Benchmarking length of stay for inpatient stroke rehabilitation without adversely affecting functional outcomes.

OBJECTIVE: To evaluate the effects of introducing the practice of targeting a discharge date for patients admitted to an inpatient stroke rehabilitation unit on process and patient outcomes. DESIGN: Comparison of retrospective (control group n = 69) and prospective (experimental group n = 60) patients. METHODS: Rehabilitation professionals assessed both groups at admission and discharge using a standard-ized assessment toolkit. Benchmarks for length of rehabilitation stay (LoRS) were introduced based on median severity-specific LoRSs in the control group. The multidisciplinary team documented facilitators and obstacles affecting the prediction of patient benchmark attainment. Categorical variables were compared using a χ2 test with exact probabilities. Ordinal and continuous variables were analysed using rank-based non-parametric analysis of variance. Effect sizes were estimated using a relative treatment effect statistic. RESULTS: The mean combined length of stay in acute care and rehabilitation beds for the experimental group (82 days) was shorter (p = 0.0084) than that of the control group (103 days). This 21-day reduction in combined length of stay included a 10-day reduction in the mean time between stroke onset and admission to the stroke rehabilitation unit (p = 0.000014). Improvements in 6 func-tional and sensorimotor outcomes with rehabilitation were of similar magnitude in both groups, while Functional Independence Measure (FIMTM) efficiency improved (p = 0.022). The team was 87% successful in predicting which patients were discharged on the LoRS benchmark. CONCLUSION: Benchmarking the length of stay in rehabilitation resulted in reduced bed occupation and system costs without adversely affecting functional and sensorimotor patient outcomes.

Recovery of Sensorimotor Functional Outcomes at Discharge from In-Patient Rehabilitation in Three Stroke Units in the Province of Quebec.

Purpose: This study aimed to portray the characteristics, process variables, and sensorimotor outcomes of patients who had received their usual post-stroke in-patient rehabilitation in three stroke rehabilitation units in Quebec in 2013-2014. Method: We assessed patients (n = 264) at admission and discharge with a subset of a standardized assessment toolkit consisting of observational and performance-based assessment tools. Results: The patients, with a mean age of 60.3 (SD 15.4) years, were admitted 27.7 (SD 8.4) days post-stroke onset. They had a mean admission FIM score of 83.0 (SD 24.0), a mean length of stay of 48.4 (SD 31.1) days, a mean FIM discharge score of 104.0 (SD 17.0), and a mean FIM efficiency score of 0.44 (SD 0.29). All patient outcomes were significantly improved (p < 0.001) and clinically meaningful at discharge (moderate to large Glass's Δ effect sizes) with the improvements greater than or equal to the minimal detectable change at the 95% confidence level in 34%-75% of the patients. Improvements were larger on five of seven outcomes in a sub-group of patients with more severe stroke. Conclusions: The use of a combination of observational and performance assessment tools was essential to capture the full range of disabilities. We have documented significant and clinically meaningful improvements in functional independence, disability, and upper and lower extremity functions after usual post-stroke in-patient rehabilitation in the province of Quebec and provided baseline data for future studies.

Objectif : décrire les caractéristiques, le processus de réadaptation et les résultats sensorimoteurs de patients ayant reçu les services de réadaptation habituels après un accident vasculaire cérébral (AVC) dans trois unités de réadaptation du Québec en 2013 et 2014. Méthodologie : évaluation des patients (n = 264) à l'admission et au congé à l'aide du sous-ensemble d'une trousse d'évaluation standardisée composée d'outils d'évaluation fondés sur l'observation et la performance. Résultats : les patients, qui avaient un âge moyen de 60,3 ans (ÉT 15,4), ont été hospitalisés en réadaptation 27,7 jours (ÉT 8,4) après leur AVC. Leur mesure d'autonomie fonctionnelle (MAF) à l'admission était de 83,0 (ÉT 24,0), et leur séjour en réadaptation a duré 48,4 jours (ÉT 31,1); leur score de MAF au congé était de 104,0 (ÉT 17,0), pour un score d'efficacité de la MAF de 0,44 (ÉT 0,29). Tous les résultats cliniques des patients s'étaient considérablement améliorés (p < 0,001) et étaient cliniquement significatifs au congé (effet de taille delta de Glass de modéré à grand), et ces améliorations étaient supérieures ou égales au changement minimal décelable à un niveau de confiance de 95 % chez 34 % à 75 % des patients. Ces améliorations pour cinq des sept mesures étaient plus élevées dans le sous-groupe de patients ayant un AVC plus grave. Conclusion : une combinaison d'outils d'évaluation d'observation et de performance s'est avérée essentielle pour saisir tout l'éventail d'incapacités. Les auteures ont constaté des améliorations importantes et cliniquement significatives de l'autonomie fonctionnelle, de l'incapacité et de la fonction des membres supérieurs et inférieurs après l'hospitalisation en réadaptation habituelle des patients ayant un AVC dans la province de Québec et ont fourni des données de référence en vue de prochaines études.

