Examining the association between balance self-efficacy and virtual balance performance in individuals with stroke: a cross-sectional study.

BACKGROUND: Balance self-efficacy is a strong predictor of fall risk after stroke and is related to performance on balance and walking tests. The use of telerehabilitation for delivering stroke rehabilitation has increased in recent years and there is a need to adapt common clinical assessments to be administered in virtual formats, but the association between balance self-efficacy and virtually administered clinical tests of balance performance has yet to be established. This study examined the association between the Activities-specific Balance Confidence (ABC) Scale and virtually administered Timed Up and Go (TUG), Tandem Stand, and Functional Reach tests (FRT) in individuals with stroke. METHODS: This was a secondary analysis of baseline data from two telerehabilitation trials with individuals with stroke. All assessments were administered by trained physical therapists through videoconferencing software. Multivariate regression analyses were used to examine the associations between the ABC scale and TUG test, Tandem Stand test, and FRT, adjusted for age and number of comorbidities. RESULTS: Data from 51 participants (n = 11 female, median age = 64 [IQR: 18] years, 9.3 ± 4.6 months poststroke) were analyzed. The ABC scores were associated with TUG (R2 = 0.56, F(3,47) = 20.26, p < 0.01), but not Tandem Stand (R2 = 0.18, F(5,45) = 1.93, p = 0.11) or FRT (R2 = 0.14, F(3,47) = 2.55, p = 0.07) tests. CONCLUSION: We observed associations between the ABC scores and virtual TUG, but not with Tandem Stand or FRT, which may be attributed to the context-specificity of balance self-efficacy. As virtual administration of outcomes assessments becomes part of common practice in stroke rehabilitation, our study supports the use of virtually administered TUG in stroke.

Social Cognitive Predictors of Health Promotion Self-Efficacy Among Older Adults During the COVID-19 Pandemic.

PURPOSE: To examine the relative importance of social cognitive predictors (ie, performance accomplishment, vicarious learning, verbal persuasion, affective state) on health promotion self-efficacy among older adults during COVID-19. DESIGN: Cross-sectional. SETTING: Data collected online from participants in British Columbia (BC), Canada. SUBJECTS: Seventy-five adults (n = 75) aged ≥65 years. MEASURES: Health promotion self-efficacy was measured using the Self-Rated Abilities for Health Practices Scale. Performance accomplishment was assessed using the health directed behavior subscale of the Health Education Impact Questionnaire; vicarious learning was measured using the positive social interaction subscale of the Medical Outcomes Survey - Social Support Scale (MOS-SSS); verbal persuasion was assessed using the informational support subscale from the MOS-SSS; and affective state was assessed using the depression subscale from the Depression Anxiety Stress Scale (DASS-21). ANALYSIS: Multiple linear regression was used to investigate the relative importance of each social cognitive predictor on self-efficacy, after controlling for age. RESULTS: Our analyses revealed statistically significant associations between self-efficacy and performance accomplishment (health-directed behavior; ß = .20), verbal persuasion (informational support; ß = .41), and affective state (depressive symptoms; ß = -.44) at P < .05. Vicarious learning (ß = -.15) did not significantly predict self-efficacy. The model was statistically significant (P < .001) explaining 43% of the self-efficacy variance. CONCLUSION: Performance accomplishment experiences, verbal persuasion strategies, and affective states may be the target of interventions to modify health promotion self-efficacy among older adults, in environments that require physical and social distancing.

The use of virtual reality for activities of daily living rehabilitation after brain injury: A scoping review.

INTRODUCTION: Individuals with acquired brain injury (ABI) experience high rates of poor functional outcomes such as inability to complete activities of daily living (ADL). Occupational therapy needs to be customised to the individual's function, goals, and environment to facilitate improvement in ADLs after ABI. Virtual reality (VR) is a novel treatment approach that aims to improve skills within an individualised environment. This study aimed to review the current literature for the use of VR platforms that incorporate ADLs to improve functional outcomes after ABI. METHODS: This review followed the six-stage framework by Arksey & O'Malley (2005). Electronic databases were searched for peer-reviewed journal articles based on inclusion and exclusion criteria. RESULTS: One thousand and six hundred eighty articles were screened, including 413 full text articles and 13 articles were included for review. Among the 13 articles, six were RCTs and the rest were pre-post intervention studies. Studies largely used non-immersive VR platforms, which incorporated ADLs such as grocery shopping, aiming to improve functional outcomes. CONSUMER AND COMMUNITY CONSULTATION: Consumer and community were not involved in executing this study. CONCLUSION: This review suggests mixed results if VR is effective at treating upper limb, cognition, and ADL function after ABI. Using their clinical reasoning, occupational therapists can determine the suitability of VR for ADL rehabilitation for specific patient populations and settings. Plain Language Summary Individuals who sustain an acquired brain injury can have difficulty performing their daily activities such as, making a meal or getting dressed, because of limited function (e.g., physical and cognitive problems). To help improve their ability to complete daily activities, occupational therapy needs to be customised to the individual's function, goals, and environment. Virtual reality is a new rehabilitation approach that allows individuals to improve their function in an individualised environment. In this study, we reviewed the current studies that have used virtual reality platforms that incorporate daily activities to improve function after acquired brain injury. We searched databases and screened the titles and abstracts of 1,680 studies. Then, 413 full-text studies were screened, and 13 studies were included. Studies mostly used non-immersive platforms to practise daily activities such as, grocery shopping, aiming to improve function after acquired brain injury. This review suggests mixed results if virtual reality can effectively treat function after acquired brain injury.

