Transcranial Direct-Current Stimulation as an Adjunct to Verb Network Strengthening Treatment in Post-stroke Chronic Aphasia: A Double-Blinded Randomized Feasibility Study.

Background: Difficulties in discourse production are common in post-stroke chronic aphasia. Previous studies have found that speech and language therapy combined with transcranial direct-current stimulation (tDCS) may improve language skills like naming and enhance aphasia treatment outcomes. However, very few studies have investigated the effect of tDCS when combined with interventions for improving higher level language skills such as the Verb Network Strengthening Treatment (VNeST). Aims: This study aimed to determine the feasibility of anodal tDCS as an adjunct to VNeST to improve discourse production in post-stroke chronic aphasia. Methods: Six people with post-stroke chronic aphasia took part in this double-blinded randomized feasibility study. Participants were randomly allocated to either the experimental group receiving a 6-week block of once weekly VNeST sessions combined with active tDCS over the left inferior frontal gyrus (LIFG) or a control group that received VNeST with sham stimulation. Feasibility outcomes included screening, eligibility, retention, and completion rates, and adverse events. Preliminary response to intervention was also examined using discourse production, functional communication, quality of life, psychological state, and cognition outcomes. Results: Overall 19 individuals were screened and ten met the inclusion criteria. Six individuals provided consent and participated in the study giving a consent rate of 60%. Participant retention and completion rates were 100% and no adverse effects were reported. Exploratory analyses revealed promising changes (i.e., estimated large effect size) in discourse production measures across discourse language tasks and functional communication for the active tDCS group. Conclusions: Our results support the feasibility of tDCS as an adjunct to VNeST. Preliminary findings provide motivation for future large-scale studies to better understand the potential of tDCS as a safe and economical tool for enhancing rehabilitation in chronic aphasia.

The Igbo Brief Illness Perceptions Questionnaire: A cross-cultural adaptation and validation study in Nigerian populations with chronic low back pain.

BACKGROUND: Illness perceptions predict chronic low back pain (CLBP) disability. This study cross-culturally adapted and validated the Igbo Brief Illness Perceptions Questionnaire (Igbo-BIPQ) in people with CLBP in rural/urban Nigeria. METHODS: A cross-cultural adaptation and validation of the Igbo-BIPQ was undertaken. The BIPQ was forward/back-translated by clinical/non-clinical translators. An expert review committee appraised the translations. The questionnaire was pre-tested on twelve rural Nigerian dwellers with CLBP. Internal consistency using Cronbach's alpha; test-retest reliability using intra-class correlation coefficient and Bland-Altman plot; and minimal detectable change were investigated amongst 50 people with CLBP in rural and urban Nigeria. Construct validity was determined by correlating the Igbo-BIPQ score with those of eleven-point box scale and Igbo Roland Morris Disability Questionnaire (Igbo-RMDQ) using Pearson's correlation analyses in 200 adults with CLBP in rural Nigeria. Ceiling and floor effects were investigated in both samples. RESULTS: Good face/content validity, internal consistency (α= 0.76) and intraclass correlation coefficient (ICC = 0.78); standard error of measurement and minimal detectable change of 5.44 and 15.08 respectively; moderate correlations with pain intensity and self-reported disability (r⩾ 0.4); no ceiling/floor effects were observed for Igbo-BIPQ. CONCLUSION: This study provides evidence of some aspects of validity and reliability of the Igbo-BIPQ.

Transcranial Direct-Current Stimulation May Improve Discourse Production in Healthy Older Adults.

Background: The use of transcranial direct-current stimulation (tDCS) for therapeutic and neurorehabilitation purposes has become increasingly popular in recent years. Previous research has found that anodal tDCS may enhance naming ability and verbal fluency in healthy participants. However, the effect of tDCS on more functional, higher level language skills such as discourse production has yet to be understood. Aims: The present study aimed to investigate in healthy, older adults (a) the effect of anodal tDCS on discourse production vs. sham stimulation and (b) optimal electrode placement for tDCS to target language improvement at the discourse level. Methods: Fourteen healthy, older right-handed participants took part in this sham controlled, repeated measures pilot study. Each participant experienced three different experimental conditions; anodal tDCS on the left inferior frontal gyrus (IFG), anodal tDCS on the right IFG and sham stimulation while performing a story telling task. Significant changes in language performance before and after each condition were examined in three discourse production tasks: recount, procedural and narrative. Results: Left and right IFG conditions showed a greater number of significant within-group improvements (p < 0.05) in discourse production compared to sham with 6/12 for left IFG, 4/12 for right IFG and 2/12 for sham. There were no significant differences noted between tDCS conditions. No relationship was noted between language performance and physical activity, age, or gender. Conclusions: This study suggests that anodal tDCS may significantly improve discourse production in healthy, older adults. In line with previous tDCS language studies, the left IFG is highlighted as an optimal stimulation site for the modulation of language in healthy speakers. The findings support further exploration of tDCS as a rehabilitative tool for higher-level language skills in persons with aphasia.

