Virtual rehabilitation: what are the practical barriers for home-based research?

Virtual reality technologies are becoming increasingly accessible and affordable to deliver, and consequently the interest in applying virtual reality within rehabilitation is growing. This has resulted in the emergence of research exploring the utility of virtual reality and interactive video gaming interventions for home use by patients. The aim of this paper is to highlight the practical factors and difficulties that may be encountered in research in this area, and to make recommendations for addressing these. Whilst this paper focuses on examples drawn mainly from stroke rehabilitation research, many of the issues raised are relevant to other conditions where virtual reality approaches have the potential to be applied to home-based rehabilitation

Is there evidence for a relationship between cognitive impairment and fatigue after acquired brain injury: a systematic review and meta-analysis

PurposeFatigue is a major symptom of ABI. Greater fatigue is associated with cognitive impairment. Our aim was to systematically review, describe and analyse the literature on the extent of this relationship.MethodsFive databases were searched from inception. Studies were included where: participants had a defined clinical diagnosis of ABI which included TBI, stroke or subarachnoid haemorrhage; a fatigue measure was included; at least one objective cognitive measure was used. Three reviewers individually identified studies and determined quality using the Quality Assessment Tool for Observational Cohort and Cross-sectional Studies.ResultsSixteen of the 412 identified studies, investigating the relationship between cognitive dysfunction and fatigue, comprising a total of 1,745 participants, were included. Quality ranged from fair to good. Meta-analysis found fatigue was significantly associated with an overall pattern of cognitive slowing on tasks of sustained attention. A narrative synthesis found weak associations with fatigue and information processing, attention, memory and executive function.ConclusionAnalysis found sustained attentional performance had stronger associations with fatigue after ABI. Whereas, weak associations were found between fatigue and information processing, attention and to some extent memory and executive function. More focused research on specific cognitive domains is needed to understand the mechanisms of fatigue.Implications for RehabilitationCognitive dysfunction is associated with higher fatigue levels after stroke, traumatic brain injury or subarachnoid haemorrhage.Management of cognitive dysfunction may improve fatigue and participation in meaningful activities after stroke, traumatic brain injury or subarachnoid haemorrhage.Intervention strategies that reduce cognitive load during everyday activities (e.g., grading the burden on attentional resources), may potentially be effective in managing post-ABI fatigue.Agreement on core measures could facilitate integration of findings into clinical practice

A feasibility study of the physiotherapy management of urinary incontinence in athletic women: trial protocol for the POsITIve study

BackgroundUrinary incontinence (UI) affects up to 40% of adult women within the UK, and pelvic floor muscle training can be effective as a treatment. The prevalence of UI is higher in athletic women than in their sedentary counterparts, but there is little research into reasons for this or into treatment within this population.The aim of this study is to investigate the feasibility of conducting a future randomised controlled trial of physiotherapeutic management of UI in athletic women.MethodsThis is a mixed methods study with three distinct but related phases.Phase 1: Semi-structured interviews with health care professionals in the community will explore current management practices of UI in women and particularly in female athletes in order to inform the control arm of a future study. It will also establish community health care professionals’ understanding of pelvic health physiotherapy.Phase 2: Athletic and regularly exercising women recruited directly from gyms and sports clubs will undergo a course of physiotherapy to manage UI. This will establish study recruitment, eligibility, consent, attendance, attrition, and data completion rates. It will provide information regarding appropriate clinical venues and outcome measures to use for this patient group.Phase 3: Semi-structured interviews with purposefully selected participants from phase 2 will investigate participant satisfaction with recruitment procedures, the intervention, outcome measures and the venues. Further, we will collect data regarding the use of a smartphone ‘app’ for adherence and monitoring of home exercises and participants’ beliefs around randomisation in a future study. We will explore the impact of UI on life and sport in more detail.DiscussionThis study will establish the ease and acceptability of recruiting athletic women directly from gyms and sports clubs and identify attrition rates. It will also explore the acceptability of the intervention, clinical venues and outcome measures. Data collected will be used to inform a future randomised controlled trial.Trial registrationNCT03986411 (clinicaltrials.gov). Registered on 14 June 201

Constraint induced movement therapy in hemiplegic cerebral palsy: a national survey of its use by physiotherapists in the UK

