Clinician Perspectives on Providing Concussion Assessment and Management via Telehealth: A Mixed-Methods Study.

OBJECTIVE: To examine clinician perspectives regarding the use of telehealth for concussion assessment and management. SETTING: A Pan-Canadian survey. PARTICIPANTS: Twenty-five purposively sampled multidisciplinary clinician-researchers with concussion expertise (female, n = 21; physician, n = 11; and other health professional, n = 14). DESIGN: Sequential mixed-method design: (1) electronic survey and (2) semistructured interviews with focus groups via videoconference. Qualitative descriptive design. MAIN OUTCOME MEASURES: Survey : A 59-item questionnaire regarding the suitability of telehealth to perform recommended best practice components of concussion assessment and management. Focus groups : 10 open-ended questions explored survey results in more detail. RESULTS: Clinicians strongly agreed that telehealth could be utilized to obtain a clinical history (96%), assess mental status (88%), and convey a diagnosis (83%) on initial assessment; to take a focused clinical history (80%); to monitor functional status (80%) on follow-up; and to manage symptoms using education on rest (92%), planning and pacing (92%), and sleep recommendations (91%); and to refer to a specialist (80%). Conversely, many clinicians believed telehealth was unsuitable to perform a complete neurologic examination (48%), cervical spine (38%) or vestibular assessment (61%), or to provide vestibular therapy (21%) or vision therapy (13%). Key benefits included convenience, provision of care, and patient-centered approach. General and concussion-specific challenges included technology, quality of care, patient and clinician characteristics, and logistics. Strategies to overcome identified challenges are presented. CONCLUSIONS: From the perspective of experienced clinicians, telehealth is suited to manage symptomatic concussion patients presenting without red flags or following an initial in-person assessment, but may have limitations in ruling out serious pathology or providing return-to-sport clearance without an in-person physical examination.

The Use of Home-Based Nonimmersive Virtual Reality to Encourage Physical and Cognitive Exercise in People With Mild Cognitive Impairment: A Feasibility Study.

Individuals with mild cognitive impairment are at risk of cognitive and physical decline. Virtual reality (VR) exercise may provide beneficial physical and cognitive exercise. The objectives of this study were to assess the feasibility and safety of home-based VR exercise and to provide pilot data for physical and cognitive efficacy. Eleven individuals with mild cognitive impairment (seven males/four females, average 78 years old, and average 3 years since diagnosis) performed a 30-min home-based VR exercise program 5 days a week for 6 weeks. The VR platform was successfully installed in participants' homes, and all participants were able to learn the VR program and progress. Participants completed 99% of the prescribed exercise. There were no major adverse events. Most participants enjoyed the VR program and reported physical benefits; fewer reported cognitive benefits. No physical or cognitive outcome measures showed change after 6 weeks. Home-based VR exercise is safe and feasible in individuals with mild cognitive impairment.

Implementation of smart supportive dementia technology in a hospital transitional care setting using human-centred design.

Supportive smart home technology, for older adults living with dementia and their informal care partners, has shown some benefits in private homes. In this study, a supportive smart home system is being implemented in a hospital alternative level of care setting. This case report describes how a team of researchers and healthcare managers are navigating the complexities of a hospital setting, using human-centred design and implementation strategies, to facilitate the implementation and adoption of the technology.

Enhancing the use of technology in the long-term care sector in Canada: Insights from citizen panels and a national stakeholder dialogue.

Enhancing the use of technology in long-term care has been identified as a key part of broader efforts to strengthen the sector in the wake of the COVID-19 pandemic. To inform such efforts, we convened a series of citizen panels, followed by a national stakeholder dialogue with system leaders focused on reimagining the long-term care sector using technology. Key actions prioritized through the deliberations convened included: developing an innovation roadmap/agenda (including national standards and guidelines); using co-design approaches for the strengthening the long-term care sector and for technological innovation; identifying and coordinating existing innovation projects to support scale and spread; enabling rapid-learning and improvement cycles to support the development, evaluation, and implementation of new technologies; and using funding models that enable the flexibility needed for such rapid-learning cycles.

Age-related changes in upper limb coordination in a complex reaching task.

