Physical therapists' guideline adherence on early mobilization and intensity of practice at dutch acute stroke units: a country-wide survey

"Your brain can't wait": perspectives of children and adolescents with acquired brain injury and their parents on physical rehabilitation during the subacute phase

PURPOSE

Physical interventions during subacute rehabilitation have potential to improve functional recovery. This study explored the perspectives of children and adolescents with acquired brain injury (ABI) and their parents with respect to physical rehabilitation during the subacute phase.

METHODS

Thirteen children and adolescents with ABI and their parents were included and interviewed using semi-structured interviews. Interview transcripts were analysed using inductive thematic analysis approach.

RESULTS

Six themes were identified: 1) beliefs of physical rehabilitation, 2) content of physical rehabilitation, 3) tailored care, 4) impact of context, 5) communication and 6) transition. The importance of intensive physical practice was widely supported. The positive can-do mentality was emphasised to create an atmosphere of hope, meaning that every effort would be made to achieve maximum recovery. Intensive involvement of parents is considered essential during subacute rehabilitation including an open and mutual dialogue about the focus of rehabilitation, therapy goals and future participation in their own environment.

CONCLUSIONS

Our findings highlight the need for an intensive rehabilitation approach, tailored to the individual's needs. The perspectives of children and adolescents and their parents in our study contribute to a better understanding of factors that are important for optimal recovery through physical rehabilitation during the subacute phase.

Home-Based Virtual Reality Exergame Program after Stroke Rehabilitation for Patients with Stroke: A Study Protocol for a Multicenter, Randomized Controlled Trial

It is essential for stroke patients to maintain their therapy even after discharging inpatient rehabilitation. This is because recovery is an ongoing process that requires consistent effort. Virtual reality exergame training (VRET) is becoming widely used in stroke rehabilitation to improve physical, social, and psychological outcomes. Home-based VRET may be a more convenient and accessible option for stroke rehabilitation. This study will aim to determine the effectiveness of home-based VRET for patients with stroke who have been discharged from the hospital. This trial will randomly assign 120 participants to 8 weeks of either a VRET (intervention group) or daily life (control group). The study will measure cardiopulmonary endurance, muscular strength, functional capacity, gait, activities of daily living, and quality of life. Our main objective is to determine whether it is safe for patients to undergo VRET at home after they have been discharged from the hospital with a doctor's note. Additionally, we aim to examine whether stroke patients are capable of exercising at home after being discharged from the hospital. This study's outcome could pave the way for developing more comprehensive exercise protocols for stroke patients. Our findings will provide valuable insights into the efficacy of VRET as a therapeutic tool for stroke patients.

Why do some people with stroke not receive the recommended 45 min of occupational therapy and physiotherapy after stroke? A qualitative study using focus groups

OBJECTIVES

To generate qualitative data on the views of Occupational Therapists and Physiotherapists about why people do not receive the Royal College of Physicians' recommended minimum of 45 minutes (min) of daily therapy after stroke, in order to inform a Delphi study.

DESIGN

Focus group study.

SETTING

Stroke services in the South of England.

PARTICIPANTS

A total of nine participants, in two groups, including therapists covering inpatient and Early Supported Discharge (ESD) services with awareness of the 45 min guideline.

RESULTS

Thematic analysis of focus group data identified five factors that influence the amount of therapy a person receives: The Person (with stroke), Individual Therapist, Stroke Multidisciplinary Team, the Organisation and the Guideline. Study findings suggest that the reasons why a person does not receive the therapy recommendation in inpatient and ESD services relate to either the suitability of the guideline for the person with stroke, or the ability of the service to deliver the guideline.

CONCLUSION

This study provides evidence for possible reasons why some people do not receive a minimum of 45 minutes of therapy, 5 days per week, related to (1) the suitability of the guideline for people with stroke and (2) services' ability to deliver this amount of intervention. These two factors are related; therapists decide who should receive therapy and how much in the context of (a) resource availability and (b) people's need and the benefit they will experience. The study findings, combined with the findings from other studies, will be used to initiate a Delphi study, which will establish consensus among therapists regarding the reasons why some people do not receive the guideline amount of therapy.

Why do some people who had a stroke not receive the recommended 45 min of occupational therapy and physiotherapy? A Delphi study

OBJECTIVES

To gain a consensus among therapists for reasons why a person who had a stroke may not receive the Royal College of Physicians' recommended minimum of 45 min of daily therapy.

DESIGN

Three-round remote e-Delphi study.

SETTING

National study, based in the UK.

PARTICIPANTS

Occupational therapists and physiotherapists with experience of delivering therapy after stroke and awareness of the 45 min guideline.

RESULTS

Forty-five therapists consented to participate in the study. Thirty-five (78%) completed round one, 29 of 35 (83%) completed round 2 and 26 of 29 (90%) completed round three. A consensus (75%) was reached for 32 statements. Reasons why a person may not receive 45 min were related to the suitability of the guideline for the individual (based on factors like therapy tolerance or medical status) or the capability of the service to provide the intervention. In addition to the statements for which there was a consensus, 32 concepts did not reach a consensus. Specifically, there was a lack of consensus concerning the suitability of the guideline for people receiving Early Supported Discharge (ESD) services and a lack of agreement about whether people who need more than 45 min of therapy actually receive it.

CONCLUSION

Some people do not receive 45 min of therapy as they are considered unsuitable for it and some do not receive it due to services' inability to provide it. It is unclear which reasons for guideline non-achievement are most common. Future research should focus on why the guideline is not achieved in ESD, and why people who require more than 45 min may not receive it. This could contribute to practical guidance for therapists to optimise therapy delivery for people after stroke.

Protocol for Community-Based Exercise Training after Discharge from Hospital-Based Stroke Rehabilitation: A Multicenter, Randomized, Parallel-Group, Double-Blind Controlled Pilot and Feasibility Trial

Exercise training participation of patients with stroke in the community after discharge from the hospital has many benefits for physical, social, and psychological rehabilitation and improves their quality of life. However, in the Republic of Korea, studies on stroke survivors who can participate in an exercise training program have not been conducted. This trial aims to investigate the effectiveness of exercise training programs after patients with stroke are discharged from the hospital with a doctor's note and referred to a community exercise center, as there is a lack of studies on this population. This multicenter, randomized, parallel-group, double-blind controlled pilot and feasibility trial will randomly assign 120 patients with stroke to either 8 weeks of a community-based exercise training program (experimental group) or activities of daily living (control group). The primary outcomes will be muscle strength, cardiorespiratory fitness, body composition, physical performance, and gait. The secondary outcomes will be quality of life and activities of daily living. This study's results may add new insights into the effectiveness of community-based exercise training programs after patients with stroke are discharged from the hospital with a doctor's note and referred to a community exercise center. The success of the new exercise training approach could offer valuable information for developing more inclusive protocols for patients with stroke in the future if it proves to be efficacious.

Healthcare professionals' perceived barriers and facilitators of implementing clinical practice guidelines for stroke rehabilitation: A systematic review

OBJECTIVE

To identify healthcare professionals' perceived barriers and facilitators to clinical practice guideline implementation within stroke rehabilitation.

DATA SOURCES

CINAHL, MEDLINE, EMBASE, AMED, Cochrane library, Academic Search Complete and Scopus. Additional papers were identified through hand searching.

REVIEW METHODS

The review followed the Preferred Reporting Item for Systematic Reviews and Meta-Analysis Protocols systematic review approach. Any empirical research that provided qualitative data on healthcare professionals' perceived factors influencing clinical guideline implementation in stroke rehabilitation was included. One reviewer screened all titles and abstract reviews (n = 669). Another two reviewers independently screened 30% of title and abstract reviews, followed by full-text reviews (n = 61). Study quality was assessed using the mixed-method appraisal tool.

