Introducing robotic upper limb training into routine clinical practice for stroke survivors: Perceptions of occupational therapists and physiotherapists.

INTRODUCTION: Robot-assisted therapy for the upper limb (RT-UL) is an emerging form of intervention for stroke survivors with upper limb deficits. However, there is limited knowledge regarding therapists' perceptions of RT-UL and the factors influencing the implementation of RT-UL into the clinical setting. This is important when considering that therapists in Australia are primarily responsible for the prescription of RT-UL in daily practice. This study aimed to explore occupational therapists' and physiotherapists' perceptions of RT-UL and the perceived barriers and enablers influencing implementation. METHODS: Two discipline-specific focus groups were conducted involving occupational therapists (n = 6) and physiotherapists (n = 6). Participants were members of the same multidisciplinary team working in an Australian public health rehabilitation facility where RT-UL (i.e. InMotion2) was being introduced for the first time. Focus groups explored therapist perceptions of the new RT-UL as well as perceived barriers and enablers to implementation. Focus groups were recorded, transcribed and deductively analysed using the Theoretical Domains Framework (TDF). RESULTS: Out of the 14 domains of the TDF, 7 were raised by participants during the focus groups: environmental context and resources, beliefs about consequences, optimism, knowledge, skills, social influences, and social and professional role and identity. Therapists' expressed their optimism towards the introduction of RT-UL but believed successful implementation would be primarily dependent on the availability of clinical leadership, training and a suitable client mix. CONCLUSION: Therapists perceived that RT-UL would provide opportunity for increased upper limb practice particularly for patients with severe upper limb impairment. To facilitate implementation, support of RT-UL should come from both management and clinical leaders and training include RT-UL efficacy, device functionality and patient suitability. The availability of a single RT-UL device in a workplace may create unique interdisciplinary and logistical challenges.

Repetitions, duration and intensity of upper limb practice following the implementation of robot assisted therapy with sub-acute stroke survivors: an observational study.

BACKGROUND: Robot assisted upper limb (UL) therapy has been identified as an intervention with the potential to help improve the amount of practice performed by stroke survivors. OBJECTIVES: This study aimed to measure the amount of UL practice (i.e., repetitions, duration, intensity) performed by subacute stroke survivors, in particular those with severe UL impairment, pre and post implementation of robot assisted upper limb therapy (RT-UL) into an inpatient rehabilitation setting. METHODS: Two observational study phases (pre-RT-UL and post-RT-UL) were undertaken of occupational therapy and physiotherapy sessions performed by subacute stroke survivors. Upper limb tasks observed and recorded in therapy were classified as either impairment-related therapy or activity-related. RESULTS: In the pre-RT-UL observational phase, 7 subacute stroke survivors were observed across 11 days involving 25 therapy sessions. Post-RT-UL, 12 subacute stroke survivors were observed across 12 days involving 29 therapy sessions. There were no significant differences in characteristics of patients observed in each phase (p > .05). The mean difference (95% CI) between pre and post RT-UL for repetitions (reps) (569 (1 to 1136) and intensity (7 (4-11)) reps/min of practice increased for all patients, including those with severe UL impairment (337 (37-638)) reps and 8 (2-14) reps/minute, with the duration of therapy unchanged. CONCLUSIONS: This is the first study to have observed an increase in UL practice with the inclusion of RT-UL as part of routine clinical practice. This increase in practice is considered to be due to RT-UL providing highly supportive and expeditious semi-supervised practice. Notably, RT-UL was able to be implemented within the existing organisational structures with only basic training of therapy staff.IMPLICATIONS FOR REHABILITATIONRobotics presents as a viable intervention to increase the amount and intensity of upper limb practice performed by stroke survivors in routine clinical practiceRobotics were able to be implemented within the existing organisational structures with only basic training of therapy staff.

The sustainability of upper limb robotic therapy for stroke survivors in an inpatient rehabilitation setting.

