What influences provision of information about recovery on stroke units? A focused ethnographic case study.

OBJECTIVE: Patients and carers frequently report dissatisfaction with post-stroke information provision. This study aimed to develop an in-depth understanding of the factors influencing provision of information about recovery in stroke units. METHODS: Focused ethnographic case-studies in two UK stroke units, including non-participant observations and semi-structured interviews with professionals, patients and carers, and documentary analysis. A Framework approach to analysis was undertaken. RESULTS: Twenty patients, 17 carers and 47 professionals participated. The unpredictable recovery trajectory led professionals to present prognostic estimates as uncertain possibilities. The need to maintain patients' motivation limited sharing of negative predictions, and generic information over-emphasised the importance of therapy in recovery. A structured multidisciplinary team approach to delivering information improved consistency. Complex clinical reasoning was required to identify and meet patients' needs. Hospital environments and routines restricted opportunities for dialogue, particularly with carers. CONCLUSIONS: The process of providing information about post-stroke recovery is complex, requiring enhanced clinical reasoning and communication. The challenges faced by professionals are numerous and if not addressed can result in suboptimal provision. PRACTICE IMPLICATIONS: Professionals should develop a co-ordinated multidisciplinary approach to information provision; and engage in dialogue to ensure a tailored approach to identifying and meeting patients' and carers' information needs.

The Strength of the Corticospinal Tract Not the Reticulospinal Tract Determines Upper-Limb Impairment Level and Capacity for Skill-Acquisition in the Sub-Acute Post-Stroke Period.

Background. Upper-limb impairment in patients with chronic stroke appears to be partly attributable to an upregulated reticulospinal tract (RST). Here, we assessed whether the impact of corticospinal (CST) and RST connectivity on motor impairment and skill-acquisition differs in sub-acute stroke, using transcranial magnetic stimulation (TMS)-based proxy measures. Methods. Thirty-eight stroke survivors were randomized to either reach training 3-6 weeks post-stroke (plus usual care) or usual care only. At 3, 6 and 12 weeks post-stroke, we measured ipsilesional and contralesional cortical connectivity (surrogates for CST and RST connectivity, respectively) to weak pre-activated triceps and deltoid muscles with single pulse TMS, accuracy of planar reaching movements, muscle strength (Motricity Index) and synergies (Fugl-Meyer upper-limb score). Results. Strength and presence of synergies were associated with ipsilesional (CST) connectivity to the paretic upper-limb at 3 and 12 weeks. Training led to planar reaching skill beyond that expected from spontaneous recovery and occurred for both weak and strong ipsilesional tract integrity. Reaching ability, presence of synergies, skill-acquisition and strength were not affected by either the presence or absence of contralesional (RST) connectivity. Conclusion. The degree of ipsilesional CST connectivity is the main determinant of proximal dexterity, upper-limb strength and synergy expression in sub-acute stroke. In contrast, there is no evidence for enhanced contralesional RST connectivity contributing to any of these components of impairment. In the sub-acute post-stroke period, the balance of activity between CST and RST may matter more for the paretic phenotype than RST upregulation per se.

Experiences and views of receiving and delivering information about recovery in acquired neurological conditions: a systematic review of qualitative literature.

OBJECTIVE: To review and synthesise qualitative literature relating to the views, perceptions and experiences of patients with acquired neurological conditions and their caregivers about the process of receiving information about recovery; as well as the views and experiences of healthcare professionals involved in delivering this information. DESIGN: Systematic review of qualitative studies. DATA SOURCES: MEDLINE, Embase, AMED, CINAHL, PsycINFO, Web of Science and the Cochrane library were searched from their inception to July 2019. DATA EXTRACTION AND SYNTHESIS: Two reviewers extracted data from the included studies and assessed quality using an established tool. Thematic synthesis was used to synthesise the findings of included studies. RESULTS: Searches yielded 9105 titles, with 145 retained for full-text screening. Twenty-eight studies (30 papers) from eight countries were included. Inductive analysis resulted in 11 descriptive themes, from which 5 analytical themes were generated: the right information at the right time; managing expectations; it's not what you say, it's how you say it; learning how to talk about recovery and manage emotions; the context of uncertainty. CONCLUSIONS: Our findings highlight the inherent challenges in talking about recovery in an emotional context, where breaking bad news is a key feature. Future interventions should focus on preparing staff to meet patients' and families' information needs, as well as ensuring they have the skills to discuss potential recovery and break bad news compassionately and share the uncertain trajectory characteristic of acquired neurological conditions. An agreed team-based approach to talking about recovery is recommended to ensure consistency and improve the experiences of patients and their families.

