Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review.

BACKGROUND: Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions. OBJECTIVE: This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT. METHODS: Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1). RESULTS: From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality. CONCLUSIONS: Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation.

Systematic Review and Meta-Analysis of the Effectiveness of Mental Practice for the Upper Limb After Stroke: Imagined or Real Benefit?

OBJECTIVES: This systematic review sought to determine the effectiveness of mental practice (MP) on the activity limitations of the upper limb in individuals after stroke, as well as when, in whom, and how MP should be delivered. DATA SOURCES: Ten electronic databases were searched from November 2009 to May 2020. Search terms included: Arm, Practice, Stroke rehabilitation, Imagination, Paresis, Recovery of function, and Stroke. Studies from a Cochrane review of MP (up to November 2009) were automatically included. The review was registered with the PROSPERO database of systematic reviews (reference no.: CRD42019126044). STUDY SELECTION: Randomized controlled trials of adults after stroke using MP for the upper limb were included if they compared MP to usual care, conventional therapy, or no treatment and reported activity limitations of the upper limb as outcomes. Independent screening was conducted by 2 reviewers. DATA EXTRACTION: One reviewer extracted data using a tool based on the Template for Intervention Description and Replication. Data extraction was independently verified by a second reviewer. Quality was assessed using the PEDro tool. DATA SYNTHESIS: Fifteen studies (n=486) were included and 12 (n=328) underwent meta-analysis. MP demonstrated significant benefit on upper limb activities compared with usual treatment (standardized mean difference [SMD], 0.6; 95% confidence interval [CI], 0.32-0.88). Subgroup analyses demonstrated that MP was most effective in the first 3 months after stroke (SMD, 1.01; 95% CI, 0.53-1.50) and in individuals with the most severe upper limb deficits (weighted mean difference, 7.33; 95% CI, 0.94-13.72). CONCLUSIONS: This review demonstrates that MP is effective in reducing activity limitations of the upper limb after stroke, particularly in the first 3 months after stroke and in individuals with the most severe upper limb dysfunction. There was no clear pattern of the ideal dosage of MP.

Interventions for eye movement disorders due to acquired brain injury.

