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

Group versus individual delivery of upper limb intervention for adults post-stroke: A systematic review and meta-analysis

ObjectiveTo systematically review the evidence and examine the effectiveness of group-based UL intervention versus individual therapy, in decreasing impairment and improving UL function post-stroke.Data SourcesA comprehensive search of four key databases (CINAHL, Embase, Emcare, and MEDLINE) identified relevant studies published from inception through to November 2024.Review methodsTwo reviewers independently performed screening for inclusion according to selection criteria. Eligible studies provided dose-matched group and individual UL rehabilitation programs. Outcomes that measured UL impairment (Fugl-Meyer Upper Extremity Test) or function (Action Research Arm Test) were extracted for meta-analysis. Methodological quality was assessed using the PEDro scale.ResultsOf 3291 publications, eight studies were included (n = 348) (seven randomised controlled trials and one controlled trial) of poor to good quality. A random effects meta-analysis model was conducted. Statistical significance was determined using analysis of covariance. No significant effects were shown in the meta-analyses on the effect of group versus individual therapy on UL impairment (mean difference 0.87, 95% CI: -0.87 to 2.62, p = .327) or function (mean difference 1.53, 95% CI: -0.23 to 3.29, p = .089). Results were limited by small sample sizes and substantial heterogeneity, with wide variation in intervention type, dosage and setting.ConclusionMeta-analyses suggest group-based UL intervention may be as effective as intervention delivered one-to-one, post-stroke. Additional studies of large sample size and rigorous methodology are necessary to substantiate these findings. Future research should investigate which types of UL intervention are most effective when provided in group-based settings across the different stages of stroke recovery.

Exploring physiotherapy staff's perceptions of physiotherapy delivery in acute stroke rehabilitation

OBJECTIVE

To explore physiotherapists' perspectives on current and alternative models of physiotherapy delivery in acute stroke rehabilitation.

DESIGN

Qualitative service evaluation.

SETTING

An acute stroke rehabilitation unit within a London teaching hospital in the UK.

PARTICIPANTS

A purposive sample of 17 physiotherapy staff (qualified physiotherapists and physiotherapy support staff) working in the acute stroke rehabilitation unit at the time of, or in the previous 3 months of the study were recruited to participate.

RESULTS

Three themes were identified: barriers to effective physiotherapy delivery, enablers of effective physiotherapy delivery, and alternative models of physiotherapy delivery. Themes were framed by the concept of providing effective and efficient physiotherapy guided by reflection. Main barriers included patients not being ready for and underutilisation of time within physiotherapy sessions. Use of timetabling and access to senior therapy support enabled more effective and efficient physiotherapy delivery. Alternative models to optimise physiotherapy delivery included different staff to patient ratios, group therapy, opportunistic physiotherapy delivery and self-management.

CONCLUSIONS

Several enablers of and barriers to providing effective and efficient physiotherapy post-stroke exist. Physiotherapists should consider implementing alternative models of physiotherapy delivery to increase the amount of physiotherapy provided to patients' post-stroke, thereby facilitating post-stroke functional recovery.

The Impact of the Total Amount of Exercise Therapy on Post-Stroke Activities of Daily Living and Motor Function: A Meta-Analysis

Although the benefits of exercise therapy in stroke rehabilitation are well-documented, the optimal amount remains a matter of debate. This study investigated the impact of the total amount of exercise therapy on clinical outcomes in adult patients with stroke. We conducted a comprehensive search of three major international databases (Medline, Embase, and the Cochrane Library) and included 18 randomized controlled trials that compared the effects of different amounts of exercise therapy on activities of daily living, upper limb function, lower limb function, and adverse events in stroke patients. We performed a risk of bias assessment, conducted a meta-analysis using a random-effects model, and evaluated the certainty of the evidence. The results indicated that more time spent in exercise therapy significantly improved activities of daily living compared to less time (standardized mean difference [SMD], 0.18; 95% confidence interval [CI], 0.06, 0.30; p = 0.002), with moderate evidence. Additionally, higher intensity of exercise therapy enhanced lower limb function compared to lower intensity (SMD, 0.66; 95% CI, 0.18, 1.13; p = 0.007), with a low level of evidence. No significant differences were found in the incidence of adverse events. Based on these findings, physicians may consider increasing the total amount of exercise therapy for stroke patients in order to improve their activities of daily living and motor function, while carefully considering each patient's neurological and medical condition.

Age-Related Differences in the Effectiveness of Rehabilitation to Improve Activities of Daily Living in Patients with Stroke: A Cross-Sectional Study

BACKGROUND

This study aimed to reveal differences in the effectiveness of rehabilitation in improving activities of daily living (ADL) in patients with acute stroke across age groups and propose age-appropriate rehabilitation strategies.

METHODS

This observational study analyzed nationwide administrative data of inpatients admitted to hospitals with acute stroke between April 1, 2018, and March 31, 2020. The data included the average length of daily rehabilitation sessions, weekly frequency of rehabilitation sessions, and initiation of rehabilitation within 3 days. The primary outcome was the improvement in the Barthel Index (BI) score from admission to discharge. We classified the patients based on age and analyzed improvements in ADL according to rehabilitation characteristics.

RESULTS

An increased daily rehabilitation dose was associated with improved ADL, except in patients aged <65 years (risk ratio [95% confidence interval] in the 65-74, 75-85, and ≥85 years age groups: 1.20 [1.14‒1.27], 1.21 [1.15‒1.27], and 1.43 [1.34‒1.53], respectively; all p<0.001 vs. <65 years: 1.05 [0.98‒1.12]; p=0.18). A rehabilitation frequency of seven sessions per week was associated with improved ADL in the 75-85 years and ≥85 years age groups (1.06 [1.02‒1.10] and 1.08 [1.03‒1.13], respectively; both p<0.001). The effects of initiating rehabilitation within 3 days on ADL post-admission did not differ across age groups.

CONCLUSION

Increasing the daily dose of rehabilitation was significantly associated with improved ADL in all age groups while increasing the frequency of rehabilitation per week improved ADL in older and very old patients.

Neuroimaging biomarkers for predicting stroke outcomes: A systematic review

Background and Aims

Stroke is a prominent cause of long-term adult impairment globally and a significant global health issue. Only 14% of stroke survivors achieve full recovery, while 25% to 50% require varying degrees of support, and over half become dependent. The aftermath of a stroke brings profound changes to an individual's life, with early choices significantly impacting their quality of life. This review aims to establish the efficacy of neuroimaging data in predicting long-term outcomes and recovery rates following a stroke.

Methods

A scientific literature search was conducted using the Centre of Reviews and Dissemination (CRD) criteria and PRISMA guidelines for a combined meta-narrative and systematic quantitative review. The methodology involved a structured search in databases like PubMed and The Cochrane Library, following inclusion and exclusion criteria to identify relevant studies on neuroimaging biomarkers for stroke outcome prediction. Data collection utilized the Microsoft Edge Zotero plugin, with quality appraisal conducted via the CASP checklist. Studies published from 2010 to 2024, including observational, randomized control trials, case reports, and clinical trials. Non-English and incomplete studies were excluded, resulting in the identification of 11 pertinent articles. Data extraction emphasized study methodologies, stroke conditions, clinical parameters, and biomarkers, aiming to provide a thorough literature overview and evaluate the significance of neuroimaging biomarkers in predicting stroke recovery outcomes.

Results

The results of this systematic review indicate that integrating advanced neuroimaging methods with highly successful reperfusion therapies following a stroke facilitates the diagnosis of the condition and assists in improving neurological impairments resulting from stroke. These measures reduce the possibility of death and improve the treatment provided to stroke patients.

Conclusion

These findings highlight the crucial role of neuroimaging in advancing our understanding of post-stroke outcomes and improving patient care.

Implementing circuit class training can increase therapy time and functional independence in people with stroke receiving inpatient rehabilitation: findings from a retrospective observational clinical audit

BACKGROUND

Increased therapy time and task-specific practice can improve functional recovery post stroke. This observational study aimed to determine whether the clinical implementation of circuit training increases therapy time and improves function in stroke rehabilitation.

METHODS

In a retrospective clinical audit, medical records of 110 people (mean age 78.7, standard deviation 13.0, 49.1% male, 57.3% severe stroke) admitted to a stroke inpatient rehabilitation ward were evaluated to determine the differences between pre (Individual Therapy (IT), n = 55) and post (Circuit Class Therapy (CCT), n = 55) service change implementation. The primary outcome was the amount of time spent in physiotherapy daily (minutes). Secondary outcomes included the Functional Independence Measure (FIM) score and length of stay (LOS).

