Engineering of a Malonyl-CoA Ligase for Production of Fluorinated Polyketide Extender Units.

Enzymatic platforms for producing malonyl-CoA-based extender units required for polyketide biosynthesis are often based on malonyl-CoA ligases such as MatB from Rhizobium trifolii and Rhodopseudomonas palustris. However, despite broad interest in the fluorination of polyketides and prior success with engineering MatB homologs, the suitability of MatB for accessing the tertiary substituted fluoromethylmalonyl-CoA needed to produce flurithromycin and solithromycin has not yet been reported. Herein, we report the structure-guided engineering of a MatB homolog to optimize the production of fluoromethylmalonyl-CoA, resulting in a variant with increased conversion and providing a platform to produce a suitable building block mixture for fluorinated macrolide production. Additionally, the mutant demonstrated broad utility for various substituted malonyl-CoAs. The MatB mutant sets the stage to access fluorinated macrolides by coupling it with altered PKS machinery to install fluorinated malonyl-CoA into macrolide scaffolds.

Considerations for developing complex post-stroke upper limb behavioural interventions: An international qualitative study.

OBJECTIVE: To simultaneously explore the perspectives and opinions of different invested participant groups on the important considerations for development of upper limb behavioural interventions that drive optimal post-stroke upper limb motor recovery. DESIGN: A qualitative descriptive study in a constructivist epistemology. PARTICIPANTS: Purposively selected participant groups (preclinical research n = 9, clinical research n = 9, clinical experience n = 9 and lived experience n = 10). SETTING: Research participants were selected from top internationally published authors. Experiential participants were recruited internationally, through networks. RESULTS: Four themes were identified with embedded subthemes. Theme 1: 'Clinical relevance should be the core of a "good" research question' with two subthemes: 'Breaking down silos: forging interdisciplinary research teams', and 'Beyond the pipeline: bench to bedside and back'; theme 2: 'Balance restitution and compensation to maximise outcomes' with three subthemes: 'Good outcome: going beyond an outcome measure', 'Recovery is a puzzle: measure all the pieces', and 'Optimising capacity: knowing when and how'; theme 3: 'Stroke demands personalised solutions' with two subthemes: 'Condition-specific considerations', and 'Person-specific considerations'; theme 4: 'Upper limb recovery requires complex interventions' with four subthemes: 'Fuelling engagement', 'Content is crucial', 'Multidimensional dose', and 'Therapist sway'. CONCLUSIONS: This study suggests that post-stroke upper limb motor interventions are the interactions of multiple intervention elements (e.g. dose and content) shaped by different contextual considerations (e.g. stroke and personal factors). Development of such interventions may need to consider both content and context of the intervention to drive optimal recovery.

To what extent are guidelines used in spasticity clinics? A qualitative study of facilitators and barriers to spasticity guideline implementation.

OBJECTIVE: To determine the common understanding of focal muscle spasticity guidelines amongst clinicians working in spasticity clinics. To examine the facilitators and barriers to their implementation as well as their influence on clinic processes. DESIGN: A qualitative study based on a phenomenological approach. SETTING: Online videoconferencing platform. PARTICIPANTS: Sixteen experienced multi-disciplinary clinicians providing specialised care across 12 spasticity clinics in Victoria, Australia. INTERVENTION: Observational. MAIN MEASURES: Two independent reviewers performed line by line coding of transcripts. Reflexive thematic analysis was undertaken with themes/subthemes inductively derived. RESULTS: Seven key themes emerged. First, knowledge of specific guideline recommendations was low amongst some clinicians. Second, there is a lack of health service resources to support guideline implementation. Third, a limited evidence base for guidelines affected clinicians' willingness to implement the recommendations. Fourth, peer support was highly valued but opportunities to collaborate were limited. Fifth, a large amount of intrinsic motivation and personal time was required from clinicians to successfully implement guideline recommendations. Sixth, the standardisation of clinic processes was one way in which clinicians felt they could better align their clinical practice to guidelines. Lastly, guidelines overall had a moderate influence on spasticity clinic processes. CONCLUSIONS: Knowledge of recommendations varied but, overall, guidelines had an influence on clinic processes and staff perceptions across the state-wide services. Health service resources, limited evidence for guideline recommendations and time constraints were considered barriers to spasticity guideline implementation. Multi-disciplinary expertise and teamwork, the individual's motivation to change and inter-clinic collaboration were considered to be the facilitators.

