Self-directed therapy programmes for arm rehabilitation after stroke: a systematic review

Utility and usability of a wearable system and progressive-challenge cued exercise program for encouraging use of the more involved arm at-home after stroke-a feasibility study with case reports

BACKGROUND

Understanding the role of adherence to home exercise programs for survivors of stroke is critical to ensure patients perform prescribed exercises and maximize effectiveness of recovery.

METHODS

Survivors of hemiparetic stroke with impaired motor function were recruited into a 7-day study designed to test the utility and usability of a low-cost wearable system and progressive-challenge cued exercise program for encouraging graded-challenge exercise at-home. The wearable system comprised two wrist-worn MetaMotionR+ activity monitors and a custom smartphone app. The progressive-challenge cued exercise program included high-intensity activities (one repetition every 30 s) dosed at 1.5 h per day, embedded within 8 h of passive activity monitoring per day. Utility was assessed using measures of system uptime and cue response rate. Usability and user experience were assessed using well-validated quantitative surveys of system usability and user experience. Self-efficacy was assessed at the end of each day on a visual analog scale that ranged from 0 to 100.

RESULTS

The system and exercise program had objective utility: system uptime was 92 ± 6.9% of intended hours and the rate of successful cue delivery was 99 ± 2.7%. The system and program also were effective in motivating cued exercise: activity was detected within 5-s of the cue 98 ± 3.1% of the time. As shown via two case studies, accelerometry data can accurately reflect graded-challenge exercise instructions and reveal differentiable activity levels across exercise stages. User experience surveys indicated positive overall usability in the home settings, strong levels of personal motivation to use the system, and high degrees of satisfaction with the devices and provided training. Self-efficacy assessments indicated a strong perception of proficiency across participants (95 ± 5.0).

CONCLUSIONS

This study demonstrates that a low-cost wearable system providing frequent haptic cues to encourage graded-challenge exercise after stroke can have utility and can provide an overall positive user experience in home settings. The study also demonstrates how combining a graded exercise program with all-day activity monitoring can provide insight into the potential for wearable systems to assess adherence to-and effectiveness of-home-based exercise programs on an individualized basis.

Effectiveness of digital home rehabilitation and supervision for stroke survivors: A systematic review and meta-analysis

Objective

Stroke survivors often experience residual impairments and motor decline post-discharge. While digital home rehabilitation combined with supervision could be a promising approach for reducing human resources, increasing motor ability, and supporting rehabilitation persistence there is a lack of reviews synthesizing the effects. Thus, this systematic review and meta-analysis aimed to synthesize the effect of digital home rehabilitation and supervision in improving motor ability of upper limb, static balance, stroke-related quality of life, and self-reported arm function among stroke survivors.

Methods

Six electronic databases, grey literature, ongoing studies, and reference lists were searched for relevant studies. Two investigators independently reviewed titles, abstracts, screened full texts for eligibility and performed data extraction. Meta-analysis of 13 independent studies were grouped into four separate meta-analyses. The Grading of Recommendations, Assessments, Development and Evaluations (GRADE) tool was used for evaluating the overall quality of the evidence.

Results

Meta-analyses showed no statistically significant difference between intervention (digital home rehabilitation) and control groups (home training/clinic-based) of all outcomes including motor ability of upper limb, static balance, stroke-related quality of life, and self-reported arm function. In the sub-group analysis digital home rehabilitation was associated with better quality of arm use (standardized mean difference = 0.68, 95% confidence interval: [0.27, 1.09], p = 0.001).

Conclusions

This result indicated that digital home rehabilitation has similar effects and could potentially replace home training or clinic-based services. This review highlights better-targeted digital motor interventions to examine the effects of interventions further. The quality of evidence was moderate to high in motor and self-reported arm outcomes, and low for balance and quality of life.

Examining Usability, Acceptability, and Adoption of a Self-Directed, Technology-Based Intervention for Upper Limb Rehabilitation After Stroke: Cohort Study

BACKGROUND

Upper limb (UL) recovery after stroke is strongly dependent upon rehabilitation dose. Rehabilitation technologies present pragmatic solutions to dose enhancement, complementing therapeutic activity within conventional rehabilitation, connecting clinicians with patients remotely, and empowering patients to drive their own recovery. To date, rehabilitation technologies have been poorly adopted. Understanding the barriers to adoption may shape strategies to enhance technology use and therefore increase rehabilitation dose, thus optimizing recovery potential.