Is Cerebral Palsy Changing in High Resource Settings? Data From the Quebec Cerebral Palsy Registry.

Advances in maternal and perinatal care in developed countries have led to improved health outcomes for children. These changes may have impacted the profile of children with a cerebral palsy (CP) and groups at risk for CP over time. Using data from the Canadian CP Registry, the objectives of this retrospective cohort study were to describe the profile of children with CP in Quebec born between 1999 and 2010 and identify possible temporal variation in CP risk factors and phenotypic profile. Our sample consisted of 662 children with CP in Quebec. No change in profile or associated risk factors was observed across the birth cohorts 1999 to 2010. Prematurity remains the largest risk factor for CP in Quebec, and children with CP have multiple comorbidities that contribute to overall CP burden. CP registries offer a unique platform to study spectrum disorders and their longitudinal changes over time.

Development, Implementation, and Clinician Adherence to a Standardized Assessment Toolkit for Sensorimotor Rehabilitation after Stroke.

Purpose: This study describes the development of a standardized assessment toolkit (SAT) and associated clinical database focusing on sensorimotor rehabilitation in three stroke rehabilitation units (SRUs). Implementation of the SAT was confirmed using objective measures of clinician adherence while exploring reasons for varied adherence. Method: Participants were patients post-stroke admitted for inpatient rehabilitation and clinicians from the three SRUs. A collaborative and iterative process was used to develop the SAT. Implementation was measured by clinician adherence, which was charted by means of assessment entries in patient records and transferred to the clinical database. Reasons for lower adherence were interpreted from therapist data logs at one SRU. Results: The SAT consisted of 25 assessment tools. Clinician adherence to a subset of the tools ranged from 33% to 99% at admission and from 28% to 94% at discharge. At one site, lower adherence among the tools was explained by patient-related factors (1%-36%) and protocol or logistical reasons (0%-7%) at admission; missing data ranged from 0% to 3%, except for the Montreal Cognitive Assessment (17%). Conclusions: In this pragmatic study, objective measures of clinician adherence demonstrated the feasibility of implementing an SAT in daily practice. Moreover, the reasons for lower adherence rates may be related to the patients, protocol, and logistics, all of which may vary with the assessment tool, rather than clinician compliance.

Objectif : décrire la création d'une trousse d'évaluation standardisée (TÉS) et d'une base de données cliniques connexe axée sur la réadaptation sensorimotrice dans trois unités de réadaptation fonctionnelle (URF). Les chercheurs ont confirmé la mise en application de la TÉS au moyen de mesures objectives de l'adhésion des cliniciens et ont exploré les raisons expliquant les variations à cette adhésion. Méthodologie : les participants étaient des patients victimes d'un accident vasculaire cérébral (AVC) admis en réadaptation et les cliniciens des trois URF. Les chercheurs ont utilisé un processus coopératif et itératif pour créer la TÉS. Ils en ont mesuré la mise en application par l'adhésion des cliniciens, recensée d'après les résultats d'évaluation dans les dossiers des patients, puis les ont transférées dans la base de données cliniques. Ils ont interprété les raisons d'une plus faible adhésion à partir des notes inscrites sur les feuilles de collecte de données des thérapeutes d'une des URF. Résultats : la TÉS se composait de 25 outils d'évaluation. L'adhésion des cliniciens à un sous-groupe d'outils se situait entre 33% et 99% à l'admission en réadaptation et entre 28% et 94% au congé. Dans un établissement, une plus faible adhésion aux outils s'expliquait par des facteurs liés aux patients (de 1% à 36%), au protocole ou à la logistique (0% à 7%) à l'admission, alors que les données manquantes variaient de 0% à 3%, sauf pour le « Montreal Cognitive Assessment ¼ (17%). Conclusions : dans cette étude pragmatique, les mesures objectives d'adhérence des cliniciens ont démontré la faisabilité de mettre en application une TÉS dans la pratique quotidienne. De plus, les raisons d'un taux d'adhérence plus faible peuvent être liées aux patients, au protocole ou à la logistique, facteurs qui peuvent varier en fonction de l'outil d'évaluation, plutôt qu'aux cliniciens.

Gait Training after Stroke on a Self-Paced Treadmill with and without Virtual Environment Scenarios: A Proof-of-Principle Study.