When reaching to targets within arm's reach, intentional trunk motion must be neutralized by compensatory motion of the upper limb (UL). Advanced age has been associated with deterioration in the coordination of multi-joint UL movements. In the current study, we looked to determine if older adults also have difficulties modifying their UL movements (i.e., coordination between the shoulder and elbow joints), during a complex reaching task when trunk motion is manipulated. Two groups of healthy participants were recruited: 18 young (mean age = 24.28 ± 2.89 years old) and 18 older (mean age = 72.11 ± 2.39 years old) adults. Participants reached to a target with their eyes closed, while simultaneously moving the trunk forward. In 40% of trials, the trunk motion was unexpectedly blocked. Participants performed the task with both their dominant and non-dominant arms, and at a preferred and fast speed. All participants were able to coordinate motion at the elbow and shoulder joints in a similar manner and modify this coordination in accordance with motion at the trunk, regardless of the hand used or speed of movement. Specifically, in reaches that involved forward trunk motion (free-trunk trials), all participants demonstrated increased elbow flexion (i.e., less elbow extension) compared to blocked-trunk trials. In contrast, when trunk motion was blocked (blocked-trunk trials), all reaching movements were accompanied by increased shoulder horizontal adduction. While coordination of UL joints was similar across older and young adults, the extent of changes at the elbow and shoulder was smaller and less consistent in older adults compared to young participants, especially when trunk motion was involved. These results suggest that older adults can coordinate their UL movements based on task requirements, but that their performance is not as consistent as young adults.

Feasibility and preliminary efficacy of a combined virtual reality, robotics and electrical stimulation intervention in upper extremity stroke rehabilitation.

BACKGROUND: Approximately 80% of individuals with chronic stroke present with long lasting upper extremity (UE) impairments. We designed the perSonalized UPper Extremity Rehabilitation (SUPER) intervention, which combines robotics, virtual reality activities, and neuromuscular electrical stimulation (NMES). The objectives of our study were to determine the feasibility and the preliminary efficacy of the SUPER intervention in individuals with moderate/severe stroke. METHODS: Stroke participants (n = 28) received a 4-week intervention (3 × per week), tailored to their functional level. The functional integrity of the corticospinal tract was assessed using the Predict Recovery Potential algorithm, involving measurements of motor evoked potentials and manual muscle testing. Those with low potential for hand recovery (shoulder group; n = 18) received a robotic-rehabilitation intervention focusing on elbow and shoulder movements only. Those with a good potential for hand recovery (hand group; n = 10) received EMG-triggered NMES, in addition to robot therapy. The primary outcomes were the Fugl-Meyer UE assessment and the ABILHAND assessment. Secondary outcomes included the Motor Activity Log and the Stroke Impact Scale. RESULTS: Eighteen participants (64%), in either the hand or the shoulder group, showed changes in the Fugl-Meyer UE or in the ABILHAND assessment superior to the minimal clinically important difference. CONCLUSIONS: This indicates that our personalized approach is feasible and may be beneficial in improving UE function in individuals with moderate to severe impairments due to stroke. TRIAL REGISTRATION: ClinicalTrials.gov NCT03903770. Registered 4 April 2019. Registered retrospectively.

The concussion recovery questionnaire (CORE-Q): conceptual model development and item generation of a concussion-specific measure of functional status.

Introduction: Defining and measuring limitations in functional status post-concussion has been challenging, as generic measures do not accurately reflect issues most relevant to adults with persistent post-concussion symptoms.Purpose: To develop a new concussion-specific measure of functional status for use in clinical practice and intervention trials.Method: We developed a conceptual model of functioning based on concepts identified from a previous qualitative study with persons with concussion and clinicians. An initial set of questionnaire items was generated from the concepts, codes, and conceptual model. Items were refined using cognitive interviews elicit feedback on their relevance and acceptability.Results: We developed an initial set of 145 items categorized by concepts that were reduced to 50. Our final item set resulted in the COncussion REcovery Questionnaire, which contains a total of 53 items split into 3 separate scales: the Post-Concussion Functional Scale, Concussion Modifiers Scale, and Global Functional Recovery Scale.Conclusion: The new Concussion Recovery Questionnaire is a self-reported measure of functional status for monitoring outcomes in clinical practice and in clinical intervention trials following concussion. Further studies are necessary to provide evidence of the measure's psychometric properties and to determine the questionnaire's ability to facilitate clinical decision-making.