OBJECTIVE

We examined the usability, acceptability, and adoption of a self-directed, exercise-gaming technology within a heterogeneous stroke survivor cohort and investigated how stroke survivor characteristics, technology usability, and attitudes toward technology influenced adoption.

METHODS

A feasibility study of a novel exercise-gaming technology for self-directed UL rehabilitation in early subacute stroke survivors (N=30) was conducted in an inpatient, acute hospital setting. Demographic and clinical characteristics were recorded; participants' performance in using the system (usability) was assessed using a 4-point performance rating scale (adapted from the Barthel index), and adherence with the system was electronically logged throughout the trial. The technology acceptance model was used to formulate a survey examining the acceptability of the system. Spearman rank correlations were used to examine associations between participant characteristics, user performance (usability), end-point technology acceptance, and intervention adherence (adoption).

RESULTS

The technology was usable for 87% (n=26) of participants, and the overall technology acceptance rating was 68% (95% CI 56%-79%). Participants trained with the device for a median of 26 (IQR 16-31) minutes daily over an enrollment period of 8 (IQR 5-14) days. Technology adoption positively correlated with user performance (usability) (ρ=0.55; 95% CI 0.23-0.75; P=.007) and acceptability as well as domains of perceived usefulness (ρ=0.42; 95% CI 0.09-0.68; P=.03) and perceived ease of use (ρ=0.46; 95% CI 0.10-0.74; P=.02). Technology acceptance decreased with increased global stroke severity (ρ=-0.56; 95% CI -0.79 to -0.22; P=.007).

CONCLUSIONS

This technology was usable and acceptable for the majority of the cohort, who achieved an intervention dose with technology-facilitated, self-directed UL training that exceeded conventional care norms. Technology usability and acceptability were determinants of adoption and appear to be mediated by stroke severity. The results demonstrate the importance of selecting technologies for stroke survivors on the basis of individual needs and abilities, as well as optimizing the accessibility of technologies for the target user group. Facilitating changes in stroke survivors' beliefs and attitudes toward rehabilitation technologies may enhance adoption. Further work is needed to understand how technology can be optimized to benefit those with more severe stroke.

Evaluating the Dissemination and Implementation Impact of a Rehabilitation Intervention: The Graded Repetitive Arm Supplementary Program (GRASP)

Purpose

To evaluate the dissemination and implementation impacts of a rehabilitation intervention.

Methods

Systematic evaluation of data sources including academic publishing metrics, publications, and surveys was used to describe the dissemination and implementation impact of the graded repetitive arm supplementary program (GRASP). Three categories in the Payback Framework were evaluated: knowledge production and dissemination, benefits to future research and research use, and real-world uptake and implementation.

Results

In the Knowledge production and dissemination category, seven publications, authored by the GRASP research team, were associated with the GRASP, and there were approximately 17,000 download counts of GRASP manuals from the website from 120 countries. In the Benefits to future research and research use category, 15 studies and 8 registered clinical trials, authored by researchers outside of the GRASP team, have used GRASP as an intervention. In the real-world uptake and implementation category, GRASP has informed recommendations in 2 clinical guidelines and 20 review papers, and had high implementation uptake (e.g., 35% [53/154] of UK therapists surveyed had used GRASP; 95% [649/681] who downloaded GRASP had used it). More than 75% of those who had used GRASP identified that GRASP provides more intensity in upper extremity rehabilitation, is evidence-based and easy to implement, and the equipment and manual are easy to obtain.

Conclusion

The Payback Framework is useful to evaluate the dissemination and implementation impacts of a rehabilitation intervention. GRASP has been implemented extensively in clinical practice and community in a relatively short time since it has been developed.

Effectiveness of robot-assisted arm therapy in stroke rehabilitation: An overview of systematic reviews

BACKGROUND

Robot-assisted arm therapy (RAT) has been used mainly in stroke rehabilitation in the last 20 years with rising expectations and growing evidence summarized in systematic reviews (SRs).

