Participant Feedback in the Evaluation of Novel Stroke Rehabilitation Technologies

Purpose: Stroke participant perspectives are used to evaluate a novel rehabilitation system employing electrical stimulation (ES) technology combined with robotic assistance and virtual reality. The broader implications of such feedback for future technological development are discussed. Method: While supported by a robot, ES was applied to the triceps and anterior deltoid muscles of 5 chronic stroke participants with upper limb impairment to assist them in completing functional, virtual reality tracking tasks. Advanced ES controllers adjusted the amount of ES applied on each attempt to improve accuracy and maximise voluntary effort. The system was evaluated in terms of participants’ perspectives, expressed during a semi-structured interview, and clinical outcome measures. Results: The rehabilitation system was well accepted by participants and viewed positively, despite mixed opinions regarding effectiveness. Feedback demonstrated an alignment in participants’ perceptions of reduced impairment and clinical outcomes, in which a significant (p < 0.001) mean change of 9.3 in Fugl-Meyer scores was observed. Participant feedback also provided insight into individual differences observed in clinical outcomes. From our findings six key issues regarding effectiveness, muscles trained, system flexibility and portability, possible discomfort and the value of participant perspectives emerged that may be relevant for researchers developing new rehabilitation technologies. Conclusion: Participant feedback via a semi-structured interview provided important insight into the usability and effectiveness of using this system as a platform for upper limb stroke rehabilitation

European evidence-based recommendations for clinical assessment of upper limb in neurorehabilitation (CAULIN): data synthesis from systematic reviews, clinical practice guidelines and expert consensus

Background: Technology-supported rehabilitation can help alleviate the increasing need for cost-effective rehabilitation of neurological conditions, but use in clinical practice remains limited. Agreement on a core set of reliable, valid and accessible outcome measures to assess rehabilitation outcomes is needed to generate strong evidence about effectiveness of rehabilitation approaches, including technologies. This paper collates and synthesizes a core set from multiple sources; combining existing evidence, clinical practice guidelines and expert consensus into European recommendations for Clinical Assessment of Upper Limb In Neurorehabilitation (CAULIN). Methods: Data from systematic reviews, clinical practice guidelines and expert consensus (Delphi methodology) were systematically extracted and synthesized using strength of evidence rating criteria, in addition to recommendations on assessment procedures. Three sets were defined: a core set: strong evidence for validity, reliability, responsiveness and clinical utility AND recommended by at least two sources; an extended set: strong evidence OR recommended by at least two sources and a supplementary set: some evidence OR recommended by at least one of the sources. Results: In total, 12 measures (with primary focus on stroke) were included, encompassing body function and activity level of the International Classification of Functioning and Health. The core set recommended for clinical practice and research: Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT); the extended set recommended for clinical practice and/or clinical research: kinematic measures, Box and Block Test (BBT), Chedoke Arm Hand Activity Inventory (CAHAI), Wolf Motor Function Test (WMFT), Nine Hole Peg Test (NHPT) and ABILHAND; the supplementary set recommended for research or specific occasions: Motricity Index (MI); Chedoke-McMaster Stroke Assessment (CMSA), Stroke Rehabilitation Assessment Movement (STREAM), Frenchay Arm Test (FAT), Motor Assessment Scale (MAS) and body-worn movement sensors. Assessments should be conducted at pre-defined regular intervals by trained personnel. Global measures should be applied within 24 h of hospital admission and upper limb specific measures within 1 week. Conclusions: The CAULIN recommendations for outcome measures and assessment procedures provide a clear, simple, evidence-based three-level structure for upper limb assessment in neurological rehabilitation. Widespread adoption and sustained use will improve quality of clinical practice and facilitate meta-analysis, critical for the advancement of technology-supported neurorehabilitation.The European Network on Robotics for NeuroRehabilitation (Working Group 1) developed these recommendations. Their work was funded by the European Co-Operation in Science and Technology (COST Action TD1006) programme. The funding body had no role in or infuence on the selected approach and synthesis, analysis, and interpretation of data and in writing the manuscript

Implementing functional electrical stimulation clinical practice guidelines to support mobility: A stakeholder consultation