Cardiorespiratory fitness assessment and training in the early sub-acute phase of recovery following traumatic brain injury: a systematic review.

OBJECTIVES: To examine the safety of cardiorespiratory fitness (CRF) assessment and training in the early sub-acute phase of recovery (≤3 months) following moderate-to-extremely severe traumatic brain injury (TBI). METHODS: A systematic review was completed in accordance with the PRISMA guidelines. Studies investigating adults and adolescents ≥15 years with moderate-to-extremely severe TBI were considered for inclusion. The methodological quality of the included studies was evaluated according to the McMaster Guidelines for Critical Review Form - Quantitative Studies. RESULTS: Eleven studies with a total of 380 participants were included in the review. Adverse events (AEs) and symptom monitoring were poorly reported. Only four studies reported on the occurrence of AEs, with a total of eight AEs reported. Three of the reported AEs were concussion-like symptoms with no further exercise-induced symptom exacerbation reported. No serious AEs were reported. CONCLUSION: There is no evidence to suggest that CRF assessment and training is unsafe in the early sub-acute phase of recovery following moderate-to-extremely severe TBI. However, despite the low AE and symptom exacerbation rates identified, a timeframe for safe commencement was unable to be established due to poor reporting and/or monitoring of exercise-induced symptoms and AEs in the current literature.

Machine learning for automating subjective clinical assessment of gait impairment in people with acquired brain injury - a comparison of an image extraction and classification system to expert scoring.

BACKGROUND: Walking impairment is a common disability post acquired brain injury (ABI), with visually evident arm movement abnormality identified as negatively impacting a multitude of psychological factors. The International Classification of Functioning, Disability and Health (ICF) qualifiers scale has been used to subjectively assess arm movement abnormality, showing strong intra-rater and test-retest reliability, however, only moderate inter-rater reliability. This impacts clinical utility, limiting its use as a measurement tool. To both automate the analysis and overcome these errors, the primary aim of this study was to evaluate the ability of a novel two-level machine learning model to assess arm movement abnormality during walking in people with ABI. METHODS: Frontal plane gait videos were used to train four networks with 50%, 75%, 90%, and 100% of participants (ABI: n = 42, healthy controls: n = 34) to automatically identify anatomical landmarks using DeepLabCut™ and calculate two-dimensional kinematic joint angles. Assessment scores from three experienced neurorehabilitation clinicians were used with these joint angles to train random forest networks with nested cross-validation to predict assessor scores for all videos. Agreement between unseen participant (i.e. test group participants that were not used to train the model) predictions and each individual assessor's scores were compared using quadratic weighted kappa. One sample t-tests (to determine over/underprediction against clinician ratings) and one-way ANOVA (to determine differences between networks) were applied to the four networks. RESULTS: The machine learning predictions have similar agreement to experienced human assessors, with no statistically significant (p < 0.05) difference for any match contingency. There was no statistically significant difference between the predictions from the four networks (F = 0.119; p = 0.949). The four networks did however under-predict scores with small effect sizes (p range = 0.007 to 0.040; Cohen's d range = 0.156 to 0.217). CONCLUSIONS: This study demonstrated that machine learning can perform similarly to experienced clinicians when subjectively assessing arm movement abnormality in people with ABI. The relatively small sample size may have resulted in under-prediction of some scores, albeit with small effect sizes. Studies with larger sample sizes that objectively and automatically assess dynamic movement in both local and telerehabilitation assessments, for example using smartphones and edge-based machine learning, to reduce measurement error and healthcare access inequality are needed.

Is early initiated cardiorespiratory fitness training within a model of stroke-integrated cardiac rehabilitation safe and feasible?