Sensorimotor delays in tracking may be compensated by negative feedback control of motion-extrapolated position.

Sensorimotor delays dictate that humans act on outdated perceptual information. As a result, continuous manual tracking of an unpredictable target incurs significant response delays. However, no such delays are observed for repeating targets such as the sinusoids. Findings of this kind have led researchers to claim that the nervous system constructs predictive, probabilistic models of the world. However, a more parsimonious explanation is that visual perception of a moving target position is systematically biased by its velocity. The resultant extrapolated position could be compared with the cursor position and the difference canceled by negative feedback control, compensating sensorimotor delays. The current study tested whether a position extrapolation model fit human tracking of sinusoid (predictable) and pseudorandom (less predictable) targets better than the non-biased position control model, Twenty-eight participants tracked these targets and the two computational models were fit to the data at 60 fixed loop delay values (simulating sensorimotor delays). We observed that pseudorandom targets were tracked with a significantly greater phase delay than sinusoid targets. For sinusoid targets, the position extrapolation model simulated tracking results more accurately for loop delays longer than 120 ms, thereby confirming its ability to compensate for sensorimotor delays. However, for pseudorandom targets, this advantage arose only after 300 ms, indicating that velocity information is unlikely to be exploited in this way during the tracking of less predictable targets. We conclude that negative feedback control of position is a parsimonious model for tracking pseudorandom targets and that negative feedback control of extrapolated position is a parsimonious model for tracking sinusoidal targets.

A systematic evaluation of the evidence for perceptual control theory in tracking studies.

Perceptual control theory (PCT) proposes that perceptual inputs are controlled to intentional 'reference' states by hierarchical negative feedback control, evidence for which comes from manual tracking experiments in humans. We reviewed these experiments to determine whether tracking is a process of perceptual control, and to assess the state-of-the-evidence for PCT. A systematic literature search was conducted of peer-review journal and book chapters in which tracking data were simulated with a PCT model (13 studies, 53 participants). We report a narrative review of these studies and a qualitative assessment of their methodological quality. We found evidence that individuals track to individual-specific endogenously-specified reference states and act against disturbances, and evidence that hierarchical PCT can simulate complex tracking. PCT's learning algorithm, reorganization, was not modelled. Limitations exist in the range of tracking conditions under which the PCT model has been tested. Future PCT research should apply the PCT methodology to identify control variables in real-world tasks and develop hierarchical PCT architectures for goal-oriented robotics to test the plausibility of PCT model-based action control.

The self-reported needs of patients following subarachnoid hemorrhage (SAH).

Background: Despite advances in the acute care of subarachnoid haemorrhage, longer-term services remain under-developed. Clinical measures are commonly used to assess outcome and quality of life, but patient-reported needs and the extent to which they are met have not been measured. This information is essential to plan and develop evidence-based, patient-centred services. The aim of this study was to describe the frequency and type of self-reported met and unmet needs of subarachnoid haemorrhage survivors, explore whether these differ early and late in recovery and the factors associated with whether needs were met.Methods: A census cross-sectional postal survey of 400 subarachnoid haemorrhage survivors discharged from a large neurosurgical unit. The Self-Reported Needs after Stroke Questionnaire was modified and used to measure the self-reported needs of subarachnoid haemorrhage survivors and the extent to which they were met 1-2 years and 3-5 years post haemorrhage.Results: 203 (51%) participants responded: 122/260 (47%) from the early and 81/143 (57%) from the late cohort. 63% were female; mean age was 55 years. 86% of survivors reported one or more need, and 78% reported at least one unmet need (median 6, range 1-19). The most commonly reported need related to fatigue (66%). This and several other health needs were reported as unmet in over 80% of identified cases. We found no consistent factors that were associated with needs remaining unmet.Conclusion: Most subarachnoid haemorrhage survivors in both cohorts had unmet needs. Future research should aim to inform the development of post-discharge services to address the persistent long-term needs identified.Implications for rehabilitationSubarachnoid haemorrhage survivors report a number of needs 1-2 years and 3-5 years post haemorrhage.Needs relating to fatigue, memory, concentration, headache and anxiety were the most commonly reported.A large proportion of needs were described as unmet.The design of rehabilitation services for subarachnoid haemorrhage survivors should consider the self-reported needs described in this study.