RESULTS

Data from 10 qualitative, six quantitative and six mixed-method studies published between 2000 and 2022, involving 1576 participants in total, were analysed and synthesised using modified thematic synthesis approach. The majority of participants were therapists n = 1297 (occupational therapists, physiotherapists, speech and language therapists). Organisational factors (time constraints, resources) alongside healthcare professionals' lack of knowledge and skills were the most cited barriers to guideline implementation. Contradictory attitudes and beliefs towards stroke guidelines applicability to real-life clinical practice and their evidence base were reported. Organisational support in the form of training, local protocols, performance monitoring and leadership were reported as perceived facilitators.

CONCLUSION

Barriers and facilitators are multifactorial and were identified at guideline, individual, team and organisational levels. There is a need to translate perceived barriers and facilitators into implementation interventions especially addressing organisational-level barriers.

Current physical therapy practice and implementation factors regarding the evidence-based 'Rehabilitation of Mobility after Stroke (ReMoS)' guideline in Germany: a cross-sectional online survey

BACKGROUND

Evaluation of the current physical therapy practice for German stroke rehabilitation with respect to the 'Rehabilitation of Mobility after Stroke (ReMoS)' guideline recommendations and the associated implementation factors.

METHODS

A descriptive cross-sectional study employing an online survey was performed among German physical therapists in 2019. The survey consisted of three sections with open and closed questions: 1) self-reported use of ReMoS recommendations, 2) barriers of guideline use and 3) socio-demographic characteristics. The benchmark level for guideline adherent physical therapy was set at > 80%.

RESULTS

Data from 170 questionnaires were eligible for analysis. Participants' mean age was 41.6 years, 69.4% were female, while 60.1% had no academic degree. The ReMoS guideline was unknown to 52.9% of the responders. Out of all the 46 ReMoS guideline recommendations, only 'intensive walking training without a treadmill' was reported to be performed in a guideline adherent manner. Respondents usually denied any personal limitations, such as limited knowledge, or that the ReMoS guideline did not fit their routine practice.

CONCLUSIONS

Among German physical therapists, the ReMoS guideline is not well-known and many interventions are not performed as recommended, illustrating the discrepancies between the ReMoS guideline recommendations and current physical therapy practice. Interventions aimed at overcoming this gap should consider both knowledge of existing barriers and facilitators of guideline usage.

TRIAL REGISTRATION

The study was retrospectively registered to the German Clinical Trials Register ( DRKS00026681 ).

Tailored GuideLine Implementation in STrokE Rehabilitation (GLISTER) in Germany. Protocol of a Mixed Methods Study Using the Behavior Change Wheel and the Theoretical Domains Framework

Objective

Evidence-based guidelines are important for informing clinical decision-making and improving patient outcomes. There is inconsistent usage of guidelines among physical therapists involved in stroke rehabilitation, suggesting the existence of a gap between theory and practice. Addressing the German guideline "evidence-based rehabilitation of mobility after stroke (ReMoS)," the aims of this project are (1) to describe the current physical therapy practice within the context of stroke rehabilitation in Germany, (2) to evaluate barriers and facilitators of guideline usage, (3) to develop, and (4) to pilot test a theory-based, tailored implementation intervention for the benefit of guideline recommendations.

Materials and Methods

This study uses a stepwise mixed methods approach for implementing a local guideline. A self-reported online questionnaire will be used to survey the current physical therapy practice in stroke rehabilitation. The same survey and systematic-mixed methods review will be used to evaluate the barriers and facilitators of guideline usage quantitatively. Semi-structured interviews will add a qualitative perspective on factors that influence ReMoS guideline implementation. The Behavior Change Wheel and Theoretical Domains Framework will be used to support the development of a tailored implementation intervention which will be pilot tested in a controlled study. Patient and physical therapy-related outcomes, as well as the appropriateness, such as acceptance and feasibility of the tailored implementation intervention, will be analyzed.

Conclusion

This will be the first endeavor to implement a guideline in German stroke rehabilitation with a focus on changing care provider behavior based on the knowledge of current practice and determining factors using a tailored and theory-based intervention.

Rehabilitation robotics after stroke: a bibliometric literature review

INTRODUCTION

Stroke is the leading cause of long-term disability in developed countries. Due to population aging, the number of people requiring rehabilitation after stroke is going to rise in the coming decades. Robot-mediated neurorehabilitation has the potential to improve clinical outcomes of rehabilitation treatments. A statistical analysis of the literature aims to focus on the main trend of this topic.

AREAS COVERED

A bibliometric survey on post-stroke robotic rehabilitation was performed through a database collection of scientific publications in the field of rehabilitation robotics. By covering the last 20 years, 17429 sources were collected. Relevant patterns and statistics concerning the main research areas were analyzed. Leading journals and conferences which publish and disseminate knowledge in the field were identified. A detailed nomenclature study was carried out. The time trends of the research field were captured. Opinions and predictions of future trends that are expected to shape the near future of the field were discussed.

EXPERT OPINION

Data analysis reveals the continuous expansion of the research field over the last two decades, which is expected to rise considerably in near future. More attention will be paid to the lower limbs rehabilitation and disease/design specific applications in early-stage patients.

Can telerehabilitation services combined with caregiver-mediated exercises improve early supported discharge services poststroke? A study protocol for a multicentre, observer-blinded, randomized controlled trial

BACKGROUND

Recovery of walking ability is an important goal for patients poststroke, and a basic level of mobility is critical for an early discharge home. Caregiver-mediated exercises could be a resource-efficient strategy to augment exercise therapy and improve mobility in the first months poststroke. A combination of telerehabilitation and face-to-face support, blended care, may empower patient-caregiver dyads and smoothen the transition from professional support to self-management. The Armed4Stroke study aims to investigate the effects of a caregiver-mediated exercise program using a blended care approach in addition to usual care, on recovery of mobility in the first 6 months poststroke.

METHODS

A multicentre, observer-blinded randomized clinical trial in which 74 patient-caregiver dyads will be enrolled in the first 3 months poststroke. Dyads are randomly allocated to a caregiver-mediated exercises intervention or to a control group. The primary endpoint is the self-reported mobility domain of the Stroke Impact Scale. Secondary endpoints include care transition preparedness and psychological functioning of dyads, length of inpatient stay, gait-related measures and extended ADL of patients, and caregiver burden. Outcomes are assessed at enrolment, end of treatment and 6 months follow-up.

RESULTS

During 8 weeks, caregivers are trained to become an exercise coach using a blended care approach. Dyads will receive a tailor-made, progressive training program containing task-specific exercises focusing on gait, balance, physical activity and outdoor activities. Dyads are asked to perform the training program a minimum of 5 times a week for 30 min per session, supported by a web-based telerehabilitation system with instruction videos and a messaging environment to communicate with their physiotherapist.

CONCLUSIONS

We hypothesize that the Armed4Stroke program will increase self-reported mobility and independence in ADL, facilitating an early discharge poststroke. In addition, we hypothesize that active involvement of caregivers and providing support using blended care, will improve the care transition when professional support tapers off. Therefore, the Armed4Stroke program may complement early supported discharge services.

TRIAL REGISTRATION

Netherlands Trial Register, NL7422 . Registered 11 December 2018.

BEAGLE-A Kinematic Sensory System for Objective Hand Function Assessment in Technology-Mediated Rehabilitation

We present a hand functions assessment system (BEAGLE) for kinematic tracking of hand and finger movements, envisioned as a technology-mediated rehabilitation tool. The system is custom-designed for fast and easy placement on an impaired hand (spastic or flaccid), featuring inertial sensors integrated into simple finger caps and a hand strap. An algorithm for a range of motion (ROM) estimation was implemented to provide an objective assessment of hand functions. The efficacy and feasibility of the BEAGLE system were examined in a pilot clinical study performed with ten stroke survivors in the subacute phase. Participants received therapy within two consecutive intensity-matched rehabilitation cycles. The first consisted of conventional therapy, while the second involved a combination of conventional therapy and advanced functional electrical stimulation. Assessments were performed before and after each phase. These included BEAGLE estimates of active voluntary ROM for wrist and various digits, as well as two referent clinical measures for hand functions assessment, Fugl-Meyer and Action Research Arm Test. The results indicate that the ROM assessments can detect change with sensitivity comparable to the standardized clinical scales. Statistically significant changes between the beginning and the end of the second cycle existed in all observed measures, whereas none of these measurements showed a statistically significant improvement in the first therapy cycle. The noted usability metrics indicate that the BEAGLE could be integrated into the rehabilitation workflow in a clinical environment.

