Home-based self-management for sedentary individuals with mild walking disability after stroke: protocol for a randomised pilot study.

BACKGROUND: A Phase I study showed that it is feasible to implement a home-based self-management program aimed at increasing physical activity in individuals after stroke with mild walking disability in Brazil. The next step is to test this program against a control group in order to provide a power analysis for a fully-powered Phase III clinical trial. METHODS: A Phase II pilot randomised clinical trial with concealed allocation, blinded measurement, and intention-to-treat analyses will be carried out. The inclusion criteria will be individuals diagnosed with stroke, in the acute or subacute phase, with mild walking disability, sedentary, and no significant language impairment. The participants will be randomly allocated to the experimental or control group. The experimental group will receive six sessions of a home-based self-management program based on behaviour change techniques through the Social-Cognitive Theory and Control Theory over 11 weeks. The control group will receive one session of education about stroke (regarding the importance of practising physical activity after a stroke) and usual care. A total of 24 participants will be recruited. The primary outcome will be physical activity, measured through steps taken per day by an activity monitor (Actigraph wGT3X-BT, Pensacola, FL, USA). The mean of daily steps will be analysed to compare groups after intervention. Secondary outcomes will be cardiovascular risk (body mass index, waist circumference, and blood pressure), depressive symptoms (Geriatric Depression Scale), walking ability (6-Minute Walk Test and 10-Meter Walk Test), exercise self-efficacy (Self-Efficacy for Exercise scale), social participation (Stroke Impact Scale) and quality of life (EuroQual-5D). Two-way analyses of variance will be implemented for all parametric outcomes, and the Kruskal-Wallis test for non-parametric outcomes will be used to determine the statistical significance of the between-group differences and reported as mean differences between groups (95% CI). All analyses will be conducted intention-to-treat. All outcomes will be measured at baseline (Week 0), post-intervention (Week 12), and follow-up (Week 24). This pilot clinical trial was registered online at Clinical Trials under number NCT05461976 on 4th April 2022. DISCUSSION: If beneficial, this Phase II pilot randomised trial will provide data to plan a fully powered future Phase III clinical trial aimed at verifying the efficacy of this program to promote physical activity after stroke. TRIAL REGISTRATION: Clinical Trials NCT05461976 on 4th April 2022.

Toward a Multi-Modal Brain-Body Assessment in Parkinson's Disease: A Systematic Review in fNIRS.

Parkinson's disease (PD) causes impairments in cortical structures leading to motor and cognitive symptoms. While common disease management and treatment strategies mainly depend on the subjective assessment of clinical scales and patients' diaries, research in recent years has focused on advances in automatic and objective tools to help with diagnosing PD and determining its severity. Due to the link between brain structure deficits and physical symptoms in PD, objective brain activity and body motion assessment of patients have been studied in the literature. This study aimed to explore the relationship between brain activity and body motion measures of people with PD to look at the feasibility of diagnosis or assessment of PD using these measures. In this study, we summarised the findings of 24 selected papers from the complete literature review using the Scopus database. Selected studies used both brain activity recording using functional near-infrared spectroscopy (fNIRS) and motion assessment using sensors for people with PD in their experiments. Results include 1) the most common study protocol is a combination of single tasks. 2) Prefrontal cortex is mostly studied region of interest in the literature. 3) Oxygenated haemoglobin (HbO 2) concentration is the predominant metric utilised in fNIRS, compared to deoxygenated haemoglobin (HHb). 4) Motion assessment in people with PD is mostly done with inertial measurement units (IMUs) and electronic walkway. 5) The relationship between brain activity and body motion measures is an important factor that has been neglected in the literature.

Utilising telehealth to support exercise and physical activity in people with Parkinson disease: a program evaluation using mixed methods.