Stroke virtual rehabilitation in rural communities: exploring the perceptions of stroke survivors, caregivers, clinicians, and health administrators.

PURPOSE: Rural-dwelling stroke survivors have unmet rehabilitation needs after returning to community-living. Virtual rehabilitation, defined as the use of technology to provide rehabilitation services from a distance, could be a viable and timely solution to address this need, especially within the COVID-19 pandemic context. There is still a minimal understanding of virtual rehabilitation delivery within rural contexts. This study sought to explore the perceptions of rural stakeholders about virtual stroke rehabilitation. METHODS: Following an interpretive description approach, 17 qualitative interviews were conducted with stroke survivors (n = 5), caregivers (n = 2), clinicians (n = 7), and health administrators (n = 3), and analyzed to understand their experiences and perceptions of virtual stroke rehabilitation. RESULTS: We identified three overarching themes from the participant responses (1) The Root of the (Rural) Problem considered how systemic inequities impact stroke survivors' and caregivers' access to stroke recovery services; (2) Common Benefits, Different Challenges identified the unique benefits and challenges of delivering virtual rehabilitation within rural contexts; and (3) Ingredients for Success described important considerations for implementing virtual rehabilitation. CONCLUSION: Virtual rehabilitation is generally accepted by all stakeholders as a supplement to in-person services. Addressing the unique barriers faced by rural clinicians and stroke survivors is necessary to provide successful virtual rehabilitation.

Understanding the perceptions of virtual rehabilitation from various stakeholders may contribute to more effective provision of stroke services.Understanding unique rural practice challenges faced by clinicians may inform future protocols for virtual rehabilitation.The need for additional support for clinicians and stroke survivors is a determining factor for successful virtual rehabilitation.Incorporating virtual rehabilitation as an adjunct to face-to-face services is accepted by all stakeholders.

A Qualitative Investigation on Chronic Disease Management and Prevention Among Older Adults During the COVID-19 Pandemic.

PURPOSE: To qualitatively describe experiences of chronic disease management and prevention in older adults (age ≥65 years) during COVID-19. APPROACH: Qualitative descriptive approach. SETTING: Data collected online via telephone and video-conferencing technologies to participants located in various cities in British Columbia, Canada. Data analyzed by researchers in the cities of Vancouver and Kelowna in British Columbia. PARTICIPANTS: Twenty-four community-living older adults (n = 24) age ≥65 years. METHODS: Each participant was invited to complete a 30-to-45-minute virtual, semi-structured, one-on-one interview with a trained interviewer. Interview questions focused on experiences managing health prior to COVID-19 and transitioning experiences of practicing health management and prevention strategies during COVID-19. Audio recordings of interviews were transcribed verbatim and analyzed thematically. RESULTS: The sample's mean age was 73.4 years (58% female) with 75% reporting two or more chronic conditions (12.5% none, 12.5% one). Three themes described participants' strategies for chronic disease management and prevention: (1) having a purpose to optimize health (i.e., managing health challenges and maintaining independence); (2) internal self-control strategies (i.e., self-accountability and adaptability); and (3) external support strategies (i.e., informational support, motivational support, and emotional support). CONCLUSION: Helping older adults identify purposes for their own health management, developing internal control strategies, and optimizing social support opportunities may be important person-centred strategies for chronic disease management and prevention during unprecedented times like COVID-19.

Investigating the Telerehabilitation With Aims to Improve Lower Extremity Recovery Poststroke Program: A Feasibility Study.

