Translation of evidence-based Assistive Technologies into stroke rehabilitation: Users' perceptions of the barriers and opportunities

Background: Assistive Technologies (ATs), defined as "electrical or mechanical devices designed to help people recover movement", demonstrate clinical benefits in upper limb stroke rehabilitation; however translation into clinical practice is poor. Uptake is dependent on a complex relationship between all stakeholders. Our aim was to understand patients', carers' (P&Cs) and healthcare professionals' (HCPs) experience and views of upper limb rehabilitation and ATs, to identify barriers and opportunities critical to the effective translation of ATs into clinical practice. This work was conducted in the UK, which has a state funded healthcare system, but the findings have relevance to all healthcare systems. Methods. Two structurally comparable questionnaires, one for P&Cs and one for HCPs, were designed, piloted and completed anonymously. Wide distribution of the questionnaires provided data from HCPs with experience of stroke rehabilitation and P&Cs who had experience of stroke. Questionnaires were designed based on themes identified from four focus groups held with HCPs and P&Cs and piloted with a sample of HCPs (N = 24) and P&Cs (N = 8). Eight of whom (four HCPs and four P&Cs) had been involved in the development. Results: 292 HCPs and 123 P&Cs questionnaires were analysed. 120 (41%) of HCP and 79 (64%) of P&C respondents had never used ATs. Most views were common to both groups, citing lack of information and access to ATs as the main reasons for not using them. Both HCPs (N = 53 [34%]) and P&C (N = 21 [47%]) cited Functional Electrical Stimulation (FES) as the most frequently used AT. Research evidence was rated by HCPs as the most important factor in the design of an ideal technology, yet ATs they used or prescribed were not supported by research evidence. P&Cs rated ease of set-up and comfort more highly. Conclusion: Key barriers to translation of ATs into clinical practice are lack of knowledge, education, awareness and access. Perceptions about arm rehabilitation post-stroke are similar between HCPs and P&Cs. Based on our findings, improvements in AT design, pragmatic clinical evaluation, better knowledge and awareness and improvement in provision of services will contribute to better and cost-effective upper limb stroke rehabilitation. © 2014 Hughes et al.; licensee BioMed Central Ltd

Response to common peroneal nerve stimulation following stroke

In this thesis I have examined the effect of functional electrical stimulation (FES) on the walking of people who have suffered a stroke. A simple, single channel stimulator, triggered by a foot-switch, based on Liberson's design of 1960, was used throughout the study. The effect of stimulation on the spasticity of the quadriceps and on the speed and the effort of walking was investigated through a randomised controlled trial with a selected sample of well motivated subjects with established hemiplegia and the walking problem described. Statistically significant improvement in walking parameters and in spasticity was identified only in the group using stimulation, but, among these subjects a wide variation in response was observed. In some cases stimulation resulted in a functional improvement in walking whereas in others little or no benefit was experienced. The second stage of the study sought to explain this observation by answering the following questions.1. Is it possible to predict response to use of the stimulator?2. Can different types of abnormal motor control be identified in apparently similar hemiplegic patients and, if so, is response associated with one or more type?3. Does the patient's perceived benefit of stimulation realte to objective measures and do either influence continued use of stimulation?A small, separate sample of similar patients were studied in depth prior to, and following, a three month period during which they used the same stimulator. Patterns of muscle activation and movement were measured and related to the functional and perceived benefits of using the stimulator.Patterns of muscle activation identified in two ways, Firstly, muscle activation, mechanical resistance to movement, ability to activate muscles appropriately and control of voluntary movement were tested in an ankle rig in which the ankle could be moved passively and in which patients were asked to follow a tracking signal. Secondly, patients were observed walking on a treadmill. Patterns of muscle activation and ankle movement were again measured, and, using pressure sensitive foot-switches, related to stages of the gait cycle.</p

A nation-wide survey exploring the views of current and future use of functional electrical stimulation in spinal cord injury

Purpose: Functional electrical stimulation (FES) can be effective in assisting physical and psychosocial difficulties experienced by people with spinal cord injury. Perceived benefits and barriers of the current and future use of FES within the wider spinal cord injury community is currently unknown. The main objective of this research was to explore the spinal cord injury community’s views of the use of FES to decrease disability in rehabilitation programmes. Materials and methods: An online and paper questionnaire was distributed to people with spinal cord injury, health care professionals and researchers working in spinal cord injury settings in the United Kingdom. Results: A total of 299 participants completed the survey (152 people with spinal cord injury, 141 health care professionals and 6 researchers). Common views between groups identified were: (1) FES can be beneficial in improving physical and psychosocial aspects and that (2) adequate support and training for FES application was provided to users. Barriers to FES use included a lack of staff time and training, financial cost and availability of the equipment. Sixty three percent of non-users felt they would use FES in the future if they had the opportunity. Conclusions: Users’ views were important in identifying that FES application can be beneficial for people with spinal cord injury but also has some resourceful barriers. In order to increase use, future research should focus on reducing the cost of FES clinical service and also address implementation of awareness and training programmes within spinal units and community rehabilitation settings.IMPLICATIONS FOR REHABILITATION Users of functional electrical stimulation think that it is beneficial for improving physical and psychosocial limitations after spinal cord injury Barriers to FES use include a lack of staff time and training, financial cost and availability of the equipment have been suggested by people with spinal cord injury and health care professionals Education and implementation programs for health care professionals and people with spinal cord injury are now necessary to increase the awareness about functional electrical stimulation application Reduction of FES cost could also increase its uptake in spinal cord injury clinical services.</p

Cognitive interviewing techniques: applied in the development of a questionnaire on Functional Electrical Stimulation in Spinal Cord Injury study

The aim of this paper is to illustrate the application of a technique, Cognitive interviewing, which was used in the development of three questionnaires to determine the views of use of Functional Electrical Stimulation (FES) by people with Spinal Cord Injury (SCI), Health Care Professionals (HCP) and researchers working in SC

European consensus on the concepts and measurement of the pathophysiological neuromuscular responses to passive muscle stretch

Background and purpose To support clinical decision-making in central neurological disorders, a physical examination is used to assess responses to passive muscle stretch. However, what exactly is being assessed is expressed and interpreted in different ways. A clear diagnostic framework is lacking. Therefore, the aim was to arrive at unambiguous terminology about the concepts and measurement around pathophysiological neuromuscular response to passive muscle stretch. Methods During two consensus meetings, 37 experts from 12 European countries filled online questionnaires based on a Delphi approach, followed by plenary discussion after rounds. Consensus was reached for agreement ≥75%. Results The term hyper-resistance should be used to describe the phenomenon of impaired neuromuscular response during passive stretch, instead of for example ‘spasticity’ or ‘hypertonia’. From there, it is essential to distinguish non-neural (tissue-related) from neural (central nervous system related) contributions to hyper-resistance. Tissue contributions are elasticity, viscosity and muscle shortening. Neural contributions are velocity dependent stretch hyperreflexia and non-velocity dependent involuntary background activation. The term ‘spasticity’ should only be used next to stretch hyperreflexia, and ‘stiffness’ next to passive tissue contributions. When joint angle, moment and electromyography are recorded, components of hyper-resistance within the framework can be quantitatively assessed. Conclusions A conceptual framework of pathophysiological responses to passive muscle stretch is defined. This framework can be used in clinical assessment of hyper-resistance and will improve communication between clinicians. Components within the framework are defined by objective parameters from instrumented assessment. These parameters need experimental validation in order to develop treatment algorithms based on the aetiology of the clinical phenomena