Clinical practice recommendations for management of lateropulsion after stroke determined by a Delphi expert panel.

OBJECTIVE: People exhibiting post-stroke lateropulsion actively push their body across the midline to the more affected side and/or resist weight shift toward the less affected side. Despite its prevalence and associated negative rehabilitation outcomes, no clinical practice guidelines exist for the rehabilitation of post-stroke lateropulsion. We aimed to develop consensus-based clinical practice recommendations for managing post-stroke lateropulsion using an international expert panel. DESIGN: This Delphi panel process conformed with Guidance on Conducting and Reporting Delphi Studies recommendations. PARTICIPANTS: Panel members had demonstrated clinical and/or scientific background in the rehabilitation of people with post-stroke lateropulsion. MAIN MEASURES: The process consisted of four electronic survey rounds. Round One consisted of 13 open questions. Subsequent rounds ascertained levels of agreement with statements derived from Round One. Consensus was defined a priori as ≥75% agreement (agree or strongly agree), or ≥70% agreement after excluding 'unsure' responses. RESULTS: Twenty participants completed all four rounds. Consensus was achieved regarding a total of 119 recommendations for rehabilitation approaches and considerations for rehabilitation delivery, positioning, managing fear of falling and fatigue, optimal therapy dose, and discharge planning. Statements for which 'some agreement' (50%-74% agreement) was achieved and those for which recommendations remain to be clarified were recorded. CONCLUSIONS: These recommendations build on existing evidence to guide the selection of interventions for post-stroke lateropulsion. Future research is required to elaborate specific rehabilitation strategies, consider the impact of additional cognitive and perceptual impairments, describe positioning options, and detail optimal therapy dose for people with lateropulsion.

The association between neuroimaging data and presence of lateropulsion after stroke.

BACKGROUND: Post-stroke lateropulsion is prevalent and has been associated with varied lesion locations, but existing imaging studies are limited by small participant cohorts. Evidence to guide lateropulsion rehabilitation is also limited. Improved understanding of lesion localization associated with lateropulsion post-stroke may inform more targeted intervention approaches. OBJECTIVES: This study investigated the associations between stroke neuroimaging data and presence of lateropulsion at inpatient rehabilitation admission. METHODS: This prospective, observational study included participants aged ≥65 years, admitted for inpatient stroke rehabilitation. Using routinely collected clinical neuroimaging data, stroke type, location, and volume were reported, and their association with lateropulsion presence (Four-Point Pusher Score - 4PPS) at admission was explored. RESULTS: Of 144 included participants, 82 (56.9%) had lateropulsion (4PPS ≥1). Lateropulsion presence was univariately associated with hemorrhagic stroke (p = 0.002), frontal cortical involvement (OR = 2.17, 95%CI 1.02-6.46), and white matter involvement (OR = 2.45, 95%CI 1.24-4.85), particularly frontal white matter (p = 0.021). Lesions involving the posterior limb of the internal capsule (OR = 2.88, 95% CI 1.14-7.27) and those involving the entire thalamus (OR = 1.0, p = 0.03) were associated with lateropulsion presence. When stratified by stroke type, no specific location was significantly associated with lateropulsion presence in hemorrhagic strokes. Among participants with ischemic stroke, involvement of the pre-central gyrus (OR = 2.45, 95%CI 1.05-5.76), post-central gyrus (OR = 2.76, 95%CI 1.15-6.60), inferior parietal cortex (OR = 3.95, 95%CI 1.43-10.90), and supramarginal gyrus (OR = 3.73, 95%CI 1.25-11.13) were associated with lateropulsion presence. The stroke laterality and size were not significantly associated with lateropulsion presence. CONCLUSIONS: The findings indicate a role of network disconnection in the post-stroke lateropulsion presence. Future, larger-cohort lesion-network mapping studies are recommended.

Lateropulsion resolution and outcomes up to one year post-stroke: a prospective, longitudinal cohort study.