Purpose: The purpose of this proof-of-principle study was to show that virtual reality (VR) technology could be coupled with a self-paced treadmill to further improve walking competency in individuals with chronic stroke. Method: A 62-year-old man with a chronic right hemispheric stroke participated in a treadmill walking programme involving first a control (CTL) protocol, then VR training. In CTL training, he walked without time constraints while viewing still pictures and reacting to treadmill movements similar to those that he would have experienced later in VR training. In VR training, he experienced treadmill movements programmed to simulate changes encountered in five virtual environments rear-projected onto a large screen. Training difficulty in nine sessions over 3 weeks was increased by varying the time constraints, terrain surface changes, and obstacles to avoid. Effects on walking competency were assessed using clinical measures (5 m walk test, 6 min walk test, Berg Balance Scale, Activities-specific Balance Confidence scale) and questionnaires (Assessment of Life Habits Scale and personal appraisal). Results: CTL and VR training resulted in a similar progression through the training sessions of total time walked on the treadmill. The VR training led to an additional increase in speed as measured by walking 5 metres as fast as possible and distance walked in 6 minutes, as well as improved balance self-efficacy and anticipatory locomotor adjustments. As reported by the participant, these improved outcomes transferred to real-life situations. Conclusions: Despite the limited potential for functional recovery from chronic stroke, an individual can achieve improvements in mobility and self-efficacy after participating in VR-coupled treadmill training, compared with treadmill training with the same intensity and surface perturbations but without VR immersion. A larger scale, randomized controlled trial is warranted to determine the efficacy of VR-coupled treadmill training for mobility intervention post-stroke.

Objectif : la présente étude de validation visait à démontrer que la réalité virtuelle (RV) peut être jumelée à un tapis roulant autocontrôlé pour améliorer l'aptitude à marcher des personnes ayant un accident vasculaire cérébral (AVC) chronique. Méthodologie : un homme de 62 ans ayant un AVC chronique de l'hémisphère droit a participé à un programme de marche sur tapis roulant, d'abord au moyen d'un protocole de contrôle (CTL), puis d'un entraînement en RV. Pendant l'entraînement CTL, l'homme a marché sans contrainte de temps tout en regardant des images fixes et en réagissant aux mouvements du tapis roulant semblables à ceux repris par la suite en RV. Pendant l'entraînement en RV, il a ressenti les mouvements du tapis roulant programmés pour simuler les changements observés dans cinq environnements virtuels rétroprojetés sur grand écran. La difficulté de l'entraînement au cours de neuf séances réparties sur trois semaines a augmenté en variant les contraintes de temps, les changements de surface du terrain et les obstacles à éviter. Les chercheurs ont évalué les effets sur l'aptitude à marcher à l'aide de mesures cliniques (tests de marche de cinq mètres et de six minutes, échelle d'évaluation de l'équilibre de Berg, échelle de confiance en l'équilibre pendant des activités) et de questionnaires (échelle d'évaluation des habitudes de vie et évaluation personnelle). Résultats : l'entraînement CTL et celui en RV ont suscité une progression similaire de la durée totale de marche sur le tapis roulant pendant les séances d'entraînement. L'entraînement en RV a favorisé une amélioration supplémentaire de la marche rapide sur cinq mètres et de la distance parcourue en six minutes, de même qu'une meilleure auto-efficacité de l'équilibre et de meilleurs ajustements locomoteurs anticipés. Comme l'a indiqué le participant, cette amélioration des résultats se transposait dans la vie quotidienne. Conclusions : malgré le potentiel limité de récupération fonctionnelle en cas d'AVC chronique, une personne peut améliorer sa mobilité et son auto-efficacité après avoir participé à un entraînement sur tapis roulant jumelé à la RV, par rapport à un entraînement sur tapis roulant de la même intensité et selon les mêmes perturbations de la surface du sol, mais sans l'immersion de la RV. Un essai aléatoire et contrôlé à plus vaste échelle s'impose pour déterminer l'efficacité de l'entraînement sur tapis roulant jumelé à la RV dans le cadre d'une intervention de mobilité après un AVC.

Amount and Content of Sensorimotor Therapy Delivered in Three Stroke Rehabilitation Units in Quebec, Canada.

Purpose: This study creates a baseline clinical portrait of sensorimotor rehabilitation in three stroke rehabilitation units (SRUs) as a first step in implementing a multi-centre clinical research platform. Method: Participants in this cross-sectional, descriptive study were the patients and rehabilitation teams in these SRUs. Prospective (recording of therapy time and content and a Web-based questionnaire) and retrospective (chart audit) methods were combined to characterize the practice of the rehabilitation professionals. Results: The 24- to 39-bed SRUs admitted 100-240 inpatients in the year audited. The mean combined duration of individual occupational and physical therapy was 6.3-7.5 hours/week/patient. When evening hours and the contributions of other professionals as well as group therapy and self-practice were included, the total amount of therapy was 13.0 (SD 3) hours/patient/week. Chart audit and questionnaire data revealed the Berg Balance Scale was the most often used outcome measure (98%-100%), and other outcome measure use varied. Clinicians favoured task-oriented therapy (35%-100%), and constraint-induced movement therapy (0%-15%), electrical stimulation of the tibialis anterior (0%-15%), and body weight-supported treadmill training (0%-1%) were less often used. Conclusions: This study is the first to provide objective data on therapy time and content of stroke rehabilitation in Quebec SRUs.