From Frontiers via Jisc Publications RouterHistory: received 2022-10-05, collection 2023, accepted 2023-01-09, epub 2023-01-26Peer reviewed: TrueAcknowledgements: Acknowledgments: The International Functional Electrical Stimulation Society (IFESS) and the Association of Chartered Physiotherapists interested in Neurology (ACPIN) are acknowledged for support in setting up workshops and encouraging participation from their members.Publication status: PublishedFunctional Electrical Stimulation (FES) has been used to support mobility for people with upper motor neuron conditions such as stroke and multiple sclerosis for over 25 years. Recent development and publication of clinical practice guidelines (CPGs) provide evidence to guide clinical decision making for application of FES to improve mobility. Understanding key barriers to the implementation of these CPGs is a critical initial step necessary to create tailored knowledge translation strategies. A public involvement and engagement consultation was conducted with international stakeholders including researchers, clinicians and engineers working with FES to inform implementation strategies for CPG use internationally. Reflexive thematic analysis of the consultation transcripts revealed themes including inconsistent use of CPGs, barriers to implementation such as limited access to FES and low clinician confidence, and the need for a tiered education approach with ongoing support. Insights derived from this consultation will inform the development of knowledge translation strategies to support the next steps to implementing FES use for mobility.pubpu

Forefoot pathology in rheumatoid arthritis identified with ultrasound may not localise to areas of highest pressure: cohort observations at baseline and twelve months

BackgroundPlantar pressures are commonly used as clinical measures, especially to determine optimum foot orthotic design. In rheumatoid arthritis (RA) high plantar foot pressures have been linked to metatarsophalangeal (MTP) joint radiological erosion scores. However, the sensitivity of foot pressure measurement to soft tissue pathology within the foot is unknown. The aim of this study was to observe plantar foot pressures and forefoot soft tissue pathology in patients who have RA.Methods A total of 114 patients with established RA (1987 ACR criteria) and 50 healthy volunteers were assessed at baseline. All RA participants returned for reassessment at twelve months. Interface foot-shoe plantar pressures were recorded using an F-Scan® system. The presence of forefoot soft tissue pathology was assessed using a DIASUS musculoskeletal ultrasound (US) system. Chi-square analyses and independent t-tests were used to determine statistical differences between baseline and twelve months. Pearson’s correlation coefficient was used to determine interrelationships between soft tissue pathology and foot pressures.ResultsAt baseline, RA patients had a significantly higher peak foot pressures compared to healthy participants and peak pressures were located in the medial aspect of the forefoot in both groups. In contrast, RA participants had US detectable soft tissue pathology in the lateral aspect of the forefoot. Analysis of person specific data suggests that there are considerable variations over time with more than half the RA cohort having unstable presence of US detectable forefoot soft tissue pathology. Findings also indicated that, over time, changes in US detectable soft tissue pathology are out of phase with changes in foot-shoe interface pressures both temporally and spatially.Conclusions We found that US detectable forefoot soft tissue pathology may be unrelated to peak forefoot pressures and suggest that patients with RA may biomechanically adapt to soft tissue forefoot pathology. In addition, we have observed that, in patients with RA, interface foot-shoe pressures and the presence of US detectable forefoot pathology may vary substantially over time. This has implications for clinical strategies that aim to offload peak plantar pressures

Upper limb and eye movement coordination during reaching tasks in people with stroke

Purpose: To enhance understanding of the relationship between upper limb and eye movements during reaching tasks in people with stroke. Methods: Eye movements were recorded from 10 control participants and 8 chronic stroke participants during a visual orienting task (Experiment 1) and a series of reaching tasks (Experiment 2). Stroke participants completed the reaching tasks using (i) their less impaired upper limb, (ii) their more impaired upper limb without support, and (iii) their more impaired upper limb, with support (SaeboMAS gravitational support and/or electrical stimulation). Participants were tested individually and completed both experiments in the same session. Results: Oculomotor control and the coordination between the upper limb and the oculomotor system were found to be intact in stroke participants when no limb movements were required, or when the less impaired upper limb was used. However, when the more impaired upper limb was used, success and accuracy in reaching decreased and patterns of eye movements changed, with an observed increase in eye movements to the limb itself. With upper limb support, patterns of hand-eye coordination were found to more closely resemble those of the control group. Conclusion: Deficits in upper limb motor systems result in changes in patterns of eye movement behavior during reaching tasks. These changes in eye movement behavior can be modulated by providing upper limb support. -Implications for Rehabilitation -Deficits in upper limb motor systems can result in changes in patterns of eye movement behavior during reaching tasks. -Upper limb support can reduce deficits in hand-eye coordination. -Stroke rehabilitation outcomes should consider motor and oculomotor performance