OBJECTIVE: The purpose of this study was to examine the feasibility of a progressive virtual exercise and self-management intervention, the TeleRehabilitation with Aims to Improve Lower extremity recovery poststroke program (TRAIL), in individuals with stroke. METHODS: A single group pre-post study design was used. Thirty-two participants were recruited who were aged 19 years or older, had a stroke within 18 months of the beginning of the study, had hemiparesis of the lower extremity, and were able to tolerate 50 minutes of activity. Participants completed TRAIL, a synchronous exercise and self-management program delivered via videoconferencing. Participants received 8 telerehabilitation sessions over 4 weeks that were 60 to 90 minutes, with a trained physical therapist in a ≤2 to 1 participant-to-therapist ratio. Feasibility indicators in the areas of process (recruitment and retention rates, perceived satisfaction), resources (treatment fidelity and adherence, participant and assessor burden, therapist burden), management (equipment, processing time), and scientific indicators (safety, treatment response, treatment effect) were collected throughout the study using a priori criteria for success. The treatment effect was examined on the Timed "Up & Go" test, the virtual Fugl-Meyer Lower Extremity Assessment, the 30-Second Sit-to-Stand Test, the Functional Reach, the Tandem Stand, the Activities-Specific Balance Confidence Scale, the Stroke Impact Scale, and the Goal Attainment Scale. RESULTS: Forty-seven individuals were screened, of which 32 (78% male; median age of 64.5 years) were included for the study from 5 sites across Canada. Nine feasibility indicators met our study-specific threshold criteria for success: retention rate (0 dropouts), perceived satisfaction, treatment fidelity, adherence, therapist burden, equipment, and safety. In terms of treatment response and effect, improvements were observed in Timed "Up & Go" test (Cohen d = 0.57); Fugl-Meyer Lower Extremity Assessment (d = 0.76); 30-Second Sit-to-Stand Test (d = 0.89); and Goal Attainment Scale (d = 0.95). CONCLUSION: The delivery of TRAIL, a lower extremity stroke rehabilitation program using videoconferencing technology, is feasible and appears to have positive influences on mobility, lower extremity impairment, strength, and goal attainment. IMPACT: Community-based telerehabilitation programs, such as TRAIL, could extend the continuum of care during the transition back to community postdischarge or during global disruptions, such as Coronavirus Disease 2019 (COVID-19). Delivery of synchronous lower extremity rehabilitation via videoconferencing to community-dwelling stroke survivors is feasible.

Economic Evaluation of Exercise or Cognitive and Social Enrichment Activities for Improved Cognition After Stroke.

Importance: Cognitive impairment is prevalent in survivors of stroke, affecting approximately 30% of individuals. Physical exercise and cognitive and social enrichment activities can enhance cognitive function in patients with chronic stroke, but their cost-effectiveness compared with a balance and tone program is uncertain. Objective: To conduct a cost-effectiveness and cost-utility analysis of multicomponent exercise or cognitive and social enrichment activities compared with a balance and tone program. Design, Setting, and Participants: This economic evaluation used a Canadian health care systems perspective and the Vitality study, a randomized clinical trial aimed at improving cognition after stroke with a 6-month intervention and a subsequent 6-month follow-up (ie, 12 months). The economic evaluation covered the duration of the Vitality trial, between June 6, 2014, and February 26, 2019. Participants were community-dwelling adults aged 55 years and older who experienced a stroke at least 12 months prior to study enrollment in the Vancouver metropolitan area, British Columbia, Canada. Data were analyzed from June 1, 2022, to March 31, 2023. Interventions: Participants were randomly assigned to twice-weekly classes for 1 of the 3 groups: multicomponent exercise program, cognitive and social enrichment activities program, or a balance and tone program (control). Main Outcomes and Measures: The primary measures for the economic evaluation included cost-effectiveness (incremental costs per mean change in cognitive function, evaluated using the Alzheimer Disease Assessment Scale-Cognitive-Plus), cost-utility (incremental cost per quality-adjusted life-year gained), intervention costs, and health care costs. Since cognitive benefits 6 months after intervention cessation were not observed in the primary randomized clinical trial, an economic evaluation at 12 months was not performed. Results: Among 120 participants (mean [SD] age, 71 [9] years; 74 [62%] male), 34 were randomized to the multicomponent exercise program, 34 were randomized to the social and cognitive enrichment activities program, and 52 were randomized to the balance and tone control program. At the end of the 6-month intervention, the cost per mean change in Alzheimer Disease Assessment Scale-Cognitive-Plus score demonstrated that exercise was more effective and costlier compared with the control group in terms of cognitive improvement with an incremental cost-effectiveness ratio of CAD -$8823. The cost per quality-adjusted life-year gained for both interventions was negligible, with exercise less costly (mean [SD] incremental cost, CAD -$32 [$258]) and cognitive and social enrichment more costly than the control group (mean [SD] incremental cost, CAD $1018 [$378]). The balance and tone program had the lowest delivery cost (CAD $777), and the exercise group had the lowest health care resource utilization (mean [SD] $1261 [$1188]) per person. Conclusions and Relevance: The findings of this economic evaluation suggest that exercise demonstrated potential for cost-effectiveness to improve cognitive function in older adults with chronic stroke during a 6-month intervention.

The influence of assistive technology and home modifications on falls in community-dwelling older adults: a systematic review protocol.

