Sensorimotor delays in tracking may be compensated by negative feedback control of motion-extrapolated position.

Sensorimotor delays dictate that humans act on outdated perceptual information. As a result, continuous manual tracking of an unpredictable target incurs significant response delays. However, no such delays are observed for repeating targets such as the sinusoids. Findings of this kind have led researchers to claim that the nervous system constructs predictive, probabilistic models of the world. However, a more parsimonious explanation is that visual perception of a moving target position is systematically biased by its velocity. The resultant extrapolated position could be compared with the cursor position and the difference canceled by negative feedback control, compensating sensorimotor delays. The current study tested whether a position extrapolation model fit human tracking of sinusoid (predictable) and pseudorandom (less predictable) targets better than the non-biased position control model, Twenty-eight participants tracked these targets and the two computational models were fit to the data at 60 fixed loop delay values (simulating sensorimotor delays). We observed that pseudorandom targets were tracked with a significantly greater phase delay than sinusoid targets. For sinusoid targets, the position extrapolation model simulated tracking results more accurately for loop delays longer than 120 ms, thereby confirming its ability to compensate for sensorimotor delays. However, for pseudorandom targets, this advantage arose only after 300 ms, indicating that velocity information is unlikely to be exploited in this way during the tracking of less predictable targets. We conclude that negative feedback control of position is a parsimonious model for tracking pseudorandom targets and that negative feedback control of extrapolated position is a parsimonious model for tracking sinusoidal targets.

A multicentre study of how goal-setting is practised during inpatient stroke rehabilitation.

OBJECTIVE: To describe goal-setting during inpatient stroke rehabilitation. DESIGN: There were two stages: an electronic questionnaire for multidisciplinary teams and an analysis of goal-setting documentation for rehabilitation patients. SETTING: Five inpatient stroke units. PARTICIPANTS: Staff involved in goal-setting and patients undergoing stroke rehabilitation. RESULTS: A total of 13 therapists and 49 patients were recruited, and 351 documented goals were examined. All units used therapist-led goal-setting (60% of goals were set by therapists). In total, 72% of goals were patient-focused but patients and families were rarely directly involved. Goals focussed on basic mobility and activities of daily living (~50% and ~25% of goals, respectively). Only 41% of documented goals met the SMART criteria. Review of progress was limited: 48% of goals were never reviewed and 24% of the remainder were merely marked as 'ongoing' without a date or plan for completion. New goals and actions were often documented without any connection to previous goals. Integration between goals and treatment/action plans was mixed. In two units, goals were unconnected to a treatment or action plan, but for the remainder it was 90%-100%. However, that connection was generally vague and amounted to suggestions of the type of treatment modality that staff might employ. CONCLUSION: Goal-setting during inpatient stroke rehabilitation is therapist-led but discussed with the multidisciplinary team. Therapists mainly identified patient-focussed mobility and activities of daily living goals. Monitoring progress and revising goals were often uncompleted. Links between goals and treatment, action plans and progress were patchy.

A scoping review of the needs of children and other family members after a child's traumatic injury.

OBJECTIVE: To review children's and their families' needs after a child's traumatic injury and assessment tools to measure needs. DATA SOURCES: Medline, Embase, CINAHL and PsycINFO databases (2005-September 2017) were searched and screened for papers (of any design) investigating children's and families' needs after a child's traumatic physical injury. REVIEW METHODS: Data regarding children's and families' needs were extracted by two independent raters. Methodological quality of the identified papers was not assessed. Thematic content analysis drew out the key needs. RESULTS: A total of 12 studies were identified, involving 932 participants including 105 injured adolescents and 827 family members or professionals. The needs of children under 12 years were identified indirectly from families or professionals. Most studies focussed on traumatic brain injuries. Two groups of needs were identified: person-related and service-related. Person-related needs were categorized into adolescent-specific needs, need for support with cognitive, emotional, social and physical problems and help with practical problems. Service-related needs were categorized into the need for information, educational needs and support during care transitions (specifically access to community-based services). These needs were largely unmet, particularly regarding information, emotional support and care transitions, which were compounded by professionals' limited understanding of the children's difficulties. We found no published measurement tools to assess children's and families' needs after a child's traumatic injury. CONCLUSION: The evidence about children's and families' needs following a child's traumatic injury was limited, but needs for information, emotional support and access to community-based services were consistently unmet.