RESULTS

The CCT Group spent significantly more time in physiotherapy daily during their rehabilitation LOS compared to the IT Group (mean difference 8.45 (95% CI 5.99 to 10.90) mins, p < 0.001). No significant between-group differences were observed for FIM scores or LOS (p ≥ 0.066).

CONCLUSION

This study suggests that the clinical implementation of CCT can significantly increase therapy time by close to 9 minutes per session, with functional gains that are equivalent to usual care. This was achieved with a patient-to-staff ratio of 3:1, compared to the 1:1 ratio in IT, concurring with existing evidence in support of CCT as an alternative service delivery model for inpatient stroke rehabilitation.

Post Stroke Exercise Training: Intensity, Dosage, and Timing of Therapy

More intense, earlier exercise in rehabilitation results in improved motor outcomes following stroke. Timing and intensity of therapy delivery vary from study to study. For more intensive therapies, there are practical challenges in implementation. However, there are also opportunities for high intensity treatment through innovative approaches and new technologies. Timing of rehabilitation is important. As time post stroke increases, the dosage of therapy required to improve motor recovery outcomes increases. Very early rehabilitation may improve motor outcomes but should be delayed for at least 24 hours post stroke.

Standardized measurement of balance and mobility post-stroke: Consensus-based core recommendations from the third Stroke Recovery and Rehabilitation Roundtable

BACKGROUND

Mobility is a key priority for stroke survivors. Worldwide consensus of standardized outcome instruments for measuring mobility recovery after stroke is an essential milestone to optimize the quality of stroke rehabilitation and recovery studies and to enable data synthesis across trials.

METHODS

Using a standardized methodology, which involved convening of 13 worldwide experts in the field of mobility rehabilitation, consensus was established through an a priori defined survey-based approach followed by group discussions. The group agreed on balance- and mobility-related definitions and recommended a core set of outcome measure instruments for lower extremity motor function, balance and mobility, biomechanical metrics, and technologies for measuring quality of movement.

RESULTS

Selected measures included the Fugl-Meyer Motor Assessment lower extremity subscale for motor function, the Trunk Impairment Scale for sitting balance, and the Mini Balance Evaluation System Test (Mini-BESTest) and Berg Balance Scale (BBS) for standing balance. The group recommended the Functional Ambulation Category (FAC, 0-5) for walking independence, the 10-meter Walk Test (10 mWT) for walking speed, the 6-Minute Walk Test (6 MWT) for walking endurance, and the Dynamic Gait Index (DGI) for complex walking. An FAC score of less than three should be used to determine the need for an additional standing test (FAC < 3, add BBS to Mini-BESTest) or the feasibility to assess walking (FAC < 3, 10 mWT, 6 MWT, and DGI are "not testable"). In addition, recommendations are given for prioritized kinetic and kinematic metrics to be investigated that measure recovery of movement quality of standing balance and walking, as well as for assessment protocols and preferred equipment to be used.

CONCLUSIONS

The present recommendations of measures, metrics, technology, and protocols build on previous consensus meetings of the International Stroke Recovery and Rehabilitation Alliance to guide the research community to improve the validity and comparability between stroke recovery and rehabilitation studies as a prerequisite for building high-quality, standardized "big data" sets. Ultimately, these recommendations could lead to high-quality, participant-specific data sets to aid the progress toward precision medicine in stroke rehabilitation.

Standardized measurement of balance and mobility post-stroke: Consensus-based core recommendations from the third Stroke Recovery and Rehabilitation Roundtable

BACKGROUND

Mobility is a key priority for stroke survivors. Worldwide consensus of standardized outcome instruments for measuring mobility recovery after stroke is an essential milestone to optimize the quality of stroke rehabilitation and recovery studies and to enable data synthesis across trials.

METHODS

Using a standardized methodology, which involved convening of 13 worldwide experts in the field of mobility rehabilitation, consensus was established through an a priori defined survey-based approach followed by group discussions. The group agreed on balance- and mobility-related definitions and recommended a core set of outcome measure instruments for lower extremity motor function, balance and mobility, biomechanical metrics, and technologies for measuring quality of movement.

RESULTS

Selected measures included the Fugl-Meyer Motor Assessment lower extremity subscale for motor function, the Trunk Impairment Scale for sitting balance, and the Mini Balance Evaluation System Test (Mini-BESTest) and Berg Balance Scale (BBS) for standing balance. The group recommended the Functional Ambulation Category (FAC, 0-5) for walking independence, the 10-meter Walk Test (10 mWT) for walking speed, the 6-Minute Walk Test (6 MWT) for walking endurance, and the Dynamic Gait Index (DGI) for complex walking. An FAC score of less than three should be used to determine the need for an additional standing test (FAC < 3, add BBS to Mini-BESTest) or the feasibility to assess walking (FAC < 3, 10 mWT, 6 MWT, and DGI are "not testable"). In addition, recommendations are given for prioritized kinetic and kinematic metrics to be investigated that measure recovery of movement quality of standing balance and walking, as well as for assessment protocols and preferred equipment to be used.

CONCLUSIONS

The present recommendations of measures, metrics, technology, and protocols build on previous consensus meetings of the International Stroke Recovery and Rehabilitation Alliance to guide the research community to improve the validity and comparability between stroke recovery and rehabilitation studies as a prerequisite for building high-quality, standardized "big data" sets. Ultimately, these recommendations could lead to high-quality, participant-specific data sets to aid the progress toward precision medicine in stroke rehabilitation.

"The right thing for our patients": perspectives of physical therapists transitioning to a 7 day a week service in an urban acute care center in Canada

BACKGROUND

True seven day a week acute care physical therapy (PT) coverage is rare. Our facility is one of a few in Canada that has increased weekend PT coverage on medicine units to seven days of full PT staffing levels.

OBJECTIVE

This article investigates the perspectives of physical therapists involved in the change with the focus on the emotional experiences of those therapists.

METHODS

Thematic analysis of interview and focus group transcripts with 18 physical therapist and 2 manager participants were aligned with four themes of: 1) optimism, hope and excitement; 2) frustration, guilt, and resentment; 3) fear, anxiety, uncertainty, and vulnerability; and 4) ambivalence, neutrality, and impartiality.

RESULTS

Although there were several perceived benefits to quality of care and work/life balance, participants' comments also reflected: frustration, guilt, and resentment related to the rapid implementation of the change and the impact of altered work schedules.

CONCLUSIONS

Participants emphasized the need to discuss large changes with staff prior to implementation in order to prevent frustration and resentment. Participants also felt that increased acute care PT coverage over seven days is valuable, but other allied health professions also need a proportional increase in staffing to improve hospital flow.

Personalised Online Upper-Limb Physiotherapy for Stroke Survivors during the Inpatient Phase: A Feasibility Study

BACKGROUND

After a stroke, inpatients often receive less than the recommended dose of therapy. Telerehabilitation may assist by providing personalised rehabilitation programmes without face-to-face therapy time. This study aimed to evaluate the acceptability and feasibility of an individualised programme of upper-limb rehabilitation that is delivered via an online rehabilitation platform for inpatient stroke survivors.

METHODS

Stroke survivors were recruited from three stroke units in one NHS Board in Scotland and randomised to the intervention (personalised upper-limb exercise programme delivered via an online physiotherapy platform for four weeks, up to 30 min five times per week, in addition to usual care) or the control group (usual care). The main outcomes are related to recruitment, attrition, adherence and safety. The clinical measures were the Action Research Arm Test, Trunk Impairment Scale and Modified Ashworth Scale. The intervention participants, their carers and physiotherapists completed questionnaires on the acceptability of the intervention.

RESULTS

Twenty-six participants, 42% males, were recruited around three weeks post-stroke, on average. There were 13 participants in each group, with a mean age of 69 years (SD of 12) and 67 years (SD of 11) for the control and intervention groups, respectively. Overall, 47% of those screened for eligibility were randomised, and attrition was 23% in the intervention group mainly due to discharge before the end of the intervention. Participants who adhered to their programme (completed more than two-thirds), generally those with an engaged carer, demonstrated a trend toward improved clinical outcomes. Overall, the patients, carers and physiotherapists were positive regarding the intervention. There was a total of five reported adverse events, none of which were related to the study.

CONCLUSION

An upper-limb unsupervised exercise intervention using an online physiotherapy platform for inpatient stroke survivors is feasible, safe and acceptable to patients, carers and physiotherapists. A fully powered RCT is warranted to investigate the clinical- and cost-effectiveness of such interventions for this patient group.

Group-based circuit training to improve mobility after stroke: a cross-sectional survey of German and Austrian physical therapists in outpatient settings

BACKGROUND

A contextual transferability analysis identified group-based circuit training (GCT) as an optimal intervention in German and Austrian outpatient physical therapy to improve mobility post-stroke. GCT incorporates task-oriented, high-repetitive, balance, aerobic and strength training and allows for increased therapy time without increasing personnel.