BACKGROUND: Physical activity and exercise play a key role in managing Parkinson disease. This study aimed to: 1) determine if physiotherapy supported by telehealth helped people with Parkinson disease (PwP) to adhere to a home-based exercise program and maintain their physical activity; and 2) understand their experiences of using telehealth during the COVID-19 pandemic. METHODS: A mixed methods program evaluation involving a retrospective file audit from a student-run physiotherapy clinic and semi-structured interviews exploring participants' experiences of telehealth. Ninety-six people with mild to moderate disease received home-based telehealth physiotherapy for 21 weeks. The primary outcome was adherence to the prescribed exercise program. Secondary outcomes were measures of physical activity. Interviews were conducted with 13 clients and seven students and analysed thematically. RESULTS: Adherence to the prescribed exercise program was high. The mean (SD) proportion of prescribed sessions completed was 108% (46%). On average clients spent 29 (12) minutes per session, and 101 (55) minutes per week exercising. Physical activity levels were maintained, with clients taking 11,226 (4,832) steps per day on entry to telehealth, and 11,305 (4,390) steps per day on exit from telehealth. The semi-structured interviews identified important features of a telehealth service required to support exercise; a flexible approach of clients and therapists, empowerment, feedback, a therapeutic relationship, and mode of delivery. CONCLUSIONS: PwP were able to continue exercising at home and maintain their physical activity when physiotherapy was provided via telehealth. The flexible approach of both the client and the service was imperative.

Functional near-infrared spectroscopy measures of frontal hemodynamic responses in Parkinson's patients and controls performing the Timed-Up-and-Go test.

Using functional near-infrared spectroscopy (fNIRS), hemodynamic responses (i.e., changes in oxygenated and deoxygenated hemoglobin) were measured while participants with Parkinson's disease (PD) and healthy controls performed the Timed-Up-and-Go test (TUGT), and differences in cortical activity at baseline and three different intervals were examined between the two groups. Seventeen PD patients and twenty-two controls participated in the study, but two PD patients were excluded from statistical analysis due to the presence of freezing of gait and using walking aids during the TUGT. During the TUGT, activity in the front, left, right and total frontal cortices initially decreased significantly, then significantly increased in PD participants and low-risk faller PD participants, compared to when in a sitting position. ΔHbO (HbO change from baseline) over the front, left and total frontal cortices in the PD group was significantly lower than the control group in interval 1 (P = 0.019, P = 0.014 and P = 0.031, respectively), while significantly higher than the control group in interval 2 over the left frontal cortex (P = 0.010). No significant differences were observed between the high-risk faller and low-risk faller subgroups of PD participants in ΔHbO and ΔHbR in the three intervals (P > 0.05). In the high-risk faller subgroup, ΔHbO over the left frontal cortex was significantly higher than the right frontal cortex in interval 2 and interval 3 (P = 0.015, P = 0.030, respectively). There was a strong positive correlation between education and HbR concentration over the right frontal cortex in PD participants (rho = 0.557, P = 0.031), while there were strong negative correlations between PD duration and HbR concentration over the right and total frontal cortices in the high-risk faller subgroup of PD participants (rho = -0.854, P = 0.014 for the right; rho = -0.784, P = 0.037 for the total). The falls prediction cutoff TUGT time for PD participants was 14.2 s. These results suggest that frontal cognition training, along with exercise training, could be used as an effective training method to improve motor performance in PD patients, especially for those at high-risk for falls.

People with mild Parkinson's disease have impaired force production in upper limb muscles: A cross-sectional study.

BACKGROUND: There has been little examination of force production of the upper limb in people with Parkinson's disease (PD), despite its impact on activities of daily living and clear evidence that force production is significantly reduced in lower limb muscle groups. The aim of this study was to determine the force production of the major muscle groups of the upper limb in people with PD during the "on" phase after medication, compared with aged-matched neurologically-normal controls. METHOD: A cross-sectional study was carried out. PARTICIPANTS: Thirty people with mild PD (Hoehn Yahr mean 1.1) and 24 age-matched neurologically-normal controls. OUTCOME MEASURES: Maximum isometric force production of the shoulder flexors, extensors, abductors, adductors, internal rotators and external rotators, elbow flexors and extensors, wrist flexors and extensors and hand grip using dynamometry. RESULTS: There was a significant impairment in force production in all upper limb muscle groups, compared with control participants, except in the wrist flexors. On average the deficit in force production was 22%, despite people with PD having mild disease, being physically active and being measured during the "on" phase of medication. The most severely affected muscle groups were the upper limb extensors. CONCLUSION: People with PD have a significant deficit in force production of the upper limb muscle groups compared with age-matched neurologically normal controls. CLINICAL IMPLICATIONS: Regular assessment of strength of the upper limb should be considered by clinicians and strengthening interventions could be implemented if a deficit is identified.

