Strategies supporting parent-delivered rehabilitation exercises to improve motor function after paediatric traumatic brain injury: A systematic review.

AIM: To identify and analyse ways in which parents are supported to deliver rehabilitation exercises to their child after traumatic brain injury (TBI), conceptualized as strategies. METHOD: A systematic search was completed using seven online databases and three grey literature databases, from inception to November 2021. The included studies focused on physical rehabilitation in children after TBI with the involvement of parents as hands-on deliverers or facilitators of rehabilitation (e.g. supervising the exercise). Intervention descriptions were reviewed to identify strategies; this was followed by fine-grained analysis using the Behaviour Change Wheel to identify intervention components. Risk of bias was analysed using the revised Cochrane Risk-of-Bias Tool for Randomized Trials or the Risk Of Bias In Non-randomized Studies - of Interventions. RESULTS: Six interventions including 211 participants and one trial protocol met the inclusion criteria. All studies included a proportion of children diagnosed with TBI and four studies included mixed samples of acquired brain injury or cerebral palsy. All interventions included elements of goal setting and instruction. INTERPRETATION: Interventions focus heavily on the initiation of physical rehabilitation, but focus less on the longer-term maintenance of rehabilitation delivery. Further research should integrate perspectives from parents to inform the development of new interventions.

On the character and production of 'active participation' in neuro-rehabilitation: an Actor-Network perspective.

The importance of patients' active involvement in neuro-rehabilitation after acquired brain injury has been consistently emphasised in recent years. However, most approaches fail to show how 'active participation' is practically enacted, focusing on individualised explanations of patient choice and behaviours, or notions of inherent patient traits. Using actor-network theory (ANT) as a sensitising concept, we investigated neuro-rehabilitation practices, asking how participation is shaped through biological and socio-material specificities, how rights to knowledge and expertise are constructed, and how a body acclimatises and adjusts within an order of participation and transformation. We analysed video-recorded fieldwork extracts, examining the work of adjusting, testing and transforming; the construction of competence and incompetence; and material and social processes involved in the division of the body and its re-composition. Our findings show how an ANT-sensitised approach provides a critical understanding and context-specific characterisation of 'active participation', produced through the association of heterogeneous actors at any one time. Such specificity and the distribution of work suggest that efforts to account for optimum therapy 'dosages', and clinical attention to establishing individually-located levels of 'self-efficacy' or 'motivation' are misdirected. The performance of 'active participation', rather, should be re-imagined as a product of diverse, mutually attuned entities. A Virtual Abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA.

Immersive technology in ophthalmology education: a systematic review.

Background: Despite the increasing use of immersive technology (IT) in ophthalmology, the effectiveness of this approach compared to other teaching practices is unclear. This systematic review aimed to determine the value of IT to teach students ophthalmic skills and whether it can supplement or replace conventional teaching practices. Methods: A systematic search was performed of CENTRAL, MEDLINE, EMBASE, ERIC and PsychINFO databases. Randomised controlled trials comparing IT interventions versus (1) no training, (2) standard training, (3) different types of IT interventions, (4) different doses of IT interventions were eligible for inclusion. Results: Seven trials involving 177 participants were included. IT offered some benefit compared to standard training as most trials demonstrated evidence of learning represented by composite performance score and performance time. Repetitive training with IT displayed similar results. Conclusion: IT appears to improve the ophthalmic skill of healthcare trainees and should be considered as a supplement to training.

The effects of increased dose of exercise-based therapies to enhance motor recovery after stroke: a systematic review and meta-analysis.

