Clinician-Prioritized Measures to Use in a Remote Concussion Assessment: Delphi Study.

BACKGROUND: There is little guidance available, and no uniform assessment battery is used in either in-person or remote evaluations of people who are experiencing persistent physical symptoms post concussion. Selecting the most appropriate measures for both in-person and remote physical assessments is challenging because of the lack of expert consensus and guidance. OBJECTIVE: This study used expert consensus processes to identify clinical measures currently used to assess 5 physical domains affected by concussion (neurological examination, cervical spine, vestibular, oculomotor, or effort) and determine the feasibility of applying the identified measures virtually. METHODS: The Delphi approach was used. In the first round, experienced clinicians were surveyed regarding using measures in concussion assessment. In the second round, clinicians reviewed information regarding the psychometric properties of all measures identified in the first round by at least 15% (9/58) of participants. In the second round, experts rank-ordered the measures from most relevant to least relevant based on their clinical experience and documented psychometric properties. A working group of 4 expert clinicians then determined the feasibility of virtually administering the final set of measures. RESULTS: In total, 59 clinicians completed survey round 1 listing all measures they used to assess the physical domains affected by a concussion. The frequency counts of the 146 different measures identified were determined. Further, 33 clinicians completed the second-round survey and rank-ordered 22 measures that met the 15% cutoff criterion retained from round 1. Measures ranked first were coordination, range of motion, vestibular ocular motor screening, and smooth pursuits. These measures were feasible to administer virtually by the working group members; however, modifications for remote administration were recommended, such as adjusting the measurement method. CONCLUSIONS: Clinicians ranked assessment of coordination (finger-to-nose test and rapid alternating movement test), cervical spine range of motion, vestibular ocular motor screening, and smooth pursuits as the most relevant measures under their respective domains. Based on expert opinion, these clinical measures are considered feasible to administer for concussion physical examinations in the remote context, with modifications; however, the psychometric properties have yet to be explored. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/40446.

Reliability and Sensitivity of a Virtual Assessment Developed for Workplace Concussions: Protocol for a Method-Comparison Study.

BACKGROUND: Workplace mild traumatic brain injuries are frequently associated with persistent symptoms, leading to a reduction in productivity at work or even disability. People who sustain workplace injuries frequently need rehabilitation and support, and the challenges of delivering these services was heightened during the COVID-19 pandemic as injured workers had to be cared for remotely. Currently, clinicians are conducting both in-person and virtual (remote) concussion assessments; however, the measures that are being used to complete these assessments have undocumented psychometric properties. OBJECTIVE: This study will document the psychometric properties of the clinical measures that are being used remotely and their ability to produce similar results to in-person assessments. Specifically, through this method-comparison study, we aim to (1) evaluate the sensitivity of the measures included in a virtual assessment toolkit when compared to an in-person assessment and (2) determine the interrater and intrarater reliabilities of the measures included in a virtual assessment toolkit. METHODS: Patient participants (people living with acquired brain injuries) will attend two assessments (in person and virtual) at the Ottawa Hospital. The two assessments will be identical, consisting of the measures included in our previously developed virtual concussion assessment toolkit, which includes finger-to-nose testing, the Vestibular/Ocular Motor Screening tool, balance testing, cervical spine range of motion, saccades testing, and evaluation of effort. All virtual assessments will occur using the Microsoft Teams platform and will be audio/video-recorded. The clinician assessor and patient participant will complete a feedback form following completion of the assessments. A different clinician will also document the findings on observed videos of the virtual assessment shortly after completion of both in-person and virtual assessments and approximately 1 month later. Interrater reliability will be assessed by comparing the second clinician's observation with the first clinician's initial virtual assessment. Intrarater reliability will be evaluated by comparing the second clinician's observation with their own assessment approximately 1 month later. Sensitivity will be documented by comparing the findings (identification of abnormality) of the in-person assessment completed by the initial clinician assessor with those of the second clinician assessor on the observation of the recording of the virtual assessment. RESULTS: As of May 2024, we have recruited 7 clinician assessors and completed study assessments with 39 patient participants. The study recruitment is expected to be completed by September 2024. CONCLUSIONS: Currently, it is unknown if completing concussion assessments virtually produces similar results to the in-person assessment. This work will serve as a first step to determining the similarity of the virtual assessment to the matching in-person assessment and will provide information on the reliability of the virtual assessment. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57663.

Donating One's Body to HIV Cure Research Through Canadian Medical Assistance in Dying: A Case Study.