BACKGROUND: Acquired brain injury can cause eye movement disorders which may include: strabismus, gaze deficits and nystagmus, causing visual symptoms of double, blurred or 'juddery' vision and reading difficulties. A wide range of interventions exist that have potential to alleviate or ameliorate these symptoms. There is a need to evaluate the effectiveness of these interventions and the timing of their implementation. OBJECTIVES: We aimed to assess the effectiveness of any intervention and determine the effect of timing of intervention in the treatment of strabismus, gaze deficits and nystagmus due to acquired brain injury. We considered restitutive, substitutive, compensatory or pharmacological interventions separately and compared them to control, placebo, alternative treatment or no treatment for improving ocular alignment or motility (or both). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (containing the Cochrane Eyes and Vision Trials Register) (2017, Issue 5), MEDLINE Ovid, Embase Ovid, CINAHL EBSCO, AMED Ovid, PsycINFO Ovid, Dissertations & Theses (PQDT) database, PsycBITE (Psychological Database for Brain Impairment Treatment Efficacy), ISRCTN registry, ClinicalTrials.gov, Health Services Research Projects in Progress (HSRProj), National Eye Institute Clinical Studies Database and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). The databases were last searched on 26 June 2017. No date or language restrictions were used in the electronic searches for trials. We manually searched the Australian Orthoptic Journal, British and Irish Orthoptic Journal, and ESA, ISA and IOA conference proceedings. We contacted researchers active in this field for information about further published or unpublished studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of any intervention for ocular alignment or motility deficits (or both) due to acquired brain injury. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies and extracted data. We used standard methods expected by Cochrane. We employed the GRADE approach to interpret findings and assess the quality of the evidence. MAIN RESULTS: We found five RCTs (116 participants) that were eligible for inclusion. These trials included conditions of acquired nystagmus, sixth cranial nerve palsy and traumatic brain injury-induced ocular motility defects. We did not identify any relevant studies of restitutive interventions.We identified one UK-based trial of a substitutive intervention, in which botulinum toxin was compared with observation in 47 people with acute sixth nerve palsy. At four months after entry into the trial, people given botulinum toxin were more likely to make a full recovery (reduction in angle of deviation within 10 prism dioptres), compared with observation (risk ratio 1.19, 95% CI 0.96 to 1.48; low-certainty evidence). These same participants also achieved binocular single vision. In the injection group only, there were 2 cases of transient ptosis out of 22 participants (9%), and 4 participants out of 22 (18%) with transient vertical deviation; a total complication rate of 24% per injection and 27% per participant. All adverse events recovered. We judged the certainty of evidence as low, downgrading for risk of bias and imprecision. It was not possible to mask investigators or participants to allocation, and the follow-up between groups varied.We identified one USA-based cross-over trial of a compensatory intervention. Oculomotor rehabilitation was compared with sham training in 12 people with mild traumatic brain injury, at least one year after the injury. We judged the evidence from this study to be very low-certainty. The study was small, data for the sham training group were not fully reported, and it was unclear if a cross-over study design was appropriate as this is an intervention with potential to have a permanent effect.We identified three cross-over studies of pharmacological interventions for acquired nystagmus, which took place in Germany and the USA. These studies investigated two classes of pharmacological interventions: GABAergic drugs (gabapentin, baclofen) and aminopyridines (4-aminopyridines (AP), 3,4-diaminopyridine (DAP)). We judged the evidence from all three studies as very low-certainty because of small numbers of participants (which led to imprecision) and risk of bias (they were cross-over studies which did not report data in a way that permitted estimation of effect size).One study compared gabapentin (up to 900 mg/day) with baclofen (up to 30 mg/day) in 21 people with pendular and jerk nystagmus. The follow-up period was two weeks. This study provides very low-certainty evidence that gabapentin may work better than baclofen in improving ocular motility and reducing participant-reported symptoms (oscillopsia). These effects may be different in pendular and jerk nystagmus, but without formal subgroup analysis it is unclear if the difference between the two types of nystagmus was chance finding. Quality of life was not reported. Ten participants with pendular nystagmus chose to continue treatment with gabapentin, and one with baclofen. Two participants with jerk nystagmus chose to continue treatment with gabapentin, and one with baclofen. Drug intolerance was reported in one person receiving gabapentin and in four participants receiving baclofen. Increased ataxia was reported in three participants receiving gabapentin and two participants receiving baclofen.One study compared a single dose of 3,4-DAP (20 mg) with placebo in 17 people with downbeat nystagmus. Assessments were made 30 minutes after taking the drug. This study provides very low-certainty evidence that 3,4-DAP may reduce the mean peak slow-phase velocity, with less oscillopsia, in people with downbeat nystagmus. Three participants reported transient side effects of minor perioral/distal paraesthesia.One study compared a single dose of 4-AP with a single dose of 3,4-DAP (both 10 mg doses) in eight people with downbeat nystagmus. Assessments were made 45 and 90 minutes after drug administration. This study provides very low-certainty evidence that both 3,4-DAP and 4-AP may reduce the mean slow-phase velocity in people with downbeat nystagmus. This effect may be stronger with 4-AP. AUTHORS' CONCLUSIONS: The included studies provide insufficient evidence to inform decisions about treatments specifically for eye movement disorders that occur following acquired brain injury. No information was obtained on the cost of treatment or measures of participant satisfaction relating to treatment options and effectiveness. It was possible to describe the outcome of treatment in each trial and ascertain the occurrence of adverse events.

Patient reported outcome measures for visual impairment after stroke: a systematic review.