OBJECTIVE

To determine the extent to which German and Austrian physical therapists (PTs) use GCT and its components in the outpatient treatment of stroke-related mobility deficits and to identify factors associated with using GCT components.

METHODS

A cross-sectional online survey was conducted. Data were analyzed descriptively and using ordinal regression.

RESULTS

Ninety-three PTs participated. None reported using GCT moderately to frequently (4- 10/10 patients). The percentage of PTs reporting frequent use (7- 10/10 patients) of task-oriented, balance, strength, aerobic, and high-repetitive training was 45.2%, 43.0%, 26.9%, 19.4%, and 8.6%, respectively. Teaching or supervising students, time for evidence-based practice activities at work, and working in Austria was associated with using GCT components frequently.

CONCLUSION

German and Austrian PTs do not yet use GCT in outpatient physical therapy for stroke. Almost half of PTs, however, employ task-oriented training as recommended across guidelines. A detailed, theory-driven and country-specific evaluation of barriers to GCT uptake is necessary to inform implementation.

Changes in the higher-level functional capacities for modern daily living in community-dwelling stroke survivors: A preliminary case series

Along with the development of modern technology, the variety of higher-level activities of daily living has steadily expanded. However, no reports have examined the capacities for the higher-level activities in stroke survivors. Moreover, the relationship between these capacities and executive functions has not been reported. This preliminary study longitudinally measured changes in the capacities for high-level activities of modern daily living in community-dwelling stroke survivors. In addition, we examined whether changes in these capacities were correlated with executive functions. The results showed no significant reduction in the capacities for high-level activities of modern daily living at 1 year after stroke. Significant improvements were observed in one aspect of executive functions: planning. The changes in the capacities for higher-level activities of modern daily living were significantly correlated with executive function. The results suggest that, in stroke survivors, (a) it is likely feasible to maintain the capacities for higher-level activities of modern daily living, and (b) these capacities are related to executive functions.

Revisiting dose and intensity of training: Opportunities to enhance recovery following stroke

PURPOSE

Stroke is a global leading cause of adult disability with survivors often enduring persistent impairments and loss of function. Both intensity and dosage of training appear to be important factors to help restore behavior. However, current practice fails to achieve sufficient intensity and dose of training to promote meaningful recovery. The purpose of this review is to propose therapeutic solutions that can help achieve a higher dose and/or intensity of therapy. Raising awareness of these intensive, high-dose, treatment strategies might encourage clinicians to re-evaluate current practice and optimize delivery of stroke rehabilitation for maximal recovery.

METHODS

Literature that tested and evaluated solutions to increase dose or intensity of training was reviewed. For each therapeutic strategy, we outline evidence of clinical benefit, supporting neurophysiological data (where available) and discuss feasibility of clinical implementation.

RESULTS

Possible therapeutic solutions included constraint induced movement therapy, robotics, circuit therapy, bursts of training, gaming technologies, goal-oriented instructions, and cardiovascular exercise.

CONCLUSION

Our view is that clinicians should evaluate current practice to determine how intensive high-dose training can be implemented to promote greater recovery after stroke.

Art skill-based rehabilitation training for upper limb sensorimotor recovery post-stroke: A feasibility study

Objective

The objective of this study was to assess the feasibility of delivering Art skill-based Rehabilitation Training (ART), a novel upper limb motor training program, to patients with stroke as an adjunct to standard care in an inpatient setting.

Design

Feasibility study.

Setting

Inpatient stroke rehabilitation unit at a university hospital.

Participants

Thirty-eight patients admitted to a stroke rehabilitation unit with upper limb motor impairment were enrolled in the ART program facilitated by trained non-healthcare professionals between December 2017 and June 2021.

Intervention

The ART program included nine, one-hour sessions of supervised tracing and freehand drawing tasks completed with both hands. This program was intended to be delivered at a frequency of three times per week over a duration of 3 weeks or for the length of inpatient stay.

Main outcome measures

Feasibility outcomes included ART program adherence, acceptability, and safety.

Results

Thirty-two (84%) participants with subacute stroke completed the ART program and 30 (79%) were included in the study analysis. Participants completed 93–100% of the ART tasks in a median [IQR] of 8 [6–10] ART sessions over a median [IQR] duration of 15 [7–19] days. ART program facilitators effectively provided upper limb assistance to patients with more severe upper limb impairments. Adherence and acceptability were high and no study-related adverse events occurred.

Conclusion

The ART program was feasible to deliver and highly acceptable to patients with stroke. Further research is warranted to explore the impact of ART on upper limb sensorimotor function and use.

Additional saturday occupational therapy for adults receiving inpatient physiotherapy rehabilitation: a prospective cohort study

BACKGROUND

The first aim of this study was to investigate the impact of providing an additional four hours of Saturday occupational therapy to patients receiving Saturday physiotherapy in an inpatient setting on length of stay, functional independence, gait and balance. The second aim was to conduct an economic evaluation to determine if the introduction of a Saturday occupational therapy service in addition to physiotherapy resulted in a net cost savings for the rehabilitation facility.

METHODS

A prospective cohort study with a historical control was conducted in an Australian private mixed rehabilitation unit from 2015-2017. Clinical outcomes included the Functional Independence Measure (Motor, Cognitive, Total), gait speed (10 Meter Walk test) and five balance measures (Timed Up and Go test, Step test, Functional Reach, Feet Together Eyes Closed and the Balance Outcome Measure of Elder Rehabilitation). Economic outcomes were rehabilitation unit length of stay and additional treatment costs.

RESULTS

A total of 366 patients were admitted to the rehabilitation unit over two 20-week periods. The prospective cohort (receiving Saturday occupational therapy and physiotherapy) had 192 participants and the historical control group (receiving Saturday physiotherapy only) had 174 participants. On admission, intervention group participants had higher cognitive (p < 0.01) and total (p < 0.01) Functional Independence Measure scores. Participation in weekend therapy by the intervention group was 11% higher, attending more sessions (p < 0.01) for a greater length of time (p < 0.01) compared to the historical control group. After controlling for differences in admission Functional Independence Measure scores, rehabilitation length of stay was estimated to be reduced by 1.39 (p = 0.08) days. The economic evaluation identified potential cost savings of AUD1,536 per patient. The largest potential savings were attributed to neurological patients AUD4,854. Traumatic and elective orthopaedic patients realised potential patient related cost savings per admission of AUD2,668 and AUD2,180, respectively.

CONCLUSIONS

Implementation of four hours of Saturday occupational therapy in addition to physiotherapy results in a more efficient service, enabling a greater amount of therapy to be provided on a Saturday over a shorter length of stay. Provision of multidisciplinary Saturday rehabilitation is potentially cost reducing for the treating hospital.

The effect of game-based in comparison to conventional circuit exercise on functions, motivation level, self-efficacy and quality of life among stroke survivors

INTRODUCTION

Stroke survivors are commonly at risk of functional decline, which increase their dependency in activities of daily living and eventually affects their motivation level, self-efficacy, and quality of life. Circuit exercise has been shown to be useful in enhancing functional performance and quality of life of chronic stroke survivors. There is a need to review the existing "usual circuit exercise" and develop a better approach, such as game-based circuit exercise. Training in enriched and fun environment may possibly further promote neuroplasticity. However, evidence on inducing fun element in the existing circuit exercise among stroke survivors is limited. Also, no studies are available to date which report the benefit of circuit exercise on stroke survivors' self-efficacy and motivation level. Therefore, this study aims to assess the effectiveness of game-based circuit exercise in comparison to conventional circuit exercise on functional outcome (lower limb strength, postural stability and aerobic endurance), motivation level, self-efficacy and quality of life among stroke survivors. This study also aims to assess whether the outcomes gained from the 2 interventions could be sustained at week 12 and 24 post-trial.

METHODS

This is an assessor-blinded randomized control trial comparing 2 types of intervention which are game-based circuit exercise (experimental group) and conventional circuit exercise (control group). Based on sample size calculation using GPower, a total number of 82 participants will be recruited and allocated into either the experimental or the control group. Participants in the experimental group will receive a set of structured game-based exercise therapy which has the components of resistance, dynamic balance and aerobic exercises. While participants in the control group will receive a conventional circuit exercise as usually conducted by physiotherapists consisting of 6 exercise stations; cycling, repeated sit to stand, upper limb exercise, lower limb exercise, stepping up/down and walking over obstacles. Both groups will perform the given interventions for 2 times per week for 12 weeks under the supervision of 2 physiotherapists. Outcomes of the interventions will be measured using 30-second chair rise test (for lower limb strength), Dynamic Gait Index (for postural stability), 6-minute walk test (aerobic capacity), Intrinsic Motivation Inventory questionnaire (for motivation level), stroke self-efficacy questionnaire (for self-efficacy) and Short Form-36 quality of life questionnaire (for quality of life). All data will be analyzed using descriptive and inferential statistics.