OBJECTIVE: To investigate the safety and feasibility of an early initiated stroke-integrated Cardiac Rehabilitation program. METHODS: People with acute first or recurrent ischaemic stroke, admitted to Epworth HealthCare were screened for eligibility and invited to participate. In addition to usual care neurorehabilitation, participants performed 1) cardiorespiratory fitness training 3-days/week during inpatient rehabilitation (Phase 1), and/or 2) 2-days/week centre-based cardiorespiratory fitness training plus education and 1-day/week home-based cardiorespiratory fitness training for 6-weeks during outpatient rehabilitation (Phase 2). Safety was determined by the number of adverse and serious adverse events. Feasibility was determined by participant recruitment, retention, and attendance rates, adherence to exercise recommendations, and participant satisfaction. RESULTS: There were no study-related adverse or serious adverse events. Of 117 eligible stroke admissions, 62 (53%) were recruited, while 10 (16.1%) participants withdrew. Participants attended 189 of 201 (94%) scheduled cardiorespiratory fitness training sessions in Phase 1 and 341/381 (89.5%) scheduled sessions in Phase 2. Only 220/381 (58%) scheduled education sessions were attended. The minimum recommended cardiorespiratory fitness training intensity (40% heart rate reserve) and duration (20 minutes) was achieved by 57% and 55% of participants respectively during Phase 1, and 60% and 92% respectively during Phase 2. All respondents strongly agreed (69%) or agreed (31%) they would recommend the stroke-integrated Cardiac Rehabilitation program to other people with stroke. CONCLUSION: Cardiorespiratory fitness training in line with multiple clinical practice guidelines included within a model of stroke-integrated Cardiac Rehabilitation appears to be safe and feasible in the early subacute phase post-stroke.

Current State-of-the-Art Toward Chemoenzymatic Synthesis of Polyketide Natural Products.

Polyketide natural products have significant promise as pharmaceutical targets for human health and as molecular tools to probe disease and complex biological systems. While the biosynthetic logic of polyketide synthases (PKS) is well-understood, biosynthesis of designer polyketides remains challenging due to several bottlenecks, including substrate specificity constraints, disrupted protein-protein interactions, and protein solubility and folding issues. Focusing on substrate specificity, PKSs are typically interrogated using synthetic thioesters. PKS assembly lines and their products offer a wealth of information when studied in a chemoenzymatic fashion. This review provides an overview of the past two decades of polyketide chemoenzymatic synthesis and their contributions to the field of chemical biology. These synthetic strategies have successfully yielded natural product derivatives while providing critical insights into enzymatic promiscuity and mechanistic activity.

Extra terrestrials: drought creates niche space for rare invertebrates in a large-scale and long-term field experiment.

Freshwater habitats are drying more frequently and for longer under the combined pressures of climate change and overabstraction. Unsurprisingly, many aquatic species decline or become locally extinct as their benthic habitat is lost during stream droughts, but less is known about the potential 'winners': those terrestrial species that may exploit emerging niches in drying riverbeds. In particular, we do not know how these transient ecotones will respond as droughts become more extreme in the future. To find out we used a large-scale, long-term mesocosm experiment spanning a wide gradient of drought intensity, from permanent flows to full streambed dewatering, and analysed terrestrial invertebrate community assembly after 1 year. Droughts that caused stream fragmentation gave rise to the most diverse terrestrial invertebrate assemblages, including 10 species with UK conservation designations, and high species turnover between experimental channels. Droughts that caused streambed dewatering produced lower terrestrial invertebrate richness, suggesting that the persistence of instream pools may benefit these taxa as well as aquatic biota. Particularly intense droughts may therefore yield relatively few 'winners' among either aquatic or terrestrial species, indicating that the threat to riverine biodiversity from future drought intensification could be more pervasive than widely acknowledged.

The effect of physical activity on health outcomes in people with moderate-to-severe traumatic brain injury: a rapid systematic review with meta-analysis.