BACKGROUND: Exercise-based therapy is known to enhance motor recovery after stroke but the most appropriate amount, i.e. the dose, of therapy is unknown. To determine the strength of current evidence for provision of a higher dose of the same types of exercise-based therapy to enhance motor recovery after stroke. METHODS: An electronic search of: MEDLINE, EMBASE, CINHAL, AMED, and CENTRAL was undertaken. Two independent reviewers selected studies using predetermined inclusion criteria: randomised or quasi randomised controlled trials with or without blinding of assessors; adults, 18+ years, with a clinical diagnosis of stroke; experimental and control group interventions identical except for dose; exercise-based interventions investigated; and outcome measures of motor impairment, movement control or functional activity. Two reviewers independently extracted outcome and follow-up data. Effect sizes and 95% confidence intervals were interpreted with reference to risk of bias in included studies. RESULTS: 9 papers reporting 7 studies were included. Only 3 of the 7 included studies had all design elements assessed as low risk of bias. Intensity of the control intervention ranged from a mean of 9 to 28 hours over a maximum of 20 weeks. Experimental groups received between 14 and 92 hours of therapy over a maximum of 20 weeks. The included studies were heterogeneous with respect to types of therapy, outcome measures and time-points for outcome and follow-up. Consequently, most effect sizes relate to one study only. Single study effect sizes suggest a trend for better recovery with increased dose at the end of therapy but this trend was less evident at follow-up Meta-analysis was possible at outcome for: hand-grip strength, -10.1 [-19.1,-1.2] (2 studies, 97 participants); Action Research Arm Test (ARAT), 0.1 [-5.7,6.0] (3 studies, 126 participants); and comfortable walking speed, 0.3 [0.1,0.5] (2 studies, 58 participants). At follow-up, between 12 and 26 weeks after start of therapy, meta-analysis findings were: Motricity Arm, 10.7 [1.7,19.8] (2 studies, 83 participants); ARAT, 2.2 [-6.0,10.4] (2 studies, 83 participants); Rivermead Mobility, 1.0 [-0.6, 2.5] (2 studies, 83 participants); and comfortable walking speed, 0.2 [0.0,0.4] (2 studies, 60 participants). CONCLUSIONS: Current evidence provides some, but limited, support for the hypothesis that a higher dose of the same type of exercised-based therapy enhances motor recovery after stroke. Prospective dose-finding studies are required.

Functional and emotional outcomes after transient ischemic attack: A 12-month prospective controlled cohort study.

BACKGROUND: Symptoms of transient ischemic attack are believed to fully resolve within 24 h of onset. Emerging evidence suggests that there may be prolonged functional and psychological impact, although studies have not been able to robustly identify whether these are the effect of transient ischemic attack or changes usually associated with ageing. We describe trajectories of disability and risk of anxiety and depression among patients seen at transient ischemic attack clinics over 12 months, compared to healthy controls. METHODS: Thirty transient ischemic attack clinics across England participated. A total of 1320 participants were included: 373 diagnosed with transient ischemic attack, 186 with minor stroke, 310 with "possible transient ischemic attack," 213 with another condition mimicking a transient ischemic attack and 238 controls recruited from primary care providers. Participants completed questionnaires after diagnosis then after 3, 6 and 12 months. Outcomes were the Nottingham Extended Activities of Daily Living Scale and the Hospital Anxiety and Depression Scale. Mixed effects regression was used to estimate group differences and trajectories. RESULTS: At baseline, confirmed transient ischemic attack patients scored 1.31 HADS-Anxiety points (s.e. = 0.28; p < 0.001) , 0.51 HADS-Depression points (s.e. = 0.26; p = 0.056), and 2.6 NEADL points (s.e. = 1.1; p = 0.020) worse than controls. At 12 months, the deficits were 0.78 (s.e. = 0.30; p = 0.008), 0.97 (s.e. = 0.23; p < 0.001), and 0.96 (s.e. = 0.92; p = 0.294) respectively. Differences among patients diagnosed with minor stroke were like or worse than transient ischemic attack patients. CONCLUSIONS: Transient ischemic attack clinic patients may have functional and emotional impairments compared to the general population irrespective of final diagnosis. The presence of emotional symptoms or risk of developing anxiety or depression did not always fully recover and may increase.

Feasibility of a randomized controlled trial of functional strength training for people between six months and five years after stroke: FeSTivaLS trial.

