Early and intensive motor training to enhance neurological recovery in people with spinal cord injury: trial protocol.

STUDY DESIGN: Protocol for a multi-centre randomised controlled trial (the SCI-MT trial). OBJECTIVES: To determine whether 10 weeks of intensive motor training enhances neurological recovery in people with recent spinal cord injury (SCI). SETTING: Fifteen spinal injury units in Australia, Scotland, England, Italy, Netherlands, Norway, and Belgium. METHODS: A pragmatic randomised controlled trial will be undertaken. Two hundred and twenty people with recent SCI (onset in the preceding 10 weeks, American Spinal Injuries Association Impairment Scale (AIS) A lesion with motor function more than three levels below the motor level on one or both sides, or an AIS C or D lesion) will be randomised to receive either usual care plus intensive motor training (12 h of motor training per week for 10 weeks) or usual care alone. The primary outcome is neurological recovery at 10 weeks, measured with the Total Motor Score from the International Standards for Neurological Classification of SCI. Secondary outcomes include global measures of motor function, ability to walk, quality of life, participants' perceptions about ability to perform self-selected goals, length of hospital stay and participants' impressions of therapeutic benefit at 10 weeks and 6 months. A cost-effectiveness study and process evaluation will be run alongside the trial. The first participant was randomised in June 2021 and the trial is due for completion in 2025. CONCLUSIONS: The findings of the SCI-MT Trial will guide recommendations about the type and dose of inpatient therapy that optimises neurological recovery in people with SCI. TRIAL REGISTRATION: ACTRN12621000091808 (1.2.2021).

Patient-reported quality of life and pain after permissive weight bearing in surgically treated trauma patients with tibial plateau fractures: a retrospective cohort study.

INTRODUCTION: A Dutch survey among orthopedic surgeons and trauma surgeons showed that almost 90% of the surgeons do not follow protocols regarding the weight bearing aftercare for tibial plateau fractures. Clinical studies comparing permissive weight bearing (PWB) versus restricted weight bearing (RWB) after surgically treated tibial plateau fractures are not available. The aim of this study was to inventory potential differences in quality of life and pain, and number of complications in patients with surgically treated tibial plateau fractures who followed a PWB regime, relative to those that followed a RWB regime. MATERIALS AND METHODS: This retrospective cohort study included surgically treated trauma patients with tibial plateau fractures, who underwent rehabilitation according to PWB or RWB between 2005 and 2015. Data such as demographics, patient-reported quality of life and pain, and patient outcome were collected. RESULTS: This cohort study included 91 patients with a tibial plateau fracture (31 and 60 patients in the PWB and RWB groups respectively). No significant between-group differences in either age or gender were found. However, a significant difference in fracture type was found between groups, (p = 0.04). No significant differences were found in either patient-reported SF-12 or VAS scores between the PWB group and RWB group. Time to full weight bearing was significantly shorter in the PWB than in the RWB group, i.e., 14.7 versus 20.7 weeks, (p = 0.02). No significant differences were found regarding postoperative complications between the PWB and the RWB groups, i.e., 6.5% versus 10.0%, respectively. CONCLUSION: PWB after surgically treated tibial plateau fractures is safe and is related to a significantly reduced time to full weight bearing with no significant differences in patient-reported quality of life and pain or complication rates.

Permissive weight bearing in trauma patients with fracture of the lower extremities: prospective multicenter comparative cohort study.