OBJECTIVE

The aim of this study is to provide an overview of SRs about the effectiveness, within the ICF domains, and safety of RAT in the rehabilitation of adult with stroke compared to other treatments.

METHODS

The search strategy was conducted using search strings adapted explicitly for each database. A screening base on title and abstract was realized to find all the potentially relevant studies. The methodological quality of the included SRs was assessed using AMSTAR-2. A pre-determined standardized form was used to realize the data extraction.

RESULTS

18 SRs were included in this overview. Generally, positive effects from the RAT were found for motor function and muscle strength, whereas there is no agreement for muscle tone effects. No effect was found for pain, and only a SR reported the positive impact of RAT in daily living activity.

CONCLUSION

RAT can be considered a valuable option to increase motor function and muscle strength after stroke. However, the poor quality of most of the included SRs could limit the certainty around the results.

Effectiveness of home-based upper limb rehabilitation in stroke survivors: A systematic review and meta-analysis

Background

Home-based training is an alternative option to provide intensive rehabilitation without costly supervised therapy. Though several studies support the effectiveness of home-based rehabilitation in improving hemiparetic upper limb function in stroke survivors, a collective evaluation of the evidence remains scarce.

Objectives

This study aims to determine the effects of home-based upper limb rehabilitation for hemiparetic upper limb recovery in stroke survivors.

Methods

The databases of the Cochrane Library, MEDLINE, CINAHL, and Web of Science were systematically searched from January 2000 to September 2020. Only randomized, controlled, and cross-over trials that evaluated the effects of home-based upper limb interventions were selected. The Pedro scale was used to assess the methodological quality of the studies. A meta-analysis of the upper limb function outcomes was performed by calculating the mean difference/standardized mean difference using a fixed/random effect model.

Results

An initial search yielded 1,049 articles. Twenty-six articles were included in the review. The pooled evidence of the meta-analysis showed that home-based upper limb intervention was more effective in improving upper limb function [SMD: 0.28, 95% CI (0.12, 0.44), I² = 0%, p < 0.001, fixed effect model] than conventional therapy. When comparing two types of home-based interventions, subgroup analysis revealed that home-based technology treatment—electrical stimulation—provided more significant improvement in upper limb function than treatment without the use of technology (SMD: 0.64, 95% CI (0.21, 1.07), I² = 0%, p = 0.003, random effect model).

Conclusion

The beneficial effects of home-based upper limb interventions were superior to conventional therapy in improving function and perceived use of the hemiparetic upper limb in daily activities. Among the home-based interventions, home-based electrical stimulation seemed to provide the most optimal benefits.

SaeboGlove therapy for upper limb disability and severe hand impairment after stroke (SUSHI): Study protocol for a randomised controlled trial

Background

Impaired active digital extension is common after stroke, hindering functional rehabilitation, and predicting poor recovery. The SaeboGlove assists digital extension and may improve outcome after stroke. We recently performed a single group, open, pilot trial of the SaeboGlove early after stroke which demonstrated satisfactory safety, feasibility and acceptability. An adequately powered randomised clinical trial is now needed to assess the clinical effectiveness of the SaeboGlove.

Methods

SUSHI is a pragmatic, multicentre, parallel-group, randomised controlled trial with blinded outcome assessment, and embedded process and economic evaluations. Adults, 7–60 days post-stroke, with upper limb disability and severe hand impairment, including reduced active digital extension, will be recruited from NHS inpatient stroke services in Scotland. Participants will be randomised on a 1:1 basis to receive 6 weeks of self-directed, repetitive, functional-based practice involving a SaeboGlove plus usual care, or usual care only. The primary outcome is upper limb function measured by the Action Research Arm Test (ARAT) at 6 weeks. Secondary outcomes will be measured at 6 and 14 weeks. A process evaluation will be performed via interviews with ‘intervention’ participants, and their carers and clinical therapists. A within-trial cost-effectiveness analysis will be performed. 110 participants are required to detect a difference between groups of 9 in the ARAT with 90% power at a 5% significance level allowing for 11% attrition.

Discussion

SUSHI will determine if SaeboGlove self-directed, repetitive, functional-based practice improves upper limb function after stroke, whether it is acceptable to stroke survivors and whether it is cost-effective.