BACKGROUND: In 2020, the World Health Organization (WHO) released the first global physical activity and sedentary behaviour guidelines for children and adults living with disability. The evidence informing the guidelines though is not specific to people living with traumatic brain injury (TBI), but rather comes from other disabling conditions such as Parkinson's disease, and stroke. There remains a clear lack of direct evidence of the effects of physical activity for people living with TBI. The objective of this rapid review was to identify direct evidence of the effect of physical activity on health outcomes in people with moderate-to-severe TBI to inform adaptation of the WHO physical activity guidelines into clinical practice guidelines. METHODS: We conducted a rapid systematic review with meta-analysis of randomised controlled trials, including people of any age with moderate-to-severe TBI, investigating physical activity interventions compared to either usual care, a physical activity intervention with different parameters, or a non-physical activity intervention. Four databases (CENTRAL, SPORTDiscus, PEDro, Ovid MEDLINE) were searched from inception to October 8, 2021. The primary outcomes were physical function, cognition, and quality of life. RESULTS: Twenty-three studies were included incorporating 812 participants (36% females, majority working-age adults, time post-TBI in studies ranged from 56 days (median) to 16.6 years (mean)). A range of physical activity interventions were evaluated in rehabilitation (n = 12 studies), community (n = 8) and home (n = 3) settings. We pooled data from the end of the intervention for eight outcomes. Participation in a virtual reality physical activity intervention improved mobility, assessed by the Community Balance and Mobility Scale (range 0 to 96; higher score indicates better mobility) more than standard balance training (two studies, 80 participants, Mean Difference = 2.78, 95% CI 1.40 to 4.16; low certainty evidence). There was uncertainty of effect for the remaining outcomes, limited by small sample sizes, diverse comparators and a wide range of outcome measures. CONCLUSION: This review consolidates the current evidence base for the prescription of physical activity for people with moderate-to-severe TBI. There remains a pressing need for further rigorous research in order to develop practice guidelines to support clinical decision-making when prescribing physical activity in this population.

Controlling modified Tardieu scale assessment speeds to match joint angular velocities during walking impacts spasticity assessment outcomes.

OBJECTIVE: To investigate whether tailoring the speed of the Modified Tardieu Scale to reflect an individual's joint angular velocity during walking influences spasticity assessment outcomes. DESIGN: Observational trial. SETTING: Inpatient and outpatient neurological hospital department. SUBJECTS: Ninety adults with lower-limb spasticity. INTERVENTIONS: N/A. MAIN MEASURES: The Modified Tardieu Scale was used to assess the gastrocnemius, soleus, hamstrings and quadriceps. The V1 (slow) and V3 (fast) movements were completed as per standardised testing. Two additional assessments were completed, reflecting joint angular velocities during walking based on (i) a healthy control database (controlled velocity) and (ii) the individual's real-time joint angular velocities during walking (matched velocity). The agreement was compared using Cohen's and Weighted Kappa statistics, sensitivity and specificity. RESULTS: There was poor agreement when rating trials as spastic or not spastic at the ankle joint (Cohen's Kappa = 0.01-0.17). Trials were classified as spastic during V3 and not spastic during the controlled conditions in 81.6-85.1% of trials when compared to stance phase dorsiflexion angular velocities and 48.0-56.4% when compared to swing phase dorsiflexion angular velocities. The severity of muscle reaction demonstrated poor agreement at the ankle (Weighted Kappa = 0.01-0.28). At the knee, there was a moderate-excellent agreement between the V3 and controlled conditions when rating a trial as spastic or not spastic (Cohen's Kappa = 0.66-0.84) and excellent agreement when comparing severity (Weighted Kappa = 0.73-0.94). CONCLUSION: The speed of assessment impacted spasticity outcomes. It is possible that the standardised protocol may overestimate the impact spasticity has on walking, especially at the ankle.

Functional Gait Disorders: Clinical presentations, Phenotypes and Implications for treatment.

