Investigations of physical therapy interventions to enhance movement recovery in people after stroke: Development and design of a novel intervention embedding Functional Strength Training within a motor learning context

Stroke is the largest cause of adult disability in the UK and stroke survivors commonly present with a partial or complete loss of movement. Physical therapy interventions as part of movement rehabilitation after stroke aim to facilitate a return to participation in activities of daily living. It has been proposed that the processes that underpin both movement recovery following stroke and motor learning are the same. By embedding physical therapies within a motor learning context it is possible that the effects of the therapy could be enhanced. Yet the application of motor learning principles within the field of movement rehabilitation after stroke is fragmented and supported by evidence of their application in studies with healthy volunteers. This thesis aims to carry out a systematic review of the evidence for the effectiveness of the application of motor learning principles in movement rehabilitation after stroke and to combine this with findings from a feasibility study of Functional Strength Training. These findings will be used to design a novel intervention embedding FST within a motor learning context. Organisation and synthesis of the systematic review was guided by the development of a motor learning framework. Interpretation of the findings from the review showed some evidence in favour of the application of motor learning principles. A phase II randomised controlled trial of FST to the upper limb and lower limb in people within six months and five years after stroke showed evidence of feasibility for both interventions but indicated efficacy of the upper limb intervention only (p=0.046). These findings were combined to inform the design and delivery of a novel intervention, testing for proof of concept for this intervention is now required. This thesis suggests an alternative approach to the development of physical therapy interventions after stroke, however consensus for this needs to be achieved

Development of a consensus classification of physiotherapy interventions in paediatric neurorehabilitation

Background and Aims Physiotherapy within paediatric neurorehabilitation is a complex process whereby the relationship between treatments delivered and resultant severity-adjusted patient outcomes have been difficult to demonstrate. An essential prerequisite for analysing physiotherapy input at the point of its delivery to the patient is to have clear descriptions and categories of physiotherapy interventions. Recent work in this area has focussed on grouping treatments based on their common essential ingredients. The aim of this work is to develop an expert-lead consensus classification of physiotherapy interventions used in paediatric neurorehabilitation, categorised according to their essential ingredients, actions and mediators. Method Comprehensive literature searches of five electronic databases (MEDLINE, EMBASE, AMED, CINAHL and PsychINFO) together with supplementary hand searching identified 4,194 studies which were separated into 34 different interventions following cross-referencing with other sources. These were then divided into eight distinct categories according to their essential treatment ingredients. A panel of 13 expert physiotherapists specialising in the field of paediatric neurorehabilitation were consulted in two rounds of an online modifiedDelphi survey (a method commonly used to glean expert consensus). Results In modified-Delphi survey rounds 1 and 2 respectively, eight (62%) and nine (69%) of the experts responded. Utilising a threshold of ≥75% agreement set a priori to represent expert consensus, there was agreement that the eight categories are comprehensive (complete) and unambiguous (easily understood). What remains less clear is the extent to which these categories are independent of one another. Discussion This categorisation of physiotherapy interventions within paediatric neurorehabilitation is the first of its kind to group treatments according to their essential treatment ingredients. Such work adds the potential for gleaning greater understanding regarding how physiotherapy leads to improved patient outcomes within paediatric neurorehabilitation. Further work is required in this area to better understand the extent to which different categories are truly independent or where similarities exist between them

The Paths People Take Through Teaching Center Services: A Descriptive Analysis

Teaching centers offer a variety of services, ranging from teaching orientations and one-time workshops to intensive programs such as learning communities to individual consultations. However, most instructors do not participate in all categories of service a center offers; rather, they create their own paths through various combinations and sequences of programs. What do we know about these pathways, and what can we learn from the patterns of use? This article shares findings from an analysis of several years of data to learn more about the sequence in which instructors experience educational development and to discuss the implications of these findings

Feasibility of a randomized controlled trial of functional strength training for people between six months and five years after stroke: FeSTivaLS trial