DISCUSSION

This study will provide the information regarding the effectiveness of including game elements into circuit exercise training. Findings from this study will enable physiotherapists to design more innovative exercise therapy sessions to promote neuroplasticity and enhance functionality and quality of life among stroke survivors under their care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN 12621001489886 (last updated 1/11/2021).

The effect of time spent in rehabilitation on activity limitation and impairment after stroke

BACKGROUND

Stroke affects millions of people every year and is a leading cause of disability, resulting in significant financial cost and reduction in quality of life. Rehabilitation after stroke aims to reduce disability by facilitating recovery of impairment, activity, or participation. One aspect of stroke rehabilitation that may affect outcomes is the amount of time spent in rehabilitation, including minutes provided, frequency (i.e. days per week of rehabilitation), and duration (i.e. time period over which rehabilitation is provided). Effect of time spent in rehabilitation after stroke has been explored extensively in the literature, but findings are inconsistent. Previous systematic reviews with meta-analyses have included studies that differ not only in the amount provided, but also type of rehabilitation.

OBJECTIVES

To assess the effect of 1. more time spent in the same type of rehabilitation on activity measures in people with stroke; 2. difference in total rehabilitation time (in minutes) on recovery of activity in people with stroke; and 3. rehabilitation schedule on activity in terms of: a. average time (minutes) per week undergoing rehabilitation, b. frequency (number of sessions per week) of rehabilitation, and c. total duration of rehabilitation.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, eight other databases, and five trials registers to June 2021. We searched reference lists of identified studies, contacted key authors, and undertook reference searching using Web of Science Cited Reference Search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adults with stroke that compared different amounts of time spent, greater than zero, in rehabilitation (any non-pharmacological, non-surgical intervention aimed to improve activity after stroke). Studies varied only in the amount of time in rehabilitation between experimental and control conditions. Primary outcome was activities of daily living (ADLs); secondary outcomes were activity measures of upper and lower limbs, motor impairment measures of upper and lower limbs, and serious adverse events (SAE)/death.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies, extracted data, assessed methodological quality using the Cochrane RoB 2 tool, and assessed certainty of the evidence using GRADE. For continuous outcomes using different scales, we calculated pooled standardised mean difference (SMDs) and 95% confidence intervals (CIs). We expressed dichotomous outcomes as risk ratios (RR) with 95% CIs.

MAIN RESULTS

The quantitative synthesis of this review comprised 21 parallel RCTs, involving analysed data from 1412 participants.  Time in rehabilitation varied between studies. Minutes provided per week were 90 to 1288. Days per week of rehabilitation were three to seven. Duration of rehabilitation was two weeks to six months. Thirteen studies provided upper limb rehabilitation, five general rehabilitation, two mobilisation training, and one lower limb training. Sixteen studies examined participants in the first six months following stroke; the remaining five included participants more than six months poststroke. Comparison of stroke severity or level of impairment was limited due to variations in measurement. The risk of bias assessment suggests there were issues with the methodological quality of the included studies. There were 76 outcome-level risk of bias assessments: 15 low risk, 37 some concerns, and 24 high risk. When comparing groups that spent more time versus less time in rehabilitation immediately after intervention, we found no difference in rehabilitation for ADL outcomes (SMD 0.13, 95% CI -0.02 to 0.28; P = 0.09; I2 = 7%; 14 studies, 864 participants; very low-certainty evidence), activity measures of the upper limb (SMD 0.09, 95% CI -0.11 to 0.29; P = 0.36; I2 = 0%; 12 studies, 426 participants; very low-certainty evidence), and activity measures of the lower limb (SMD 0.25, 95% CI -0.03 to 0.53; P = 0.08; I2 = 48%; 5 studies, 425 participants; very low-certainty evidence). We found an effect in favour of more time in rehabilitation for motor impairment measures of the upper limb (SMD 0.32, 95% CI 0.06 to 0.58; P = 0.01; I2 = 10%; 9 studies, 287 participants; low-certainty evidence) and of the lower limb (SMD 0.71, 95% CI 0.15 to 1.28; P = 0.01; 1 study, 51 participants; very low-certainty evidence). There were no intervention-related SAEs. More time in rehabilitation did not affect the risk of SAEs/death (RR 1.20, 95% CI 0.51 to 2.85; P = 0.68; I2 = 0%; 2 studies, 379 participants; low-certainty evidence), but few studies measured these outcomes. Predefined subgroup analyses comparing studies with a larger difference of total time spent in rehabilitation between intervention groups to studies with a smaller difference found greater improvements for studies with a larger difference. This was statistically significant for ADL outcomes (P = 0.02) and activity measures of the upper limb (P = 0.04), but not for activity measures of the lower limb (P = 0.41) or motor impairment measures of the upper limb (P = 0.06).

AUTHORS' CONCLUSIONS

An increase in time spent in the same type of rehabilitation after stroke results in little to no difference in meaningful activities such as activities of daily living and activities of the upper and lower limb but a small benefit in measures of motor impairment (low- to very low-certainty evidence for all findings). If the increase in time spent in rehabilitation exceeds a threshold, this may lead to improved outcomes. There is currently insufficient evidence to recommend a minimum beneficial daily amount in clinical practice. The findings of this study are limited by a lack of studies with a significant contrast in amount of additional rehabilitation provided between control and intervention groups. Large, well-designed, high-quality RCTs that measure time spent in all rehabilitation activities (not just interventional) and provide a large contrast (minimum of 1000 minutes) in amount of rehabilitation between groups would provide further evidence for effect of time spent in rehabilitation.

Effects of different rehabilitation provision systems on functional recovery in patients with subacute stroke

INTRODUCTION

The extent of rehabilitation is a key element in promoting functional recovery in patients with stroke. However, the type of rehabilitation therapy that should be provided to improve functional outcomes remains unclear.

OBJECTIVE

This study aimed to compare the effects of three different rehabilitation provision systems, namely conventional rehabilitation therapy, conventional rehabilitation therapy plus physical therapy (PT) on weekends, and conventional rehabilitation therapy plus PT and occupational therapy (OT) on weekends, on functional recovery in patients with subacute stroke.

DESIGN

Retrospective observational cohort study.

SETTING

Convalescence Rehabilitation Hospital.

PATIENTS

Three hundred and one patients with subacute stroke (mean age, 69.7 ± 12.8 years).

INTERVENTIONS

Patients were classified into three groups according to rehabilitation therapy they received: a conventional group (only weekdays PT and OT; n = 70), an additional PT group (additional PT on weekends; n = 119), and an additional PT + OT group (additional PT and OT on weekends; n = 112).

MAIN OUTCOME MEASURE

Functional Independence Measure (FIM) effectiveness was calculated as (discharge FIM - admission FIM/maximum FIM - admission FIM) × 100. A multivariate general linear model was used to assess the difference in FIM effectiveness among the groups.

RESULTS

The mean FIM effectiveness in the conventional, additional PT, and additional PT + OT groups were 39.3 ± 30.1, 43.4 ± 33.2, and 54.3 ± 29.1, respectively. The multivariate analysis revealed a significant difference in FIM effectiveness among the three groups (P = 0.036), and the η_p ² was 0.02, indicating a small effect. The additional PT + OT group showed significantly greater improvements in FIM effectiveness than the conventional group (mean difference = 8.78, SE = 3.58, 95% confidence interval: 0.17-17.39).

CONCLUSIONS

This study showed that the additional PT + OT group had better functional recovery than did the conventional group. This indicates that increasing the amount of both PT and OT can promote post-stroke functional recovery. This article is protected by copyright. All rights reserved.

Advancing Stroke Recovery Through Improved Articulation of Nonpharmacological Intervention Dose

Dose articulation is a universal issue of intervention development and testing. In stroke recovery, dose of a nonpharmaceutical intervention appears to influence outcome but is often poorly reported. The challenges of articulating dose in nonpharmacological stroke recovery research include: (1) the absence of specific internationally agreed dose reporting guidelines; (2) inadequate conceptualization of dose, which is multidimensional; and (3) unclear and inconsistent terminology that incorporates the multiple dose dimensions. To address these challenges, we need a well-conceptualized and consistent approach to dose articulation that can be applied across stroke recovery domains to stimulate critical thinking about dose during intervention development, as well as promote reporting of planned intervention dose versus actually delivered dose. We followed the Design Research Paradigm to develop a framework that guides how to articulate dose, conceptualizes the multidimensional nature and systemic linkages between dose dimensions, and provides reference terminology for the field. Our framework recognizes that dose is multidimensional and comprised of a duration of days that contain individual sessions and episodes that can be active (time on task) or inactive (time off task), and each individual episode can be made up of information about length, intensity, and difficulty. Clinical utility of this framework was demonstrated via hypothetical application to preclinical and clinical domains of stroke recovery. The suitability of the framework to address dose articulation challenges was confirmed with an international expert advisory group. This novel framework provides a pathway for better articulation of nonpharmacological dose that will enable transparent and accurate description, implementation, monitoring, and reporting, in stroke recovery research.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical activity and physical fitness are low after stroke. Interventions to increase physical fitness could reduce mortality and reduce disability through increased function.