BACKGROUND: Fall-related injuries can reduce older adults' independence and result in economic burdens. The assistive technologies and home modifications explored in this review are suggested to reduce the risk of falls of community-dwelling older people. However, the location of the in-home assistive technology being used, and the in-home modification likely interact and influence fall reduction and injury prevention of community-dwelling older adults. This interactive effect is poorly understood. A better understanding of the impact of assistive technologies and modifications in the homes of older adults is needed to support the appropriate application of these devices. OBJECTIVE: The objective of this systematic review is to detail the contribution of assistive technology and home modification on falls, fall frequency, fall severity, and fall location within the homes of community-dwelling older adults. METHODS: We will source articles from 3 databases (MEDLINE, CINAHL, Web of Science Core Collection) and will assess them using a set of pre-defined inclusion and exclusion criteria. Reporting will be in accordance with PRISMA 2020. Two independent reviewers will screen each study at the title and abstract and full-text level. We are managing citations within the Covidence software. Data extraction and analysis will be reported in a systematic review. DISCUSSION: The outcome variables of interest are fall frequency, fall location, injury, mortality, and hospitalization. These variables of interest all relate to falls, their severity, and their locations in the home. We are seeking a better understanding of how these outcomes vary with the use of different assistive technologies and home modifications as reported in the literature. This will help us understand where falls occur which may inform how different assistive technologies can be used by community-dwelling older adults to prevent falls and adverse outcomes in different areas of their homes. Our review will provide a basis for more intentional prescription of ambulatory assistive technologies and evidence-based recommendations of home modifications. It may also inform adaptations to existing technologies to foster safer mobility in the homes of community-dwelling older adults. SYSTEMATIC REVIEW REGISTRATION: This protocol has been submitted for registration in PROSPERO CRD42022370172 on October 24, 2022.

TeleRehabilitation with Aims to Improve Lower extremity recovery in community-dwelling individuals who have had a stroke: protocol for a multisite, parallel group, assessor-blinded, randomised attention-controlled trial.

INTRODUCTION: Telerehabilitation is an accessible service delivery model that may support innovative lower extremity rehabilitation programmes that extend the stroke recovery continuum into the community. Unfortunately, there is limited evidence on the provision of exercises for lower extremity recovery after stroke delivered using telerehabilitation. In response, we developed the TeleRehabilitation with Aims to Improve Lower extremity recovery poststroke (TRAIL) programme, a 4-week progressive exercise and self-management intervention delivered synchronously using video-conferencing technology. Our primary hypothesis is that individual within 1-year poststroke who participate in TRAIL will experience significantly greater improvements in functional mobility than individuals in an attention-controlled education programme (EDUCATION). METHODS AND ANALYSIS: In this multisite, parallel group, assessor-blinded randomised attention-controlled trial, 96 community-living stroke survivors within 1-year poststroke will be recruited from five sites (Vancouver, Winnipeg, Toronto, London and Halifax, Canada) from the CanStroke Recovery Trials Platform which is a network of Canadian hospital sites that are affiliated with academic institutions to facilitate participant recruitment and quality trial practices. Participants will be randomised on a 1:1 basis to TRAIL or EDUCATION. Participants randomised to TRAIL will receive eight telerehabilitation sessions where they will perform exercises and receive self-management support to improve lower extremity recovery from a TRAIL physical therapist. The primary outcome will be measured using the Timed Up and Go. Secondary outcomes include lower extremity muscle strength, functional balance, motor impairment, balance self-efficacy, health-related quality of life and health service use for our economic evaluation. Measurements will be taken at baseline, immediately after the intervention, 3-month and 6-month postintervention. ETHICS AND DISSEMINATION: Ethics approval for this research has been obtained by all participating sites. All study participants will provide their informed consent prior to enrolling them in the study. Findings from this trial will be disseminated in peer-reviewed journals and presentations at international scientific meetings. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, NCT04908241.

Clinical effects of Emblica officinalis fruit consumption on cardiovascular disease risk factors: a systematic review and meta-analysis.

BACKGROUND: Emblica officinalis (EO) fruit consumption has been found to have a beneficial effect on cardiovascular disease (CVD) physiological risk factors in preliminary clinical intervention trials; however, questions remain regarding the overall effectiveness of EO on CVD risk. The purpose of this systematic review and meta-analysis is to: 1) systematically describe the clinical research examining EO; and 2) quantitatively assess the effects of EO on CVD physiological risk factors. METHODS: The Pubmed, Embase, Web of Science, and Google Scholar electronic platforms were searched for relevant randomized controlled trials (RCTs) published until April 7, 2021. Studies were included if they involved adults (age ≥ 18 years) ingesting a form of EO fruit; included blood lipids, blood pressure, and/or inflammatory biomarkers as outcomes; had clearly defined intervention and control treatments with pre- and post-intervention data; were peer-reviewed; and were written in English. Studies were excluded if they compared EO with another risk reduction intervention without a usual care control group. RCTs were assessed for methodological quality using the Cochrane risk-of-bias version 2 (ROB2) tool, qualitatively described, and quantitatively evaluated using random and fixed effect meta-analysis models. RESULTS: A total of nine RCTs (n = 535 participants) were included for review. Included studies followed parallel-group (n = 6) and crossover (n = 3) designs, with EO dosage ranging from 500 mg/day to 1500 mg/day, and treatment duration ranging from 14 to 84 days. Meta-analyses revealed EO to have a significant composite effect at lowering low-density lipoprotein cholesterol (LDL-C; Mean difference (MD) = -15.08 mg/dL [95% Confidence interval (CI) = -25.43 to -4.73], I2 = 77%, prediction interval = -48.29 to 18.13), very low-density lipoprotein cholesterol (VLDL-C; MD = -5.43 mg/dL [95% CI = -8.37 to -2.49], I2 = 44%), triglycerides (TG; MD = -22.35 mg/dL [95% CI = -39.71 to -4.99], I2 = 62%, prediction interval = -73.47 to 28.77), and high-sensitivity C-reactive protein (hsCRP; MD = -1.70 mg/L [95% CI = -2.06 to -1.33], I2 = 0%) compared with placebo. CONCLUSIONS: Due to statistical and clinical heterogeneity in the limited number of clinical trials to date, the promising effects of EO on physiologic CVD risk factors in this review should be interpreted with caution. Further research is needed to determine if EO offers an efficacious option for primary or secondary prevention of CVD as either monotherapy or adjunct to evidence-based dietary patterns and/or standard pharmacotherapy.