Background: Functional Strength Training (FST) could enhance recovery late after stroke. The aim of this study was to evaluate the feasibility of a subsequent fully powered, randomized controlled trial. Methods: The study was designed as a randomized, observer-blind trial. Both interventions were provided for up to one hour a day, four days a week, for six weeks. Evaluation points were before randomization (baseline), after six weeks intervention (outcome), and six weeks thereafter (follow-up). The study took place in participants’ own homes. Participants (n = 52) were a mean of 24.4 months after stroke with a mean age of 68.3 years with 67.3% male. All had difficulty using their paretic upper (UL) and lower limb (LL). Participants were allocated to FST-UL or FST-LL by an independent randomization service. The outcome measures were recruitment rate, attrition rate, practicality of recruitment strategies, occurrence of adverse reactions, acceptability of FST, and estimation of sample size for a subsequent trial. Primary clinical efficacy outcomes were the Action Research Arm Test (ARAT) and the Functional Ambulation Categories (FAC). Analysis was conducted using descriptive statistics and thematic analysis of participants’ views of FST. A power calculation used estimates of clinical efficacy variance to estimate sample size for a subsequent trial. Results: The screening process identified 1,127 stroke survivors of whom 52 (4.6%) were recruited. The recruitment rate was higher for referral from community therapists than for systematic identification of people discharged from an acute stroke unit. The attrition rate was 15.5% at the outcome and follow-up time-points. None of the participants experienced an adverse reaction. The participants who remained in the study at outcome had received 68% of the total possible amount of therapy. Participants reported that their experience of FST provided a sense of purpose and involvement and increased their confidence in performing activities. The power calculation provides estimation that 150 participants in each group will be required for a subsequent clinical trial. Conclusions: This study found that a subsequent clinical trial was feasible with modifications to the recruitment strategy to be used

Strategies supporting parent-delivered rehabilitation exercises to improve motor function after paediatric traumatic brain injury: A systematic review

Aim: To identify and analyse ways in which parents are supported to deliver rehabilitation exercises to their child after traumatic brain injury (TBI), conceptualized as strategies. Method: A systematic search was completed using seven online databases and three grey literature databases, from inception to November 2021. The included studies focused on physical rehabilitation in children after TBI with the involvement of parents as hands-on deliverers or facilitators of rehabilitation (e.g. supervising the exercise). Intervention descriptions were reviewed to identify strategies; this was followed by fine-grained analysis using the Behaviour Change Wheel to identify intervention components. Risk of bias was analysed using the revised Cochrane Risk-of-Bias Tool for Randomized Trials or the Risk Of Bias In Non-randomized Studies - of Interventions. Results: Six interventions including 211 participants and one trial protocol met the inclusion criteria. All studies included a proportion of children diagnosed with TBI and four studies included mixed samples of acquired brain injury or cerebral palsy. All interventions included elements of goal setting and instruction. Interpretation: Interventions focus heavily on the initiation of physical rehabilitation, but focus less on the longer-term maintenance of rehabilitation delivery. Further research should integrate perspectives from parents to inform the development of new interventions

Functional and emotional outcomes after transient ischaemic attack: A 12-month prospective controlled cohort study