BACKGROUND: The standard aftercare treatment in surgically treated trauma patients with fractures around or in a joint, known as (peri)- or intra-articular fractures of the lower extremities, is either non-weight bearing or partial weight bearing. We have developed an early permissive weight bearing post-surgery rehabilitation protocol in surgically treated patients with fractures of the lower extremities. In this proposal we want to compare our early permissive weight bearing protocol to the existing current non-weight bearing guidelines in a prospective comparative cohort study. METHODS/DESIGN: The study is a prospective multicenter comparative cohort study in which two rehabilitation aftercare treatments will be contrasted, i.e. permissive weight bearing and non-weight bearing according to the AO-guideline. The study population consists of patients with a surgically treated fracture of the pelvis/acetabulum or a surgically treated (peri)- or intra-articular fracture of the lower extremities. The inclusion period is 12 months. The duration of follow up is 6 months, with measurements taken at baseline, 2,6,12 and 26 weeks post-surgery. PRIMARY OUTCOME MEASURE: ADL with Lower Extremity Functional Scale. Outcome variables for compliance, as measured with an insole pressure measurement system, encompass peak load and step duration. DISCUSSION: This study will investigate the (cost-) effectiveness of a permissive weight bearing aftercare protocol. The results will provide evidence whether a permissive weight bearing protocol is more effective than the current non-weight bearing protocol. TRIAL REGISTRATION: The study is registered in the Dutch Trial Register ( NTR6077 ). Date of registration: 01-09-2016.

Arm hand skilled performance in cerebral palsy: activity preferences and their movement components.

BACKGROUND: Assessment of arm-hand use is very important in children with cerebral palsy (CP) who encounter arm-hand problems. To determine validity and reliability of new instruments to assess actual performance, a set of standardized test situations including activities of daily living (ADL) is required. This study gives information with which such a set for upper extremity skill research may be fine-tuned, relative to a specific research question. Aim of this study is to a) identify upper extremity related ADL children with CP want to improve on, b) determine the 10 most preferred goals of children with CP, and c) identify movement components of all goals identified. METHOD: The Canadian Occupational Performance Measure was used to identify upper extremity-related ADL preferences (goals) of 53 children with CP encountering arm-hand problems (mean age 9 ± 4.5 year). Goals were ranked based on importance attributed to each goal and the number of times a goal was mentioned, resulting in a gross list with goals. Additionally, two studies were performed, i.e. study A to determine the 10 most preferred goals for 3 age groups (2.5-5 years; 6-11 years, 12-19 years), based on the total preference score, and study B to identify movement components, like reaching and grasping, of all goals identified for both the leading and the assisting arm-hand. RESULTS: Seventy-two goals were identified. The 10 most preferred goals differed with age, changing from dressing and leisure-related goals in the youngest children to goals regarding personal care and eating for children aged 6-11 years. The oldest children preferred goals regarding eating, personal care and computer use. The movement components 'positioning', 'reach', 'grasp', and 'hold' were present in most tasks. 'Manipulating' was more important for the leading arm-hand, whereas 'fixating' was more important for the assisting arm-hand. CONCLUSION: This study gave insight into the preferences regarding ADL children with CP would like to improve on, and the movement components characterizing these activities. This information can be used to create a set of standardized test situations, which can be used to assess the validity and reliability of new measurement instruments to gauge actual arm-hand skilled performance.

TagTrainer: supporting exercise variability and tailoring in technology supported upper limb training.

BACKGROUND: Rehabilitation technology for upper limb training can potentially increase the amount, duration, and quality of therapy offered to patients by targeting the needs of individual patients. Empirical evaluations of such technologies focus on clinical effectiveness; however, little is known regarding the implications of their implementation in daily practice. Tailoring training content to patients requires active participation by therapists, and requires an extension of their role to include authoring and modifying exercises. It is not yet known whether this is feasible, and the socio-technical requirements that will make it successful in practice have not yet been explored. The current study investigates the extent to which therapists can take the role of authoring patient-specific training content and whether effort savings can be achieved by sharing the created content. METHOD: We present TagTrainer: an interactive tabletop system for rehabilitation that can be operated by manipulating every day physical objects in order to carry out exercises that simulate daily living tasks. TagTrainer supports therapists in creating their own exercises that fit individual patient needs, in adjusting existing exercises, and in putting together personalized exercise programs for and with patients. Four therapists in stroke- and paraplegia-rehabilitation have used TagTrainer for three weeks. Semi-structured interviews were conducted with the therapists, questionnaires were administered to them, and observation notes and usage logs were collected. RESULTS: A total of 20 exercises were created from scratch, while another three exercises were created as variations of the existing ones. Importantly, all these exercises were created to address specific needs that patients expressed. The patients found the exercises motivating and these exercises were integrated into their regular training. CONCLUSIONS: TagTrainer can support arm-hand rehabilitation training by increasing therapy variability and tailoring. Therapists consider TagTrainer most suited for group sessions where they supervise many patients at once. Therapists are motivated and are able to, with minimal training, create and tailor exercises for patients fitting individual needs and capabilities. Future research will examine the socio-technical conditions that will encourage therapists to contribute and share training content, and provide the peer support needed for the adoption of a new technology.