BACKGROUND: Finding a cure for HIV is challenged by persisting reservoirs, the mapping of which necessitates invasive procedures. Inviting people with HIV (PWHIV) at the end of life to donate body specimens post-mortem through research autopsies is a novel approach, raising ethical concerns. OBJECTIVE: This case study aims to explore the motivations, barriers, and facilitators of a terminally-ill Canadian PWHIV who requested medical assistance in dying (MAID) and expressed interest in donating his body for HIV cure research. CASE PRESENTATION: An in-depth 3-hour and semi-structured interview was conducted with the participant. The interview transcription was thematically coded to identify motivations and perceived barriers and facilitators to participate in end-of-life HIV cure research. Our analysis identified six themes. Two themes expressed motivations: Collaboration in progress in health and science, seeing cure research as collaboration with professionals; and Opportunity to learn more, mostly about science and health. One theme expressed a barrier: Losing interest in or identification with long-term care research matters, especially those related to the management of long-term care. Three themes expressed by facilitators: Receiving information from professionals one trusts and knows, especially clinical and research teams; Perceiving research procedures as simple, useful, and embedded in care, perceiving clinical, educational, and interpersonal benefits that surpass costs of participation; and Perceiving research as one last way to contribute, that is, feeling useful or give back. CONCLUSION: Several circumstances facilitated the patient's participation: being a single man, having time to participate, having no strong religious belief, and valuing clear, direct communication. His motivations to participate in HIV cure research were altruistic, and also an experience of working with clinical and research teams. Finally, this perspective highlights HIV cure research participant candidates' need for education about research procedures.

The Impact of Two Telerehabilitation Supervision Schedules on Physical Activity, Mobility, and Balance Among People with Moderate to Severe Traumatic Brain Injury: A Mixed-Method Single-Subject Design.

Background: Many individuals who experience a moderate or severe traumatic brain injury (TBI) have long-term deficits in physical activity, balance, and mobility requiring specialized care. New delivery models are being investigated for interventions to address challenges caused by living in remote communities, difficulties with transportation, and/or physical distancing requirements. Determining the effectiveness of telerehabilitation is critical given the current movement toward remote health care delivery. Objective: We investigated the effectiveness of two teletherapy supervision schedules used to deliver a home-based, intensive exercise programme on 1) physical activity, mobility, balance, participation, and 2) concerns with falling, and satisfaction with life. Methods: A mixed methods approach with alternating single subject design (SSD) and interviews was used. Five individuals who experienced a moderate or severe TBI completed two intensive home-based telerehabilitation programmes. Programmes differed only by supervision schedule - daily or weekly. Impacts on objective and patient-reported outcomes were measured. Results: Four individuals demonstrated clinically significant improvements in physical activity level, balance, and mobility. One individual experienced less concerns with falling after both schedules, while two other individuals showed a trend in that direction after the weekly remote supervision. Important functional gains (i.e., improved balance and decreased fatigue) were also perceived and reported by family partners regardless of supervision schedule. Conclusion: Although the study has limitations, the findings indicate that exercise programmes delivered via telerehabilitation can improve balance and mobility as well as positively affect concerns with falling and physical activity levels for this population. No clear differences were seen between the two telerehabilitation supervision schedules.

Historique : de nombreuses personnes qui sont victimes d'un traumatisme crânien (TC) modéré ou grave ont des déficits à long terme en matière d'activité physique, d'équilibre et de mobilité et doivent recevoir des soins spécialisés. De nouveaux modèles de prestation sont en cours d'étude afin que les interventions relèvent les problèmes liés à la vie en région éloignée, au transport ou à la distanciation physique. Il est essentiel de déterminer l'efficacité de la téléréadaptation en raison du mouvement actuel vers la prestation des soins à distance. Objectif : examiner l'efficacité de deux horaires de supervision de la téléthérapie utilisés pour fournir un programme d'exercice intensif à domicile sur 1) l'activité physique, la mobilité, l'équilibre et la participation et 2) les craintes de chutes et la satisfaction de vivre. Méthodologie : méthodologie mixte faisant appel à une alternance entre la méthodologie individuelle et les entrevues. Cinq personnes qui avaient été victimes d'un TC modéré ou grave ont suivi deux programmes intensifs de téléréadaptation à domicile. Les programmes différaient seulement en fonction de l'horaire de supervision, qui était quotidien ou hebdomadaire. Les chercheurs ont mesuré les répercussions sur les résultats cliniques objectifs et déclarés par les patients. Résultats : quatre personnes ont démontré des améliorations cliniquement significatives au taux d'activité physique, à l'équilibre et à la mobilité. Une personne craignait moins les chutes après les deux programmes tandis que les deux autres ressentaient une tendance dans cette direction après la supervision hebdomadaire à distance. Des gains fonctionnels importants (amélioration de l'équilibre et diminution de la fatigue) étaient également perçus et déclarés par les partenaires familiaux, quel que soit l'horaire de supervision. Conclusion : même si l'étude comporte des limites, les observations indiquent que les programmes d'exercices donnés en téléréadaptation peuvent améliorer l'équilibre et la mobilité et avoir des effets positifs sur les craintes de tomber et les taux d'activité physique dans cette population. Il n'y avait pas de différences évidentes entre les deux horaires de supervision de la téléréadaptation.

