Development of a virtual reality-based intervention for community walking post stroke: an integrated knowledge translation approach.

PURPOSE: To develop a virtual reality (VR) based intervention targeting community walking requirements. METHODS: Two focus groups each involving 7 clinicians allowed exploring optimal features, needed support and perceived favorable/unfavorable factors associated with the use of the VR-based intervention from the clinicians' perspective. Three stroke survivors and 2 clinicians further interacted with the intervention and filled questionnaires related to acceptability and favorable/unfavorable perceptions on the VR intervention. Stroke participants additionally rated their perceived effort (NASA Tax Load Index), presence (Slater-Usoh-Steed) and cybersickness (Simulator Sickness Questionnaire). RESULTS: Results identified optimal features (patient eligibility criteria, task complexity), needed support (training, human assistance), as well as favorable (cognitive stimulation, engagement, representativeness of therapeutic goals) and unfavorable factors (misalignment with a natural walking pattern, client suitability, generalization to real-life) associated with the intervention. Acceptability scores following the interaction with the tool were 28 and 42 (max 56) for clinicians and ranged from 43 to 52 for stroke participants. Stroke participants reported moderate perceptions of effort (range:20-33/max:60), high levels of presence (29-42/42) and minimal cybersickness (0-3/64). CONCLUSION: Findings collected in the early development phase of the VR intervention will allow addressing favorable/unfavorable factors and incorporating desired optimal features, prior to conducting effectiveness and implementation studies.

This study presents the development process of a new virtual reality (VR) intervention for community walking and participation in stroke survivors.Results from the focus group and hands-on pilot trial suggest that the VR intervention is feasible and accepted by clinicians and stroke survivors.Addressing favorable/unfavorable factors and incorporating features desired by clinicians in the development of the VR tool should promote its eventual implementation in clinical setting.

Higher social tolerance is associated with more complex facial behavior in macaques.

The social complexity hypothesis for communicative complexity posits that animal societies with more complex social systems require more complex communication systems. We tested the social complexity hypothesis on three macaque species that vary in their degree of social tolerance and complexity. We coded facial behavior in >3000 social interactions across three social contexts (aggressive, submissive, affiliative) in 389 animals, using the Facial Action Coding System for macaques (MaqFACS). We quantified communicative complexity using three measures of uncertainty: entropy, specificity, and prediction error. We found that the relative entropy of facial behavior was higher for the more tolerant crested macaques as compared to the less tolerant Barbary and rhesus macaques across all social contexts, indicating that crested macaques more frequently use a higher diversity of facial behavior. The context specificity of facial behavior was higher in rhesus as compared to Barbary and crested macaques, demonstrating that Barbary and crested macaques used facial behavior more flexibly across different social contexts. Finally, a random forest classifier predicted social context from facial behavior with highest accuracy for rhesus and lowest for crested, indicating there is higher uncertainty and complexity in the facial behavior of crested macaques. Overall, our results support the social complexity hypothesis.

NetFACS: Using network science to understand facial communication systems.

Understanding facial signals in humans and other species is crucial for understanding the evolution, complexity, and function of the face as a communication tool. The Facial Action Coding System (FACS) enables researchers to measure facial movements accurately, but we currently lack tools to reliably analyse data and efficiently communicate results. Network analysis can provide a way to use the information encoded in FACS datasets: by treating individual AUs (the smallest units of facial movements) as nodes in a network and their co-occurrence as connections, we can analyse and visualise differences in the use of combinations of AUs in different conditions. Here, we present 'NetFACS', a statistical package that uses occurrence probabilities and resampling methods to answer questions about the use of AUs, AU combinations, and the facial communication system as a whole in humans and non-human animals. Using highly stereotyped facial signals as an example, we illustrate some of the current functionalities of NetFACS. We show that very few AUs are specific to certain stereotypical contexts; that AUs are not used independently from each other; that graph-level properties of stereotypical signals differ; and that clusters of AUs allow us to reconstruct facial signals, even when blind to the underlying conditions. The flexibility and widespread use of network analysis allows us to move away from studying facial signals as stereotyped expressions, and towards a dynamic and differentiated approach to facial communication.