Concussed athletes walk slower than non-concussed athletes during cognitive-motor dual-task assessments but not during single-task assessments 2 months after sports concussion: a systematic review and meta-analysis using individual participant data.

OBJECTIVES: To determine whether individuals who sustained a sports concussion would exhibit persistent impairments in gait and quiet standing compared to non-injured controls during a dual-task assessment . DESIGN: Systematic review and meta-analysis using individual participant data (IPD). DATA SOURCES: The search strategy was applied across seven electronic bibliographic and grey literature databases: MEDLINE, EMBASE, CINAHL, SportDISCUS, PsycINFO, PsycARTICLES and Web of Science, from database inception until June 2017. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Studies were included if; individuals with a sports concussion and non-injured controls were included as participants; a steady-state walking or static postural balance task was used as the primary motor task; dual-task performance was assessed with the addition of a secondary cognitive task; spatiotemporal, kinematic or kinetic outcome variables were reported, and; included studies comprised an observational study design with case-control matching. DATA EXTRACTION AND SYNTHESIS: Our review is reported in line with the Preferred Reporting Items for Systematic review and Meta-Analyses-IPD Statement. We implemented the Risk of Bias Assessment tool for Non-randomised Studies to undertake an outcome-level risk of bias assessment using a domain-based tool. Study-level data were synthesised in one of three tiers depending on the availability and quality of data: (1) homogeneous IPD; (2) heterogeneous IPD and (3) aggregate data for inclusion in a descriptive synthesis. IPD were aggregated using a 'one-stage', random-effects model. RESULTS: 26 studies were included. IPD were available for 20 included studies. Consistently high and unclear risk of bias was identified for selection, detection, attrition, and reporting biases across studies. Individuals with a recent sports concussion walked with slower average walking speed (χ2=51.7; df=4; p<0.001; mean difference=0.06 m/s; 95% CI: 0.004 to 0.11) and greater frontal plane centre of mass displacement (χ2=10.3; df=4; p=0.036; mean difference -0.0039 m; 95% CI: -0.0075 to -0.0004) than controls when evaluated using a dual-task assessment up to 2 months following concussion. SUMMARY/CONCLUSIONS: Our IPD evidence synthesis identifies that, when evaluated using a dual-task assessment, individuals who had incurred a sports concussion exhibited impairments in gait that persisted beyond reported standard clinical recovery timelines of 7-10 days. Dual-task assessment (with motion capture) may be a useful clinical assessment to evaluate recovery after sports concussion. PROTOCOL PRE-REGISTRATION: This systematic review was prospectively registered in PROSPERO CRD42017064861.

Age differences in arm-trunk coordination during trunk-assisted reaching.

Reaching for an object is a basic motor skill that requires precise coordination between elbow, shoulder and trunk motion. The purpose of this research study was to examine age-related differences in compensatory arm-trunk coordination during trunk-assisted reaching. To engage the arm and trunk, an older and younger group of participants were asked to (1) maintain a fixed hand position while flexing forward at the trunk [stationary hand task (SHT)] and (2) reach to a within-arm's reach target while simultaneously flexing forward at the trunk [reaching hand task (RHT)] (Raptis et al. in J Neurophysiol 97:4069-4078, 2007; Sibindi et al. in J Vestib Res 23:237-247, 2013). Both tasks were completed with eyes closed. Participants completed the two tasks with their dominant and non-dominant arms, and at both a fast and a preferred speed. On average, young and older participants performed in a similar manner in the SHT, such that they maintained their hand position by compensating for trunk movement with modifications of the elbow and shoulder joints. In the RHT, young and older participants had similar endpoint accuracy. This similarity in performance between young and older participants in the SHT and RHT tasks was observed regardless of the arm used or movement speed. However, for both tasks, movements in older adults were significantly more variable compared to younger adults as shown by the larger variability in arm-trunk coordination performance (gain scores) in the SHT and higher movement time variability in the RHT. Thus, results imply that older adults maintain their ability to coordinate arm and trunk movements efficiently during reaching actions but are not as consistent as younger adults.

