Enablers of Tele-Neurorehabilitation in Pre- and Post-COVID-19 Pandemic Era - A Scoping Review

Neurorehabilitation (NR), a major component of neurosciences, is the process of restoring a patient's damaged/disorganized neurological function, through training, therapy, and education, while focusing on patient's independence and well-being. Since the advent of the COVID-19 pandemic, various applications of telecare and telehealth services surged drastically and became an integral part of current clinical practices. Tele-Neurorehabilitation (TNR) is one of such applications. When rehabilitation services were disrupted globally due to lockdown and travel restrictions, the importance of TNR was recognized, especially in developed, low, and middle-income countries. With exponential deployment of telehealth interventions in neurosciences, TNR has become a distinct stand-alone sub-specialty of neurosciences and telehealth. Digital technologies, such as wearables, robotics, and Virtual Reality (VR) have enabled TNR to improve the quality of patients' lives. Providing NR remotely using digital technologies and customized digital devices is now a reality, and likely to be the new norm soon. This article provides an overview of the needs, utilization, and deployment of TNR, and focuses on digital technology enablers of TNR in pre- and post-COVID-19 pandemic era.

Identifying central elements of the therapeutic alliance in the setting of telerehabilitation: A qualitative study

INTRODUCTION

Therapeutic alliance is a relevant aspect of healthcare and may influence patient outcomes. So far, little is known about the therapeutic alliance in telerehabilitation.

PURPOSE

To identify and describe central elements of therapeutic alliance in the setting of telerehabilitation and compare it to those in conventional rehabilitation.

METHODS

In this qualitative study, a literature search and in-depth semi-structured interviews with rehabilitation and telerehabilitation experts were conducted from 15.5.-10.8.2020 on elements influencing the therapeutic alliance in rehabilitation and telerehabilitation. Using a combined deductive and inductive approach, qualitative content analysis was used to identify categories and derive central themes.

RESULTS

The elements bond, communication, agreement on goals and tasks and external factors were identified in the literature search and informed the development of the interview guide. Twelve purposively sampled experts from the fields of physiotherapy, occupational therapy, speech and language therapy, psychology, general medicine, sports science and telerehabilitation software development participated in the interviews. We identified three central themes: building effective communication; nurturing a mutual relationship of trust and respect; and agreement on goals and tasks and drivers of motivation.

CONCLUSIONS

In this qualitative study, key elements of therapeutic alliance in rehabilitation confirmed those reported in the literature, with additional elements in telerehabilitation comprising support from others for ensuring physical safety and technical connectedness, caregivers acting as co-therapists and applying professional touch, and promoting patient autonomy and motivation using specific strategies.

Uptake of Technology for Neurorehabilitation in Clinical Practice: A Scoping Review

OBJECTIVE

Technology-based interventions offer many opportunities to enhance neurorehabilitation, with associated research activity gathering pace. Despite this fact, translation for use in clinical practice has lagged research innovation. An overview of the current "state of play" regarding the extent of clinical uptake and factors that might influence use of technologies is required. This scoping review explored the uptake of technologies as neurorehabilitation interventions in clinical practice and factors that are reported to influence their uptake.

METHODS

This systematic scoping review was conducted with narrative synthesis and evidence mapping. Studies of any design reporting uptake or implementation of technology (wearable devices, virtual reality, robotics, and exergaming) for movement neurorehabilitation after stroke and other neurological conditions were sought via a formal search strategy in MEDLINE (Ovid), CINAHL, AMED, and Embase. Full-text screening and data extraction were completed independently by 2 reviewers.

RESULTS

Of 609 studies returned, 25 studies were included after title, abstract, and full-text screening. Studies investigated a range of technologies at various stages of development. Only 4 of the included studies explored the sustained use of technology in practice. The following 5 themes representing experiences of technology use emerged: perceived usefulness, technology design, social interaction, integration with services, and suggested improvements to enhance uptake.

CONCLUSION

Reporting of uptake and use of neurorehabilitation technologies in clinical practice is limited. The synthesis provided comprehensive knowledge of barriers to and facilitators of uptake to be considered in future protocols, including a steep learning curve required to engage with technology, a need for a supportive organizational culture, and a need for user involvement in both design and development.

IMPACT

This scoping review has provided indicators from current evidence of important factors to consider in the planning of research into and clinical implementation of technologies for neurorehabilitation. It serves to support an evidence-based, user-centered platform for improved research on and translation of technologies in neurorehabilitation clinical practice.

Knowledge, attitude, and practice of patients with major depressive disorder on exercise therapy

BACKGROUND

This study aimed to explore the knowledge, attitude, and practice (KAP) toward exercise therapy of patients with major depressive disorder (MDD).

METHODS

This cross-sectional study was conducted at the First Hospital of Shanxi Medical University between April and October 2023 in patients with MDD. A self-designed questionnaire was used to evaluate the KAP (Cronbach's α = 0.787). The minimum-maximum scores were 2-23 for knowledge, 11-55 for attitude, and 7-35 for practice.

RESULTS

A total of 494 valid questionnaires were analyzed. The mean KAP dimension scores were 15.39 ± 3.34/23 (66.91%), 36.54 ± 19.33/55 (66.44%), and 19.33 ± 5.22/35 (55.23%), indicating poor knowledge, negative attitude, and weak practice. Multivariable logistic regression analysis showed that female (OR = 0.613, 95%CI: 0.376-1.000, P = 0.050), urban residence (OR = 0.443, 95%CI: 0.259-0.758, P = 0.003), suburban residence (OR = 0.047, 95%CI: 0.016-0.138, P < 0.001), higher income (OR = 3.889-7.928, all P < 0.001), and unclear self-reported depression level (OR = 0.078, 95%CI: 0.027-0.221, P < 0.001) were independently associated with the knowledge scores. Knowledge scores (OR = 1.102, 95%CI: 1.022-1.188, P = 0.011), female gender (OR = 0.437, 95%CI: 0.246-0.776, P = 0.005), city (OR = 0.410, 95%CI: 0.226-0.744, P = 0.003), married (OR = 3.577, 95%CI: 1.751-7.650, P < 0.001), higher income (OR = 0.065-0.392, both P < 0.050), depressive trend (OR = 2.640, 95%CI: 1.110-6.278, P = 0.028), high depression score level (OR = 0.176, 95%CI: 0.104-0.300, P < 0.001), and unclear self-reported depression score (OR = 0.023, 95%CI: 0.007-0.076, P < 0.001) were independently associated with the attitude scores. Finally, knowledge scores (OR = 1.130, 95%CI: 1.051-1.215, P = 0.001), attitude scores (OR = 1.199, 95%CI: 1.124-1.280, P < 0.001), and city (OR = 0.583, 95%CI: 0.352-0.965, P = 0.036) were independently associated with the practice scores. The structural equation modeling analysis showed that knowledge, but not attitude (β = 0.103, P = 0.092) or practice (β = 0.034, P = 0.603), influenced the depression level (β=-0.074, P < 0.001); attitude influenced practice (β = 0.369, P < 0.001).

CONCLUSION

The KAP toward exercise among MDD patients is poor in Shanxi. Females, people living in urban or suburban areas, with lower income, and self-reported unclear depression levels should be targeted by education interventions.

Evaluating Feasibility of a Secondary Stroke Prevention Program

Healthy lifestyles including exercise and diet can reduce stroke risk, but stroke survivors often lack guidance to modify their lifestyles after hospital discharge. We evaluated the implementation of a new, secondary stroke prevention program involving supervised exercise, multidisciplinary education and coaching to address modifiable risk factors. The group-based program involved face-to-face and telehealth sessions. The primary outcomes were feasibility, examined via service information (referrals, uptake, participant demographics and costs), and participant acceptability (satisfaction and attendance). Secondary outcomes examined self-reported changes in lifestyle factors and pre-post scores on standardized clinical tests (e.g., waist circumference and 6-Minute Walk (6MWT)). We ran seven programs in 12 months, and 37 people participated. Attendance for education sessions was 79%, and 30/37 participants completed the full program. No adverse events occurred. Participant satisfaction was high for 'relevance' (100%), 'felt safe to exercise' (96%) and 'intend to continue' (96%). Most participants (88%) changed (on average) 2.5 lifestyle factors (diet, exercise, smoking and alcohol). Changes in clinical outcomes seemed promising, with some being statistically significant, e.g., 6MWT (MD 59 m, 95% CI 38 m to 80,159 m, p < 0.001) and waist circumference (MD -2.1 cm, 95%CI -3.9 cm to -1.4 cm, p < 0.001). The program was feasible to deliver, acceptable to participants and seemed beneficial for health. Access to similar programs may assist in secondary stroke prevention.

Barriers and facilitators to implementing self-directed therapy activities in inpatient rehabilitation settings

BACKGROUND

Self-directed therapy activities are not currently part of routine care during inpatient rehabilitation. Understanding patient and clinician perspectives on self-directed therapy is key to increasing implementation. The aim of this study was to investigate barriers and facilitators to implementing a self-directed therapy programme ("My Therapy") in adult inpatient rehabilitation settings.