Recovery of Sensorimotor Functional Outcomes at Discharge from In-Patient Rehabilitation in Three Stroke Units in the Province of Quebec.

Purpose: This study aimed to portray the characteristics, process variables, and sensorimotor outcomes of patients who had received their usual post-stroke in-patient rehabilitation in three stroke rehabilitation units in Quebec in 2013-2014. Method: We assessed patients (n = 264) at admission and discharge with a subset of a standardized assessment toolkit consisting of observational and performance-based assessment tools. Results: The patients, with a mean age of 60.3 (SD 15.4) years, were admitted 27.7 (SD 8.4) days post-stroke onset. They had a mean admission FIM score of 83.0 (SD 24.0), a mean length of stay of 48.4 (SD 31.1) days, a mean FIM discharge score of 104.0 (SD 17.0), and a mean FIM efficiency score of 0.44 (SD 0.29). All patient outcomes were significantly improved (p < 0.001) and clinically meaningful at discharge (moderate to large Glass's Δ effect sizes) with the improvements greater than or equal to the minimal detectable change at the 95% confidence level in 34%-75% of the patients. Improvements were larger on five of seven outcomes in a sub-group of patients with more severe stroke. Conclusions: The use of a combination of observational and performance assessment tools was essential to capture the full range of disabilities. We have documented significant and clinically meaningful improvements in functional independence, disability, and upper and lower extremity functions after usual post-stroke in-patient rehabilitation in the province of Quebec and provided baseline data for future studies.

Objectif : décrire les caractéristiques, le processus de réadaptation et les résultats sensorimoteurs de patients ayant reçu les services de réadaptation habituels après un accident vasculaire cérébral (AVC) dans trois unités de réadaptation du Québec en 2013 et 2014. Méthodologie : évaluation des patients (n = 264) à l'admission et au congé à l'aide du sous-ensemble d'une trousse d'évaluation standardisée composée d'outils d'évaluation fondés sur l'observation et la performance. Résultats : les patients, qui avaient un âge moyen de 60,3 ans (ÉT 15,4), ont été hospitalisés en réadaptation 27,7 jours (ÉT 8,4) après leur AVC. Leur mesure d'autonomie fonctionnelle (MAF) à l'admission était de 83,0 (ÉT 24,0), et leur séjour en réadaptation a duré 48,4 jours (ÉT 31,1); leur score de MAF au congé était de 104,0 (ÉT 17,0), pour un score d'efficacité de la MAF de 0,44 (ÉT 0,29). Tous les résultats cliniques des patients s'étaient considérablement améliorés (p < 0,001) et étaient cliniquement significatifs au congé (effet de taille delta de Glass de modéré à grand), et ces améliorations étaient supérieures ou égales au changement minimal décelable à un niveau de confiance de 95 % chez 34 % à 75 % des patients. Ces améliorations pour cinq des sept mesures étaient plus élevées dans le sous-groupe de patients ayant un AVC plus grave. Conclusion : une combinaison d'outils d'évaluation d'observation et de performance s'est avérée essentielle pour saisir tout l'éventail d'incapacités. Les auteures ont constaté des améliorations importantes et cliniquement significatives de l'autonomie fonctionnelle, de l'incapacité et de la fonction des membres supérieurs et inférieurs après l'hospitalisation en réadaptation habituelle des patients ayant un AVC dans la province de Québec et ont fourni des données de référence en vue de prochaines études.

Development, Implementation, and Clinician Adherence to a Standardized Assessment Toolkit for Sensorimotor Rehabilitation after Stroke.

