A prospective assessment of gait kinematics and related clinical examination measures in cerebral palsy crouch gait [version 1; peer review: awaiting peer review]

Background While prospectively assessed crouch gait in cerebral palsy (CP) does not necessarily progress, prospective changes in clinical examination measures have not been reported. This study prospectively examined the association between selected clinical examination variables and change in crouch gait in a cohort with bilateral CP.  Methods Inclusion criteria were a diagnosis of ambulant bilateral CP, knee flexion at mid-stance >190 and a minimum of two-years between gait analyses. The change in kinematic variables was assessed using Statistical Parameter Mapping (SPM) and changes in clinical measures using appropriate paired tests. Linear regression examined the association between progression of crouch and clinical examination variables.  Results There was no mean change in crouch in 27 participants over 3.29 years. However, there was significant variability within this group. Clinical hamstring tightness (60.000 to 70.480, p Conclusions The variability crouch gait progression highlights the pitfall of group mean values in such a heterogeneous population.  The lack of association between changes in clinical examination variables and changes in crouch highlights the multi-factorial aetiolog </p

A prospective assessment of the progression of flexed-knee gait over repeated gait analyses in the absence of surgical intervention in bilateral cerebral palsy

Background: Flexed-knee gait is a common pattern associated with cerebral palsy (CP). It leads to excessive forces on the knee and is thought to contribute to pain and deformity. While studies have shown improvements in mid-stance knee flexion following surgery there remains a lack of prospective data on the progression of flexed-knee gait in the absence of surgery. Research question: Does knee flexion progress over repeated assessments in the absence of surgery in a prospectively assessed cohort with CP? Methods: Inclusion criteria were a diagnosis of bilateral CP, knee flexion at mid-stance >19° and no surgery within one year of the first gait analysis. Gait analysis was carried out at six-month intervals (minimum of three and maximum of six assessments). The progression of knee flexion over repeated analyses was assessed. The association between changes in knee flexion between assessments and gender, age, GMFCS level, change in ankle dorsiflexion, change in height and change in weight was examined. Results: Forty-eight participants met the initial inclusion criteria and 32 (GMFCS I = 11, II = 17, III = 4) completed the minimum three assessments. Of the 32 included participants, 21 participants (66%) demonstrated decreased knee flexion at mid-stance (mean decrease 6.6° ± 3.4°; range 2.0°-13.0°) and 11 participants (34%) demonstrated increased knee flexion at mid-stance (mean increase 10.4° ± 7.1°; range 2.0°-20.0°) at one-year follow-up. Eighteen (56%) then demonstrated an overall decrease (mean 7.4° ± 5.1°) in knee flexion between the first and last assessment with last follow-up at 1-2 years (n = 3), 2-3 years (n = 3) and 3-4 years (n = 12). The majority of participants (78%) demonstrated episodes of both increasing and decreasing Knee flexion between individual assessments and further analysis found that age was associated with this inter-assessment variability in knee flexion. Significance: Flexed-knee gait is not always progressive in bilateral CP and demonstrated variability associated with age.</p

Managing frailty in an Irish primary care setting: a qualitative study of perspectives of healthcare professionals and frail older patients.

Objectives: Little is known about the views of key stakeholders on frailty in Primary Care in Ireland. The aim of this study was to explore the views of Irish healthcare professionals and patients on frailty and its management in Primary Care. Methods: A qualitative descriptive design was used. Seventeen healthcare professionals and three patients were recruited using purposive sampling. Data were collected using semi-structured interviews which were analysed thematically. Results: Three themes were identified: (i) Perceptions of Frailty (ii) Current Management of Frailty and (iii) Comprehensive Geriatric Assessment in Primary Care. The results demonstrated variability in perspectives on frailty. Healthcare professionals described a fragmented service often delivering substandard care to frail older patients. The general consensus was that frailty management required an adequately resourced Primary Care service. Support for frailty screening and Comprehensive Geriatric Assessment was evident while the suitability of the current pathway for patients requiring assessment was questioned. Conclusion: This study highlights an absence of a shared and complete understanding of frailty among healthcare professionals and a fragmented model of care for community-dwelling frail older patients. Based on these findings, inter-professional training, investment in Primary Care, the development of a frailty pathway and an interface service is recommended.</p

