Re-Imagining Hospital Patient Room Design for People After stroke: A Randomized Controlled Study Using Virtual Reality.

BACKGROUND: The hospital's physical environment can impact health and well-being. Patients spend most of their time in their hospital rooms. However, little experimental evidence supports specific physical design variables in these rooms, particularly for people poststroke. The study aimed to explore the influence of patient room design variables modeled in virtual reality using a controlled experimental design. METHODS: Adults within 3 years of stroke who had spent >2 nights in hospital for stroke and were able to consent were included (Melbourne, Australia). Using a factorial design, we immersed participants in 16 different virtual hospital patient rooms in both daytime and nighttime conditions, systematically varying design attributes: patient room occupancy, social connectivity, room size (spaciousness), noise (nighttime), greenery outlook (daytime). While immersed, participants rated their affect (Pick-A-Mood Scale) and preference. Mixed-effect regression analyses were used to explore participant responses to design variables in both daytime and nighttime conditions. Feasibility and safety were monitored throughout. Australian New Zealand Clinical Trials Registry, Trial ID: ACTRN12620000375954. RESULTS: Forty-four adults (median age, 67 [interquartile range, 57.3-73.8] years, 61.4% male, and a third with stroke in the prior 3-6 months) completed the study in 2019-2020. We recorded and analyzed 701 observations of affective responses (Pick-A-Mood Scale) in the daytime (686 at night) and 698 observations of preference responses in the daytime (685 nighttime) while continuously immersed in the virtual reality scenarios. Although single rooms were most preferred overall (daytime and nighttime), the relationship between affective responses differed in response to different combinations of nighttime noise, social connectivity, and greenery outlook (daytime). The virtual reality scenario intervention was feasible and safe for stroke participants. CONCLUSIONS: Immediate affective responses can be influenced by exposure to physical design variables other than room occupancy alone. Virtual reality testing of how the physical environment influences patient responses and, ultimately, outcomes could inform how we design new interventions for people recovering after stroke. REGISTRATION: URL: https://anzctr.org.au; Unique identifier: ACTRN12620000375954.

Considering the Importance of Personal and Injury Factors Influencing Outcome After Traumatic Brain Injury.

OBJECTIVE: Given the high variability in traumatic brain injury (TBI) outcomes and relative lack of examination of the influence of noninjury factors on outcome, this study aimed to examine factors associated with functional outcome at 1 and 2 years after moderate to severe TBI, including both preinjury and injury-related factors. DESIGN: Observational cohort study. SETTING: Inpatient hospital recruitment with outpatient follow-up at 1 and 2 years post injury. PARTICIPANTS: Individuals with moderate to severe TBI were recruited prospectively into a Longitudinal Head Injury Outcome Study. Of the eligible 3253 individuals who were eligible, 1899 participants consented to the study (N=1899). MAIN OUTCOME MEASURE: Functional outcome was measured using the Glasgow Outcome Scale-Extended (GOS-E). RESULTS: 1476 participants (73.6% males) and 1365 participants (73% males) completed the GOS-E at 1 and 2 years post injury. They had a mean age at injury of 40 years and mean duration of post-traumatic amnesia (PTA) of 26 days. Good recovery, representing return to previous activities on the GOS-E (score 7-8), was present in 31% of participants at 1 year post injury and 33.5% at 2 years post injury. When predictor variables were entered into regression together, good outcome was significantly associated with not being from a culturally and linguistically diverse background and not having preinjury mental health or alcohol treatment, shorter PTA duration, and absence of limb injuries at both 1 and 2 years; higher education was also a significant predictor at 1 year post injury. CONCLUSIONS: Alongside consideration of injury severity, understanding and addressing preinjury factors is important to maximize outcomes.

Statement of the Rehabilitation Medicine Society of Australia and New Zealand for the therapeutic use of botulinum toxin A in spasticity management.