Compression Therapy Is Cost-Saving in the Prevention of Lower Limb Recurrent Cellulitis in Patients with Chronic Edema.

Background: Cellulitis is a common and often recurrent infection that causes substantial financial burden and morbidity. Compression therapy reduces the risk of recurrent cellulitis episodes for adults with chronic edema; however, little is known about the cost-effectiveness of the intervention. Methods and Results: A cost analysis was undertaken during a randomized controlled trial (RCT) involving 84 participants with lower limb chronic edema and a history of recurrent cellulitis. The intervention group received compression therapy and education, while the control group received education only. A clinical audit and survey were used to measure health service and patient resource use for (1) the most recent episode of cellulitis, and (2) compression therapy over 18 months. Australian reference costs were used to calculate cellulitis and compression therapy costs, and the mean expenditure in both the RCT groups. Of the 84 RCT participants, 43 were surveyed and audited on the cost of cellulitis, and 40 on the cost of compression therapy. The mean cost of a hospitalized and nonhospitalized episode of cellulitis was $9071 and $506 from a health service perspective, and $4496 and $1320 from a patient perspective. The mean cost of compression therapy per participant over 18 months was $1905 and $421 from health service and patient perspectives, respectively. During the RCT, the mean annual cost per participant was $4972 in the experimental group and $26,382 in the control group, giving a cost-saving of $21,483 (95% confidence interval, 3136-48,176) per participant. Conclusion: For patients with lower limb chronic edema and recurrent cellulitis, compression therapy is both efficacious and cost-saving. Trial Registration: ACTRN12617000412336.

Cardiovascular Rehabilitation for transient ischaemic Attack and Mild Stroke: the CRAMS effectiveness-implementation hybrid study protocol.

BACKGROUND: Internationally, stroke and cardiac rehabilitation clinicians agree that current cardiac rehabilitation models are a suitable secondary prevention program for people following a transient ischaemic attack (TIA) or mild stroke. There is strong evidence for exercise-based cardiac rehabilitation in people with heart disease, however, the evidence for cardiac rehabilitation post-TIA or stroke is limited. Here we will explore the effectiveness and implementation of an integrated (TIA, mild stroke, heart disease) traditional exercise-based cardiovascular rehabilitation (CVR) program for people with TIA or mild stroke over 6-months. METHODS: This type 1 effectiveness-implementation hybrid study will use a 2-arm single-centre assessor-blind randomised controlled trial design, recruiting 140 participants. Adults who have had a TIA or mild stroke in the last 12-months will be recruited by health professionals from hospital and primary healthcare services. Participants will be assessed and randomly allocated (1:1) to the 6-week CVR program or the usual care 6-month wait-list control group. Distance completed in the 6-min walk test will be the primary effectiveness outcome, with outcomes collected at baseline, 6-weeks (complete CVR) and 6-months in both groups. Other effectiveness outcome measures include unplanned cardiovascular disease-related emergency department and hospital admissions, daily minutes of accelerometer moderate-to-vigorous physical activity, body mass index, waist circumference, blood pressure, quality of life, anxiety and depression. Implementation outcomes will be assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, including a cost-effectiveness analysis. Semi-structured interviews will be conducted with participants and CVR program health professionals, investigating the acceptability, value, and impact of the CVR program. Qualitative analyses will be guided by the Consolidated Framework for Implementation Research. DISCUSSION: Few studies have assessed the effectiveness of cardiac rehabilitation for people with TIA and mild stroke, and no studies appear to have investigated the cost-effectiveness or implementation determinants of such programs. If successful, the CVR program will improve health outcomes and quality of life of people who have had a TIA or mild stroke, guiding future research, policy, and clinical practice, reducing the risk of repeat heart attacks and strokes for this population. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621001586808 , Registered 19 November 2021.