Self-Rehabilitation for Post-Stroke Motor Function and Activity-A Systematic Review and Meta-Analysis

Background. Due to an increasing stroke incidence, a lack of resources to implement effective rehabilitation and a significant proportion of patients with remaining impairments after treatment, there is a rise in demand for effective and prolonged rehabilitation. Development of self-rehabilitation programs provides an opportunity to meet these increasing demands.Objective. The primary aim of this meta-analysis was to determine the effect of self-rehabilitation on motor outcomes, in comparison to conventional rehabilitation, among patients with stroke. The secondary aim was to assess the influence of trial location (continent), technology, time since stroke (acute/subacute vs chronic), dose (total training duration > vs ≤ 15 hours), and intervention design (self-rehabilitation in addition/substitution to conventional therapy) on effect of self-rehabilitation.Methods. Studies were selected if participants were adults with stroke; the intervention consisted of a self-rehabilitation program defined as a tailored program where for most of the time, the patient performed rehabilitation exercises independently; the control group received conventional therapy; outcomes included motor function and activity; and the study was a randomized controlled trial with a PEDro score ≥5.Results. Thirty-five trials were selected (2225 participants) and included in quantitative synthesis regarding motor outcomes. Trials had a median PEDro Score of 7 [6-8]. Self-rehabilitation programs were shown to be as effective as conventional therapy. Trial location, use of technology, stroke stage, and intervention design did not appear to have a significant influence on outcomes.Conclusion. This meta-analysis showed low to moderate evidence that self-rehabilitation and conventional therapy efficacy was equally valuable for post-stroke motor function and activity.

Self-Directed Exergaming for Stroke Upper Limb Impairment Increases Exercise Dose Compared to Standard Care

Background. One of the strongest modifiable determinants of rehabilitation outcome is exercise dose. Technologies enabling self-directed exercise offer a pragmatic means to increase dose, but the extent to which they achieve this in unselected cohorts, under real-world constraints, is poorly understood. Objective. Here we quantify the exercise dose achieved by inpatient stroke survivors using an adapted upper limb (UL) exercise gaming (exergaming) device and compare this with conventional (supervised) therapy. Methods. Over 4 months, patients presenting with acute stroke and associated UL impairment were screened at a single stroke centre. Participants were trained in a single session and provided with the device for unsupervised use during their inpatient admission. Results. From 75 patients referred for inpatient UL therapy, we recruited 30 (40%), of whom 26 (35%) were able to use the device meaningfully with their affected UL. Over a median enrolment time of 8 days (IQR: 5–14), self-directed UL exercise duration using the device was 26 minutes per day (median; IQR: 16–31), in addition to 25 minutes daily conventional UL therapy (IQR: 12–34; same cohort plus standard care audit; joint n = 50); thereby doubling total exercise duration (51 minutes; IQR: 32–64) relative to standard care (Z = 4.0, P <.001). The device enabled 104 UL repetitions per day (IQR: 38–393), whereas conventional therapy achieved 15 UL repetitions per day (IQR: 11–23; Z = 4.3, P <.001). Conclusion. Self-directed adapted exergaming enabled participants in our stroke inpatient cohort to increase exercise duration 2-fold, and repetitions 8-fold, compared to standard care, without requiring additional professional supervision.

Virtual Reality in Neurorehabilitation: An Umbrella Review of Meta-Analyses

Neurological disorders are a leading cause of death and disability worldwide. Can virtual reality (VR) based intervention, a novel technology-driven change of paradigm in rehabilitation, reduce impairments, activity limitations, and participation restrictions? This question is directly addressed here for the first time using an umbrella review that assessed the effectiveness and quality of evidence of VR interventions in the physical and cognitive rehabilitation of patients with stroke, traumatic brain injury and cerebral palsy, identified factors that can enhance rehabilitation outcomes and addressed safety concerns. Forty-one meta-analyses were included. The data synthesis found mostly low- or very low-quality evidence that supports the effectiveness of VR interventions. Only a limited number of comparisons were rated as having moderate and high quality of evidence, but overall, results highlight potential benefits of VR for improving the ambulation function of children with cerebral palsy, mobility, balance, upper limb function, and body structure/function and activity of people with stroke, and upper limb function of people with acquired brain injury. Customization of VR systems is one important factor linked with improved outcomes. Most studies do not address safety concerns, as only nine reviews reported adverse effects. The results provide critical recommendations for the design and implementation of future VR programs, trials and systematic reviews, including the need for high quality randomized controlled trials to test principles and mechanisms, in primary studies and in meta-analyses, in order to formulate evidence-based guidelines for designing VR-based rehabilitation interventions.