Spatial Neglect in Stroke: Identification, Disease Process and Association with Outcome During Inpatient Rehabilitation.

We established spatial neglect prevalence, disease profile and amount of therapy that inpatient stroke survivors received, and outcomes at discharge using Sentinel Stroke National Audit Programme (SSNAP) data. We used data from 88,664 National Health Service (NHS) admissions in England, Wales and Northern Ireland (July 2013-July 2015), for stroke survivors still in hospital after 3 days with a completed baseline neglect National Institute for Health Stroke Scale (NIHSS) score. Thirty percent had neglect (NIHSS item 11 ≥ 1) and they were slightly older (78 years) than those without neglect (75 years). Neglect was observed more commonly in women (33 vs. 27%) and in individuals with a premorbid dependency (37 vs. 28%). Survivors of mild stroke were far less likely to present with neglect than those with severe stroke (4% vs. 84%). Those with neglect had a greatly increased length of stay (27 vs. 10 days). They received a comparable amount of average daily occupational and physiotherapy during their longer inpatient stay but on discharge a greater percentage of individuals with neglect were dependent on the modified Rankin scale (76 vs. 57%). Spatial neglect is common and associated with worse clinical outcomes. These results add to our understanding of neglect to inform clinical guidelines, service provision and priorities for future research.

How are balance and mobility problems after stroke treated in England? An observational study of the content, dose and context of physiotherapy.

OBJECTIVE: To describe the dose, intensity and context of physiotherapy for balance and mobility problems after stroke. DESIGN: Process mapping to describe the context and non-participant observation of therapy sessions to describe the dose and content of therapy. SETTING: Four inpatient stroke units in North-West England. PARTICIPANTS: Therapy staff and previously mobile stroke survivors who were treating, or receiving treatment for balance and mobility problems in the participating units. RESULTS: Two units were stand-alone rehabilitation units; two offered a service at the weekends. One had no access to community-based rehabilitation. All had dedicated treatment facilities but often did not use them because of lack of space and difficulty transporting patients. Twenty-two patients participated and 100 treatment sessions were observed. Practicing walking, sit-to-stand and transfers were the most frequent objectives and interventions usually with the therapist(s) physically facilitating the patient's movements. The dose of practise was low; mean repetitions of sit-to-stand per session was 5 (SD 6.4); mean time spent upright per session was 11.24 (SD = 7) minutes, and mean number of steps per session was 202 (SD 118). The mean number of staff per patient was 2.1 (SD = 0.6, mode = 2), usually involving two qualified therapists. Falls prevention or management, wheelchair skills and bed mobility were not practised. CONCLUSION: Stroke physiotherapy for balance and mobility problems features low-dose, low-intensity therapist-led practice, mainly of walking and sit-to-stand. Staff:patient ratios were high. Therapists need to organize treatment sessions to maximize the intensity of functional task practice.