BACKGROUND: Functional Strength Training (FST) could enhance recovery late after stroke. The aim of this study was to evaluate the feasibility of a subsequent fully powered, randomized controlled trial. METHODS: The study was designed as a randomized, observer-blind trial. Both interventions were provided for up to one hour a day, four days a week, for six weeks. Evaluation points were before randomization (baseline), after six weeks intervention (outcome), and six weeks thereafter (follow-up). The study took place in participants' own homes. Participants (n = 52) were a mean of 24.4 months after stroke with a mean age of 68.3 years with 67.3% male. All had difficulty using their paretic upper (UL) and lower limb (LL). Participants were allocated to FST-UL or FST-LL by an independent randomization service. The outcome measures were recruitment rate, attrition rate, practicality of recruitment strategies, occurrence of adverse reactions, acceptability of FST, and estimation of sample size for a subsequent trial. Primary clinical efficacy outcomes were the Action Research Arm Test (ARAT) and the Functional Ambulation Categories (FAC). Analysis was conducted using descriptive statistics and thematic analysis of participants' views of FST. A power calculation used estimates of clinical efficacy variance to estimate sample size for a subsequent trial. RESULTS: The screening process identified 1,127 stroke survivors of whom 52 (4.6%) were recruited. The recruitment rate was higher for referral from community therapists than for systematic identification of people discharged from an acute stroke unit. The attrition rate was 15.5% at the outcome and follow-up time-points. None of the participants experienced an adverse reaction. The participants who remained in the study at outcome had received 68% of the total possible amount of therapy. Participants reported that their experience of FST provided a sense of purpose and involvement and increased their confidence in performing activities. The power calculation provides estimation that 150 participants in each group will be required for a subsequent clinical trial. CONCLUSIONS: This study found that a subsequent clinical trial was feasible with modifications to the recruitment strategy to be used. TRIAL REGISTRATION: Controlled-trials.com ISCTN71632550, 30 January 2009.

Observation-to-imitate plus practice could add little to physical therapy benefits within 31 days of stroke: translational randomized controlled trial.

BACKGROUND AND PURPOSE: Observation of action with intention-to-imitate (OTI) might enhance motor recovery. This early phase trial investigated whether OTI followed by physical practice (OTI + PP) enhanced the benefits of conventional physical therapy (CPT) on upper limb recovery early after stroke. METHODS: Participants were 3 to 31 days poststroke. They had substantial paresis and ability to imitate action with their ipsilesional arm. After baseline measures, participants were randomized to either OTI + PP in addition to CPT or to CPT only. Outcome measures were made after 15 days of treatment. The measurement battery was the Motricity Index (MI) and the Action Research Arm Test (ARAT). Change, baseline to outcome, was examined using the Wilcoxon test for within group and Mann-Whitney U test for between groups. RESULTS: Sixty-five of 570 stroke survivors were eligible, 55 were able to imitate, 37 gave informed consent, 7 were transferred out of area before baseline, and 29 were randomized. Outcome measures were completed with 13 CPT participants and 9 OTI + PP participants. Both groups showed statistically significant improvements for the MI (CPT median change 8, P = .003; OTI + PP median change 10, P = .012) but the median (95% confidence interval [CI]) between-group difference was 0.0 (-11, 16), P = 1.000. For the ARAT, only the CPT group showed a statistically significant improvement (median 9, P = .006). The median (95% CI) between-group difference of 1.0 (-18, 23) was not statistically significant (P = .815). CONCLUSIONS: These findings suggest that OTI + PP might add little to the benefits of CPT early after stroke.

The FeSTivaLS trial protocol: a randomized evaluation of the efficacy of functional strength training on enhancing walking and upper limb function later post stroke.

RATIONALE: Functional Strength Training may enhance motor function of people who are more than six months post stroke. AIMS: to evaluate the clinical efficacy of enhancing upper and lower limb motor function with FST to explore participants' views (expectations and experiences) of FST, and to determine what cost-effectiveness data to collect in a subsequent Phase III trial. DESIGN: Randomized, observer-blind trial with embedded qualitative investigation of participants' views of FST (n = 6, purposive sampling). STUDY: Participants (n = 58), six months to five years after stroke with difficulty using their paretic upper (UL) and lower limbs (LL) for everyday functional activity. All will be randomized to either FST-UL or FST-LL delivered in their own homes for four days each week for six weeks. FST involves repetitive progressive resisted exercise during goal directed functional activities. The therapist's main input is to provide verbal prompting and feedback. OUTCOMES: Measures will be undertaken before randomization (baseline), after the six-week intervention (outcome) and six weeks thereafter (follow-up). Primary outcomes for clinical efficacy will be the Functional Ambulation Categories (FAC) and the Action Research Arm Test (ARAT). Clinical efficacy analysis will use the proportional odds model for FAC and a Mann-Whitney test for ARAT. Participants' views of FST will be explored at baseline and outcome through audiotaped, semi-structured, narrative approach, interviews. The analytic process for interviews will sort transcribed data thematically and seek categories to inform conceptualization (theory-building). A purpose-designed cost questionnaire will identify what cost resource items are likely to be affected by FST.