How are balance and mobility problems after stroke treated in England? An observational study of the content, dose and context of physiotherapy.

OBJECTIVE: To describe the dose, intensity and context of physiotherapy for balance and mobility problems after stroke. DESIGN: Process mapping to describe the context and non-participant observation of therapy sessions to describe the dose and content of therapy. SETTING: Four inpatient stroke units in North-West England. PARTICIPANTS: Therapy staff and previously mobile stroke survivors who were treating, or receiving treatment for balance and mobility problems in the participating units. RESULTS: Two units were stand-alone rehabilitation units; two offered a service at the weekends. One had no access to community-based rehabilitation. All had dedicated treatment facilities but often did not use them because of lack of space and difficulty transporting patients. Twenty-two patients participated and 100 treatment sessions were observed. Practicing walking, sit-to-stand and transfers were the most frequent objectives and interventions usually with the therapist(s) physically facilitating the patient's movements. The dose of practise was low; mean repetitions of sit-to-stand per session was 5 (SD 6.4); mean time spent upright per session was 11.24 (SD = 7) minutes, and mean number of steps per session was 202 (SD 118). The mean number of staff per patient was 2.1 (SD = 0.6, mode = 2), usually involving two qualified therapists. Falls prevention or management, wheelchair skills and bed mobility were not practised. CONCLUSION: Stroke physiotherapy for balance and mobility problems features low-dose, low-intensity therapist-led practice, mainly of walking and sit-to-stand. Staff:patient ratios were high. Therapists need to organize treatment sessions to maximize the intensity of functional task practice.

Bespoke versus off-the-shelf ankle-foot orthosis for people with stroke: randomized controlled trial.

OBJECTIVE: The aim of the study was to compare the effect of two designs of ankle-foot orthosis on people with stroke. DESIGN: The study design was an assessor-blind, multicentre randomized controlled trial. SETTING: The setting was community stroke services. PARTICIPANTS: A total of 139 community-dwelling stroke survivors with limited mobility were recruited. INTERVENTIONS: The two most commonly used types of ankle-foot orthosis (bespoke and off-the-shelf) were chosen. MAIN MEASURES: The main measures of the study were as follows: short- (6 weeks) and long-term (12 weeks) effects on stroke survivors' satisfaction; adverse events; mobility (Walking Handicap Scale); fear of falling (Falls Efficacy Scale-International (FES-I)) and walking impairments (gait speed and step length using the 5-m walk test). RESULTS: Long-term satisfaction was non-significantly higher in the off-the-shelf group: 72% versus 64%; OR (95% CI) = 0.64 (0.31 to 1.3); P = 0.21. No statistically significant differences were found between the orthoses except that the off-the-shelf group had less fear of falling at short-term follow-up than the bespoke group: mean difference (95% CI) = -4.6 (-7.6 to -1.6) points on the FES-I; P = 0.003. CONCLUSION: No differences between off-the-shelf and bespoke ankle-foot orthoses were found except that participants in the off-the-shelf orthosis group had less fear of falling at short-term follow-up.

Why do stroke survivors not receive recommended amounts of active therapy? Findings from the ReAcT study, a mixed-methods case-study evaluation in eight stroke units.

OBJECTIVE: To identify why the National Clinical Guideline recommendation of 45 minutes of each appropriate therapy daily is not met in many English stroke units. DESIGN: Mixed-methods case-study evaluation, including modified process mapping, non-participant observations of service organisation and therapy delivery, documentary analysis and semi-structured interviews. SETTING: Eight stroke units in four English regions. SUBJECTS: Seventy-seven patients with stroke, 53 carers and 197 stroke unit staff were observed; 49 patients, 50 carers and 131 staff participants were interviewed. RESULTS: Over 1000 hours of non-participant observations and 433 patient-specific therapy observations were undertaken. The most significant factor influencing amount and frequency of therapy provided was the time therapists routinely spent, individually and collectively, in information exchange. Patient factors, including fatigue and tolerance influenced therapists' decisions about frequency and intensity, typically resulting in adaptation of therapy rather than no provision. Limited use of individual patient therapy timetables was evident. Therapist staffing levels were associated with differences in therapy provision but were not the main determinant of intensity and frequency. Few therapists demonstrated understanding of the evidence underpinning recommendations for increased therapy frequency and intensity. Units delivering more therapy had undertaken patient-focused reorganisation of therapists' working practices, enabling them to provide therapy consistent with guideline recommendations. CONCLUSION: Time spent in information exchange impacted on therapy provision in stroke units. Reorganisation of therapists' work improved alignment with guidelines.