Post-stroke gait training practices in a low resource setting: a cross-sectional survey among Indian physiotherapists

BACKGROUND

Independent mobility is the most important determinant of quality of life after stroke and it is vital that training aimed at restoration of gait is based on contemporary evidence. Despite several practice guidelines for gait rehabilitation after stroke existing globally, their feasibility of application in low-resource settings is often questionable.

OBJECTIVE

To investigate the current practices in gait training among Indian physiotherapists involved in the rehabilitation of stroke survivors.

METHODS

A questionnaire on the various aspects of gait training was developed and the content was validated by experts. The survey was made available online and distributed among Indian physiotherapists working in the field of stroke rehabilitation, using snowball sampling. Frequency distribution was used to summarize responses to each component of the questionnaire.

RESULTS

Responses were obtained from 250 practicing physiotherapists. The majority of the respondents (55%) reported that they initiate gait training within seven days after stroke. Gait training sessions ranged from 15-30 minutes (55%), once every day (44%), and the majority (89%) reported use of subjective outcome measures to evaluate gait. Although most respondents agreed on the use of assistive aids, 24% indicated that their use may deter gait, rather than improve it. Nearly 86% of the respondents reported that they do not follow standard guidelines pertaining to gait rehabilitation for stroke survivors.

CONCLUSION

The findings of the study point toward a lack of evidence-based practice among Indian physiotherapists while training gait after stroke. This implied the urgent need for development and implementation of country specific guidelines for stroke rehabilitation.

The Use of the Term Virtual Reality in Post-Stroke Rehabilitation: A Scoping Review and Commentary

Virtual reality (VR) offers many opportunities for post-stroke rehabilitation. However, "VR" can refer to several types of computer-based rehabilitation systems. Since these systems may impact the feasibility and the efficacy of VR interventions, consistent terminology is important. In this study, we aimed to optimize the terminology for VR-based post-stroke rehabilitation by assessing whether and how review papers on this topic defined VR and what types of mixed reality systems were discussed. In addition, this review can inspire the use of consistent terminology for other researchers working with VR. We assessed the use of the term VR in review papers on post-stroke rehabilitation extracted from Scopus, Web of Science and PubMed. We also developed a taxonomy distinguishing 16 mixed reality systems based on three factors: immersive versus semi-immersive displays, the way in which real and virtual information is mixed, and the main input device. 64% of the included review papers (N = 121) explicitly defined VR and 33% of them described different subtypes of VR, with immersive and non-immersive VR as the most common distinction. The most frequently discussed input devices were motion-capture cameras and handheld devices, while regular 2D monitors were the most frequently mentioned output devices. Our analysis revealed that reviews on post-stroke VR rehabilitation did not or only broadly defined "VR" and did not focus on a specific system. Since the efficacy and feasibility of rehabilitation may depend on the specific system, we propose a new data-driven taxonomy to distinguish different systems, which is expected to facilitate communication amongst researchers and clinicians working with virtual reality.

Co-designing organisational improvements and interventions to increase inpatient activity in four stroke units in England: a mixed-methods process evaluation using normalisation process theory

OBJECTIVE

To explore facilitators and barriers to using experience-based co-design (EBCD) and accelerated EBCD (AEBCD) in the development and implementation of interventions to increase activity opportunities for inpatient stroke survivors.

DESIGN

Mixed-methods process evaluation underpinned by normalisation process theory (NPT).

SETTING

Four post-acute rehabilitation stroke units in England.

PARTICIPANTS

Stroke survivors, family members, stroke unit staff, hospital managers, support staff and volunteers. Data informing our NPT analysis comprised: ethnographic observations, n=366 hours; semistructured interviews with 76 staff, 53 stroke survivors and 27 family members pre-EBCD/AEBCD implementation or post-EBCD/AEBCD implementation; and observation of 43 co-design meetings involving 23 stroke survivors, 21 family carers and 54 staff.

RESULTS

Former patients and families valued participation in EBCD/AEBCD perceiving they were equal partners in co-design. Staff engaged with EBCD/AEBCD, reporting it as a valuable improvement approach leading to increased activity opportunities. The structured EBCD/AEBCD approach was influential in enabling coherence and cognitive participation and legitimated staff involvement in the change process. Researcher facilitation of EBCD/AEBCD supported cognitive participation, collective action and reflexive monitoring; these were important in implementing and sustaining co-design activities. Observations and interviews post-EBCD/AEBCD cycles confirmed creation and use of new social spaces and increased activity opportunities in all units. EBCD/AEBCD facilitated engagement with wider hospital resources and local communities, further enhancing activity opportunities. However, outside of structured group activity, many individual staff-patient interactions remained task focused.

CONCLUSIONS

EBCD/AEBCD facilitated the development and implementation of environmental changes and revisions to work routines which supported increased activity opportunities in stroke units providing post-acute and rehabilitation care. Former stroke patients and carers contributed to improvements. NPT's generative mechanisms were instrumental in analysis and interpretation of facilitators and barriers at the individual, group and organisational level, and can help inform future implementations of similar approaches.

A cross-sectional study of early mobility practice in intensive care units in Sarawak Hospitals, Malaysia

Aims

To determine the prevalence, characteristics of EM activities, the relationship between level of activity and mode of ventilation and adherence rate of EM protocol.

Background

Mobilizing ICU patients remains a challenge, despite its safety, feasibility and positive short-term outcomes.

Design

A cross-sectional point prevalence study.

Methods

All patients who were eligible and admitted to the adult ICUs during March 2018 were recruited. Data were analysed by using the Statistical Package for Social Sciences version 24 for Windows.

Results

The prevalence of EM practice was 65.6%. The most frequently reported avoidable and unavoidable factors inhibit mobility were deep sedation and vasopressor infusion, respectively. Level II of activity was the most common level of activity performed in ICU patients. The invasive ventilated patient had 12.53 the odds to stay in bed as compared to non-invasive ventilated patient. An average adherence rate of EM protocol was 52.5%.

White Paper: Movement System Diagnoses in Neurologic Physical Therapy

BACKGROUND AND PURPOSE

The APTA recently established a vision for physical therapists to transform society by optimizing movement to promote health and wellness, mitigate impairments, and prevent disability. An important element of this vision entails the integration of the movement system into the profession, and necessitates the development of movement system diagnoses by physical therapists. At this point in time, the profession as a whole has not agreed upon diagnostic classifications or guidelines to assist in developing movement system diagnoses that will consistently capture an individual's movement problems. We propose that, going forward, diagnostic classifications of movement system problems need to be developed, tested, and validated. The Academy of Neurologic Physical Therapy's Movement System Task Force was convened to address these issues with respect to management of movement system problems in patients with neurologic conditions. The purpose of this article is to report on the work and recommendations of the Task Force.

SUMMARY OF KEY FINDINGS

The Task Force identified 4 essential elements necessary to develop and implement movement system diagnoses for patients with primarily neurologic involvement from existing movement system classifications. The Task Force considered the potential impact of using movement system diagnoses on clinical practice, education and, research. Recommendations were developed and provided recommendations for potential next steps to broaden this discussion and foster the development of movement system diagnostic classifications.

RECOMMENDATIONS FOR CLINICAL PRACTICE

The Task Force proposes that diagnostic classifications of movement system problems need to be developed, tested, and validated with the long-range goal to reach consensus on and adoption of a movement system diagnostic framework for clients with neurologic injury or disease states.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A198).

Caregiver-mediated exercises with e-health support for early supported discharge after stroke (CARE4STROKE): A randomized controlled trial

BACKGROUND AND PURPOSE

We designed an 8-week caregiver-mediated exercise program with e-health support after stroke (CARE4STROKE) in addition to usual care with the aim to improve functional outcome and to facilitate early supported discharge by increasing the intensity of task specific training.