Remotely Supervised Exercise Programmes to Improve Balance, Mobility, and Activity Among People with Moderate to Severe Traumatic Brain Injury: Description and Feasibility.

Purpose: Further investigation into the feasibility of using videoconferencing and activity tracking devices to provide high-intensity home-based exercise programmes for people with a moderate or severe traumatic brain injury (TBI) is needed to inform clinical implementation and patient adoption. This study aimed to (1) determine if home-based telerehabilitation exercise programmes were feasible for people with a moderate or severe TBI and (2) better understand the lived experience of people with a TBI and their family partners with this programme. Methods: A mixed-methods approach consisting of measures of feasibility and semi-structured interviews was used. Five participants with moderate to severe TBI and their family partners completed two high-intensity home-based exercise programmes delivered remotely by a physiotherapist (i.e., daily and weekly). Results: Telerehabilitation services in home-based settings were feasible for this population. Adherence and engagement were high. Dyads were satisfied with the use of technology to deliver physiotherapy sessions. Conclusion: Telerehabilitation provides a delivery option that allows people with TBI to spend energy on therapy rather than on travelling. A pre-programme training on key components, such as the use of technology, safety precautions, and communication methods, likely improved the overall feasibility. Further research is needed to better understand the effectiveness of such a programme on balance, mobility, and physical activity levels.

Objectif : des recherches plus approfondies s'imposent sur la faisabilité d'utiliser les visioconférences et les dispositifs de suivi des activités pour fournir des programmes d'exercices à domicile à haute intensité aux personnes atteintes d'un traumatisme crânien (TC) modéré à grave qui éclaireront la mise en œuvre clinique et l'adoption par le patient. Cette étude visait à 1) déterminer s'il était faisable d'offrir des programmes d'exercices en téléréadaptation à domicile pour les personnes atteintes d'un TC modéré à grave et 2) mieux comprendre l'expérience vécue des personnes atteintes d'un TC et de leurs partenaires familiaux au sein de ce programme. Méthodologie : les chercheurs ont utilisé une approche mixte composée de mesures de faisabilité et d'entrevues semi-structurées. Cinq participants atteints d'un TC modéré à grave et leurs partenaires familiaux ont effectué deux programmes d'exercices à domicile à haute intensité donnés à distance par un physiothérapeute (quotidiennement et hebdomadairement). Résultats : les services de téléréadaptation à domicile étaient faisables pour cette population. L'adhésion et la participation étaient élevées. Les dyades étaient satisfaites par l'utilisation de la technologie pour la prestation des séances de physiothérapie. Conclusion : la téléréadaptation fournit un mode de prestation qui permet aux personnes atteintes d'un TC à consacrer leur énergie au traitement plutôt qu'aux déplacements. Une formation avant le programme portant sur les principaux éléments, tels que le recours à la technologie, les mesures de précaution et les modes de communication, améliorait probablement la faisabilité globale. D'autres recherches seront réalisées pour mieux comprendre l'efficacité de ce programme sur l'équilibre, la mobilité et les taux d'activité physique.

Sex differences concerning the effects of ankle muscle fatigue on static postural control and spinal proprioceptive input at the ankle.

Aims: The main aim of this study was to determine sex differences in postural control changes with ankle muscle fatigue during a standing forward leaning (FL) task under different vision conditions. The secondary aim was to examine sex differences in the effect of fatigue on soleus (SOL) H-reflex amplitude, a measure of motoneuron excitability with activation of Ia afferents. Methods: Fifteen healthy young adult males (mean age: 28.0 years) and 16 healthy young adult females (mean age: 26.1 years) were asked to perform four consecutive FL tasks [30 s; two with eyes open (EO) and two with eyes closed (EC)] before, and immediately following a fatiguing exercise consisting of alternating ankle plantarflexion (6 s) and dorsiflexion (2 s) maximal isometric contractions, and at 5 and 10 min of recovery. Center of pressure (COP) sway variables (mean position, standard deviation, ellipse area, average velocity, and frequency), an ankle co-contraction index, and a ratio of SOL H-reflex to the maximum amplitude of the compound muscle action potential (M-max) were obtained during the FL tasks. A rating of perceived fatigue (RPF) was also documented at the different time points. Results: Time to task failure (reduction of 50% in maximal voluntary isometric contraction torque of ankle plantar flexors) and the increase in RPF value were not significantly different between males and females. Both sex groups showed similar and significant increases (p < 0.05) in mean COP sway velocity with no significant changes in co-contraction indices. No significant effects of fatigue and related interactions were found for SOL H/M-max ratio. Discussion: The absence of a significant sex difference in postural control change (sway and co-contraction) with fatigue could be explained by similar perceived (RPF) and performance fatigability (exercise duration) between males and females in the present study. Fatigue did not lead to significant changes in SOL spinal motoneuron excitability with activation of Ia afferents.