The Effects of a 5-Day Virtual-Reality Based Exercise Program on Kinematics and Postural Muscle Activity in Youth with Cerebral Palsy.

Aims: To determine the effects of a 5-day virtual reality (VR)-based intervention on anticipatory and reactive mechanisms of postural control in children and adolescents with cerebral palsy (CP). Methods: Eleven youth with CP (GMFCS levels I and II), ages 7-17, were allocated to intervention (N = 5) and control (N = 6) groups. Both groups attended balance assessment sessions 1 week apart. Participants in the intervention group received 1-hour one-on-one physiotherapist-supervised VR balance games for 5 consecutive days between assessments. For balance assessments, participants stood erect with eyes open on a movable platform that translated progressively through four speeds in the anterior/posterior direction. Participants performed two trials each of experimenter-triggered and self-triggered perturbations. Postural muscle activity and kinematics were recorded. The Anchoring Index and body segment cross-correlations were calculated as an indication of body stabilization, and the number of steps taken to regain balance/avoid falling were counted. Mann-Whitney U tests for between group differences in change scores were undertaken with an accepted significance level of 0.01. Results: No consistent differences in change scores were identified between groups. Conclusions: There was no effect of a 5-day VR-based intervention on postural control mechanisms used in response to oscillating platform perturbations. Subsequent studies will further tailor VR interventions to patients' functional balance needs.

Kinematics and postural muscular activity during continuous oscillating platform movement in children and adolescents.

The aims of this study were to (1) characterize anticipatory and reactive postural strategies in typically developing (TD) children and adolescents; (2) determine if TD youth shift from reactive to anticipatory mechanisms based on knowledge of platform movement; and (3) determine whether TD youth further modify postural strategies when additional information about the perturbation is provided. Sixteen typically developing youth aged 7-17 years stood with eyes open on a movable platform that progressively translated anteroposteriorly (20 cm peak-to-peak) through four speeds (0.1, 0.25, 0.5, and 0.61 Hz). Participants performed two trials each of experimenter-triggered and self-triggered perturbations. Postural muscle activity (1000 Hz) of the tibialis anterior, gastrocnemius, quadriceps and hamstrings and 3D whole body kinematics (100 Hz) were recorded. The Anchoring Index and marker-pair trajectory cross-correlations were calculated as indications of body stabilization. The number of steps taken to regain balance/avoid falling were counted. Transition states and steady states were analyzed separately. Generally, the higher frequencies resulted in more steps being taken, lower correlations coupled with greater temporal lags between marker trajectories, and postural muscle activity similar to older adults. The provision of self-triggered perturbations allowed participants to make the appropriate changes to their balance by use of anticipatory postural control mechanisms.

Identifying the concepts contained within health-related quality of life outcome measures in concussion research using the International Classification of Functioning, Disability, and Health as a reference: a systematic review.

PURPOSE: To identify the concepts contained within health-related quality of life (HRQOL) outcome measures used in concussion-specific research using the International Classification of Functioning, Disability, and Health (ICF) as a reference. METHODS: Eight electronic databases were searched from January 1, 1992 to March 12, 2017. Gray literature was searched, reference lists scanned, and relevant journals hand-searched. Agreement for inclusion was reached by consensus by two reviewers. A standardized data extraction tool was used to document study design, population, and key findings. Questionnaire items were linked as concepts to the corresponding second-level category of the ICF. Quality of studies was not assessed, as review was exploratory. RESULTS: Five outcome measures met the inclusion criteria, including the Perceived Quality of Life Scale, EuroQoL-5 dimensions, Quality of Life after Brain Injury, WHOQOL-100, and WHOQOL-BREF. A total of 373 concepts were extracted. 34 questions were linked to activities and participation (50.7%), 16 questions (23.9%) referred to body functions, and 17 questions (25.4%) were related to the environment. CONCLUSIONS: The wide range of concepts covered by different outcome measures demonstrates the complexity of recovery post-concussion and a lack of universal agreement in terms of what should be measured in this population. A working conceptual model of HRQOL post-concussion is proposed. Registration Prospero #CRD42017068241 (June 15, 2017).