Perseverance with technology-facilitated home-based upper limb practice after stroke: a systematic mixed studies review

Background

Technology is being increasingly investigated as an option to allow stroke survivors to exploit their full potential for recovery by facilitating home-based upper limb practice. This review seeks to explore the factors that influence perseverance with technology-facilitated home-based upper limb practice after stroke.

Methods

A systematic mixed studies review with sequential exploratory synthesis was undertaken. Studies investigating adult stroke survivors with upper limb disability undertaking technology-facilitated home-based upper limb practice administered ≥ 3 times/week over a period of ≥ 4 weeks were included. Qualitative outcomes were stroke survivors’ and family members’ perceptions of their experience utilising technology to facilitate home-based upper limb practice. Quantitative outcomes were adherence and dropouts, as surrogate measures of perseverance. The Mixed Methods Appraisal Tool was used to assess quality of included studies.

Results

Forty-two studies were included. Six studies were qualitative and of high quality; 28 studies were quantitative and eight were mixed methods studies, all moderate to low quality. A conceptual framework of perseverance with three stages was formed: (1) getting in the game; (2) sticking with it, and; (3) continuing or moving on. Conditions perceived to influence perseverance, and factors mediating these conditions were identified at each stage. Adherence with prescribed dose ranged from 13 to 140%. Participants were found to be less likely to adhere when prescribed sessions were more frequent (6–7 days/week) or of longer duration (≥ 12 weeks).

Conclusion

From the mixed methods findings, we propose a framework for perseverance with technology-facilitated home-based upper limb practice. The framework offers opportunities for clinicians and researchers to design strategies targeting factors that influence perseverance with practice, in both the clinical prescription of practice and technology design. To confirm the clinical utility of this framework, further research is required to explore perseverance and the factors influencing perseverance.

Registration: PROSPERO CRD42017072799—https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=72799

Dynamic hand orthoses for the recovery of hand and arm function in adults after stroke: A systematic review and meta-analysis of randomised controlled trials

Background: Repetitive, functional-based rehabilitation is recommended after stroke. However, impaired active digital extension is common after stroke, which limits functional-based rehabilitation and recovery. Non-robotic dynamic hand orthoses (DHOs) may address this.Objectives: We did a systematic review and meta-analysis to determine whether non-robotic DHOs improve upper limb recovery after stroke in comparison to i)placebo or no intervention and ii)usual care.Methods: We followed PRISMA guidelines. We included randomized controlled trials (RCTs) assessing upper limb recovery associated with the use of non-robotic DHOs in adults after stroke. Outcomes of interest were functional upper limb movement and activities of daily living.We performed searches on 27 September 2019 in 10 bibliographic databases including Cochrane Stroke Groups Specialized Trials Register and Cochrane Central Register of Controlled Trials. We also searched gray literature and citations from included studies.Two reviewers independently screened abstracts and full text, extracted data and assessed risk of bias using a Cochrane risk of bias tool.Results: We reviewed 7225 titles and included four studies involving 56 randomized participants, all with a high risk of bias. A positive effect in favor of non-robotic DHOs was observed for two outcomes; upper limb function (mean difference (MD) 6.23, 95% confidence interval (CI) 0.28-12.19 (p = 0.04)) and dexterity (MD 2.99, 95% CI 0.39-5.60 (p = 0.02).Conclusions: The results are encouraging but included studies were small with high risk of bias meaning there is currently insufficient evidence that non-robotic DHOs improve upper limb recovery after stroke.Review Registration: PROSPERO, CRD42020179180. Registered on 20 May 2020.

Video-guided exercise after stroke: a feasibility randomised controlled trial

BACKGROUND

Facilitating self-directed upper-limb exercise in people after a stroke whilst not in therapy sessions may increase therapy intensity and improve outcomes. Objectives: To investigate the feasibility and acceptability of video-guided exercise for facilitating upper-limb exercise after stroke.

