Implicit and explicit motor imagery ability after SCI: Moving the elbow makes the difference.

Cervical spinal cord injury (SCI) causes dramatic sensorimotor deficits that restrict both activity and participation. Restoring activity and participation requires extensive upper limb rehabilitation focusing elbow and wrist movements, which can include motor imagery. Yet, it remains unclear whether MI ability is impaired or spared after SCI. We investigated implicit and explicit MI ability in individuals with C6 or C7 SCI (SCIC6 and SCIC7 groups), as well as in age- and gender-matched controls without SCI. Inspired by previous studies, implicit MI evaluations involved hand laterality judgments, hand orientation judgments (HOJT) and hand-object interaction judgments. Explicit MI evaluations involved mental chronometry assessments of physically possible or impossible movements due to the paralysis of upper limb muscles in both groups of participants with SCI. HOJT was the paradigm in which implicit MI ability profiles differed the most between groups, particularly in the SCIC6 group who had impaired elbow movements in the horizontal plane. MI ability profiles were similar between groups for explicit MI evaluations, but reflected task familiarity with higher durations in the case of unfamiliar movements in controls or attempt to perform movements which were no longer possible in persons with SCI. Present results, obtained from a homogeneous population of individuals with SCI, suggest that people with long-term SCI rely on embodied cognitive motor strategies, similar to controls. Differences found in behavioral response pattern during implicit MI mirrored the actual motor deficit, particularly during tasks that involved internal representations of affected body parts.

Association of Personality Traits With the Efficacy of Stress Management Interventions for Medical Students Taking Objective Structured Clinical Examinations.

PURPOSE: Personality traits are associated with psychophysiological stress, but few studies focus on medical students. This study aimed to better understand the association of personality traits with the efficacy of stress management interventions for medical students. METHOD: A randomized controlled trial was conducted with fourth-year students who took the objective structured clinical examination at Bernard University Lyon 1 in December 2021. Students were randomized in cardiac biofeedback, mindfulness, and control groups. Each intervention was implemented for 6 minutes before the examination. Physiological stress levels were collected during the intervention. Psychological stress levels were rated by students at baseline and after the intervention. Personality traits were assessed via the Big-Five Inventory. Interactions between personality traits and the efficacy of the interventions were analyzed using multivariable linear regression models. RESULTS: Four hundred eighty-one students participated. Higher baseline psychological stress levels were associated with higher neuroticism and agreeableness (ß = 10.27, 95% confidence interval (CI) [7.40, 13.13], P < .001 and ß = 3.42, 95% CI [0.98, 5.85], P = .006, respectively) and lower openness (ß = -4.95, 95% CI [-7.40, -2.49], P < .001). As compared to the control intervention, both stress management interventions led to lower levels of psychological (P < .001 for both) and physiological stress levels (biofeedback: P < .001 and mindfulness: P = .009). Biofeedback efficacy varied by extraversion score for psychological (ß = -5.66, 95% CI [-10.83, -0.50], P = .03) and physiological stress reduction (ß = -0.002, 95% CI [-0.003, -0.00004], P = .045). Mindfulness efficacy varied by agreeableness score for psychological stress reduction (ß = -7.87, 95% CI [-13.05, -2.68], P = .003). CONCLUSIONS: Students with a high score in extraversion may benefit more from biofeedback interventions, while students with high scores in agreeableness may benefit more from mindfulness interventions.

Interrater reliability in neurology objective structured clinical examination across specialties.

PURPOSE: To assess interrater reliability and examiners' characteristics, especially specialty, associated with scoring of neurology objective structured clinical examination (OSCE). MATERIAL AND METHODS: During a neurology mock OSCE, five randomly chosen students volunteers were filmed while performing 1 of the 5 stations. Video recordings were scored by physicians from the Lyon and Clermont-Ferrand university teaching hospitals to assess students performance using both a checklist scoring and a global rating scale. Interrater reliability between examiners were assessed using intraclass coefficient correlation. Multivariable linear regression models including video recording as random effect dependent variable were performed to detect factors associated with scoring. RESULTS: Thirty examiners including 15 (50%) neurologists participated. The intraclass correlation coefficient of checklist scores and global ratings between examiners were 0.71 (CI95% [0.45-0.95]) and 0.54 (CI95% [0.28-0.91]), respectively. In multivariable analyses, no factor was associated with checklist scores, while male gender of examiner was associated with lower global rating (ß coefficient = -0.37; CI 95% [-0.62-0.11]). CONCLUSIONS: Our study demonstrated through a video-based scoring method that agreement among examiners was good using checklist scoring while moderate using global rating scale in neurology OSCE. Examiner's specialty did not affect scoring whereas gender was associated with global rating scale.