Purpose: This study describes the development of a standardized assessment toolkit (SAT) and associated clinical database focusing on sensorimotor rehabilitation in three stroke rehabilitation units (SRUs). Implementation of the SAT was confirmed using objective measures of clinician adherence while exploring reasons for varied adherence. Method: Participants were patients post-stroke admitted for inpatient rehabilitation and clinicians from the three SRUs. A collaborative and iterative process was used to develop the SAT. Implementation was measured by clinician adherence, which was charted by means of assessment entries in patient records and transferred to the clinical database. Reasons for lower adherence were interpreted from therapist data logs at one SRU. Results: The SAT consisted of 25 assessment tools. Clinician adherence to a subset of the tools ranged from 33% to 99% at admission and from 28% to 94% at discharge. At one site, lower adherence among the tools was explained by patient-related factors (1%-36%) and protocol or logistical reasons (0%-7%) at admission; missing data ranged from 0% to 3%, except for the Montreal Cognitive Assessment (17%). Conclusions: In this pragmatic study, objective measures of clinician adherence demonstrated the feasibility of implementing an SAT in daily practice. Moreover, the reasons for lower adherence rates may be related to the patients, protocol, and logistics, all of which may vary with the assessment tool, rather than clinician compliance.

Objectif : décrire la création d'une trousse d'évaluation standardisée (TÉS) et d'une base de données cliniques connexe axée sur la réadaptation sensorimotrice dans trois unités de réadaptation fonctionnelle (URF). Les chercheurs ont confirmé la mise en application de la TÉS au moyen de mesures objectives de l'adhésion des cliniciens et ont exploré les raisons expliquant les variations à cette adhésion. Méthodologie : les participants étaient des patients victimes d'un accident vasculaire cérébral (AVC) admis en réadaptation et les cliniciens des trois URF. Les chercheurs ont utilisé un processus coopératif et itératif pour créer la TÉS. Ils en ont mesuré la mise en application par l'adhésion des cliniciens, recensée d'après les résultats d'évaluation dans les dossiers des patients, puis les ont transférées dans la base de données cliniques. Ils ont interprété les raisons d'une plus faible adhésion à partir des notes inscrites sur les feuilles de collecte de données des thérapeutes d'une des URF. Résultats : la TÉS se composait de 25 outils d'évaluation. L'adhésion des cliniciens à un sous-groupe d'outils se situait entre 33% et 99% à l'admission en réadaptation et entre 28% et 94% au congé. Dans un établissement, une plus faible adhésion aux outils s'expliquait par des facteurs liés aux patients (de 1% à 36%), au protocole ou à la logistique (0% à 7%) à l'admission, alors que les données manquantes variaient de 0% à 3%, sauf pour le « Montreal Cognitive Assessment ¼ (17%). Conclusions : dans cette étude pragmatique, les mesures objectives d'adhérence des cliniciens ont démontré la faisabilité de mettre en application une TÉS dans la pratique quotidienne. De plus, les raisons d'un taux d'adhérence plus faible peuvent être liées aux patients, au protocole ou à la logistique, facteurs qui peuvent varier en fonction de l'outil d'évaluation, plutôt qu'aux cliniciens.

Amount and Content of Sensorimotor Therapy Delivered in Three Stroke Rehabilitation Units in Quebec, Canada.

Purpose: This study creates a baseline clinical portrait of sensorimotor rehabilitation in three stroke rehabilitation units (SRUs) as a first step in implementing a multi-centre clinical research platform. Method: Participants in this cross-sectional, descriptive study were the patients and rehabilitation teams in these SRUs. Prospective (recording of therapy time and content and a Web-based questionnaire) and retrospective (chart audit) methods were combined to characterize the practice of the rehabilitation professionals. Results: The 24- to 39-bed SRUs admitted 100-240 inpatients in the year audited. The mean combined duration of individual occupational and physical therapy was 6.3-7.5 hours/week/patient. When evening hours and the contributions of other professionals as well as group therapy and self-practice were included, the total amount of therapy was 13.0 (SD 3) hours/patient/week. Chart audit and questionnaire data revealed the Berg Balance Scale was the most often used outcome measure (98%-100%), and other outcome measure use varied. Clinicians favoured task-oriented therapy (35%-100%), and constraint-induced movement therapy (0%-15%), electrical stimulation of the tibialis anterior (0%-15%), and body weight-supported treadmill training (0%-1%) were less often used. Conclusions: This study is the first to provide objective data on therapy time and content of stroke rehabilitation in Quebec SRUs.