Active Video Gaming for Children with Cerebral Palsy: Does a Clinic-Based Virtual Reality Component Offer an Additive Benefit? A Pilot Study.

AIMS: To compare changes in gross motor skills and functional mobility between ambulatory children with cerebral palsy who underwent a 1-week clinic-based virtual reality intervention (VR) followed by a 6-week, therapist-monitored home active video gaming (AVG) program and children who completed only the 6-week home AVG program. METHODS: Pilot non-randomized controlled trial. Five children received 1 hour of VR training for 5 days followed by a 6-week home AVG program, supervised online by a physical therapist. Six children completed only the 6-week home AVG program. The Gross Motor Function Measure Challenge Module (GMFM-CM) and Six Minute Walk Test (6MWT) evaluated change. RESULTS: There were no significant differences between groups. The home AVG-only group demonstrated a statistically and clinically significant improvement in GMFM-CM scores following the 6-week AVG intervention (median difference 4.5 points, interquartile range [IQR] 4.75, p = 0.042). The VR + AVG group demonstrated a statistically and clinically significant decrease in 6MWT distance following the intervention (median decrease 68.2 m, IQR 39.7 m, p = 0.043). All 6MWT scores returned to baseline at 2 months post-intervention. CONCLUSION: Neither intervention improved outcomes in this small sample. Online mechanisms to support therapist-child communication for exercise progression were insufficient to individualize exercise challenge.

A knowledge translation intervention to enhance clinical application of a virtual reality system in stroke rehabilitation.

BACKGROUND: Despite increasing evidence for the effectiveness of virtual reality (VR)-based therapy in stroke rehabilitation, few knowledge translation (KT) resources exist to support clinical integration. KT interventions addressing known barriers and facilitators to VR use are required. When environmental barriers to VR integration are less amenable to change, KT interventions can target modifiable barriers related to therapist knowledge and skills. METHODS: A multi-faceted KT intervention was designed and implemented to support physical and occupational therapists in two stroke rehabilitation units in acquiring proficiency with use of the Interactive Exercise Rehabilitation System (IREX; GestureTek). The KT intervention consisted of interactive e-learning modules, hands-on workshops and experiential practice. Evaluation included the Assessing Determinants of Prospective Take Up of Virtual Reality (ADOPT-VR) Instrument and self-report confidence ratings of knowledge and skills pre- and post-study. Usability of the IREX was measured with the System Usability Scale (SUS). A focus group gathered therapist experiences. Frequency of IREX use was recorded for 6 months post-study. RESULTS: Eleven therapists delivered a total of 107 sessions of VR-based therapy to 34 clients with stroke. On the ADOPT-VR, significant pre-post improvements in therapist perceived behavioral control (p = 0.003), self-efficacy (p = 0.005) and facilitating conditions (p =0.019) related to VR use were observed. Therapist intention to use VR did not change. Knowledge and skills improved significantly following e-learning completion (p = 0.001) and was sustained 6 months post-study. Below average perceived usability of the IREX (19th percentile) was reported. Lack of time was the most frequently reported barrier to VR use. A decrease in frequency of perceived barriers to VR use was not significant (p = 0.159). Two therapists used the IREX sparingly in the 6 months following the study. Therapists reported that client motivation to engage with VR facilitated IREX use in practice but that environmental and IREX-specific barriers limited use. CONCLUSIONS: Despite increased knowledge and skills in VR use, the KT intervention did not alter the number of perceived barriers to VR use, intention to use or actual use of VR. Poor perceived system usability had an impact on integration of this particular VR system into clinical practice.

Toilet Grab-Bar Preference and Center of Pressure Deviation During Toilet Transfers in Healthy Seniors, Seniors With Hip Replacements, and Seniors Having Suffered a Stroke.