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

OBJECTIVE: To identify why the National Clinical Guideline recommendation of 45 minutes of each appropriate therapy daily is not met in many English stroke units. DESIGN: Mixed-methods case-study evaluation, including modified process mapping, non-participant observations of service organisation and therapy delivery, documentary analysis and semi-structured interviews. SETTING: Eight stroke units in four English regions. SUBJECTS: Seventy-seven patients with stroke, 53 carers and 197 stroke unit staff were observed; 49 patients, 50 carers and 131 staff participants were interviewed. RESULTS: Over 1000 hours of non-participant observations and 433 patient-specific therapy observations were undertaken. The most significant factor influencing amount and frequency of therapy provided was the time therapists routinely spent, individually and collectively, in information exchange. Patient factors, including fatigue and tolerance influenced therapists' decisions about frequency and intensity, typically resulting in adaptation of therapy rather than no provision. Limited use of individual patient therapy timetables was evident. Therapist staffing levels were associated with differences in therapy provision but were not the main determinant of intensity and frequency. Few therapists demonstrated understanding of the evidence underpinning recommendations for increased therapy frequency and intensity. Units delivering more therapy had undertaken patient-focused reorganisation of therapists' working practices, enabling them to provide therapy consistent with guideline recommendations. CONCLUSION: Time spent in information exchange impacted on therapy provision in stroke units. Reorganisation of therapists' work improved alignment with guidelines.

Bespoke versus off-the-shelf ankle-foot orthosis for people with stroke: randomized controlled trial.

OBJECTIVE: The aim of the study was to compare the effect of two designs of ankle-foot orthosis on people with stroke. DESIGN: The study design was an assessor-blind, multicentre randomized controlled trial. SETTING: The setting was community stroke services. PARTICIPANTS: A total of 139 community-dwelling stroke survivors with limited mobility were recruited. INTERVENTIONS: The two most commonly used types of ankle-foot orthosis (bespoke and off-the-shelf) were chosen. MAIN MEASURES: The main measures of the study were as follows: short- (6 weeks) and long-term (12 weeks) effects on stroke survivors' satisfaction; adverse events; mobility (Walking Handicap Scale); fear of falling (Falls Efficacy Scale-International (FES-I)) and walking impairments (gait speed and step length using the 5-m walk test). RESULTS: Long-term satisfaction was non-significantly higher in the off-the-shelf group: 72% versus 64%; OR (95% CI) = 0.64 (0.31 to 1.3); P = 0.21. No statistically significant differences were found between the orthoses except that the off-the-shelf group had less fear of falling at short-term follow-up than the bespoke group: mean difference (95% CI) = -4.6 (-7.6 to -1.6) points on the FES-I; P = 0.003. CONCLUSION: No differences between off-the-shelf and bespoke ankle-foot orthoses were found except that participants in the off-the-shelf orthosis group had less fear of falling at short-term follow-up.

How active are patients in setting goals during rehabilitation after stroke? A qualitative study of clinician perceptions.

PURPOSE: We investigated stroke rehabilitation clinician's perceptions of the patient as an active partner in setting goals within stroke rehabilitation and factors that influence patient engagement. METHODS: Semi-structured interviews, subject to general inductive analysis with 20 Clinicians' working in three UK based stroke rehabilitation teams (one in-patient ward and two community based rehabilitation teams). RESULTS: There were three key themes that impacted on the patients active involvement in setting goals for rehabilitation after stroke: Patient barriers to goal setting (knowledge of the patient and family, who is the patient and the stroke's impact); How we work as a team (the role of the patient in setting goals, the effect of clinician attributes on goal setting); and How systems impact goal setting (goal-setting practice, home versus hospital, and professional/funder expectations of clinicians'). CONCLUSIONS: Goal setting served a range of different, sometimes conflicting, functions within rehabilitation. Clinicians' identified the integral nature of goals to engage and motivate patients and to provide direction and purpose for rehabilitation. Further, there was an identified need to consider the impact of prioritizing clinician-derived goals at the expense of patient-identified goals. Lastly the reliance on the SMART goal format requires further consideration, both in terms of the proposed benefits and whether they disempower the patient during rehabilitation. Implications for rehabilitation Goal setting is often promoted as a relatively simple, straightforward way to structure interactions with patients Patient-related factors together with resourcing constraints are significant barriers to patient-centered goal setting, particularly during inpatient rehabilitation Clinicians need to have pragmatic tools that can be integrated into practice to ensure that goal-setting practice can be maximized for patients with different intrinsic characteristics.

A scoping review of the needs of children and other family members after a child's traumatic injury.