Effects of task-oriented robot training on arm function, activity, and quality of life in chronic stroke patients: a randomized controlled trial.

BACKGROUND: Over fifty percent of stroke patients experience chronic arm hand performance problems, compromising independence in daily life activities and quality of life. Task-oriented training may improve arm hand performance after stroke, whereby augmented therapy may lead to a better treatment outcome. Technology-supported training holds opportunities for increasing training intensity. However, the effects of robot-supported task-oriented training with real life objects in stroke patients are not known to date. The aim of the present study was to investigate the effectiveness and added value of the Haptic Master robot combined with task-oriented arm hand training in chronic stroke patients. METHODS: In a single-blind randomized controlled trial, 22 chronic stroke patients were randomly allocated to receive either task-oriented robot-assisted arm-hand training (experimental group) or task-oriented non-robotic arm-hand training (control group). For training, the T-TOAT (Technology-supported Task-Oriented Arm Training) method was applied. Training was provided during 8 weeks, 4 times/week, 2 × 30 min/day. RESULTS: A significant improvement after training on the Action Research Arm Test (ARAT) was demonstrated in the experimental group (p = 0.008). Results were maintained until 6 months after cessation of the training. On the perceived performance measure (Motor Activity Log (MAL)), both, the experimental and control group improved significantly after training (control group p = 0.008; experimental group p = 0.013). The improvements on MAL in both groups were maintained until 6 months after cessation of the training. With regard to quality of life, only in the control group a significant improvement after training was found (EuroQol-5D p = 0.015, SF-36 physical p = 0.01). However, the improvement on SF-36 in the control group was not maintained (p = 0.012). No between-group differences could be demonstrated on any of the outcome measures. CONCLUSION: Arm hand performance improved in chronic stroke patients, after eight weeks of task oriented training. The use of a Haptic Master robot in support of task-oriented arm training did not show additional value over the video-instructed task-oriented exercises in highly functional stroke patients. CLINICAL TRIAL REGISTRATION INFORMATION: Current Controlled Trials ISRCTN82787126.

Measures and procedures utilized to determine the added value of microprocessor-controlled prosthetic knee joints: a systematic review.

BACKGROUND: The effectiveness of microprocessor-controlled prosthetic knee joints (MPKs) has been assessed using a variety of outcome measures in a variety of health and health-related domains. However, if the patient is to receive a prosthetic knee joint that enables him to function optimally in daily life, it is vital that the clinician has adequate information about the effects of that particular component on all aspects of persons' functioning. Especially information concerning activities and participation is of high importance, as this component of functioning closely describes the person's ability to function with the prosthesis in daily life. The present study aimed to review the outcome measures that have been utilized to assess the effects of microprocessor-controlled prosthetic knee joints (MPK), in comparison with mechanically controlled prosthetic knee joints, and aimed to classify these measures according to the components and categories of functioning defined by the International Classification of Functioning, Disability and Health (ICF). Subsequently, the gaps in the scientific evidence regarding the effectiveness of MPKs were determined. METHODS: A systematic literature search in 6 databases (i.e. PubMed, CINAHL, Cochrane Library, Embase, Medline and PsychInfo) identified scientific studies that compared the effects of using MPKs with mechanically controlled prosthetic knee joints on persons' functioning. The outcome measures that have been utilized in those studies were extracted and categorized according to the ICF framework. Also, a descriptive analysis regarding all studies has been performed. RESULTS: A total of 37 studies and 72 outcome measures have been identified. The majority (67%) of the outcome measures that described the effects of using an MPK on persons' actual performance with the prosthesis covered the ICF body functions component. Only 31% of the measures on persons' actual performance investigated how an MPK may affect performance in daily life. Research also typically focused on young, fit and active persons. CONCLUSIONS: Scientifically valid evidence regarding the performance of persons with an MPK in everyday life is limited. Future research should specifically focus on activities and participation to increase the understanding of the possible functional added value of MPKs.