METHODS

My Therapy was recommended by physiotherapists and occupational therapists and completed by rehabilitation inpatients independently, outside of supervised therapy sessions. Physiotherapists, occupational therapists, and patients were invited to complete an online questionnaire comprising open-ended questions on barriers and facilitators to prescribing and participating in My Therapy. A directed content analysis of free-text responses was undertaken, with data coded using categories of the Capability, Opportunity, and Motivation Model of Behaviour (COM-B model).

RESULTS

Eleven patients and 20 clinicians completed the questionnaire. Patient capability was reported to be facilitated by comprehensive education by clinicians, with mixed attitudes towards the format of the programme booklet. Clinician capability was facilitated by staff collaboration. One benefit was the better use of downtime between the supervised therapy sessions, but opportunities for patients to engage in self-directed therapy were compromised by the lack of space to complete the programme. Clinician opportunity was reported to be provided via organisational support but workload was a reported barrier. Patient motivation to engage in self-directed therapy was reported to be fostered by feeling empowered, engaged, and encouraged to participate. Clinician motivation was associated with belief in the value of the programme.

CONCLUSION

Despite some barriers to rehabilitation patients independently practicing therapeutic exercises and activities outside of supervised sessions, both clinicians and patients agreed it should be considered as routine practice. To do this, patient time, ward space, and staff collaboration are required. Further research is needed to scale-up the implementation of the My Therapy programme and evaluate its effectiveness.

Comprehensive Assessment of the Activity Level of the ICF Using Both Capacity and Performance Measures: A Case Report

Individuals with neurologic conditions seek physical therapy services to improve mobility in their daily lives. While clinicians commonly track activity capacity, measurement of activity performance in daily life is an emerging yet unstandardized practice within routine clinical physical therapy. The purpose of this case report is to (1) provide an example of the structure, clinical reasoning, and implementation of both activity capacity and activity performance level assessments across an episode of outpatient physical therapy and (2) to describe how objective activity performance in daily life tracking supported the physical therapy intervention and education plan. A 42-year-old woman presented to outpatient neurologic physical therapy with a rare autoimmune-mediated disorder with primary goals of independently caring for her youngest child and grandchild, walking without limitations in the home and community, participating in exercise, and returning to work due to deconditioning and dizziness. The patient participated in 12 visits across a span of 4.5 months targeting performance in daily life (steps per day), aerobic conditioning, and vestibular habituation. Activity capacity measurement served as a standardized assessment of what the patient was able to do in the clinic, and activity performance in daily life tracking via a Samsung wrist worn consumer-grade device provided a quantitative assessment of real-world daily stepping activity. Tracking of activity performance in daily life was an essential component of physical therapy management that provided an objective quantification of daily stepping activity to identify barriers and facilitators to increasing daily performance in an individual with a medical diagnosis of Susac syndrome.

The Critical Period After Stroke Study (CPASS) Upper Extremity Treatment Protocol

Objective

To present the development of a novel upper extremity (UE) treatment and assess how it was delivered in the Critical Periods After Stroke Study (CPASS), a phase II randomized controlled trial (RCT).

Design

Secondary analysis of data from the RCT.

Setting

Inpatient and outpatient settings the first year after stroke.

Participants

Of the 72 participants enrolled in CPASS (N=72), 53 were in the study groups eligible to receive the treatment initiated at ≤30 days (acute), 2-3 months (subacute), or ≥6 months (chronic) poststroke. Individuals were 65.1±10.5 years of age, 55% were women, and had mild to moderate UE motor capacity (Action Research Arm Test=17.2±14.3) at baseline.

Intervention

The additional 20 hours of treatment began using the Activity Card Sort (ACS), a standardized assessment of activities and participation after stroke, to identify UE treatment goals selected by the participants that were meaningful to them. Treatment activities were broken down into smaller components from a standardized protocol and process that operationalized the treatments essential elements.

Main Outcome Measures

Feasibility of performing the treatment in a variety of clinical settings in an RCT and contextual factors that influenced adherence.

Results

A total of 49/53 participants fully adhered to the CPASS treatment. The duration and location of the treatment sessions and the UE activities practiced during therapy are presented for the total sample (n=49) and per study group as an assessment of feasibility and the contextual factors that influenced adherence.

Conclusions

The CPASS treatment and therapy goals were explicitly based on the meaningful activities identified by the participants using the ACS as a treatment planning tool. This approach provided flexibility to customize UE motor therapy without sacrificing standardization or quantification of the data regardless of the location and UE impairments of participants within the first year poststroke.

mHealth Impact on Gait and Dynamic Balance Outcomes in Neurorehabilitation: Systematic Review and Meta-analysis

Gait and dynamic balance are two main goals in neurorehabilitation that mHealth systems could address. To analyze the impact of using mHealth systems on gait and dynamic balance outcomes in subjects with neurological disorders. Randomized controlled trials (RCT) published in PubMed, Web of Science, Scopus, and PEDro databases were searched up to April 2023. Studies including adults with neurological disorders, analyzing the effectiveness of mHealth systems on gait and dynamic balance compared with conventional therapy and/or not intervention, were included. The PEDro scale and the Cochrane Collaboration's 2.0 tool were used for the methodological quality and risk of bias assessment. The Review Manager 5.4 software was used to obtain meta-analyses. 13 RCT were included in the systematic review and 11 in the meta-analyses, involving 528 subjects. A total of 21 mobile applications were identified for gait and balance training, and to enhance physical activity behaviors. There were significant differences in gait parameters, speed by 0.10 s/m (95% confidence interval (CI)=0.07,0.13;p<0.001), cadence by 8.01 steps/min (95%CI=3.30,12.72;p<0.001), affected step length by 8.89 cm (95%CI=4.88,12.90;p<0.001), non-affected step length by 8.08 cm (5%CI=2.64,13.51;p=0.004), and in dynamic balance, Timed Up and Go by -7.15 s (95%CI=-9.30,-4.99;p<0.001), and mobility subscale of Posture Assessment Scale for Stroke by 1.71 points (95%CI=1.38,2.04;p<0.001). Our findings suggested the use of mHealth systems for improving gait in subjects with neurological disorders, but controversial results on dynamics balance recovery were obtained. However, the quality of evidence is insufficient to strongly recommend them, so further research is needed.

Exercise Self-Efficacy and Fatigue as Predictors of Adherence to Home-Based Exercise Among Patients with Multiple Sclerosis

Background

Adherence to home-based exercise programs can be improved by determining the factors associated with exercise adoption and maintenance in patients with multiple sclerosis. However, the factors that influence adherence to home-based exercise have been poorly studied among patients with multiple sclerosis in Saudi Arabia. This study aimed to examine predictors of adherence to home-based exercise programs among patients with multiple sclerosis in Saudi Arabia.

Methods

This was a cross-sectional observational study. A total of forty individuals (mean age = 38.65 ± 8.16 years) diagnosed with multiple sclerosis participated in the study. Outcome measures were self-reported exercise adherence, the Arabic version of exercise self-efficacy, the Arabic version of patient-determined disease steps, and the Arabic version of the fatigue severity scale. All outcome measures were assessed at baseline, except for self-reported adherence to exercise, which was measured after 2 weeks.

Results

Our results showed that the adherence to home-based exercise programs was significantly positively correlated with exercise self-efficacy and negatively correlated with fatigue and disability. Exercise self-efficacy (β = 0.62, p < 0.01) and fatigue (β = -0.24, p = 0.04) were significant predictors of adherence to home-based exercise programs.

Conclusion

These findings suggest that exercise self-efficacy and fatigue should be considered by physical therapists when designing a tailored exercise program for patients with multiple sclerosis. This may facilitate greater adherence to the home-based exercise programs and improve functional outcomes.

Assessing the impact of a knowledge translation intervention on physical therapists' self-efficacy and implementation of motor learning practice

BACKGROUND

The application of motor learning (ML) principles and research in physical therapy can optimize patient outcomes. However, the translation of the accumulated knowledge in ML to clinical practice is limited. Knowledge translation interventions, which are designed to promote changes in clinical behaviors, have the potential to address this implementation gap. We developed, implemented, and evaluated a knowledge translation intervention for ML implementation that focuses on building clinical capacity among physical therapists for the systematic application of ML knowledge in clinical practice.

METHODS

A total of 111 physical therapists underwent the intervention, which consisted of the following: (1) an interactive didactic 20-hour course; (2) an illustrated conceptual model of ML elements; and (3) a structured clinical-thinking form. Participants completed the Physical Therapists' Perceptions of Motor Learning (PTP-ML) questionnaire pre and post intervention. The PTP-ML was used to assess ML-related self-efficacy and implementation. Participants also provided post-intervention feedback. A sub-sample (n = 25) provided follow-up feedback more than a year after the completion of the intervention. Pre-post and post-follow-up changes in the PTP-ML scores were calculated. The information gathered from the open-ended items of the post-intervention feedback was analyzed to identify emerging themes.