Social Prescribing Outcomes for Trials (SPOT): Protocol for a modified Delphi study on core outcomes.

PURPOSE: This is a study protocol to co-create with knowledge users a core outcome set focused on middle-aged and older adults (40 years+) for use in social prescribing research. METHODS: We will follow the Core Outcome Measures in Effectiveness Trials (COMET) guide and use modified Delphi methods, including collating outcomes reported in social prescribing publications, online surveys, and discussion with our team to finalize the core outcome set. We intentionally center this work on people who deliver and receive social prescribing and include methods to evaluate collaboration. Our three-part process includes: (1) identifying published systematic reviews on social prescribing for adults to extract reported outcomes; and (2) up to three rounds of online surveys to rate the importance of outcomes for social prescribing. For this part, we will invite people (n = 240) who represent the population experienced in social prescribing, including researchers, members of social prescribing organizations, and people who receive social prescribing and their caregivers. Finally, we will (3) convene a virtual team meeting to discuss and rank the findings and finalize the core outcome set and our knowledge mobilization plan. CONCLUSION: To our knowledge, this is the first study designed to use a modified Delphi method to co-create core outcomes for social prescribing. Development of a core outcome set contributes to improved knowledge synthesis via consistency in measures and terminology. We aim to develop guidance for future research, and specifically on the use of core outcomes for social prescribing at the person/patient, provider, program, and societal-level.

Activity and Recovery Among Youth With Concussion: A Meta-analysis.

CONTEXT: Concussions in youth are highly prevalent. Previously, rest was prescribed to prevent adverse outcomes; however, early return to activity is emerging to improve the recovery trajectory. OBJECTIVES: To evaluate the effectiveness of early return to physical and social activity interventions on recovery outcomes in youth with concussion. DATA SOURCES: A systematic review was conducted up to October 2022. STUDY SELECTION: We included randomized controlled trials (RCTs) and non-RCTs that reported effects of activity-based interventions on symptoms, quality-of-life (QoL), and return to preinjury activity levels in children and youth after a concussion. DATA EXTRACTION: Three authors independently extracted data on publication year and country, study setting and design, sample size, participant demographics, intervention, outcome(s), and author conclusion. Meta-analysis was conducted on appropriate RCTs. RESULTS: Twenty-four studies were included in the final review, of which 10 were RCTs. There was a significant effect of activity interventions on symptom reporting (standardized mean difference, 0.39 [95% confidence interval, 0.15 to 0.63]; I2, 0%; P = .002). There was not a significant effect of activity-based interventions on QoL (mean difference, -0.91 [95% confidence interval, -7.76 to 5.94]; I2, 0%; P = .79). No meta-analysis was performed on return to preinjury activity levels because of insufficient number of RCTs conducted. LIMITATIONS: One outcome was excluded from the meta-analysis. Interventions emphasizing social activity were lacking. CONCLUSIONS: Findings indicate that activity-based interventions may significantly improve concussion symptoms. There is insufficient data to understand the effect of activity-based intervention on QoL and return to preinjury activity levels.

Older adults and social prescribing experience, outcomes, and processes: a meta-aggregation systematic review.

OBJECTIVE: Social prescribing is a complex care model, which aims to address unmet non-medical needs and connect people to community resources. The purpose of this systematic review was to synthesize available evidence from qualitative methods (e.g. interviews or focus groups) on experience, outcomes, and processes for social prescribing and older adults (from the person or provider level). STUDY DESIGN: This was a systematic review using the Joanna Brigg's meta-aggregative approach. METHODS: We searched multiple online databases for peer-reviewed studies, which included older adults aged ≥60 years (group mean age) and social prescribing experience, outcomes, or processes. We included all qualitative or mixed methods designs from all years and languages. Date of the last primary search was March 24, 2022. Two authors used online software to conduct the screening independently and then decided on the final list of included studies via notes and online discussion. RESULTS: We screened 376 citations (after duplicates) and included eight publications. There were 197 older adult participants (59% women), and many people were living with chronic health conditions. Few details were provided for participants' ethnicity, education, and related factors. We created five synthesized findings related to (1) the approach of social prescribing; implementation factors such as (2) relationships, (3) behavior change strategies, and (4) the environment; and (5) older adults' perceived health and psychosocial outcomes. CONCLUSIONS: Despite the limited number of available studies, data provide an overview of people and processes involved with social prescribing, identified research and practice gaps, and possible next steps for implementing and evaluating social prescribing for older adults in primary care.