METHODS

An observer-blinded randomized controlled trial in which 66 stroke patient-caregiver couples were included during inpatient rehabilitation. Patients allocated to the CARE4STROKE program trained an additional amount of 150 minutes a week with a caregiver and were compared to a control group that received usual care alone. Primary outcomes: self-reported mobility domain of the Stroke Impact Scale 3.0 (SIS) and length of stay (LOS). Secondary outcomes: motor impairment, strength, walking ability, balance, mobility and (Extended) Activities of Daily Living of patients, caregiver strain of caregivers, and mood, self-efficacy, fatigue and quality of life of both patients and caregivers. Outcomes were assessed at baseline, 8 and 12 weeks after randomization.

RESULTS

No significant between-group differences were found regarding SIS-mobility after 8 (β 6.21, SD 5.16; P = 0.229) and 12 weeks (β 0.14, SD 2.87; P = 0.961), and LOS (P = 0.818). Significant effects in favor of the intervention group were found for patient's anxiety (β 2.01, SD 0.88; P = 0.023) and caregiver's depression (β 2.33, SD 0.77; P = 0.003) post intervention. Decreased anxiety in patients remained significant at the 12-week follow-up (β 1.01, SD 0.40; P = 0.009).

CONCLUSIONS

This proof-of concept trial did not find significant effects on both primary outcomes mobility and LOS as well as the secondary functional outcomes. Treatment contrast in terms of total exercise time may have been insufficient to achieve these effects. However, caregiver-mediated exercises showed a favorable impact on secondary outcome measures of mood for both patient and caregiver.

CLINICAL TRIAL REGISTRATION

NTR4300, URL- http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4300.

Physiological Responses and Perceived Exertion During Robot-Assisted and Body Weight-Supported Gait After Stroke

INTRODUCTION

Physiological responses are rarely considered during walking after stroke and if considered, only during a short period (3-6 minutes). The aims of this study were to examine physiological responses during 30-minute robot-assisted and body weight-supported treadmill and overground walking and compare intensities with exercise guidelines.

METHODS

A total of 14 ambulatory stroke survivors (age: 61 ± 9 years; time after stroke: 2.8 ± 2.8 months) participated in 3 separate randomized walking trials. Patients walked overground, on a treadmill, and in the Lokomat (60% robotic guidance) for 30 minutes at matched speeds (2.0 ± 0.5 km/h) and matched levels of body weight support (BWS; 41% ± 16%). Breath-by-breath gas analysis, heart rate, and perceived exertion were assessed continuously.

RESULTS

Net oxygen consumption, net carbon dioxide production, net heart rate, and net minute ventilation were about half as high during robot-assisted gait as during body weight-supported treadmill and overground walking ( P < .05). Net minute ventilation, net breathing frequency, and net perceived exertion significantly increased between 6 and 30 minutes (respectively, 1.8 L/min, 2 breaths/min, and 3.8 units). During Lokomat walking, exercise intensity was significantly below exercise recommendations; during body weight-supported overground and treadmill walking, minimum thresholds were reached (except for percentage of heart rate reserve during treadmill walking).

CONCLUSION

In ambulatory stroke survivors, the oxygen and cardiorespiratory demand during robot-assisted gait at constant workload are considerably lower than during overground and treadmill walking at matched speeds and levels of body weight support. Future studies should examine how robotic devices can be Future studies should examine how robotic devices can be exploited to induce aerobic exercise.

Experiences of patients with stroke and their caregivers with caregiver-mediated exercises during the CARE4STROKE trial

Purpose: Caregiver-mediated exercises are a novel way of delivering augmented exercise therapy for patients with stroke, in which patients do additional therapeutic exercises together with a caregiver. This explorative qualitative study is part of the CARE4STROKE trial and focused on how participants manage these exercises together. The research questions were: (1) how do the patient-caregiver couples exercise together? and (2) what does exercising together bring about, besides more hours of practice?Methods: Semi-structured interviews were conducted with patients and caregivers who participated in the CARE4STROKE intervention. Inductive thematic data analysis was applied.Results: Seven patients and seven caregivers were interviewed. Three different role-dynamics were found during caregiver-mediated exercises: (1) patient in control, (2) in concert, and (3) the caregiver as informal carer. In addition, three themes were identified about what exercising together brings about: (a) tailor-made exercises through active involvement, (b) preparation for the home situation, and (c) opportunity to be involved.Conclusion: Different role-dynamics are at play in caregiver-mediated exercises, and it is important for participating staff to be aware of their possible effects on the strain of patient or caregiver. Caregiver-mediated exercises were found to enhance individualization of the treatment plan and preparation for home discharge.Implications for rehabilitationCaregiver-mediated exercises, in which a caregiver does exercises with a patient, are currently under investigation as a new form of augmented exercise delivery after strokeDoing exercises together seems to make patient and caregivers actively involved in rehabilitation, which they appreciate, and which seems to help them prepare for the home situationCaregiver selection and monitoring role-dynamics during exercising is an important task of the rehabilitation team.

Why do stroke survivors not receive recommended amounts of active therapy? Findings from the ReAcT study, a mixed-methods case-study evaluation in eight stroke units

OBJECTIVE

To identify why the National Clinical Guideline recommendation of 45 minutes of each appropriate therapy daily is not met in many English stroke units.

DESIGN

Mixed-methods case-study evaluation, including modified process mapping, non-participant observations of service organisation and therapy delivery, documentary analysis and semi-structured interviews.

SETTING

Eight stroke units in four English regions.

SUBJECTS

Seventy-seven patients with stroke, 53 carers and 197 stroke unit staff were observed; 49 patients, 50 carers and 131 staff participants were interviewed.

RESULTS

Over 1000 hours of non-participant observations and 433 patient-specific therapy observations were undertaken. The most significant factor influencing amount and frequency of therapy provided was the time therapists routinely spent, individually and collectively, in information exchange. Patient factors, including fatigue and tolerance influenced therapists' decisions about frequency and intensity, typically resulting in adaptation of therapy rather than no provision. Limited use of individual patient therapy timetables was evident. Therapist staffing levels were associated with differences in therapy provision but were not the main determinant of intensity and frequency. Few therapists demonstrated understanding of the evidence underpinning recommendations for increased therapy frequency and intensity. Units delivering more therapy had undertaken patient-focused reorganisation of therapists' working practices, enabling them to provide therapy consistent with guideline recommendations.

CONCLUSION

Time spent in information exchange impacted on therapy provision in stroke units. Reorganisation of therapists' work improved alignment with guidelines.

Functional Strength Training and Movement Performance Therapy for Upper Limb Recovery Early Poststroke-Efficacy, Neural Correlates, Predictive Markers, and Cost-Effectiveness: FAST-INdiCATE Trial

BACKGROUND

Variation in physiological deficits underlying upper limb paresis after stroke could influence how people recover and to which physical therapy they best respond.

OBJECTIVES

To determine whether functional strength training (FST) improves upper limb recovery more than movement performance therapy (MPT). To identify: (a) neural correlates of response and (b) whether pre-intervention neural characteristics predict response.

DESIGN

Explanatory investigations within a randomised, controlled, observer-blind, and multicentre trial. Randomisation was computer-generated and concealed by an independent facility until baseline measures were completed. Primary time point was outcome, after the 6-week intervention phase. Follow-up was at 6 months after stroke.

PARTICIPANTS

With some voluntary muscle contraction in the paretic upper limb, not full dexterity, when recruited up to 60 days after an anterior cerebral circulation territory stroke.

INTERVENTIONS

Conventional physical therapy (CPT) plus either MPT or FST for up to 90 min-a-day, 5 days-a-week for 6 weeks. FST was "hands-off" progressive resistive exercise cemented into functional task training. MPT was "hands-on" sensory/facilitation techniques for smooth and accurate movement.