Discriminative value of different combinations of tests to detect unilateral neglect in patients with right hemisphere damage.

BACKGROUND AND PURPOSE: This study was undertaken to assess the most sensitive combination of tests to detect peripersonal unilateral neglect (UN) after stroke. METHODS: The present study is a secondary analysis of a previously reported multicentric study of 203 individuals with right hemisphere damage (RHD), mainly subacute stroke, 11 weeks postonset on average, and 307 healthy controls. A battery of seven tests, providing 19 age- and education-adjusted z-scores, were given: the bells test, line bisection, figure copying, clock drawing, overlapping figures test, and reading and writing. Statistical analyses used a logistic regression and a receiver operating characteristic (ROC) curve after adjustment on demographic variables. RESULTS: A combination of four z-scores based on the following three tests provided good discrimination of patients with RHD from matched healthy controls: the starting point and the difference between the number of omissions on left and right sides from the bells test, rightward deviation in bisection of long lines (20 cm), and left-sided omissions in a reading task. The area under the ROC curve was 0.865 (95% confidence interval = 0.83-0.901), with sensitivity = 0.68, specificity = 0.95, accuracy = 0.85, positive predictive value = 0.90, and negative predictive value = 0.82. CONCLUSIONS: The most sensitive and parsimonious combination of tests to detect UN after stroke relies on four scores from three simple tests (bells test, line bisection, and reading). Future study is warranted to assess its ability to account for the functional difficulties of UN in daily life in the patient's actual environment.

Evaluation of Selective Tibial Neurotomy for the Spastic Foot Treatment Using a Personal Goal-Centered Approach: A 1-Year Cohort Study.

BACKGROUND: Selective tibial neurotomy (STN) has already demonstrated its effectiveness to reduce foot deformities and spasticity, but assessment according to a goal-centered approach is missing. OBJECTIVE: To evaluate the effectiveness of STN associated with a postoperative rehabilitation program for the treatment of the spastic foot, according to a goal-centered approach. METHODS: Interventional study (before-after STN and rehabilitation program) with observational design including consecutive adult patients with spastic foot, who received STN followed by a rehabilitation program, was performed. The primary outcome measure was the achievement of individual goals at the 1-year follow-up using the Goal Attainment Scaling methodology (with T-score). The secondary outcomes measures were the Modified Ashworth Scale and the modified Rankin Score. RESULTS: A total of 104 patients were included. At the 1-year follow-up, 228/252 (90.5%) goals were achieved: 62/252 (24.6%) were achieved as initially expected, 86/252 (34.1%) were achieved better than initially expected, and 80 (31.7%) were achieved much better than initially expected. The mean T-score was significantly increased at the 1-year follow-up (61.5 ± 10.5) compared with the preoperative period (38.1 ± 2.9, P < .00001), and 95/104 (91.3%) patients had a T-score ≥50, meaning that these patients have achieved their goals. At follow-up, spastic deformities were all significantly decreased ( P < .0001), the Modified Ashworth Scale was significantly lower for each muscle targeted ( P < .0001), and the modified Rankin Score was significantly decreased ( P < .0001) allowing the patient population to improve from a moderate to a slight disability status. CONCLUSION: This study showed that STN, associated with a postoperative rehabilitation program, successfully achieve personal goals in patients with spastic foot.

Rehabilitation professionals' views on individual peer support interventions for assisting stroke survivors with reintegration into the community: a qualitative study.