Objectif : créer un portrait clinique de base de la réadaptation sensorimotrice offerte après un accident vasculaire cérébral dans trois unités de réadaptation fonctionnelle intensive (URFI) comme première étape en vue de la mise en œuvre d'une plateforme de recherche clinique multicentrique. Méthodologie : les participants à cette étude descriptive transversale étaient des patients et des équipes de réadaptation de ces URFI. Les chercheurs ont combiné la méthode prospective (consignation de la durée et du contenu du traitement et questionnaire en ligne) et la méthode rétrospective (audit de dossiers) pour caractériser la pratique des professionnels en réadaptation. Résultats : les URFI de 24 à 39 lits ont admis de 100 à 240 patients hospitalisés pendant l'année de l'audit. Les interventions en ergothérapie et physiothérapie étaient d'une durée moyenne combinée de 6,3 à 7,5 heures par semaine par patient. Lorsqu'on incluait les soirées, l'apport d'autres professionnels, la thérapie de groupe et la pratique autonome, le total s'élevait à 13,0 heures (ÉT 3,0) par semaine par patient. Les données tirées de l'audit des dossiers et des questionnaires ont révélé que l'échelle d'évaluation de l'équilibre de Berg était la plus utilisée (98 % à 100 %), alors que l'utilisation des autres mesures était variable. Les cliniciens favorisaient les traitements orientés vers les tâches (35 % à 100 %), et utilisaient moins la thérapie par contrainte induite (0 % à 15 %), la stimulation électrique du jambier antérieur (0 % à 15 %) et l'entraînement sur tapis roulant avec support de poids (0 % à 1 %). Conclusions : la présente étude est la première à fournir des données objectives sur la durée et le contenu de la réadaptation après un accident vasculaire cérébral dans les URFI du Québec.

Six hours of task-oriented training optimizes walking competency post stroke: a randomized controlled trial in the public health-care system of South Africa.

OBJECTIVE: To evaluate a minimal dose intervention of six 1-hour sessions of task-oriented circuit gait training including a caregiver over a 12-week period to persons post stroke in the South African public health sector. DESIGN: Stratified, single blinded, randomized controlled trial with three intervention groups. PARTICIPANTS: Persons post stroke ( n = 144, mean age 50 years, 72 women), mean 9.5 weeks post stroke. INTERVENTIONS: Task group ( n = 51)-accompanied by a caregiver; task-oriented circuit gait training (to improve strength, balance, and task performance while standing and walking). Strength group ( n = 45); strength training of lower extremities while sitting and lying. Control group ( n = 48); one 90-minute educational session on stroke management. MEASURES: The six-minute walk test (6MinWT) was the primary outcome; the secondary outcomes included comfortable and fast gait speeds, Berg Balance Scale (BBS), and Timed Up and Go (TUG). Particpants evaluated at baseline, post intervention (12 weeks), and at follow-up 12 weeks later. Change scores were compared using generalized repeated measures analysis of variance (ANOVA). RESULTS: Task group change scores for all outcomes post intervention and at follow-up were improved compared to the other groups ( P-values between 0.000005 and 0.04). The change scores (mean, 1SD) between baseline and follow-up for the Task, Strength, and Control groups, respectively, were as follows: 6MinWT:119.52 m (81.92), 81.05 m (79.53), and 60.99 m (68.38); comfortable speed 0.35 m/s (0.23), 0.24 m/s (0.22), and 0.19 m/s (0.21); BBS: 9.94 (7.72), 6.93 (6.01), and 5.19 (4.80); and TUG: -14.24 seconds (16.86), -6.49 seconds (9.88), and -5.65 seconds (8.10). CONCLUSION: Results support the efficacy of a minimal dose task-oriented circuit training program with caregiver help to enhance locomotor recovery and walking competency in these persons with stroke.

Converting Functional Autonomy Measurement System Scores of Patients Post-Stroke to FIM Scores.