PURPOSE: To investigate the sustainability of Robot-assisted upper limb therapy (RT-UL) as part of routine occupational therapy and physiotherapy clinical practice. METHODS: Two separate audits, 12 months apart, of RT-UL computer data records were undertaken to determine sustainability in a subacute rehabilitation unit. Records of the two audits were compared in terms of the number of early subacute stroke survivors using RT-UL, the number of RT-UL sessions, duration of RT-UL sessions, and disciplines prescribing RT-UL. RESULTS: During Audit 1 58% (n = 18) of stroke survivors received RT-UL compared to 50% (n = 7) in Audit 2. The total number of RT-UL sessions reduced between audits (148 vs. 36 sessions) reflecting the overall reduction in admission rates for stroke survivors. There was no significant difference between audits in the average number of RT-UL sessions per patient (p = 0.203) nor the length of sessions (p = 0.762). Patients engaged in active therapy more than three-quarters of the time when on the robotic device. Physiotherapists were the primary prescribers of RT-UL when compared to occupational therapists. CONCLUSIONS: RT-UL was in continued and regular use with stroke survivors 2 years after initial implementation within an inpatient rehabilitation setting. RT-UL practice was intensive and used routinely with patients.IMPLICATIONS FOR REHABILITATIONRT-UL is a sustainable and intensive intervention for stroke survivors within an inpatient rehabilitative setting.The cost-benefits of RT-UL should be evaluated from the perspective of the whole rehabilitation service not just at an individual patient level.RT-UL may be considered a "bridging" form of UL practice for those with more limited active UL movement until there is sufficient UL movement and power for more complex real-world task-specific practice.

Management of Metastatic Spinal Cord Compression in Secondary Care: A Practice Reflection from Medway Maritime Hospital, Kent, UK.

INTRODUCTION: Malignant spinal cord compression (MSCC) is one of the most devastating complications of cancer. This event requires rapid decision-making on the part of several specialists, given the risk of permanent spinal cord injury or death. The goals of treatment in spinal metastases are pain control and improvement of neurological function. There can be challenges in delivering prompt diagnosis and treatment in a secondary care setting. We have reflected on the experience of managing MSCC in a district general setting. AIM: Our retrospective audit identified 53 patients with suspected MSCC who entered the relevant pathway from April 2017 to March 2018 at Medway, United Kingdom (UK). Our audit standards were set out by Medway Maritime Hospital and Maidstone and Tunbridge Wells NHS Trust MSCC working group members, using a combination of published evidence and best practice. RESULTS: The patients with suspected MSCC were 53 and 29 of them (54.7%) had confirmed MSCC. The most common malignancies within the confirmed MSCC were lung (11 patients, 37.9%), breast (5 patients 17.2%), and renal (3 patients, 10.3%), followed by prostate, myeloma and carcinoma of unknown primary (2 patients (6.9%) each), as well as pancreatic, colorectal, lymphoma and, bladder (1 patient (3.4%) each). A magnetic resonance imaging (MRI) scan was performed in 48 patients (90.5%); the majority (31 patients, 64.6%) underwent the MRI within the first 24 h, whereas 3 patients had the investigation between 24 and 72 h from the admission. Among the 29 patients with confirmed MSCC, 6 (20.6%) were treated with surgical decompression, while 20 (69%) received radiotherapy (RT) and 3 (10.3%) best supportive care, respectively. Median time to surgery was 5 days (ranged between 2 and 8 days), whereas for RT 44.4 h (ranged between 24 and 72 h). Finally, all 3 patients that decided on symptom control were referred to a palliative care team within the first 24 h following the MRI scan. CONCLUSIONS: MSCC is frequently presented outside tertiary care. This may cause subsequent delays in investigation, diagnosis, and treatment, which can be improved by following a fast track referral pathway.

Clock drawing from the occupational therapy adult perceptual screening test: its correlation with demographic and clinical factors in the stroke population.

BACKGROUND/AIM: The aim of this study was to explore the relationships between clock drawing ability following stroke, and key clinical variables including cognition, functional independence, side and type of stroke, educational level and age. METHODS: One hundred and ninety-seven people with stroke were recruited from 12 hospital and rehabilitation facilities. The participants' scores from the Clock Drawing Test in the Occupational Therapy Adult Perceptual Screening Test were the dependent variables and were entered into logistic regression with Functional Independence Measure motor scores, side of stroke, Oxfordshire Classification System of Stroke, educational level and age as independent variables. Correlation with the Mini-Mental State Examination was analysed independently, due to its strong correlation with other variables. RESULTS: The Mini-Mental State Examination correlated significantly with the Clock Drawing Test ( Exp (B) = 0.826, P < 0.001). In the multivariate analysis, a significant relationship was found with age (Exp ( B) = 1.052, P < 0.001), Functional Independence Measure - motor (Exp (B) = 0.984, P = 0.030) and side of stroke (Exp (B) = 0.384, P = 0.003). Age demonstrated the strongest correlation with the Clock Drawing Test ability and the greatest decline was from approximately 70 years of age. CONCLUSIONS: The Clock Drawing Test may be a useful and quick screen of cognitive impairments following stroke. Age-related decline must be considered and it is essential that clinicians use this only as a strategy to determine whether a more comprehensive assessment is required.