A physiotherapist's perception of their own behavior compared to the perception of their behavior by persons with TBI within the context of telerehabilitation: A self-determination theory perspective.

BACKGROUND: According to Self-Determination Theory, the fulfillment of basic psychological needs of autonomy, competence, and relatedness plays an important role in one's motivation, engagement, and well-being. How a therapist is perceived to support or thwart these needs can impact adherence to treatment, thus influencing the effectiveness of therapeutic interventions. OBJECTIVES: This alternating single-subject design explores how the physiotherapist self-reports interpersonal behaviors, how the person living with a disability (PwD) perceives the physiotherapist's supportive/thwarting interpersonal behaviors, and how the two align in the context of telerehabilitation. METHODS: Five PwD and their physiotherapist completed two telerehabilitation exercise programs. The PwD completed the Interpersonal Behavior Questionnaire (IBQ) to examine how they perceived the physiotherapist interpersonal behaviors. The physiotherapist completed the Interpersonal Behavior Questionnaire-Self (IBQ-Self) to document how they self-reported these same behaviors. Descriptive statistics were used to document self-reports and perceptions of behaviors. RESULTS: Each PwD perceived the physiotherapist as being more supportive than thwarting. The supportive/thwarting behaviors varied across relationships. Greater alignment of the perceptions of therapist and the PwD was observed at the end of the programme when compared to baseline. CONCLUSION: Assessing how therapist support/thwart psychological needs and how these behaviors are perceived by PwD is recommended as it may influence the therapist's behavior and the PwD's adherence to future telerehabilitation exercise programs.

Willingness of Older Canadians with HIV to Participate in HIV Cure Research Near and After the End of Life: A Mixed-Method Study.

HIV cure research requires interrogating latent HIV reservoirs in deep tissues, which necessitates autopsies to avoid risks to participants. An HIV autopsy biobank would facilitate this research, but such research raises ethical issues and requires participant engagement. This study explores the willingness to participate in HIV cure research at the end of life. Participants include Canadians with HIV [people with HIV (PWHIV)] aged 55 years or older. Following a mixed-method study design, all participants completed a phone or online survey, and a subset of participants participated in in-depth phone or videoconference interviews. We produced descriptive statistics of quantitative data and a thematic analysis of qualitative data. Barriers and facilitators were categorized under domains of the Theoretical Domains Framework. From April 2020 to August 2021, 37 participants completed the survey (mean age = 69.9 years old; mean duration of HIV infection = 28.5 years), including 15 interviewed participants. About three quarters of participants indicated being willing to participate in hypothetical medical studies toward the end of life (n = 30; 81.1%), in HIV biobanking (n = 30; 81.1%), and in a research autopsy (n = 28; 75.7%) to advance HIV cure research, mainly for altruistic benefits. The main perceived risks had to do with physical pain and confidentiality. Barriers and facilitators were distributed across five domains: social/professional role and identity, environmental context and resources, social influences, beliefs about consequences, and capabilities. Participants wanted more information about study objectives and procedures, possible accommodations with their last will, and rationale for studies or financial interests funding studies. Our results indicate that older PWHIV would be willing to participate in HIV cure research toward the end of life, HIV biobanking, and research autopsy. However, a dialogue should be initiated to inform participants thoroughly about HIV cure studies, address concerns, and accommodate their needs and preferences. Additional work is required, likely through increased community engagement, to address educational needs.

Sex differences in central and peripheral fatigue induced by sustained isometric ankle plantar flexion.