OUTCOMES

The primary efficacy measure was the Action Research Arm Test (ARAT). Neural measures: fractional anisotropy (FA) corpus callosum midline; asymmetry of corticospinal tracts FA; and resting motor threshold (RMT) of motor-evoked potentials.

ANALYSIS

Covariance models tested ARAT change from baseline. At outcome: correlation coefficients assessed relationship between change in ARAT and neural measures; an interaction term assessed whether baseline neural characteristics predicted response.

RESULTS

288 Participants had: mean age of 72.2 (SD 12.5) years and mean ARAT 25.5 (18.2). For 240 participants with ARAT at baseline and outcome the mean change was 9.70 (11.72) for FST + CPT and 7.90 (9.18) for MPT + CPT, which did not differ statistically (p = 0.298). Correlations between ARAT change scores and baseline neural values were between 0.199, p = 0.320 for MPT + CPT RMT (n = 27) and -0.147, p = 0.385 for asymmetry of corticospinal tracts FA (n = 37). Interaction effects between neural values and ARAT change between baseline and outcome were not statistically significant.

CONCLUSIONS

There was no significant difference in upper limb improvement between FST and MPT. Baseline neural measures did not correlate with upper limb recovery or predict therapy response.

TRIAL REGISTRATION

Current Controlled Trials: ISRCT 19090862, http://www.controlled-trials.com.

Intensifying Functional Task Practice to Meet Aerobic Training Guidelines in Stroke Survivors

Objective: To determine whether stroke survivors could maintain workloads during functional task practice that can reach moderate levels of cardiometabolic stress (i.e., ≥40% oxygen uptake reserve ([Formula: see text]O2R) for ≥20 min) without the use of ergometer-based exercise. Design: Cross-sectional study using convenience sampling. Setting: Research laboratory in a tertiary rehabilitation hospital. Participants: Chronic hemiparetic stroke survivors (>6-months) who could provide consent and walk with or without assistance. Intervention: A single bout of intermittent functional training (IFT). The IFT protocol lasted 30 min and involved performing impairment specific multi-joint task-oriented movements structured into circuits lasting ~3 min and allowing 30-45 s recovery between circuits. The aim was to achieve an average heart rate (HR) 30-50 beats above resting without using traditional ergometer-based aerobic exercise. Outcome measures: Attainment of indicators for moderate intensity aerobic exercise. Oxygen uptake ([Formula: see text]O2), carbon dioxide production ([Formula: see text]CO2), and HR were recorded throughout the 30 min IFT protocol. Values were reported as percentage of [Formula: see text]O2R, HR reserve (HRR) and HRR calculated from predicted maximum HR (HRRpred), which were determined from a prior maximal graded exercise test. Results: Ten (3-female) chronic (38 ± 33 months) stroke survivors (70% ischemic) with significant residual impairments (NIHSS: 3 ± 2) and a high prevalence of comorbid conditions (80% ≥ 1) participated. IFT significantly increased all measures of exercise intensity compared to resting levels: [Formula: see text]O2 (Δ 820 ± 290 ml min-1, p < 0.001), HR (Δ 42 ± 14 bpm, p < 0.001), and energy expenditure (EE; Δ 4.0 ± 1.4 kcal min-1, p < 0.001). Also, mean values for percentage of [Formula: see text]O2R (62 ± 19), HRR (55 ± 14), and HRRpred (52 ± 18) were significantly higher than the minimum threshold (40%) indicating achievement of moderate intensity aerobic exercise (p = 0.004, 0.016, and 0.043, respectively). Conclusion: Sufficient workloads to achieve moderate levels of cardiometabolic stress can be maintained in chronic stroke survivors using impairment-focused functional movements that are not dependent on ergometers or other specialized equipment.

Perspectives of health care professionals on the facilitators and barriers to the implementation of a stroke rehabilitation guidelines cluster randomized controlled trial

Background

The Stroke Canada Optimization of Rehabilitation by Evidence Implementation Trial (SCORE-IT) was a cluster randomized controlled trial that evaluated two knowledge translation (KT) interventions for the promotion of the uptake of best practice recommendations for interventions targeting upper and lower extremity function, postural control, and mobility. Twenty rehabilitation centers across Canada were randomly assigned to either the facilitated or passive KT intervention. The objective of the current study was to understand the factors influencing the implementation of the recommended treatments and KT interventions from the perspective of nurses, occupational therapists and physical therapists, and clinical managers following completion of the trial.

Methods

A qualitative descriptive approach involving focus groups was used. Thematic analysis was used to understand the factors influencing the implementation of the recommended treatments and KT interventions. The Clinical Practice Guidelines Framework for Improvement guided the analysis.

Results

Thirty-three participants were interviewed from 11 of the 20 study sites (6 sites from the facilitated KT arm and 5 sites from the passive KT arm). The following factors influencing the implementation of the recommended treatments and KT interventions emerged: facilitation, agreement with the intervention – practical, familiarity with the recommended treatments, and environmental factors, including time and resources. Each of these themes includes the sub-themes of facilitator and/or barrier. Improved team communication and interdisciplinary collaboration emerged as an unintended outcome of the trial across both arms in addition to a facilitator to the implementation of the treatment recommendations. Facilitation was identified as a facilitator to implementation of the KT interventions in the passive KT intervention arm despite the lack of formally instituted facilitators in this arm of the trial.

Conclusions

This is one of the first studies to examine the factors influencing the implementation of stroke recommendations and associated KT interventions within the context of a trial. Findings highlight the important role of self-selected facilitators to implementation efforts. Future research should seek to better understand the specific characteristics of facilitators that are associated with successful implementation and clinical outcomes, especially within the context of stroke rehabilitation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2389-7) contains supplementary material, which is available to authorized users.

Caregiver-mediated exercises for improving outcomes after stroke

BACKGROUND

Stroke is a major cause of long-term disability in adults. Several systematic reviews have shown that a higher intensity of training can lead to better functional outcomes after stroke. Currently, the resources in inpatient settings are not always sufficient and innovative methods are necessary to meet these recommendations without increasing healthcare costs. A resource efficient method to augment intensity of training could be to involve caregivers in exercise training. A caregiver-mediated exercise programme has the potential to improve outcomes in terms of body function, activities, and participation in people with stroke. In addition, caregivers are more actively involved in the rehabilitation process, which may increase feelings of empowerment with reduced levels of caregiver burden and could facilitate the transition from rehabilitation facility (in hospital, rehabilitation centre, or nursing home) to home setting. As a consequence, length of stay might be reduced and early supported discharge could be enhanced.

OBJECTIVES

To determine if caregiver-mediated exercises (CME) improve functional ability and health-related quality of life in people with stroke, and to determine the effect on caregiver burden.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (October 2015), CENTRAL (the Cochrane Library, 2015, Issue 10), MEDLINE (1946 to October 2015), Embase (1980 to December 2015), CINAHL (1982 to December 2015), SPORTDiscus (1985 to December 2015), three additional databases (two in October 2015, one in December 2015), and six additional trial registers (October 2015). We also screened reference lists of relevant publications and contacted authors in the field.

SELECTION CRITERIA

Randomised controlled trials comparing CME to usual care, no intervention, or another intervention as long as it was not caregiver-mediated, aimed at improving motor function in people who have had a stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials. One review author extracted data, and assessed quality and risk of bias, and a second review author cross-checked these data and assessed quality. We determined the quality of the evidence using GRADE. The small number of included studies limited the pre-planned analyses.