The relationship between cognition and functional outcomes in rehabilitation: FIMCog vs. MoCA.

AIM: To understand the relationship between scores on two standardized measures of cognition, the Montreal Cognitive Assessment (MoCA) and the cognitive subscale of the Functional Independence Measure (FIMCog), and whether these scores can predict functional outcomes in rehabilitation. METHODS: Retrospective data analysis was conducted on all inpatients admitted to a general rehabilitation unit within a 6-month period (N = 477). The average age of patients was 74 years. The Functional Independence Measure (FIM) was completed for all patients on admission and discharge. The MoCA was administered to patients on clinical suspicion of cognitive impairment. The MoCA was completed with 116 patients. Cognitive status was assessed using FIMCog and MoCA. The motor subscale of FIM was used to assess functional status in calculating the motor Rehabilitation Functional Gain (mRFG) and motor Rehabilitation Functional Efficiency (mRFE) scores. Discharge destination was also used as an outcome measure. RESULTS: There was a moderate correlation between FIMCog and MoCA scores on admission (r = 0.49, P < 0.001). Higher FIMCog and MoCA scores were associated with higher mRFG and mRFE scores. There was an indication that patients with higher MoCA scores were more likely to be discharged to a private residence (adjusted odds ratio 1.11; 95% confidence interval: 0.99, 1.25, P = 0.072). Cut-off points of <25 on the MoCA (sensitivity 88.9%, specificity 48.9%), and <29 on the FIMCog (sensitivity 77.8%, specificity 53.3%) predicted those patients who were less likely to discharge to a private residence. CONCLUSIONS: FIMCog and MoCA scores on admission were moderately correlated, and strongly correlated with functional rehabilitation outcomes. The FIMCog and MoCA had moderately high utility in predicting discharge destination. Geriatr Gerontol Int 2020; 20: 336-342.

Factors affecting the number and type of impairments of visual perception and praxis following stroke.

AIM: This study aimed to examine the effect of clinical factors including side of stroke, region of affected cerebral circulation, type of stroke and time since stroke, as well as age on the number and type of impairments of visual perception and praxis in patients following stroke. METHODS: Two hundred and eight participants with stroke were conveniently sampled from 12 hospitals in Brisbane and the Gold Coast. Background information was collected and each participant was assessed for impairments of visual perception and praxis using the Occupational Therapy Adult Perceptual Screening Test. RESULTS: Participants with left-hemisphere stroke were more likely to have impaired body scheme than participants with right-hemisphere stroke. Additionally, participants with right-hemisphere stroke were more likely to have unilateral neglect and impaired constructional skills than those with left-hemisphere stroke. There was a significant relationship between region of affected cerebral circulation and the occurrence of agnosia, unilateral neglect and constructional skill impairment. Moreover, the number of visual perceptual impairments experienced by participants was associated with the region of affected cerebral circulation. Increasing age was significantly related to the occurrence of constructional skill impairment and acalculia. CONCLUSIONS: Side of stroke, region of affected cerebral circulation and age affected the type of impairments of visual perception and praxis experienced by patients following stroke. Furthermore, region of affected cerebral circulation also influenced the number of impairments of visual perception and praxis in patients after stroke. The results have implications for more specific targeting of assessment and treatment practices following stroke.

PARP Inhibitors in Ovarian Cancer: The Route to "Ithaca".

Poly (ADP-ribose) polymerase (PARP) inhibitors are a novel class of therapeutic agents that target tumors with deficiencies in the homologous recombination DNA repair pathway. Genomic instability characterizes high-grade serous ovarian cancer (HGSOC), with one half of all tumors displaying defects in the important DNA repair pathway of homologous recombination. Early studies have shown significant efficacy for PARP inhibitors in patients with germline breast related cancer antigens 1 and 2 (BRCA1/2) mutations. It has also become evident that BRCA wild-type patients with other defects in the homologous recombination repair pathway benefit from this treatment. Companion homologous recombination deficiency (HRD) scores are being developed to guide the selection of patients that are most likely to benefit from PARP inhibition. The choice of which PARP inhibitor is mainly based upon the number of prior therapies and the presence of a BRCA mutation or HRD. The identification of patients most likely to benefit from PARP inhibitor therapy in view of HRD and other biomarker assessments is still challenging. The aim of this review is to describe the current evidence for PARP inhibitors in ovarian cancer, their mechanism of action, and the outstanding issues, including the rate of long-term toxicities and the evolution of resistance.

Spinal Ewing Sarcoma Debuting with Cord Compression: Have We Discovered the Thread of Ariadne?