Evidence, theory and context: using intervention mapping in the development of a community-based self-management program for chronic low back pain in a rural African primary care setting - the good back program.

BACKGROUND: Rural Nigeria has one of the greatest burdens of low back pain but there are no effective evidence-based interventions to manage it in this population. This paper presents the application of the intervention mapping (IM) approach in the development of a complex behavior change intervention - The Good Back program, aimed at reducing non-specific chronic low back pain (CLBP) disability in rural Nigeria. METHODS: The first four steps of IM were applied. A critical review of the literature, 2 qualitative studies and a population-based cross-sectional study in rural Nigeria helped to identify two key program objectives in order to reduce CLBP disability in this population: reduce the impact of illness perceptions, fear avoidance beliefs, catastrophising, anxiety and depression by targeting maladaptive illness perceptions about CLBP; and facilitate the adoption of exercises and good posture to limit disability. A systematic review plus these studies, identified the personal and environmental determinants of the performance objectives including health literacy, self-awareness, self-efficacy, personal preference, health professional skills, health facility structure and family/community support. The theory, techniques and strategies for modifying personal and environmental determinants were also identified from these studies. Intervention components and materials were then produced for practical application. The initial developed intervention was described. RESULTS: The feasibility and acceptability of the developed program was then tested using a small pragmatic non-randomised controlled study incorporating qualitative exit feedback interviews in a rural Nigerian primary health care centre. The program appeared feasible and acceptable when delivered by a highly trained physiotherapist. There were promising clinical outcomes in disability, pain intensity, illness perceptions, fear avoidance beliefs and pain medication use. Suggestions for program improvement included shorter but ongoing sessions, video demonstration of exercises/good posture, spacious exercise/demonstration rooms, and community legitimisation of exercise as treatment for back pain. Subsequent modifications to program content and delivery were then described. Theoretical modification included the addition of aspects of the social cognitive theory to the Leventhal's self-regulatory model of illness cognitions. CONCLUSIONS: IM appears to be a suitable framework for designing complex behavior change interventions in rural Nigeria. The need for further testing of the intervention was highlighted.

Assessing self-reported disability in a low-literate population with chronic low back pain: cross-cultural adaptation and psychometric testing of Igbo Roland Morris disability questionnaire.

PURPOSE: Cross-culturally adapt and validate the Igbo Roland Morris Disability Questionnaire. METHOD: Cross-cultural adaptation, test-retest, and cross-sectional psychometric testing. Roland Morris Disability Questionnaire was forward and back translated by clinical/non-clinical translators. An expert committee appraised the translations. Twelve participants with chronic low back pain pre-tested the measure in a rural Nigerian community. Internal consistency using Cronbach's alpha; test-retest reliability using intra-class correlation coefficient and Bland-Altman plot; and minimal detectable change were investigated in a convenient sample of 50 people with chronic low back pain in rural and urban Nigeria. Pearson's correlation analyses using the eleven-point box scale and back performance scale, and exploratory factor analysis were used to examine construct validity in a random sample of 200 adults with chronic low back pain in rural Nigeria. Ceiling and floor effects were investigated in the two samples. RESULTS: Modifications gave the option of interviewer-administration and reflected Nigerian social context. The measure had excellent internal consistency (α = 0.91) and intraclass correlation coefficient (ICC =0.84), moderately high correlations (r > 0.6) with performance-based disability and pain intensity, and a predominant uni-dimensional structure, with no ceiling or floor effects. CONCLUSIONS: Igbo Roland Morris Disability Questionnaire is a valid and reliable measure of pain-related disability. Implications for rehabilitation Low back pain is the leading cause of years lived with disability worldwide, and is particularly prevalent in rural Nigeria, but there are no self-report measures to assess its impact due to low literacy rates. This study describes the cross-cultural adaptation and validation of a core self-report back pain specific disability measure in a low-literate Nigerian population. The Igbo Roland Morris Disability Questionnaire is a reliable and valid measure of self-reported disability in Igbo populations as indicated by excellent internal consistency (α = 0.91) and intra-class correlation coefficient (ICC =0.84), moderately high correlations (r > 0.6) with performance-based disability and pain intensity that supports a pain-related disability construct, a predominant one factor structure with no ceiling or floor effects. The measure will be useful for researchers and clinicians examining the factors associated with low back pain disability or the effects of interventions on low back pain disability in this culture. This measure will support global health initiatives concurrently involving people from several cultures or countries, and may inform cross-cultural disability research in other populations.