Purpose: The Functional Independence Measure (FIM) is widely used to assess persons post-stroke. The Quebec government has selected the Functional Autonomy Measurement System (SMAF) for use in all care settings. In this article, we propose simple equations to convert SMAF scores to FIM scores for persons undergoing post-stroke rehabilitation. Method: Persons post-stroke (n=143) from three rehabilitation centres were assessed at admission and discharge using the FIM and SMAF. The sample was randomly split into derivation and validation data sets. Regression analysis was performed on the first data set to derive a conversion equation at each time point. The validity of the equations was measured using correlation coefficients, and differences between the observed and predicted FIM scores were computed from the second data set. Results: The relationship between the SMAF and FIM scores was linear at admission but quadratic at discharge. The proposed equations are, at admission, FIM=139-1.5×SMAF and, at discharge, FIM=118-0.018×SMAF2. The observed and predicted FIM scores were highly correlated in the validation data set (rs=0.92 and 0.93 at admission and discharge, respectively). Furthermore, the equations performed well in classifying stroke severity compared with a classification based on the observed FIM scores. Conclusions: SMAF scores can be reliably converted to FIM scores using the proposed equations, thus facilitating international trials in stroke rehabilitation.

Objectif : la mesure de l'indépendance fonctionnelle (MIF) est largement utilisée lors de l'évaluation après un accident vasculaire cérébral (AVC). Le gouvernement du Québec a retenu l'utilisation du système de mesure de l'autonomie fonctionnelle (SMAF) dans tous les établissements de soins. Le présent article présente des équations simples pour convertir les scores du SMAF en scores de MIF chez les personnes en réadaptation après un AVC. Méthodologie : les chercheurs ont évalué les personnes qui avaient subi un AVC (n=143) de trois centres de réadaptation à l'aide de la MIF et du SMAF à l'admission et au congé. Ils ont divisé l'échantillon aléatoirement en ensembles de données de dérivation et de validation. Ils ont procédé à une analyse de régression du premier ensemble de données pour dériver une équation de conversion à chaque point dans le temps. Ils ont mesuré la validité des équations au moyen de coefficients de corrélation et calculé les différences entre les scores de MIF observés et prédits à partir du deuxième ensemble de données. Résultats : la relation entre les scores du SMAF et de MIF était linéaire à l'admission, mais quadratique au congé. À l'admission, l'équation proposée est MIF=139−1,5×SMAF et, au congé, MIF=118−0,018×SMAF2. Les scores de MIF observés et prédits étaient hautement corrélés dans l'ensemble de données de validation (r = 0,92 et 0,93 à l'admission et au congé, respectivement). De plus, les équations donnaient de bons résultats dans le classement de la gravité des AVC par rapport au classement reposant sur les scores de MIF observés. Conclusions : on peut convertir les scores de SMAF en toute fiabilité à l'aide des équations proposées, facilitant ainsi les essais internationaux sur la réadaptation après un AVC.

Facilitated interprofessional implementation of a physical rehabilitation guideline for stroke in inpatient settings: process evaluation of a cluster randomized trial.

BACKGROUND: The Stroke Canada Optimization of Rehabilitation by Evidence-Implementation Trial (SCORE-IT) showed that a facilitated knowledge translation (KT) approach to implementing a stroke rehabilitation guideline was more likely than passive strategies to improve functional walking capacity, but not gross manual dexterity, among patients in rehabilitation hospitals. This paper presents the results of a planned process evaluation designed to assess whether the type and number of recommended treatments implemented by stroke teams in each group would help to explain the results related to patient outcomes. METHODS: As part of a cluster randomized trial, 20 rehabilitation units were stratified by language and allocated to a facilitated or passive KT intervention group. Sites in the facilitated group received the guideline with treatment protocols and funding for a part-time nurse and therapist facilitator who attended a 2-day training workshop and promoted guideline implementation for 16 months. Sites in the passive group received the guideline excluding treatment protocols. As part of a process evaluation, nurses, and occupational and physical therapists, blinded to study hypotheses, were asked to record their implementation of 18 recommended treatments targeting motor function, postural control and mobility using individualized patient checklists after treatment sessions for 2 weeks pre- and post-intervention. The percentage of patients receiving each treatment pre- and post-intervention and between groups was compared after adjusting for clustering and covariates in a random-effects logistic regression analysis. RESULTS: Data on treatment implementation from nine and eight sites in the facilitated and passive KT group, respectively, were available for analysis. The facilitated KT intervention was associated with improved implementation of sit-to-stand (p = 0.028) and walking (p = 0.043) training while the passive KT intervention was associated with improved implementation of standing balance training (p = 0.037), after adjusting for clustering at patient and provider levels and covariates. CONCLUSIONS: Despite multiple strategies and resources, the facilitated KT intervention was unsuccessful in improving integration of 18 treatments concurrently. The facilitated approach may not have adequately addressed barriers to integrating numerous treatments simultaneously and complex treatments that were unfamiliar to providers. TRIAL REGISTRATION: Unique identifier- NCT00359593.

Accuracy of administrative claims data for cerebral palsy diagnosis: a retrospective cohort study.