Task-oriented arm training for stroke patients based on remote handling technology concepts: A feasibility study.

BACKGROUND: Improving arm-hand skill performance is a major therapeutic target in stroke rehabilitation. Arm-hand rehabilitation may be enriched in content and variation by using technology-assisted training. Especially for people with a severely affected arm, technology-assisted training offers more challenging training possibilities. OBJECTIVE: The aim of this study was to explore the feasibility of ReHab-TOAT, a "Remote Handling Based Task-Oriented Arm Training" approach featuring enriched haptic feedback aimed at improving daily activities and participation. METHODS: Five subacute or chronic stroke patients suffering moderate to severe arm-hand impairments and five rehabilitation therapists participated. All participants received 2 ReHab-TOAT sessions. Outcome measure was a bespoke feasibility questionnaire on user experiences and satisfaction regarding 'motivation', 'individualization of training', 'potential training effects', and 'implementation in rehabilitation' of patients and therapists. RESULTS: Both patients and therapists experienced ReHab-TOAT as being feasible. They found ReHab-TOAT very motivating and challenging. All patients perceived an added value of ReHab-TOAT and would continue the training. Small improvements regarding exercise variability were suggested. CONCLUSION: ReHab-TOAT seems to be a feasible and very promising training approach for arm-hand rehabilitation of stroke patients with a moderately or severely affected arm. Further research is necessary to investigate potential training effects of ReHab-TOAT.

Motor training programs of arm and hand in patients with MS according to different levels of the ICF: a systematic review.

BACKGROUND: The upper extremity plays an important role in daily functioning of patients with Multiple Sclerosis (MS) and strongly influences their quality of life. However, an explicit overview of arm-hand training programs is lacking. The present review aims to investigate the training components and the outcome of motor training programs for arm and hand in MS. METHODS: A computerized systematic literature search in 5 databases (PubMed, CINAHL, EMBASE, PEDro and Cochrane) was performed using the following Mesh terms: Multiple Sclerosis, Rehabilitation, Physical Education and Training, Exercise, Patient-Centered Care, Upper Extremity, Activities of Daily Living, Motor Skills, Motor Activity, Intervention Studies and Clinical Trial. The methodological quality of the selected articles was scored with the Van Tulder Checklist. A descriptive analyses was performed using the PICO principle, including scoring of training components with the calculation of Hedges'g effect sizes. RESULTS: Eleven studies were eligible (mean Van Tulder-score = 10.82(SD2.96)). Most studies reported a specific improvement in arm hand performance at the ICF level that was trained at. The mean number of training components was 5.5(SD2.8) and a significant correlation (r = 0.67; p < 0.05) between the number of training components and effect sizes was found. The components 'client-centered' and 'functional movement' were most frequently used, whereas 'distribution based practice', 'feedback' and 'random practice' were never used. The component 'exercise progression' was only used in studies with single ICF body function training, with the exception of 1 study with activity level training. Studies including the component 'client-centred' demonstrated moderate to high effect sizes. CONCLUSION: Motor training programs (both at the ICF body function and activity level) have shown to improve arm and hand performance in MS in which the value of the training specificity was emphasized. To optimize upper extremity training in MS the component 'client-centred' and 'exercise progression' may be important. Furthermore, given the importance attributed to the components 'distribution based practice', 'feedback' and 'random practice' in previous research in stroke patients, the use of these components in arm hand training should be explored in future research.

Valid and reliable instruments for arm-hand assessment at ICF activity level in persons with hemiplegia: a systematic review.