BACKGROUND: Post-stroke lateropulsion is prevalent and associated with poor rehabilitation outcomes; however, data regarding long-term function associated with lateropulsion are lacking. OBJECTIVES: This study aimed to explore lateropulsion resolution and associations between lateropulsion, functional outcomes, and fall occurrence up to 12 months post-stroke. METHODS: Participants for this prospective, longitudinal cohort study were recruited from a Stroke Rehabilitation Unit (SRU). Assessments were conducted at SRU admission, at discharge, and at three, six, nine, and twelve months post-stroke. Outcomes included the Four-Point Pusher Score (4PPS), Functional Independence Measure (FIM), and fall occurrence. Longitudinal outcomes were modeled using generalized linear mixed-effects models. RESULTS: The final analyses included data from 144 participants. Eighty-two participants (56.9) had lateropulsion (4PPS ≥ 1) on admission. Odds of resolved lateropulsion (4PPS = 0) increased longitudinally from discharge for people who participated in rehabilitation physiotherapy (OR: 9.7, 28.1, 43.1, 81.3: <0.001 at three, six, nine, and twelve months respectively). The greatest FIM improvement among participants in all 4PPS categories occurred during the SRU inpatient phase. The probability of falls post-discharge was greatest among participants with 4PPS = 1 at three months, when compared with 4PPS = 0 (p= 0.022). CONCLUSIONS: This study showed that lateropulsion can continue to resolve up to one year post-stroke. Earlier lateropulsion resolution was associated with ongoing rehabilitation physiotherapy participation. Long-term functional gains were maintained among people discharged home, whereas functional status deteriorated after six months among those in residential care. Study findings will allow rehabilitation and service providers to better plan for and accommodate the long-term rehabilitation and care needs of people with post-stroke lateropulsion.

Dietary supplement use and folate status during pregnancy in the United States.

Adequate folate and iron intake during pregnancy is critical for maternal and fetal health. No previous studies to our knowledge have reported dietary supplement use and folate status among pregnant women sampled in NHANES, a nationally representative, cross-sectional survey. We analyzed data on 1296 pregnant women who participated in NHANES from 1999 to 2006 to characterize overall supplement use, iron and folic acid use, and RBC folate status. The majority of pregnant women (77%) reported use of a supplement in the previous 30 d, most frequently a multivitamin/-mineral containing folic acid (mean 817 µg/d) and iron (48 mg/d). Approximately 55-60% of women in their first trimester reported taking a folic acid- or iron-containing supplement compared with 76-78% in their second trimester and 89% in their third trimester. RBC folate was lowest in the first trimester and differed by supplement use across all trimesters. Median RBC folate was 1628 nmol/L among users and 1041 nmol/L among nonusers. Among all pregnant women, median RBC folate increased with trimester (1256 nmol/L in the first, 1527 nmol/L in the second, and 1773 nmol/L in the third). Given the role of folic acid in the prevention of neural tube defects, it is notable that supplement use and median RBC folate was lowest in the first trimester of pregnancy, with 55% of women taking a supplement containing folic acid. Future research is needed to determine the reasons for low compliance with supplement recommendations, particularly folic acid, in early pregnancy.

Perceptions of school nurses in the care of students with disabilities.

Many children are surviving prematurity and serious childhood illnesses due to advances in technology and medical care. As a result, more children are entering public school systems with complex health care needs and intellectual and developmental disabilities. School nurses are responsible for caring for these children; however, many nurses feel unprepared due to a lack education on disability studies in nursing school, difficulty with effective communication, and a lack of experience. A qualitative study was conducted to explore the perceptions and challenges of school nurses who worked with students with intellectual and developmental disabilities. Participants included eight nurses who worked in a public school setting, and data were collected through personal interviews, observations, and field notes. Results were analyzed categorically, and data showed that school nurses identified that they lacked education in disability studies and encountered challenges with communication, conducting health assessments, and screenings in students with intellectual and developmental disabilities.