MAIN RESULTS

We included nine trials about CME, of which six trials with 333 patient-caregiver couples were included in the meta-analysis. The small number of studies, participants, and a variety of outcome measures rendered summarising and combining of data in meta-analysis difficult. In addition, in some studies, CME was the only intervention (CME-core), whereas in other studies, caregivers provided another, existing intervention, such as constraint-induced movement therapy. For trials in the latter category, it was difficult to separate the effects of CME from the effects of the other intervention.We found no significant effect of CME on basic ADL when pooling all trial data post intervention (4 studies; standardised mean difference (SMD) 0.21, 95% confidence interval (CI) -0.02 to 0.44; P = 0.07; moderate-quality evidence) or at follow-up (2 studies; mean difference (MD) 2.69, 95% CI -8.18 to 13.55; P = 0.63; low-quality evidence). In addition, we found no significant effects of CME on extended ADL at post intervention (two studies; SMD 0.07, 95% CI -0.21 to 0.35; P = 0.64; low-quality evidence) or at follow-up (2 studies; SMD 0.11, 95% CI -0.17 to 0.39; P = 0.45; low-quality evidence).Caregiver burden did not increase at the end of the intervention (2 studies; SMD -0.04, 95% CI -0.45 to 0.37; P = 0.86; moderate-quality evidence) or at follow-up (1 study; MD 0.60, 95% CI -0.71 to 1.91; P = 0.37; very low-quality evidence).At the end of intervention, CME significantly improved the secondary outcomes of standing balance (3 studies; SMD 0.53, 95% CI 0.19 to 0.87; P = 0.002; low-quality evidence) and quality of life (1 study; physical functioning: MD 12.40, 95% CI 1.67 to 23.13; P = 0.02; mobility: MD 18.20, 95% CI 7.54 to 28.86; P = 0.0008; general recovery: MD 15.10, 95% CI 8.44 to 21.76; P < 0.00001; very low-quality evidence). At follow-up, we found a significant effect in favour of CME for Six-Minute Walking Test distance (1 study; MD 109.50 m, 95% CI 17.12 to 201.88; P = 0.02; very low-quality evidence). We also found a significant effect in favour of the control group at the end of intervention, regarding performance time on the Wolf Motor Function test (2 studies; MD -1.72, 95% CI -2.23 to -1.21; P < 0.00001; low-quality evidence). We found no significant effects for the other secondary outcomes (i.e.

PATIENT

motor impairment, upper limb function, mood, fatigue, length of stay and adverse events; caregiver: mood and quality of life).In contrast to the primary analysis, sensitivity analysis of CME-core showed a significant effect of CME on basic ADL post intervention (2 studies; MD 9.45, 95% CI 2.11 to 16.78; P = 0.01; moderate-quality evidence).The methodological quality of the included trials and variability in interventions (e.g. content, timing, and duration), affected the validity and generalisability of these observed results.

AUTHORS' CONCLUSIONS

There is very low- to moderate-quality evidence that CME may be a valuable intervention to augment the pallet of therapeutic options for stroke rehabilitation. Included studies were small, heterogeneous, and some trials had an unclear or high risk of bias. Future high-quality research should determine whether CME interventions are (cost-)effective.

Motivation, expectations, and usability of a driven gait orthosis in stroke patients and their therapists

BACKGROUND

In the development of efficacious driven gait orthoses (DGO), it is an added value to consider patients' and therapists' perspectives concerning robot-assisted gait training (RAGT). A better understanding of these issues may improve the process of care and outcome.

OBJECTIVES

This study aimed to examine stroke patients' motivation and expectations of RAGT, and therapists' expectations and perspectives on the usability of RAGT. Additionally, the differences in expectations between stroke patients and their therapists were analyzed.

METHODS

A cross sectional, multi-center, three-group trial was conducted. Included were (1) stroke patients who have experience with RAGT (i.e. the stroke user group), (2) stroke patients who have no experience with RAGT (i.e. the stroke non-user group), and (3) therapists who have experience with RAGT (i.e. the therapist user group). The Intrinsic Motivation Inventory (IMI), Credibility/Expectancy Questionnaire (CEQ), and Usefulness, Satisfaction and Ease of Use Questionnaire (USE) were used. Descriptive statistics and non-parametric Kruskal-Wallis tests were conducted.

RESULTS

In total, 46 subjects were assessed (stroke user group: n = 23, stroke non-user group: n = 14, therapist user group: n = 9). IMI subscale scores ranged from 42 to 88%. Mean credibility and expectancy ranged from 80 to 85% and 57 to 72%, respectively, with no significant differences between groups. USE subscale scores ranged from 61 to 72%.

CONCLUSIONS

Stroke user group patients seem quite motivated to train with the DGO and both patients and therapists reasonably believe that this training could improve gait functioning. Therapists are moderately satisfied with the usability of the DGO, but there is room for improvement with respect to usefulness and ease of use.

Selecting relevant and feasible measurement instruments for the revised Dutch clinical practice guideline for physical therapy in patients after stroke

PURPOSE

To select relevant and feasible instruments for the revision of the Dutch clinical practice guideline for physical therapy in patients with stroke.

METHODS

In this implementation study a comprehensive proposal for ICF categories and matching instruments was developed, based on reliability and validity. Relevant instruments were then selected in a consensus round by 11 knowledge brokers who were responsible for the implementation of the selected instruments. The feasibility of the selected instruments was tested by 36 physical therapists at different work settings within stroke services. Finally, instruments that were deemed relevant and feasible were included in the revised guideline.

RESULTS

A total of 28 instruments were recommended for inclusion in the revised guideline. Nineteen instruments were retained from the previous guideline. Ten new instruments were tested in clinical practice, seven of which were found feasible. Two more instruments were added after critical appraisal of the set of the measurement instruments.

CONCLUSIONS

The revised guideline contains 28 relevant and feasible instrument selected and tested in clinical practice by physical therapists. Further education and implementation is needed to integrate instruments in clinical practice. Further research is proposed for developing and implementing a core set of measurement instruments to be used at fixed time points to establish data registries that allow for continuous improvement of rehabilitation for stroke patients. Implications for Rehabilitation The revised Dutch Stroke Physical Therapy Guideline recommends a total of 28 instruments, that are relevant and feasible for clinical practice of physical therapist in the different settings of stroke rehabilitation. The selection of instrument in daily practice should be part of the clinical reasoning process of PTs and be tailored to individual patients' needs and the degree of priority of the affected ICF category. Suggested education strategies for further integration of instruments in of the daily practice of PTs in Stroke Rehabilitation are: 'Training on the job' and 'peer assessment in clinical situations'.

What influences the implementation of the New Zealand stroke guidelines for physiotherapists and occupational therapists?

Purpose To explore perceived barriers and facilitators to the use of the New Zealand (NZ) stroke guidelines by occupational therapists and physiotherapists. Methods A qualitative descriptive methodology was used. Eligible physiotherapists and occupational therapists (NZ registered, working in one of two hospitals, treating at least 10 patients with stroke in the previous year) were invited to participate in semi-structured interviews to elicit their perceptions of the utility and feasibility of the NZ stroke guidelines and identify barriers and facilitators to their implementation. All interviews were audio-recorded and transcribed. Conventional content analysis with constant comparative methods was used for coding and analysis. Results The main themes influencing guideline implementation were resources and characteristics of the guidelines, the organization, the patient and family and the therapist. Insufficient resources were a major barrier that crossed many of the themes. Participants suggested a range of strategies relating to the organization to improve therapists' alignment to the guidelines. Conclusion Alignment to the guidelines in NZ is influenced both positively and negatively by a range of interacting factors, consistent with other studies. Alignment might be improved by the introduction of some relatively simple strategies, such as ring-fencing time for access to resources and training in the use of the guidelines. Many of the barriers and related interventions are likely to be more complex. Implications for rehabilitation Alignment with stroke guidelines has been shown to improve patient outcomes. Therapist alignment with the implementation of the New Zealand stroke guidelines is influenced by guideline characteristics, organizational characteristics, resources, patient and family characteristics and therapist characteristics. Frequently encountered barriers related to limited resources, particularly time. Ring-fencing regular time for access to resources and training in the use of guidelines are examples of simple strategies that may reduce barriers.

Caregiver-mediated exercises with e-health support for early supported discharge after stroke (CARE4STROKE): study protocol for a randomized controlled trial

BACKGROUND

Several systematic reviews have shown that additional exercise therapy has a positive effect on functional outcome after stroke. However, there is an urgent need for resource-efficient methods to augment rehabilitation services without increasing health care costs. Asking informal caregivers to do exercises with their loved ones, combined with e-health services may be a cost-effective method to promote early supported discharge with increased functional outcome. The primary aim of the CARE4STROKE study is to evaluate the effects and cost-effectiveness of a caregiver-mediated exercises program combined with e-health services after stroke in terms of self-reported mobility and length of stay.