Preliminary investigation of the student-delivered Community Outreach teleheAlth program for Covid education and Health promotion (COACH).

BACKGROUND: COVID-19 public health restrictions (i.e. physical distancing) compromise individuals' ability to self-manage their health behaviours and may increase the risks of adverse health events. OBJECTIVES: To evaluate the student-delivered Community Outreach teleheAlth program for Covid education and Health promotion (COACH) on health-directed behaviour (self-management) among older adults (≥65 years of age, n = 75). Secondary objectives estimated the influence of COACH on perceived depression, anxiety, and stress; social support; health-related quality of life; health promotion self-efficacy; and other self-management domains. METHODS: COACH was developed to provide chronic disease management and prevention support among older adults via telephone or videoconferencing platforms (i.e. Zoom). In this single-group, pre-post study, our primary outcome was measured using the health-directed behaviour subscale of the Health Education Impact Questionnaire. Secondary measures included the Depression, Anxiety and Stress Scale, Medical Outcomes Study: Social Support Survey, MOS Short Form-36, and Self-Rated Abilities for Health Practices Scale. Paired sample t-tests were used to analyse outcome changes. RESULTS: Mean age of participants was 72.4 years (58.7% female; 80% ≥2 chronic conditions). Health-directed behaviour significantly improved after COACH (P < 0.001, d = 0.45). Improved health promotion self-efficacy (P < 0.001, d = 0.44) and decreased mental health were also observed (P < 0.001, d = -1.69). DISCUSSION: COACH likely contributed to improved health-directed behaviour and health promotion self-efficacy despite the diminished mental health-related quality of life during COVID-19. Our findings also highlight the benefits of using health professional students for the delivery of virtual health promotion programs. CLINICAL TRIAL INFORMATION: ClinicalTrials.gov ID: NCT04492527.

Implementation of increased physical therapy intensity for improving walking after stroke: Walk 'n watch protocol for a multisite stepped-wedge cluster-randomized controlled trial.

RATIONALE: Clinical practice guidelines support structured, progressive protocols for improving walking after stroke. Yet, practice is slow to change, evidenced by the little amount of walking activity in stroke rehabilitation units. Our recent study (n = 75) found that a structured, progressive protocol integrated with typical daily physical therapy improved walking and quality-of-life measures over usual care. Research therapists progressed the intensity of exercise by using heart rate and step counters worn by the participants with stroke during therapy. To have the greatest impact, our next step is to undertake an implementation trial to change practice across stroke units where we enable the entire unit to use the protocol as part of standard of care. AIMS: What is the effect of introducing structured, progressive exercise (termed the Walk 'n Watch protocol) to the standard of care on the primary outcome of walking in adult participants with stroke over the hospital inpatient rehabilitation period? Secondary outcomes will be evaluated and include quality of life. METHODS AND SAMPLE SIZE ESTIMATES: This national, multisite clinical trial will randomize 12 sites using a stepped-wedge design where each site will be randomized to deliver Usual Care initially for 4, 8, 12, or 16 months (three sites for each duration). Then, each site will switch to the Walk 'n Watch phase for the remaining duration of a total 20-month enrolment period. Each participant will be exposed to either Usual Care or Walk 'n Watch. The trial will enroll a total of 195 participants with stroke to achieve a power of 80% with a Type I error rate of 5%, allowing for 20% dropout. Participants will be medically stable adults post-stroke and able to take five steps with a maximum physical assistance from one therapist. The Walk 'n Watch protocol focuses on completing a minimum of 30 min of weight-bearing, walking-related activities (at the physical therapists' discretion) that progressively increase in intensity informed by activity trackers measuring heart rate and step number. STUDY OUTCOME(S): The primary outcome will be the change in walking endurance, measured by the 6-Minute Walk Test, from baseline (T1) to 4 weeks (T2). This change will be compared across Usual Care and Walk 'n Watch phases using a linear mixed-effects model. Additional physical, cognitive, and quality of life outcomes will be measured at T1, T2, and 12 months post-stroke (T3) by a blinded assessor. DISCUSSION: The implementation of stepped-wedge cluster-randomized trial enables the protocol to be tested under real-world conditions, involving all clinicians on the unit. It will result in all sites and all clinicians on the unit to gain expertise in protocol delivery. Hence, a deliberate outcome of the trial is facilitating changes in best practice to improve outcomes for participants with stroke in the trial and for the many participants with stroke admitted after the trial ends.