METHODS

A single-blind feasibility randomized controlled trial with embedded qualitative study in stroke wards at a large teaching hospital in the United Kingdom. Fourteen participants with stroke were randomized to either video-guided exercise intervention or a "treatment-as-usual" control group. Intervention participants received a computer tablet containing filmed individualized exercises to guide out of therapy practice. The primary outcome measure was the Motor status scale (MSS) for the upper limb, which was used to guide possible sample sizes for a future main trial. Qualitative focus group and interview data on feasibility/acceptability were collected and analyzed.

RESULTS

The intervention was acceptable, but the need for motivation/support to exercise was highlighted. Based on similar assumptions to the feasibility study, circa ninety-two patients in each group would be needed to detect a difference of 5 in upper-limb motor status for a main trial.

CONCLUSION

A trial of video-guided exercise is feasible, although an optimal main trial would require some relatively minor changes to design, outcome measures, eligibility, and the intervention.

Evaluation of a staff behaviour change intervention to increase the use of ward-based practice books and active practice during inpatient stroke rehabilitation: a phase-1 pre-post observational study

OBJECTIVE

The aim of this study was to evaluate a staff behaviour change intervention to increase the use of ward-based practice books and active practice by stroke inpatients.

DESIGN

This is a pre-post observational study.

SETTING

This study was conducted in a inpatient rehabilitation unit in Australia.

SUBJECTS

Stroke inpatients participated in the study.

INTERVENTION

A staff behaviour change intervention was designed to support staff to implement practice books. The intervention included staff training on motivation and coaching, and weekly audit and feedback for six months. The environment was restructured to bring staff together weekly at the bedside to review audit data and share skills.

MAIN MEASURES

Medical record audit and behavioural mapping were used to compare the number of stroke participants with/using a practice book pre- and post-intervention. Pre- and post-intervention, the percentage of observations where a stroke participant was actively practising, repetitions of practice recorded and type of supervision were compared.

RESULTS

A total of 24 participants were observed (n = 12 pre, n = 12 post). Post-intervention, the number of participants with practice books increased from one to six (OR = 11, 95% CI = (0.9, 550.7)), but this change was not statistically significant (P = 0.069). Five participants recorded repetitions in their practice books post-intervention, three were observed using practice books. There was no change in median repetitions recorded (r_pbs = 0.00, 95% CI = (-0.4, 0.4), P = 1.000) or observed active practice (r_pbs = -0.02, 95% CI = (-0.4, 0.4), P = 0.933). Active practice was often fully supervised by a therapist.

CONCLUSION

A staff behaviour change intervention has the potential to increase the number of stroke survivors receiving ward-based practice books but did not increase active practice.

Home-based rehabilitation using a soft robotic hand glove device leads to improvement in hand function in people with chronic spinal cord injury:a pilot study

BACKGROUND

Loss of hand function following high level spinal cord injury (SCI) is perceived as a high priority area for rehabilitation. Following discharge, it is often impractical for the specialist care centre to provide ongoing therapy for people living with chronic SCI at home, which can lead to further deterioration of hand function and a direct impact on an individual's capability to perform essential activities of daily living (ADL).

OBJECTIVE

This pilot study investigated the therapeutic effect of a self-administered home-based hand rehabilitation programme for people with cervical SCI using the soft extra muscle (SEM) Glove by Bioservo Technologies AB.

METHODS

Fifteen participants with chronic cervical motor incomplete (AIS C and D) SCI were recruited and provided with the glove device to use at home to complete a set task and perform their usual ADL for a minimum of 4 h a day for 12 weeks. Assessment was made at Week 0 (Initial), 6, 12 and 18 (6-week follow-up). The primary outcome measure was the Toronto Rehabilitation Institute hand function test (TRI-HFT), with secondary outcome measures including pinch dynamometry and the modified Ashworth scale.

RESULTS

The TRI-HFT demonstrated improvement in hand function at Week 6 of the therapy including improvement in object manipulation (58.3 ±3.2 to 66.9 ±1.8, p ≈ 0.01), and palmar grasp assessed as the length of the wooden bar that can be held using a pronated palmar grip (29.1 ±6.0 cm to 45.8 ±6.8 cm, p <0.01). A significant improvement in pinch strength, with reduced thumb muscle hypertonia was also detected. Improvements in function were present during the Week 12 assessment and also during the follow-up.