Ewing's sarcoma (ES) of the spine with cord or radicular compression as an initial sign is infrequent. It is unclear, in alleviating a neurological deficit, whether decompressive laminectomy is preferred over chemotherapy. Herein, a literature review of the treatment approaches to the primary or metastatic ES of the spine has been performed. Collected data included clinical features of the patients, treatment, and outcome. There are reported 69 cases with initial presentation of cord or radicular compression of spinal cord, arising from primary or metastatic ES, treated either with initial chemotherapy and/or radiotherapy (RT) (33.33%, n=23), or decompressive surgery (66.66%, n=46). The median age at diagnosis was 17.95 years old (range=0.06-60), and 38 patients (55.07%) were male. Eighteen (78.26%) were initially treated with chemotherapy combined with RT, whereas 3 (13.04%) were managed with RT alone. One patient (4.35%) received only corticosteroids, while there are not available data for the treatment of another one (4.35%). The remaining 46 patients (66.66%) were initially treated with decompressive surgery. Among them, 40 (57.97%) received postoperative chemotherapy, RT or combined modality therapy, whereas 6 patients (8.69%) were not treated adjuvantly. Sixteen out of 23 patients (69.6%) treated with systemic therapy, and 37 from 46 (80.43%) of those managed with decompressive laminectomy were still alive at a mean follow-up period of 2.11 years (range=0.16-6) and 3.45 years (range=0.16-26.08), respectively. To summarize, spinal resection and reconstruction followed by adjuvant treatment reduce the risk of local recurrence, and improve long-term survival. However, ES of the spine is not a distinct clinical entity and can be either managed with chemotherapy and/or RT, similarly to other localization.

Metastatic Spinal Cord Compression: Unraveling the Diagnostic and Therapeutic Challenges.

Malignant spinal cord compression (MSCC) is one of the most devastating complications of cancer. Patients often present with a history of progressive pain, paralysis, sensory loss, progressive spinal deformity, and loss of sphincter control. It is an emergency that requires rapid decision making on the part of several specialists, given the risk of permanent spinal cord injury or death. The goals of treatment in spinal metastases are pain control and improvement of neurological function in order to achieve better quality of life (QoL). The standard of care in most cases is rapid initiation of corticosteroids in combination with either surgical decompression in case of an operable candidate, followed by radiation therapy (RT) or RT alone. Surgery is associated with improved outcomes, but is not appropriate for many patients presenting with advanced symptoms of MSCC, such as paralysis, or those with a poor performance status, or cachexic state, as well as altered mental conditions, co-morbidities, surgical risks, and limited life expectancy. On the other hand, aggressive surgical treatment and post-operative RT is advocated for those with more favorable prognosis, or who are expected to have higher neurological recovery potential. Many candidates may require for combined anterior and posterior approaches to effectively deal with the compressive pathology and stabilize the spine. Most patients are presently treated by primary RT, given with the aim of improving function and symptom management. However, there is still debate regarding the most appropriate RT schedule. Rehabilitation can serve to relieve symptoms, QoL, enhance functional independence, and prevent further complications. Ambulatory status has been found to be an important prognostic factor for patients with MSCC.

Criterion validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST).

This paper reports on the criterion validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST) including concurrent criterion validity and its sensitivity and specificity. The performance of 208 people following stroke on the OT-APST and a reference tool (either the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) or the LOTCA--Geriatric version (LOTCA-G)) was compared. The OT-APST subscale scores and performance outcome (intact or impaired) on related subscales of the reference tool was analyzed to evaluate the concurrent criterion validity of the OT-APST and its sensitivity and specificity at selected cut-off scores. Significant correlations were found between participants' performance (intact or impaired) on the reference tool and scores on the OT-APST. The sensitivity and specificity of the OT-APST were analyzed at selected cut-off scores to explore the validity of decisions based on OT-APST performance when compared with the reference tool. This study shows that the OT-APST is a tool with demonstrated concurrent criterion validity for the assessment of visual perception.

Construct and ecological validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST).

This paper reports on the construct validity (scale design and convergent validity) and ecological validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST). The performance of 208 participants following stroke on the OT-APST and a reference tool (either the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) or the LOTCA-Geriatric version (LOTCA-G)) was compared. The OT-APST performance of the stroke sample was compared with a healthy normative sample (n = 356). The relationship between the OT-APST performance and the Functional Independence Measure (FIM) score of the participants following stroke was also examined. Factor analysis and internal consistency results supported the scale design of the OT-APST. Significant correlations between the performance of the participants following stroke on the OT-APST and the reference tool supported the convergent validity of the OT-APST. The ability of the OT-APST to separate the two participant groups provided further evidence of its construct validity. Significant correlations between OT-APST and FIM scores supported the ecological validity of this tool. This study shows that the OT-APST is an ecologically valid tool with demonstrated construct validity in the assessment of visual perception.