RESULTS

Comparing pre- and post-intervention scores, significant changes were found in the total questionnaire scores, self-efficacy subscale scores, reported implementation subscale scores (P < .0001), and general perceptions and work environment subscale score (P < .005). The mean changes in the total questionnaire and self-efficacy scores also significantly exceeded the Reliable Change Index. In the follow-up sample, these changes were maintained. Participants felt that the intervention helped them organize their knowledge in a structured manner and consciously link their practice elements to concepts in ML. Discussion of clinical cases was reported to be the most valuable educational method, and the illustrated conceptual model of ML elements was the least valued. Respondents also suggested support activities to maintain and enhance the learning experience, including on-site mentorship and hands-on experience.

CONCLUSIONS

Findings support the positive effect of an educational tool, most prominently on physical therapists' ML self-efficacy. The addition of practical modeling or ongoing educational support may enhance intervention effects.

Effect of Self-Directed Home Therapy Adherence Combined with TheraBracelet on Poststroke Hand Recovery: A Pilot Study

Hand impairment is a common consequence of stroke, resulting in long-term disability and reduced quality of life. Recovery may be augmented through self-directed therapy activities at home, complemented by the use of rehabilitation devices such as peripheral sensory stimulation. The objective of this study was to determine the effect of adherence to self-directed therapy and the use of TheraBracelet (subsensory random-frequency vibratory stimulation) on hand function for stroke survivors. In a double-blind, randomized controlled pilot trial, 12 chronic stroke survivors were assigned to a treatment or control group (n = 6/group). All participants were instructed to perform 200 repetitions of therapeutic hand tasks 5 days/week while wearing a wrist-worn device 8 hours/day for 4 weeks. The treatment group received TheraBracelet vibration from the device, while the control group received no vibration. Home task repetition adherence and device wear logs, as well as hand function assessment (Stroke Impact Scale Hand domain), were obtained weekly. Repetition adherence was comparable between groups but varied among participants. Participants wore the device to a greater extent than adhering to completing repetitions. A linear mixed model analysis showed a significant interaction between repetition and group (p = 0.01), with greater adherence resulting in greater hand function change for the treatment group (r = 0.94; R ² = 0.88), but not for the control group. Secondary analysis revealed that repetition adherence was greater for those with lower motor capacity and greater self-efficacy at baseline. This pilot study suggests that adherence to self-directed therapy at home combined with subsensory stimulation may affect recovery outcomes in stroke survivors. This trial is registered with NCT04026399.

Improvement in the Capacity for Activity Versus Improvement in Performance of Activity in Daily Life During Outpatient Rehabilitation

We addressed questions about the potential discrepancy between improvements in activity capacity and improvements in activity performance in daily life. We asked whether this discrepancy is: Common in routine, outpatient care, or an artifact of intervention studies? Unique to upper limb (UL) rehabilitation, or is it seen in walking rehabilitation too? Only seen in persons with stroke, or a broader neurorehabilitation problem?

Psychometric Properties of the Action Research Arm Test (ARAT) Scale in Post-Stroke Patients-Spanish Population

The validation of measuring instruments in the field of health is a requirement before they can be used safely and reliably. The action research arm test (ARAT) tool is an instrument validated in numerous countries and languages and for different populations, and its use is widespread. The objective of this research was to determine the psychometric properties of ARAT for a sample composed of post-stroke patients. To achieve this, a psychometric analysis was performed, where internal consistency tests were carried out using Cronbach's alpha, correlations between items and item-total and half-level tests to verify their reliability. Regarding validity, criteria validity tests were performed, taking the motor function dimension of the Fugl-Meyer scale as gold standard, and convergent validity tests were performed by correlation with the FIM-FAM, ECVI-38 and Lawton and Brody scales. The results showed very good internal consistency as well as good criterion and convergent validity. In conclusion, the ARAT can be considered a valid and reliable instrument for the evaluation of upper limb function in post-stroke patients.

How to Best Develop and Deliver Generic Long-Term Condition Rehabilitation Programmes in Rural Settings: An Integrative Review

People living rurally frequently experience health disparities especially if living with a long-term condition (LTC) or multi-morbidity. Self-management support is a key component of LTC management and commonly included in rehabilitation programmes to enhance ability to self-manage health and encourage physical activity. Such programmes are however often condition focussed and despite evidence for their effectiveness, are not always feasible to deliver in rural settings. Generic programmes are arguably more optimal in the rural context and delivery can be face to face or remotely (via telehealth). The aim of this explorative integrative review was to collate and present international evidence for development, delivery, integration, and support of community-based, generic LTC group rehabilitation programmes delivered rurally in person, or remotely using telehealth. Electronic databases were systematically searched using MeSH terms and keywords. For inclusion, articles were screened for relevance to the aim, and practical information pertaining to the aim were extracted, charted, and organized deductively into themes of Development, Delivery, Integration, and Support. Within each theme, data were synthesized inductively into categories (Theory, Context, Interpersonal aspects, and Technology and Programme aspects). Fifty-five studies were included. Five studies contributed information about community based programmes delivered via the internet. Development was the only theme populated by information from all categories. The theme of Support was only populated with information from one category. Our review has drawn together a large body of diverse work. It has focused on finding practical information pertaining to the best ways to develop, deliver, integrate, and support a community-based generic rehabilitation programme for people living with long-term health conditions, delivered rurally and/or potentially via the internet. Practical suggestions were thematically organized into categories of theory, context, interpersonal aspects, and technology and programme aspects. While the findings of this review might appear simple and self-evident, they are perhaps difficult to enact in practice.

Common Bias and Challenges in Physical and Rehabilitation Medicine Research: How to Tackle Them

The importance of evidence-based medicine is crucial, especially in physical and rehabilitation medicine (PRM), where there is a need to conduct rigorous experimental protocols, as in any medical field. Currently, in clinical practice, therapeutic approaches are often based on empirical data rather than evidence-based medicine. However, the field of PRM faces several challenges that may complicate scientific research. In addition, there is often a lack of appropriate research training in educational programs. In this context, we aim to review the methodological challenges in PRM and provide clear examples for each of them as well as potential solutions when possible. This article will cover the following themes: (1) Choosing the right study design and conducting randomized and benchmarking controlled trials; (2). Selecting the appropriate controlled, placebo or sham condition and the issue of blinding in non-pharmacological trials; (3) The impact of populations' heterogeneity and multi-comorbidities; (4). The challenge of recruitment and adherence; (5). The importance of homogeneity and proper quantification of rehabilitative strategies; and (6). Ethical issues. We are convinced that teaching the basics of scientific research in PRM could help physicians and therapists to choose a treatment based on (novel) scientific evidence. It may also promote scientific research in PRM to develop novel and personalized rehabilitation strategies using rigorous methodologies and randomized or benchmarking controlled trials in order to improve patients' management.

The process of commitment to exercise among stroke survivors in Canada

The objective of this research was to understand the process of commitment to exercise participation for functional recovery among community-living survivors of stroke following discharge from formal rehabilitation. Participants were recruited from a mid-sized city in south-western Ontario, Canada. Between September 2017 and March 2018, 10 individuals living in the community with the effects of stroke, who continued to engage in regular exercise post-stroke, were recruited for participation. Constructivist grounded theory methodology was employed, utilising in-depth individual interviews and theoretical sampling, whereby data collection and analysis occurred simultaneously. Analysis involved constant comparison between data and codes to reduce knowledge gaps and formulate the proposed theory. The process of commitment to exercise involved four phases. Initiation of the process followed a significant interaction with a healthcare provider who advocated for participants to learn the foundations of exercise. Through planned exercise, maintenance of a positive attitude and comparisons with their pre-stroke selves and peers, participants identified future goals and imparted the desire to get back to life before stroke. Over time individuals navigated exercise opportunities-trialling different types and environments-to learn what works. Finally, participants developed a commitment to exercise as a way of life, supported by social connections and reinforced with pride in successes-mastering self-care skills, improved mobility and meaningful function. The process of commitment to exercise among survivors of stroke required early interactions with healthcare providers to initiate exercise participation for long-term engagement, and navigation through various exercise elements fuelled by a desire to reconnect with their pre-stroke selves.

Leveraging Factors of Self-Efficacy and Motivation to Optimize Stroke Recovery

The International Classification of Functioning, Disability and Health framework recognizes that an individual's functioning post-stroke reflects an interaction between their health condition and contextual factors encompassing personal and environmental factors. Personal factors significantly impact rehabilitation outcomes as they determine how an individual evaluates their situation and copes with their condition in daily life. A key personal factor is self-efficacy-an individual's belief in their capacity to achieve certain outcomes. Self-efficacy influences an individual's motivational state to execute behaviors necessary for achieving desired rehabilitation outcomes. Stroke rehabilitation practice and research now acknowledge self-efficacy and motivation as critical elements in post-stroke recovery, and increasing evidence highlights their contributions to motor (re)learning. Given the informative value of neuroimaging-based biomarkers in stroke, elucidating the neurological underpinnings of self-efficacy and motivation may optimize post-stroke recovery. In this review, we examine the role of self-efficacy and motivation in stroke rehabilitation and recovery, identify potential neural substrates underlying these factors from current neuroimaging literature, and discuss how leveraging these factors and their associated neural substrates has the potential to advance the field of stroke rehabilitation.