PURPOSE: We aimed to explore stroke rehabilitation professionals' understanding and representations of peer support; the benefits they anticipated for patients; and the levers and barriers they perceived to implement the intervention in their practice. MATERIALS AND METHODS: This qualitative study comprised four focus groups with 21 rehabilitation professionals and four semi-structured interviews. It was held in a French hospital. Interpretation was guided by the Consolidated Framework for Implementation Research. RESULTS: Although professionals had poor knowledge on peer support, they identified many unmet needs of stroke survivors that peer support could meet such as social, emotional and informational support. Main barriers were the lack of human and financial resources, and of linkage between hospital and community professionals, and the fear that peer support would give false hope to survivors if not delivered properly. They showed ambivalence towards patient engagement, acknowledging its importance, but demonstrating top-down attitudes. They also identified potential avenues for the implementation of peer support for stroke survivors. CONCLUSIONS: Our study supports the necessity to involve professionals in the construction of peer-support interventions and to sensitise them to provide patient-centred care. It delivers insights on effective implementation strategies to develop peer support interventions for stroke survivors reintegrating the community.

Stroke survivors experience many difficulties especially when transitioning from hospital to home, in which peer-support could be helpful.Success of peer-support interventions rely on the collaboration of healthcare professionals with peer supporters.Individual peer-support might be useful for stroke survivors in the following key dimensions: healthcare pathway orientation, social/administrative procedures, emotional support, informational support, informal caregivers support.Rehabilitation departments planning to implement individual peer-support, should consider supporting and training both the team and the peer-supporters to work together and adopt partnership postures.

Factors associated with post-stroke social participation: A quantitative study based on the ICF framework.

BACKGROUND: Post-stroke social participation is a major determinant of quality of life and life satisfaction. However, few data relating to participation determinants are available, especially the influence of psychological factors and factors related to the living environment. OBJECTIVES: This study investigated determinants of post-stroke social participation within the International Classification of Functioning, Disability and Health framework. METHODS: We contacted people with stroke who had been hospitalized in the Rhône County, included in a previous cohort study, were aged ≥18 years and were not institutionalized. The primary outcome was social participation measured with the Stroke Impact Scale (SIS) 2.0. We performed multiple hierarchical linear regressions to test the following predictors: clinical factors (stroke-related variables, limitations in Activities of Daily Living [ADL]/Instrumental ADL), personal factors (sociodemographic factors, coping strategies) and environmental factors (satisfaction with social relationships and living environment). RESULTS: Among the 352 participants, 63% were men, and mean age was 68.7(SD 14.5) years. In the last multivariate model, variables associated with higher levels of social participation were the use of the positive thinking coping strategy (B (SD)=1.17(0.52), p = 0.03), higher perceived satisfaction with the living environment (B (SD)=0.17(0.07), p = 0.03) and fewer perceived activity limitations (B (SD)=0.55 (0.06), p < 0.001). Conversely, the seeking social support coping style (B (SD)= -1.98 (0.60), p = 0.001), and a higher number of stroke-related sequelae (B (SD)= -1.93(0.53), p = 0.001) were associated with lower social participation. CONCLUSIONS: The identification of potentially modifiable personal and environmental factors that influence social participation provides elements to strengthen existing rehabilitation programs and opens the way for possible psychosocial interventions.

Case Report: True Motor Recovery of Upper Limb Beyond 5 Years Post-stroke.

Most of motor recovery usually occurs within the first 3 months after stroke. Herein is reported a remarkable late recovery of the right upper-limb motor function after a left middle cerebral artery stroke. This recovery happened progressively, from two to 12 years post-stroke onset, and along a proximo-distal gradient, including dissociated finger movements after 5 years. Standardized clinical assessment and quantified analysis of the reach-to-grasp movement were repeated over time to characterize the recovery. Twelve years after stroke onset, diffusion tensor imaging (DTI), functional magnetic resonance imaging (fMRI), and transcranial magnetic stimulation (TMS) analyses of the corticospinal tracts were carried out to investigate the plasticity mechanisms and efferent pathways underlying motor control of the paretic hand. Clinical evaluations and quantified movement analysis argue for a true neurological recovery rather than a compensation mechanism. DTI showed a significant decrease of fractional anisotropy, associated with a severe atrophy, only in the upper part of the left corticospinal tract (CST), suggesting an alteration of the CST at the level of the infarction that is not propagated downstream. The finger opposition movement of the right paretic hand was associated with fMRI activations of a broad network including predominantly the contralateral sensorimotor areas. Motor evoked potentials were normal and the selective stimulation of the right hemisphere did not elicit any response of the ipsilateral upper limb. These findings support the idea that the motor control of the paretic hand is mediated mainly by the contralateral sensorimotor cortex and the corresponding CST, but also by a plasticity of motor-related areas in both hemispheres. To our knowledge, this is the first report of a high quality upper-limb recovery occurring more than 2 years after stroke with a genuine insight of brain plasticity mechanisms.