The Rehabilitation Medicine Society of Australia and New Zealand advocates the safe, effective and evidence-based use of botulinum toxin type A for spasticity management. The process requires appropriate training, alongside considerable knowledge and skills, to maximise efficacy. The processes before and after injection contribute to effectiveness. The gold standard of managing spasticity is for assessment by a multidisciplinary specialist team, deriving patient-centric goals, and designing an injection protocol to match these goals. The patient and/or carers are considered part of the decision-making team. Postinjection therapy and measurement of goal achievement are highly recommended as part of the wider holistic approach to management. The Society believes treatment failures can be minimised by following clear clinical guidelines.

Cardiorespiratory fitness assessment and training in the early sub-acute phase of recovery following traumatic brain injury: a systematic review.

OBJECTIVES: To examine the safety of cardiorespiratory fitness (CRF) assessment and training in the early sub-acute phase of recovery (≤3 months) following moderate-to-extremely severe traumatic brain injury (TBI). METHODS: A systematic review was completed in accordance with the PRISMA guidelines. Studies investigating adults and adolescents ≥15 years with moderate-to-extremely severe TBI were considered for inclusion. The methodological quality of the included studies was evaluated according to the McMaster Guidelines for Critical Review Form - Quantitative Studies. RESULTS: Eleven studies with a total of 380 participants were included in the review. Adverse events (AEs) and symptom monitoring were poorly reported. Only four studies reported on the occurrence of AEs, with a total of eight AEs reported. Three of the reported AEs were concussion-like symptoms with no further exercise-induced symptom exacerbation reported. No serious AEs were reported. CONCLUSION: There is no evidence to suggest that CRF assessment and training is unsafe in the early sub-acute phase of recovery following moderate-to-extremely severe TBI. However, despite the low AE and symptom exacerbation rates identified, a timeframe for safe commencement was unable to be established due to poor reporting and/or monitoring of exercise-induced symptoms and AEs in the current literature.

Is early initiated cardiorespiratory fitness training within a model of stroke-integrated cardiac rehabilitation safe and feasible?

OBJECTIVE: To investigate the safety and feasibility of an early initiated stroke-integrated Cardiac Rehabilitation program. METHODS: People with acute first or recurrent ischaemic stroke, admitted to Epworth HealthCare were screened for eligibility and invited to participate. In addition to usual care neurorehabilitation, participants performed 1) cardiorespiratory fitness training 3-days/week during inpatient rehabilitation (Phase 1), and/or 2) 2-days/week centre-based cardiorespiratory fitness training plus education and 1-day/week home-based cardiorespiratory fitness training for 6-weeks during outpatient rehabilitation (Phase 2). Safety was determined by the number of adverse and serious adverse events. Feasibility was determined by participant recruitment, retention, and attendance rates, adherence to exercise recommendations, and participant satisfaction. RESULTS: There were no study-related adverse or serious adverse events. Of 117 eligible stroke admissions, 62 (53%) were recruited, while 10 (16.1%) participants withdrew. Participants attended 189 of 201 (94%) scheduled cardiorespiratory fitness training sessions in Phase 1 and 341/381 (89.5%) scheduled sessions in Phase 2. Only 220/381 (58%) scheduled education sessions were attended. The minimum recommended cardiorespiratory fitness training intensity (40% heart rate reserve) and duration (20 minutes) was achieved by 57% and 55% of participants respectively during Phase 1, and 60% and 92% respectively during Phase 2. All respondents strongly agreed (69%) or agreed (31%) they would recommend the stroke-integrated Cardiac Rehabilitation program to other people with stroke. CONCLUSION: Cardiorespiratory fitness training in line with multiple clinical practice guidelines included within a model of stroke-integrated Cardiac Rehabilitation appears to be safe and feasible in the early subacute phase post-stroke.

Controlling modified Tardieu scale assessment speeds to match joint angular velocities during walking impacts spasticity assessment outcomes.