A Prediction Model of Rehabilitation Motivation in Middle-Aged Survivors of Stroke in Rehabilitation Facilities in Korea

BACKGROUND

To improve the health outcomes of survivors of stroke, it is critical that they are highly motivated to engage in rehabilitation activities. Despite the increasing prevalence of strokes among middle-aged adults, there is limited knowledge regarding factors that may affect survivors' motivation to engage in rehabilitation.

OBJECTIVE

The aim of this study was to examine the relationship among factors that predict the rehabilitation motivation of middle-aged survivors after a stroke through structural equation modeling.

METHODS

A total of 200 middle-aged (40-64 years) survivors of stroke from 9 rehabilitation hospitals in Korea completed questionnaires on depressive symptoms, self-efficacy, social support, and rehabilitation motivation. Information on clinical characteristics, including physical function (activities performed during daily life), was collected through the review of medical records. Structural equation modeling was used to construct a prediction model of rehabilitation motivation.

RESULTS

The average subject's age was 56.2 ± 6.6 years, and the mean time since the event of their stroke was 15.02 ± 8.95 months. Subjects' self-efficacy (being able to live everyday life) after their stroke (β = .500, P < .001) and the social support provided by family and medical personnel (β = .284, P < .010) directly affected their rehabilitation motivation. The bootstrapping method showed that depressive symptoms indirectly affected rehabilitation motivation through self-efficacy, as did physical function.

CONCLUSIONS

In middle-aged survivors of stroke, self-efficacy and social support play a critical role in maintaining intrinsic motivation to engage in rehabilitation activities. Self-efficacy should be evaluated periodically and improved by encouraging individuals to achieve goals, emphasizing their self-regulation, especially among those who reported depressive symptoms and low physical function.

Upper Limb Performance in Daily Life Approaches Plateau Around Three to Six Weeks Post-stroke

Background. Wearable sensors allow for direct measurement of upper limb (UL) performance in daily life. Objective. To map the trajectory of UL performance and its relationships to other factors post-stroke. Methods. Participants (n = 67) with first stroke and UL paresis were assessed at 2, 4, 6, 8, 12, 16, 20, and 24 weeks after stroke. Assessments captured UL impairment (Fugl-Meyer), capacity for activity (Action Research Arm Test), and performance of activity in daily life (accelerometer variables of use ratio and hours of paretic limb activity), along with other potential modifying factors. We modeled individual trajectories of change for each measurement level and the moderating effects on UL performance trajectories. Results. Individual trajectories were best fit with a 3-parameter logistic model, capturing the rapid growth early after stroke within the longer data collection period. Plateaus (90% of asymptote) in impairment (bootstrap mean ± SE: 32 ± 4 days post-stroke) preceded those in capacity (41 ± 4 days). Plateau in performance, as measured by the use ratio (24 ± 5 days), tended to precede plateaus in impairment and capacity. Plateau in performance, as measured by hours of paretic activity (41 ± 6 days), occurred at a similar time to that of capacity and slightly lagged impairment. Modifiers of performance trajectories were capacity, concordance, UL rehabilitation, depressive symptomatology, and cognition. Conclusions. Upper limb performance in daily life approached plateau 3 to 6 weeks post-stroke. Individuals with stroke started to achieve a stable pattern of UL use in daily life early, often before neurological impairments and functional capacity started to stabilize.

Developing a Framework for Designing and Deploying Technology-Assisted Rehabilitation After Stroke: A Qualitative Study

OBJECTIVE

Many unmet rehabilitation needs of patients with stroke can be addressed effectively using technology. However, technological solutions have not yet been seamlessly incorporated into clinical care. The purpose of this pilot study was to examine how to bridge the gaps between the recovery process, technology, and clinical practice to impact stroke rehabilitation meaningfully.

DESIGN

Semistructured interviews were performed using a grounded theory approach with purposive sampling of 17 diverse expert providers in acute care, inpatient, and outpatient stroke rehabilitation settings. Common themes were identified from qualitative analyses of the transcribed conversations to develop a guiding framework from the emerging concepts.

RESULTS

Four core themes emerged that addressed major barriers in stroke rehabilitation and technology-assisted solutions to overcome these barriers: (1) accessibility to quality rehabilitation, (2) adaptability to patient differences, (3) accountability or compliance with rehabilitation, and (4) engagement with rehabilitation.

CONCLUSIONS

The results suggest a four-pronged framework, the A3E framework that stands for Accessibility, Adaptability, Accountability, and Engagement, to comprehensively address existing barriers in providing rehabilitation services. This framework can guide technology developers and clinicians in designing and deploying technology-assisted rehabilitation solutions for poststroke rehabilitation, particularly using telerehabilitation.

Home-Based Exercise Training in Multiple Sclerosis: A Systematic Review with Implications for Future Research

BACKGROUND

Substantial evidence supports the benefits of supervised exercise training (ET) in people with multiple sclerosis (MS). However, there are limitations such as transportation problems preventing physical activity for some people with MS. One opportunity for increasing physical activity participant in people with MS is home-based exercise training (HBET), yet we are unaware of a systematic review of HBET in people with MS. We undertook a systematic review for enhancing the knowledge about HBET in people with MS.

METHODS

To identify eligible studies, we included the medical subject headings (MeSH) keywords including 'multiple sclerosis' OR 'MS' OR 'degenerative nerve disease' AND 'home-based exercise' OR 'home-based training' OR 'home-based balance training' OR 'home-based rehabilitation' OR 'physical telerehabilitation' OR 'home-based walking' OR 'home-based step training.' Studies were included in this review that examined the effect of HBET in people with MS, were written in English, and available in full-text.

RESULTS

According to inclusion and exclusion criteria, 24 studies were judged eligible to be included in this systematic review. The results indicated that a total number of 10 studies had mainly implemented combined ET interventions. Balance and aerobic ET had been included in 5 studies. Three studies had further administered resistance ET interventions and one study had applied exergaming. Moreover, 13 studies had focused on the effects of ET on physical fitness, one article had reflected on the impact of ET on fatigue, and nine cases had included fatigue, quality of life, and fitness as outcome measures.

CONCLUSIONS

Home-based ET, 2-7 times per week, is beneficial, feasible, and safe in people with MS. Nevertheless, there were notable limitations, including (a) adherence to interventions, which needs to be addressed in future studies, and (b) disability-related outcomes which should be considered in future HBET studies.

Adherence Rate, Barriers to Attend, Safety, and Overall Experience of a Remote Physical Exercise Program During the COVID-19 Pandemic for Individuals After Stroke

Introduction: The actions taken by the government to deal with the consequences of the coronavirus diseases 2019 (COVID-19) pandemic caused different levels of restriction on the mobility of the population. The need to continue offering physical exercise to individuals after stroke became an emergency. However, these individuals may have barriers to adhere to the programs delivered remotely. There is a lack of evidence related to adherence, attendance, safety, and satisfaction of remote exercise programs for this population.

Objective: The aim was to evaluate adherence and barriers to attend a remote physical exercise program for individuals after stroke. We aimed (a) to identify adherence and attendance rate of the remote physical exercise program (i.e., number of participants engaged, number of sessions attended, and exercise time in remote program); (b) to identify the safety of a remote physical exercise program (i.e., falls, pain, or dizziness when performing the exercises, fear, or insecurity); and (c) to identify the overall experience to participate in a remote program.

Materials and methods: This is a longitudinal study, including 36 stroke survivors who already attended a face-to-face physical exercise program prior to the COVID-19 pandemic. The remote physical exercise program included sessions for 2 days/week for a duration of 22 weeks, with a total of 44 sessions, which were delivered asynchrony via recorded video sessions. As outcome measures, we performed two questionnaires (via weekly telephone calls) to identify attendance, barriers, safety, and overall experience related to the program.

Results: The adherence rate was 86 (9%). The attendance rate was 19, with a total of 8 sessions (108.3 min/week). The main barriers for lower attendance rate were as follows: lack of motor skills and physical fitness to workout in 80 reports (20.6%), followed by no exercise companion in 44 reports (11.3%). The remote physical program has been shown to be safe, and the overall experience was positive from the perspectives of the participants and the family members.

Conclusion: Although the adherence rate was high, the attendance rate was low on the remote physical exercise program. The main barriers to attending the program remotely reflect the need of tailoring individually an asynchrony mode of delivering the sessions to individuals after stroke. Our results also indicate how the COVID-19 impacted the health conditions of stroke survivors. The program was safe, and the overall experience indicated a change in the mental, physical, and social health of individuals after stroke and their family members.

Clinical value of assessing motor performance in postacute stroke patients

Background

Rehabilitative treatment plans after stroke are based on clinical examinations of functional capacity and patient-reported outcomes. Objective information about daily life performance is usually not available, but it may improve therapy personalization.

Objective

To show that sensor-derived information about daily life performance is clinically valuable for counseling and the planning of rehabilitation programs for individual stroke patients who live at home. Performance information is clinically valuable if it can be used as a decision aid for the therapeutic management or counseling of individual patients.