Post-Stroke Lateropulsion: Resolution and Function After Discharge From Inpatient Rehabilitation - A Cohort Study.

Purpose: A person with post-stroke lateropulsion pushes their body toward their hemiparetic side and/or resists accepting weight onto their nonparetic side. Research findings regarding long-term persistence of lateropulsion and its association with function are lacking. This study reports associations between lateropulsion severity (Four Point Pusher Score - 4PPS) and functional outcome (Functional Independence Measure - FIM) at three months after discharge. Methods: This prospective cohort study included 41 consecutive admissions to a stroke rehabilitation unit. Lateropulsion severity and FIM were measured at admission, discharge and three-month follow-up. Lateropulsion status at discharge, stroke laterality, ongoing physiotherapy after discharge, and demographic variables (age and sex) were tested for association with FIM change over the follow-up period. Results: Complete data were available for 38 participants. Among these, 17 (44.7%) showed lateropulsion (4PPS ≥ 1) on admission, 9 (23.7%) showed persistent lateropulsion on discharge, and 7 (18.4%) showed persistent lateropulsion at three month follow-up. Improved functional status (FIM score) was seen at follow-up in those discharged with lateropulsion who had right-sided lesions but not in those with left-sided lesions. Conclusions: Lateropulsion can continue to resolve after discharge from inpatient rehabilitation. Larger cohort studies are needed to further explore associations between persistent lateropulsion and long-term outcomes.

Objectif: une personne présentant une latéropulsion après un accident vasculaire cérébral (AVC) pousse son corps du côté hémiplégique ou résiste à soutenir son poids du côté non parétique. Peu de recherches portent sur la persistance à long terme de la latéropulsion et son association avec la fonction. La présente étude rend compte des associations entre la gravité de la latéropulsion (score de Pusher en quatre points ­ 4PPS) et les résultats fonctionnels (mesure d'autonomie fonctionnelle ­ MAF) trois mois après le congé. Méthodologie: cette étude de cohorte prospective incluait 41 admissions consécutives dans une unité de réadaptation après un AVC. La gravité de la latéropulsion et la MAF ont été mesurées à l'admission, au congé et au suivi trois mois plus tard. Les chercheurs ont vérifié l'état de la latéropulsion au congé, la latéralité des AVC, la poursuite de la physiothérapie après le congé et les variables démographiques (âge et sexe) pour déterminer leur association avec les changements à la MAF pendant la période de suivi. Résultats: les chercheurs ont obtenu des données complètes au sujet de 38 participants. De ce nombre, 17 (44,7 %) présentaient une latéropulsion (4PPS ≥ 1) à l'admission, neuf (23,7 %), une latéropulsion persistante au congé, et sept (18,4 %) une latéropulsion persistante au suivi de trois mois. Les chercheurs ont observé une amélioration de l'état fonctionnel (score de MAF) au suivi chez les personnes qui présentaient une latéropulsion au congé et qui avaient des lésions du côté droit, mais pas chez celles dont les lésions se situaient du côté gauche. Conclusions: la latéropulsion peut continuer de s'atténuer après le congé de la réadaptation hospitalière. Il faudra tenir des vastes études de cohorte pour explorer davantage les associations entre la latéropulsion persistante et les résultats cliniques à long terme.

Accuracy of the Australian National Sub-Acute and Non-Acute Patient Classification in predicting rehabilitation length of stay for stroke survivors who are ≥65 years of age and have lateropulsion.