OBJECTIVES

The primary objectives of this updated review were to determine whether fitness training after stroke reduces death, death or dependence, and disability. The secondary objectives were to determine the effects of training on adverse events, risk factors, physical fitness, mobility, physical function, health status and quality of life, mood, and cognitive function.

SEARCH METHODS

In July 2018 we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, and four additional databases. We also searched ongoing trials registers and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses and assessed the quality of the evidence using the GRADE approach. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 75 studies, involving 3017 mostly ambulatory participants, which comprised cardiorespiratory (32 studies, 1631 participants), resistance (20 studies, 779 participants), and mixed training interventions (23 studies, 1207 participants). Death was not influenced by any intervention; risk differences were all 0.00 (low-certainty evidence). There were few deaths overall (19/3017 at end of intervention and 19/1469 at end of follow-up). None of the studies assessed death or dependence as a composite outcome. Disability scores were improved at end of intervention by cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% CI 0.19 to 0.84; 8 studies, 462 participants; P = 0.002; moderate-certainty evidence) and mixed training (SMD 0.23, 95% CI 0.03 to 0.42; 9 studies, 604 participants; P = 0.02; low-certainty evidence). There were too few data to assess the effects of resistance training on disability. Secondary outcomes showed multiple benefits for physical fitness (VO2 peak and strength), mobility (walking speed) and physical function (balance). These physical effects tended to be intervention-specific with the evidence mostly low or moderate certainty. Risk factor data were limited or showed no effects apart from cardiorespiratory fitness (VO2 peak), which increased after cardiorespiratory training (mean difference (MD) 3.40 mL/kg/min, 95% CI 2.98 to 3.83; 9 studies, 438 participants; moderate-certainty evidence). There was no evidence of any serious adverse events. Lack of data prevents conclusions about effects of training on mood, quality of life, and cognition. Lack of data also meant benefits at follow-up (i.e. after training had stopped) were unclear but some mobility benefits did persist. Risk of bias varied across studies but imbalanced amounts of exposure in control and intervention groups was a common issue affecting many comparisons.

AUTHORS' CONCLUSIONS

Few deaths overall suggest exercise is a safe intervention but means we cannot determine whether exercise reduces mortality or the chance of death or dependency. Cardiorespiratory training and, to a lesser extent mixed training, reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve fitness, balance and the speed and capacity of walking. The magnitude of VO2 peak increase after cardiorespiratory training has been suggested to reduce risk of stroke hospitalisation by ˜7%. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription, the range of benefits and any long-term benefits.

Quantifying dosage of physical therapy using lower body kinematics: a longitudinal pilot study on early post-stroke individuals

Background

While therapy is an important part of the recovery process, there is a lack of quantitative data detailing the “dosage” of therapy received due to the limitations on in/outpatient accessibility and mobility. Advances in wearable sensor technology have allowed us to obtain an unprecedented glimpse into joint-level kinematics in an unobtrusive manner. The objective of this observational longitudinal pilot study was to evaluate the relations between lower body joint kinematics during therapy and functional gait recovery over the first three months after stroke.

Methods

Six individuals with subacute stroke (< 1 month) were monitored for a total of 59 one-hour physical therapy sessions including gait and non-gait activities. Participants donned a heart rate monitor and an inertial motion capture system to measure full lower body joint kinematics during each therapy session. Linear mixed regression models were used to examine relations between functional gait recovery (speed) and activity features including total joint displacements, defined as amount of motion (AoM), step number, change in heart rate (∆HR), and types of tasks performed.

Results

All activity features including AoM, step number, types of tasks performed (all p < 0.01), and ∆HR (p < 0.05) showed strong associations with gait speed. However, AoM (R² = 32.1%) revealed the greatest explained variance followed by step number (R² = 14.1%), types of tasks performed (R² = 8.0%) and ∆HR (R² = 5.8%). These relations included both gait and non-gait tasks. Contrary to our expectations, we did not observe a greater relation of functional recovery to motion in the impaired limb (R² = 27.8%) compared to the unimpaired limb (R² = 32.9%).

Conclusions

This proof-of-concept study shows that recording joint kinematics during gait therapy longitudinally after stroke is feasible and yields important information for the recovery process. These initial results suggest that compared to step number, more holistic outcome measures such as joint motions may be more informative and help elucidate the dosage of therapy.

Patient and family experience of physical rehabilitation on the intensive care unit: a qualitative exploration

OBJECTIVES

To explore the experience of physical rehabilitation in the intensive care unit (ICU), from the perspective of patients and relatives.

DESIGN

Exploratory, qualitative study.

PARTICIPANTS

Five former ICU patients and five family members of former ICU patients recruited from ICU support groups across the UK.

INTERVENTIONS

Semi-structured interviews.

MAIN OUTCOME MEASURES

Participants' experiences of physical rehabilitation in the ICU. Data were analysed using an iterative thematic approach.

RESULTS

Four main themes were identified: Trust and Rapport, Necessity (of treatment), Psychological Benefit, and Goal Setting: Whose goal is it anyway? Despite a lack of enjoyment, patients tend to comply with physical rehabilitation, due in part to a positive patient-therapist relationship. There was agreement across participants that physical rehabilitation should be started as soon as possible after admission to ICU and exhaustion was highlighted as the biggest challenge to participation. In addition to aiding physical recovery, physical rehabilitation in the ICU may also provide psychological support for both patients and relatives. Finally, participants described a desire for therapists to direct goal setting in the early stages of recovery as they felt unable to engage in the process due to other priorities.

CONCLUSIONS

The experience of physical rehabilitation on ICU may be influenced by key aspects of person-centred care. This study suggests that patients and relatives are keen for physical rehabilitation to start as soon as possible, which is a crucial new finding to support the practice of early rehabilitation in the ICU.

Extra upper limb practice after stroke: a feasibility study

Background

There is a need to provide a large amount of extra practice on top of usual rehabilitation to adults after stroke. The purpose of this study was to determine if it is feasible to add extra upper limb practice to usual inpatient rehabilitation and whether it is likely to improve upper limb activity and grip strength.

Method

A prospective, single-group, pre- and post-test study was carried out. Twenty adults with upper limb activity limitations who had some movement in the upper limb completed an extra hour of upper limb practice, 6 days per week for 4 weeks. Feasibility was measured by examining recruitment, intervention (adherence, efficiency, acceptability, safety) and measurement. Clinical outcomes were upper limb activity (Box and Block Test, Nine-Hole Peg Test) and grip strength (dynamometry) measured at baseline (week 0) and end of intervention (week 4).

Results

Of the 212 people who were screened, 42 (20%) were eligible and 20 (9%) were enrolled. Of the 20 participants, 12 (60%) completed the 4-week program; 7 (35%) were discharged early, and 1 (5%) withdrew. Participants attended 342 (85%) of the possible 403 sessions and practiced for 324 (95%) of the total 342 h. In terms of safety, there were no study-related adverse events. Participants increased 0.29 blocks/s (95% CI 0.19 to 0.39) on the Box and Block Test, 0.20 pegs/s (95% CI 0.10 to 0.30) on the Nine-Hole Peg Test, and 4.4 kg (95% CI 2.9 to 5.9) in grip strength, from baseline to end of intervention.

Conclusions

It appears feasible for adults who are undergoing inpatient rehabilitation and have some upper limb movement after stroke to undertake an hour of extra upper limb practice. The magnitude of the clinical outcomes suggests that further investigation is warranted and this study provides useful information for the design of a phase II randomized trial.

Trial registration

Australian and New Zealand Clinical Trial Registry (ACTRN12615000665538).

Physical Fitness Training in Patients with Subacute Stroke (PHYS-STROKE): multicentre, randomised controlled, endpoint blinded trial

OBJECTIVE

To determine the safety and efficacy of aerobic exercise on activities of daily living in the subacute phase after stroke.

DESIGN

Multicentre, randomised controlled, endpoint blinded trial.

SETTING

Seven inpatient rehabilitation sites in Germany (2013-17).