The main aim of this study was to determine sex differences in central and peripheral fatigue produced by a sustained isometric exercise of ankle plantar flexors in healthy young adults. Ten males and fourteen females performed a sustained isometric ankle exercise until task failure. Maximal voluntary isometric contraction (MVIC) torque (plantarflexion), voluntary activation level (using the twitch interpolation technique), and resting twitch contractile properties [twitch peak torque (ST), twitch half relaxation time, and low frequency fatigue (LFF) ratio] were measured before, immediately after, and throughout a recovery period (1, 2, 5, and 10 min) following the exercise protocol in order to characterize neuromuscular fatigue. Fatigue had effects (p≤ 0.05) on all dependent variables (reduction in MVIC, VA and twitch torque and slowing of relaxation time). However, no significant differences in performance fatigability markers (MVIC torque decline and time to fatigue) and only minor differences in the variables reflecting central and peripheral fatigue mechanisms were found between males and females. A regression analysis did suggest a somewhat greater role of central fatigue in males compared with females. Females also showed a slightly greater and more prolonged decline in ST and LFF after exercise compared with males. The presence of only minor differences in central and peripheral fatigue mechanisms between males and females in the present study could be explained by the lack of important sex differences in performance fatigability, which could be due to lesser sex differences in the relative area of type I muscle fibers and in contractile function (muscle strength) of ankle plantar flexors as compared with other muscle groups.

Sex differences in the effect of muscle fatigue on static postural control under different vision and task conditions.

The main aim of this study was to compare the effects of ankle plantar flexors fatigue on postural control between healthy young adult males and females. The secondary aim was to determine the effects of vision on the fatigue-induced postural changes. Ten healthy young males and nine females were asked to perform quiet standing (QS) and standing forward lean (FL) tasks with eyes open (EO) and closed (EC) before and immediately following exercise, and throughout a 15-min recovery period. A sustained isometric exercise of ankle plantar flexors was performed until participants were no longer able to maintain a target torque of 50% of maximal voluntary isometric contraction (MVIC). Mean anteroposterior (AP) and mediolateral (ML) positions of the center of pressure (COP), mean COP sway velocity, and 95% ellipse area of COP sway were measured. Ankle plantar flexors fatigue had significant effects on all dependent variables, except for sway area. A fatigue X sex interaction was found for sway velocity with the most challenging task condition (FL-EC), where males showed a significant increase in sway velocity up to 15 min following exercise, whereas females did not. Fatigue X vision interactions for AP position were also found, with the withdrawal of vision leading to a greater backward shift during recovery for both the QS (5 to 15 min) and FL (5 to 10 min) tasks. Our findings suggest the use of different postural control strategies with ankle fatigue between males and females, and also a contribution of vision to compensate for fatigue-induced instability that is not dependent on task difficulty.

The Use of Home-Based Nonimmersive Virtual Reality to Encourage Physical and Cognitive Exercise in People With Mild Cognitive Impairment: A Feasibility Study.

Individuals with mild cognitive impairment are at risk of cognitive and physical decline. Virtual reality (VR) exercise may provide beneficial physical and cognitive exercise. The objectives of this study were to assess the feasibility and safety of home-based VR exercise and to provide pilot data for physical and cognitive efficacy. Eleven individuals with mild cognitive impairment (seven males/four females, average 78 years old, and average 3 years since diagnosis) performed a 30-min home-based VR exercise program 5 days a week for 6 weeks. The VR platform was successfully installed in participants' homes, and all participants were able to learn the VR program and progress. Participants completed 99% of the prescribed exercise. There were no major adverse events. Most participants enjoyed the VR program and reported physical benefits; fewer reported cognitive benefits. No physical or cognitive outcome measures showed change after 6 weeks. Home-based VR exercise is safe and feasible in individuals with mild cognitive impairment.

Rating of perceived exertion (RPE) in studies of fatigue-induced postural control alterations in healthy adults: Scoping review of quantitative evidence.

BACKGROUND: Amongst the literature researching the effects of exercise-induced fatigue on postural control in healthy adults, many studies have used the Borg scales to document the rating of perceived exertion (RPE) and have shown a broad range of RPE values. Our main aim was to map fatigue-induced RPE values in included publications. Secondary aims were to summarize the preference and purpose for the use of Borg scales within the included publications and to explore the potential associations between fatigue-induced RPE values and postural control changes. METHODS: Five databases (Ovid Medline, PubMed, CINAHL, Scopus, and SPORTDiscus) were systematically searched for synthesizing data among the publications that reported RPE values on the Borg RPE- and Category-Ratio (CR) 10 scales and also found fatigue effects on postural control in healthy adults. Spearman's rank correlations were conducted to assess potential associations between fatigue-induced RPE values and maximal postural control changes across the included publications (group data). RESULTS: 45 of 51 studies included in this review reported maximal RPE values following exercise and ranged from 10.4-20 (6-20 Borg RPE) or 0.9-10 (CR10) indicating "very light" or "very weak" to "maximal" exertions. The 6-20 Borg and CR10 scales were mainly used to assess cardiovascular and muscular exertion, respectively. The scales were used mostly to estimate fatigue levels (n = 45), and to a lesser extent to produce a specific exercise intensity (n = 5) and as the criterion for exercise termination (n = 1). In general, there was no significant association between RPE and postural control changes across studies. CONCLUSION: The broad range of RPE values and weak correlations may suggest that various fatigue levels can lead to postural control changes. However, one should be careful in comparing the extent of fatigue from RPE values and its potential effect on postural control in the light of many confounding factors.

