Digitally enabled aged care and neurological rehabilitation to enhance outcomes with Activity and MObility UsiNg Technology (AMOUNT) in Australia: A randomised controlled trial

Background: Digitally enabled rehabilitation may lead to better outcomes but has not been tested in large pragmatic trials. We aimed to evaluate a tailored prescription of affordable digital devices in addition to usual care for people with mobility limitations admitted to aged care and neurological rehabilitation. Methods and findings: We conducted a pragmatic, outcome-assessor-blinded, parallel-group randomised trial in 3 Australian hospitals in Sydney and Adelaide recruiting adults 18 to 101 years old with mobility limitations undertaking aged care and neurological inpatient rehabilitation. Both the intervention and control groups received usual multidisciplinary inpatient and post-hospital rehabilitation care as determined by the treating rehabilitation clinicians. In addition to usual care, the intervention group used devices to target mobility and physical activity problems, individually prescribed by a physiotherapist according to an intervention protocol, including virtual reality video games, activity monitors, and handheld computer devices for 6 months in hospital and at home. Co-primary outcomes were mobility (performance-based Short Physical Performance Battery [SPPB]; continuous version; range 0 to 3; higher score indicates better mobility) and upright time as a proxy measure of physical activity (proportion of the day upright measured with activPAL) at 6 months. The dataset was analysed using intention-to-treat principles. The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000936628). Between 22 September 2014 and 10 November 2016, 300 patients (mean age 74 years, SD 14; 50% female; 54% neurological condition causing activity limitation) were randomly assigned to intervention (n = 149) or control (n = 151) using a secure online database (REDCap) to achieve allocation concealment. Six-month assessments were completed by 258 participants (129 intervention, 129 control). Intervention participants received on average 12 (SD 11) supervised inpatient sessions using 4 (SD 1) different devices and 15 (SD 5) physiotherapy contacts supporting device use after hospital discharge. Changes in mobility scores were higher in the intervention group compared to the control group from baseline (SPPB [continuous, 0–3] mean [SD]: intervention group, 1.5 [0.7]; control group, 1.5 [0.8]) to 6 months (SPPB [continuous, 0–3] mean [SD]: intervention group, 2.3 [0.6]; control group, 2.1 [0.8]; mean between-group difference 0.2 points, 95% CI 0.1 to 0.3; p = 0.006). However, there was no evidence of a difference between groups for upright time at 6 months (mean [SD] proportion of the day spent upright at 6 months: intervention group, 18.2 [9.8]; control group, 18.4 [10.2]; mean between-group difference −0.2, 95% CI −2.7 to 2.3; p = 0.87). Scores were higher in the intervention group compared to the control group across most secondary mobility outcomes, but there was no evidence of a difference between groups for most other secondary outcomes including self-reported balance confidence and quality of life. No adverse events were reported in the intervention group. Thirteen participants died while in the trial (intervention group: 9; control group: 4) due to unrelated causes, and there was no evidence of a difference between groups in fall rates (unadjusted incidence rate ratio 1.19, 95% CI 0.78 to 1.83; p = 0.43). Study limitations include 15%–19% loss to follow-up at 6 months on the co-primary outcomes, as anticipated; the number of secondary outcome measures in our trial, which may increase the risk of a type I error; and potential low statistical power to demonstrate significant between-group differences on important secondary patient-reported outcomes. Conclusions: In this study, we observed improved mobility in people with a wide range of health conditions making use of digitally enabled rehabilitation, whereas time spent upright was not impacted. Trial registration: The trial was prospectively registered with the Australian New Zealand Clinical Trials Register; ACTRN1261400093662

Amount of exercise in the first week after stroke predicts walking speed and unassisted walking

Background. Predicting walking outcomes poststroke is a challenge for clinicians. Objective. To identify the extent to which exercise dose (repetitions of leg movements) in the first week of a comprehensive stroke unit stay predicts discharge mobility. Methods. A cohort study was conducted on 200 consecutive people admitted to a comprehensive stroke unit who required physical therapy. Results. Discharge and predictor data were available for 191 survivors (99%). On admission, 86 participants were able to walk, and the average walking velocity was 0.42 m/s. On discharge, the average walking velocity was 0.77 m/s, and 152 participants were able to walk. A discharge walking velocity of greater than 0.8 m/s was predicted by the exercise dose achieved in the first week after admission. Adding other predictors did not significantly increase the predictive ability of the model. Completion of more than the median number of exercise repetitions (703) in the first week of admission was associated with a quicker recovery of unassisted walking. This effect persisted after adjustment for walking velocity on admission, cognition, and comorbidity. Conclusion. Exercise dose in the first week after admission for stroke is an important indicator of walking speed at discharge and the time to achieve unassisted walking.7 page(s

Many participants in inpatient rehabilitation can quantify their exercise dosage accurately : an observational study