OBJECTIVE: To investigate whether tailoring the speed of the Modified Tardieu Scale to reflect an individual's joint angular velocity during walking influences spasticity assessment outcomes. DESIGN: Observational trial. SETTING: Inpatient and outpatient neurological hospital department. SUBJECTS: Ninety adults with lower-limb spasticity. INTERVENTIONS: N/A. MAIN MEASURES: The Modified Tardieu Scale was used to assess the gastrocnemius, soleus, hamstrings and quadriceps. The V1 (slow) and V3 (fast) movements were completed as per standardised testing. Two additional assessments were completed, reflecting joint angular velocities during walking based on (i) a healthy control database (controlled velocity) and (ii) the individual's real-time joint angular velocities during walking (matched velocity). The agreement was compared using Cohen's and Weighted Kappa statistics, sensitivity and specificity. RESULTS: There was poor agreement when rating trials as spastic or not spastic at the ankle joint (Cohen's Kappa = 0.01-0.17). Trials were classified as spastic during V3 and not spastic during the controlled conditions in 81.6-85.1% of trials when compared to stance phase dorsiflexion angular velocities and 48.0-56.4% when compared to swing phase dorsiflexion angular velocities. The severity of muscle reaction demonstrated poor agreement at the ankle (Weighted Kappa = 0.01-0.28). At the knee, there was a moderate-excellent agreement between the V3 and controlled conditions when rating a trial as spastic or not spastic (Cohen's Kappa = 0.66-0.84) and excellent agreement when comparing severity (Weighted Kappa = 0.73-0.94). CONCLUSION: The speed of assessment impacted spasticity outcomes. It is possible that the standardised protocol may overestimate the impact spasticity has on walking, especially at the ankle.

Experience of adapted cognitive behaviour therapy to address sexuality problems after traumatic brain injury: A qualitative study.

Although sexuality has been shown to be negatively impacted in up to half of individuals who sustain traumatic brain injury (TBI), few studies have sought to evaluate the efficacy of targeted interventions. Gaining insight into the participant experience of undergoing treatment for post-TBI sexuality changes is a crucial aspect of intervention evaluation. This study aimed to investigate participants with TBI experience of undergoing eight sessions of a novel CBT intervention designed to help both couples and singles improve sexual wellbeing after TBI. Eight participants (50% male) with moderate-severe TBI, and a mean age of 46.38-years (SD = 13.54), completed a qualitative interview. A six-phase reflexive thematic analysis approach was used. Despite variability in participant characteristics, the findings suggested that participants with TBI experience reflected that of a positive treatment journey characterized by high levels of enjoyment and satisfaction. Key themes identified included contextual factors that preceded treatment, factors that facilitated treatment engagement, outcomes derived from the treatment experience, and feedback provided on reflection. The results not only provide an enriched understanding of the client experience of the intervention but provide corroborating preliminary evidence of efficacy for this novel CBT intervention in addressing complex and persistent sexuality problems after TBI.

Long-term effect of additional rehabilitation following botulinum toxin-A on upper limb activity in chronic stroke: the InTENSE randomised trial.

BACKGROUND: It is common for people with persistent spasticity due to a stroke to receive an injection of botulinum toxin-A in the upper limb, however post-injection intervention varies. AIM: To determine the long-term effect of additional upper limb rehabilitation following botulinum toxin-A in chronic stroke. METHOD: An analysis of long-term outcomes from national, multicenter, Phase III randomised trial with concealed allocation, blinded measurement and intention-to-treat analysis was carried out. Participants were 140 stroke survivors who were scheduled to receive botulinum toxin-A in any muscle(s) that cross the wrist because of moderate to severe spasticity after a stroke greater than 3 months ago, who had completed formal rehabilitation and had no significant cognitive impairment. Experimental group received botulinum toxin-A plus 3 months of evidence-based movement training while the control group received botulinum toxin-A plus a handout of exercises. Primary outcomes were goal attainment (Goal Attainment Scale) and upper limb activity (Box and Block Test) at 12 months (ie, 9 months beyond the intervention). Secondary outcomes were spasticity, range of motion, strength, pain, burden of care, and health-related quality of life. RESULTS: By 12 months, the experimental group scored the same as the control group on the Goal Attainment Scale (MD 0 T-score, 95% CI -5 to 5) and on the Box and Block Test (MD 0.01 blocks/s, 95% CI -0.01 to 0.03). There were no differences between groups on any secondary outcome. CONCLUSION: Additional intensive upper limb rehabilitation following botulinum toxin-A in chronic stroke survivors with a disabled upper limb is not more effective in the long-term. TRIAL REGISTRATION: ACTRN12615000616572 (12/06/2015).