Assessing the implementation of community-based learning in public health: a mixed methods approach.

BACKGROUND: The French government has set up a community-based learning programme on health promotion for undergraduate health students to involve them in key public health objectives. At the University of Lyon, students first underwent formal instruction, including e-learning, lectures, and interactive seminars, and then became health educators for school pupils. The main objective of the present study was to assess the process of implementing this programme during the 2018-2019 academic year. METHODS: The satisfaction and perception of medical and midwife students with community-based learning experiences were assessed by a questionnaire, semi-directive interviews, and observations. Replies to the questionnaire were described by median and interquartile range or by proportion. A paired Wilcoxon-Mann-Whitney test was used to compare self-evaluated students' competence scores before and after the seminars (alpha risk of 5%). Thematic analyses using grounded theory were performed on recorded and transcribed interviews, and on transcribed notes taken during the observations. RESULTS: Over time the students have evolved from a negative perception of the community-based learning to a positive one. The students were mostly satisfied by interactive seminars that allowed them to gain confidence and competencies in health education. Their involvement in the programme increased their self-esteem. They became more aware of their educative responsibilities regarding public health issues as future professionals. CONCLUSIONS: The students had a positive perception of the implementation of a community-based learning programme in our University, as it appeared a pertinent strategy to raise their awareness of prevention and health education issues.

Multiprofessional intervention to improve adherence to medication in stroke patients: a study protocol for a randomised controlled trial (ADMED AVC study).

INTRODUCTION: Adherence to secondary preventive medications is often suboptimal in patients with stroke, exposing them to an increased risk of recurrent cerebral and/or cardiovascular events. Effective actions in the long term to improve adherence to medication are needed. The study will evaluate the efficacy of a collaborative multiprofessional patient-centred intervention conducted by a pharmacist on adherence to secondary preventive medication in stroke survivors. METHODS AND ANALYSIS: This is a multicentre cluster-randomised controlled trial. Two groups of 91 patients (intervention vs standard care) will be recruited. The clinical pharmacist intervention targeting secondary preventive medication will consist of three parts over 1 year: (1) an individual semi-structured interview at hospital discharge; (2) follow-up telephone interviews at 3, 6 and 9 months after discharge; and (3) a final individual semi-structured interview 1 year after discharge. Information on patient follow-up will be shared with the general practitioner and the community pharmacist by sending a report of each interview. The primary outcome is adherence to medication during the 12 months after hospital discharge, assessed using a composite endpoint: the medication possession ratio associated with a self-administered questionnaire. ETHICS AND DISSEMINATION: The local ethics committee, the national committee for use of personal data in medical research and the national data protection agency approved the study. The sponsor has no role in study design; collection, analysis and interpretation of data; or report writing. DISCUSSION: This pharmacist-led educational programme has the potential to significantly improve adherence to medication in stroke survivors which could lead to a decrease in recurrent cerebral and/or cardiovascular events. TRIAL REGISTRATION NUMBER: NCT02611440.

Determining the Interrater Reliability of the SOFMER Activity Score (version 2) for Individuals in Rehabilitation Centers.