PURPOSE: The aim of this review was to identify patient reported outcome measures (PROMs) for use in research and clinical practice involving individuals with visual impairment following stroke and to evaluate their content validity against quality assessment criteria. METHOD: A systematic review of the literature was conducted to identify articles related to the development and/or validation of PROMS. We searched scholarly online resources and hand searched journals. Search terms included MESH terms and alternatives relating to PROMs, visual impairments and quality of life. Data were extracted relating to the development and validation of the included instruments. The quality of the development process was assessed using a modified version of a PROM quality assessment tool. RESULTS: A total of 142 PROMs were identified, 34 vision-specific PROMs were relevant and available to be analysed in this review. Quality appraisal identified four highly rated instruments: the National Eye Institute Visual Functional Questionnaire (NEI-VFQ), Activity Inventory (AI), Daily Living Tasks Dependant on Vision (DLTV) and Veterans Affairs Low Visual Function Questionnaire (VA LV VFQ). The four instruments have only been used with either a limited number of stroke survivors or a sub-population within visual impairment following stroke. CONCLUSION: No instruments were identified which specifically targeted individuals with visual impairment following stroke. Further research is required to identify the items which a population of stroke survivors with visual impairment consider to be of most importance. The validation of a combination of instruments or a new instrument for use with this population is required.

Risk of Urinary Infections in Veterans on Empagliflozin With Concurrent Catheter Use.

There has been concern over whether to use sodium-glucose-cotransporter-2 (SGLT-2) inhibitors in patients that use catheters due to the concern for increased urinary tract infections (UTIs). The concern is that patients who use catheters are already at an increased risk for UTIs and that SGLT-2-inhibitors may promote bacterial growth due their mechanism of action, ie. increasing glycosuria. The objective of this study was to evaluate whether using empagliflozin, a SGLT-2-inhibitor, in patients who also use catheters, increases their risks for UTIs. A retrospective chart review of electronic health records at a single-center was completed of all Veterans who received an empagliflozin prescription and were also using catheters between October 1, 2015 and September 30, 2022. Veterans were included if they were using catheters for at least 2 months prior to starting empagliflozin and were on both therapies for at least 2 months concurrently. The primary outcome for this study is the number of UTIs occurring prior to and after beginning empagliflozin treatment. Additional secondary outcomes included change in A1c, change in body mass index (BMI), UTI-hospitalizations, and fungal infections. Of the 91 patients with concurrent empagliflozin and catheter-use, only 25 Veterans were included. There was an occurrence of .09 UTIs/month pre-empagliflozin compared to .07 post-empagliflozin (P = .61). There was an observed trend in Veterans with Type 2 Diabetes having an increased rate of UTIs. There was no statistically significant difference found in UTI rates when comparing catheters alone to concurrent catheter and empagliflozin-use.

Understanding the Barriers and Facilitators of Digital Health Technology (DHT) Implementation in Neurological Rehabilitation: An Integrative Systematic Review.

Background: Digital Health technologies (DHT) have potential to deliver intensive, novel and engaging rehabilitation for people with neurological conditions, yet health services lack a strong track record in embedding DHT into practice. The aim of this review was to synthesise factors that have been shown to influence implementation of DHT into neurological rehabilitation. Method: An integrative review was undertaken. An extensive search of MEDLINE, CINAHL, AMED, EMBASE was undertaken. The title and abstract of all retrieved sources were screened against pre-defined criteria. Retained sources underwent full text review. The quality of all included sources was assessed. A meta-ethnographic synthesis explored commonalities and contradictions of the included studies. Results: Fourteen studies (1 quantitative, 8 qualitative and 5 mixed methods) were included. Eleven implementation theories/models/frameworks were used across the 14 studies. Five themes were identified: (i) individual factors; (ii) user experience of the technology; (iii) the content of the intervention; (iv) access to the technology and (v) supporting use. Conclusions: Key factors which appear to influence the implementation of DHT into clinical settings are highlighted. Implementation theories, models and frameworks are under-utilised in DHT rehabilitation research. This needs to be addressed if DHT are to realise their potential in neurological rehabilitation. Registration: The protocol was registered and is available from PROSPERO (CRD42021268984).