Background/aims: There is an emerging evidence base into the use of Constraint Induced Movement Therapy (CIMT) in hemiplegic Cerebral Palsy (CP). However, there is little evidence of its use in the UK. This study aimed to conduct a national survey of physiotherapists to explore their use of CIMT in hemiplegic CP and to identify barriers and facilitators to its use. Methods: An online survey was distributed to members of the Association of Paediatric Chartered Physiotherapists (APCP) within the UK. At this time, there were approximately 2300 members on the professional database. Participants were asked about their experience and views regarding CIMT use/training, including their beliefs regarding delivery of CIMT in the UK health system. Findings: Responses were from 121 therapists from 12 regions of the UK, working across the National Health Service, private sector and education; based in inpatient, outpatient, community and school settings. Fifty three percent had never used CIMT although 73.6% felt it was an appropriate treatment. Most therapists felt they did not have enough training to use CIMT. Barriers included ethical issues, resources and training. Facilitators to its use included treatment modification, support of others and outcome appraisal. The ethical and legal ramifications of restraint were a common concern which prevented therapists from using CIMT. Family compliance influenced therapists’ decision to use CIMT. Conclusions: There is evidence to suggest physiotherapists in the UK are using CIMT to some extent in this patient group and that there is established clinical interest. Further research is needed to clarify ethical and legal ramifications of restraint

Post-stroke fatigue: a scoping review

Background: Post-stroke fatigue (PSF) is one of the most common and frustrating outcomes of stroke. It has a high prevalence and it can persist for many years after stroke. PSF itself contributes to a wider range of undesirable outcomes that affect all aspects of daily life. The aim of this review was to identify and summarise the most recent research on PSF, in order to update the evidence base.Methods: We updated an existing review (Hinkle et al. 2017) systematically searching CINAHL, MEDLINE, PsycINFO, and PubMed to cover new research studies between 1st March 2016 and the search date (19th January 2020). We included interventional and observational research, and clinical practice guidelines that were not covered in the original review. After duplicate removal in EndNote, two reviewers screened the search results in Rayyan, and data from eligible full texts were extracted onto an Excel spreadsheet. Finally, we used RobotReviewer and a human reviewer to assess the risk of bias of randomised trials for this scoping review.Results: We identified 45 records for 30 studies (14 observational, 10 interventional studies, and 6 guidelines). Apart from one, the interventional studies were single-centred, had high risk of bias and small sample size (median 50). They investigated exercise, pharmacotherapy, psychotherapy, education, and light therapy. Observational studies mainly reported the factors related to PSF including co-morbidities, depression and anxiety, quality of life, activities of daily living, stroke severity, medication use and polypharmacy, polymorphism, pain, apathy, limb heaviness, neuroticism, mobility, and thyroid-stimulating hormone. Guidelines either did not report on PSF or, when reported, their recommendations were supported by little or low level of evidence.Conclusion: Although we identified a number of recent studies which have added to our current knowledge on PSF, none are robust enough to change current clinical practice

An introduction to economic evaluation in occupational therapy: cost-effectiveness of pre-discharge home visits after stroke (HOVIS)

Introduction: Occupational therapy interventions, such as home visits, have been identified as being resource-intensive, but cost-effectiveness analyses are rarely, if ever, carried out. We sought to estimate the cost-effectiveness of occupational therapy home visits after stroke, as part of a feasibility study, and to demonstrate the value and methods of economic evaluation. Method: We completed a cost-effectiveness analysis of pre-discharge occupational therapy home visits after stroke compared with a hospital-based interview, carried out alongside a feasibility randomized controlled trial. Our primary outcome was quality-adjusted life years. Full cost and outcome data were available for 65 trial participants. Results: We found that the mean total cost of a home visit was £183, compared with £75 for a hospital interview. Home visits are shown to be slightly more effective, resulting in a cost per quality-adjusted life year of just over £20,000. Conclusion: Our analysis is the only economic evaluation of this intervention to date. Home visits are shown to be more expensive and more effective than a hospital-based interview, but our results are subject to a high level of uncertainty and should be treated as such. Further economic evaluations in this field are encouraged

Virtually home: Exploring the potential of virtual reality to support patient discharge after stroke