Maintenance of Cardiorespiratory Fitness in People With Stroke: A Systematic Review and Meta-analysis.

OBJECTIVE: To determine if improvements in cardiorespiratory fitness are maintained in the short-, medium- and long-term after a cardiorespiratory fitness intervention in people with stroke. DATA SOURCES: MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, (CENTRAL) Cochrane, Web of Science, Sports Discus, and Physiotherapy Evidence Database were searched from inception. STUDY SELECTION: Randomized controlled trials and cohort studies including (1) people with stroke; (2) cardiorespiratory fitness interventions; (3) a direct measure of cardiorespiratory fitness; and (4) short- (0 to <3 months), medium- (3-6 months), or long-term (>6 months) follow-up data. DATA EXTRACTION: Two reviewers independently screened full texts and extracted data, including study methods, participant demographic information, stroke type and severity, outcome measures, intervention information, follow-up time points, and results, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A lower limit of -1.0 mL•kg-1•min-1 was used to determine maintenance (ie, no change) of cardiorespiratory fitness. DATA SYNTHESIS: Fourteen studies (N=324 participants) were included. Participants completed cardiorespiratory fitness training 2-5 days per week over 4-13 weeks at moderate to high intensity (40%-70% heart rate reserve [HRR]; n=4 studies), high intensity (60% to <90% HRR; n=7 studies), and intervals of high intensity (85%-95% peak heart rate or maximal heart rate; n=3 studies). Most people with stroke did maintain cardiorespiratory fitness in the short- (-0.19 mL•kg-1•min-1 [95% CI, -1.66 to 1.28]), medium- (-0.61 mL•kg-1•min-1 [95% CI, -3.95 to 2.74]), and long-term (0.00 mL•kg-1•min-1 [95% CI, -2.23 to 2.23]) after completion of cardiorespiratory fitness interventions. CONCLUSIONS: People with stroke maintain cardiorespiratory fitness after a cardiorespiratory fitness intervention in the short-, medium-, and longer-term. However, little is known about the impact of participant and intervention characteristics on the long-term maintenance of cardiorespiratory fitness.

Burnout in rehabilitation medicine trainees: a call for more research.

Burnout is recognised as a significant occupational hazard for medical professionals. For graduate trainees, across various medical specialties, there is growing evidence burnout results in personal harm and reduces the quality of patient care. Rehabilitation medicine, with its challenge of emotional exhaustion bought about by greater involvement in patient psychosocial well-being over a prolonged period, is significantly under-represented in research into burnout prevalence, impact and prevention strategies. We argue the lack of any evidence base in the Australian healthcare context negatively impacts the ability of training organisations to appropriately support trainees experiencing burnout.

Is inpatient rehabilitation a predictor of a lower incidence of persistent knee pain 3-months following total knee replacement? A retrospective, observational study.