A pilot exploration of staff and service-user perceptions of a novel digital health technology (Virtual Engagement Rehabilitation Assistant) in complex inpatient rehabilitation.

PURPOSE: Digital health technologies have the potential to advance rehabilitation. The Virtual Engagement Rehabilitation Assistant (VERA) is a digital technology, co-designed to increase service-user engagement and promote self-management. This qualitative study explored staff and service-user perceptions of implementing VERA on a UK complex inpatient rehabilitation ward. METHODS: Purposively sampled service-users were allocated to VERA for up to six weeks. The Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework underpinned service-user post-intervention interviews and staff focus groups, and structured analysis of the data. Seven service-users were interviewed. Nine staff contributed to focus groups. RESULTS: A framework analysis identified themes (and subthemes) structured by the NASSS framework domains: 1. Nature of Clinical Condition, 2. Technology (Ease of Use, Holding Information/Resources in a single Digital Location, Appointments), 3. Value Proposition (Structuring Time, Feedback, Unexpected Benefits) 4. Adopters (Confidence in using Technology, Usefulness), 5. Wider Organisation. Ease of use and storage of key information in a single location were beneficial. Reliability, and provision of accurate and timely feedback to staff and service-users, were identified as essential. CONCLUSIONS: A blended approach is required to meet staff and service-user needs. The potential for VERA in a community setting was identified and requires further investigation. Learning from VERA will support development of other digital technologies and their implementation.

Digital health technologies have the potential to positively impact rehabilitation but may not be suitable for all service-users.Digital health technologies for rehabilitation must be easy to use and reliable.Relevant and informative feedback from the digital health technology was considered essential by both staff and service-users.Utilising a theoretical framework that focuses on key components of implementation was instrumental for development and evaluation of Virtual Engagement Rehabilitation Assistant (VERA).

Diagnosis and management of Crohn's disease.

Crohn's disease is a chronic inflammatory condition affecting the gastrointestinal tract at any point from the mouth to the rectum. Patients may experience diarrhea, abdominal pain, fever, weight loss, abdominal masses, and anemia. Extraintestinal manifestations of Crohn's disease include osteoporosis, inflammatory arthropathies, scleritis, nephrolithiasis, cholelithiasis, and erythema nodosum. Acute phase reactants, such as C-reactive protein level and erythrocyte sedimentation rate, are often increased with inflammation and may correlate with disease activity. Levels of vitamin B12, folate, albumin, prealbumin, and vitamin D can help assess nutritional status. Colonoscopy with ileoscopy, capsule endoscopy, computed tomography enterography, and small bowel follow-through are often used to diagnose Crohn's disease. Ultrasonography, computed axial tomography, scintigraphy, and magnetic resonance imaging can assess for extraintestinal manifestations or complications (e.g., abscess, perforation). Mesalamine products are often used for the medical management of mild to moderate colonic Crohn's disease. Antibiotics (e.g., metronidazole, fluoroquinolones) are often used for treatment. Patients with moderate to severe Crohn's disease are treated with corticosteroids, azathioprine, 6-mercaptopurine, or anti-tumor necrosis factor agents (e.g., infliximab, adalimumab). Severe disease may require emergent hospitalization and a multidisciplinary approach with a family physician, gastroenterologist, and surgeon.

Initial evaluation of a virtual reality bomb-defusing simulator for development of undergraduate healthcare student communication and teamwork skills.