Impact of classroom-based MASK-ED™ (KRS simulation) on physiotherapy student clinical performance: a randomized cluster trial.

BACKGROUND: In physiotherapy there is a growing body of literature exploring the benefits simulation could have in the university-setting, prior to the commencement of work-integrated learning. MASK-ED™ simulation is one form of simulation that could be beneficial for student learning and improve performance in the clinical setting. MASK-ED™ simulation involves an educator donning a silicone mask and portraying a patient role that has been specifically developed to meet learning objectives. OBJECTIVE: To evaluate the effectiveness of MASK-ED™ simulation compared to role-play with peers for training pre-clinical physiotherapy students. METHODS: A single-centre, single-blind, cluster randomized trial with concealed allocation, between group post-measures, and intention-to-treat analysis was conducted at an Australian university between February 2018 - January 2021. Participants were 144 physiotherapy students, cluster randomized by tutorial groups (exp n = 70, con n = 74), undertaking their neurological curricula. The experimental group was exposed to MASK-ED™ simulation in five out of a potential thirty-two tutorials (16%) whilst the control continued with role-play with peers. The primary outcome measure was Assessment of Physiotherapy Practice scores from the students' rehabilitation work-integrated learning clinical placement. These were compared between the experimental and control groups using Mann-Whitney U tests. Secondary outcome measures include practical and written examination scores. These were compared between groups via independent t-tests. Participant satisfaction surveys were also administered to the experimental group. RESULTS: One hundred thirty-two participants' (exp n = 62, con n = 72) results were analyzed. There were no significant differences between the experimental and control groups for Assessment of Physiotherapy Practice scores (p = 0.699-0.995). There were no significant differences found between the groups, across the secondary outcome measures. Participants found MASK-ED™ simulation was somewhat helpful for preparing them for clinical practice, however felt that a group setting was not as effective as a one-on-one encounter would have been. CONCLUSIONS: MASK-ED™ simulation was no more effective than role-play with peers in preparing physiotherapy students for work-integrated learning. The influence of the design of simulation on effective learning and the number of classroom-based simulation encounters required to impact clinical performance requires further investigation.

Exercising with Parkinson's: The good, the bad and the need for support to keep exercising. A qualitative study.

OBJECTIVES: To explore the experiences of people with Parkinson's disease exercising and to determine if the location (home versus centre) or exercising in a group impacted on their experience. DESIGN: A qualitative study. PARTICIPANTS: Community-dwelling people with mild to moderate Parkinson's disease who had undertaken a 10-week exercise intervention. METHOD: Semi-structured interviews were conducted with 17 participants; nine participants had completed 10-weeks of predominately home-based exercise and eight participants had predominately centre-based excercise. Interviews were recorded, transcribed verbatim and analysed using inductive thematic analysis. RESULTS: Four key themes emerged. Two themes: 'targeted exercise is important when you have Parkinson's disease' and 'support helps me to gain the most from the exercise', were related to exercising with Parkinson's disease and were not specific to location. Two themes encompassed the perceptions when exercising at a centre in a group compared to exercising at home: 'the good and the bad of exercising in a group' and 'exercising at home, can I do it?' CONCLUSION: Experiences of people with Parkinson's disease when exercising were primarily influenced by the prescription of specific exercise and the support provided. There was no clear preference for the location of exercise but maintaining the motivation to exercise at home was challenging.

Prediction of Independent Walking in People Who Are Nonambulatory Early After Stroke: A Systematic Review.