BACKGROUND: Lateropulsion is a common impairment after stroke. Regardless of stroke severity, functional recovery is slower in people with lateropulsion, resulting in requirement for longer rehabilitation duration. In Australia, inpatient rehabilitation funding is determined via the Australian National Sub-Acute and Non-Acute Patient Classification (AN-SNAP). AN-SNAP class is determined using age, diagnosis, weighted Functional Independence Measure (FIM) motor score, and FIM cognitive score. OBJECTIVES: To explore accuracy of the AN-SNAP to predict length of stay (LOS) for people with poststroke lateropulsion. METHODS: A retrospective database audit was undertaken. AN-SNAP predicted LOS for each participant was calculated based on 2019 calendar year national benchmarks. A multivariable linear regression model estimated mean differences in reported LOS and AN-SNAP predicted LOS after adjusting for lateropulsion severity (Four Point Pusher Score). A separate logistic regression model assessed whether FIM change during admission was associated with reported LOS exceeding AN-SNAP predicted LOS. RESULTS: Data were available from 1126 admissions. Reported LOS exceeding AN-SNAP predicted LOS was associated with greater lateropulsion severity on admission. Where AN-SNAP predicted LOS was longer, those with no lateropulsion on admission showed shorter reported than predicted LOS. Greater improvement in FIM during rehabilitation was associated with increased odds of reported LOS exceeding AN-SNAP predicted LOS (OR 1.02, 95%CI 1.01-1.03, p < .001). CONCLUSIONS: Inclusion of a measure of poststroke lateropulsion in the AN-SNAP classification model would result in more accurate LOS predictions to inform funding. Costs of longer rehabilitation LOS may be countered by optimized long-term physical function, reducing requirement for ongoing care.

A prospective, multicentre, randomized, double-blind, placebo-controlled trial of onabotulinumtoxinA to treat plantarflexor/invertor overactivity after stroke.

OBJECTIVE: To examine the safety and efficacy of onabotulinumtoxinA (Botox) for plantarflexor overactivity following stroke. DESIGN: Double-blind randomized controlled trial, open-label extension phase. SETTING: Neurology rehabilitation facilities. SUBJECTS: Eighty-five subjects with lower limb hypertonia received 200 U (n = 28) or 300 U (n = 28) of onabotulinumtoxinA or saline (n = 29) injection. PRIMARY MEASURES: Plantarflexor Ashworth scores at 12 weeks post injection and adverse events. Secondary measures: self-reported spasm frequency and pain, physician rating of hypertonia severity, gait quality and active dorsiflexion. RESULTS: Differences were not seen between onabotulinumtoxinA groups; hence data were pooled. Incidence of adverse events was not different between groups (P = 0.61). Reduction in hypertonia was not different between groups at 12 weeks (P = 0.53); however for subjects with Ashworth scores of >3 at baseline, 14/31 in the onabotulinumtoxinA group demonstrated a reduction of >1 grade versus 1/17 receiving placebo injection (P = 0.01). Overall, onabotulinumtoxinA-injected subjects demonstrated significantly greater improvement in spasm frequency (22/54 versus 4/29, P = 0.01), pain reduction (8/54 versus 1/29, P = 0.02), active dorsiflexion (8/54 versus 1/29 P = 0.03) and gait quality (17/54 versus 6/29, P = 0.02) than controls. In the open-label phase, a second onabotulinumtoxinA injection was associated with greater hypertonia reduction (P = 0.005) and gait quality (P = 0.002) compared with single injection. CONCLUSIONS: OnabotulinumtoxinA injection for ankle flexor overactivity after stroke was safe and well tolerated but did not alter local spasticity at 12 weeks; it did reduce spasms and improve gait quality. There were no detectable differences between higher and lower doses. A second injection may be associated with greater change.

The use of botulinum toxin type A in the management of adult-onset focal spasticity: a survey of Australian allied health professionals.