Introduction: The level of assessment and intervention received by patients prior to discharge varies widely across stroke services in the United Kingdom. This study aimed to explore the potential value of virtual reality in preparing patients for discharge following stroke. Method: Semi-structured interviews were carried out with 13 occupational therapists, eight patients with a stroke and four community stroke survivors. Views were sought of the perceived acceptability, potential utility and limitations of a ‘virtual home’ environment for use in pre-discharge education and assessment. Data were analysed thematically. Findings: Interviewees found the virtual home to be an acceptable and visual means of facilitating discussions about discharge. It was perceived as valuable in assessing patient insight into safety risks and exploring the implications of installing assistive equipment at home. Limitations were identified relating to specific software issues and the use of virtual reality with patients with cognitive or perceptual impairments. Conclusion: The results demonstrate the potential utility of the virtual home within stroke rehabilitation. Patients and therapists engaged with the virtual home and, moreover, made practical suggestions for future development. Feasibility and pilot testing in a clinical setting is required to compare the use of the virtual home with traditional approaches of pre-discharge assessment.Stroke Association (ref: TSA SRTF 2013/01) and Nottingham Hospitals Charity and NUH Department of Research and Development – Pump Priming Awar

Virtually home: feasibility study and pilot randomised controlled trial of a virtual reality intervention to support patient discharge after stroke

Introduction: Virtual reality has the potential to assist occupational therapists in preparing patients for discharge by facilitating discussions and providing education about relevant practical issues and safety concerns. This study aimed to explore the feasibility of using a virtual reality intervention to support patient discharge after stroke and pilot its use. Method: Practical aspects of delivering a virtual reality intervention prior to discharge were explored by means of a non-randomised feasibility study and a subsequent pilot randomised controlled trial. Factors considered included eligibility, recruitment, intervention delivery, attrition and suitability of outcome measures. Outcome measures included standardised assessments of stroke severity, mobility, health-related quality of life, functional ability, satisfaction with services and concerns about falling. Results: Thirty-three participants were recruited in total: 17 to the feasibility study and 16 to the pilot trial. At 1-month follow-up, 14 participants (82%) were re-assessed in the feasibility study and 12 (75%) in the pilot trial. The main difficulties encountered related to recruitment, particularly regarding post-stroke cognitive impairments, the presence of mild deficits or illness. Conclusion: It was feasible to recruit and retain participants, deliver the intervention and collect outcome measures, despite slow recruitment rates. These findings could inform the design of a definitive trial

Systematic review of the epidemiology of non-collision injuries occurring to older people during use of public buses in high income countries

Each year more than 6,000 people are injured on public buses in the UK, approximately half of whom are aged 65 or over. This review synthesises the published literature on the epidemiology of non-collision injuries occurring in older people using public buses, to enable understanding of the size and nature of the problem of injuries, and to explore strategies for improving the safety of public transport for older people. We searched PubMed, Embase, CINAHL, Web of Science, and Transport International Research Documentation (TRID). Studies were included if they were cross-sectional, case-control or cohort studies. Pairs of reviewers independently screened studies for inclusion, assessed risk of bias, and extracted data. Ten studies were included in the review. Older people and women were found to be over-represented in non-collision injuries. Most injuries occurred during daytime hours and on weekdays. Injuries most commonly occurred whilst passengers were standing and either moving around the bus, boarding, or alighting, and whilst the bus was accelerating or decelerating. Bruising was the most common injury amongst emergency department attenders, although between 18% and 33% suffered more serious injuries such as fractures or dislocations. Many injuries to older public transport users are potentially preventable. Public transport needs to be safe and accessible, and to be perceived as such by older people to ensure independence in outdoor mobility

Hip precautions after hip operation (HippityHop): protocol for a before and after study evaluating hip precautions following total hip replacement

Introduction Hip precautions are routinely used despite inconclusive evidence that they reduce dislocations, and concern that they impede activities of daily living. HippityHop compares a change in practice locally from implementing routine hip precautions to no routine precautions, in order to: 1. Compare patient outcomes in quality of life, functional performance, pain, sleep, mood and satisfaction. 2. Ascertain staff and patient perceptions of the two regimes. 3. Determine the cost of precautions. Methods Before and after study: phase one patients will receive hip precautions, while phase two patients will receive no routine precautions. We propose to collect data from 342 participants at baseline, and at one week, six weeks, and three months postoperatively. Interviews will be conducted with 20 staff and 20 patients, and data collected relating to costs. Results Statistical analysis will be conducted to compare the two groups to determine any differences in patient outcomes. Thematic analysis will be used to identify and report themes within the interview data. Conclusion If there are no additional advantages to hip precautions, patients could resume everyday activities more quickly, potentially improving their quality of life. Conversely, if withdrawing hip precautions is detrimental, evidence for precautions will be provided