Background and Purpose: One systematic review has examined factors that predict walking outcome at one month in initially nonambulatory patients after stroke. The purpose of this systematic review was to examine, in nonambulatory people within a month of stroke, which factors predict independent walking at 3, 6, and 12 months. Methods: Prognostic factors: Any factors measured within one month after stroke with the aim of predicting independent walking. Outcome of interest: Independent walking defined as walking with or without an aid but with no human assistance. Results: Fifteen studies comprising 2344 nonambulatory participants after stroke were included. Risk of bias was low in 7 studies and moderate in 8 studies. Individual meta-analyses of 2 to 4 studies were performed to calculate the pooled estimate of the odds ratio for 12 prognostic factors. Younger age (odds ratio [OR], 3.4, P<0.001), an intact corticospinal tract (OR, 8.3, P<0.001), good leg strength (OR, 5.0, P<0.001), no cognitive impairment (OR, 3.5, P<0.001), no neglect (OR, 2.4, P=0.006), continence (OR, 2.3, P<0.001), good sitting (OR, 7.9, P<0.001), and independence in activities of daily living (OR 10.5, P<0.001) predicted independent walking at 3 months. Younger age (OR, 2.1, P<0.001), continence (OR, 13.8, P<0.001), and good sitting (OR, 19.1, P<0.001) predicted independent walking at 6 months. There were insufficient data at 12 months. Conclusions: Younger age, an intact corticospinal tract, good leg strength, continence, no cognitive impairment, no neglect, good sitting, and independence in activities of daily living in patients who are nonambulatory early after stroke predict independent walking at 3 months. REGISTRATION: URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42018108794.

Home-based, tailored intervention for reducing falls after stroke (FAST): Protocol for a randomized trial.

RATIONALE: People with stroke experience falls at more than twice the rate of the general older population resulting in high fall-related injuries. However, there are currently no effective interventions that prevent falls after stroke. AIMS: To determine the effect and cost-benefit of an innovative, home-based, tailored intervention to reduce falls after stroke. SAMPLE SIZE ESTIMATE: A total of 370 participants will be recruited in order to be able to detect a clinically important between-group difference of a 30% lower rate of falls with 80% power at a two-tailed significance level of 0.05. METHODS AND DESIGN: Falls after stroke trial (FAST) is a multistate, Phase III randomized trial with concealed allocation, blinded assessment, and intention-to-treat analysis. Ambulatory stroke survivors within five years of stroke who have been discharged from formal rehabilitation to the community and who have no significant language impairment will be randomly allocated to receive habit-forming exercise, home safety, and community mobility training or usual care. STUDY OUTCOMES: The primary outcome is the rate of falls over the previous 12 months. Secondary outcomes are the risk of falling (proportion of fallers), community participation, self-efficacy, balance, mobility, physical activity, depression, and health-related quality of life. Health care utilization will be collected retrospectively at baseline and prospectively to 6 and 12 months. DISCUSSION: The results of FAST are anticipated to directly influence intervention for stroke survivors in the community.Trial Registration: ANZCTR 12619001114134.

Home-based exercise monitored with telehealth is feasible and acceptable compared to centre-based exercise in Parkinson's disease: A randomised pilot study.

OBJECTIVES: To investigate the feasibility and acceptability of a home-based exercise program monitored using telehealth for people with Parkinson's disease. DESIGN: Pilot randomised control trial. SETTING: University physiotherapy clinic, participants' homes. PARTICIPANTS: Forty people with mild to moderate Parkinson's disease, mean age 72 (6.9). INTERVENTION: In Block 1 (5 weeks) all participants completed predominantly centre-based exercise plus a self-management program. Participants were then randomised to continue the centre-based exercise (n = 20) or to a home-based program with telehealth (n = 20) for Block 2 (5 weeks). The exercises targeted balance and gait. OUTCOMES: The primary outcomes were the feasibility and acceptability of the intervention. Secondary outcomes were balance, gait speed and freezing of gait. RESULTS: Adherence was high in Block 1 (93%), and Block 2 (centre-based group = 93%, home-based group = 84%). In Block 2, the physiotherapist spent 6.4 hours providing telehealth to the home-based group (mean 10 (4) minutes per participant) and 32.5 hours delivering the centre-based exercise classes (98 minutes per participant). Participants reported that exercise was helpful, they could follow the home program and they would recommend exercising at home or in a group. However, exercising at home was less satisfying and there was a mixed response to the acceptability of the self-management program. There was no difference between groups in any of the secondary outcome measures (preferred walking speed mean difference -0.04 (95% CI: -0.12 to 0.05). CONCLUSION: Home-based exercise monitored using telehealth for people with Parkinson's disease is feasible and acceptable.