BACKGROUND: Loss of arm-hand performance due to a hemiparesis as a result of stroke or cerebral palsy (CP), leads to large problems in daily life of these patients. Assessment of arm-hand performance is important in both clinical practice and research. To gain more insight in e.g. effectiveness of common therapies for different patient populations with similar clinical characteristics, consensus regarding the choice and use of outcome measures is paramount. To guide this choice, an overview of available instruments is necessary. The aim of this systematic review is to identify, evaluate and categorize instruments, reported to be valid and reliable, assessing arm-hand performance at the ICF activity level in patients with stroke or cerebral palsy. METHODS: A systematic literature search was performed to identify articles containing instruments assessing arm-hand skilled performance in patients with stroke or cerebral palsy. Instruments were identified and divided into the categories capacity, perceived performance and actual performance. A second search was performed to obtain information on their content and psychometrics. RESULTS: Regarding capacity, perceived performance and actual performance, 18, 9 and 3 instruments were included respectively. Only 3 of all included instruments were used and tested in both patient populations. The content of the instruments differed widely regarding the ICF levels measured, assessment of the amount of use versus the quality of use, the inclusion of unimanual and/or bimanual tasks and the inclusion of basic and/or extended tasks. CONCLUSIONS: Although many instruments assess capacity and perceived performance, a dearth exists of instruments assessing actual performance. In addition, instruments appropriate for more than one patient population are sparse. For actual performance, new instruments have to be developed, with specific focus on the usability in different patient populations and the assessment of quality of use as well as amount of use. Also, consensus about the choice and use of instruments within and across populations is needed.

Embracing change: practical and theoretical considerations for successful implementation of technology assisting upper limb training in stroke.

BACKGROUND: Rehabilitation technology for upper limb training of stroke patients may play an important role as therapy tool in future, in order to meet the increasing therapy demand. Currently, implementation of this technology in the clinic remains low. This study aimed at identifying criteria and conditions that people, involved in development of such technology, should take into account to achieve a (more) successful implementation of the technology in the clinic. METHODS: A literature search was performed in PubMed and IEEE databases, and semi-structured interviews with therapists in stroke rehabilitation were held, to identify criteria and conditions technology should meet to facilitate (implementation of) technology-assisted arm-hand skills training in rehabilitation therapy of stroke patients. In addition, an implementation strategy frequently applied in general health care was used to compose a stepwise guidance to facilitate successful implementation of this technology in therapy of stroke patients. Implementation-related criteria mentioned by therapists during the interviews were integrated in this guidance. RESULTS: Results indicate that, related to therapy content, technology should facilitate repetition of task-related movements, tailored to the patient and patient's goals, in a meaningful context. Variability and increasing levels of difficulty in exercises should be on offer. Regarding hardware and software design of technology, the system should facilitate quick familiarisation and be easily adjustable to individual patients during therapy by therapists (and assistants). The system should facilitate adaptation to individual patients' needs and their progression over time, should be adjustable as to various task-related variables, should be able to provide instructions and feedback, and should be able to document patient's progression. The implementation process of technology in the clinic is provided as a stepwise guidance that consists of five phases therapists have to go through. The guidance includes criteria and conditions that motivate therapists, and make it possible for them, to actually use technology in their daily clinical practice. CONCLUSIONS: The reported requirements are important as guidance for people involved in the development of rehabilitation technology for arm-hand therapy of stroke patients. The stepwise guide provides a tool for facilitating successful implementation of technology in clinical practice, thus meeting future therapy demand.

Assessment of arm activity using triaxial accelerometry in patients with a stroke.