BACKGROUND: Functional Gait Disorders (FGD) are a common presentation of motor-Functional Neurological Disorders (motor-FND) that affect walking ability. AIM: To provide a narrative review of the current literature on FGD. METHODS: A narrative overview of published literature was undertaken, based on a systematic search of relevant databases, authoritative texts and citation tracking. RESULTS: FGD is multidimensional and disabling, with numerous phenotypes described in the literature, including 'knee buckling,' 'astasia-abasia' and 'excessive slowness.' Motor symptoms such as weakness or tremor, and non-motor symptoms, such as pain and fatigue may contribute to the disability and distress in FGD. Phenotypic features and clinical signs are seen in FGD that demonstrate inconsistency and incongruity with structural disease. A limited number of treatment studies have specifically focussed on FGD, however, reporting of outcomes from motor-FND cohorts has demonstrated short and long-term improvements in walking ability through multidisciplinary rehabilitation. CONCLUSIONS: The relative contribution of motor and non-motor symptoms in FGD remains unknown, but it is likely that non-motor symptoms increase the illness burden and should be considered during assessment and treatment. Recommended treatment for FGD involves multidisciplinary rehabilitation, but optimum treatment elements are yet to be determined.

Association of Lower Limb Focal Spasticity With Kinematic Variables During Walking in Traumatic Brain Injury.

BACKGROUND AND PURPOSE: Focal muscle spasticity is defined as spasticity that affects a localized group of muscles. It is prevalent in many adult-onset neurological conditions, yet the relationship of focal muscle spasticity with walking remains unclear. Therefore, the aim of this study was to determine the relationship of focal muscle spasticity with the kinematics of walking in traumatic brain injury (TBI). METHODS: Ninety-one participants with TBI underwent clinical gait analysis and assessment of focal lower limb muscle spasticity in a prospective cross-sectional study. A matched group of 25 healthy controls (HCs) were recruited to establish a reference dataset. Kinematic data for each person with and without focal muscle spasticity following TBI were compared with the HC cohort at a matched walking speed. RESULTS: The TBI and HC cohorts were well matched. Only those with focal hamstring muscle spasticity walked significantly different to those without. They had significantly greater knee flexion (23.4° compared with 10.5°, P < 0.01) at initial contact. There were no other significant differences in kinematic variables between those with and without focal muscle spasticity. There was no significant association between focal muscle spasticity and walking speed. DISCUSSION AND CONCLUSIONS: Focal muscle spasticity and abnormal kinematics whilst walking were common in this cohort of people with TBI. However, focal muscle spasticity had little relationship with kinematic variables, and no significant relationship with walking speed. This finding has implications for the treatment of focal muscle spasticity to improve walking following TBI. Focal muscle spasticity had little relationship with kinematic variables and walking speed in this cohort of people with TBI who could walk without assistance.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A381).

Factors Associated With Physical Therapy Engagement During the Period of Posttraumatic Amnesia.

BACKGROUND AND PURPOSE: Physical therapy is important in the management of traumatic brain injury (TBI) and associated multitrauma. Providing therapy during the posttraumatic amnesia (PTA) phase is challenging, given that hallmark features including confusion, amnesia, agitation, and fatigue may impede the person's ability to engage in and benefit from rehabilitation. To date, there is little empirical evidence to guide the provision of therapy during PTA. This observational study aimed to explore the frequency, duration, location, and engagement of physical therapy provision during PTA and the impact of cognition, agitation, and fatigue. SUMMARY OF KEY POINTS: The majority of patients were found to meaningfully engage and participate in physical therapy for the majority of sessions. Only a small proportion were unable to participate in physical therapy. Patient refusal and fatigue were identified as the most prominent barriers to rehabilitation. Despite fatigue and agitation reaching clinical levels, therapy could still successfully proceed on most occasions. RECOMMENDATIONS FOR CLINICAL PRACTICE: Physical therapy is feasible during the acute recovery stages after TBI. Current results support the notion that therapy should commence early to minimize secondary complications and promote the recovery of mobility. A patient-centered therapeutic model that tailors the therapeutic approach to meet the individual's current physical and fluctuating cognitive capabilities may be most suited for this population. Clinicians working with people after TBI need experience in understanding and managing the cognitive limitations and associated symptoms of PTA to optimize the provision of therapy. These findings could inform guidelines for the management of patients in PTA.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A368).

Maintenance of Cardiorespiratory Fitness in People With Stroke: A Systematic Review and Meta-analysis.