CONCLUSIONS

Self-administered rehabilitation using the SEM Glove is effective for improving and retaining gross and fine hand motor function for people living with chronic spinal cord injury at home. Retention of improved hand function suggests that an intensive activity-based rehabilitation programme in specific individuals is sufficient to improve long-term neuromuscular activity. Future studies should characterise the neuromuscular mechanism of action and the minimal rehabilitation programme necessary with the assistive device to improve ADL tasks following chronic cervical SCI.

TRIAL REGISTRATION NUMBER

Trial registration: ISRCTN, ISRCTN98677526, Registered 01/June/2017 - Retrospectively registered, http://www.isrctn.com/ISRCTN98677526.

Telerehabilitation System in Nursing Post Stroke - A Systematic Review

Background: Stroke is currently the main cause of disability worldwide. Telerehabilitation is a rehabilitation approach that can be used to repair the damage to motor, sensory and cognitive functions. This can also substantially reduce the travel time for the health workers and therefore increase the number of patients who are consulted in a day.Method: A search using specific keywords was done in both the journal articles and in the database. In total, 119 articles were from Scopus, 45 articles were from PubMed, 87 articles were from Science Direct, 52 articles were from EBSCO and 97 articles were from Proquest. There were 15 articles that matched the inclusion criteria. Most of the available literature only refers to short-term results and most of the research is of low quality.Result: Evidence of the relative effectiveness was found in the types of videos, VR, cellphones and computer use. The location of the network support and technological progress are still obstacles that must be addressed immediately. Based on the current scientific evidence, only a few telerehabilitation methods can be recommended for wider use.Conclusion: The telerehabilitation system can provide long-term therapy, meet the patient needs and save the health resources needed to minimize the severity of the patients’ condition. The application of telerehabilitation is used by the nurses to optimize their role in improving patient health and telerehabilitation will answer the problem of penetrating the distance dimension.

Wristband Accelerometers to motiVate arm Exercises after Stroke (WAVES): a pilot randomized controlled trial

OBJECTIVE

To evaluate the feasibility of a multicentre, observer-blind, pilot randomized controlled trial (RCT) of a wristband accelerometer with activity-dependent vibration alerts to prompt impaired arm use after stroke.

DESIGN

Parallel-group pilot RCT.

SETTING

Four English stroke services.

PARTICIPANTS

Patients 0-3 months post stroke with a new arm deficit.

INTERVENTION

Participants were randomized to wear a prompting or 'sham' wristband during a four-week self-directed therapy programme with twice-weekly therapy review.

MAIN OUTCOMES

Recruitment, retention and adherence rates, safety and completion of assessments were reported. Arm recovery was measured by Action Research Arm Test (ARAT) and Motor Activity Log (MAL) without statistical comparison.

RESULTS

In total, 33 patients were recruited (0.6 per month/site; median time post stroke: 26 days (interquartile range (IQR):15.5-45)). Baseline, four-week and eight-week median (IQR) ARAT for the control group (n = 19) were 15 (2-35), 35 (15-26) and 31 (21-55) and those for the intervention group (n = 14) were 37 (16-45), 57 (29-57) and 57 (37-57), respectively; for MAL Amount of Use, the corresponding values in the control group were 0.2 (0.0-1.2), 1.1 (0.3-2.9) and 1.2 (0.7-2.9) and in the intervention group were 1.4 (0.5-2.6), 3.8 (1.9-4.5) and 3.7 (2.1-4.3). Four participants withdrew from the study. Wristbands were worn for 79% of the recommended time. The intervention and control group participants received a median of 6.0 (IQR: 4.3-8.0) and 7.5 (IQR: 6.8-8.0) therapy reviews. A median of 8 (IQR: 6-10) prompts were delivered per intervention participant/day. Research assessments were completed for 28/29 and 25/28 patients at four and eight weeks. Eight serious adverse events were reported, all unrelated to the intervention.

CONCLUSION

A multicentre RCT of wristband accelerometers to prompt arm activity early after stroke is feasible. A total sample of 108 participants would be required.