What are the barriers and facilitators to goal-setting during rehabilitation for stroke and other acquired brain injuries? A systematic review and meta-synthesis.

OBJECTIVE: To identify the barriers and facilitators to goal-setting during rehabilitation for stroke and other acquired brain injuries. DATA SOURCES: AMED, Proquest, CINAHL and MEDLINE. REVIEW METHODS: Two reviewers independently screened, extracted data and assessed study quality using the Mixed Methods Appraisal Tool and undertook thematic content analysis for papers examining the barriers and facilitators to goal-setting during stroke/neurological rehabilitation (any design). Last searches were completed in May 2016. RESULTS: Nine qualitative papers were selected, involving 202 participants in total: 88 patients, 89 health care professionals and 25 relatives of participating patients. Main barriers were: Differences in staff and patients perspectives of goal-setting; patient-related barriers; staff-related barriers, and organisational level barriers. Main facilitators were: individually tailored goal-setting processes, strategies to promote communication and understanding, and strategies to avoid disappointment and unrealistic goals. In addition, patients' and staff's knowledge, experience, skill, and engagement with goal-setting could be either a barrier (if these aspects were absent) or a facilitator (if they were present). CONCLUSION: The main barriers and facilitators to goal-setting during stroke rehabilitation have been identified. They suggest that current methods of goal-setting during inpatient/early stage stroke or neurological rehabilitation are not fit for purpose.

Mechanisms of action of an implementation intervention in stroke rehabilitation: a qualitative interview study.

BACKGROUND: Despite best evidence demonstrating the effectiveness of increased intensity of exercise after stroke, current levels of therapy continue to be below those required to optimise motor recovery. We developed and tested an implementation intervention that aims to increase arm exercise in stroke rehabilitation. The aim of this study was to illustrate the use of a behaviour change framework, the Behaviour Change Wheel, to identify the mechanisms of action that explain how the intervention produced change. METHODS: We implemented the intervention at three stroke rehabilitation units in the United Kingdom. A purposive sample of therapy team members were recruited to participate in semi-structured interviews to explore their perceptions of how the intervention produced change at their work place. Audio recordings were transcribed and imported into NVivo 10 for content analysis. Two coders separately analysed the transcripts and coded emergent mechanisms. Mechanisms were categorised using the Theoretical Domains Framework (TDF) (an extension of the Capability, Opportunity, Motivation and Behaviour model (COM-B) at the hub of the Behaviour Change Wheel). RESULTS: We identified five main mechanisms of action: 'social/professional role and identity', 'intentions', 'reinforcement', 'behavioural regulation' and 'beliefs about consequences'. At the outset, participants viewed the research team as an external influence for whom they endeavoured to complete the study activities. The study design, with a focus on implementation in real world settings, influenced participants' intentions to implement the intervention components. Monthly meetings between the research and therapy teams were central to the intervention and acted as prompt or reminder to sustain implementation. The phased approach to introducing and implementing intervention components influenced participants' beliefs about the feasibility of implementation. CONCLUSIONS: The Behaviour Change Wheel, and in particular the Theoretical Domains Framework, were used to investigate mechanisms of action of an implementation intervention. This approach allowed for consideration of a range of possible mechanisms, and allowed us to categorise these mechanisms using an established behaviour change framework. Identification of the mechanisms of action, following testing of the intervention in a number of settings, has resulted in a refined and more robust intervention programme theory for future testing.

The reliability and validity of the English version of the Evaluation of Daily Activity Questionnaire for people with rheumatoid arthritis.