How do we define and measure sarcopenia? A meta-analysis of observational studies.

OBJECTIVE: this study aimed to investigate how sarcopenia has been defined and measured in the literature reporting its prevalence, and how different definitions and measurement tools can affect prevalence estimates. DESIGN: systematic review and meta-analysis. SETTING AND PARTICIPANTS: community-dwelling older people. METHODS: meta-analysis of data collected from observational studies. We performed an electronic search in five databases to identify studies reporting the prevalence of sarcopenia. We used descriptive statistics to present data pertaining sarcopenia definition and measurement tools, and the quality-effects model for meta-analysis of pooled prevalence. RESULTS: we found seven different operational definitions for sarcopenia and a variety of tools applied to assess the sarcopenic markers; muscle mass, muscle strength and physical performance. The prevalence of sarcopenia varied between the definitions with general estimates ranging from 5% based on the European Working Group on Sarcopenia in Older People (EWGSOP1) criterion to 17% with the International Working Group on Sarcopenia. According to the tool used to assess muscle mass, strength and physical performance, prevalence values also varied within definitions extending from 1 to 7%, 1 to 12% and 0 to 22%, respectively. CONCLUSION AND IMPLICATIONS: the criteria used to define sarcopenia, as well as the measurement tools applied to assess sarcopenic markers have influence in the prevalence of sarcopenia. The establishment of a unique definition for sarcopenia, the use of methods that guarantee an accurate evaluation of muscle mass and the standardisation of measurement tools are necessary to allow a proper diagnosis and comparison of sarcopenia prevalence among populations.

Implementation of a randomized controlled trial on an inpatient stroke rehabilitation unit: Lessons learned.

BACKGROUND/AIMS: The objective of this manuscript is to present challenges and solutions that arose during a mid-sized single-site RCT of a rehabilitation intervention performed in an inpatient stroke rehabilitation setting. METHODS: Seventy-six participants from an inpatient stroke rehabilitation unit were randomized to experimental and control groups. All participants did 30-45 min of virtual reality (VR) daily for 10-12 sessions. The experimental group did VR targeting sitting balance while the control group did VR with limited arm movement. Challenges during the implementation of the RCT were documented and strategies to mitigate them were applied. RESULTS: Challenges were placed into five categories:1. Recruitment. Our recruitment procedures required multiple steps prior to initiating direct patient contact; one solution would be to have patients consent to be approached about research upon admission to the inpatient unit.2. Patient-specific Issues. Fatigue, pain, vision problems and engagement were managed through scheduling, increasing the workload slowly and personalized modifications to the VR.3./4. Scheduling and Staffing. Recruitment and attendance at VR sessions were maximized through good communication, flexibility and cooperation, between research staff, clinical staff, volunteers, students and participants.5. Technology. Because hospital internet service was poor, a mobile internet data plan was purchased to ensure the system's reliability. CONCLUSIONS: We have identified challenges in delivering a rehabilitation intervention on an inpatient stroke rehabilitation unit and some of the measures taken to surmount these challenges. Through good planning, flexibility and collaboration, almost all of the challenges were successfully addressed. CLINICAL TRIAL REGISTRATION NUMBER: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02285933.

Sitting Balance Exercise Performed Using Virtual Reality Training on a Stroke Rehabilitation Inpatient Service: A Randomized Controlled Study.