OBJECTIVE: To study the validity of accelerometry in the assessment of arm activity of patients with impaired arm function after stroke. DESIGN: Cross-sectional concurrent validity study. SETTING: Rehabilitation center. PARTICIPANTS: Patients (N=45) at different stages after stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: All patients wore 2 triaxial accelerometers around their wrists during 3 consecutive days. Arm activity was assessed, based on unilateral (activity of the affected arm) and bilateral accelerometry (ratio between the activity of the affected and nonaffected arm). The Motor Activity Log-26 (MAL-26) Amount of Use (AOU) scale was used as the main external criterion to test the concurrent validity of arm accelerometry. In addition, the MAL-26 Quality of Movement (QOM) scale and the Stroke Impact Scale (SIS) subscale Hand Function were used. To test the divergent validity, the SIS subscale Mobility was used. Spearman correlation coefficients were calculated. In an additional regression analysis, the hypothesized confounding influence of spasm, therapy intensity, and interobserver differences was studied. RESULTS: Both unilateral (ρ=.58, P<.001) and bilateral (ρ=.60, P<.001) accelerometry were significantly related to the MAL-AOU scale. Associations of both unilateral and bilateral accelerometry with the MAL-QOM and SIS subscale Hand Function corroborated these findings. The SIS subscale Mobility was not significantly associated with unilateral accelerometry (ρ=.41, P=.01) or bilateral accelerometry (ρ=.23, P=.11). None of the hypothesized confounders influenced these associations significantly. CONCLUSIONS: Based on the results, both the concurrent and divergent validity of unilateral and bilateral arm accelerometry for measuring arm activity after stroke are good.

Effectiveness of surgical treatments on healing of cartilage and function level in patients with osteochondral lesions of the tibial plafond: A systematic review.

BACKGROUND: Osteochondral lesions of the tibial plafond (OLTPs) occur less frequently than those of the talus, and treatment guidelines have not been determined. The aim of the current review was to evaluate the effectiveness of surgical treatments on the healing of cartilage and on function level, i.e. pain reduction, reduced swelling and improved joint range of motion, in patients with OLTPs. METHODS: A comprehensive literature search in PubMed/MEDLINE, Cochrane Database of Systematic Reviews and Google Scholar was performed up to December 2020. The outcome measures were healing of cartilage and function level. RESULTS: Four studies investigating treatment of OLTPs were included. Three studies investigated treatment by means of microfracture. One of these studies showed an osteochondral defect filling in 52.0% of patients. All three studies showed an improvement in function level. Antegrade drilling was evaluated in one study, showing contrasting results in two patients. One-step bone marrow-derived cell transplantation was evaluated in one study, showing an osteochondral defect filling in 68.0% of patients and improvements in patients' function level. CONCLUSIONS: Arthroscopic treatment of OLTPs by means of microfracture and bone marrow-derived cell transplantation (BMDCT) seem effective for the outcome at the patient's function level, while BMDCT showed more promising results regarding defect filling. However, this is based on the current available evidence with poor quality of methodology. Further research is of paramount importance to understand this injury and to evaluate the best treatments.

Medium-Term Patient-Reported Quality of Life and Activities of Daily Living in Surgically Treated Trauma Patients With Pelvic, Acetabular or Combined Pelvic and Acetabular Fractures in a Retrospective Single-Center Study.

OBJECTIVE: To gain more insights in the medium-term patient-reported quality of life (QoL), activities of daily living (ADL), and number of complications in trauma patients with an acetabular fracture (AF), a pelvic fracture (PF), and those with a surgically combined pelvic and AF (PAF). DESIGN: Retrospective single-center study. SETTING: Level I academic trauma center. PATIENTS/PARTICIPANTS: 51 trauma patients with PF, AF, or PAF who were surgically treated between 2014 and 2017. INTERVENTION: Open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS: Primary outcome measures are patient-reported outcome questionnaire, which includes 2 items, the QoL, as measured with the Short Form-12, and the ADL, as measured with the Lower Extremity Functional Scale. The secondary outcome parameter was the occurrence of complications during a follow-up of at least 2 years. RESULTS: The mean physical component score (PCS) of the QoL (P = 0.03) and the ADL (P = 0.03) were significantly higher in patients with AF compared with patients with PF. The incidence of the overall postoperative complications did not significantly differ between the PF, AF, and PAF groups (P = 0.28). CONCLUSIONS: This study found that the PCS of the QoL and the ADL in surgically treated trauma patients with PF were significantly lower compared with patients with AF. No significant differences were found in overall complication rate between the PF, AF, and PAF groups. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Feasibility and validity of ambulant biofeedback devices to improve weight-bearing compliance in trauma patients with lower extremity fractures: A narrative review.