UNLABELLED: Multiple toilet grab-bar configurations are required by people with a diverse spectrum of disability. The study purpose was to determine toilet grab-bar preference of healthy seniors, seniors with a hip replacement, and seniors post-stroke, and to determine the effect of each configuration on centre of pressure (COP) displacement during toilet transfers. METHODS: 14 healthy seniors, 7 ambulatory seniors with a hip replacement, and 8 ambulatory seniors post-stroke participated in the study. Toilet transfers were performed with no bars (NB), commode (C), two vertical bars (2VB), one vertical bar (1VB), a horizontal bar (H), two swing-away bars (S) and a diagonal bar (D). COP was measured using pressure sensitive floor mats. Participants rated the safety, ease of use, helpfulness, comfort and preference for instalment. RESULTS: 2VB was most preferred and had the smallest COP deviation. Least preferred was H and NB. C caused largest COP displacement but had favourable ratings. DISCUSSION: The preference and safety of the 2VB should be considered in the design of accessible toilets and in accessibility construction guidelines. However these results need to be verified in non-ambulatory populations. C is frequently prescribed, but generates large COP deviation, suggesting it may present an increased risk of falls.

Virtual reality exercise improves mobility after stroke: an inpatient randomized controlled trial.

BACKGROUND AND PURPOSE: Exercise using virtual reality (VR) has improved balance in adults with traumatic brain injury and community-dwelling older adults. Rigorous randomized studies regarding its efficacy, safety, and applicability with individuals after stroke are lacking. The purpose of this study was to determine whether an adjunct VR therapy improves balance, mobility, and gait in stroke rehabilitation inpatients. METHODS: A blinded randomized controlled trial studying 59 stroke survivors on an inpatient stroke rehabilitation unit was performed. The treatment group (n=30) received standard stroke rehabilitation therapy plus a program of VR exercises that challenged balance (eg, soccer goaltending, snowboarding) performed while standing. The control group (n=29) received standard stroke rehabilitation therapy plus exposure to identical VR environments but whose games did not challenge balance (performed in sitting). VR training consisted of 10 to 12 thirty-minute daily sessions for a 3-week period. Objective outcome measures of balance and mobility were assessed before, immediately after, and 1 month after training. RESULTS: Confidence intervals and effect sizes favored the treatment group on the Timed Up and Go and the Two-Minute Walk Test, with both groups meeting minimal clinical important differences after training. More individuals in the treatment group than in the control group showed reduced impairment in the lower extremity as measured by the Chedoke McMaster Leg domain (P=0.04) immediately after training. CONCLUSIONS: This VR exercise intervention for inpatient stroke rehabilitation improved mobility-related outcomes. Future studies could include nonambulatory participants as well as the implementation strategies for the clinical use of VR. CLINICAL TRIAL REGISTRATION URL: http://www.ANZCTR.org.au/. Unique identifier: ACTRN12613000710729.

Impact of forearm fatigue on the postural response to an externally initiated, predictable perturbation.

PURPOSE: The objective was to examine the impact of non-postural muscle fatigue on anticipatory postural control, during postural perturbations induced by platform translations. The experimental setup investigated the central changes caused by fatigue without the potential confounding influence of peripheral fatigue within the postural muscles. METHODS: Fatigue induced in forearm muscles by a maximal handgrip contraction has been previously shown to influence forearm force production for 10 min, reduce ankle plantarflexion force for 1 min and create measureable central fatigue for 30 s. The peak-to-peak anterior/posterior displacement of the center of mass and center of pressure (COP) and muscle activity were measured during the postural perturbation tasks performed before the fatigue protocol and for 10 min post-fatigue. RESULTS: The fatigue protocol decreased the peak-to-peak COP displacement from 128.0 ± 12.3 mm pre-fatigue to 81.9 ± 7.8 mm post-fatigue during the forwards platform translation (p < 0.05) and from 133.8 ± 12.0 to 89.2 ± 7.9 mm during the backwards translation (p < 0.05). The fatigue protocol also caused the tibialis anterior (TA pre-fatigue = -0.25 ± 0.04 s, TA post-fatigue = -0.41 ± 0.02 s, p = 0.001) and medial gastrocnemius muscles (MG pre-fatigue = -0.39 ± 0.03 s, MG post-fatigue = -0.48 ± 0.02 s, p = 0.028) to be recruited significantly earlier relative to the pre-fatigue condition. CONCLUSION: This experimental setup ensured that peripheral fatigue did not develop in the postural muscles; therefore, a general fatigued-induced modification of the postural strategy is proposed as the origin of the postural changes and delayed recovery.