OBJECTIVE: To assess the interrater reliability of the SOFMER Activity Score (SAS) (version 2 [v2], an 8-item [4 motor and 4 cognitive] and 5-level scale) and improve its scoring system before conducting further validation steps. DESIGN: Cross-sectional, prospective, observational, noninterventional, and multicentric study. SETTING: The study was conducted between November 2018 and September 2019 in 4 French rehabilitation centers (2 public university hospitals for adults and 2 private not-for-profit rehabilitation centers for children). PARTICIPANTS: The study included 101 participants (N=101; mean age, 44.5±25.4 years; 28.7% younger than 18 and 18.8% older than 65 years). The female/male sex ratio was 0.6. The causes for admission to the center were mainly neurologic (65%) or orthopedic (24%). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Activity limitation was rated with the SAS the same day by 2 independent multidisciplinary teams. The interrater reliabilities of the score items were assessed using weighted kappa coefficients. RESULTS: All weighted kappa coefficients ranged between 0.83 and 0.92, indicating "good" to "excellent" interrater reliability. Interteam score disagreements occurred in 227 of 808 scores (28%). The reason for most disagreements was unnoticed human or material aid during the observation period. CONCLUSIONS: The results demonstrate the high interrater reliability of the SASv2 and allow carrying out further validation steps after minor changes to item scoring instructions and clearer definitions of some items that help improving scoring standardization. The SASv2 may then become a consistent measure of activity level for clinical research or burden of care investigations.

Effects of prismatic adaptation on balance and postural disorders in patients with chronic right stroke: protocol for a multicentre double-blind randomised sham-controlled trial.

INTRODUCTION: Patients with right stroke lesion have postural and balance disorders, including weight-bearing asymmetry, more pronounced than patients with left stroke lesion. Spatial cognition disorders post-stroke, such as misperceptions of subjective straight-ahead and subjective longitudinal body axis, are suspected to be involved in these postural and balance disorders. Prismatic adaptation has showed beneficial effects to reduce visuomotor disorders but also an expansion of effects on cognitive functions, including spatial cognition. Preliminary studies with a low level of evidence have suggested positive effects of prismatic adaptation on weight-bearing asymmetry and balance after stroke. The objective is to investigate the effects of this intervention on balance but also on postural disorders, subjective straight-ahead, longitudinal body axis and autonomy in patients with chronic right stroke lesion. METHODS AND ANALYSIS: In this multicentre randomised double-blind sham-controlled trial, we will include 28 patients aged from 18 to 80 years, with a first right supratentorial stroke lesion at chronic stage (≥12 months) and having a bearing ≥60% of body weight on the right lower limb. Participants will be randomly assigned to the experimental group (performing pointing tasks while wearing glasses shifting optical axis of 10 degrees towards the right side) or to the control group (performing the same procedure while wearing neutral glasses without optical deviation). All participants will receive a 20 min daily session for 2 weeks in addition to conventional rehabilitation. The primary outcome will be the balance measured using the Berg Balance Scale. Secondary outcomes will include weight-bearing asymmetry and parameters of body sway during static posturographic assessments, as well as lateropulsion (measured using the Scale for Contraversive Pushing), subjective straight-ahead, longitudinal body axis and autonomy (measured using the Barthel Index). ETHICS AND DISSEMINATION: The study has been approved by the ethical review board in France. Findings will be submitted to peer-reviewed journals relative to rehabilitation or stroke. TRIAL REGISTRATION NUMBER: NCT03154138.

Quantitative Assessment of Motor Neglect.

Background and Purpose: We used differential actigraphy as a novel, objective method to quantify motor neglect (a clinical condition whereby patients mimic hemiplegia even in the absence of sensorimotor deficits), whose diagnosis is at present highly subjective, based on the clinical observation of patients' spontaneous motor behavior. Methods: Patients wear wristwatch-like accelerometers, which record spontaneous motor activity of their upper limbs during 24 hours. Asymmetries of motor behavior are then automatically computed offline. On the basis of normal participants' performance, we calculated cutoff scores of left/right motor asymmetry. Results: Differential actigraphy showed contralesional motor neglect in 9 of 35 patients with unilateral strokes, consistent with clinical assessment. An additional patient with clinical signs of motor neglect obtained a borderline asymmetry score. Lesion location in a subgroup of 25 patients was highly variable, suggesting that motor neglect is a heterogenous condition. Conclusions: Differential actigraphy provides an ecological measure of spontaneous motor behavior, and can assess upper limb motricity in an objective and quantitative manner. It thus offers a convenient, cost-effective, and relatively automatized procedure for following-up motor behavior in neurological patients and to assess the effects of rehabilitation.