The Relationship Between Ankle Proprioception and Functional Mobility in People With Parkinson's Disease: A Cross-Sectional Study.

Previous research has found ankle proprioception to be impaired in people with Parkinson's disease (PD). However, the relationship between ankle proprioception and functional mobility in people with PD has not been fully investigated. The purpose of this study was to examine whether ankle proprioception is related to the functional mobility of people with PD. Forty-two participants with mild to moderate PD volunteered. Ankle proprioceptive acuity was measured in standing, by using active movement extent discrimination assessment (AMEDA). Functional mobility measures included the timed-up-and-go test (TUG), 30 s sit-to-stand test (30s-STS) and 10-meter walking test (10MWT). Step length and step cadence were recorded during the 10MWT. No significant correlation was found between ankle proprioceptive discrimination scores and any mobility performance measure in people with PD (-0.20 0.05). However, ankle proprioception scores were significantly correlated with step length (r = 0.38, p < 0.05) and step cadence (r = -0.30, p < 0.05), and were significantly and negatively correlated with the stage of modified Hoehn and Yahr (rho = -0.53, p < 0.01). The lack of relationship between ankle proprioceptive acuity and functional mobility in PD suggests that people with PD may be more limited by reduced sensorimotor integration or may rely more on other sensory input, rather than ankle proprioception, to achieve functional mobility, a finding consistent with sensory reweighting theory. In addition, poorer ankle proprioceptive acuity was associated with decreased step length and increased step cadence, suggesting that the shuffling gait observed in PD may be related to impaired ankle proprioception, which has important clinical implications for gait retraining in people with PD. Given that ankle proprioception was significantly and negatively correlated with the stage of modified Hoehn and Yahr, it may warrant being used as an objective biomarker to monitor the progression of PD.

Profile of upper limb recovery and development of secondary impairments in patients after stroke with a disabled upper limb: An observational study.

Purpose: To investigate, in patients after stroke with a very weak upper limb, the profile of recovery for upper limb activity over the first 12 weeks, and whether early secondary impairments predict later upper limb activity. Method: Forty patients within 2 weeks of stroke with a very weak upper limb (<4/6 Item 6 of Motor Assessment Scale) were observed longitudinally. Upper limb activity (Items 6, 7, and 8 of Motor Assessment Scale), shoulder subluxation (vertical distance), shoulder pain (visual analogue scale), and upper limb range of motion were measured at 2, 6, and 12 weeks poststroke. Results: By Week 12, upper limb activity was 1.0/18 (IQR 3.0). Shoulder subluxation was 42 mm (SD 8), 7 mm > the intact side at 2 weeks. Pain at rest was 0.1/10 (IQR 1.1), and pain during movement was 2.6/10 (IQR 4.5). Passive shoulder external rotation was 23° (SD 34), 30% of the intact side at 2 weeks. Shoulder pain during movement at 2 weeks predicted shoulder pain during movement at 6 and 12 weeks after stroke (p = 0.05). Conclusion: Most patients with a disabled upper limb after stroke have little recovery of activity in the first 12 weeks. Shoulder pain on movement at 2 weeks should be flagged as a predictor of future pain.

Home-based prescribed exercise improves balance-related activities in people with Parkinson's disease and has benefits similar to centre-based exercise: a systematic review.