BACKGROUND: Moderate to severe levels of persistent knee pain have been estimated to affect up to 25% of people 3-months or more after a total knee replacement. It is unknown whether the type of rehabilitation pathway is associated with persistent high pain after surgery. Using a prospectively followed Australian cohort who underwent total knee replacement for knee osteoarthritis, this study aimed to i) report the incidence of high-intensity knee pain (defined as a score ≤ 15 on the Oxford Knee Score pain subscale) across time and ii) identify whether referral to inpatient rehabilitation was one of the predictors of persistent pain at 3-months post-surgery. METHODS: A retrospective analysis of a large prospective study was conducted using the Oxford Knee Score pain subscale to determine if participants had high pain at 3-months, 12-months and 36-months post-surgery. Relative risks for high pain at 3-, 12- and 36-months between the type of rehabilitation pathway were determined using Poisson multivariable regression with robust standard errors. The same technique was also employed to determine potential predictors, including rehabilitation pathway, of high pain at 3 months. RESULTS: The incidence of high pain in all participants was 73% pre-surgery and 10, 5 and 6% at 3-, 12- and 36-months respectively following knee replacement. There was a significant interaction between time and rehabilitation pathway, suggesting that the effect of the rehabilitation pathway varied across time. The incidence of high pain at 3-months did not significantly differ between those who attended inpatient rehabilitation (11.6%) and those discharged directly home (9.5%). Multivariable Poisson regression analysis identified the pre-surgical presence of high pain, co-morbid low back pain or other lower limb problem, younger age and having a major complication within 3-months following surgery as significant predictors of persistent pain whilst discharge to inpatient rehabilitation was not. CONCLUSION: A small but clinically significant minority of people continued to have high pain levels at 3-, 12- and 36-months following a primary total knee replacement for osteoarthritis. Participation in an inpatient rehabilitation program does not appear to be an important predictor of ongoing knee pain. TRIAL REGISTRATION: The data were collected in the Evidence-based Processes and Outcomes of Care (EPOC) study, ClinicalTrials.gov Identifier: NCT01899443.

Post Stroke Outcome: Global Insight into Persisting Sequelae Using the Post Stroke Checklist.

BACKGROUND: Following stroke, individuals commonly experience persisting loss of function. Whilst long-term care should involve continued support for ongoing stroke sequelae, this is often not routinely practiced globally. The Post Stroke Checklist was designed to standardise the process of detecting persisting treatable problems following stroke. AIMS: This cross-sectional study aimed to identify the long-term problems reported in Australian and Chinese participants at six months post stroke using the Post Stroke Checklist. It also aimed to provide global insight into poststroke sequelae by comparing the study results to previously published studies which administered the Post Stroke Checklist in other countries. METHODS: Participants were recruited from two hospitals in Australia and one hospital in China. The Post Stroke Checklist consists of 11 problem areas commonly experienced after stroke. This study follows a sequence of studies which have applied the checklist to monitor long-term outcomes after stroke in Germany, Italy, Singapore, Sweden and the United Kingdom. RESULTS: Comparisons between Australia (n = 112) and China (n = 97) demonstrated statistically significant differences on the Post Stroke Checklist items. Across all seven countries, collectively the most common persisting difficulties post-stroke related to: cognition, life after stroke, mood, mobility and activities of daily living. An analysis of means procedure compared individual countries for each checklist item against the overall group mean (all countries combined). CONCLUSIONS: Globally, individuals report persisting functional difficulties following stroke. There appear to be differences in the proportions affected across the various countries, and healthcare systems may benefit from geographically tailoring post-stroke care.

Effect of Additional Rehabilitation After Botulinum Toxin-A on Upper Limb Activity in Chronic Stroke: The InTENSE Trial.