Capability, opportunity, motivation, and social participation after stroke.

BACKGROUND: Stroke survivors report limited social participation, despite it being an important rehabilitation outcome. Interdisciplinary interventions for increasing social participation amongst stroke survivors lack theoretical guidance and evidence-based approaches. The Behavior Change Wheel (BCW) theorizes that capability, opportunity, and motivation contribute to behavior change. OBJECTIVES: This study applied the BCW to understand the relationship between social participation and stroke survivors' capability, opportunity, and motivation. METHODS: In this cross-sectional study, we recruited 30 community-dwelling adult stroke survivors. Assessments explored the frequency and satisfaction of social participation; physical and psychological capability; environmental accessibility and social opportunity; and motivation. A linear regression analysis was done. RESULTS: Motivation (R2 change = 29.3%, ß = 0.55) and environmental opportunity (R2 change = 11%, ß = 0.39) were statistically significant predictors of social participation frequency. Motivation (R2 change = 36.9%, ß = 0.61) was the only statistically significant predictor of satisfaction with social performance. CONCLUSIONS: Motivation and environmental accessibility are statistically significant independent predictors of frequency of social participation after stroke. Motivation is the strongest predictor of satisfaction with social participation. Clinicians may support stroke survivors to promote social participation using approaches that increase motivation and environmental accessibility. Development of such theoretically sound interventions may be guided by the BCW.

The influence of a virtual reality entertainment program on depressive symptoms and sedentary behaviour in inpatient stroke survivors: a research protocol for a pilot randomized controlled trial.

BACKGROUND: Sedentary behaviour among stroke inpatients may be due to high rates of depressive symptoms after stroke. Thus, efforts to address depressive symptoms among stroke inpatients are warranted to in turn lessen sedentary behaviour. Despite evidence that virtual reality (VR) is emerging as a method to help with depression, the use of VR to improve depression among inpatient stroke survivors has yet to be studied. In this paper, we report on the protocol investigating the feasibility of a VR entertainment system at improving depressive symptoms among stroke survivors receiving inpatient rehabilitation. METHODS: In this single-blind randomized controlled trial, 30 inpatient stroke survivors from the rehabilitation unit at Kelowna General Hospital will be randomized to either (1) intervention: 3 times per week of VR entertainment for duration of inpatient rehabilitation or (2) control: usual care. Individuals will be included if they have a confirmed diagnosis of stroke, are 19 years of age or older, able to provide informed consent, have physician clearance to participate in the study (medically stable or fit), or are able to understand English. Outcome measures to address depressive symptoms (primary outcome), sedentary behaviour, motivation, anxiety, stress, and happiness (secondary outcome) will be administered at two timepoints: (1) baseline (T1) and (2) post-intervention (T2). Study analyses will consider study feasibility indicators and clinical (statistical) outcomes. Means and standard deviations (for continuous variables) and frequencies and proportions (for categorical variables) will be used to summarize the variables. Feasibility indicators will be dichotomized into either 'success' if they meet the a priori criteria, or 'revise' if they do not meet the criteria. Intervention effects post-intervention (T2) for the primary and secondary clinical outcomes will be estimated using linear regression including baseline (T1) controlling for age and sex. DISCUSSION: The results of this trial will add to our understanding of depression and sedentary behaviour among individuals receiving inpatient stroke rehabilitation as well as the feasibility of a VR entertainment program to improve depressive symptoms, which will in turn may lessen sedentary behaviour in inpatient stroke survivors. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04011202 . First posted July 8, 2019 (study postponed from March 2020 to July 2021 due to COVID-19).

Mobility-Focused Physical Outcome Measures Over Telecommunication Technology (Zoom): Intra and Interrater Reliability Trial.