QUESTIONS: In people with Parkinson's disease, does home-based prescribed exercise improve balance-related activities and quality of life compared with no intervention? Are the effects of home-based exercise similar to those of equivalent centre-based exercise? DESIGN: Systematic review and meta-analysis of randomised and quasi-randomised controlled trials. PARTICIPANTS: Adults diagnosed with idiopathic Parkinson's disease. INTERVENTION: Predominantly home-based prescribed exercise (defined as a minimum of two-thirds of the exercise being completed at home). The intervention had to primarily involve physical practice of exercises targeting gait and/or standing balance compared with either control (ie, usual care only, a sham intervention or no physiotherapy) or equivalent predominantly centre-based exercise. OUTCOME MEASURES: The primary outcome was balance-related activities and the secondary outcomes were gait speed, Berg Balance Scale, Functional Reach test, and quality of life. RESULTS: Sixteen trials met the inclusion criteria and all contributed to the meta-analyses. Twelve trials compared home-based prescribed exercise with control, and four trials compared home-based prescribed exercise with equivalent centre-based exercise. Home-based prescribed exercise improved balance-related activities (SMD 0.21, 95% CI 0.10 to 0.32) and gait speed (SMD 0.30, 95% CI 0.12 to 0.49), but not quality of life (SMD 0.11, 95% CI -0.01 to 0.23) compared with control. Home-based and centre-based exercise had similar effects on balance-related activities (SMD -0.04, 95% CI -0.36 to 0.27) and quality of life (SMD -0.08, 95% CI -0.41 to 0.24). CONCLUSION: Home-based prescribed exercise improves balance-related activities and gait speed in people with Parkinson's disease, and these improvements are similar to improvements with equivalent centre-based exercise. REGISTRATION: PROSPERO CRD 42018107331.

Promoting physical activity after stroke via self-management: a feasibility study.

BACKGROUND: Many people with mild disability after stroke are physically inactive despite the risk of recurrent stroke. A self-management program may be one strategy to increase physical activity in stroke survivors. OBJECTIVES: To investigate the feasibility of a self-management program, and determine whether self-management can increase daily physical activity levels and self-efficacy for exercise, decrease cardiovascular risk, and improve walking ability, participation, and quality of life in people with mild disability after stroke. METHOD: A Phase I, single-group, pre-post intervention study was carried out with twenty stroke survivors who had mild disability and were discharged directly home from acute stroke units. A self-management program was delivered via five home-based sessions over 3 months, incorporating: education, goal setting, barrier identification, self-monitoring, and feedback. Feasibility of the intervention was determined by examining adherence, duration, usefulness, and safety. Clinical outcomes were amount of physical activity (duration of moderate physical activity in min/day and counts of physical activity in steps/day), self-efficacy, cardiovascular risk, walking ability, participation, and quality of life. RESULTS: The intervention was feasible with 96% of sessions being delivered, each taking less than an hour (41 min, SD 12). Participants perceived the self-management program to be useful and there were few adverse events. At 3 months, participants completed 27 min/day (95% CI 4-49) more moderate physical activity than at baseline and 16 min/day (95% CI -10 to 42) at 6 months. CONCLUSION: Self-management appears to be feasible and has the potential to increase physical activity in people with mild disability after stroke. A Phase II randomized trial is warranted.

Lap-tray and triangular sling are no more effective than a hemi-sling in preventing shoulder subluxation in those at risk early after stroke: a randomized trial.