Question: Are inpatients undergoing rehabilitation who appear able to count exercises able to quantify accurately the amount of exercise they undertake? Design: Observational study. Participants: Inpatients in an aged care rehabilitation unit and a neurological rehabilitation unit, who appeared able to count their exercises during a 1-2 min observation by their treating physiotherapist. Measurements: Participants were observed for 30 min by an external observer while they exercised in the physiotherapy gymnasium. Both the participants and the observer counted exercise repetitions with a hand-held tally counter and the two tallies were compared. Results: Of the 60 people admitted for aged care rehabilitation during the study period, 49 (82%) were judged by their treating therapist to be able to count their own exercise repetitions accurately. Of the 30 people admitted for neurological rehabilitation during the study period, 20 (67%) were judged by their treating therapist to be able to count their repetitions accurately. Of the 69 people judged to be accurate, 40 underwent observation while exercising. There was excellent agreement between these participants' counts of their exercise repetitions and the observers' counts, ICC (3,1) of 0.99 (95% CI 0.98 to 0.99). Eleven participants (28%) were in complete agreement with the observer. A further 19 participants (48%) varied from the observer by less than 10%. Conclusion: Therapists were able to identify a group of rehabilitation participants who were accurate in counting their exercise repetitions. Counting of exercise repetitions by therapist-selected patients is a valid means of quantifying exercise dosage during inpatient rehabilitation.6 page(s

After-hours or weekend rehabilitation improves outcomes and increases physical activity but does not affect length of stay : a systematic review

Question: In adults undergoing inpatient rehabilitation, does additional after-hours rehabilitation decrease length of stay and improve functional outcome, activities of daily living performance and physical activity? Design: Systematic review with meta-analysis of randomised trials. Participants: Adults participating in an inpatient rehabilitation program. Intervention: Additional rehabilitation provided after hours (evening or weekend). Outcome measures: Function was measured with tests such as the Motor Assessment Scale, 10-m walk test, the Timed Up and Go test, and Berg Balance Scale. Performance on activities of daily living was measured with the Barthel index or the Functional Independence Measure. Length of stay was measured in days. Physical activity levels were measured as number of steps or time spent upright. Standardised mean differences (SMD) or mean differences (MD) were used to combine these outcomes. Adverse events were summarised using relative risks (RR). Study quality was assessed using PEDro scores. Results: Seven trials were included in the review. All trials had strong methodological quality, scoring 8/10 on the PEDro scale. Among the measures of function, only balance showed a significant effect: the MD was 14 points better (95% CI 5 to 23) with additional after-hours rehabilitation on a 0-to-56-point scale. The improvement in activities of daily living performance with additional after-hours rehabilitation was of borderline statistical significance (SMD 0.10, 95% CI 0.00 to 0.21). Hospital length of stay did not differ significantly (MD –1.8 days, 95% CI –5.1 to 1.6). Those receiving additional rehabilitation had significantly higher step counts and spent significantly more time upright. Overall, the risk of adverse events was not increased by the provision of after-hours or weekend rehabilitation (RR 0.87, 95% CI 0.70 to 1.10). Conclusion: Additional after-hours rehabilitation can increase physical activity and may improve activities of daily living, but does not seem to affect the hospital length of stay. An errata exists for this article, and can be found at http://doi.org/10.1016/j.jphys.2015.08.0087 page(s

Feasibility of a Nurse-Led Weekend Group Exercise Program for People after Stroke

Background. Additional physical activity including repetitive task practice can improve outcomes after stroke. The additional practice can be facilitated by therapists and family members or could also be delivered by nursing staff. Objective. To investigate the feasibility of a nurse-led weekend exercise program after stroke. Participants. Individuals after stroke, who participated in a weekend exercise program during their hospital admission. Methods. A retrospective audit of the number of referrals to and amount of exercise repetitions achieved in a nurse-led weekend exercise program was undertaken. The weekend exercise program occurs on each Saturday and Sunday for one hour. The repetitions of exercise completed during each class were documented by staff. An audit was conducted to ascertain the amount and type of exercise completed within the class. Results. During the study period 284 people were referred to the exercise program. The mean number of exercise repetitions completed per participant in each class was 180.7 (SD 205.4). The number of exercise repetitions completed by participants was highly variable ranging from 0 to 1190 per class. Conclusion. The amount of average exercise repetitions completed in the Weekend Warrior program was large but with significant variability. A nurse-led exercise class is a feasible method of delivering exercise opportunities to individuals in hospital after stroke

App-based supplemental exercise during inpatient orthopaedic rehabilitation increases activity levels: a pilot randomised control trial