Community-based self-management of chronic low back pain in a rural African primary care setting: a feasibility study.

A small pragmatic non-randomised controlled study investigated the feasibility and acceptability of a novel theory-informed community-based self-management programme targeting the biopsychosocial factors associated with chronic low back pain disability in a rural Nigerian primary care centre. Participants either received the programme, once weekly for 6 weeks, or usual care. The programme combined group exercise sessions with group/individual discussion sessions, informed by cognitive behavioural therapy and motivational interviewing. Recruitment rate, intervention delivery, proportion of planned treatment attended, retention/dropout rate, adherence to recommended self-management strategies and biopsychosocial outcomes were used to determine feasibility. Structured qualitative exit feedback interviews ascertained acceptability. Recruitment rate was 100%, treatment uptake was 83% and loss to follow-up was 8%. Greater benefits for the self-management group compared with control were observed for primary and secondary biopsychosocial outcomes. Although the programme appears promising, the exploratory design of this study warrants more rigorous intervention testing following suggested programme improvement.

Unconventional Practitioners' Causal Beliefs and Treatment Strategies for Chronic Low Back Pain in Rural Nigeria.

Chronic low back pain (CLBP) is highly prevalent and CLBP disability reinforces poverty and Nigerian rural-urban inequality. Most rural Nigerian dwellers with CLBP consult unconventional practitioners due to difficulty in accessing conventional health care. This interaction may influence back pain beliefs and behaviours, and health outcomes including disability. In line with the recent Lancet Low Back Pain series call to address widespread misconceptions in the population and among health practitioners about low back pain, this study explored the beliefs and management strategies of unconventional practitioners consulted by people living with CLBP in rural Nigeria. Qualitative semi-structured face-to-face individual interviews. Thematic analysis of transcripts was performed using the Framework approach. Nine unconventional practitioners consented to participate in this study. Patent medicine sellers and herbalists had biomedical beliefs about CLBP and encouraged passivity and drug dependence in patients. Pastors adopted spiritual or biopsychosocial-spiritual management models and either encouraged spiritual CLBP causal beliefs and spiritual healing expectations; or patients' resilience and acceptance, respectively. Unconventional practitioners' CLBP beliefs and management strategies aligned with the beliefs and coping strategies of patients who consulted them. Unconventional practitioners' beliefs and management strategies may therefore contribute to the adverse impact of CLBP in rural Nigeria.

Physical activity containing behavioural interventions for adults living with modifiable chronic non-communicable diseases in Africa: a systematic mixed-studies review.

Background: Physical activity improves physiological, cognitive and psychosocial functioning in chronic non-communicable diseases (NCDs). This study reviewed papers on the effects and patients' experiences of physical activity interventions for chronic NCDs in Africa. Methods: We conducted a systematic review of clinical and qualitative studies by searching eight bibliographic databases and grey literature until 19 April 2017. The mixed-methods appraisal and Cochrane Collaboration's tools were used for quality and risk of bias assessments. Three-stage sequential explanatory syntheses were done. Results: One randomized controlled trial (RCT), two non-controlled before and after studies and two qualitative studies of diabetic South African and Reunion patients were included. Exercise and sports unrelated to home and occupational activities were increased in the long term (1 year, moderate quality evidence) and short term immediately after a 4-week intervention (low quality evidence). There was conflicting evidence of intervention effects on home and occupational physical activities. Behaviour-change techniques improving chronic disease knowledge, addressing environmental barriers and stimulating/supporting physical activity were important to patients. Procedure-related components-health professional training and adequate health facilities-were important to patients, but were not addressed. Conclusion: High quality RCTs are needed to confirm the intervention components for improving physical activity for chronic NCD management in Africa.

Biopsychosocial factors associated with chronic low back pain disability in rural Nigeria: a population-based cross-sectional study.