BACKGROUND: Recently, the European Journal of Neurology published international consensus statements for the assessment, treatment and aftercare associated with the use of botulinum neurotoxin type A. This survey examined current allied health practice in relation to botulinum neurotoxin type A use in Australia in the light of these guidelines. METHODS: An electronic questionnaire was distributed to members of neurology groups of the Australian Physiotherapy Association and Occupational Therapy Australia. The questionnaire explored assessment processes used, familiarity with pharmaceutical benefits scheme indications for botulinum neurotoxin type A use, goal setting and outcome measurement, follow-up therapy and access to spasticity management services. RESULTS: The 123 survey respondents (81 from the Australian Physiotherapy Association - response rate 16.2%, 42 from Occupational Therapy Australia - response rate 6.4%) reported that focal spasticity was a major problem for which botulinum neurotoxin type A was a primary intervention. The Tardieu scale was more frequently used than the modified Ashworth scale (82% vs. 48%). Most therapists (76.3%) reported being confident diagnosing spasticity and its functional implications (84.2%), but fewer were confident discussing referral for botulinum neurotoxin type A with doctors (56.1%). Goals were set in conjunction with the client (93.6%). Barriers to injection and adjunctive therapy (motor training etc.) included waiting times for botulinum neurotoxin type A injection, access to specialist adjunctive therapists and referral for treatment. CONCLUSIONS: Allied health practitioners in Australia report clinical practice to be closely aligned with international guidelines for the use of botulinum neurotoxin type A in adult spasticity. Therapist confidence in advocating for botulinum neurotoxin type A injection, consistent use of objective measures of spasticity and treatment outcomes and barriers to providing adjunctive therapy need to be addressed.

The association between contraversive lateropulsion and outcomes post stroke: A systematic review.

BACKGROUND: Contraversive lateropulsion is a common post-stroke impairment. Rehabilitation outcomes in stroke survivors exhibiting lateropulsion may differ from those without lateropulsion. OBJECTIVES: To systematically review evidence regarding associations between:1. Presence/severity of lateropulsion after stroke and functional outcome, rehabilitation length of stay, and discharge destination;2. Stroke-related factors and resolution of lateropulsion, functional outcome, rehabilitation length of stay, and discharge destination in affected stroke survivors. METHODS: Medline, CINAHL, and Embase databases were searched. Journal articles published in English reporting on resolution of lateropulsion, length of stay, functional outcome, and/or discharge destination associated with post-stroke lateropulsion were included for review. Studies that did not include a comparison group (stroke survivors without lateropulsion, or sub-groups of participants with lateropulsion based on stroke-related factors), animal studies, and studies reporting only on ipsiversive lateropulsion and/or lateral medullary syndrome were excluded. Two authors independently assessed studies for inclusion. Included studies were evaluated using the Risk of Bias Assessment Tool for Nonrandomized Studies. RESULTS: Screening identified 133 articles. Seven articles met inclusion criteria. People with contraversive lateropulsion after stroke can achieve similar improvements in function as those without lateropulsion, increasing likelihood of discharge home, but require longer rehabilitation durations to do so. CONCLUSIONS: The finding that longer rehabilitation durations are required for people with post-stroke lateropulsion to achieve their functional potential and increase likelihood of discharge home has implications for resourcing rehabilitation services. Given an additional three to four weeks in rehabilitation, people with post-stroke lateropulsion can achieve functional improvements function similar to those without lateropulsion.

Post-stroke lateropulsion and rehabilitation outcomes: a retrospective analysis.