BACKGROUND: Virtual reality training (VRT) is engaging and may enhance rehabilitation intensity. Only one previous study has looked at its use to improve sitting balance after stroke. OBJECTIVE: To determine if supplemental sitting balance exercises, administered via VRT, improve control of sitting balance and upper extremity function in stroke rehabilitation inpatients. DESIGN: Assessor-blinded, placebo-controlled randomized controlled trial. SETTING: Stroke inpatient rehabilitation unit. PARTICIPANTS: Seventy-six participants (out of 130 approached) with subacute stroke who could not stand independently were randomized to experimental and control groups. Sixty-nine completed the study. INTERVENTIONS: The experimental group did VRT that required leaning and reaching, whereas the control group had their trunk restrained and performed VRT that involved only small upper extremity movements to minimize trunk movement. Both groups performed 10-12 sessions of 30-45 minutes. Participants were assessed pre, post, and 1 month after the sessions by a blinded examiner. OUTCOME MEASURES: Function in Sitting Test (FIST, primary outcome measure); Ottawa Sitting Scale; Reaching Performance Scale; Wolf Motor Function Test (WMFT). RESULTS: Thirty-three participants completed the experimental intervention and 36 the control. Pre/post differences for FIST were 3.4 (confidence interval [CI] 0.5;6.3) for the experimental group and 5.3 (2.9;7.7) for the control group. There was a significant improvement over time (adjusted for multiple comparisons, P < .006) on most outcome measures except the WMFT Performance Time Scale (control group; P = .007) and grip strength (P = .008); there were no differences between groups (P > .006). CONCLUSIONS: Siting balance outcomes were similar for both groups; therefore, this study does not support the use of sitting balance exercises provided via VRT for the rehabilitation of sitting balance after stroke. However, because it is only the second study to investigate VRT for sitting balance and upper extremity function, more research, using more challenging exercises and a greater treatment intensity, is required before definitive conclusions are made.

Effect of Bilateral and Unilateral Plantarflexor Muscle Fatigue on Blind Navigation Precision and Gait Parameters.

The objective was to evaluate the impact of bilateral and unilateral fatigue of the plantarflexor muscles on blind navigation. Thirty-eight young adults walked 8-m without vision before fatigue (pre-fatigue), then fatigued either one or both of their plantarflexor muscles by performing isometric contractions. After each fatigue, two blind navigation trials were performed (post-fatigue trials 1 and 2). Results revealed no effect of bilateral muscle fatigue on navigation precision and gait parameters. Unilateral muscle fatigue led to longer linear distance travelled during post-fatigue trial 2 compared to pre-fatigue and to a change in angular deviation between pre- and post-fatigue. In general, results suggest that participants were able to make adaptive changes to counter muscle fatigue during blind navigation.

Challenges of Patient Engagement in an HIV Clinical Research Program: A Qualitative Analysis of Stakeholder Accounts.

Patient engagement (PE) promotes collaboration between stakeholders (researchers, patients, clinicians, etc). It often faces challenges due to tensions between its ethical/political and scientific underpinnings. This article explores how stakeholders applied the guiding principles of a PE project ("co-build," "support and mutual respect," and "inclusiveness") for an HIV clinical research program initiated in January 2016. Three researchers/clinicians, a PE agent, and 2 patients held 3 meetings (June-October 2018) to discuss challenges faced and how these impacted their approach to PE. Regular stakeholder discussions about PE in clinical research could be documented and help guide PE to better meet stakeholder needs.

Centre of pressure displacements produced in sitting during virtual reality training in younger and older adults and patients who have had a stroke.

Purpose: Poor sitting balance is common after stroke and makes leaning and reaching while sitting difficult and dangerous. Virtual reality training (VRT) uses computer hardware and software to track a person's movements and allow him or her to interact with a virtual environment. VRT games are available to train sitting balance after stroke; however, it is unknown how challenging they are. The objectives of this study were to characterize the centre of pressure displacements generated during the performance of VRT in stroke patients (ST) and compare their performance to that of young (YA) and older adults (OA).Materials and Methods: Eight ST participants who could stand for at least four minutes were recruited from an inpatient stroke rehabilitation unit for this cross-sectional, observational pilot study. Eight YA and eight OA were recruited from the community. Participants sat on a pressure mat and played 17 VRT game/difficulty combinations. The area, range and average velocity of centre of pressure displacement were determined for each game/difficulty.Results: Virtually manoeuvring a motorcycle around barriers and leaning to move a ball down a maze produced the greatest displacement of the centre of pressure, particularly in the mediolateral direction. OA moved further and faster in the mediolateral direction than YA. ST's performance was more variable.Conclusions: Some VRT games were more likely to push participants to challenge their limits of stability. Others required less displacement but more trunk stability. These results can guide which VRT games are used for the rehabilitation of sitting balance after stroke.Implications for rehabilitationSome virtual reality training games produce greater displacements of the centre of pressure in sitting than others, suggesting that careful matching between game challenge and desired therapeutic outcome is necessary when selecting games.Virtual reality training performed in sitting with feet on the floor challenges sitting balance in the frontal plane more so than in the sagittal plane.Older adults tend to lean more than younger adults while individuals with stroke move more or less than others, depending on the game.