PARTICIPANTS

200 adults with subacute stroke (days 5-45 after stroke) with a median National Institutes of Health stroke scale (NIHSS, range 0-42 points, higher values indicating more severe strokes) score of 8 (interquartile range 5-12) were randomly assigned (1:1) to aerobic physical fitness training (n=105) or relaxation sessions (n=95, control group) in addition to standard care.

INTERVENTION

Participants received either aerobic, bodyweight supported, treadmill based physical fitness training or relaxation sessions, each for 25 minutes, five times weekly for four weeks, in addition to standard rehabilitation therapy. Investigators and endpoint assessors were masked to treatment assignment.

MAIN OUTCOME MEASURES

The primary outcomes were change in maximal walking speed (m/s) in the 10 m walking test and change in Barthel index scores (range 0-100 points, higher scores indicating less disability) three months after stroke compared with baseline. Safety outcomes were recurrent cardiovascular events, including stroke, hospital readmissions, and death within three months after stroke. Efficacy was tested with analysis of covariance for each primary outcome in the full analysis set. Multiple imputation was used to account for missing values.

RESULTS

Compared with relaxation, aerobic physical fitness training did not result in a significantly higher mean change in maximal walking speed (adjusted treatment effect 0.1 m/s (95% confidence interval 0.0 to 0.2 m/s), P=0.23) or mean change in Barthel index score (0 (-5 to 5), P=0.99) at three months after stroke. A higher rate of serious adverse events was observed in the aerobic group compared with relaxation group (incidence rate ratio 1.81, 95% confidence interval 0.97 to 3.36).

CONCLUSIONS

Among moderately to severely affected adults with subacute stroke, aerobic bodyweight supported, treadmill based physical fitness training was not superior to relaxation sessions for maximal walking speed and Barthel index score but did suggest higher rates of adverse events. These results do not appear to support the use of aerobic bodyweight supported fitness training in people with subacute stroke to improve activities of daily living or maximal walking speed and should be considered in future guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01953549.

Effectiveness of acute in-hospital occupational therapy for older patients with hip fracture

AIM

To test the hypothesis that hip fracture patients who receive occupational therapy (OT) have better functional ability than those who do not.

METHODS

This retrospective observational study utilized data from the Japan Rehabilitation Database spanning 2005-2015. In-hospital hip fracture patients admitted to acute hospitals were identified. In total, 1266 patients were eligible based on the exclusion criteria. The primary outcome was motor Functional Independence Measure (FIM) efficiency.

RESULTS

Patients who received OT were 50.9% of hip fracture patients. Patients who received OT had significantly higher scores in motor FIM efficiency (mean 0.79 vs 0.70; P = 0.02) and FIM effectiveness (mean 0.49 vs 0.41; P < 0.01) than the patients who did not receive OT. From multivariate linear regression analysis, OT was identified as a significant factor in motor FIM efficiency (coefficient 1.29, 95% confidence interval 1.14-1.47; P < 0.01) and FIM effectiveness (coefficient 1.07, 95% confidence interval 1.02-1.12; P < 0.01).

CONCLUSIONS

The present cohort analysis showed that OT for hip fracture patients in the acute phase likely contributes to improved functional ability. Geriatr Gerontol Int 2019; 19: 611-615.

Pedometers alone do not increase mobility in inpatient rehabilitation: a randomized controlled trial

OBJECTIVE

To test if pedometers, as a motivational tool, could affect mobility outcomes in inpatient rehabilitation.

DESIGN

Randomized controlled clinical trial.

SETTING

Subacute hospital rehabilitation unit in Australia.

PARTICIPANTS

A total of 78 participants with reduced mobility and clinician-determined capacity to improve.

INTERVENTIONS

Both groups received usual care. For the intervention group, a pedometer was worn on the hip with the step count visible to participant and recorded daily on an exercise log. For the control group, a pedometer fixed shut was worn on the hip and they recorded estimated distances walked on an exercise log.

MAIN MEASURES

Primary outcome was functional mobility - De Morton Mobility Index. Secondary outcome measures were walking velocity, functional independence measure, time spent upright and daily step count.

RESULTS

Significant improvements over time (P < 0.001) in functional mobility, comfortable walking velocity and functional independence measure were not influenced by the intervention. The daily average upright time (hours) in the first week of intervention was different (P = 0.004) between the intervention group (median, interquartile range (IQR): 1.67, 1.77) compared to the control group (median, IQR: 1.12, 0.82).

CONCLUSION

Pedometers as a motivational tool without targets do not improve functional mobility in this population. Pedometers may improve daily upright time in this setting.

Content Reporting in Post-Stroke Therapeutic Circuit-Class Exercise Programs in randomized control trials

BACKGROUND

Therapeutic exercise in the form of group circuit-class training can improve mobility and gait while being cost-effective among patients who survived a stroke. Accurate clinical replication of interventions, especially when they are effective, is needed to advance research and treatment. However, replication is difficult when reporting is not detailed.

OBJECTIVE

The objective of this study was to assess the quality of reporting of interventions within the selected studies using three different scales and to assess the criterion validity between the scales.

METHODS

Two independent assessors used the CERT, the CONTENT scale, and TIDieR checklist to review the quality of reporting of 16 randomized controlled trials (RCTs) from a recent Cochrane Review. Assessments were done independently before a consensus was reached with an experienced third reviewer mediating any disagreements. Criterion validity between the three quality reporting tools was measured using weighted Cohen's kappa coefficients.

RESULTS

The mean (±SD) for the CERT was 9.31 (±1.66) out of 19 points; the TIDieR checklist was 8.81 (±1.33) out of 12 points; and the CONTENT was 4.82 (±1.22) out of 9 points for the 16 included RCTs. The CERT and CONTENT scale had a fair agreement (k = 0.455, p = 0.064), while both CERT and CONTENT had only slight agreement with TIDieR (k = 0.143, p = 0.267; k = 0.200, p = 0.182, respectively).

CONCLUSIONS

The results of this study indicate a lack of reporting from the 16 RCTs on post-stroke therapeutic circuit-class exercise programs. This presents a major barrier to knowledge translation and clinical implementation of effective exercise programs for stroke rehabilitation.

Steps, duration and intensity of usual walking practice during subacute rehabilitation after stroke: an observational study

BACKGROUND

Duration of therapy time is an inadequate indicator of stroke rehabilitation. Steps, duration, and intensity of active therapy time may provide a better indicator of practice.

OBJECTIVE

This study quantified usual walking practice in terms of steps, duration and intensity of active therapy time, and distance walked during physical therapy sessions in people with sub-acute stroke undertaking inpatient rehabilitation and to examine whether usual walking practice differed depending on walking ability.

METHODS

A prospective observational study was conducted across two metropolitan rehabilitation units in Australia. Twenty-four stroke survivors were observed over three physical therapy sessions. Walking ability was categorized as unassisted or assisted based on Item 5 of the Motor Assessment Scale. Walking practice was categorized as basic or advanced. Steps, duration, intensity and distance walked were measured during physical therapy sessions.

RESULTS

Overall, participants took 560 steps (SD 309) over 13min (SD 6) at an intensity of steps 44 steps/min (SD 17) and walked 222m (SD 143) in physical therapy. Unassisted walkers (n=6, 25%) undertook more (or trended towards more) practice of advanced walking than assisted walkers in terms of steps (MD 254 steps, 95% CI 48-462), duration (MD 5min, 95% CI 0-10), intensity (MD 18steps/min, 95% CI -8 to 44) and distance (MD 112m, 95% CI -12 to 236).

CONCLUSION

Stroke survivors undergoing inpatient rehabilitation spent approximately 20% of physical therapy actively engaged in walking practice. Those able to walk without assistance took more steps for longer, at a higher intensity.

TRIAL REGISTRATION

ACTRN12613000764730 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364545).

Stepping Up to Rethink the Future of Rehabilitation: IV STEP Considerations and Inspirations

BACKGROUND AND PURPOSE

The IV STEP conference challenged presenters and participants to consider the state of science in rehabilitation, highlighting key area of progress since the previous STEP conference related to prediction, prevention, plasticity, and participation in rehabilitation.

KEY POINTS

Emerging from the thought-provoking discussions was recognition of the progress we have made as a profession and a call for future growth. In this summary article, we present a recap of the key points and call for action. We review the information presented and the field at large as it relates to the 4 Ps: prediction, prevention, plasticity, and participation.

RECOMMENDATIONS FOR PRACTICE

Given that personalized medicine is an increasingly important approach that was clearly woven throughout the IV STEP presentations, we took the liberty of adding a fifth "P," Personalized, in our discussion of the future direction of the profession.

Is Environmental Enrichment Ready for Clinical Application in Human Post-stroke Rehabilitation?