PURPOSE: A person with post-stroke lateropulsion actively pushes themselves toward their hemiplegic side, or resists moving onto their non-hemiplegic side. This study aimed to determine the association of lateropulsion severity with: • Change in function (Functional Independence Measure - FIM) and lateropulsion severity (Four-Point Pusher Score - 4PPS) during inpatient rehabilitation; • Inpatient rehabilitation length of stay (LOS); • Discharge destination from inpatient rehabilitation. METHODS: Retrospective data for 1,087 participants (aged ≥65 years) admitted to a stroke rehabilitation unit (2005-2018) were analysed using multivariable regression models. RESULTS: Complete resolution of lateropulsion was seen in 69.4% of those with mild lateropulsion on admission (n = 160), 49.3% of those with moderate lateropulsion (n = 142), and 18.8% of those with severe lateropulsion (n = 181). Average FIM change was lower in those with severe lateropulsion on admission than those with no lateropulsion (p < 0.001). Higher admission 4PPS was associated with reduced FIM efficiency (p < 0.001), longer LOS (p < 0.001), (adjusted mean LOS: 35.6 days for those with severe lateropulsion versus 27.0 days for those without), and reduced likelihood of discharge home (p < 0.001). CONCLUSION: Post-stroke lateropulsion is associated with reduced functional improvement and likelihood of discharge home. However, given a longer rehabilitation duration, most stroke survivors with moderate to severe lateropulsion can achieve important functional improvement.Implications for RehabilitationWhile people with post-stroke lateropulsion can be difficult to treat and require more resources than those without lateropulsion, the majority of those affected, even in severe cases, can make meaningful recovery with appropriate rehabilitation.Although those with moderate to severe post-stroke lateropulsion may have poorer outcomes (longer LOS and reduced likelihood of discharge home) it is still important to advocate for access to rehabilitation for this patient group to give them the opportunity for optimal functional recovery.

Post-stroke lateropulsion terminology: pushing for agreement amongst experts.

Post-stroke lateropulsion is prevalent. The global inconsistency in terminology used to describe the condition presents obstacles in accurately comparing research results, reaching consensus on use of measurement tools, agreeing upon a consistent approach to rehabilitation, and translating research to clinical practice. Commencing in 2021, 20 international experts undertook a Delphi Process that aimed to compile clinical practice recommendations for the rehabilitation of lateropulsion. As a part of the process, the panel agreed to aim to reach consensus regarding terminology used to describe the condition. Improved understanding of the condition could lead to improved management, which will enhance patient outcomes after stroke and increase efficiency of healthcare resource utilisation. While consensus was not reached, the panel achieved some agreement that 'lateropulsion' is the preferred term to describe the phenomenon of 'active pushing of the body across the midline toward the more affected side, and / or actively resisting weight shift toward the less affected side'. This group recommends that 'lateropulsion' is used in future research and in clinical practice.

Treatment of refractory anterior knee pain using botulinum toxin type A (Dysport) injection to the distal vastus lateralis muscle: a randomised placebo controlled crossover trial.

OBJECTIVES: This randomised controlled crossover trial examined the efficacy of botulinum toxin type A (BoNT-A) injection, plus an exercise programme, to remediate chronic anterior knee pain (AKP) associated with quadriceps muscle imbalance. METHODS: 24 individuals with refractory AKP received either BoNT-A (500 U Dysport) or the same volume saline injection to the vastus lateralis (VL) muscle and performed home exercises focusing on re-training the vastus medialis (VM) muscle. All subjects were offered open-label injection at 12 weeks. Knee-related disability (anterior knee pain scale; AKPS) and activity-induced pain (10 cm visual analogue scale) at 12 weeks were the primary outcomes. Peak isometric extensor force was recorded and normalised VL:VM ratios were derived from simultaneous surface electromyography. Self-reported pain and disability measures were collected at six time points to a mean of 20±8 months. RESULTS: 14 subjects received BoNT-A and 10 placebo injection. Improvement at 12 weeks was significantly greater for BoNT-A compared with placebo-injected subjects for the AKPS (p<0.03), pain on kneeling (p<0.004), squatting (p<0.02) and level walking (p<0.04). At week 12, five placebo subjects crossed over to open-label injection. At 24 weeks, 16 of 19 BoNT-A-injected and two of the remaining five placebo-injected subjects were either satisfied or very satisfied with treatment outcomes. Improvements were maintained in 11 of 14 BoNT-A-injected and two of five placebo subjects available at longer-term follow-up. CONCLUSION: BoNT-A injection produced a greater reduction in pain and disability than placebo injection in carefully selected patients with chronic AKP related to quadriceps muscle imbalance.