OBJECTIVE: To determine if improvements in cardiorespiratory fitness are maintained in the short-, medium- and long-term after a cardiorespiratory fitness intervention in people with stroke. DATA SOURCES: MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, (CENTRAL) Cochrane, Web of Science, Sports Discus, and Physiotherapy Evidence Database were searched from inception. STUDY SELECTION: Randomized controlled trials and cohort studies including (1) people with stroke; (2) cardiorespiratory fitness interventions; (3) a direct measure of cardiorespiratory fitness; and (4) short- (0 to <3 months), medium- (3-6 months), or long-term (>6 months) follow-up data. DATA EXTRACTION: Two reviewers independently screened full texts and extracted data, including study methods, participant demographic information, stroke type and severity, outcome measures, intervention information, follow-up time points, and results, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A lower limit of -1.0 mL•kg-1•min-1 was used to determine maintenance (ie, no change) of cardiorespiratory fitness. DATA SYNTHESIS: Fourteen studies (N=324 participants) were included. Participants completed cardiorespiratory fitness training 2-5 days per week over 4-13 weeks at moderate to high intensity (40%-70% heart rate reserve [HRR]; n=4 studies), high intensity (60% to <90% HRR; n=7 studies), and intervals of high intensity (85%-95% peak heart rate or maximal heart rate; n=3 studies). Most people with stroke did maintain cardiorespiratory fitness in the short- (-0.19 mL•kg-1•min-1 [95% CI, -1.66 to 1.28]), medium- (-0.61 mL•kg-1•min-1 [95% CI, -3.95 to 2.74]), and long-term (0.00 mL•kg-1•min-1 [95% CI, -2.23 to 2.23]) after completion of cardiorespiratory fitness interventions. CONCLUSIONS: People with stroke maintain cardiorespiratory fitness after a cardiorespiratory fitness intervention in the short-, medium-, and longer-term. However, little is known about the impact of participant and intervention characteristics on the long-term maintenance of cardiorespiratory fitness.

Ankle Power Generation Has a Greater Influence on Walking Speed Reserve Than Balance Following Traumatic Brain Injury.

OBJECTIVE: Reduced walking speed is common following traumatic brain injury (TBI). Walking speed reserve (WSR) refers to the ability to increase walking speed on demand and is calculated as the difference between self-selected and fast walking speeds. Walking speed reserve is important for adaptive functional mobility in the community. Predictors of WSR following TBI are yet to be determined. The aim of the study was to identify whether static balance or ankle power generation (APG) was a stronger predictor of WSR following TBI. SETTING: A major metropolitan rehabilitation hospital. PARTICIPANTS: A total of 92 individuals receiving inpatient physiotherapy for mobility limitations following TBI were recruited. DESIGN: A cross-sectional study. METHODS: Walking speed (self-selected and fast), APG, and a summed single-leg stance scores were measured. The ability to increase walking speed on demand by 0.20 m/s or more defined WSR. Correlations, logistic regression, and receiver operating characteristic (ROC) curve analyses were performed to investigate independent relationships between WSR, APG, and static balance. RESULTS: Fifty participants (54.3%) had a WSR of 0.20 m/s or more. The strongest predictor of WSR was APG (odds ratio [OR] = 3.34; 95% CI, 1.50-7.43) when compared with static balance (OR = 1.03; 95% CI, 1.01-1.06). The ROC curve demonstrated that APG could accurately discriminate between individuals with a WSR from those without (AUC [area under the ROC curve] = 0.79; 95% CI, 0.70-0.88). The APG cutoff score identified on the curve that maximized combined sensitivity (92.0%) and specificity (54.8%) was 0.75 W/kg. CONCLUSION: Following TBI, APG was a stronger predictor of WSR than static balance. Clinicians should consider interventions that preferentially target APG in order to increase WSR for community mobility.

Inertia Sensors for Measuring Spasticity of the Ankle Plantarflexors Using the Modified Tardieu Scale-A Proof of Concept Study.