Clinical and therapeutic applications of neuromuscular stimulation: a review of current use and speculation into future developments

In this paper we present an overview of current research into clinical and therapeutic applications of electrical neuromuscular stimulation (NMS). As this is now such a huge subject we have focused our attention on the therapeutic rather than orthotic uses of stimulation and limited the field almost exclusively to upper limb applications in hemiplegia. The evidence that NMS influences motor re-learning and how this may be measured is discussed. We have identified the following as the three most important unresolved issues: 1) an understanding of how NMS modifies the interactions within the nervous system, 2) clinical effectiveness of NMS, and 3) inexpensive, simple to insert and reliable controllable implanted systems. We discuss recent research aimed at resolving these issues and based on this we make some suggestions for future research. To resolve these issues we propose: 1) neurophysiologic research into the mechanism through which NMS interacts with the nervous system; 2) large multicenter randomized controlled trials using rigorous methodology that compare different applications of NMs; 3) continued technical development that is closely linked to clinical applications

Internal and external focus of attention during gait re-education: an observational study of physical therapist practice in stroke rehabilitation

Background Focus of attention is known to play an important role in motor skill learning, yet little is known about how attention is directed within the context of stroke rehabilitation. Objective: The aims of this study were: (1) to identify physical therapists' use of internal and external focus of attention during gait rehabilitation for individuals with hemiplegia following stroke and (2) to use the findings to design an experimental study examining the impact of focus of attention on learning poststroke. Design: The study design involved direct nonparticipation observation of physical therapy treatment sessions. Methods: Eight physical therapy treatment sessions, in which gait rehabilitation was taking place, were video recorded. Patients were aged between 36 and 85 years, and ranged from 7 to 216 days poststroke; physical therapists had between 3 and 12 years of experience in stroke rehabilitation. Data analysis took 2 forms: (1) clear definitions of internal and external focus of attention were agreed on via a consensus group and used to develop an analysis matrix through which incidences of instruction and feedback were identified, categorized, and counted; and (2) verbal dialogue was transcribed verbatim and transcripts were thematically analyzed to provide a detailed description of how instructions and feedback were used, illustrated by examples. Results: The use of instructions and feedback (internal and external focus) was high; an average of one verbal instruction or feedback statement was delivered every 14 seconds. Sixty-seven percent of the statements were internally focused, 22% were externally focused, and 11% were of mixed focus. Unfocused statements (eg, “good”) also were used regularly. Patients were frequently encouraged to “think about” their performance. Limitations: Observational data collection methods may result in changes in the behavior of those observed, which is a potential source of bias. The small sample size also was a limitation of the study. Conclusion: Physical therapists frequently encouraged patients to be aware of their movements and their performance (internal focus). This approach may reduce automaticity and hinder learning and retention. <br/

Forced use as a home-based intervention in children with congenital hemiplegic cerebral palsy: choosing the appropriate constraint

Purpose: The purpose of this study was (1) to identify the most appropriate splint from children's and parents' perspective as reflected by effectiveness and adherence to home-based forced use therapy (FUT). (2) To provide guidance in the development of a practical and effective protocol based on forced use principles. Method: A crossover design with a convenience sample of children with hemiplegic cerebral palsy and their parents was used to test three types of splint (mitt, short splint and long splint) during home-based FUT. Children wore the splints for a minimum of 1 h/ day during physical activity. Outcome measures included a daily log and a questionnaire (completed by parents), an actometer worn on the affected hand to quantify movement and video recordings to inform quality of movement. Results: The short splint was found to be the most effective and acceptable restraining device. Wearing devices for more than 1 h per day was not considered acceptable by either parents or children. Conclusion: A short splint, worn for 1 h per day was found to be the most acceptable protocol.<br/