Life without limbs: Technology to the rescue.

BACKGROUND: This article reports a rare and inspirational case of a four-limb amputee, the range of integrated technology solutions that enable him to be a productive member of his family and the process and pitfalls of seeking technology solutions. CASE DESCRIPTION AND METHODS: A complex case of bilateral transhumeral amputation and bilateral transfemoral amputation with residual upper limbs too short to oppose is presented. The multiple 'high-tech' and 'low-tech' devices used on a daily basis to move around his house and community, control his environment, communicate and feed himself without the use of limbs, prostheses or a second person are outlined. FINDINGS AND OUTCOMES: Recent advances in electronics, computing and telecommunications technologies provide him with capabilities not possible 10 years ago. CONCLUSION: The process and pitfalls in sourcing technology solutions and the innovative solutions to meet the unique functional needs of this individual provide guidance to those with similarly severe and profound limitations to independence. CLINICAL RELEVANCE: Descriptions of technology solutions to improve independent functioning of those with quadruple amputation without prostheses as well as those with high-level spinal cord injury are of value to occupational therapists, patients and families alike.

Development of a standardized occupational therapy screening tool for visual perception in adults.

Occupational therapy assessment and treatment of visual perceptual impairments are integral to the rehabilitation of clients following stroke and other acquired brain injuries. Occupational therapists need to identify the nature of visual perceptual performance impairments in order to choose rehabilitation intervention strategies appropriate for remediation of specific problems or to compensate for limitations in daily function. This paper describes the variations in visual perception terminology and occupational therapy approaches to visual perceptual assessment. Limitations of existing assessment tools for visual perception are highlighted in terms of reliability, validity, normative information, length of time to administer, and comprehensiveness in screening for visual perceptual impairment. In response to these limitations, a battery of items, called the Occupational Therapy Adult Perceptual Screening Test (OT-APST) was selected to screen adults comprehensively for impairments of agnosia, visuospatial skills including body scheme and neglect, constructional skills, apraxia, and acalculia. It also includes a subtest to evaluate functional skills directly observed during screening. This new battery has established reliability, validity and age-stratified normative data for adults 16 to 97 years of age. The OT-APST is recommended for use in conjunction with observational assessment of activities of daily living for clients with stroke and acquired brain injury.

Role of occupational therapy after stroke.

Internationally recognized best practice care in the early management and rehabilitation of individuals following stroke includes multidisciplinary assessment and treatment by a coordinated team of health care professionals that includes occupational therapists. Occupational therapists assess the impact of changes in motor function, sensation, coordination, visual perception, and cognition on a person's capacity to manage daily life tasks. Intervention improves participation in meaningful roles, tasks, and activities; remediates deficits; minimizes secondary complications; and provides education and support to the patient and caregivers. Occupational therapists' focus on independence and function, individual goal-setting, and their specialist skills in task adaptation and environmental modification underpin the profession's contribution to the multidisciplinary stroke rehabilitation team. The aim of this paper is to provide an overview of occupational therapy practice in stroke patients.

The incidence of visual perceptual impairment in patients with severe traumatic brain injury.

PRIMARY OBJECTIVES: To investigate the incidence of visual perceptual impairments in a sample of patients with traumatic brain injury (TBI) using the Occupational Therapy Adult Perceptual Screening Test (OT-APST), compare incidence rates to a normative sample and explore the relationship between the presence of visual perceptual impairment and the severity of cognitive and functional impairment following TBI. RESEARCH DESIGN: Cohort study using a convenience sample of patients with TBI and a normative sample. METHODS AND PROCEDURES: Thirty-one patients with severe TBI and 195 healthy people were compared on the OT-APST and measures of cognition and function. MAIN OUTCOMES AND RESULTS: The most common impairments in the TBI sample were unilateral neglect (45.2%) and impairments of body scheme (25.8%) and constructional skills (25.8%). Significantly higher incidences of agnosia, apraxia, unilateral neglect and impairments in body scheme and constructional skills were found in the TBI sample compared to the normative sample. No significant relationship was found between the presence of visual perceptual impairments and the level of cognitive and functional impairment after TBI. CONCLUSIONS: Visual perceptual changes are evident in patients with severe TBI when compared to a normative sample. Routine use of a screening tool such as the OT-APST may help identify visual perceptual impairments in these patients and the need for more detailed assessment.