Abstract Background There is a known positive relationship between time in therapy and therapy outcomes. Effective rehabilitation should therefore include larger doses of therapy. However, individuals participating in inpatient rehabilitation have low levels of activity throughout the day. This level of inactivity may limit rehabilitation potential. New technologies which deliver personalised exercise programs and track time spent on exercises may lead to greater activity levels and therefore improve functional outcomes in rehabilitation. This pilot randomised control trial aimed to investigate whether an app-based supplemental exercise program in orthopaedic rehabilitation will be feasible and acceptable to participants, increase activity levels and improve functional outcomes. Methods Participants were randomised to receive supplemental exercise via an app (PTPal™) on a tablet device additional to usual care or usual care alone. Primary outcome measures were participant satisfaction with app-based supplemental exercise, total repetitions of each activity and time in supplemental exercise programs. Secondary measures were 10-m walk test (10MWT), 6-min walk test (6MWT), Timed Up and Go (TUG), Functional Independence Measure and length of stay assessed by a blinded assessor. Results Twenty individuals admitted into an inpatient private general rehabilitation unit for orthopaedic rehabilitation over a 4-week duration were included in this study. High acceptance of the app-based supplemental exercise program was demonstrated. Those using the app completed an additional 549 exercise repetitions during their admission (694 supplemental app-based repetitions vs 146 supplemental paper-based repetitions in the control group, mean difference [MD] 549, 95% CI 95 to 1002, p = 0.02) and an additional 157 min in supplemental exercise throughout their admission (195.3 min vs 38.7 min, MD 157 min, 95% CI 0.9–312.3 min, p = 0.05). There was insufficient power to demonstrate statistical significance in functional outcomes, but a trend towards improved functional outcomes was observed in the intervention group. Conclusion An app-based exercise program increases activity levels, is feasible and is a safe intervention with the potential to improve functional outcomes. This pilot study should be followed with a larger study powered to demonstrate functional effects with more participants having greater impairment. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR); trial number ACTRN12617000817347. This study was retrospectively registered (registration date 05/06/2017)

Clinical physiotherapists had both positive and negative perceptions about delivering two different interventions in a clinical trial : a mixed methods study

Question: What are clinical physiotherapists' perceptions about delivering two interventions during a randomised trial: the MOBILISE trial? Design: Mixed methods study using semi-structured interviews involving closed- and open-ended questions. Participants: Thirteen physiotherapists involved in delivering the intervention for the trial. Results: All thirteen physiotherapists (100%) had a preference for their patients to get one of the interventions, mostly dependent on the individual patient. Most were frustrated if their patients were not allocated to their preferred intervention but 62% were satisfied with the intervention they delivered and 100% would be happy to be involved in future research. Two significant themes emerged from the open-ended data: that there were both positive and negative aspects of being involved in the trial. The positive aspects included the trial's value as a way of participating in research and as a way of providing evidence for practice. The negative aspects were that the design of the trial was not always reflective of usual clinical practice and the trial's impact on departments, therapists and patients. Conclusion: Clinical physiotherapists had both positive and negative perceptions about delivering two different interventions in a clinical trial. However, they were all interested in participating in future research, suggesting that the positive aspects outweighed the negative.6 page(s

Bobath therapy is inferior to task-specific training and not superior to other interventions in improving lower limb activities after stroke : A systematic review

Question In adults with stroke, does Bobath therapy improve lower limb activity performance, strength or co-ordination when compared with no intervention or another intervention? Design Systematic review of randomised trials with meta-analyses. Participants Adults after stroke. Intervention Bobath therapy compared with another intervention or no intervention. Outcome measures Lower limb activity performance (eg, sit to stand, walking, balance), lower limb strength and lower limb co-ordination. Trial quality was assessed using the PEDro scale. Results Twenty-two trials were included in the review and 17 in the meta-analyses. The methodological quality of the trials varied, with PEDro scale scores ranging from 2 to 8 out of 10. No trials compared Bobath therapy to no intervention. Meta-analyses estimated the effect of Bobath therapy on lower limb activities compared with other interventions, including: task-specific training (nine trials), combined interventions (four trials), proprioceptive neuromuscular facilitation (one trial) and strength training (two trials). The pooled data indicated that task-specific training has a moderately greater benefit on lower limb activities than Bobath therapy (SMD 0.48), although the true magnitude of the benefit may be substantially larger or smaller than this estimate (95% CI 0.01 to 0.95). Bobath therapy did not clearly improve lower limb activities more than a combined intervention (SMD −0.06, 95% CI −0.73 to 0.61) or strength training (SMD 0.35, 95% CI −0.37 to 1.08). In one study, Bobath therapy was more effective than proprioceptive neuromuscular facilitation for improving standing balance (SMD −1.40, 95% CI −1.92 to −0.88), but these interventions did not differ on any other outcomes. Bobath therapy did not improve strength or co-ordination more than other interventions. Conclusions Bobath therapy was inferior to task-specific training and not superior to other interventions, with the exception of proprioceptive neuromuscular facilitation. Prioritising Bobath therapy over other interventions is not supported by current evidence. Registration PROSPERO CRD42019112451