OBJECTIVE: To review children's and their families' needs after a child's traumatic injury and assessment tools to measure needs. DATA SOURCES: Medline, Embase, CINAHL and PsycINFO databases (2005-September 2017) were searched and screened for papers (of any design) investigating children's and families' needs after a child's traumatic physical injury. REVIEW METHODS: Data regarding children's and families' needs were extracted by two independent raters. Methodological quality of the identified papers was not assessed. Thematic content analysis drew out the key needs. RESULTS: A total of 12 studies were identified, involving 932 participants including 105 injured adolescents and 827 family members or professionals. The needs of children under 12 years were identified indirectly from families or professionals. Most studies focussed on traumatic brain injuries. Two groups of needs were identified: person-related and service-related. Person-related needs were categorized into adolescent-specific needs, need for support with cognitive, emotional, social and physical problems and help with practical problems. Service-related needs were categorized into the need for information, educational needs and support during care transitions (specifically access to community-based services). These needs were largely unmet, particularly regarding information, emotional support and care transitions, which were compounded by professionals' limited understanding of the children's difficulties. We found no published measurement tools to assess children's and families' needs after a child's traumatic injury. CONCLUSION: The evidence about children's and families' needs following a child's traumatic injury was limited, but needs for information, emotional support and access to community-based services were consistently unmet.

A multicentre study of how goal-setting is practised during inpatient stroke rehabilitation.

OBJECTIVE: To describe goal-setting during inpatient stroke rehabilitation. DESIGN: There were two stages: an electronic questionnaire for multidisciplinary teams and an analysis of goal-setting documentation for rehabilitation patients. SETTING: Five inpatient stroke units. PARTICIPANTS: Staff involved in goal-setting and patients undergoing stroke rehabilitation. RESULTS: A total of 13 therapists and 49 patients were recruited, and 351 documented goals were examined. All units used therapist-led goal-setting (60% of goals were set by therapists). In total, 72% of goals were patient-focused but patients and families were rarely directly involved. Goals focussed on basic mobility and activities of daily living (~50% and ~25% of goals, respectively). Only 41% of documented goals met the SMART criteria. Review of progress was limited: 48% of goals were never reviewed and 24% of the remainder were merely marked as 'ongoing' without a date or plan for completion. New goals and actions were often documented without any connection to previous goals. Integration between goals and treatment/action plans was mixed. In two units, goals were unconnected to a treatment or action plan, but for the remainder it was 90%-100%. However, that connection was generally vague and amounted to suggestions of the type of treatment modality that staff might employ. CONCLUSION: Goal-setting during inpatient stroke rehabilitation is therapist-led but discussed with the multidisciplinary team. Therapists mainly identified patient-focussed mobility and activities of daily living goals. Monitoring progress and revising goals were often uncompleted. Links between goals and treatment, action plans and progress were patchy.

Perceptual control models of pursuit manual tracking demonstrate individual specificity and parameter consistency.

Computational models that simulate individuals' movements in pursuit-tracking tasks have been used to elucidate mechanisms of human motor control. Whilst there is evidence that individuals demonstrate idiosyncratic control-tracking strategies, it remains unclear whether models can be sensitive to these idiosyncrasies. Perceptual control theory (PCT) provides a unique model architecture with an internally set reference value parameter, and can be optimized to fit an individual's tracking behavior. The current study investigated whether PCT models could show temporal stability and individual specificity over time. Twenty adults completed three blocks of 15 1-min, pursuit-tracking trials. Two blocks (training and post-training) were completed in one session and the third was completed after 1 week (follow-up). The target moved in a one-dimensional, pseudorandom pattern. PCT models were optimized to the training data using a least-mean-squares algorithm, and validated with data from post-training and follow-up. We found significant inter-individual variability (partial η2: .464-.697) and intra-individual consistency (Cronbach's α: .880-.976) in parameter estimates. Polynomial regression revealed that all model parameters, including the reference value parameter, contribute to simulation accuracy. Participants' tracking performances were significantly more accurately simulated by models developed from their own tracking data than by models developed from other participants' data. We conclude that PCT models can be optimized to simulate the performance of an individual and that the test-retest reliability of individual models is a necessary criterion for evaluating computational models of human performance.