Background and Purpose- The aim of this trial was to determine the effect of additional upper limb rehabilitation following botulinum toxin-A for upper limb activity in chronic stroke. Methods- We conducted a multicenter phase III randomized trial with concealed allocation, blinded measurement, and intention-to-treat analysis. One hundred forty stroke survivors who were scheduled to receive botulinum toxin-A in any muscle(s) that cross the wrist because of moderate to severe spasticity after a stroke >3 months ago, who had completed formal rehabilitation and had no significant cognitive impairment. Experimental group received botulinum toxin-A plus evidence-based movement training while the control group received botulinum toxin-A plus a handout of exercises. Primary outcomes were goal attainment (Goal Attainment Scaling) and upper limb activity (Box and Block Test) at 3 months (end of intervention). Secondary outcomes were spasticity, range of motion, strength, pain, burden of care, and health-related quality of life. Results- In terms of goal attainment, the experimental group scored the same (mean difference, 2 T-score [95% CI, -2 to 7]) as the control group on the Goal Attainment Scale. In terms of upper limb activity, by 3 months the experimental group moved blocks at the same speed (mean difference, 0.00 blocks/s [95% CI, -0.02 to 0.01]) as the control group on the Box and Block Test. There were no differences between groups on any secondary outcome except strength, in favor of the experimental group (mean difference, 1.4 kg [95% CI, 0.2-2.7]). Conclusions- Findings suggest that additional intensive upper limb rehabilitation following botulinum toxin-A in chronic stroke survivors with a disabled upper limb is not effective. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: ACTRN12615000616572.

The reproducibility and responsiveness of subjective assessment of upper limb associated reactions in people with acquired brain injury during walking.

OBJECTIVE: The aim of this study is to determine inter-rater, test-retest and intra-rater reproducibility and responsiveness of subjective assessment of upper limb associated reactions in people with acquired brain injury using (1) the 'Qualifiers Scale' of the International Classification of Functioning, Disability and Health Framework, and (2) visually estimated elbow flexion angle during walking. DESIGN: Observational study. SETTING: A brain injury rehabilitation centre, Melbourne, Australia. SUBJECTS: People with acquired brain injury and upper limb associated reactions and experienced neurological physiotherapists. MAIN MEASURES: The Qualifiers Scale applied to individual upper limb joints and global associated reaction on a 5-point scale (0-4), a summed upper limb severity score and visually estimated elbow flexion angle. RESULTS: A total of 42 people with acquired brain injury (mean age: 48.4 ± 16.5 years) were videoed walking at self-selected and fast speeds. A subset of 30 chronic brain injury participants (mean time post injury: 8.2 ± 9.3 years) were reassessed one week later for retest reproducibility. Three experienced neurological physiotherapists (mean experience: 22.7 ± 9.1 years) viewed these videos and subjectively rated the upper limb associated reactions. Strong-to-very strong test-retest, intra- and inter-rater reproducibility was found for elbow flexion angle (ICC > 0.86) and the Qualifiers Scale applied to global and individual upper limb joints (ICC > 0.60). Responsiveness of change from self-selected to fast walking speed (mean increase 0.46 m/s) was highest for elbow flexion angle (effect size = 0.83) and low-to-moderate for the Qualifiers Scale. CONCLUSION: Subjectively rated associated reactions during walking demonstrated strong reproducibility and moderate responsiveness to speed change. The Qualifiers Scale and elbow flexion angle can both subjectively quantify associated reactions during walking in a clinical setting.

Subacute sleep disturbance in moderate to severe traumatic brain injury: a systematic review.

Objective: This systematic review evaluated subacute sleep disturbance following moderate to severe traumatic brain injury (TBI) and the impact of secondary factors such as mood or pain.Methods: A comprehensive search strategy was applied to nine databases. Inclusion criteria included: adults ≥18 years, moderate and severe TBI and within 3 months of injury. Eligible studies were critically appraised using the McMaster Quantitative Critical Review Form. Study characteristics, outcomes, and methodological quality were synthesized. This systematic review was registered with PROSPERO (Registration number: CRD42018087799).Results: Ten studies were included. Research identified early-onset sleep disturbances; characterized as fragmented sleep periods and difficulty initiating sleep. Alterations to sleep architecture (e.g. rapid eye movement sleep) were reported. Sleep disturbance appears to associate with alterations of consciousness. Sleep disturbance tended to be particularly increased during the phase of post-traumatic amnesia (PTA) (78.7%).Conclusions: There is a limited amount of research available, which has inherent measurement and sample size limitations. The gold standard for measuring sleep (polysomnography) was rarely utilized, which may affect the detection of sleep disturbance and sleep architecture. Secondary factors potentially influencing sleep were generally not reported. Further evaluation on associations between sleep and PTA is needed.