BACKGROUND: Rehabilitation provided via telehealth offers an alternative to currently limited in-person health care. Effective rehabilitation depends on accurate and relevant assessments that reliably measure changes in function over time. The reliability of a suite of relevant assessments to measure the impact of rehabilitation on physical function is unknown. OBJECTIVE: We aimed to measure the intrarater reliability of mobility-focused physical outcome measures delivered via Zoom (a commonly used telecommunication platform) and interrater reliability, comparing Zoom with in-person measures. METHODS: In this reliability trial, healthy volunteers were recruited to complete 7 mobility-focused outcome measures in view of a laptop, under instructions from a remotely based researcher who undertook the remote evaluations. An in-person researcher (providing the benchmark scores) concurrently recorded their scores. Interrater and intrarater reliability were assessed for Grip Strength, Functional Reach Test, 5-Time Sit to Stand, 3- and 4-Meter Walks and Timed Up and Go, using intraclass correlation coefficients (ICC) and Bland-Altman plots. These tests were chosen because they cover a wide array of physical mobility, strength, and balance constructs; require little to no assistance from a clinician; can be performed in the limits of a home environment; and are likely to be feasible over a telehealth delivery mode. RESULTS: A total of 30 participants (mean age 36.2, SD 12.5 years; n=19, 63% male) completed all assessments. Interrater reliability was excellent for Grip Strength (ICC=0.99) and Functional Reach Test (ICC=0.99), good for 5-Time Sit to Stand (ICC=0.842) and 4-Meter Walk (ICC=0.76), moderate for Timed Up and Go (ICC=0.64), and poor for 3-Meter Walk (ICC=-0.46). Intrarater reliability, accessed by the remote researcher, was excellent for Grip Strength (ICC=0.91); good for Timed Up and Go, 3-Meter Walk, 4-Meter Walk, and Functional Reach (ICC=0.84-0.89); and moderate for 5-Time Sit to Stand (ICC=0.67). Although recorded simultaneously, the following time-based assessments were recorded as significantly longer via Zoom: 5-Time Sit to Stand (1.2 seconds), Timed Up and Go (1.0 seconds), and 3-Meter Walk (1.3 seconds). CONCLUSIONS: Untimed mobility-focused physical outcome measures have excellent interrater reliability between in-person and telehealth measurements. Timed outcome measures took approximately 1 second longer via Zoom, reducing the reliability of tests with a shorter duration. Small time differences favoring in-person attendance are of a similar magnitude to clinically important differences, indicating assessments undertaken using telecommunications technology (Zoom) cannot be compared directly with face-to-face delivery. This has implications for clinicians using blended (ie, some face-to-face and some via the internet) assessments. High intrarater reliability of mobility-focused physical outcome measures has been demonstrated in this study.

Telerehabilitation for lower extremity recovery poststroke: a systematic review and meta-analysis protocol.

INTRODUCTION: Approximately 30% of individuals with stroke report unmet lower extremity recovery needs after formal hospital-based rehabilitation programmes have ended. Telerehabilitation can mitigate issues surrounding accessibility of rehabilitation services by providing ongoing support to promote recovery, however, no review exists that is specific to telerehabilitation for lower extremity recovery. This paper describes the protocol of a systematic review and meta-analysis that aims to describe and evaluate the effectiveness of lower extremity-focused telerehabilitation interventions on clinical outcomes poststroke. METHODS AND ANALYSIS: A systematic review of relevant electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, Google Scholar, PEDro, PubMed and Cochrane Library) between inception and February 2022 will be undertaken to identify eligible interventional studies published in English that compared telerehabilitation focusing on lower extremity recovery to another intervention or usual care for individuals living in the community with stroke. Clinical outcomes examined will include those related to physical function and impairment, activities and participation that are typically assessed in clinical practice and research. Two reviewers will independently screen results, identify studies to be included for review, extract data and assess risk of bias. Meta-analyses will be performed if sufficient data exist. Sensitivity analyses will be performed by removing studies with low methodological quality, and subgroup analyses will be performed if data allow by stratifying papers based on salient demographic or stroke factors and comparing results. The reporting of the review will follow the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The quality of evidence regarding various outcomes for telerehabilitation for lower extremity recovery poststroke will be assessed according to the Grading of Recommendation, Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: No ethical approval or informed consent is needed for this systematic review. The findings of this review will be disseminated via peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42021246886.

The effects of a primary care low-carbohydrate, high-fat dietary educational intervention on laboratory and anthropometric data of patients with chronic disease: a retrospective cohort chart review.

BACKGROUND: Low-carbohydrate and high-fat (LCHF) diets are shown to have health benefits such as weight loss and improved cardiovascular health. Few studies, however, on LCHF diets have been completed in a real-world primary care setting over an extended period of time. OBJECTIVES: To examine the efficacy of a low-carbohydrate, high-fat dietary educational intervention delivered in a family practice setting on weight, body mass index (BMI), blood pressure, glycated haemoglobin (HbA1c), fasting insulin, estimated glomerular filtration rate (eGFR), and albumin to creatinine ratio (ACR). A secondary objective was to determine whether compliance to the program had an effect on outcomes. METHODS: In this retrospective chart review, we collected laboratory and anthropometric data from an electronic medical record system for patients (n = 122) at least 19 years of age, who attended at least 2 LCHF educational sessions between January 2018 and May 2020. Pre-post mean differences of outcome were analysed using paired sample t-tests. Independent sample t-tests examined the effect of compliance on the outcomes. RESULTS: Statistically significant reductions in weight (3.96 kg [P < 0.001]) and BMI (1.46 kg/m2 [P = 0.001]) were observed. Compared with patients who participated in ≤5 educational visits, patients who participated in >5 visits showed trends towards more clinically significant changes in weight, BMI, systolic blood pressure, diastolic blood pressure, HbA1c, eGFR, and ACR. CONCLUSION: Improvements in weight and BMI indicate the utility of providing LCHF health promotion interventions in primary care settings. Greater compliance to LCHF interventions results in greater improvement in laboratory and anthropometric outcomes, including HbA1c.