OBJECTIVES: The Evaluation of Daily Activity Questionnaire (EDAQ) includes 138 items in 14 domains identified as important by people with RA. The aim of this study was to test the validity and reliability of the English EDAQ. METHODS: A total of 502 participants completed two questionnaires 3 weeks apart. The first consisted of the EDAQ, HAQ, RA Quality of Life (RAQoL) and the Medical Outcomes Scale (MOS) 36-item Short-Form Health Survey (SF-36v2), and the second consisted of the EDAQ only. The 14 EDAQ domains were tested for: unidimensionality-using confirmatory factor analysis; fit, response dependency, invariance across groups (differential item functioning)-using Rasch analysis; internal consistency [Person Separation Index (PSI)]; concurrent validity-by correlations with the HAQ, SF-36v2 and RAQoL; and test-retest reliability (Spearman's correlations). RESULTS: Confirmatory factor analysis of the 14 EDAQ domains indicated unidimensionality, after adjustment for local dependency in each domain. All domains achieved a root mean square error of approximation <0.10 and satisfied Rasch model expectations for local dependency. DIF by age, gender and employment status was largely absent. The PSI was consistent with individual use (PSI = 0.94 for all 14 domains). For all domains, except Caring, concurrent validity was good: HAQ (rs = 0.72-0.91), RAQoL (rs = 0.67-0.82) and SF36v2 Physical Function scale (rs = -0.60 to -0.84) and test-retest reliability was good (rs = 0.70-0.89). CONCLUSION: Analysis supported a 14-domain, two-component structure (Self care and Mobility) of the EDAQ, where each domain, and both components, satisfied Rasch model requirements, and have robust reliability and validity.

The effect of a structured model for stroke rehabilitation multi-disciplinary team meetings on functional recovery and productivity: a Phase I/II proof of concept study.

OBJECTIVE: Regular multidisciplinary team meetings are the main way that teams operate, yet our earlier research found they can sometimes be suboptimal. We developed a model to structure multidisciplinary team meetings and assessed the feasibility, acceptability and impact of its implementation on meeting quality and patient outcomes. DESIGN: Longitudinal cohort design with non-participant observation of multidisciplinary team meetings before and after implementation of the intervention. SETTING: Inpatient stroke rehabilitation units. SUBJECTS: Members of the multidisciplinary inpatient stroke rehabilitation teams. INTERVENTION: A model to structure multidisciplinary team meetings. MAIN MEASURES: Quality of multidisciplinary team meetings (using a predefined checklist); change in independence (Barthel Index) during admission; length of stay; meeting duration and the number of patients discussed. RESULTS: At baseline, meeting quality was generally low. Following implementation, all aspects of meeting quality improved by 5%-58%. This was achieved without loss of staff productivity or additional resources: The mean number of patients treated during the observation periods was 36 (SD 17.6), which was unchanged after implementation. Nor were there any significant changes in the length of meetings (mean = 76 minutes), time spent discussing each patient (5.4 vs. 7 minutes) or length of stay (26.7 vs. 30.3 days), but there was a greater increase in Barthel Index score after implementation (3.8 vs. 4.7) indicating greater functional recovery. CONCLUSIONS: A feasible and acceptable model to structure multidisciplinary stroke team meetings has been developed and implemented. This increased meeting quality without increase in resources and may increase patient recovery.

How to measure fatigue in neurological conditions? A systematic review of psychometric properties and clinical utility of measures used so far.

OBJECTIVE: To systemically review the psychometric properties and clinical utility (feasibility) of tools to measure fatigue in neurological conditions. DATA SOURCES: AMED, CINAHL, MEDLINE, Science Direct and Web of Knowledge were searched for studies of the psychometric properties of fatigue measures in adults with central nervous system disorders. Search terms were: Fatigue AND assess* OR measure* OR tool OR outcome OR index OR test OR scale AND stroke OR cerebrovascular* OR hemi* OR parkinson* OR sclerosis OR head injury OR brain injury OR motor neurone disease OR neuro* REVIEW METHODS: Articles that addressed validity; reliability and ability to detect change were selected. Two authors independently selected articles and extracted data. Strength of the psychometric properties and clinical utility were assessed against predetermined thresholds. RESULTS: A total of 25 articles were selected and 17 measurement tools identified including six versions of the Fatigue Severity Scale and five versions of the Fatigue Impact Scale. All were clinically feasible but none met all the criteria. Most were valid. Reliability and ability to detect change were infrequently evaluated, but were adequate when reported. The most thoroughly developed and psychometrically robust measures were the Neurological Fatigue Indices. CONCLUSION: Although many measures of fatigue in neurological conditions have published, none met all of the criteria for psychometric robustness and clinical utility but the Neurological Fatigue Indices are the best and can be used with caution.

How to measure pain in neurological conditions? A systematic review of psychometric properties and clinical utility of measurement tools.