The natural history of crouch gait in bilateral cerebral palsy: a systematic review

Aim: To systematically review the natural history of crouch gait in bilateral cerebral palsy (CP) in the absence of surgical intervention and to review any relationship between clinical variables and progression of knee crouch. Methods: Relevant literature was identified by searching article databases (PubMed, CINAHL, EMBASE, and Web of Science). Included studies reported on participants with bilateral CP who had 3-dimensional gait analysis on at least two occasions with no surgical interventions between analyses. Results: Five papers (4 retrospective cohort studies; 1 case report) comprised the final selection. Studies varied in follow-up times and participant numbers. Increased knee flexion over time was reported in the four retrospective studies with two distinct patterns of increasing knee flexion evident. Only the case-study reported improved knee extension between assessments. Four studies demonstrated increased hamstring tightness over time with the biggest increases related to longer follow-up time rather than increase in crouch. Conclusion and implications: The existing literature suggests that the natural history of crouch gait is towards increasing knee flexion over time. Future prospective studies of bigger groups are needed to examine the relationship between increasing crouch and clinical variables.</p

Clinical guideline adherence by physiotherapists working in acute stroke care.

The publication of the Irish Clinical Guidelines for Stroke in 2009 provided healthcare professionals with an essential tool for improving stroke services. The aim of this study was to identify the degree to which Senior Physiotherapists in acute stroke care adhered to the Irish Clinical Guidelines for Stroke. This was a cross-sectional study, a postal or online survey was distributed to 31 Senior Physiotherapists working in acute stroke care, 23 responded, achieving a 74% response rate. There was excellent compliance with guidelines for the completion and documentation of full assessment within 5 working days of admission 19 respondents (82.6%), and the involvement of the patient in goal setting 19 (82.6%). Poor compliance was reported in relation to the provision of early assessment 10 (43.5%) and adequate rehabilitation intensity 9 (39%). The main barriers to compliance in these areas were organisational in nature.</p

Factors associated with walking in older medical inpatients.

Objective: To identify patient characteristics on admission and daily events during hospitalization that could influence older medical inpatients walking activity during hospitalization. Design: A cohort study. Setting: Acute hospitalized care. Participants: Premorbidly mobile, nonsurgical, nonelective inpatients (50% women) aged ≥65 years (N=154), with an anticipated ≥3-day inpatient stay were recruited consecutively within 48 hours of hospital admission. Of the 227 patients screened, 69 did not meet study criteria and 4 refused. Interventions: Not applicable. Main outcome measures: Age, comorbidities (Cumulative Illness Rating Scale), cognitive status (6-item Cognitive Impairment Test), falls history and efficacy (Falls Efficacy Scale-International), physical performance (short physical performance battery), and medications were recorded within 2 days of admission. Walking activity (step count) was recorded for 7 days or until discharge. Daily events (procedures, falls, fear of falling, ordered bedrest, devices or treatments that hindered walking [eg, intravenous fluids, wall-mounted oxygen therapy], patient- and nurse-reported medial status, fatigue, sleep quality, physiotherapy, or occupational therapy intervention) were measured on concurrent weekdays. Their associations with daily (log) step count were estimated using linear mixed-effects models, adjusted for patient-characteristics measured at admission. Results: Approximately half of the variability in step count was described at the within-patient level. Multivariable models suggested positive associations with Wednesdays (+25% in step count; 95% confidence interval, 4-53), admission physical performance (+15%, 8-22), improving medical status (+33%, 7-64), negative associations with devices or treatments that hinder walking (-29%, -9 to -44), and instructed bedrest (-69%, -55 to -79). Conclusion: Day-to-day step count fluctuated, suggesting considerable scope for intervention. Devices or treatments that hinder walking should be reviewed daily and walking activity should become a clinical priority. Admission physical performance may identify vulnerable patients.</p

Rehabilitation needs of people with brain tumours in Ireland: "Brain-Restore"

Action research study of rehabilitation needs of people with brain tumours</p

Healthcare professionals’ experiences of delivering a stroke early supported discharge service – an example from Ireland