Is it me or the injury: Students' perspectives on adjusting to life after traumatic brain injury through participation in study.

Following traumatic brain injury (TBI), participating in education often provides a pathway for returning to a student's pre-injury life. In this paper, we explore themes related to adjustment and identity that emerged from students' reflections about their study journey. The data for this project are drawn from a longitudinal, predominantly qualitative investigation. Twelve students (aged: 17-32 years) completed up to three in-depth interviews over a period of 4-15 months, capturing a total of 30 time points. Data were analysed using grounded theory methods. A significant theme of "Is it Me or is it the Injury?" emerged from the context of students' descriptions of self, "Me" and thoughts about their injury, "The Injury." This emergent theme was indicative of the complex processes involved in adjusting and reshaping identity that arose from students' participation in education. The concepts identified in this research suggest that clinicians and educators must adopt a comprehensive, holistic and flexible approach to supporting students that can be adapted to reflect the individual and dynamic processes involved.

Improving Walking Ability in People With Neurologic Conditions: A Theoretical Framework for Biomechanics-Driven Exercise Prescription.

The purpose of this paper is to discuss how knowledge of the biomechanics of walking can be used to inform the prescription of resistance exercises for people with mobility limitations. Muscle weakness is a key physical impairment that limits walking in commonly occurring neurologic conditions such as cerebral palsy, traumatic brain injury, and stroke. Few randomized trials to date have shown conclusively that strength training improves walking in people living with these conditions. This appears to be because (1) the most important muscle groups for forward propulsion when walking have not been targeted for strengthening, and (2) strength training protocols have focused on slow and heavy resistance exercises, which do not improve the fast muscle contractions required for walking. We propose a theoretical framework to improve exercise prescription by integrating the biomechanics of walking with the principles of strength training outlined by the American College of Sports Medicine to prescribe exercises that are specific to improving the task of walking. The high angular velocities that occur in the lower limb joints during walking indicate that resistance exercises targeting power generation would be most appropriate. Therefore, we propose the prescription of plyometric and ballistic resistance exercise, applied using the American College of Sports Medicine guidelines for task specificity, once people with neurologic conditions are ambulating, to improve walking outcomes. This new theoretical framework for resistance training ensures that exercise prescription matches how the muscles work during walking.

Toward Accurate Clinical Spasticity Assessment: Validation of Movement Speed and Joint Angle Assessments Using Smartphones and Camera Tracking.

OBJECTIVE: To investigate whether a three-dimensional (3-D) camera (Microsoft Kinect) and a smartphone can be used to accurately quantify the joint angular velocity and range of motion (ROM) compared to a criterion-standard 3-D motion analysis system during a lower limb spasticity assessment. DESIGN: Observational, criterion-standard comparison study. SETTING: Large rehabilitation center. PARTICIPANTS: A convenience sample of 35 controls, 35 patients with a neurologic condition, and 34 rehabilitation professionals (physiotherapists and rehabilitation doctors) participated (N=104). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Modified Tardieu Scale was used to assess spasticity of the quadriceps, hamstrings, soleus, and gastrocnemius. Data for each trial were collected concurrently using the criterion-standard Optitrack 3-D motion analysis (3DMA) system, Microsoft Kinect, and a smartphone. Each healthy control participant was assessed by 1 health professional and each patient with a neurological condition was assessed by 3 health professionals. Spearman correlation coefficient and intraclass correlation coefficient with 95% confidence intervals were used to report the strength of the relationships investigated. RESULTS: The smartphone and Microsoft Kinect demonstrated excellent concurrent validity with the 3DMA system. Overall, 74.8% of the relationships investigated demonstrated a very strong (≥0.80) correlation across all of the testing parameters. The Microsoft Kinect was superior to the smartphone for measuring joint start and end angle, the smartphone was superior for measuring joint angular velocity, and the 2 systems were comparable for measuring total joint ROM. CONCLUSIONS: These findings provide preliminary evidence that user-friendly, low-cost technologies can be used to facilitate accurate measurements of joint angular velocity and angles during a lower limb spasticity assessment in a clinical setting.