Ankle spasticity is clinically assessed using goniometry to measure the angle of muscle reaction during the Modified Tardieu Scale (MTS). The precision of the goniometric method is questionable as the measured angle may not represent when the spastic muscle reaction occurred. This work proposes a method to accurately determine the angle of muscle reaction during the MTS assessment by measuring the maximum angular velocity and the corresponding ankle joint angle, using two affordable inertial sensors. Initially we identified the association between muscle onset and peak joint angular velocity using surface electromyography and an inertial sensor. The maximum foot angular velocity occurred 0.049 and 0.032 s following the spastic muscle reaction for Gastrocnemius and Soleus, respectively. Next, we explored the use of two affordable inertial sensors to identify the angle of muscle reaction using the peak ankle angular velocity. The angle of muscle reaction and the maximum dorsiflexion angle were significantly different for both Gastrocnemius and Soleus MTS tests (p = 0.028 and p = 0.009, respectively), indicating that the system is able to accurately detect a spastic muscle response before the end of the movement. This work successfully demonstrates how wearable technology can be used in a clinical setting to identify the onset of muscle spasticity and proposes a more accurate method that clinicians can use to measure the angle of muscle reaction during the MTS assessment. Furthermore, the proposed method may provide an opportunity to monitor the degree of spasticity where the direct help of experienced therapists is inaccessible, e.g., in rural or remote areas.

Effects of 12-Week Supervised Early Resistance Training (SEcReT) Versus Aerobic-Based Rehabilitation on Cognitive Recovery Following Cardiac Surgery via Median Sternotomy: A Pilot Randomised Controlled Trial.

AIMS: To investigate the effects of a 12-week early moderate-intensity resistance training program compared to aerobic-based rehabilitation on postoperative cognitive recovery following cardiac surgery via median sternotomy. METHODS: This was a multicentre, prospective, pragmatic, non-blinded, pilot randomised controlled trial (1:1 randomisation) of two parallel groups that compared a 12-week early moderate-intensity resistance training group to a control group, receiving aerobic-based rehabilitation. English-speaking adults (≥18 years) undergoing elective cardiac surgery via median sternotomy were randomised using sealed envelopes, with allocation revealed before surgery. The primary outcome was cognitive function, assessed using the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog), at baseline, 14 weeks and 6 months postoperatively. RESULTS: The ADAS-cog score at 14 weeks was significantly better for the resistance training group (n=14, 7.2±1.4; 95% CI 4.3, 10.2, vs n=17, 9.2±1.3; 95% CI 6.6, 11.9, p=0.010). At 14 weeks postoperatively, 53% of the aerobic-based rehabilitation group (n=9/17) experienced cognitive decline by two points or more from baseline ADAS-cog score, compared to 0% of the resistance training group (n=0/14; p=0.001). CONCLUSION: Early resistance training appears to be safe and may improve cognitive recovery compared to standard, aerobic-based rehabilitation following cardiac surgery via median sternotomy, however as this was a pilot study, the sample size was small and further research is needed to determine a causal relationship.

Factors Affecting Participation in Physical Therapy During Posttraumatic Amnesia.

OBJECTIVES: To examine the effect of agitation, cognitive impairment, fatigue, and pain on physical therapy participation and outcomes during posttraumatic amnesia (PTA) after traumatic brain injury (TBI). DESIGN: Prospective longitudinal study. SETTING: Inpatient rehabilitation hospital. PARTICIPANTS: Participants (N=77) with moderate-to-severe TBI who were deemed to be experiencing PTA using the Westmead Post-Traumatic Amnesia Scale. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Pittsburgh Rehabilitation Participation Scale and time in therapy (min) were recorded twice daily after routine physical therapy sessions during PTA. The FIM-motor (select items related to physical therapy) score rated on admission and after emergence from PTA was used to calculate FIM-motor change. RESULTS: Agitation was associated with lower participation in therapy. The presence of agitation and pain both predicted lower FIM-motor change at emergence from PTA. Higher levels of cognitive impairment and fatigue were also associated with lower participation and less time in therapy. CONCLUSIONS: The presence of agitation, fatigue, pain, and cognitive impairment impede rehabilitation success during PTA. This study strengthens the case for implementing environmental and behavioral recommendations, such as conducting therapy earlier in the day within a familiar space (ie, on the ward) and tailoring session duration to patient needs. This is with the aim of minimizing fatigue, agitation, and pain, while promoting cognitive recovery and arousal during PTA to maximize physical gains. Further research is warranted to examine the factors associated with rehabilitation success across other therapeutic disciplines.