Objective: To explore healthcare professionals’ experiences of the development and delivery of Early Supported Discharge for people after stroke, including experiences of the COVID-19 pandemic. Design: Qualitative descriptive study using one-to-one semi-structured interviews. Data were analysed using reflexive thematic analysis. Setting: Nine Early Supported Discharge service sites in Ireland. Participants: Purposive sampling identified 16 healthcare professionals. Results: Five key themes were identified (1) Un-coordinated development of services, (2) Staff shortages limit the potential of Early Supported Discharge, (3) Limited utilisation of telerehabilitation post COVID-19 pandemic, (4) Families need information and support, and (5) Early Supported Discharge involves collaboration with people after stroke and their families. Conclusions: Findings highlight how Early Supported Discharge services adapted during the COVID-19 pandemic and how gaps in the service impacts on service delivery. Practice implications include the need to address staff recruitment and retention issues to prevent service shortages and ensure consistent access to psychology services. Early Supported Discharge services should continue to work closely with families and address their information and support needs. Future research on how telerehabilitation can optimally be deployed and the impact of therapy assistants in Early Supported Discharge is needed.</p

Inclusion of stroke patients in expanded cardiac rehabilitation services: a cross-national qualitative study with cardiac and stroke rehabilitation professionals

Purpose: This qualitative study explored healthcare professionals’ views in relation to the potential expansion of cardiac rehabilitation services to include stroke patients, thereby becoming a cardiovascular rehabilitation model. Design and methods: 23 semi-structured interviews were completed with hospital and community-based stroke and cardiac rehabilitation professionals in Switzerland (n = 7) and Ireland (n = 19). The sample comprised physiotherapists, occupational therapists, speech and language therapists, stroke physicians, cardiologists, psychologists, dieticians and nurses. Interviews were audio-recorded and the transcripts were analysed in NVivo using inductive Thematic Analysis. Results: Barriers and facilitators to cardiovascular rehabilitation were captured under four broad themes; (i) Cardiac rehabilitation as “low-hanging fruit,” (ii) Cognitive impairment (“the elephant in the room”), (iii) Adapted cardiac rehabilitation for mild stroke, and (iv) Resistance to change. Conclusions: Hybrid cardiac rehabilitation programmes could be tailored to deliver stroke-specific education, exercises and multidisciplinary expertise. Post-stroke cognitive impairment was identified as a key barrier to participation in cardiac rehabilitation. A cognitive rehabilitation intervention could potentially be delivered as part of cardiac rehabilitation, to address the cognitive needs of stroke and cardiac patients. Implications for rehabilitation The cardiac rehabilitation model has the potential to be expanded to include mild stroke patients given the commonality of secondary prevention needs. Up to half of stroke survivors are affected by post-stroke cognitive impairment, consequently mild stroke patients may not be such an “easy fit” for cardiac rehabilitation. A cardiovascular programme which includes common rehabilitation modules, in addition to stroke- and cardiac-specific content is recommended. A cognitive rehabilitation module could potentially be added as part of the cardiac rehabilitation programme to address the cognitive needs of stroke and cardiac patients.</div

Designing stroke services for the delivery of cognitive rehabilitation: a qualitative study with stroke rehabilitation professionals

This qualitative study explored the potential to deliver cognitive rehabilitation for post-stroke cognitive impairment (PSCI), with a specific focus on barriers and facilitators to its delivery from the perspective of Irish stroke rehabilitation professionals. Sixteen semi-structured interviews were completed with healthcare professionals in both hospital and community settings. The sample comprised physiotherapists, occupational therapists, nurses, a stroke physician, a psychologist, a neuropsychologist, a speech and language therapist, a dietician, and a public health nurse. Interviews were audio-recorded and analysed in NVivo using inductive Thematic Analysis. Barriers and facilitators to the delivery of cognitive rehabilitation were identified and described under four key themes: (i) Cognitive screening; (ii) Cognitive rehabilitation: no one size fits all; (iii) Psychology: the lost dimension of stroke rehabilitation; and (iv) Joining the dots in the community. Staffing required to deliver cognitive rehabilitation for PSCI was highlighted as under-resourced in the Republic of Ireland. Inadequate resourcing of neuropsychology and stroke-related psychological services, in particular, has had negative implications for the delivery of cognitive rehabilitation. Stroke-specific cognitive rehabilitation expertise is virtually inaccessible in the community, highlighting an urgent need for investment in specialist rehabilitation teams to deliver cognitive rehabilitation in this setting