Methods

This was an observational, cross-sectional case series including 15 ambulatory stroke patients. Motor performance in daily life was assessed with body-worn inertial sensors attached to the wrists, shanks and trunk that estimated basic physical activity and various measures of walking and arm activity in daily life. Stroke severity, motor function and activity, and degree of independence were quantified clinically by standard assessments and patient-reported outcomes. Motor performance was recorded for an average of 5.03 ± 1.1 h on the same day as the clinical assessment. The clinical value of performance information is explored in a narrative style by considering individual patient performance and capacity information.

Results

The patients were aged 59.9 ± 9.8 years (mean ± SD), were 6.5 ± 7.2 years post stroke, and had a National Institutes of Health Stroke Score of 4.0 ± 2.6. Capacity and performance measures showed high variability. There were substantial discrepancies between performance and capacity measures in some patients.

Conclusions

This case series shows that information about motor performance in daily life can be valuable for tailoring rehabilitative therapy plans and counseling according to the needs of individual stroke patients. Although the short recording time (average of 5.03 h) limited the scope of the conclusions, this study highlights the usefulness of objective measures of daily life performance for the planning of rehabilitative therapies. Further research is required to investigate whether information about performance in daily life leads to improved rehabilitative therapy results.

Use of artificial intelligence as an instrument of evaluation after stroke: a scoping review based on international classification of functioning, disability and health concept

Introduction: To understand the current practices in stroke evaluation, the main clinical decision support system and artificial intelligence (AI) technologies need to be understood to assist the therapist in obtaining better insights about impairments and level of activity and participation in persons with stroke during rehabilitation. Methods: This scoping review maps the use of AI for the functional evaluation of persons with stroke; the context involves any setting of rehabilitation. Data were extracted from CENTRAL, MEDLINE, EMBASE, LILACS, CINAHL, PEDRO Web of Science, IEEE Xplore, AAAI Publications, ACM Digital Library, MathSciNet, and arXiv up to January 2021. The data obtained from the literature review were summarized in a single dataset in which each reference paper was considered as an instance, and the study characteristics were considered as attributes. The attributes used for the multiple correspondence analysis were publication year, study type, sample size, age, stroke phase, stroke type, functional status, AI type, and AI function. Results: Forty-four studies were included. The analysis showed that spasticity analysis based on ML techniques was used for the cases of stroke with moderate functional status. The techniques of deep learning and pressure sensors were used for gait analysis. Machine learning techniques and algorithms were used for upper limb and reaching analyses. The inertial measurement unit technique was applied in studies where the functional status was between mild and severe. The fuzzy logic technique was used for activity classifiers. Conclusion: The prevailing research themes demonstrated the growing utility of AI algorithms for stroke evaluation.

Self-care research: How to grow the evidence base? (reprint)

BACKGROUND AND OBJECTIVE

The number of studies in the area of self-care is growing and international researchers are increasingly developing self-care interventions to improve outcomes of individual patients and communities. However, growth of the evidence is still slow due to challenges with designing and testing self-care interventions. In this article we address major methodological challenges with regard to the definition of self-care, use of theory, and research design, intended to provide guidance to researchers in this field.

METHOD

During the inaugural conference of the International Center for Self-Care Research held in Rome, Italy in June 2019 we identified important issues in existing self-care research. Discussion and literature review lead to eight recommendation for future self-care research.

RESULTS

In preparation, begin with a theoretically sound definition of self-care. In planning the intervention, build on and extend previous studies. Use theory to develop self-care interventions and consider translational models to guide development, evaluation and implementation of complex self-care interventions. Employ a study design that fits the current phase and objectives of the research and measure self-care and related factors carefully. In reporting, describe the sample and setting sufficiently so that others can draw conclusions about generalizability and applicability to their practice and patient population. In interpretation, describe how the intervention is assumed to work (causal assumptions) and its key components.

CONCLUSION

Our review of existing self-care research clearly illustrates that the recommendations we provide are needed if we are to substantially grow the evidence base supporting self-care. Embracing a core set of principles will allow us to build on each other's work. Tweetable abstract: A core set of methodological principles is needed to substantially grow the evidence base supporting self-care.

Training with Agency-Inspired Feedback from an Instrumented Glove to Improve Functional Grasp Performance

Sensory feedback from wearables can be effective to learn better movement through enhanced information and engagement. Facilitating greater user cognition during movement practice is critical to accelerate gains in motor function during rehabilitation following brain or spinal cord trauma. This preliminary study presents an approach using an instrumented glove to leverage sense of agency, or perception of control, to provide training feedback for functional grasp. Seventeen able-bodied subjects underwent training and testing with a custom-built sensor glove prototype from our laboratory. The glove utilizes onboard force and flex sensors to provide inputs to an artificial neural network that predicts achievement of "secure" grasp. Onboard visual and audio feedback was provided during training with progressively shorter time delay to induce greater agency by intentional binding, or perceived compression in time between an action (grasp) and sensory consequence (feedback). After training, subjects demonstrated a significant reduction (p < 0.05) in movement pathlength and completion time for a functional task involving grasp-move-place of a small object. Future work will include a model-based algorithm to compute secure grasp, virtual reality immersion, and testing with clinical populations.

Identifying user-centered content, design, and features for mobile health apps to support long-term assessment, behavioral intervention, and transitions of care in neurological rehabilitation: An exploratory study

Introduction

The use of mobile health technology has the potential to increase healthcare accessibility, promote self-management, provide education materials, and support self-monitoring of biometrics. This may be of particular benefit to those living in the community with chronic neurological conditions. The purpose of this research was to characterize perspectives of individuals with brain injury or stroke, their care partners, and neuro-rehabilitation clinicians to inform the design of mobile health app-based interventions that address the need for ongoing community-based health-related professional support.

Methods

Individuals with stroke or traumatic brain injury, their care partners, and clinicians were recruited from a large university hospital with a specialized neuro-rehabilitation program. Data were collected via semi-structured focus groups and were examined using descriptive statistics and content analysis.

Results

Five consistent themes emerged: (a) all-in-one app with customized features; (b) communication with healthcare providers; (c) cognitive strategies; (d) app accessibility; and (e) user education. The clinician focus group reiterated these consumer focus group themes, with one additional theme: (f) logistics of clinician time and effort to provide effective app-based services to patients.

Conclusions

Results have directly informed the ongoing development of a community-based mobile health app intervention, and may also inform the content and design of future mHealth technological development in this population.

Experiences of augmented arm rehabilitation including supported self-management after stroke: a qualitative investigation

OBJECTIVE

To explore the experiences of stroke survivors and their carers of augmented arm rehabilitation including supported self-management in terms of its acceptability, appropriateness and relevance.

DESIGN

A qualitative design, nested within a larger, multi-centre randomized controlled feasibility trial that compared augmented arm rehabilitation starting at three or nine weeks after stroke, with usual care. Semi-structured interviews were conducted with participants in both augmented arm rehabilitation groups. Normalization Process Theory was used to inform the topic guide and map the findings. Framework analysis was applied.

SETTING

Interviews were conducted in stroke survivors' homes, at Glasgow Caledonian University and in hospital.

PARTICIPANTS

17 stroke survivors and five carers were interviewed after completion of augmented arm rehabilitation.

INTERVENTION

Evidence-based augmented arm rehabilitation (27 additional hours over six weeks), including therapist-led sessions and supported self-management.

RESULTS

Three main themes were identified: (1) acceptability of the intervention (2) supported self-management and (3) coping with the intervention. All stroke survivors coped well with the intensity of the augmented arm rehabilitation programme. The majority of stroke survivors engaged in supported self-management and implemented activities into their daily routine. However, the findings suggest that some stroke survivors (male >70 years) had difficulties with self-management, needing a higher level of support.

CONCLUSION

Augmented arm rehabilitation commencing within nine weeks post stroke was reported to be well tolerated. The findings suggested that supported self-management seemed acceptable and appropriate to those who saw the relevance of the rehabilitation activities for their daily lives, and embedded them into their daily routines.

Motivational Strategies for Stroke Rehabilitation: A Delphi Study

OBJECTIVES

The primary objective was to provide a list of effective motivational strategies based on consensus among rehabilitation experts, generated using the Delphi technique. The secondary objective was to identify the types of information that are important when selecting motivational strategies.

DESIGN

Delphi study.

SETTING

On-site survey at academic conferences and web-based survey.

PARTICIPANTS

Rehabilitation experts (N=198) including physicians, physical therapists, occupational therapists, and speech-language-hearing therapists who had worked in stroke rehabilitation for at least 5 years.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Panelists were asked to rate the effectiveness of motivational strategies and to rate the importance of different types of information using a 5-point Likert scale. Consensus was defined as having been reached for items with an interquartile range of 1 or less.

RESULTS

A total of 116 experts (58.6%) completed the third round of the Delphi survey. Consensus was reached on all of the 26 presented strategies. Seven strategies, such as control of task difficulty and goal setting, were considered to be very effective in increasing patient motivation. In addition, all 11 of the presented types of information regarding patient health status, environmental factors, and personal factors were deemed very important or important in determining which motivational strategies to use.