Prolonged vastus lateralis denervation after botulinum toxin type A injection.

Intramuscular injection of botulinum toxin (BoNT) produces reversible blockade of neuromuscular transmission. In animal experimental models, recovery begins within four weeks and is usually complete by twelve weeks. We present evidence of prolonged denervation following BoNT injection of the vastus lateralis (VL) muscle to correct quadriceps muscle imbalance in patients with chronic anterior knee pain. Needle electromyography data were obtained from 10 subjects who had received a single BoNT treatment 5 to 19 months earlier as part of a clinical trial. Insertional and spontaneous activity, recruitment, and motor unit action potentials were examined. Clear differences between the injected and non-injected VL muscles, which correlated with the time since injection, were identified in all subjects. All 10 subjects studied with needle EMG showed evidence of persisting denervation in the BoNT-A injected VL muscle beyond the period of neuromotor recovery expected from animal experimental studies.

Making the transition from lead poisoning prevention to healthy homes: a qualitative study.

CONTEXT AND OBJECTIVE: The goal of this study was to create a guide for programs considering transition from Lead Poisoning Prevention to Healthy Homes. Healthy Homes programs are comprehensive, focusing on multiple residential housing hazards. This study focused on the Baltimore City Healthy Homes Division, which was selected by the Centers for Disease Control and Prevention to pilot the transition process. DESIGN, SETTING, AND PARTICIPANTS: For this qualitative study, data were collected through interviews with program staff from the Baltimore City Healthy Homes Division and followed up by focus groups with community members who received its services. Grounded theory procedures were used for data analysis. Interviews and focus groups were conducted in Baltimore City near the Health Department. Seventeen interviews were conducted with Baltimore City Healthy Homes Division staff. Three focus groups were held with 3 to 6 community participants in each group. RESULTS: Findings for the study are arranged around an organizational framework for which transition from Lead Poisoning Prevention to Healthy Homes is the central phenomenon. Three general themes emerged: (1) programmatic changes; (2) policy changes; and (3) partnerships. Quotations from participating staff and community members provide supporting evidence for the results. CONCLUSIONS: Findings provide insight into the strengths and challenges of transition for 1 program. The study has implications for change on a national level as programs around the country transition to provide families with comprehensive Healthy Homes services.

An exploration of factors influencing physical activity levels amongst a cohort of people living in the community after stroke in the south of England.

PURPOSE: To explore factors influencing physical activity (PA) reported by people living in rural/semi-rural communities in the south of England post-stroke, and to understand relationships between personal, interpersonal and environmental barriers and self-reported levels of PA. METHOD: A survey was mailed to patients of NHS Trusts who were identified as potential participants. Self-reported PA levels, type, and frequency of reported barriers were tabulated. Spearman's rank correlation coefficient was used to explore associations between self-reported PA level and: age, gender, level of physical function, fear of falling, beliefs regarding PA, available supports, and socioeconomic status. RESULTS: Seventy-six of 322 questionnaires distributed were returned (24%). Only 55.2% of respondents reported undertaking PA of sufficient intensity to meet current guidelines. Personal barriers included fear of falling, stroke-related disability, pain, and fatigue. Interpersonal and environmental barriers included lack of social support, transport, and inclement weather. Significant relationships existed between self-reported PA and fear of falling, functional mobility, and beliefs relating to PA. CONCLUSIONS: Almost half of the survey cohort reported PA levels insufficient to meet current guidelines. Similar to barriers reported in previous studies in USA and other parts of the UK, numerous interlinking and overlapping personal, interpersonal, and environmental barriers to undertaking PA were identified. Implications for Rehabilitation This study found that although more than 60% of the survey population were able to ambulate >200 m, only 55.2% reported undertaking sufficient PA to meet current guidelines, putting them at increased risk of further stroke and other co-morbidities. Participants reported a number of interlinking and overlapping personal, interpersonal, and environmental barriers to undertaking PA, which may explain this discrepancy between mobility status and self reported activity levels. Rehabilitation professionals and primary care providers are well positioned to address the barriers identified in this survey, such as providing interventions to reduce fear of falling, pain, and fatigue, providing support and education about safely increasing physical activity and addressing unhelpful beliefs about PA. Behaviour change strategies, such as increasing self-efficacy, and partnering with the person with stroke to problem solve strategies to address the barriers identified by this, and related research, are likely to be more successful in increasing PA than providing information alone.