OBJECTIVE: To systematically review the psychometric properties and clinical utility of measures of pain in neurological conditions. DATA SOURCES: Electronic databases (AMED, CINAHL, MEDLINE, PEDro and Web of Knowledge) were searched from their inception to February 2013. REVIEW METHODS: Studies investigating any measurement tool to assess pain in central nervous system conditions were systematically identified. Data about their psychometric properties and clinical utility were extracted and analysed independently. The strength of the psychometric properties and clinical utility were assessed. RESULTS: A total of 13 articles met the selection criteria, which assessed 11 measurement tools; eight pain rating scales; one Neuropathic Pain Scale; and two measures of pain interference with every-day life. Most of the pain rating scales were specifically for hemiplegic shoulder pain. None had been sufficiently developed to recommend for use in clinical practice or research. Evaluation of reliability and the ability to detect change were particularly sparse. Reliability depended on the type of tools used. Patients with right hemisphere damage favoured verbal/written responses, while people with left hemisphere damage preferred and reported more effectively using visual/numeric responses. Validity between measures of pain intensity was moderate, while validity with mood or quality of life was weak to moderate. CONCLUSION: None of the selected measures of pain have been fully developed or evaluated to demonstrate that they provide accurate, relevant reproducible information.

Service users' views of the assessment process in stroke rehabilitation.

OBJECTIVE: To investigate the service users' (stroke survivors and care-givers) experiences and views of the rehabilitation assessment process. DESIGN: Qualitative data analysis from three focus groups using a content analysis to identify the major themes. SETTING: Participants were recruited from stroke support groups and community rehabilitation services in a large UK city. SUBJECTS: Seventeen community-dwelling stroke survivors who had completed their rehabilitation within the previous year and six care-givers. RESULTS: Five themes emerged: understanding the purpose of the assessment; repetition of assessments; feedback about assessments and progress; format of feedback and barriers to feedback. While all participants reported undergoing assessment, some felt their purpose was not always explained and resented unexplained repetitions of tests. Some participants reported a positive experience, but most wanted more information about their progress and predictions of recovery. They wanted regular, consistent, objective information presented in layman's terms; verbally and in writing. Some carers reported difficulty accessing information particularly as a result of confidentiality policies. While some participants accepted these short-comings, others considered them due to staff's disinterest or ineptitude, which undermined their trust in the team. CONCLUSIONS: Stroke service users require clear information about the purpose of assessments and regular, consistent, objective feedback about their progress using layman's language both verbally and in writing.

What influences provision of information about recovery on stroke units? A focused ethnographic case study.

OBJECTIVE: Patients and carers frequently report dissatisfaction with post-stroke information provision. This study aimed to develop an in-depth understanding of the factors influencing provision of information about recovery in stroke units. METHODS: Focused ethnographic case-studies in two UK stroke units, including non-participant observations and semi-structured interviews with professionals, patients and carers, and documentary analysis. A Framework approach to analysis was undertaken. RESULTS: Twenty patients, 17 carers and 47 professionals participated. The unpredictable recovery trajectory led professionals to present prognostic estimates as uncertain possibilities. The need to maintain patients' motivation limited sharing of negative predictions, and generic information over-emphasised the importance of therapy in recovery. A structured multidisciplinary team approach to delivering information improved consistency. Complex clinical reasoning was required to identify and meet patients' needs. Hospital environments and routines restricted opportunities for dialogue, particularly with carers. CONCLUSIONS: The process of providing information about post-stroke recovery is complex, requiring enhanced clinical reasoning and communication. The challenges faced by professionals are numerous and if not addressed can result in suboptimal provision. PRACTICE IMPLICATIONS: Professionals should develop a co-ordinated multidisciplinary approach to information provision; and engage in dialogue to ensure a tailored approach to identifying and meeting patients' and carers' information needs.

Effects of an ankle-foot orthosis on balance and walking after stroke: a systematic review and pooled meta-analysis.