Background: Symptoms of transient ischemic attack are believed to fully resolve within 24 h of onset. Emerging evidence suggests that there may be prolonged functional and psychological impact, although studies have not been able to robustly identify whether these are the effect of transient ischemic attack or changes usually associated with ageing. We describe trajectories of disability and risk of anxiety and depression among patients seen at transient ischemic attack clinics over 12 months, compared to healthy controls. Methods: Thirty transient ischemic attack clinics across England participated. A total of 1320 participants were included: 373 diagnosed with transient ischemic attack, 186 with minor stroke, 310 with “possible transient ischemic attack,” 213 with another condition mimicking a transient ischemic attack and 238 controls recruited from primary care providers. Participants completed questionnaires after diagnosis then after 3, 6 and 12 months. Outcomes were the Nottingham Extended Activities of Daily Living Scale and the Hospital Anxiety and Depression Scale. Mixed effects regression was used to estimate group differences and trajectories. Results: At baseline, confirmed transient ischemic attack patients scored 1.31 HADS-Anxiety points (s.e. = 0.28; p < 0.001), 0.51 HADS-Depression points (s.e. = 0.26; p = 0.056), and 2.6 NEADL points (s.e. = 1.1; p = 0.020) worse than controls. At 12 months, the deficits were 0.78 (s.e. = 0.30; p = 0.008), 0.97 (s.e. = 0.23; p < 0.001), and 0.96 (s.e. = 0.92; p = 0.294) respectively. Differences among patients diagnosed with minor stroke were like or worse than transient ischemic attack patients. Conclusions: Transient ischemic attack clinic patients may have functional and emotional impairments compared to the general population irrespective of final diagnosis. The presence of emotional symptoms or risk of developing anxiety or depression did not always fully recover and may increase

Challenges and opportunities in rapid disaster research: lessons from the field in New Mexico and Vanuatu

Rapid research is essential to assess impacts in communities affected by disasters, particularly those communities made “hard-to-reach” due to their active marginalization across history and in contemporary practices. In this article, we describe two rapid research projects developed to assess needs for and experiences of communities hard-hit by disasters. The first is a project on the COVID-19 pandemic in southern New Mexico (USA) that was developed to provide information to local agencies that are deploying programs to rebuild and revitalize marginalized communities. The second is a project on population displacement due to a volcanic eruption in Vanuatu, a lower-middle income country in the South Pacific, with mental and physical health outcomes data shared with the Vanuatu Ministry of Health. We describe the similar and unique challenges that arose doing rapid research in these two different contexts, the potential broader impacts of the research, and a synthesis of lessons learned. We discuss the challenges of rapidly changing rules and regulations, lack of baseline data, lack of survey instruments validated for specific populations and in local languages, limited availability of community partners, finding funding for rapid deployment of projects, rapidly training and working with research assistants, health and safety concerns of researchers and participants, and communicating with local and international partners. We also specifically discuss how we addressed our own personal challenges while also conducting time-intensive rapid research. In both studies, researchers shared results with governmental and non-governmental partners who may use the data to inform the design of their own relief programs. While different in context, type of disaster, and research strategy, our discussion of these projects provides insights into common lessons learned for working with communities at elevated risk for the worst outcomes during disasters, such as the need for flexibility, compromise, and good working relationships with community partners

Advanced clinical practice in stroke and neurological rehabilitation: The development and co-production of an educational framework

Stroke and neurological rehabilitation seeks to work with patients and caregivers to develop personalised strategies for living with and managing the effects of their diagnosis. A consistent method for delivering these services has however yet to be established. Health Education England state that the implementation of Advanced Clinical Practice (ACP) roles have the potential to “transform and modernise pathways of care”. Working in partnership with HEE this project aims to co-produce an educational framework for ACP in NR

Immersive technology in ophthalmology education: A systematic review

Background: Despite the increasing use of immersive technology (IT) in ophthalmology, the effectiveness of this approach compared to other teaching practices is unclear. This systematic review aimed to determine the value of IT to teach students ophthalmic skills and whether it can supplement or replace conventional teaching practices.  Methods: A systematic search was performed of CENTRAL, MEDLINE, EMBASE, ERIC and PsychINFO databases. Randomised controlled trials comparing IT interventions versus (1) no training, (2) standard training, (3) different types of IT interventions, (4) different doses of IT interventions were eligible for inclusion.  Results: Seven trials involving 177 participants were included. IT offered some benefit compared to standard training as most trials demonstrated evidence of learning represented by composite performance score and performance time. Repetitive training with IT displayed similar results.  Conclusion: IT appears to improve the ophthalmic skill of healthcare trainees and should be considered as a supplement to training