CONCLUSIONS

We generated a list of effective motivational strategies for stroke rehabilitation based on expert consensus. Our results suggest that experts consider a comprehensive range of patient information when choosing motivational strategies. These findings represent a group of consensus-based recommendations for increasing patient adherence to stroke rehabilitation programs, which may be beneficial to many medical professionals working in stroke rehabilitation.

Promoting Physical Activity via Telehealth in People With Parkinson Disease: The Path Forward After the COVID-19 Pandemic?

OBJECTIVE

There is mounting evidence in support of exercise and physical activity as a first-line approach to managing symptoms and potentially altering disease progression in people with Parkinson disease (PD). For many patients, a critical gap is the need for expert guidance to overcome barriers, set realistic goals, and provide personalized advice to optimize exercise uptake and adherence. The purpose of this case report is to describe a physical activity coaching program (Engage-PD) for individuals newly diagnosed with PD and to highlight rapid modifications made to this program in response to the COVID-19 pandemic.

METHODS (CASE DESCRIPTION)

Engage-PD is a single cohort implementation study of a coaching intervention grounded in self-determination theory being conducted at Columbia University Parkinson's Foundation Center of Excellence in New York City, NY (USA), the early epicenter of the COVID-19 pandemic in the United States. The project was uniquely positioned to be adapted to telehealth delivery and to address an immediate need for support and guidance in the home environment, including people with early-mid-stage PD. Participants completed baseline and follow-up (3 months) assessments and participated in up to 4 coaching sessions, all delivered via a telehealth platform. The intervention incorporated 1:1 coaching, goal-setting, physical activity monitoring, and use of a disease-specific workbook to promote and support safe exercise uptake.

RESULTS

While the program is ongoing, 52 referrals were received and 27 individuals with PD enrolled in the first 2 months of the pandemic for a recruitment rate of 52%. Although direct comparisons with pre-coronavirus recruitment are difficult due to the recency of the Engage-PD implementation study, this recruitment rate was larger than expected, which may have been due to several factors (eg, most patients had limited, if any, access to in-person programs and therapy services during this time, so the Engage program filled an immediate need to provide exercise and activity guidance). There was a wide range of scores for both baseline physical activity and self-efficacy measures.

CONCLUSION

Remotely delivered interventions may serve as a sustainable platform for physical activity coaching programs for people with PD as well as other neurodegenerative diseases.

IMPACT

With the uncertainty brought about by the current pandemic, this case report highlights the opportunity to shift the current model of care for individuals with neurodegenerative diseases such as PD.

Motivational Strategies for Stroke Rehabilitation: A Descriptive Cross-Sectional Study

Background: The addition of motivational strategies to a rehabilitation program is thought to enhance patient adherence and improve outcomes. However, little is known about how rehabilitation professionals motivate stroke patients during rehabilitation. The primary objective of this study was to provide a comprehensive and quantitative list of motivational strategies for stroke rehabilitation. In addition, we aimed to examine (1) whether professionals with more clinical experience used a higher number of motivational strategies, (2) the purpose for using each strategy, and (3) the information considered when choosing strategies.

Methods: This descriptive, cross-sectional study was conducted using a web survey with a convenience sample of 407 rehabilitation professionals including physicians, nurses, physical therapists, occupational therapists, and speech-language-hearing therapists.

Results: We received data for 362 participants. Fifteen strategies were found to be used by more than 75% of the respondents to motivate their patients. Almost all of the respondents reported that they actively listened to and praised their patients to increase patient adherence to rehabilitation programs. Respondents with more clinical experience tended to use a higher number of motivational strategies (rho = 0.208, p < 0.001). For 11 of the 15 strategies selected by more than 75% of the respondents, the highest percentage of respondents reported that they used the strategies to make rehabilitation worthwhile for their patients. The majority of respondents reported that they decided which motivational strategy to use by considering comprehensive information regarding the patient health condition, environmental factors, and personal factors.

Conclusions: The comprehensive list of motivational strategies obtained may be useful for increasing patient adherence to rehabilitation, especially for professionals with less clinical experience. Furthermore, our findings regarding the purpose for using each strategy and the information considered when choose strategies might help rehabilitation professionals to optimally utilize the motivational strategy list.

Design of the WHIP-PD study: a phase II, twelve-month, dual-site, randomized controlled trial evaluating the effects of a cognitive-behavioral approach for promoting enhanced walking activity using mobile health technology in people with Parkinson-disease

Background

Parkinson disease (PD) is a debilitating and chronic neurodegenerative disease resulting in ambulation difficulties. Natural walking activity often declines early in disease progression despite the relative stability of motor impairments. In this study, we propose a paradigm shift with a “connected behavioral approach” that targets real-world walking using cognitive-behavioral training and mobile health (mHealth) technology.

Methods/design

The Walking and mHealth to Increase Participation in Parkinson Disease (WHIP-PD) study is a twelve-month, dual site, two-arm, randomized controlled trial recruiting 148 participants with early to mid-stage PD. Participants will be randomly assigned to connected behavioral or active control conditions. Both conditions will include a customized program of goal-oriented walking, walking-enhancing strengthening exercises, and eight in-person visits with a physical therapist. Participants in the connected behavioral condition also will (1) receive cognitive-behavioral training to promote self-efficacy for routine walking behavior and (2) use a mHealth software application to manage their program and communicate remotely with their physical therapist. Active control participants will receive no cognitive-behavioral training and manage their program on paper. Evaluations will occur at baseline, three-, six-, and twelve-months and include walking assessments, self-efficacy questionnaires, and seven days of activity monitoring. Primary outcomes will include the change between baseline and twelve months in overall amount of walking activity (mean number of steps per day) and amount of moderate intensity walking activity (mean number of minutes per day in which > 100 steps were accumulated). Secondary outcomes will include change in walking capacity as measured by the six-minute walk test and ten-meter walk test. We also will examine if self-efficacy mediates change in amount of walking activity and if change in amount of walking activity mediates change in walking capacity.

Discussion

We expect this study to show the connected behavioral approach will be more effective than the active control condition in increasing the amount and intensity of real-world walking activity and improving walking capacity. Determining effective physical activity interventions for persons with PD is important for preserving mobility and essential for maintaining quality of life. Clinical trials registration NCT03517371, May 7, 2018.

Trial registration

ClinicalTrials.gov: NCT03517371. Date of registration: May 7, 2018. Protocol version: Original.

Clinical recommendations to guide physical therapy practice for Huntington disease

OBJECTIVE

In the past decade, an increasing number of studies have examined the efficacy of physical therapy interventions in people with Huntington disease (HD).

METHODS

We performed a mixed-methods systematic review using Joanna Briggs Institute (JBI) methodology and included experimental and observational study designs. The search resulted in 23 quantitative studies and 3 qualitative studies from which we extracted data using JBI standardized extraction tools. Results of this review suggested that physical therapy interventions may improve motor impairments and activity limitations in people with HD. Here, we expand on the review findings to provide specific recommendations to guide clinical practice.

RESULTS

We recommend the following specific physical therapy interventions for people with HD: aerobic exercise (grade A evidence), alone or in combination with resistance training to improve fitness and motor function, and supervised gait training (grade A evidence) to improve spatiotemporal features of gait. In addition, there is weak (grade B) evidence that exercise training improves balance but does not show a reduction in the frequency of falls; inspiratory and expiratory training improves breathing function and capacity; and training of transfers, getting up from the floor, and providing strategies to caregivers for involvement in physical activity in the midstages of HD may improve performance. There is expert consensus for the use of positioning devices, seating adaptations, and caregiver training in late stages of HD.

CONCLUSIONS

There is strong evidence to support physical therapy interventions to improve fitness, motor function, and gait in persons with HD.

The impact of a patient-directed activity program on functional outcomes and activity participation after stroke during inpatient rehabilitation—a randomized controlled trial

Objective:

Individuals post stroke are inactive, even during rehabilitation, contributing to ongoing disability and risk of secondary health conditions. Our aims were to (1) conduct a randomized controlled trial to examine the efficacy of a “Patient-Directed Activity Program” on functional outcomes in people post stroke during inpatient rehabilitation and (2) examine differences three months post inpatient rehabilitation discharge.

Design:

Randomized control trial.

Setting:

Inpatient rehabilitation facility.

Subjects:

Patients admitted to inpatient rehabilitation post stroke.

Interventions:

Patient-Directed Activity Program (PDAP) or control (usual care only). Both groups underwent control (three hours of therapy/day), while PDAP participants were prescribed two additional 30-minute activity sessions/day.

Main measures:

Outcomes (Stroke Rehabilitation Assessment of Movement Measure, Functional Independence Measure, balance, physical activity, Stroke Impact Scale) were collected at admission and discharge from inpatient rehabilitation and three-month follow-up.