BACKGROUND: Ambulant biofeedback devices can be used to provide real-time feedback for trauma patients on weight-bearing regimes. The devices also enable prescribing clinicians to monitor and train patients' level of weight-bearing. However, there is limited evidence regarding the feasibility of use of such devices in controlling weight-bearing, and their full potential remains to be elucidated. OBJECTIVE: To investigate the feasibility of using ambulant biofeedback training devices to improve compliance with weight-bearing regimes in trauma patients with lower extremity fractures. METHODS: A literature review of the feasibility and clinical validity of ambulant biofeedback devices. RESULTS: Three clinically validated biofeedback devices were found feasible for use in monitoring the compliance of patients who have lower extremity fractures with different weight-bearing regimes. CONCLUSION: Further information about the feasibility and clinical validity of biofeedback training devices is nee-ded in order to optimize weight-bearing instructions for patients.

Technology-assisted training of arm-hand skills in stroke: concepts on reacquisition of motor control and therapist guidelines for rehabilitation technology design.

BACKGROUND: It is the purpose of this article to identify and review criteria that rehabilitation technology should meet in order to offer arm-hand training to stroke patients, based on recent principles of motor learning. METHODS: A literature search was conducted in PubMed, MEDLINE, CINAHL, and EMBASE (1997-2007). RESULTS: One hundred and eighty seven scientific papers/book references were identified as being relevant. Rehabilitation approaches for upper limb training after stroke show to have shifted in the last decade from being analytical towards being focussed on environmentally contextual skill training (task-oriented training). Training programmes for enhancing motor skills use patient and goal-tailored exercise schedules and individual feedback on exercise performance. Therapist criteria for upper limb rehabilitation technology are suggested which are used to evaluate the strengths and weaknesses of a number of current technological systems. CONCLUSION: This review shows that technology for supporting upper limb training after stroke needs to align with the evolution in rehabilitation training approaches of the last decade. A major challenge for related technological developments is to provide engaging patient-tailored task oriented arm-hand training in natural environments with patient-tailored feedback to support (re) learning of motor skills.

Arm and hand skills: training preferences after stroke.

PURPOSE: An increasing demand for training after stroke has brought about the need to develop rehabilitation technology. This article reports an inquiry into skill preferences of persons after stroke regarding arm-hand training and examines the relationship between the use of the affected arm and the patient's training preference. METHOD: Data collection involved a semi-structured interview of 20 persons in the subacute and 20 persons in the chronic stage after stroke, based on an adaptation of the motor activity log. RESULTS: Subacute and chronic patients after stroke agreed on seven out of 10 most preferred training skills. Patient preferences related mostly to 'manipulation in combination with positioning' and 'manipulation'. Eight motivation aspects for skill training were identified as being important. A positive correlation was found between skill preference scores and use of the impaired arm (r= 0.64) (p < 0.001). CONCLUSIONS: This study has resulted in an inventory of skills that persons after stroke prefer to train on. This list can be used for implementation of exercises in rehabilitation technology. Motivation for skill training pertains to optimising participation level, rather than function or activity level. This study suggests that client-centred assessment is advocated to set therapy goals that match patient training preferences.

Evidence-based rehabilitation therapy following surgery for (peri-)articular fractures: A systematic review.

OBJECTIVE: To assess the availability of explicitly reported protocols describing post-surgery rehabilitation of (peri-)articular fractures of the proximal humerus, acetabulum and/or tibial plateau, and to critically review any scientific evidence on the effectiveness of these protocols. DATA SOURCES: MEDLINE (PubMed), Cochrane databases, CINAHL, PEDro and Embase (Ovid) were searched to November 2018. Furthermore, stakeholder internet sites, clinical guidelines and standard textbooks were searched. STUDY SELECTION: Screening was performed independently by 2 researchers based on a priori defined eligibility criteria. DATA SYNTHESIS: Five papers addressed post-surgical rehabilitation of proximal humerus fractures, 1 paper that of acetabulum fractures. No eligible information was found on stakeholder sites or in standard textbooks. Overall, the main focus of the protocols identified was on the International Classification of Functioning, Disability and Health (ICF) Body Functions and Structures level. In general, little information about therapy dosage was reported. None of the protocols provided scientific evidence on which the content of described rehabilitation programmes was based. CONCLUSION: This review reveals a paucity of explicitly formulated protocols focussing on post-surgical rehabilitation of common (peri-)articular fractures targeting patient-centred care at all ICF levels. There is a need for more scientific evidence on which to base protocols regarding common (peri-)articular fracture rehabilitation.