From Compliance to Care: Qualitative Findings from a Survey of Essential Caregivers in Ontario Long-Term Care Homes.

BACKGROUND: The COVID-19 pandemic highlighted the importance of the care provided by family members and close friends to older people living in long-term care (LTC) homes. Our implementation science team helped three Ontario LTC homes to implement an intervention to allow family members to enter the homes during pandemic lockdowns. OBJECTIVE: We used a variety of methods to support the implementation, and this paper reports results from an Ontario-wide survey intended to help us understand the nature of the care provided by family caregivers. METHODS: We administered a survey of essential caregivers in Ontario, and a single open-ended question yielded a substantial qualitative data set that we analysed with a coding and theming procedure that yielded 13 themes. FINDINGS: The 13 themes reveal deficiencies in Ontario's LTC sector, attempts to cope with the deficiencies, and efforts to influence change and improvement. DISCUSSION: Our findings indicate that essential caregivers find it necessary to take on vital roles in order to shore up two significant gaps in the current system: they provide psychosocial and emotional (and sometimes even basic) care to residents, and they play a monitoring and advocacy role to compensate for the failings of the current regulatory compliance regime.

Motor learning in children with hemiplegic cerebral palsy and the role of sensation in short-term motor training of goal-directed reaching.

AIM: Our aim was to determine if improved upper limb kinematics in children with cerebral palsy (CP) during a reach-to-grasp task could be retained and transferred to a similar task. We also characterized the relationship between sensation and motor learning. METHOD: We used a prospective, single-participant research design with 16 children (seven males, nine females; mean/median age 8.6/9 y; age range 6-11 y) with spastic hemiparesis (Manual Ability Classification System levels II-IV). Children were randomly allocated to one of two groups: (1) task-oriented training with or (2) without trunk restraint. The intervention consisted of three 1-hour sessions per week for 5 weeks (total 15 h). Evaluations consisted of sensory modalities (tactile threshold, touch, proprioception, stereognosis) and upper limb kinematics during reach-to-grasp of an object located near and far from the body (five assessments: three pre-intervention, immediately post-intervention and 3 mo post-intervention). RESULTS: Motor improvements could be retained 3 months after the intervention and transferred to a similar task in children with CP. Proprioception and tactile thresholds were associated with retention of improvements in endpoint velocity (F2,13 =4.832, p=0.027). INTERPRETATION: Practice of activities aimed at improving upper limb kinematics led to better learning and retention of movement patterns in children with CP. Our results underline the importance of sensation for motor learning in children with CP.

Fatiguing handgrip exercise alters maximal force-generating capacity of plantar-flexors.

Exercise-induced fatigue causes changes within the central nervous system that decrease force production capacity in fatigued muscles. The impact on unrelated, non-exercised muscle performance is still unclear. The primary aim of this study was to examine the impact of a bilateral forearm muscle contraction on the motor function of the distal and unrelated ankle plantar-flexor muscles. The secondary aim was to compare the impact of maximal and submaximal forearm contractions on the non-fatigued ankle plantar-flexor muscles. Maximal voluntary contractions (MVC) of the forearm and ankle plantar-flexor muscles as well as voluntary activation (VA) and twitch torque of the ankle plantar-flexor muscles were assessed pre-fatigue and throughout a 10-min recovery period. Maximal (100 % MVC) and submaximal (30 % MVC) sustained isometric handgrip contractions caused a decreased handgrip MVC (to 49.3 ± 15.4 and 45.4 ± 11.4 % of the initial MVC for maximal and submaximal contraction, respectively) that remained throughout the 10-min recovery period. The fatigue protocols also caused a decreased ankle plantar-flexor MVC (to 77 ± 8.3 and 92.4 ± 6.2 % of pre-fatigue MVC for maximal and submaximal contraction, respectively) and VA (to 84.3 ± 15.7 and 97.7 ± 16.1 % of pre-fatigue VA for maximal and submaximal contraction, respectively). These results suggest central fatigue created by the fatiguing handgrip contraction translated to the performance of the non-exercised ankle muscles. Our results also show that the maximal fatigue protocol affected ankle plantar-flexor MVC and VA more severely than the submaximal protocol, highlighting the task-specificity of neuromuscular fatigue.