BACKGROUND: Shoulder subluxation is a common secondary impairment of the upper limb following stroke. A range of supportive devices are used in rehabilitation to prevent shoulder subluxation, including hemi-slings and firm supports, such as arm troughs, however, there is little evidence regarding their efficacy. AIM: To determine whether a modified lap-tray during sitting and a triangular sling during standing is more effective than a hemi-sling in preventing shoulder subluxation, pain, contracture and upper limb activity limitation after stroke. DESIGN: A prospective, randomized trial with concealed allocation, assessor blinding and intention-to-treat analysis. SETTING: Three inpatient rehabilitation units in Australia and Norway. POPULATION: Forty-six acute stroke survivors within 3 weeks of stroke who were at risk of subluxation. METHODS: The experimental group used a modified lap-tray while sitting and a triangular sling while standing to support the affected arm for four weeks. The control group used a hemi-sling while sitting and standing. The primary outcome was amount of shoulder subluxation on X-ray. Secondary outcomes were upper limb activity, pain and contracture. RESULTS: There was no significant difference between groups in terms of shoulder subluxation (MD -3 mm, 95% CI -8 to 3). There was a trend for the experimental group to develop less pain at rest (MD -0.7 out of 10, 95% CI -2.2 to 0.8) and during shoulder external rotation (MD -1.7 out of 10, 95% CI -3.7 to 0.3) and a trend towards having less contracture of shoulder external rotation (MD -10 deg, 95% CI -22 to 2). There was no significant difference between groups in terms of other contractures and activity of the upper limb. CONCLUSIONS: A lap-tray during sitting combined with a triangular sling during standing is no more effective than a hemi-sling in preventing subluxation, pain, contracture and activity limitation in acute stroke survivors at risk of shoulder subluxation. CLINICAL REHABILITATION IMPACT: The use of a lap-tray during sitting and triangular sling during standing is not indicated as an alternative to the hemi-sling to prevent shoulder subluxation in patients after stroke, so alternative strategies with proven efficacy, such as electrical stimulation, should be considered.

Proprioception of the Ankle is Impaired in People with Parkinson's Disease.

BACKGROUND: Proprioception has not been examined in the lower limb in people with Parkinson's disease (PD). Impaired proprioception may contribute to activity limitations, including falls in individuals with PD. OBJECTIVES: The aims of this study were to determine whether: (1) people with PD have impaired proprioception in the ankles during active movements; (2) there are correlations between ankle proprioception and history of falls, fear of falling, and parkinsonian symptoms. METHODS: This was a cross-sectional observational study of ankle proprioception in people with mild to moderate PD and healthy age-matched controls. Included in the study were thirteen participants with mild to moderate PD, aged 71 SD (31) years, and 14 age-matched controls, aged 66 SD (21) years. Proprioception of the ankle was measured using the Active Movement Extent Discrimination Apparatus. Symptom severity was measured using the PDQ-39. Fear of falling was measured using the Falls Efficacy Scale, and participants were questioned about their history of falls during the previous 12 months. All measures were completed on one occasion. RESULTS: People with PD had significantly worse proprioception in plantarflexion (mean difference 0.045, 95% CI 0.00 to 0.09), inversion (mean difference 0.059, 95% CI 0.02 to 0.10), and overall proprioception (mean difference 0.048, 95% CI 0.00 to 0.10) than control participants. In people with PD, there was a significant moderate negative correlation between impaired proprioception and Parkinson's symptoms (r = -0.441, P = 0.021). CONCLUSIONS: Impaired proprioception of the ankle is evident in people with PD. Further research is warranted to determine whether proprioception can be improved in people with PD.

Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke: a systematic review.

QUESTION: Is biofeedback during the practice of lower limb activities after stroke more effective than usual therapy in improving those activities, and are any benefits maintained beyond the intervention? DESIGN: Systematic review with meta-analysis of randomised trials with a PEDro score > 4. PARTICIPANTS: People who have had a stroke. INTERVENTION: Biofeedback (any type delivered by any signal or sense) delivered concurrently during practice of sitting, standing up, standing or walking compared with the same amount of practice without biofeedback. OUTCOME MEASURES: Measures of activity congruent with the activity trained. RESULTS: Eighteen trials including 429 participants met the inclusion criteria. The quality of the included trials was moderately high, with a mean PEDro score of 6.2 out of 10. The pooled effect size was calculated as a standardised mean difference (SMD) because different outcome measures were used. Biofeedback improved performance of activities more than usual therapy (SMD 0.50, 95% CI 0.30 to 0.70). CONCLUSION: Biofeedback is more effective than usual therapy in improving performance of activities. Further research is required to determine the long-term effect on learning. Given that many biofeedback machines are relatively inexpensive, biofeedback could be utilised widely in clinical practice. [Stanton R, Ada L, Dean CM, Preston E (2016) Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke: a systematic review.Journal of Physiotherapy63: 11-16].