OBJECTIVE: To determine the effectiveness of an ankle-foot orthosis (AFO) on mobility, walking, and balance in people with stroke. DATA SOURCES: The following databases were searched from inception to November 2011: Cochrane Stroke, Movement Disorders and Injuries Groups, MEDLINE, Embase, CINAHL, AMED, PsycINFO, and the Physiotherapy Evidence Database. Previous reviews, reference lists, and citation tracking of the selected articles were screened, and the authors of selected trials were contacted for any further unpublished data. STUDY SELECTION: Randomized controlled trials of AFOs in people with stroke, which measured balance, walking impairments, or mobility and were reported in English, were selected. Then we independently identified trials, extracted data, and assessed trial quality. DATA EXTRACTION: Trials with a low risk of selection, performance, and attrition bias were selected for analysis. Information on the trial design, population recruited, intervention delivered, outcomes measured, and the mean ± SD values for the treatment and control groups were extracted. DATA SYNTHESIS: Continuous outcomes were combined using weighted or standardized mean differences with 95% confidence intervals and a fixed-effect model. Thirteen trials with 334 participants were selected. The effect of an AFO on walking activity (P=.000-.001), walking impairment (P=.02), and balance (weight distribution) (P=.003) was significant and beneficial. The effect on postural sway (P=.10) and timed mobility tests (P=.07-.09) was nonsignificant, and the effect on functional balance was mixed. The selected trials were all crossover trials of the immediate effects; long-term effects are unexplored. CONCLUSIONS: An AFO can improve walking and balance after stroke, but only the immediate effects have been examined. The effects and acceptability of long-term usage need to be evaluated.

The effects of transcutaneous electrical nerve stimulation on strength, proprioception, balance and mobility in people with stroke: a randomized controlled cross-over trial.

OBJECTIVE: To investigate the feasibility and potential efficacy of 'activeTENS' (that is transcutaneous electrical nerve stimulation (TENS) during everyday activities) by assessing the immediate effects on strength, proprioception, balance/falls risk and mobility after stroke. DESIGN: A paired-sample randomized cross-over trial. SUBJECTS: Twenty-nine mobile chronic stroke survivors with no pre-existing conditions limiting balance or mobility or contra-indications to TENS. SETTING: University clinical research facility. INTERVENTION: A single session of 'activeTENS' delivered via a 'sock electrode' (70-130 Hz, five second cycle) plus a session of control treatment (wearing the sock electrode with no stimulation), lasting approximately two hours in total. MAIN OUTCOMES: Dorsiflexor and plantarflexor strength and proprioception using an isokinetic dyanometer, balance and falls risk (Standing Forward Reach Test) and gait speed (10-m walk test). RESULTS: All participants tolerated 'active TENS'. Most parameters improved during stimulation with activeTENS; balance (p = 0.009), gait speed (p = 0.002), plantarflexor strength (p = 0.008) and proprioception of plantarflexion (p = 0.029), except dorsiflexor strength (p = 0.194) and dorsiflexion proprioception (p = 0.078). CONCLUSIONS: The results provide initial evidence of the potential of 'active TENS' to benefit physical function after stroke which warrants further phase II trials to develop the intervention. Concerns that stimulation could have a detrimental impact on balance and increase risk of falls were not supported.

Sensory impairments of the lower limb after stroke: a pooled analysis of individual patient data.

OBJECTIVE: To obtain more generalizable information on the frequency and factors influencing sensory impairment after stroke and their relationship to mobility and function. METHOD: A pooled analysis of individual data of stroke survivors (N = 459); mean (SD) age = 67.2 (14.8) years, 54% male, mean (SD) time since stroke = 22.33 (63.1) days, 50% left-sided weakness. Where different measurement tools were used, data were recorded. Descriptive statistics described frequency of sensory impairments, kappa coefficients investigated relationships between sensory modalities, binary logistic regression explored the factors influencing sensory impairments, and linear regression assessed the impact of sensory impairments on activity limitations. RESULTS: Most patients' sensation was intact (55%), and individual sensory modalities were highly associated (κ = 0.60, P < .001). Weakness and neglect influenced sensory impairment (P < .001), but demographics, stroke pathology, and spasticity did not. Sensation influenced independence in activities of daily living, mobility, and balance but less strongly than weakness. CONCLUSIONS: Pooled individual data analysis showed sensation of the lower limb is grossly preserved in most stroke survivors but, when present, it affects function. Sensory modalities are highly interrelated; interventions that treat the motor system during functional tasks may be as effective at treating the sensory system as sensory retraining alone.

Clinical reality of measuring upper-limb ability in neurologic conditions: a systematic review.