Environmental enrichment (EE) has been widely used as a means to enhance brain plasticity mechanisms (e.g., increased dendritic branching, synaptogenesis, etc.) and improve behavioral function in both normal and brain-damaged animals. In spite of the demonstrated efficacy of EE for enhancing brain plasticity, it has largely remained a laboratory phenomenon with little translation to the clinical setting. Impediments to the implementation of enrichment as an intervention for human stroke rehabilitation and a lack of clinical translation can be attributed to a number of factors not limited to: (i) concerns that EE is actually the "normal state" for animals, whereas standard housing is a form of impoverishment; (ii) difficulty in standardizing EE conditions across clinical sites; (iii) the exact mechanisms underlying the beneficial actions of enrichment are largely correlative in nature; (iv) a lack of knowledge concerning what aspects of enrichment (e.g., exercise, socialization, cognitive stimulation) represent the critical or active ingredients for enhancing brain plasticity; and (v) the required "dose" of enrichment is unknown, since most laboratory studies employ continuous periods of enrichment, a condition that most clinicians view as impractical. In this review article, we summarize preclinical stroke recovery studies that have successfully utilized EE to promote functional recovery and highlight the potential underlying mechanisms. Subsequently, we discuss how EE is being applied in a clinical setting and address differences in preclinical and clinical EE work to date. It is argued that the best way forward is through the careful alignment of preclinical and clinical rehabilitation research. A combination of both approaches will allow research to fully address gaps in knowledge and facilitate the implementation of EE to the clinical setting.

Additional weekend allied health services reduce length of stay in subacute rehabilitation wards but their effectiveness and cost-effectiveness are unclear in acute general medical and surgical hospital wards: a systematic review

QUESTION

Are additional weekend allied health services effective and cost-effective for acute general medical and surgical wards, and subacute rehabilitation hospital wards?

DESIGN

Systematic review and meta-analysis of studies published between January 2000 and May 2017. Two reviewers independently screened studies for inclusion, extracted data, and assessed methodological quality. Meta-analyses were conducted for relative measures of effect estimates.

PARTICIPANTS

Patients admitted to acute general medical and surgical wards, and subacute rehabilitation wards.

INTERVENTION

All services delivered by allied health professionals during weekends (Saturday and/or Sunday). This study limited allied health professions to: occupational therapy, physiotherapy, social work, speech pathology, dietetics, art therapy, chiropractic, exercise physiology, music therapy, oral health (not dentistry), osteopathy, podiatry, psychology, and allied health assistants.

OUTCOME MEASURES

Hospital length of stay, hospital re-admission, adverse events, discharge destination, functional independence, health-related quality of life, and cost of hospital care.

RESULTS

Nineteen articles (20 studies) were identified, comprising 10 randomised and 10 non-randomised trials. Physiotherapy was the most commonly investigated profession. A meta-analysis of randomised, controlled trials showed that providing additional weekend allied health services in subacute rehabilitation wards reduced hospital length of stay by 2.35days (95% CI 0.45 to 4.24, I²=0%), and may be a cost-effective way to improve function (SMD 0.09, 95% CI -0.01 to 0.19, I²=0%), and health-related quality of life (SMD 0.10, 95% CI -0.01 to 0.20, I²=0%). For acute general medical and surgical hospital wards, it was unclear whether the weekend allied health service model provided in the two identified randomised trials led to significant changes in measured outcomes.

CONCLUSION

The benefit of providing additional allied health services is clearer in subacute rehabilitation settings than for acute general medical and surgical wards in hospitals.

REGISTRATION

PROSPERO CRD76771. [Sarkies MN, White J, Henderson K, Haas R, Bowles J, Evidence Translation in Allied Health (EviTAH) Group (2018) Additional weekend allied health services reduce length of stay in subacute rehabilitation wards but their effectiveness and cost-effectiveness are unclear in acute general medical and surgical hospital wards: a systematic review. Journal of Physiotherapy 64: 142-158].

Extra practice outside therapy sessions to maximize training opportunity during inpatient rehabilitation after traumatic brain injury

OBJECTIVE

To determine if extra practice outside therapy sessions can be conducted for patients with traumatic brain injury and identify factors that influence their participation.

METHODS

A purpose-designed survey was conducted on consecutive eligible patients with traumatic brain injury and their relatives on discharge from inpatient rehabilitation.

RESULTS

In total, 68 of the 69 of patients who took part in the survey reported that they participated in extra practice outside therapy sessions. Also, 58% reported that they conducted extra practice more than three times a week on average and 70% reported no barriers in conducting extra practice. Patients with poor motivation, reduced executive functioning and less severe brain injury are less likely to participate in extra practice and may require more support. Relatives tended to be involved in extra practice for patients who were dependent. A wide range of barriers were identified with poor motivation and lack of confidence being the main ones.

CONCLUSION

With appropriate support, extra practice outside therapy sessions is generally feasible to maximize training opportunity for patients with traumatic brain injury. Motivation, perception of being listened to, executive functioning and severity of injury are factors that influence participation in extra practice. Strategies that improve motivation, interaction and confidence are likely to enhance participation. Relatives are a useful source of support for the more dependent patients.

Additional Physical Therapy Services Reduce Length of Stay and Improve Health Outcomes in People With Acute and Subacute Conditions: An Updated Systematic Review and Meta-Analysis

OBJECTIVE

To update a previous review on whether additional physical therapy services reduce length of stay, improve health outcomes, and are safe and cost-effective for patients with acute or subacute conditions.

DATA SOURCES

Electronic database (AMED, CINAHL, EMBASE, MEDLINE, Physiotherapy Evidence Database [PEDro], PubMed) searches were updated from 2010 through June 2017.

STUDY SELECTION

Randomized controlled trials evaluating additional physical therapy services on patient health outcomes, length of stay, or cost-effectiveness were eligible. Searching identified 1524 potentially relevant articles, of which 11 new articles from 8 new randomized controlled trials with 1563 participants were selected. In total, 24 randomized controlled trials with 3262 participants are included in this review.

DATA EXTRACTION

Data were extracted using the form used in the original systematic review. Methodological quality was assessed using the PEDro scale, and the Grading of Recommendation Assessment, Development, and Evaluation approach was applied to each meta-analysis.

DATA SYNTHESIS

Postintervention data were pooled with an inverse variance, random-effects model to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). There is moderate-quality evidence that additional physical therapy services reduced length of stay by 3 days in subacute settings (mean difference [MD]=-2.8; 95% CI, -4.6 to -0.9; I²=0%), and low-quality evidence that it reduced length of stay by 0.6 days in acute settings (MD=-0.6; 95% CI, -1.1 to 0.0; I²=65%). Additional physical therapy led to small improvements in self-care (SMD=.11; 95% CI, .03-.19; I²=0%), activities of daily living (SMD=.13; 95% CI, .02-.25; I²=15%), and health-related quality of life (SMD=.12; 95% CI, .03-.21; I²=0%), with no increases in adverse events. There was no significant change in walking ability. One trial reported that additional physical therapy was likely to be cost-effective in subacute rehabilitation.

CONCLUSIONS

Additional physical therapy services improve patient activity and participation outcomes while reducing hospital length of stay for adults. These benefits are likely safe, and there is preliminary evidence to suggest they may be cost-effective.

Effectiveness of weekend physical rehabilitation for functional recovery in geriatric patients with hip fracture

AIM

To test the hypothesis that the functional outcome of hip fracture patients who receive weekend rehabilitation is better than that of similar patients who undergo non-weekend rehabilitation.

METHODS

The present retrospective observational study used data from the Japan Rehabilitation Database spanning 2005-2015. We identified in-hospital hip fracture patients admitted to acute hospitals. After applying exclusion criteria, 469 patients were eligible. The primary outcome was motor Functional Independence Measure (FIM) efficiency.

RESULTS

Of the patients with hip fracture, 68.0% received weekend rehabilitation. The patients who received weekend rehabilitation had significantly higher scores in motor FIM efficiency (mean 1.08 vs 0.73, P < 0.001), FIM efficiency (mean 1.12 vs 0.79, P = 0.001) and shorter length of stay (mean 32 vs 54, P < 0.001) than the patients without weekend rehabilitation. Multivariate linear regression analysis identified the weekend rehabilitation as a significant factor in motor FIM efficiency (coefficient 0.237, 95% confidence interval 0.074-0.400, P = 0.004), FIM efficiency (coefficient 0.235, 95% confidence interval 0.079-0.391, P = 0.003) and length of stay (coefficient -9.649, 95% confidence interval -18.194 to -1.104, P = 0.027).

CONCLUSIONS

The present cohort analysis showed that weekend rehabilitation for hip fracture patients can lead to functional recovery and reduce the length of stay. Geriatr Gerontol Int 2018; 18: 1143-1146.