The nature and extent of upper limb associated reactions during walking in people with acquired brain injury.

BACKGROUND: Upper limb associated reactions (ARs) are common in people with acquired brain injury (ABI). Despite this, there is no gold-standard outcome measure and no kinematic description of this movement disorder. The aim of this study was to determine the upper limb kinematic variables most frequently affected by ARs in people with ABI compared with a healthy cohort at matched walking speed intention. METHODS: A convenience sample of 36 healthy control adults (HCs) and 42 people with ABI who had upper limb ARs during walking were recruited and underwent assessment of their self-selected walking speed using the criterion-reference three dimensional motion analysis (3DMA) at Epworth Hospital, Melbourne. Shoulder flexion, abduction and rotation, elbow flexion, forearm rotation and wrist flexion were assessed. The mean angle, standard deviation (SD), peak joint angles and total joint angle range of motion (ROM) were calculated for each axis across the gait cycle. On a group level, ANCOVA was used to assess the between-group differences for each upper limb kinematic outcome variable. To quantify abnormality prevalence on an individual participant level, the percentage of ABI participants that were outside of the 95% confidence interval of the HC sample for each variable were calculated. RESULTS: There were significant between-group differences for all elbow and shoulder abduction outcome variables (p < 0.01), most shoulder flexion variables (except for shoulder extension peak), forearm rotation SD and ROM and for wrist flexion ROM. Elbow flexion and shoulder abduction were the axes most frequently affected by ARs. Despite the elbow being the most prevalently affected (38/42, 90%), a large proportion of participants had abnormality, defined as ±1.96 SD of the HC mean, present at the shoulder (32/42, 76%), forearm (20/42, 48%) and wrist joints (10/42, 24%). CONCLUSION: This study provides valuable information on ARs, and highlights the need for clinical assessment of ARs to include all of the major joints of the upper limb. This may inform the development of a criterion-reference outcome measure or classification system specific to ARs.

Preliminary Psychometric Evaluation of the Brachial Assessment Tool Part 2: Construct Validity and Responsiveness.

OBJECTIVES: To evaluate construct validity and responsiveness of the Brachial Assessment Tool (BrAT), a new patient-reported outcome measure for people with traumatic brachial plexus injury (BPI), and to compare it to the Disabilities of the Arm, Shoulder and Hand (DASH) and the Upper Extremity Functional Index (UEFI). DESIGN: Cross-sectional study. SETTING: Outpatient clinics. PARTICIPANTS: Adults (N=29; age range, 20-69y) with confirmed traumatic BPI. INTERVENTIONS: Participants completed the BrAT 3 times over an 18-month period together with 16 DASH activity items and the UEFI. Evaluations were undertaken of construct validity, known-groups validity, 1-way repeated analysis of variance, and effect size. MAIN OUTCOME MEASURES: BrAT, DASH, and UEFI. RESULTS: The BrAT demonstrated a moderate to low correlation with the DASH activity items (<0.7) and a large correlation with the UEFI (>0.7). According to known-groups validity, only the BrAT was able to discriminate between people who stated they could use their hand versus those who were unable to use their hand to perform activities. All measures indicated a significant effect for time with the exception of BrAT subscale 1. The effect size was highest for the BrAT but lower than expected (BrAT, .52-.40; DASH, .15; UEFI, .36). CONCLUSIONS: These preliminary findings support the BrAT as a valid and responsive patient-reported outcome measure for adults with traumatic BPI. The BrAT activity items appear to be more targeted than the DASH or UEFI particularly for people with more severe BPI. The BrAT also appears to be measuring a different activity construct than the DASH and the UEFI. Further work is required to confirm these results with larger sample sizes.