Results:

Seventy-three patients (PDAP ( n = 37); control ( n = 36)) were included in the primary analysis. Patients in PDAP completed a total of 23.1 ± 16.5 sessions (10.7 ± 8.5 upper extremity; 12.4 ± 8.6 lower extremity) during inpatient rehabilitation. No differences were observed between groups at discharge in functional measures. PDAP completed significantly more steps/day (PDAP = 657.70 ± 655.82, control = 396.17 ± 419.65; P = 0.022). The Stroke Impact Scale showed significantly better memory and thinking (PDAP = 86.2 ± 11.4, control = 80.8 ± 16.7; P = 0.049), communication (PDAP = 93.6 ± 8.3, control = 89.6 ± 12.4; P = 0.042), mobility (PDAP = 62.2 ± 22.5, control = 53.8 ± 21.8; P = 0.038), and overall recovery from stroke (PDAP = 62.1 ± 19.1, control = 52.2 ± 18.7; P = 0.038) for PDAP compared to control. At three months post discharge, PDAP ( n = 11) completed significantly greater physical activity ( P = 0.014; 3586.5 ± 3468.5 steps/day) compared to control ( n = 10; 1760.9 ± 2346.3 steps/day).

Conclusion:

Functional outcome improvement was comparable between groups; however, PDAP participants completed more steps and perceived greater recovery.

Psychoeducational Interventions for Problematic Anger in Chronic Moderate to Severe Traumatic Brain Injury: A Study of Treatment Enactment

OBJECTIVES

Treatment enactment, a final stage of treatment implementation, refers to patients' application of skills and concepts from treatment sessions into everyday life situations. We examined treatment enactment in a two-arm, multicenter trial comparing two psychoeducational treatments for persons with chronic moderate to severe traumatic brain injury and problematic anger.

METHODS

Seventy-one of 90 participants from the parent trial underwent a telephone enactment interview at least 2 months (median 97 days, range 64-586 days) after cessation of treatment. Enactment, quantified as average frequency of use across seven core treatment components, was compared across treatment arms: anger self-management training (ASMT) and personal readjustment and education (PRE), a structurally equivalent control. Components were also rated for helpfulness when used. Predictors of, and barriers to, enactment were explored.

RESULTS

More than 80% of participants reported remembering all seven treatment components when queried using a recognition format. Enactment was equivalent across treatments. Most used/most helpful components concerned normalizing anger and general anger management strategies (ASMT), and normalizing traumatic brain injury-related changes while providing hope for improvement (PRE). Higher baseline executive function and IQ were predictive of better enactment, as well as better episodic memory (trend). Poor memory was cited by many participants as a barrier to enactment, as was the reaction of other people to attempted use of strategies.

CONCLUSIONS

Treatment enactment is a neglected component of implementation in neuropsychological clinical trials, but is important both to measure and to help participants achieve sustained carryover of core treatment ingredients and learned material to everyday life.

A Scoping Review of Self-Management Interventions Following Spinal Cord Injury

Objective: To conduct a scoping review to identify what components of self-management are embedded in self-management interventions for spinal cord injury (SCI). Methods: In accordance with the approach and stages outlined by Arksey and O'Malley (2005), a comprehensive literature search was conducted using five databases. Study characteristics were extracted from included articles, and intervention descriptions were coded using Practical Reviews in Self-Management Support (PRISMS) (Pearce et al, 2016), Barlow et al (2002), and Lorig and Holman's (2003) taxonomy. Results: A total of 112 studies were included representing 102 unique self-management programs. The majority of the programs took an individual approach (52.0%) as opposed to a group (27.4%) or mixed approach (17.6%). While most of the programs covered general information, some provided specific symptom management. Peers were the most common tutor delivering the program material. The most common Barlow components included symptom management (n = 44; 43.1%), information about condition/treatment (n = 34; 33.3%), and coping (n = 33; 32.4%). The most common PRISMS components were information about condition and management (n = 85; 83.3%), training/rehearsal for psychological strategies (n = 52; 51.0%), and lifestyle advice and support (n = 52; 51.0%). The most common Lorig components were taking action (n = 62; 60.8%), resource utilization (n = 57; 55.9%), and self-tailoring (n = 55; 53.9%). Conclusion: Applying self-management concepts to complex conditions such as SCI is only in the earliest stages of development. Despite having studied the topic from a broad perspective, this review reflects an ongoing program of research that links to an initiative to continue refining and testing self-management interventions in SCI.

Home program practices for supporting and measuring adherence in post-stroke rehabilitation: a scoping review

BACKGROUND

After stroke, individuals face a variety of impairments that impact function. Increasingly, rehabilitation for these impairments has moved into the community and home settings through the use of home programs. However, adherence to these programs is often low, limiting effectiveness.

OBJECTIVE

This scoping review investigated home program implementation and measurement of adherence with persons post-stroke to identify commonly reported practices and determine areas for further research.

METHODS

The electronic databases of PubMed, CINAHL, Scopus, Cochrane Database of Systematic Reviews, and PEDro were searched. Studies focused on post-stroke rehabilitation with an independent home program were selected. Qualitative studies, commentaries, and single-case studies were excluded. Title and abstract screenings were completed by two reviewers with a third for tie-breaking. The full-text review was completed by two reviewers using consensus to resolve any differences. Of the 1,197 articles initially found only 6% (n = 70) met criteria for data extraction. Elements for data extraction included: type of study, area of intervention, description of home program, presence of strategies to support adherence, methods to measure adherence and reported adherence.

RESULTS

Most commonly reported strategies to support home practice were the use of technology, personalization, and written directions. Only 20 studies reported achieving adherence at or greater than 75% and 18 studies did not report adherence outcomes.

CONCLUSIONS

Future investigations that directly compare and identify the most effective strategies to support adherence to home programs for this population are warranted. The implementation of guidelines for reporting adherence to home programs is recommended.

From Motor Learning Theory to Practice: A Scoping Review of Conceptual Frameworks for Applying Knowledge in Motor Learning to Physical Therapist Practice

BACKGROUND

The importance of motor learning knowledge for physical therapist practice is well known; however, its application is lacking. Conceptual frameworks that place motor learning knowledge within a clinical context are a potential mediator to overcome this gap.

PURPOSE

This study aimed to conduct a scoping review of the literature to identify and describe the content of such conceptual frameworks in physical therapy/rehabilitation, including the approaches taken in their development and the "elements" or building blocks of motor learning-based interventions within each conceptual framework.

DATA SOURCES

The data sources used were PubMed, CINAHL, and PsychInfo databases.

STUDY SELECTION

Articles that were selected had a primary focus on motor learning and its application in physical therapy/rehabilitation and were published between 2000 and 2017.

DATA EXTRACTION

Twelve of 62 relevant articles met the inclusion criteria.

DATA SYNTHESIS

Papers attempted to translate theoretical knowledge into a coherent, clinically accessible conceptual framework via 3 main approaches: synthesizing selected motor learning elements into original new conceptual frameworks, mapping motor learning elements in current clinical practices, and assembling selected motor learning elements. The elements of motor learning that were common across papers included theoretical concepts (such as "meaningful goal setting" and "active involvement"); practice variables (including the type, frequency, and timing of feedback; the focus of instructions; task breakdown; and the amount, variability, and order of practice); and intervention strategies (task specific and mental practice). Psychological aspects related to self-efficacy and motivation were also considered integral.

LIMITATIONS

Papers published before the year 2000 were excluded.

CONCLUSION

The scoping review revealed that the presentation of motor learning elements in a coherent framework encompassed very diverse approaches and used different categorization systems. In addition, to fully grasp the complexity of clinical practice, motor learning should be coupled with other fields of knowledge.

Translingual Neurostimulation for the Treatment of Chronic Symptoms Due to Mild-to-Moderate Traumatic Brain Injury

OBJECTIVE

To compare the efficacy of high- and low-frequency noninvasive translingual neurostimulation (TLNS) plus targeted physical therapy (PT) for treating chronic balance and gait deficits due to mild-to-moderate traumatic brain injury (mmTBI).

DESIGN

Participants were randomized 1:1 in a 26-week double-blind phase 1/2 study (NCT02158494) with 3 consecutive treatment stages: in-clinic, at-home, and no treatment. Arms were high-frequency pulse (HFP) and low-frequency pulse (LFP) TLNS.

SETTING

TLNS plus PT training was initiated in-clinic and then continued at home.

PARTICIPANTS

Participants (N=44; 18-65y) from across the United States were randomized into the HFP and LFP (each plus PT) arms. Forty-three participants (28 women, 15 men) completed at least 1 stage of the study. Enrollment requirements included an mmTBI ≥1 year prior to screening, balance disorder due to mmTBI, a plateau in recovery with current PT, and a Sensory Organization Test (SOT) score ≥16 points below normal.

INTERVENTIONS

Participants received TLNS (HFP or LFP) plus PT for a total of 14 weeks (2 in-clinic and 12 at home), twice daily, followed by 12 weeks without treatment.

MAIN OUTCOME MEASURES

The primary endpoint was change in SOT composite score from baseline to week 14. Secondary variables (eg, Dynamic Gait Index [DGI], 6-minute walk test [6MWT]) were also collected.