INTRODUCTION: Many people in Nigeria are living with disability due to chronic low back pain (CLBP), with the greatest burden accounted for by people living in rural Nigeria. However, factors associated with disability in rural Nigeria have not yet been established. We investigated the biomechanical and psychosocial predictors of CLBP disability in a rural Nigerian population. METHODS: A cross-sectional study of adults with non-specific CLBP recruited from rural communities in Enugu State, South-eastern Nigeria. Measures of self-reported and performance-based disability, pain intensity, anxiety and depression, coping strategies, social support, occupational biomechanical factors, illness perceptions and fear avoidance beliefs were collected by trained community health workers. We used univariate and multivariate analyses. RESULTS: 200 individuals were recruited. Psychosocial factors were the most important factors associated with CLBP disability, and accounted for 62.5% and 49.1% of the variance in self-reported and performance-based disability, respectively. The significant predictors of self-reported disability were: illness perceptions (ß=0.289; p<0.0005), pain intensity (ß=0.230; p<0.0005), catastrophising (ß=0.210; p=0.001), fear avoidance beliefs (ß=0.198; p=0.001) and anxiety (ß=0.154; p=0.023). The significant predictors of performance-based disability were: illness perceptions (ß=0.366; p<0.0005), social support (ß=0.290; p<0.0005), fear avoidance beliefs (ß=0.189; p<0.01) and female gender (ß=0.184; p<0.01). Illness concern was the most salient dimension of illness perceptions predicting self-reported and performance-based disability. CONCLUSIONS: These results provide evidence which can be used to inform the development of interventions to reduce CLBP disability in rural Nigeria, and may have relevance in other rural African contexts.

"A life of living death": the experiences of people living with chronic low back pain in rural Nigeria.

PURPOSE: This study explored the experiences of people living with non-specific chronic low back pain (CLBP) in a rural Nigerian community. METHOD: Qualitative in-depth semi-structured face-to-face interviews were conducted with purposively sampled participants until data saturation. Questions explored back pain beliefs, coping/management strategies and daily activities. Thematic analysis of transcripts was performed using the Framework approach. RESULTS: Themes showed that back pain beliefs were related to manual labour/deprivation, infection/degeneration, spiritual/cultural beliefs and rural-urban divide. These beliefs impacted on gender roles resulting in adaptive or maladaptive coping. Adaptive coping was facilitated by positive beliefs, such as not regarding CLBP as an illness, whereas viewing CLBP as illness stimulated maladaptive coping strategies. Spirituality was associated with both adaptive and maladaptive coping. Maladaptive coping strategies led to dissatisfaction with health care in this community. CONCLUSIONS: CLBP-related disability in rural Nigeria is strongly influenced by beliefs that facilitate coping strategies that either enhance or inhibit recovery. Interventions should therefore target maladaptive beliefs while emphasizing behavioural modification. Implications for Rehabilitation Non-specific chronic low back pain (CLBP) is highly prevalent and responsible for much pain and disability in rural Nigeria. No qualitative study has investigated the experiences of people living with CLBP in rural Nigeria or any other rural African context. Qualitative study of peoples' experiences of living with CLBP in rural Nigeria has the potential of exposing complex socio-cultural and psychological factors associated with CLBP which has potential implications for designing effective interventions. The results of this study may inform the development of complex interventions for reducing the disability associated with CLBP in rural Nigeria and other rural African contexts.

The effect of combined somatosensory stimulation and task-specific training on upper limb function in chronic stroke: a double-blind randomized controlled trial.

BACKGROUND: Somatosensory stimulation (SS) is a potential adjuvant to stroke rehabilitation, but the effect on function needs further investigation. OBJECTIVE: To explore the effect of combining SS with task-specific training (TST) on upper limb function and arm use in chronic stroke survivors and determine underlying mechanisms. METHODS: In this double-blinded randomized controlled trial (ISRCTN 05542931), 33 patients (mean 37.7 months poststroke) were block randomized to 2 groups: active or sham SS. They received 12 sessions of 2 hours of SS (active or sham) to all 3 upper limb nerves immediately before 30 minutes of TST. The primary outcome was the Action Research Arm Test (ARAT) score. Secondary outcomes were time to perform the ARAT, Fugl-Meyer Assessment score (FM), Motor Activity Log (MAL), and Goal Attainment Scale (GAS). Underlying mechanisms were explored using transcranial magnetic stimulation stimulus-response curves and intracortical inhibition. Outcomes were assessed at baseline, immediately following the intervention (mean 2 days), and 3 and 6 months (mean 96 and 190 days) after the intervention. RESULTS: The active group (n = 16) demonstrated greater improvement in ARAT score and time immediately postintervention (between-group difference; P < .05), but not at 3- or 6-month follow-ups (P > .2). Within-group improvements were seen for both groups for ARAT and GAS, but for the active group only for FM and MAL (P < .05). Corticospinal excitability did not change. CONCLUSIONS: Long-lasting improvements in upper limb function were observed following TST. Additional benefit of SS was seen immediately post treatment, but did not persist and the underlying mechanisms remain unclear.