METHODS

An observer-blinded randomized controlled trial, in which 66 stroke-patients admitted to a hospital stroke unit, rehabilitation center or nursing home are randomly assigned to either 8 weeks of the CARE4STROKE program in addition to usual care (i.e., experimental group) or 8 weeks of usual care alone (i.e., control group). The CARE4STROKE program is compiled in consultation with a trained physical therapist. A tablet computer is used to present video-based exercises for gait and gait-related activities in which a caregiver acts as an exercise coach. Primary outcomes are the mobility domain of the Stroke Impact Scale and length of stay. Secondary outcomes are the other domains of the Stroke Impact Scale, motor impairment, strength, walking ability, balance, mobility, (Extended) Activities of Daily Living, psychosocial functioning, self-efficacy, fatigue, health-related quality of life of the patient as well as the experienced strain, psychosocial functioning and quality of life of the caregiver. An economic evaluation will be conducted from the societal and health care perspective.

DISCUSSION

The main aspects of the CARE4STROKE program are 1) increasing intensity of training by doing exercises with a caregiver in addition to usual care and 2) e-health support. We hypothesize this program leads to better functional outcome and early supported discharge, resulting in reduced costs.

TRIAL REGISTRATION

The study is registered in the Dutch trial register as NTR4300, registered 2 December 2013.

Why do patients with stroke not receive the recommended amount of active therapy (ReAcT)? Study protocol for a multisite case study investigation

INTRODUCTION

Increased frequency and intensity of inpatient therapy contributes to improved outcomes for stroke survivors. Differences exist in the amount of therapy provided internationally. In England, Wales and Northern Ireland it is recommended that a minimum of 45 min of each active therapy should be provided at least 5 days a week provided the therapy is appropriate and that the patient can tolerate this. Sentinel Stroke National Audit Programme (2014) data demonstrate this standard is not being achieved for most patients. No research been undertaken to explore how therapists in England manage their practice to meet time-specific therapy recommendations. The ReAcT study aims to develop an in-depth understanding of stroke therapy provision, including how the guideline of 45 min a day of each relevant therapy, is interpreted and implemented by therapists, and how it is experienced by stroke-survivors and their families.

METHODS AND ANALYSIS

A multisite ethnographic case study design in a minimum of six stroke units will include modified process mapping, observations of service organisation, therapy delivery and documentary analysis. Semistructured interviews with therapists and service managers (n=90), and with patients and informal carers (n=60 pairs) will be conducted. Data will be analysed using the Framework approach.

ETHICS AND DISSEMINATION

The study received a favourable ethical opinion via the National Research Ethics Service (reference number: 14/NW/0266). Participants will provide written informed consent or, where stroke-survivors lack capacity, a consultee declaration will be sought. ReAcT is designed to generate insights into the organisational, professional, social, practical and patient-related factors acting as facilitators or barriers to providing the recommended amount of therapy. Provisional recommendations will be debated in consensus meetings with stakeholders who have not participated in ReAcT case studies or interviews. Final recommendations will be disseminated to therapists, service managers, clinical guideline developers and policymakers and stroke-survivors and informal carers.

Standardised care plans for in hospital stroke care improve documentation of health care assessments

AIMS AND OBJECTIVES

To compare stroke unit staff members' documentation of care in line with evidence-based guidelines pre- and postimplementation of a multi-professional, evidence-based standardised care plan for stroke care in the electronic health record.

BACKGROUND

Rapid and effective measures for patients with stroke or suspected stroke can limit the extent of damage; it is imperative that patients be observed, assessed and treated in accordance with evidence-based practice in hospital.

DESIGN

Quantitative, comparative.

METHODS

Structured retrospective health record reviews were made prior to (n 60) and one and a half years after implementation (n 60) of a multi-professional evidence-based standardised care plan with a quality standard for stroke care in the electronic health record.

RESULTS

Significant improvements were found in documentation of assessed vital signs, except for body temperature, Day 1 post compared with preimplementation. Documentation frequency regarding body temperature Day 1 and blood pressure and pulse Day 2 decreased post compared with preimplementation. Improvements were also detected in documented observations of patients' micturition capacity, swallowing capacity and mouth status and the proportion of physiotherapist-documented aid assessments. Observations of blood glucose, mobilisation ability and speech and communication ability were unchanged.

CONCLUSIONS

An evidence-based standardised care plan in an electronic health record assists staff in improving documentation of health status assessments during the first days after a stroke diagnosis.

RELEVANCE TO CLINICAL PRACTICE

Use of a standardised care plan seems to have the potential to help staff adhere to evidence-based patient care and, thereby, to increase patient safety.

Effects of additional, dynamic supported standing practice on functional recovery in patients with sub-acute stroke: a randomized pilot and feasibility trial

OBJECTIVE

To evaluate the feasibility and preliminary effectiveness of additional dynamic versus static passive standing performed by patients with sub-acute stroke supervised by trained helpers.

DESIGN

Assessor blinded, randomized pilot and feasibility trial.

SETTING

Neurological rehabilitation centre.

PARTICIPANTS

Non-ambulatory participants in the sub-acute phase after stroke.

INTERVENTION

Usual care plus additional standing training, consisting of either dynamic standing practice in a modified standing frame (intervention group, n=14) or static standing practice in a conventional standing frame (control group, n=14) for 5 weeks.

MAIN MEASURES

Feasibility was assessed through occurrence of adverse events, patient satisfaction and operability of the technical device handled by trained helpers. Preliminary effectiveness was assessed with the Berg Balance Scale (primary outcome) and other measures of physical functioning.

RESULTS

Trained helpers were capable to apply the intervention, and no adverse events occurred. Both groups were comparable at baseline. Within-group changes tended to be higher for the intervention group, but did not reach a significant level except for the Functional Ambulation Categories. Specifically, median pre-post improvements in the Berg Balance Scale tended to be higher in the dynamic (20, inter quartile range (IQR): 2-33 points) than in the static standing group (4.5, IQR: 0-16 points; U=62; P=0.052; effect size=0.478).

CONCLUSIONS

In severely affected individuals after stroke, dynamic supported standing practice can be performed safely by trained helpers. In a larger-scale phase III study, a total of 116 patients would be needed to prove the preliminary effectiveness found in this study.

[The early post-stroke mobilization]

Early mobilization is an important prerequisite for the successful recovery after stroke. However, it is unclear at present how early mobilization should be started after stroke. Three randomized controlled trials were devoted to the comparison of the effectiveness and safety of very early (within the first day after stroke) and early (within two days after stroke) mobilization. The meta-analysis of the results of these studies did not reveal any advantages of very early mobilization over early mobilization. One randomized control study was designed to compare the consequences of mobilization within 3 and 7 days after stroke. It has demonstrated that earlier mobilization is associated with fewer complications and does not exert negative effect on cerebral haemodynamics. A number of observational studies confirmed the positive effect of early mobilization on the outcome of stroke. It is concluded that it may be justified to start mobilization on the second day after stroke provided there are no contraindications to such modality. The practicability of very early mobilization remains to be elucidated.

Circuit class therapy or seven-day week therapy for increasing rehabilitation intensity of therapy after stroke (CIRCIT): a randomized controlled trial

BACKGROUND

Increased therapy has been linked to improvements in functional ability of people with stroke.

AIM

To determine the effectiveness of two alternative models of increased physiotherapy service delivery (seven-day week therapy or group circuit class therapy five days a week) to usual care.

METHOD

Three-armed randomized controlled trial with blinded assessment of outcome. People admitted with a diagnosis of stroke, previously independently ambulant and with a moderate level of disability were recruited. 'Usual care' was individual physiotherapy provided five-days a week. Seven-day week therapy was usual care physiotherapy provided seven-days a week. Participants in the circuit class therapy arm of the trial received physiotherapy in group circuit classes in two 90-min sessions, five-days a week. Primary outcome was distance walked on the six-minute walk test at four-weeks post-randomization.