Objectif : créer un portrait clinique de base de la réadaptation sensorimotrice offerte après un accident vasculaire cérébral dans trois unités de réadaptation fonctionnelle intensive (URFI) comme première étape en vue de la mise en œuvre d'une plateforme de recherche clinique multicentrique. Méthodologie : les participants à cette étude descriptive transversale étaient des patients et des équipes de réadaptation de ces URFI. Les chercheurs ont combiné la méthode prospective (consignation de la durée et du contenu du traitement et questionnaire en ligne) et la méthode rétrospective (audit de dossiers) pour caractériser la pratique des professionnels en réadaptation. Résultats : les URFI de 24 à 39 lits ont admis de 100 à 240 patients hospitalisés pendant l'année de l'audit. Les interventions en ergothérapie et physiothérapie étaient d'une durée moyenne combinée de 6,3 à 7,5 heures par semaine par patient. Lorsqu'on incluait les soirées, l'apport d'autres professionnels, la thérapie de groupe et la pratique autonome, le total s'élevait à 13,0 heures (ÉT 3,0) par semaine par patient. Les données tirées de l'audit des dossiers et des questionnaires ont révélé que l'échelle d'évaluation de l'équilibre de Berg était la plus utilisée (98 % à 100 %), alors que l'utilisation des autres mesures était variable. Les cliniciens favorisaient les traitements orientés vers les tâches (35 % à 100 %), et utilisaient moins la thérapie par contrainte induite (0 % à 15 %), la stimulation électrique du jambier antérieur (0 % à 15 %) et l'entraînement sur tapis roulant avec support de poids (0 % à 1 %). Conclusions : la présente étude est la première à fournir des données objectives sur la durée et le contenu de la réadaptation après un accident vasculaire cérébral dans les URFI du Québec.

Sensorimotor enhancement with a mixed reality system for balance and mobility rehabilitation.

We have developed a mixed reality system incorporating virtual reality (VR), surface perturbations and light touch for gait rehabilitation. Haptic touch has emerged as a novel and efficient technique to improve postural control and dynamic stability. Our system combines visual display with the manipulation of physical environments and addition of haptic feedback to enhance balance and mobility post stroke. A research study involving 9 participants with stroke and 9 age-matched healthy individuals show that the haptic cue provided while walking is an effective means of improving gait stability in people post stroke, especially during challenging environmental conditions such as downslope walking.

Cognitive load and dual-task performance during locomotion poststroke: a feasibility study using a functional virtual environment.

BACKGROUND: Gait and cognitive functions can deteriorate during dual tasking, especially in people with neurological deficits. Most studies examining the simultaneous effects of dual tasking on motor and cognitive aspects were not performed in ecological environments. Using virtual reality technology, functional environments can be simulated to study dual tasking. OBJECTIVES: The aims of this study were to test the feasibility of using a virtual functional environment for the examination of dual tasking and to determine the effects of dual tasking on gait parameters in people with stroke and age-matched controls who were healthy. DESIGN: This was a cross-sectional observational study. METHODS: Twelve community-dwelling older adults with stroke and 10 age-matched older adults who were healthy participated in the study. Participants walked on a self-paced treadmill while viewing a virtual grocery aisle projected onto a screen placed in front of them. They were asked to walk through the aisle (single task) or to walk and select ("shop for") items according to instructions delivered before or during walking (dual tasking). RESULTS: Overall, the stroke group walked slower than the control group in both conditions, whereas both groups walked faster overground than on the treadmill. The stroke group also showed larger variability in gait speed and shorter stride length than the control group. There was a general tendency to increase gait speed and stride length during dual-task conditions; however, a significant effect of dual tasking was found only in one dual-task condition for gait speed and stride duration variability. All participants were able to complete the task with minimal mistakes. LIMITATIONS: The small size and heterogeneity of the sample were limitations of the study. CONCLUSIONS: It is feasible to use a functional virtual environment for investigation of dual tasking. Different gait strategies, including an increase or decrease in gait speed, can be used to cope with the increase in cognitive demands required for dual tasking.