BACKGROUND: Cerebral palsy is the most common cause of childhood physical disability, with multiple associated comorbidities. Administrative claims data provide population-level prevalence estimates for cerebral palsy surveillance; however, their diagnostic accuracy has never been validated in Quebec. This study aimed to assess the accuracy of administrative claims data for the diagnosis of cerebral palsy. METHODS: We conducted a retrospective cohort study of children with cerebral palsy born between 1999 and 2002 within 6 health administrative regions of Quebec. Provincial cerebral palsy registry data (reference standard) and administrative physician claims were linked. We explored differences between true-positive and false-negative cases using subgroup sensitivity analysis. RESULTS: A total of 301 children were identified with confirmed cerebral palsy from the provincial registry, for an estimated prevalence of 1.8 (95% confidence interval [CI] 1.6-2.1) per 1000 children 5 years of age. The sensitivity and specificity of administrative claims data for cerebral palsy were 65.5% (95% CI 59.8%-70.8%) and 99.9% (95% CI 99.9%-99.9%), respectively, yielding a prevalence of 2.0 (95% CI 1.9-2.3) per 1000 children 5 years of age. The positive and negative predictive values were 58.8% (95% CI 53.3%-64.1%) and 99.9% (95% CI 99.9%-99.9%), respectively. The κ value was 0.62 (95% CI 0.57-0.67). Administrative claims data were more sensitive for children from rural regions, born preterm, with spastic quadriparesis and with higher levels of motor impairment. INTERPRETATION: Administrative claims data do not capture the full spectrum of children with cerebral palsy. This suggests the need for a more sensitive case definition and caution when using such data without validation.

Perspectives of health care professionals on the facilitators and barriers to the implementation of a stroke rehabilitation guidelines cluster randomized controlled trial.

BACKGROUND: The Stroke Canada Optimization of Rehabilitation by Evidence Implementation Trial (SCORE-IT) was a cluster randomized controlled trial that evaluated two knowledge translation (KT) interventions for the promotion of the uptake of best practice recommendations for interventions targeting upper and lower extremity function, postural control, and mobility. Twenty rehabilitation centers across Canada were randomly assigned to either the facilitated or passive KT intervention. The objective of the current study was to understand the factors influencing the implementation of the recommended treatments and KT interventions from the perspective of nurses, occupational therapists and physical therapists, and clinical managers following completion of the trial. METHODS: A qualitative descriptive approach involving focus groups was used. Thematic analysis was used to understand the factors influencing the implementation of the recommended treatments and KT interventions. The Clinical Practice Guidelines Framework for Improvement guided the analysis. RESULTS: Thirty-three participants were interviewed from 11 of the 20 study sites (6 sites from the facilitated KT arm and 5 sites from the passive KT arm). The following factors influencing the implementation of the recommended treatments and KT interventions emerged: facilitation, agreement with the intervention - practical, familiarity with the recommended treatments, and environmental factors, including time and resources. Each of these themes includes the sub-themes of facilitator and/or barrier. Improved team communication and interdisciplinary collaboration emerged as an unintended outcome of the trial across both arms in addition to a facilitator to the implementation of the treatment recommendations. Facilitation was identified as a facilitator to implementation of the KT interventions in the passive KT intervention arm despite the lack of formally instituted facilitators in this arm of the trial. CONCLUSIONS: This is one of the first studies to examine the factors influencing the implementation of stroke recommendations and associated KT interventions within the context of a trial. Findings highlight the important role of self-selected facilitators to implementation efforts. Future research should seek to better understand the specific characteristics of facilitators that are associated with successful implementation and clinical outcomes, especially within the context of stroke rehabilitation.

A Virtual Reality avatar interaction (VRai) platform to assess residual executive dysfunction in active military personnel with previous mild traumatic brain injury: proof of concept.

PURPOSE: This proof of concept study tested the ability of a dual task walking protocol using a recently developed avatar-based virtual reality (VR) platform to detect differences between military personnel post mild traumatic brain injury (mTBI) and healthy controls. METHODS: The VR platform coordinated motion capture, an interaction and rendering system, and a projection system to present first (participant-controlled) and third person avatars within the context of a specific military patrol scene. A divided attention task was also added. A healthy control group was compared to a group with previous mTBI (both groups comprised of six military personnel) and a repeated measures ANOVA tested for differences between conditions and groups based on recognition errors, walking speed and fluidity and obstacle clearance. RESULTS: The VR platform was well tolerated by both groups. Walking fluidity was degraded for the control group within the more complex navigational dual tasking involving avatars, and appeared greatest in the dual tasking with the interacting avatar. This navigational behaviour was not seen in the mTBI group. CONCLUSIONS: The present findings show proof of concept for using avatars, particularly more interactive avatars, to expose differences in executive functioning when applying context-specific protocols (here for the military). Implications for rehabilitation Virtual reality provides a means to control context-specific factors for assessment and intervention. Adding human interaction and agency through avatars increases the ecologic nature of the virtual environment. Avatars in the present application of the Virtual Reality avatar interaction platform appear to provide a better ability to reveal differences between trained, military personal with and without mTBI.