RESULTS

Two hundred eighty-three participants were randomized; primary outcome data were available for 259 (92%). In the seven-day arm participants received an additional three hours of physiotherapy and those in the circuit class arm an additional 22 h. There were no significant between-group differences at four-weeks in walking distance (P = 0.72). Length of stay was shorter for seven-day (mean difference -2.9 days, 95% confidence interval -17.9 to 12.0) and circuit class participants (mean difference -9.2 days, 95% confidence interval -24.2 to 5.8) compared to usual care, but this was not significant.

CONCLUSIONS

Both seven-day therapy and group circuit class therapy increased physiotherapy time, but walking outcomes were equivalent to usual care.

Quality of Grasping and the Role of Haptics in a 3-D Immersive Virtual Reality Environment in Individuals With Stroke

Reaching and grasping parameters with and without haptic feedback were characterized in people with chronic post-stroke behaviors. Twelve (67 ± 10 years) individuals with chronic stroke and arm/hand paresis (Fugl-Meyer Assessment-Arm: ≥ 46/66 pts) participated. Three dimensional (3-D) temporal and spatial kinematics of reaching and grasping movements to three objects (can: cylindrical grasp; screwdriver: power grasp; pen: precision grasp) in a physical environment (PE) with and without additional haptic feedback and a 3-D virtual environment (VE) with haptic feedback were recorded. Participants reached, grasped and transported physical and virtual objects using similar movement strategies in all conditions. Reaches made in VE were less smooth and slower compared to the PE. Arm and trunk kinematics were similar in both environments and glove conditions. For grasping, stroke subjects preserved aperture scaling to object size but used wider hand apertures with longer delays between times to maximal reaching velocity and maximal grasping aperture. Wearing the glove decreased reaching velocity. Our results in a small group of subjects suggest that providing haptic information in the VE did not affect the validity of reaching and grasping movement. Small disparities in movement parameters between environments may be due to differences in perception of object distance in VE. Reach-to-grasp kinematics to smaller objects may be improved by better 3-D rendering. Comparable kinematics between environments and conditions is encouraging for the incorporation of high quality VEs in rehabilitation programs aimed at improving upper limb recovery.

Feasibility of Early Physical Therapy Program In-Hospital Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE: Clinical practice guidelines for patients with stroke recommend early stroke rehabilitation at acute stroke unit care. The purpose of the study is to determine the feasibility of the application of feedback breathing device for respiratory training during the acute period in patients with ischemic cerebral stroke and appropriate program of physical therapy.MATERIAL AND METHODS: Seven patients in acute period – not later than 48 hours after the accident with light to moderate stroke severity under the NIHSS scale. The applied study methods are the following: functional respiratory evaluation, inspiratory capacity with incentive spirometer device, assessing diaphragmatic movement by ultrasonography.RESULTS: Better results in Forced Vital Capacity, Peak Expiratory Flow, inspiratory capacity and ultrasonography have been observed.CONCLUSION: An early targeted impact on respiratory disorders in patients with ischemic cerebral stroke is applicable. To determine the clinical significance larger studies are needed.

Speech pathologists' experiences with stroke clinical practice guidelines and the barriers and facilitators influencing their use: a national descriptive study

Background

Communication and swallowing disorders are a common consequence of stroke. Clinical practice guidelines (CPGs) have been created to assist health professionals to put research evidence into clinical practice and can improve stroke care outcomes. However, CPGs are often not successfully implemented in clinical practice and research is needed to explore the factors that influence speech pathologists’ implementation of stroke CPGs. This study aimed to describe speech pathologists’ experiences and current use of guidelines, and to identify what factors influence speech pathologists’ implementation of stroke CPGs.

Methods

Speech pathologists working in stroke rehabilitation who had used a stroke CPG were invited to complete a 39-item online survey. Content analysis and descriptive and inferential statistics were used to analyse the data.

Results

320 participants from all states and territories of Australia were surveyed. Almost all speech pathologists had used a stroke CPG and had found the guideline “somewhat useful” or “very useful”. Factors that speech pathologists perceived influenced CPG implementation included the: (a) guideline itself, (b) work environment, (c) aspects related to the speech pathologist themselves, (d) patient characteristics, and (e) types of implementation strategies provided.

Conclusions

There are many different factors that can influence speech pathologists’ implementation of CPGs. The factors that influenced the implementation of CPGs can be understood in terms of knowledge creation and implementation frameworks. Speech pathologists should continue to adapt the stroke CPG to their local work environment and evaluate their use. To enhance guideline implementation, they may benefit from a combination of educational meetings and resources, outreach visits, support from senior colleagues, and audit and feedback strategies.

What is the evidence for physical therapy poststroke? A systematic review and meta-analysis

BACKGROUND

Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

METHODS AND FINDINGS

Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N = 25373; median PEDro score 6 [IQR 5-7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03-0.70; I(2) = 0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84-4.11; I(2) = 77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02-0.39; I(2) = 6%) for motor function of the paretic arm to 0.61 (95%CI 0.41-0.82; I(2) = 41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.

CONCLUSIONS

There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.

Robotic technologies and rehabilitation: new tools for stroke patients' therapy

Introduction. The role of robotics in poststroke patients' rehabilitation has been investigated intensively. This paper presents the state-of-the-art and the possible future role of robotics in poststroke rehabilitation, for both upper and lower limbs. Materials and Methods. We performed a comprehensive search of PubMed, Cochrane, and PeDRO databases using as keywords “robot AND stroke AND rehabilitation.” Results and Discussion. In upper limb robotic rehabilitation, training seems to improve arm function in activities of daily living. In addition, electromechanical gait training after stroke seems to be effective. It is still unclear whether robot-assisted arm training may improve muscle strength, and which electromechanical gait-training device may be the most effective for walking training implementation. Conclusions. In the field of robotic technologies for stroke patients' rehabilitation we identified currently relevant growing points and areas timely for developing research. Among the growing points there is the development of new easily transportable, wearable devices that could improve rehabilitation also after discharge, in an outpatient or home-based setting. For developing research, efforts are being made to establish the ideal type of treatment, the length and amount of training protocol, and the patient's characteristics to be successfully enrolled to this treatment.

Clinician adherence to a standardized assessment battery across settings and disciplines in a poststroke rehabilitation population

OBJECTIVES

(1) To examine clinician adherence to a standardized assessment battery across settings (acute hospital, inpatient rehabilitation facilities [IRFs], outpatient facility), professional disciplines (physical therapy [PT], occupational therapy, speech-language pathology), and time of assessment (admission, discharge/monthly), and (2) to evaluate how specific implementation events affected adherence.

DESIGN

Retrospective cohort study.

SETTING

Acute hospital, IRF, and outpatient facility with approximately 118 clinicians (physical therapists, occupational therapists, speech-language pathologists).

PARTICIPANTS

Participants (N=2194) with stroke who were admitted to at least 1 of the above settings. All persons with stroke underwent standardized clinical assessments.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Adherence to Brain Recovery Core assessment battery across settings, professional disciplines, and time. Visual inspections of 17 months of time-series data were conducted to see if the events (eg, staff meetings) increased adherence ≥5% and if so, how long the increase lasted.

RESULTS

Median adherence ranged from .52 to .88 across all settings and professional disciplines. Both the acute hospital and the IRF had higher adherence than the outpatient setting (P≤.001), with PT having the highest adherence across all 3 disciplines (P<.004). Of the 25 events conducted across the 17-month period to improve adherence, 10 (40%) resulted in a ≥5% increase in adherence the following month, with 6 services (60%) maintaining their increased level of adherence for at least 1 additional month.

CONCLUSIONS

Actual adherence to a standardized assessment battery in clinical practice varied across settings, disciplines, and time. Specific events increased adherence 40% of the time with those gains maintained for >1 month 60% of the time.