Medical students attitudes toward and intention to work with the underserved: a systematic review and meta-analysis.

BACKGROUND: Experts in the field of medical education emphasized the need for curricula that improve students' attitudes toward the underserved. However, some studies have shown that medical education tends to worsen these attitudes in students. We aimed at systematically reviewing the literature assessing the change in medical students' attitudes toward the underserved and intention to work with the underserved throughout medical education, the sociodemographic and educational factors associated with favorable medical student attitudes toward and/or intention to work with the underserved and the effectiveness of educational interventions to improve medical student attitudes toward and/or intention to work with the underserved. METHOD: We conducted a systematic review on MEDLINE, Scopus, and Web of Science databases. Three investigators independently conducted the electronic search. We assessed the change in medical students attitudes toward the underserved by computing a weighted mean effect size of studies reporting scores from validated scales. The research team performed a meta-analysis for the sociodemographic and educational factors associated with medical students attitudes toward and/or intention to work with the underserved. RESULTS: Fifty-five articles met the inclusion criteria, including a total of 109,647 medical students. The average response rate was 73.2%. Most of the studies were performed in the USA (n = 45). We observed a significant decline of medical students attitudes toward the underserved throughout medical education, in both US and non-US studies. A moderate effect size was observed between the first and fourth years (d = 0.51). Higher favorable medical students attitudes toward or intention to work with the underserved were significantly associated with female gender, being from an underserved community or ethnic minority, exposure to the underserved during medical education and intent to practice in primary care. Regarding educational interventions, the effectiveness of experiential community-based learning and curricula dedicated to social accountability showed the most positive outcome. CONCLUSIONS: Medical students attitudes toward the underserved decline throughout medical education. Educational interventions dedicated to improving the attitudes or intentions of medical students show encouraging but mixed results. The generalizability of our results is impeded by the high number of studies from the global-North included in the review.

Stroke patients' support: evaluation of knowledge, practices and training needs of French community pharmacists.

Background Stroke represents a major Public Health issue in industrialized countries because of its frequency and severity. In secondary stroke prevention, treatment efficacy is correlated to medication adherence. However, it remains suboptimal in stroke patients. Community pharmacists, in light of their positioning in the care pathway and proximity to patients, can play an essential role in patient support and improving treatment adherence. However, it is currently unknown whether pharmacists are ready to perform this task. Objective Evaluate knowledge, practices and training needs for community pharmacists in therapeutic stroke management to improve long term care for stroke patients. Setting Community pharmacies in the Rhone Alpes region (France). Method We conducted a cross sectional study via a standardized self-assessment questionnaire consisting of 40 questions divided into three parts. The latter was designed by a multidisciplinary team and distributed electronically to community pharmacists of the Rhône-Alpes region (France). Main outcome measure (a) global knowledge score on the pathology, risk factors and clinical care management, (b) description of the support practices for stroke patients, (c) training needs for pharmacists. Results The 104 participants presented a moderate level of knowledge (global score: 12/20 ± 3). Topics best mastered were: pathophysiology, target blood pressure and place of antiplatelets in the therapeutic strategy. Knowledge items that needed improvement were: warning signs correctly identified by 44% of participants, time delay for thrombolysis for which 14% answered correctly, target glycated hemoglobin levels were correct for 41%, and the 3 recommended antihypertensive drug classes were only identified by 5% of participants. Patient education received from pharmacists concerned dosage (89%), treatment adherence (88%), benefits (66%) and administration modalities of medicines (64%), management of risk factors (75% for diet, 73% for physical activity, 70% for smoking and 53% for alcohol). All pharmacists wanted additional training on risk factors and clinical management guidelines. Conclusion Based on this small study, the fragmented knowledge and varied practices promote the need for further training for pharmacists to optimize support of stroke patients. This study promotes the elaboration of training systems adapted to pharmacists' needs. This will help support the development of a targeted pharmaceutical care approach for stroke patients.