Communication and teamworking skills are essential healthcare professional skills, yet undergraduates exhibit reluctance to engage with group work, especially in interprofessional groups. The aim of the study was to investigate whether a virtual reality bomb-defusing simulator would enable students to gain these skills through an enjoyable and challenging scenario without profession-specific knowledge. Students took it in turns to play the role of the 'Defuser' immersed in a headset, while the rest of the group were 'Experts' with a printed manual, but no sight of the bomb. The task challenged students to relay obscure symbols and instructions to each other rapidly and effectively. A subsequent focus group explored the impact of the simulation on students' perceived learning, engagement and communication skills. The focus group of five multiprofessional healthcare students reported high levels of engagement and satisfaction while highlighting value in developing communication and teamwork. The simulator nurtured initial group dynamics and team bonding. Evaluation data indicated that the intervention facilitated cooperation, team bonding and the development of good communication skills. This method of encouraging communication would fit well into an interprofessional learning session as a useful tool ahead of more technical and clinically based group work. The focus group of five multiprofessional healthcare students reported high levels of engagement and satisfaction while highlighting value in developing communication and teamwork. The simulator nurtured initial group dynamics and team bonding.

Implementation in rehabilitation: a roadmap for practitioners and researchers.

Purpose: Despite growth in rehabilitation research, implementing research findings into rehabilitation practice has been slow. This creates inequities for patients and is an ethical issue. However, methods to investigate and facilitate evidence implementation are being developed. This paper aims to make these methods relevant and accessible for rehabilitation researchers and practitioners.Methods: Rehabilitation practice is varied and complex and occurs within multilevel healthcare systems. Using a "road map" analogy, we describe how implementation concepts and theories can inform implementation strategies in rehabilitation. The roadmap involves a staged journey that considers: the nature of evidence; context for implementation; navigation tools for implementation; strategies to facilitate implementation; evaluation of implementation outcomes; and sustainability of implementation. We have developed a model to illustrate the journey, and four case studies exemplify implementation stages in rehabilitation settings.Results and Conclusions: Effective implementation strategies for the complex world of rehabilitation are urgently required. The journey we describe unpacks that complexity to provide a template for effective implementation, to facilitate translation of the growing evidence base in rehabilitation into improved patient outcomes. It emphasizes the importance of understanding context and application of relevant theory, and highlights areas which should be targeted in new implementation research in rehabilitation.Implications for rehabilitationEffective implementation of research evidence into rehabilitation practice has many interconnected steps and a roadmap analogy is helpful in defining them.Understanding context for implementation is critically important and using theory can facilitate development of understanding.Research methods for implementation in rehabilitation should be carefully selected and outcomes should evaluate implementation success as well as clinical change.Sustainability requires regular revisiting of the interconnected steps.

Current therapy for the upper limb after stroke: a cross-sectional survey of UK therapists.

OBJECTIVES: To survey the reported content, frequency and duration of upper limb treatment provided by occupational and physiotherapists for people after stroke in the UK. DESIGN: A cross-sectional online survey was used. Description and analysis of the data were based on items from the Template for Intervention Description and Replication (Who, Where, What and How much). SETTING: The online survey was distributed via professional and social networks to UK-based therapists. PARTICIPANTS: Respondents were occupational or physiotherapists currently working clinically in the UK with people after stroke. Over the 6 week data collection period, 156 respondents opened the survey, and 154 completed it. Respondents comprised 85 physiotherapists and 69 occupational therapists. RESULTS: Respondents reported treating the upper limb a median of three times a week (range: 1 to 7) for a mean of 29 min (SD: 18). Most (n=110) stated this was supplemented by rehabilitation assistants, family and/or carers providing additional therapy a median of three times a week (range 1 to 7). Functional training was the most commonly reported treatment for people with mild and moderate upper limb deficits (>40%). There was much less consistency in treatments reported for people with severe upper limb deficits with less than 20% (n=28) reporting the same treatments. CONCLUSIONS: This study provides a contemporaneous description of reported therapy in the UK for people with upper limb deficits after stroke and a detailed template to inform standard therapy interventions in future research. Several evidence-based therapies were reported to be used by respondents (eg, constraint induced movement therapy), but others were not (eg, mental imagery). The findings also highlight that the current reported provision of upper limb therapy is markedly less than what is likely to be effective. This underlines an urgent need to configure and fund services to empower therapists to deliver greater amounts of evidence-based treatment for people with upper limb deficits after stroke.