Ballistic Resistance Training: Feasibility, Safety, and Effectiveness for Improving Mobility in Adults With Neurologic Conditions: A Systematic Review.

OBJECTIVES: To determine whether ballistic resistance training is feasible, safe, and effective in improving muscle strength, power generation, and mobility in adults with neurologic conditions. DATA SOURCES: Nine electronic databases were searched from inception to March 2019 in addition to the reference lists of included articles. STUDY SELECTION: Articles were independently screened by 2 authors and were included if they were full-text; English-language articles published in a peer-reviewed journal; investigated ballistic resistance training for adults with a neurologic condition; and reported on feasibility, safety, strength, power, or mobility. DATA EXTRACTION: Two authors independently extracted data. Study quality was assessed using the McMaster critical review form and the Physiotherapy Evidence Database scale. DATA SYNTHESIS: The search identified 1540 articles, with 13 articles describing 9 studies meeting the criteria for inclusion. Five studies were randomized controlled trials and 4 were cohort studies. Ballistic resistance training was feasible and safe with only 1 intervention-related adverse event reported. Findings indicated improvements in strength for hip abduction, leg press, knee flexion, and ankle dorsiflexion, but not for hip flexion, hip extension, knee extension, or ankle plantarflexion. Muscle power generation improved for hip flexion, hip abduction, leg press, knee extension, and knee flexion, but not for ankle plantarflexion. Treatment effect was positive for self-selected walking speed, with a standardized mean difference (SMD) of 0.69 (95% confidence interval [CI], 0.01-1.38) from 3 studies. However, fastest comfortable walking speed results were inconclusive with a SMD from 4 studies of 0.45 (95% CI, -0.01 to 0.91). CONCLUSIONS: Ballistic training is safe and feasible for people with a neurologic condition. The effects on muscle strength, power generation, and mobility were found to be positive but not conclusive.

The reproducibility and responsiveness of subjective assessment of upper limb associated reactions in people with acquired brain injury during walking.

OBJECTIVE: The aim of this study is to determine inter-rater, test-retest and intra-rater reproducibility and responsiveness of subjective assessment of upper limb associated reactions in people with acquired brain injury using (1) the 'Qualifiers Scale' of the International Classification of Functioning, Disability and Health Framework, and (2) visually estimated elbow flexion angle during walking. DESIGN: Observational study. SETTING: A brain injury rehabilitation centre, Melbourne, Australia. SUBJECTS: People with acquired brain injury and upper limb associated reactions and experienced neurological physiotherapists. MAIN MEASURES: The Qualifiers Scale applied to individual upper limb joints and global associated reaction on a 5-point scale (0-4), a summed upper limb severity score and visually estimated elbow flexion angle. RESULTS: A total of 42 people with acquired brain injury (mean age: 48.4 ± 16.5 years) were videoed walking at self-selected and fast speeds. A subset of 30 chronic brain injury participants (mean time post injury: 8.2 ± 9.3 years) were reassessed one week later for retest reproducibility. Three experienced neurological physiotherapists (mean experience: 22.7 ± 9.1 years) viewed these videos and subjectively rated the upper limb associated reactions. Strong-to-very strong test-retest, intra- and inter-rater reproducibility was found for elbow flexion angle (ICC > 0.86) and the Qualifiers Scale applied to global and individual upper limb joints (ICC > 0.60). Responsiveness of change from self-selected to fast walking speed (mean increase 0.46 m/s) was highest for elbow flexion angle (effect size = 0.83) and low-to-moderate for the Qualifiers Scale. CONCLUSION: Subjectively rated associated reactions during walking demonstrated strong reproducibility and moderate responsiveness to speed change. The Qualifiers Scale and elbow flexion angle can both subjectively quantify associated reactions during walking in a clinical setting.