Self-perceived utilization of the paretic arm in chronic stroke requires high upper limb functional ability.

OBJECTIVE: To explore potential predictors of self-reported paretic arm use at baseline and after task-specific training (TST) in survivors of stroke. DESIGN: Data were obtained from a randomized controlled trial of somatosensory stimulation and upper limb TST in chronic stroke. SETTING: University laboratory. PARTICIPANTS: Chronic (≥3mo) survivors of stroke (N=33; mean age, 62y; mean stroke duration, 38mo). INTERVENTIONS: Participants received 12 sessions of TST preceded by either active (n=16) or sham (n=17) somatosensory stimulation to all 3 peripheral nerves. MAIN OUTCOME MEASURES: Demographic and clinical characteristics were entered stepwise into multiple linear regression analyses to determine the factors that best predict baseline Motor Activity Log (MAL) amount of use rating and change 3 months after TST. RESULTS: The Action Research Arm Test (ARAT) score predicted the amount of use at baseline (R(2)=.47, P<.001); in using this model, an ARAT score of 54 (maximum of 57) is required to score 2.5 on the MAL (use described as between rarely and sometimes). After TST the change in the ARAT score predicted the change in the amount of use (R(2)=.31, P=.001). The predictive power of the model for change at 3 months increased if the Fugl-Meyer Assessment wrist component score was added (R(2)=.41, P=.001). CONCLUSIONS: Utilization of the paretic upper limb in activities of daily living requires high functional ability. The increase in self-reported arm use after TST is dependent on the change in functional ability. These results provide further guidance for rehabilitation decisions.

The effect of coil type and navigation on the reliability of transcranial magnetic stimulation.

The objective of this study was to investigate reliability of transcranial magnetic stimulation (TMS) parameters for three coil systems; hand-held circular and figure-of-eight and navigated figure-of-eight coils. Stimulus response curves, intracortical inhibition (SICI) and facilitation (ICF) were studied in the right first dorsal interosseus muscle of 10 healthy adults. Each coil system was tested twice per subject. Navigation was conducted by a custom built system. Cortical excitability showed moderate-to-good reliability for the hand-held and navigated figure-of-eight coils (Intraclass correlation coefficients (ICCs) 0.55-0.89). The circular coil showed poor reliability for motor evoked potential (MEP) amplitude at 120% resting motor threshold (RMT; MEP(120)) and MEP sum (ICCs 0.09 & 0.48). Reliability for SICI was good for all coil systems when an outlier was removed (ICCs 0.87-0.93), but poor for ICF (ICCs < 0.3). The circular coil had a higher MEP(120) than the navigated figure-of-eight coil (p = 0.004). Figure-of-eight coils can be used confidently to investigate cortical excitability over time. ICF should be interpreted with caution. The navigation device frees the experimenter and enables tracking of the position of the coil and subject. The results help guide the choice of coil system for longitudinal measurements of motor cortex function.

Electromyographic response to manual passive stretch of the hemiplegic wrist: accuracy, reliability, and correlation with clinical spasticity assessment and function.

BACKGROUND: The management of spasticity is important in neurorehabilitation and needs to be assessed accurately. The commonly used clinical tools have been criticized for lack of validity and sensitivity. OBJECTIVE: To investigate the reliability of electromyographic (EMG) response to manual stretches of the hemiplegic wrist and its correlation with clinical assessments of spasticity and physical function. METHODS: EMG activity was measured in 10 stroke patients and control participants (53.7 +/- 10 and 32 +/- 9.1 years respectively, mean +/- SEM) during 3 cycles of 10 seconds passive manual movements of the wrist at 60 to 360 degrees * s(-1). Isometric maximal voluntary contractions (MVC) strength, range of movement (ROM) of the wrist flexors and extensors, spasticity (Modified Ashworth Scale [MAS]) and hand function (Block and Box Test [BBT]) were also assessed. RESULTS: EMG activity of the stroke patients increased with velocity from 4% to 40% MVC (P < .001) but there was none in the controls. It was unaffected by repetition and good to moderate reliability occurred at all speeds (ICC, 0.71-0.81). EMG correlated negatively with MVC strength (r = -.9), active wrist flexion ROM ( r = -.8), and hand function scores (r = -.7), but not with clinical measures of spasticity except at the lowest velocity (r = .72). CONCLUSIONS: Consistent and accurate stretch velocities and EMG responses can be achieved with manual wrist stretches for the assessment of the neural component of spasticity. These objective tests did not correlate well with the standard clinical assessment of spasticity. They showed significant negative relationships with function, indicating that increased reflex excitability contributes to hand disability after stroke.