Mechanisms of action of an implementation intervention in stroke rehabilitation: a qualitative interview study.

BACKGROUND: Despite best evidence demonstrating the effectiveness of increased intensity of exercise after stroke, current levels of therapy continue to be below those required to optimise motor recovery. We developed and tested an implementation intervention that aims to increase arm exercise in stroke rehabilitation. The aim of this study was to illustrate the use of a behaviour change framework, the Behaviour Change Wheel, to identify the mechanisms of action that explain how the intervention produced change. METHODS: We implemented the intervention at three stroke rehabilitation units in the United Kingdom. A purposive sample of therapy team members were recruited to participate in semi-structured interviews to explore their perceptions of how the intervention produced change at their work place. Audio recordings were transcribed and imported into NVivo 10 for content analysis. Two coders separately analysed the transcripts and coded emergent mechanisms. Mechanisms were categorised using the Theoretical Domains Framework (TDF) (an extension of the Capability, Opportunity, Motivation and Behaviour model (COM-B) at the hub of the Behaviour Change Wheel). RESULTS: We identified five main mechanisms of action: 'social/professional role and identity', 'intentions', 'reinforcement', 'behavioural regulation' and 'beliefs about consequences'. At the outset, participants viewed the research team as an external influence for whom they endeavoured to complete the study activities. The study design, with a focus on implementation in real world settings, influenced participants' intentions to implement the intervention components. Monthly meetings between the research and therapy teams were central to the intervention and acted as prompt or reminder to sustain implementation. The phased approach to introducing and implementing intervention components influenced participants' beliefs about the feasibility of implementation. CONCLUSIONS: The Behaviour Change Wheel, and in particular the Theoretical Domains Framework, were used to investigate mechanisms of action of an implementation intervention. This approach allowed for consideration of a range of possible mechanisms, and allowed us to categorise these mechanisms using an established behaviour change framework. Identification of the mechanisms of action, following testing of the intervention in a number of settings, has resulted in a refined and more robust intervention programme theory for future testing.

What are the barriers and facilitators to goal-setting during rehabilitation for stroke and other acquired brain injuries? A systematic review and meta-synthesis.

OBJECTIVE: To identify the barriers and facilitators to goal-setting during rehabilitation for stroke and other acquired brain injuries. DATA SOURCES: AMED, Proquest, CINAHL and MEDLINE. REVIEW METHODS: Two reviewers independently screened, extracted data and assessed study quality using the Mixed Methods Appraisal Tool and undertook thematic content analysis for papers examining the barriers and facilitators to goal-setting during stroke/neurological rehabilitation (any design). Last searches were completed in May 2016. RESULTS: Nine qualitative papers were selected, involving 202 participants in total: 88 patients, 89 health care professionals and 25 relatives of participating patients. Main barriers were: Differences in staff and patients perspectives of goal-setting; patient-related barriers; staff-related barriers, and organisational level barriers. Main facilitators were: individually tailored goal-setting processes, strategies to promote communication and understanding, and strategies to avoid disappointment and unrealistic goals. In addition, patients' and staff's knowledge, experience, skill, and engagement with goal-setting could be either a barrier (if these aspects were absent) or a facilitator (if they were present). CONCLUSION: The main barriers and facilitators to goal-setting during stroke rehabilitation have been identified. They suggest that current methods of goal-setting during inpatient/early stage stroke or neurological rehabilitation are not fit for purpose.

The effectiveness of an exercise programme on dynamic balance in patients with medial knee osteoarthritis: A pilot study.