A protocol for permissive weight-bearing during allied health therapy in surgically treated fractures of the pelvis and lower extremities.

OBJECTIVE: To optimize rapid clinical recovery and restoration of function and functionality, permissive weight-bearing has been designed as a new aftercare mobilization regimen, within the upper boundary of the therapeutic bandwidth, yet safe enough to avoid overloading. The aim of the present paper is to describe a comprehensive protocol for permissive weight-bearing during allied health therapy and to report on the time to full weight-bearing, as well as the number of complications, in patients with surgically treated fractures of the pelvis and lower extremities undergoing permissive weight-bearing. PATIENTS AND METHODS: This study included surgically treated trauma patients with (peri)- or intra-articular fractures of the pelvis and lower extremities. A standardized permissive weight-bearing protocol was used for all patients. Time to full weight-bearing and number of complications were recorded. RESULTS: This study included 150 patients, 69% male, with a median age of 48 years (interquartile range (IQR) 33.0, 57.0). The median time to full weight bearing was 12.0 weeks (IQR 6.8, 19.2). The complication rate during rehabilitation was 10%. CONCLUSION: The permissive weight-bearing protocol, as described, might be beneficial and has potential to be implemented in trauma patients with surgically treated (peri)- or intra-articular fractures of the pelvis and lower extremities.

Cost-effectiveness of an integrated 'fast track' rehabilitation service for multi-trauma patients: A non-randomized clinical trial in the Netherlands.

BACKGROUND: Multidisciplinary rehabilitation has been recommended for multi-trauma patients, but there is only low-quality evidence to support its use with these patients. This study examined whether a Supported Fast track multi-Trauma Rehabilitation Service (Fast Track) was cost-effective compared to conventional trauma rehabilitation service (Care As Usual) in patients with multi-trauma from a societal perspective with a one-year follow-up. METHODS: An economic evaluation alongside a prospective, multi-center, non-randomized, controlled clinical study, was conducted in the Netherlands. The primary outcome measure was the Functional Independence Measure (FIM). Generic Quality of Life and Quality Adjusted Life Years (QALYs) of the patients were derived using the Short-form 36 Health Status Questionnaire. Incremental Cost-Effectiveness Ratios (ICERs) were stated in terms of costs per unit of FIM improvement and costs per QALY. To investigate the uncertainty around the ICERs, non-parametric bootstrapping was used. RESULTS: In total, 132 patients participated, 65 Fast Track patients and 67 Care As Usual patients. Mean total costs per person were €18,918 higher in the Fast Track group than in the Care As Usual group. Average incremental effects on the FIM were 3.7 points (in favor of the Fast Track group) and the incremental (extra) bootstrapped costs were €19,033, resulting in an ICER for cost per FIM improvement of €5,177. Care As Usual dominated Fast Track in cost per QALY as it gave both higher QALYs and lower costs. All sensitivity analyses attested to the robustness of our results. CONCLUSIONS: This study demonstrated that a multidisciplinary rehabilitation program for multi-trauma patients according to the supported fast track principle is promising but cost-effectiveness evidence remains inconclusive. In terms of functional outcome, Fast Track was more expensive but yielded also more effects compared to the Care As Usual group. Looking at the costs per QALYs, unfavorable ICERs were found. Given the lack of a willingness-to-pay threshold for functional recovery and the relatively short time horizon, it is not possible to draw firm conclusions about the first. TRIAL REGISTRATION: (Current Controlled Trials register: ISRCTN68246661).