Attitudes of cardiac rehabilitation and stroke teams towards integration of stroke survivors into adapted cardiac rehabilitation: A focus group study.

OBJECTIVE: To explore the attitudes and beliefs of cardiac rehabilitation and stroke teams towards adapted cardiac rehabilitation, and the broader topics of exercise, healthy lifestyles and health behaviour change, for people with mild-to-moderate severity stroke in the sub-acute phase of recovery. DESIGN: Qualitative focus group-based study. SETTING: Acute and community national health service trusts. PARTICIPANTS: Stroke and cardiac rehabilitation team members. INTERVENTION: Adapted cardiac rehabilitation. MAIN MEASURES: Focus groups. Thematic analysis was applied to the transcribed data. RESULTS: Overall, 57 health professionals participated in 12 focus groups. Positive impacts for teams and stroke survivors were identified particularly confidence. However, there were negatives, barriers and adaptations identified. In addition, there was a lack of knowledge for cardiac rehabilitation teams in relation to stroke survivors and stroke teams in relation to cardiac rehabilitation, exercise and healthy lifestyles. CONCLUSIONS: Cardiac rehabilitation and stroke staff attitudes to cardiac rehabilitation for stroke survivors showed a range of benefits, negatives, barriers and adaptations needed. Confidence and knowledge of the cardiac rehabilitation and stroke teams needs to be addressed. REGISTRATION: ISRCTN65957980.

[Mirror, mirror of the wall: mirror therapy in the treatment of phantom limbs and phantom limb pain]. / Specchio, specchio delle mie brame: la "terapia dello specchio" nel trattamento dell'arto fantasma e del dolore.

Phantom limb and phantom limb pain control are pivotal points in the sequence of intervention to bring the amputee to functional autonomy. The alterations of perception and sensation, the pain of the residual limb and the phantom limb are therefore aspects of amputation that should be taken into account in the "prise en charge" of these patients. Within the more advanced physical therapies to control phantom and phantom limb pain there is the use of mirrors (mirror therapy). This article willfocus on its use and on the possible side effects induced by the lack of patient selection and a conflict of body schema restoration through mirror therapy with concurrent prosthetic training and trauma acceptance. Advice on the need to select patients before treatment decisions, with regard to their psychological as well as clinical profile (including time since amputation and clinical setting), and the need to be aware of the possible adverse effects matching different and somehow conflicting therapeutic approaches, are put forward. Thus a coordinated sequence of diagnostic, prognostic and therapeutic procedures carried out by an interdisciplinary rehabilitation team that works globally on all patients' problems is fundamental in the management of amputees and phantom limb pain. Further studies and the development of a multidisciplinary network to study this and other applications of mirror therapy are needed.

Inter-lateral Referral of Sensation in Health and Disease Using a Mirror Illusion-A Scoping Review.

OBJECTIVE: Perception of touch is expected at the location where it is applied. However, there are indications that being touched may be perceived on the contralateral side when seen as a reflection in a mirror at midline. Such inter-lateral referral of sensation (RS) lacks evidence, as mirror therapy research usually focusses on movement-based techniques. This study aimed to map out existing research across disciplines regarding the effect of RS in health and disease, and to understand whether there is rehabilitation potential in RS. METHOD: A scoping review was conducted to map out concepts and keywords across disciplines interested in this topic, using keywords in several languages, and a wide range of databases and additional sources. RESULTS: The review revealed mostly cross-sectional experiments and included over 486 participants: healthy, or with stroke, complex regional pain syndrome, amputation, nerve graft surgery or radial fracture. Procedures varied regarding stimulation tool, time and location, with two stimulating replacements, one the face and one a variety of areas. Response rates ranged from 0 to 100%.In general, RS was regarded as a phenomenon or even as a predictor of maladaptive neuroplasticity. There was little research into using RS stimulation as a modulatory tool to improve sensory perception. CONCLUSIONS: RS challenges the understanding of touch perception and elicits a range of questions regarding neuro-processing. A modulatory approach using RS has not been described, requires investigation and, if promising, development as an intervention.

The validity and reliability of the Incremental Shuttle Walk Test and Six-minute Walk Test compared to an Incremental Cycle Test for people who have had a mild-to-moderate stroke.

OBJECTIVE: To determine the construct validity and test re-test reliability of the Six-minute Walk Test (6MWT) and Incremental Shuttle Walk Test (ISWT) in the sub-acute recovery phase following mild-to-moderate severity stroke. PARTICIPANTS: 40 stroke patients (mean age: 68.27 years, SD: 13.48) of median National Institutes of Health Stroke Scale (NIHSS) score 1.2 (range: 0 to 8) within six months of stroke. METHOD: Each participant completed one Incremental Cycle Test (ICT) followed by two ISWT and two 6MWT in a randomised order. Pearson's Correlation Coefficients were used to determine the validity and Bland Altman plots were used to determine the test re-test reliability. RESULTS: The Incremental Cycle Test (ICT) was positively correlated with the ISWT (r=0.59, 95% confidence intervals 0.35 to 0.76, P=0.001) and the 6MWT (0.55, 0.35 to 0.71, P<0.001). The correlation of the ICT with the ISWT and 6MWT was higher for the 17 patients with no residual (ISWT: r=0.79, P<0.001; 6MWT: 0.826, P<0.001) compared to mild-to-moderate neurological impairment (ISWT: r=0.45, P=0.03; 6MWT: r=0.38, P=0.08). Test-retest reliability for both the ISWT and the 6MWT showed that there was some variability between the first and second tests with a better performance on the second test. CONCLUSION: The ISWT and 6MWT have a significant, modest correlation with the ICT for stroke patients in the sub-acute recovery phase. The ISWT and 6MWT are not strongly correlated with ICT (VO2 peak) in a stroke population that is disabled. The test-retest reliability of the ISWT and 6MWT indicated that two tests may be needed to accurately assess an individual's capabilities.

Mirror visual feedback for phantom pain: international experience on modalities and adverse effects discussed by an expert panel: a delphi study.

BACKGROUND: Mirror visual feedback (mirror therapy) is practiced worldwide in very different ways to alleviate phantom pain; no study has compared these variations yet or researched the associated risk and harm. OBJECTIVES: To establish use and justification of a generally accepted mirror visual feedback treatment plan after amputation; to explore the occurrence and handling of adverse effects; and to increase knowledge about contributing factors. METHODS: Experiential knowledge of 13 experienced practitioners from 6 countries and 5 professions was explored with a 3-round Delphi technique. RESULTS: Experience with the use of 5 different treatment plans was described, of which 1 has never been mentioned in the literature: an intense 1-off plan in which the illusion was carefully set up before the patient was left to the experience with no interference, resolving pain as well as adverse effects. In the 4 known treatment plans, the expectations of response time varied, which influenced the definition of responders/nonresponders; the set-ups, control, and use of material reflected the professional background of the practitioners. Contraindications also were defined according to the professional confidence to deal with the adverse effects. Adverse effects were reported, including emotional reactions, pain increase, sensory changes, freezing of the phantom limb, dizziness, and sweating. The attitude toward, and the handling of, adverse effects varied in patients as in practitioners according to their professional background. A tool to fine tune the experience was reported with covering of the limb during therapy. Full consensus was reached on several treatment modalities. CONCLUSION: Analysis of the results suggests that the different treatment plans suit different patients and practitioners. Matching these could enhance effectiveness and compliance. Knowledge about adverse effects needs to inform treatment decisions. These findings triggered the development of a mirror visual feedback gateway to guide patients to the treatment plan for their needs, and to collect data from the practitioners to enhance neuroscientific understanding and inform practice.