BACKGROUND: Dynamic balance and quiet standing balance are decreased in knee osteoarthritis (OA), with dynamic balance being more affected. This study aimed to investigate the effectiveness of a group exercise programme of lower extremity muscles integrated with education on dynamic balance using the Star Excursion Balance test (SEBT) in knee OA. METHODS: Experimental before-and-after pilot study design. Nineteen participants with knee OA attended the exercise sessions once a week for six weeks, in addition to home exercises. Before and after the exercise programme, dynamic balance was assessed using the SEBT in the anterior and medial directions in addition to hip and knee muscle strength, pain, and function. RESULTS: Fourteen participants completed the study. Dynamic balance on the affected side demonstrated significant improvements in the anterior and medial directions (p=0.02 and p=0.01, respectively). The contralateral side demonstrated significant improvements in dynamic balance in the anterior direction (p<0.001). However, balance in the medial direction did not change significantly (p=0.07). Hip and knee muscle strength, pain, and function significantly improved (p<0.05) after the exercise programme. CONCLUSIONS: This is the first study to explore the effect of an exercise programme on dynamic balance using the SEBT in knee OA. The exercise programme was effective in improving dynamic balance which is required in different activities of daily living where the patients might experience the risk of falling. This might be attributed to the improvement in muscle strength and pain after the exercise programme.

Case Series of a Knowledge Translation Intervention to Increase Upper Limb Exercise in Stroke Rehabilitation.

BACKGROUND AND PURPOSE: Current approaches to upper limb rehabilitation are not sufficient to drive neural reorganization and maximize recovery after stroke. To address this evidence-practice gap, a knowledge translation intervention using the Behaviour Change Wheel was developed. The intervention involves collaboratively working with stroke therapy teams to change their practice and increase therapy intensity by therapists prescribing supplementary self-directed arm exercise. The purposes of this case series are: (1) to provide an illustrative example of how a research-informed process changed clinical practice and (2) to report on staff members' and patients' perceptions of the utility of the developed intervention. CASE DESCRIPTIONS: A participatory action research approach was used in 3 stroke rehabilitation units in the United Kingdom. The intervention aimed to change 4 therapist-level behaviors: (1) screening patients for suitability for supplementary self-directed arm exercise, (2) provision of exercises, (3) involving family and caregivers in assisting with exercises, and (4) monitoring and progressing exercises. Data on changes in practice were collected by therapy teams using a bespoke audit tool. Utility of the intervention was explored in qualitative interviews with patients and staff. OUTCOMES: Components of the intervention were successfully embedded in 2 of the 3 stroke units. At these sites, almost all admitted patients were screened for suitability for supplementary self-directed exercise. Exercises were provided to 77%, 70%, and 88% of suitable patients across the 3 sites. Involving family and caregivers and monitoring and progressing exercises were not performed consistently. CONCLUSIONS: This case series is an example of how a rigorous research-informed knowledge translation process resulted in practice change. Research is needed to demonstrate that these changes can translate into increased intensity of upper limb exercise and affect patient outcomes.

The effectiveness of an exercise programme on knee loading, muscle co-contraction, and pain in patients with medial knee osteoarthritis: A pilot study.

BACKGROUND: Osteoarthritis (OA), which increases knee loading, muscle co-contraction, and pain, is a mechanical disease that requires biomechanical exploration to reduce pain in the knee. Therefore, this article aims to investigate the effectiveness of an exercise programme on the aforementioned outcomes in people with medial knee OA. METHODS: Cohort pilot study design. A total of 19 patients with knee OA attended a six-week group exercise programme integrated with self-management education. The following outcomes were assessed before and after the exercise programme: external knee adduction moment (EKAM), knee adduction angular impulse (KAAI), knee antagonist muscle co-contraction, and pain subscale of the knee injury and osteoarthritis outcome score (KOOS). RESULTS: Of the 19 patients, 14 completed the study. The EKAM and KAAI did not show statistical significance post-exercise intervention (p=0.21-0.7 and 0.56, respectively). Muscle co-contraction between vastus lateralis and biceps femoris muscles decreased in early-stance (64.78 (44.35) compared with 38.10 (23.10), p=0.01) and mid-stance (27.62 (32.12) compared with 14.94 (17.40), p=0.04). A corresponding significant pain reduction was observed (p=0.00) with a median (range) of 51.50 (47.00 to 62.50) at week 6 compared with 34.50 (29.25 to 41.25) at baseline. CONCLUSION: This is the first known study to explore the effect of an exercise programme on knee loading and muscle co-contraction in patients with OA. Although the value of EKAM did not change, the findings suggest that the reduction in vastus lateralis and biceps femoris co-contraction might be the mechanism behind the reduction of pain.