RESULTS

Both arms had a significant (P<.0001) improvement in SOT scores from baseline at weeks 2, 5, 14 (primary endpoint), and 26. DGI scores had significant improvement (P<.001-.01) from baseline at the same test points; 6MWT evaluations after 2 weeks were significant. The SOT, DGI, and 6MWT scores did not significantly differ between arms at any test point. There were no treatment-related serious adverse events.

CONCLUSIONS

Both the HFP+PT and LFP+PT groups had significantly improved balance scores, and outcomes were sustained for 12 weeks after discontinuing TLNS treatment. Results between arms did not significantly differ from each other. Whether the 2 dosages are equally effective or whether improvements are because of provision of PT cannot be conclusively established at this time.

Feasibility Study of Problem-Solving Training for Care Partners of Adults With Traumatic Brain Injury, Spinal Cord Injury, Burn Injury, or Stroke During the Inpatient Hospital Stay

OBJECTIVE

To determine the feasibility of delivering an evidence-based self-management intervention, problem-solving training (PST), to care partners of individuals with traumatic brain injury (TBI), spinal cord injury (SCI), burn injury, or stroke during the inpatient hospital stay.

DESIGN

In this single group pre-post intervention pilot feasibility study.

SETTING

Inpatient rehabilitation or acute care and community.

PARTICIPANTS

Care partners (spouse or partner, family member, friend who is in any way responsible for the health or well-being of the care recipient) of individuals with TBI, SCI, burn injury, or stroke (N=39).

INTERVENTION

PST is a metacognitive self-management intervention that teaches individuals a global strategy for addressing self-selected problems. Participants received up to 6 sessions of PST in person or via telephone during their care recipient's inpatient stay.

MAIN OUTCOME MEASURES

We measured feasibility of recruitment, intervention delivery, and postintervention use of a smartphone app (Care Partner Problem Solving [CaPPS]) and participant satisfaction (Client Satisfaction Questionnaire [CSQ]) and engagement (Pittsburgh Rehabilitation Participation Scale [PRPS]) with the intervention.

RESULTS

Of 39 care partners approached, n=10 (25.6%) were ineligible. Of n=29 (74.4%) who were eligible, n=17 (58.6%) refused, and n=12 (41.4%) consented, of whom n=8 (66.7%) completed ≥3 PST sessions. Not perceiving any benefit was the most common reason for refusal, followed by no interest in research. Participants were very satisfied with PST (CSQ mean=3.35, SD=0.60), reported strong working alliance (Working Alliance Inventory mean=6.8, SD=3.1), and demonstrated very good engagement (PRPS mean=4.75, SD=1.41). CaPPS was downloaded and used by only n=3 participants.

CONCLUSIONS

Delivering a self-management intervention to care partners during the care recipient's acute hospital stay is feasible for a subset of potential participants. Short lengths of stay, language fluency, and perceiving no potential benefit were noted barriers. Boosters via smartphone app have potential, but several barriers must first be overcome.

Impacts of a multicomponent intervention programme on neuropsychiatric symptoms in people with dementia and psychological health of caregivers: A feasibility pilot study

OBJECTIVES

The objectives of this study are to explore the feasibility of a multicomponent intervention programme and to evaluate its impacts on behavioural and psychological symptoms of dementia (BPSD) and psychological health of caregivers.

METHODS

Fifty-six community-dwelling people with dementia (PWD) and knee osteoarthritis (OA) and their caregivers were recruited and randomized into the intervention group (IG) or comparison group (CG). Each participant in both groups received an individual physiotherapy session (personalized home exercises and care education) and underwent 8 weeks of a 1-hour-structured group exercise session weekly at a day care centre. They were instructed to follow the prescribed home exercise. The IG received a multicomponent programme, combining knee OA-specific therapeutic exercise with self-management support, while the CG attended the routine group exercise programme. The attendance rate and reasons for non-attendance were recorded for evaluating the feasibility. The Chinese versions of the Revised Scale for Caregiving Self-Efficacy (RSCSE) and the Neuropsychiatric Inventory Questionnaire (NPI-Q) were measured at the baseline and postintervention.

RESULTS

Fifty-four dyads completed the programme with high attendance rate (94.4%). Compared with the CG, caregivers in the IG significantly improved in three domains of RSCSE scores (P ≤ .005) and caregivers' distress (P = .004) after the intervention. However, no effects were observed in terms of BPSD severity in PWD. No adverse events or falls were reported.

CONCLUSION

This multicomponent programme is feasible and safe for dementia caregivers and older people with mild-to-moderate dementia and knee OA. The programme has beneficial effects on caregiving self-efficacy and distress of dementia caregivers.

Aerobic Exercise Recommendations to Optimize Best Practices in Care After Stroke: AEROBICS 2019 Update

Most stroke survivors have very low levels of cardiovascular fitness, which limits mobility and leads to further physical deconditioning, increased sedentary behavior, and heightened risk of recurrent stroke. Although clinical guidelines recommend that aerobic exercise be a part of routine stroke rehabilitation, clinical uptake has been suboptimal. In 2013, an international group of stroke rehabilitation experts developed a user-friendly set of recommendations to guide screening and prescription-the Aerobic Exercise Recommendations to Optimize Best Practices in Care after Stroke (AEROBICS 2013). The objective of this project was to update AEROBICS 2013 using the highest quality of evidence currently available. The first step was to conduct a comprehensive review of literature from 2012 to 2018 related to aerobic exercise poststroke. A working group of the original consensus panel members drafted revisions based on synthesis. An iterative process was used to achieve agreement among all panel members. Final revisions included: (1) addition of 115 new references to replace or augment those in the original AEROBICS document, (2) rewording of the original recommendations and supporting material, and (3) addition of 2 new recommendations regarding prescription. The quality of evidence from which these recommendations were derived ranged from low to high. The AEROBICS 2019 Update should make it easier for clinicians to screen for, and prescribe, aerobic exercise in stroke rehabilitation. Clinical implementation will not only help to narrow the gap between evidence and practice but also reduce current variability and uncertainty regarding the role of aerobic exercise in recovery after stroke.

Upper Limb Performance in Daily Life Improves Over the First 12 Weeks Poststroke

Background. Upper limb (UL) performance, or use, in daily life is complex and likely influenced by many factors. While the recovery trajectory of UL impairment poststroke is well documented, little is known about the recovery trajectory of sensor-measured UL performance in daily life early after stroke and the potential moderating role of psychosocial factors. Objective. To examine the recovery trajectory of UL performance within the first 12 weeks poststroke and characterize the potential moderating role of belief, confidence, and motivation on UL performance. Methods. This was a longitudinal, prospective cohort study quantifying UL performance and related psychosocial factors early after stroke. UL performance was quantified via bilateral, wrist-worn accelerometers over 5 assessment sessions for 24 hours. Belief, confidence, and motivation to use the paretic UL, and self-perceived barriers to UL recovery were quantified via survey. Change in 4 accelerometer variables and the moderating role of psychosocial factors was tested using hierarchical linear modeling. The relationship between self-perceived barriers and UL performance was tested via Spearman rank-order correlation analysis. Results. UL performance improved over the first 12 weeks after stroke. Belief, confidence, and motivation did not moderate UL performance over time. There was a negative relationship between UL performance and self-perceived barriers to UL recovery at week 2, which declined over time. Conclusions. Sensor-measured UL performance can improve early after stroke. Early after stroke, rehabilitation interventions may not need to directly target belief, confidence, and motivation but may instead focus on reducing self-perceived barriers to UL recovery.

Belief, Confidence, and Motivation to Use the Paretic Upper Limb in Daily Life Over the First 24 Weeks After Stroke

BACKGROUND AND PURPOSE

The recovery patterns of upper limb (UL) impairment after stroke are established. Psychosocial factors such as belief that paretic UL recovery is possible, confidence, and motivation to use the paretic UL in everyday tasks are unexplored early after stroke. The purpose of this exploratory study was to characterize belief, confidence, and motivation to use the paretic UL in daily life, and self-perceived barriers to UL recovery over the first 24 weeks after stroke.

METHODS

This was a longitudinal cohort study (N = 30) with 8 assessment sessions over the first 24 weeks after stroke. Belief, confidence, and motivation to use the paretic UL and self-perceived barriers were quantified via survey and analyzed using descriptive statistics. Change in the number of self-perceived barriers between weeks 2 and 24 was tested using a paired-samples t test. The relationship between UL capacity, depressive symptomatology, cognition, and each psychosocial factor was examined using Spearman rank-order correlation analyses.

RESULTS

Twenty-two participants completed all study assessments. Belief, confidence, and motivation were high across the 24 weeks, with little variation. There was no difference between the average number of barriers from weeks 2 to 24. There was no relationship between the clinical measures and psychosocial factors at week 2, 12, or 24.

DISCUSSION AND CONCLUSIONS

High levels of belief, confidence, and motivation appear consistent over the first 6 months after stroke. The lack of correlations between psychosocial factors and clinical measures suggests belief, confidence, and motivation may not be vulnerable to functional status early after stroke.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A283).