The role of botulinum toxin injections in the management of muscle overactivity of the lower limb.

Muscle overactivity is common in patients with adult onset central nervous system damage. It can produce significant disablement in conjunction with other impairments such as adaptive soft tissue shortening and loss of muscle strength. Muscle overactivity is not evenly distributed throughout the body; across joints there is frequently imbalance between agonist and antagonist, producing abnormal joint postures and movement patterns. Due to the asymmetric nature of the abnormal activity across joints, in general we recommend local treatment targeting the more overactive of the two agonists, rather than systemic treatment. Considerable experience with the use of botulinum toxin, both serotypes A and B, in the treatment of muscle overactivity has been accumulated in the last two decades through pragmatic clinical practice and open label studies, supported by an increasing number of randomized controlled trials. In most cases, it is important to use botulinum toxin injection for treatment of muscle overactivity in the setting of wider rehabilitation goals and interventions. Focal and partial blocks with botulinum toxin should be used as a component of a general neurorehabilitation programme rather than as an alternative to other treatments. We review the evidence supporting the use of botulinum toxin to treat muscle overactivity in the lower limb, present practical guidelines on when and how to use botulinum toxin and provide direction for future research.

Assessing student clinical learning experiences.

BACKGROUND: This article describes the use of an activity worksheet and questionnaire to investigate the learning experience of students on clinical placement. The worksheet measures the amount of time students spend in different learning activities, and the questionnaire explores student satisfaction and preferred learning activities. An activity worksheet and questionnaire … investigate[d] the learning experiences of students on clinical placement METHODS: The activity worksheet and questionnaire were used in a cohort pilot study of physiotherapy students on clinical placement. RESULTS: The activity worksheet provides details of the amount of time students engage in a range of clinical and non-clinical tasks while on placement, such as time spent treating patients, working individually, working with their peers and engaging in reflective practice. In combination with the questionnaire results, it allows clinicians to gain an understanding of the clinical learning environment experienced by their students. DISCUSSION: The data collected using these tools provide a description of the students' activities while undertaking the clinical placement. This information may guide the refinement of the clinical experience, and offers an opportunity to individualise learning activities to match students' needs and preferences.

The Role of Botulinum Toxin Type A in the Clinical Management of Refractory Anterior Knee Pain.

Anterior knee pain is a highly prevalent condition affecting largely young to middle aged adults. Symptoms can recur in more than two thirds of cases, often resulting in activity limitation and reduced participation in employment and recreational pursuits. Persistent anterior knee pain is difficult to treat and many individuals eventually consider a surgical intervention. Evidence for long term benefit of most conservative treatments or surgical approaches is currently lacking. Injection of Botulinum toxin type A to the distal region of vastus lateralis muscle causes a short term functional "denervation" which moderates the influence of vastus lateralis muscle on the knee extensor mechanism and increases the relative contribution of the vastus medialis muscle. Initial data suggest that, compared with other interventions for anterior knee pain, Botulinum toxin type A injection, in combination with an active exercise programme, can lead to sustained relief of symptoms, reduced health care utilisation and increased activity participation. The procedure is less invasive than surgical intervention, relatively easy to perform, and is time- and cost-effective. Further studies, including larger randomized placebo-controlled trials, are required to confirm the effectiveness of Botulinum toxin type A injection for anterior knee pain and to elaborate the possible mechanisms underpinning pain and symptom relief.