Cardiorespiratory fitness and cognitive functioning following short-term interventions in chronic stroke survivors with cognitive impairment: a pilot study.

This study, a quasi-experimental, one-group pretest-post-test design, evaluated the effects on cognitive functioning and cardiorespiratory fitness of 8-week interventions (aerobic exercise alone and aerobic exercise and cognitive training combined) in patients with chronic stroke and cognitive impairment living in the community (participants: n=14, 61.93±9.90 years old, 51.50±38.22 months after stroke, n=7 per intervention group). Cognitive functions and cardiorespiratory fitness were evaluated before and after intervention, and at a 3-month follow-up visit (episodic memory: revised-Hopkins Verbal Learning Test; working memory: Brown-Peterson paradigm; attention omission and commission errors: Continuous Performance Test; cardiorespiratory fitness: peak oxygen uptake during a symptom-limited, graded exercise test performed on a semirecumbent ergometer). Friedman's two-way analysis of variance by ranks evaluated differences in score distributions related to time (for the two groups combined). Post-hoc testing was adjusted for multiple comparisons. Compared with before the intervention, there was a significant reduction in attention errors immediately following the intervention (omission errors: 14.6±21.5 vs. 8±13.9, P=0.01; commission errors: 16.4±6.3 vs. 10.9±7.2, P=0.04), and in part at follow-up (omission errors on follow-up: 3.4±4.3, P=0.03; commission errors on follow-up: 13.2±7.6, P=0.42). These results suggest that attention may improve in chronic stroke survivors with cognitive impairment following short-term training that includes an aerobic component, without a change in cardiorespiratory fitness. Randomized-controlled studies are required to confirm these findings.

Comparison of kinetic strategies for avoidance of an obstacle with either the paretic or non-paretic as leading limb in persons post stroke.

The task of stepping over obstacles is known to be particularly risky for persons post stroke. A kinetic analysis informing on the movement strategies used to ensure clearance of the leading limb over an obstacle is, however, lacking. We examined obstacle avoidance strategies in six community dwelling stroke survivors comparing the use of paretic and non-paretic limb as the leading limb for clearance over obstacles measuring 7.5% and 15% of their total leg length. Subjects were able to increase foot clearance height in both limbs in order to avoid the two obstacles. Obstacle clearance with the non-paretic limb leading was associated with positive knee flexor work that increased when stepping over each obstacle, thus showing a normal knee strategy that flexes both the knee and the hip for foot clearance. There was also slightly increased hip flexor contribution for non-paretic obstacle clearance that was the same for both obstacle heights. When the paretic limb led during obstacle clearance, there was also evidence of an increased knee flexor moment, suggesting a residual knee strategy, but it was less pronounced than for the non-paretic limb and was assisted by greater vertical hip elevation and additional positive hip flexor work that both gained greater importance with increased obstacle height. These findings suggest that rehabilitation should explore the ability to improve the residual, but less powerful, knee flexor strategy in the paretic limb in specific patients, with further promotion of a hip flexor and limb elevation strategy depending on patient deficits and obstacle height.

Stroke rehabilitation: clinical picture, assessment, and therapeutic challenge.

This chapter reviews the evolution of stroke rehabilitation in the last 20 years. It begins by describing the different types of stroke that can occur in adults, their potential consequences on a person's capacity to function in daily life and statistics on the number of strokes and their burden on families and the economy. The assessment of stroke severity, recovery of function over time, and the impact of initial stroke severity and age on potential recovery are then addressed as well as the concept of rehabilitation to enhance recovery. Fueled by the synthesis of an ever-increasing research knowledge base and the creation of stroke rehabilitation recommendations for optimal delivery of rehabilitation services and of therapeutic interventions, stroke rehabilitation has changed dramatically. Examples of improvements in stroke rehabilitation in Canada are given with emphasis on the "best practices" inspired stroke rehabilitation continuum recently recommended for the Province of Quebec. The need for an improved community-based rehabilitation approach that includes regular follow-ups and community-based programs promoting reintegration is emphasized. The importance of knowledge translation strategies to promote the uptake of best-practice recommendations is illustrated by describing the activities of the Sensorimotor Rehabilitation Research Team. Over the past 3 years, the researchers of this team and clinicians in three rehabilitation centers, two in Montreal and one in Quebec City, have collaborated to adopt standardized assessment tools, create a common stroke registry, a best-practice recommended approach to interventions and the participation of clinicians in the research process.