Virtual Reality Training for Upper Extremity in Subacute Stroke (VIRTUES)

Objective:

To compare the effectiveness of upper extremity virtual reality rehabilitation training (VR) to time-matched conventional training (CT) in the subacute phase after stroke.

Methods:

In this randomized, controlled, single-blind phase III multicenter trial, 120 participants with upper extremity motor impairment within 12 weeks after stroke were consecutively included at 5 rehabilitation institutions. Participants were randomized to either VR or CT as an adjunct to standard rehabilitation and stratified according to mild to moderate or severe hand paresis, defined as ≥20 degrees wrist and 10 degrees finger extension or less, respectively. The training comprised a minimum of sixteen 60-minute sessions over 4 weeks. The primary outcome measure was the Action Research Arm Test (ARAT); secondary outcome measures were the Box and Blocks Test and Functional Independence Measure. Patients were assessed at baseline, after intervention, and at the 3-month follow-up.

Results:

Mean time from stroke onset for the VR group was 35 (SD 21) days and for the CT group was 34 (SD 19) days. There were no between-group differences for any of the outcome measures. Improvement of upper extremity motor function assessed with ARAT was similar at the postintervention (p = 0.714) and follow-up (p = 0.777) assessments. Patients in VR improved 12 (SD 11) points from baseline to the postintervention assessment and 17 (SD 13) points from baseline to follow-up, while patients in CT improved 13 (SD 10) and 17 (SD 13) points, respectively. Improvement was also similar for our subgroup analysis with mild to moderate and severe upper extremity paresis.

Conclusions:

Additional upper extremity VR training was not superior but equally as effective as additional CT in the subacute phase after stroke. VR may constitute a motivating training alternative as a supplement to standard rehabilitation.

ClinicalTrials.gov identifier:

NCT02079103.

Classification of evidence:

This study provides Class I evidence that for patients with upper extremity motor impairment after stroke, compared to conventional training, VR training did not lead to significant differences in upper extremity function improvement.

Stepping Up to Rethink the Future of Rehabilitation: IV STEP Considerations and Inspirations

BACKGROUND AND PURPOSE

The IV STEP conference challenged presenters and participants to consider the state of science in rehabilitation, highlighting key area of progress since the previous STEP conference related to prediction, prevention, plasticity, and participation in rehabilitation.

KEY POINTS

Emerging from the thought-provoking discussions was recognition of the progress we have made as a profession and a call for future growth. In this summary article, we present a recap of the key points and call for action. We review the information presented and the field at large as it relates to the 4 Ps: prediction, prevention, plasticity, and participation.

RECOMMENDATIONS FOR PRACTICE

Given that personalized medicine is an increasingly important approach that was clearly woven throughout the IV STEP presentations, we took the liberty of adding a fifth "P," Personalized, in our discussion of the future direction of the profession.

Circuit class therapy for improving mobility after stroke

BACKGROUND

Circuit class therapy (CCT) offers a supervised group forum for people after stroke to practise tasks, enabling increased practice time without increasing staffing. This is an update of the original review published in 2010.

OBJECTIVES

To examine the effectiveness and safety of CCT on mobility in adults with stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched January 2017), CENTRAL (the Cochrane Library, Issue 12, 2016), MEDLINE (1950 to January 2017), Embase (1980 to January 2017), CINAHL (1982 to January 2017), and 14 other electronic databases (to January 2017). We also searched proceedings from relevant conferences, reference lists, and unpublished theses; contacted authors of published trials and other experts in the field; and searched relevant clinical trials and research registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) including people over 18 years old, diagnosed with stroke of any severity, at any stage, or in any setting, receiving CCT.

DATA COLLECTION AND ANALYSIS

Review authors independently selected trials for inclusion, assessed risk of bias in all included studies, and extracted data.

MAIN RESULTS

We included 17 RCTs involving 1297 participants. Participants were stroke survivors living in the community or receiving inpatient rehabilitation. Most could walk 10 metres without assistance. Ten studies (835 participants) measured walking capacity (measuring how far the participant could walk in six minutes) demonstrating that CCT was superior to the comparison intervention (Six-Minute Walk Test: mean difference (MD), fixed-effect, 60.86 m, 95% confidence interval (CI) 44.55 to 77.17, GRADE: moderate). Eight studies (744 participants) measured gait speed, again finding in favour of CCT compared with other interventions (MD 0.15 m/s, 95% CI 0.10 to 0.19, GRADE: moderate). Both of these effects are considered clinically meaningful. We were able to pool other measures to demonstrate the superior effects of CCT for aspects of walking and balance (Timed Up and Go: five studies, 488 participants, MD -3.62 seconds, 95% CI -6.09 to -1.16; Activities of Balance Confidence scale: two studies, 103 participants, MD 7.76, 95% CI 0.66 to 14.87). Two other pooled balance measures failed to demonstrate superior effects (Berg Blance Scale and Step Test). Independent mobility, as measured by the Stroke Impact Scale, Functional Ambulation Classification and the Rivermead Mobility Index, also improved more in CCT interventions compared with others. Length of stay showed a non-significant effect in favour of CCT (two trials, 217 participants, MD -16.35, 95% CI -37.69 to 4.99). Eight trials (815 participants) measured adverse events (falls during therapy): there was a non-significant effect of greater risk of falls in the CCT groups (RD 0.03, 95% CI -0.02 to 0.08, GRADE: very low). Time after stroke did not make a difference to the positive outcomes, nor did the quality or size of the trials. Heterogeneity was generally low; risk of bias was variable across the studies with poor reporting of study conduct in several of the trials.

AUTHORS' CONCLUSIONS

There is moderate evidence that CCT is effective in improving mobility for people after stroke - they may be able to walk further, faster, with more independence and confidence in their balance. The effects may be greater later after the stroke, and are of clinical significance. Further high-quality research is required, investigating quality of life, participation and cost-benefits, that compares CCT with standard care and that also investigates the influence of factors such as stroke severity and age. The potential risk of increased falls during CCT needs to be monitored.

Structure and feasibility of extra practice during stroke rehabilitation: A systematic scoping review

BACKGROUND/AIM

Improved motor performance is related to the amount of practice completed after a stroke. Australian guidelines recommend that at least one hour of active practice should be completed per day. Yet active practice levels remain low. The aims of this scoping review were to describe how extra practice at the activity level is structured for stroke survivors, and explore the feasibility of participants completing extra practice.

METHODS

A systematic search was conducted of five electronic databases up to August 2015. Trials were included when the intended dose of the control intervention was less than the experimental intervention. The structure of extra practice was classified by the level of supervision, type of personnel, and whether equipment was used. Feasibility of practice was explored by comparing the intended and actual dose of practice completed.

RESULTS

Thirty-five trials, comprising 40 comparisons were included. Multiple configurations of personnel, supervision and equipment were used to structure extra practice. The structure most often used was full supervision by staff without equipment (30 comparisons), typically involving a therapist (17 comparisons), with equipment being used occasionally (12 comparisons). Sixteen comparisons reported both the intended and the actual dose of extra practice completed. The mean percentage of actual extra practice completed was 80% (SD 18) of the intended dose.

CONCLUSIONS

Extra practice during rehabilitation after stroke is most often structured using full supervision by a therapist, and appears feasible for stroke survivors to complete. Less often, extra practice is structured using equipment, non-therapists and/or group classes.

What makes weekend allied health services effective and cost-effective (or not) in acute medical and surgical wards? Perceptions of medical, nursing, and allied health workers

Background

There is strong public support for acute hospital services to move to genuine 7-day models, including access to multidisciplinary team assessment. This study aimed to identify factors that might enable an effective and cost-effective weekend allied health services on acute hospital wards.

Methods

This qualitative study included 22 focus groups within acute wards with a weekend allied health service and 11 telephone interviews with weekend service providers. Data were collected from 210 hospital team members, including 17 medical, 97 nursing, and 96 allied health professionals from two Australian tertiary public hospitals. All were recorded and imported into nVivo 10 for analysis. Thematic analysis methods were used to develop a coding framework from the data and to identify emerging themes.

Results

Key themes identified were separated into issues perceived as being enablers or barriers to the effective or cost-effective delivery of weekend allied health services. Perceived enablers of effectiveness and cost-effectiveness included prioritizing interventions that prevent decline, the right person delivering the right service, improved access to the patient’s family, and ability to impact patient flow. Perceived barriers were employment of inexperienced weekend staff, insufficient investment to see tangible benefit, inefficiencies related to double-handling, unnecessary interventions and/or inappropriate referrals, and difficulty recruiting and retaining skilled staff.

Conclusions

Suggestions for ensuring effective and cost effective weekend allied health care models include minimization of task duplication and targeting interventions so that the right patients receive the right interventions at the right time. Further research into the effectiveness and cost effectiveness of these services should factor in hidden costs, including those associated with managing the service.