OBJECTIVE: To review the psychometric properties and clinical utility of upper-limb measurement tools in people with neurologic conditions to provide recommendations for practice. DATA SOURCES: MEDLINE, CINAHL, EMBASE, PEDro, and AMED. STUDY SELECTION: Independent reviewers searched, selected, and extracted data from articles that assessed reliability, validity, ability to detect change, and clinical utility of measures of the upper limb in adult neurologic conditions. DATA EXTRACTION: Measures with good psychometrics and 8 or higher (out of 10) clinical utility scores were recommended. DATA SYNTHESIS: The searches identified 31 measures of the upper limb. However, only 2 measures fulfilled all of the psychometric and clinical utility criteria; the Box and Block Test and the Action Research Arm Test. CONCLUSIONS: The Box and Block and the Action Research Arm Tests produce robust data and are feasible for use in clinical practice. Future development of new or existing measures should ensure the construct and content validity of the measure is clearly identified, standardized guidelines are easily available, and ensure that it is individualized and contemporary. Attention to measures of upper-limb activity for people who are unable to grip objects is also needed.

The Strength of the Corticospinal Tract Not the Reticulospinal Tract Determines Upper-Limb Impairment Level and Capacity for Skill-Acquisition in the Sub-Acute Post-Stroke Period.

Background. Upper-limb impairment in patients with chronic stroke appears to be partly attributable to an upregulated reticulospinal tract (RST). Here, we assessed whether the impact of corticospinal (CST) and RST connectivity on motor impairment and skill-acquisition differs in sub-acute stroke, using transcranial magnetic stimulation (TMS)-based proxy measures. Methods. Thirty-eight stroke survivors were randomized to either reach training 3-6 weeks post-stroke (plus usual care) or usual care only. At 3, 6 and 12 weeks post-stroke, we measured ipsilesional and contralesional cortical connectivity (surrogates for CST and RST connectivity, respectively) to weak pre-activated triceps and deltoid muscles with single pulse TMS, accuracy of planar reaching movements, muscle strength (Motricity Index) and synergies (Fugl-Meyer upper-limb score). Results. Strength and presence of synergies were associated with ipsilesional (CST) connectivity to the paretic upper-limb at 3 and 12 weeks. Training led to planar reaching skill beyond that expected from spontaneous recovery and occurred for both weak and strong ipsilesional tract integrity. Reaching ability, presence of synergies, skill-acquisition and strength were not affected by either the presence or absence of contralesional (RST) connectivity. Conclusion. The degree of ipsilesional CST connectivity is the main determinant of proximal dexterity, upper-limb strength and synergy expression in sub-acute stroke. In contrast, there is no evidence for enhanced contralesional RST connectivity contributing to any of these components of impairment. In the sub-acute post-stroke period, the balance of activity between CST and RST may matter more for the paretic phenotype than RST upregulation per se.

Experiences and views of receiving and delivering information about recovery in acquired neurological conditions: a systematic review of qualitative literature.

OBJECTIVE: To review and synthesise qualitative literature relating to the views, perceptions and experiences of patients with acquired neurological conditions and their caregivers about the process of receiving information about recovery; as well as the views and experiences of healthcare professionals involved in delivering this information. DESIGN: Systematic review of qualitative studies. DATA SOURCES: MEDLINE, Embase, AMED, CINAHL, PsycINFO, Web of Science and the Cochrane library were searched from their inception to July 2019. DATA EXTRACTION AND SYNTHESIS: Two reviewers extracted data from the included studies and assessed quality using an established tool. Thematic synthesis was used to synthesise the findings of included studies. RESULTS: Searches yielded 9105 titles, with 145 retained for full-text screening. Twenty-eight studies (30 papers) from eight countries were included. Inductive analysis resulted in 11 descriptive themes, from which 5 analytical themes were generated: the right information at the right time; managing expectations; it's not what you say, it's how you say it; learning how to talk about recovery and manage emotions; the context of uncertainty. CONCLUSIONS: Our findings highlight the inherent challenges in talking about recovery in an emotional context, where breaking bad news is a key feature. Future interventions should focus on preparing staff to meet patients' and families' information needs, as well as ensuring they have the skills to discuss potential recovery and break bad news compassionately and share the uncertain trajectory characteristic of acquired neurological conditions. An agreed team-based approach to talking about recovery is recommended to ensure consistency and improve the experiences of patients and their families.