Remotely Supervised Home-Based Intensive Exercise Intervention to Improve Balance, Functional Mobility, and Physical Activity in Survivors of Moderate or Severe Traumatic Brain Injury: Protocol for a Mixed Methods Study.

BACKGROUND: Traumatic brain injury (TBI) may impact an individual physically, cognitively, socially, and emotionally. Poor balance, reduced mobility, and low daily physical activity often will require ongoing physical rehabilitation intervention. However, face-to-face specialized physiotherapy is not always accessible for individuals living in rural settings. OBJECTIVE: We will answer four questions: (1) What is the feasibility of a remotely supervised, home-based, intensive exercise intervention with survivors of moderate and severe TBI? (2) Does the frequency of remote supervision have an impact on the feasibility of completing a home-based intensive exercise program? (3) Does the frequency of remote supervision impact balance, functional mobility, and physical activity? (4) What is the lived experience of remote supervision for both survivors and caregivers? METHODS: Four participants will complete two intensive, 4-week (five days per week) home-based exercise interventions remotely supervised via synchronous videoconference. Each exercise intervention will have a goal of 160 to 300 repetitions or 60 minutes of tailored exercises to promote neuroplasticity and be defined as an intensive home-based exercise intervention. An alternating single-subject design will allow for the comparison between two frequencies of remote supervision, once weekly and five times weekly. Daily repeated outcome measures, pre- and postintervention outcome measures, and 1-month follow-up outcome measures will be collected to explore the effect on feasibility and physical variables. Daily outcome measures include step count and Five Times Sit-to-Stand test. Pre-post measures include assessment of quiet stance and the Community Balance and Mobility Scale. A semistructured interview will be completed at the end of each intervention segment to document the lived experience of both survivors and their study partners. Finally, five questionnaires will be used to understand the overall experience: the Mayo-Portland Adaptability Inventory-4 Participation Index, Satisfaction With Life Scale, Fall Efficacy Scale-International, Interpersonal Behavior Questionnaire, and System Usability Scale. Data will be analyzed following traditional single-subject methods of analysis. RESULTS: Ethics approval was received from both the Bruyère Research Institute and University of Ottawa review boards in March 2019. Recruitment is underway. CONCLUSIONS: The proposed intervention is complex in nature due to the involvement of multiple technology sources and the inclusion of a complex dyad (survivors and caregivers) in a community setting. This type of research is timely given that alternative methods of physical intervention delivery are needed to facilitate gains in balance, mobility, physical activity among TBI survivors with limited access to clinical care, and the quality of the patients' experience. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/14867.

Home-based virtual reality training after discharge from hospital-based stroke rehabilitation: a parallel randomized feasibility trial.

BACKGROUND: Virtual reality training (VRT) uses computer software to track a user's movements and allow him or her to interact with a game presented on a television screen. VRT is increasingly being used for the rehabilitation of arm function, balance and walking after stroke. Patients often require ongoing therapy post discharge from inpatient rehabilitation. Outpatient therapy may be limited or inaccessible due to waiting lists, transportation issues, distance etc.; therefore, home-based VRT could provide the required therapy in a more convenient and accessible setting. The objectives of this parallel randomized feasibility trial are to determine (1) the feasibility of using VRT in the home post stroke and (2) the feasibility of a battery of quantitative and qualitative outcome measures of stroke recovery. METHODS: Forty patients who can stand for at least 2 min and are soon to be discharged from inpatient or outpatient rehabilitation post stroke are being recruited in Ottawa, Canada and being randomized to control and experimental groups. Participants in the experimental group use home-based VRT to do rehabilitative exercises for standing balance, stepping, reaching, strengthening and gentle aerobic fitness. Control group participants use an iPad with apps selected to rehabilitate cognition, hand fine motor skills and visual tracking/scanning. Both groups are instructed to perform 30 min of exercise 5 days a week for 6 weeks. VRT intensity and difficulty are monitored and adjusted remotely. Weekly telephone contact is made with all participants. Ability to recruit participants, ability to handle the technology and learn the activities, compliance, safety, enjoyment, perceived efficacy and cost of program delivery will be assessed. A battery of assessments of standing balance, gait and community integration will be assessed for feasibility of completion within this population and potential for improvement following the intervention. Effect sizes will be calculated. DISCUSSION: The results of this study will be used to support the creation of a definitive randomized controlled trial on the efficacy of home-based VRT for rehabilitation post stroke. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03261713 . Registered on 21 August 2017. Registration amended on 1 June 2018 to decrease enrollment from 40 to 20 due to a cut in study funding and difficulty recruiting participants.