Getting on with the rest of your life following stroke: a randomized trial of a complex intervention aimed at enhancing life participation post stroke.

OBJECTIVE: To enhance participation post stroke through a structured, community-based program. DESIGN: A controlled trial with random allocation to immediate or four-month delayed entry. SETTING: Eleven community sites in seven Canadian cities. SUBJECTS: Community dwelling persons within five years of stroke onset, cognitively intact, able to toilet independently. INTERVENTIONS: Evidence-based program delivered in three 12-week sessions including exercise and project-based activities, done as individuals and in groups. MAIN MEASURES: Hours spent per week in meaningful activities outside of the home and Reintegration to Normal Living Index; Stroke-Specific Geriatric Depression Scale, Apathy Scale, gait speed, EuroQuol EQ-5D, and Preference-Based Stroke Index. All measures were transformed to a scale from 0 to 100. Assessments prior to randomization, after the first session at three months, six months, 12 months, and 15 months. RESULTS: A total of 186 persons were randomized. The between-group analysis showed no disadvantage to waiting and so groups were combined and a within-person analysis was carried out at three time points. There were statistically significant increases in all study outcomes on average over all persons. Over 45% of people met or exceeded the pre-specified target of a three hour per week increase in meaningful activity and this most often took a full year of intervention to achieve. Greatest gains were in satisfaction with community integration (mean 4.78; 95% CI: 2.01 to 7.55) and stroke-specific health-related quality of life (mean 4.14; 95% CI: 2.31 to 5.97). CONCLUSIONS: Community-based programs targeting participation are feasible and effective, but stroke survivors require time to achieve meaningful gains.

Modifications in ankle dorsiflexor activation by applying a torque perturbation during walking in persons post-stroke: a case series.

BACKGROUND: Results obtained in a previous study (Gait Posture 34:358-363, 2011) have shown that, in non-disabled participants, a specific increase in ankle dorsiflexor (Tibialis anterior [TA]) activation can be induced by walking with a torque perturbation that plantarflexes the ankle during the swing phase. After perturbation removal, the increased TA activation persisted temporarily and was associated with a more dorsiflexed ankle during swing. The objective of the present case-series study was to verify if these results can be reproduced in persons post-stroke. METHODS: Six participants who sustained a stroke walked on a treadmill before, during and after exposure to a torque perturbation applied at the ankle by a robotized ankle-foot orthosis. Spatiotemporal gait parameters, ankle and knee kinematics, and the electromyographic activity of TA and Soleus were recorded. Mean amplitude of the TA burst located around toe off and peak ankle dorsiflexion angle during swing were compared across the 3 walking periods for each participant. RESULTS: At the end of the walking period with the perturbation, TA mean amplitude was significantly increased in 4 of the 6 participants. Among these 4 participants, modifications in TA activation persisted after perturbation removal in 3 of them, and led to a statistically significant increase in peak dorsiflexion during swing. CLINICAL IMPLICATIONS: This approach may be helpful to evaluate the residual adaptive capacity in the ankle dorsiflexors after a stroke and guide decision-making for the selection of optimal rehabilitation interventions. Future work will investigate the clinical impact of a multiple-session gait training based on this approach in persons presenting a reduced ankle dorsiflexion during the swing phase of walking.

Effects of walking with loads above the ankle on gait parameters of persons with hemiparesis after stroke.

BACKGROUND: Walking with a load at the ankle during gait training is a simple way to resist lower limb movements to induce functional muscle strengthening. This study investigated the effects of walking with different loads attached above the paretic ankle on biomechanical gait parameters during over ground walking in post-stroke participants. METHODS: Ten participants with moderate chronic hemiparesis were evaluated while walking over ground with three different loads (0.5, 1.0, and 1.5kg) attached above the paretic ankle. Gait speed, cadence, step lengths as well as hip and knee angular displacements, joint moments and power of the paretic limb were compared while walking with and without loads. FINDINGS: Walking with a load led to an increased in gait speed (+0.03-0.05m/s), and in step length of the paretic leg (+5.6 to 9.4% step length, effect size=0.49-0.63), but not of the non-paretic leg. The proportion of the stance and swing phases did not change. Maximal joint moments (+20 to 48%, effect size=0.26-0.55) and power (+20 to 114%, effect size=0.30-0.57) increases varied across participants but were mostly affected in early stance at the hip and during the late swing phase at the knee. Mean angular displacement changes were less than 4°. INTERPRETATION: Post-stroke participants are able to increase hip and knee power bursts to meet the increased mechanical demand of added loads attached to the paretic ankle, while preserving the basic pattern of walking. Further study is needed before using loading to functionally strengthen paretic muscles.