Reply to Morone, G.; Giansanti, D. Comment on “Anwer et al. Rehabilitation of Upper Limb Motor Impairment in Stroke: A Narrative Review on the Prevalence, Risk Factors, and Economic Statistics of Stroke and State of the Art Therapies. Healthcare 2022, 10, 190”

© 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).Peer reviewedFinal Published versio

Rehabilitation of Upper Limb Motor Impairment in Stroke: A Narrative Review on the Prevalence, Risk Factors, and Economic Statistics of Stroke and State of the Art Therapies

This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://creativecommons.org/licenses/by/4.0/Stroke has been one of the leading causes of disability worldwide and is still a social health issue. Keeping in view the importance of physical rehabilitation of stroke patients, an analytical review has been compiled in which different therapies have been reviewed for their effectiveness, such as functional electric stimulation (FES), noninvasive brain stimulation (NIBS) including transcranial direct current stimulation (t-DCS) and transcranial magnetic stimulation (t-MS), invasive epidural cortical stimulation, virtual reality (VR) rehabilitation, task-oriented therapy, robot-assisted training, tele rehabilitation, and cerebral plasticity for the rehabilitation of upper extremity motor impairment. New therapeutic rehabilitation techniques are also being investigated, such as VR. This literature review mainly focuses on the randomized controlled studies, reviews, and statistical meta-analyses associated with motor rehabilitation after stroke. Moreover, with the increasing prevalence rate and the adverse socio-economic consequences of stroke, a statistical analysis covering its economic factors such as treatment, medication and post-stroke care services, and risk factors (modifiable and non-modifiable) have also been discussed. This review suggests that if the prevalence rate of the disease remains persistent, a considerable increase in the stroke population is expected by 2025, causing a substantial economic burden on society, as the survival rate of stroke is high compared to other diseases. Compared to all the other therapies, VR has now emerged as the modern approach towards rehabilitation motor activity of impaired limbs. A range of randomized controlled studies and experimental trials were reviewed to analyse the effectiveness of VR as a rehabilitative treatment with considerable satisfactory results. However, more clinical controlled trials are required to establish a strong evidence base for VR to be widely accepted as a preferred rehabilitation therapy for stroke.Peer reviewe

Community Integration After Traumatic Brain Injury: Conceptualisation and Measurement

Community integration remains the ultimate goal of rehabilitation for persons affected by Traumatic Brain Injury (TBI). A number of studies have presented different definitions of community integration over the past few decades, however a standardised conceptual model of community integration has not yet been articulated. Varying definitions and a lack of agreement regarding the theoretical underpinnings of the construct community integration, has presented problems for both the measurement of community integration and its use when implementing and evaluating rehabilitation interventions aimed at improving community integration outcomes. The key aims of this research were to gain a more in-depth understanding of the concept of community integration in order to develop a comprehensive conceptual framework of community integration and inform the development of a conceptually sound, robust, culturally relevant, and contemporary measure of community integration for people with TBI. The thesis includes a concept analysis to explore how community integration has been conceptualised in the healthcare literature pertaining to brain injury, followed by a measurement review to identify a widely used outcome measure of community integration, with acceptable psychometric properties. The empirical work used a mixed methods approach comprising of three studies which endeavoured to examine and enhance psychometric properties of the most prominent measure: the Community Integration Questionnaire (CIQ) and an updated version of the measure made available during the course of the research, known as the Community Integration Questionnaire-Revised (CIQ-R). The measure was evaluated using two quantitative studies. One study was based on a longitudinal TBI cohort and the other on cross-sectional TBI data, including 117 individuals with TBI for the CIQ-R that was collected specifically as a part of this doctoral research. These studies applied Classical Test Theory methods and Rasch analysis methods to examine psychometric properties of the CIQ and CIQ-R and enhance functioning of their items and precision of the scale. A qualitative study using a ‘concurrent nested approach’ was conducted with 12 people with TBI, to examine the content and appropriateness of the CIQ-R. Several findings from this research challenge and/or enhance existing knowledge on the conceptualisation and measurement of community integration. One of the key contributions was the development of a more comprehensive definition and conceptual framework of community integration. The proposed definition describes community integration as ‘being independent and having a sense of belonging within the community; having a place to live; being socially and psychologically integrated into the community; and involved in meaningful occupational activity’. The CIQ-R was found to be providing only limited coverage of the multi-dimensional construct, community integration. The quantitative work determined that the CIQ-R has sound psychometric properties while Rasch analysis identified some non-functioning items and provided a conversion algorithm to transform ordinal responses to interval-level data. The qualitative findings revealed that the content of the CIQ-R was mostly appropriate. However, the scale requires several amendments to enhance its relevance, comprehensiveness and interpretability for people with TBI. This research makes significant contributions to the field of community integration for people with TBI in terms of conceptual clarity and raises an overarching issue that self-report measures assessing constructs such as community integration, return to work, psychosocial reintegration may not always provide very useful information when measured objectively. The study also depicted the process of outcome measure selection in research or clinical settings and alluded to advanced methods that can be applied in future practice

The Brain Injury Screening Tool (BIST): Tool development, factor structure and validity.

Currently health care pathways (the combination and order of services that a patient receives to manage their injury) following a mild traumatic brain injury vary considerably. Some clinicians lack confidence in injury recognition, management and knowing when to refer. A clinical expert group developed the Brain Injury Screening Tool (BIST) to provide guidance on health care pathways based on clinical indicators of poor recovery. The tool aims to facilitate access to specialist services (if required) to improve longer term prognosis. The tool was developed using a three-step process including: 1) domain mapping; 2) item development and 3) item testing and review. An online retrospective survey of 114 adults (>16 years) who had experienced a mild brain injury in the past 10 years was used to determine the initial psychometric properties of the 15-item symptom scale of the BIST. Participants were randomised to complete the BIST and one of two existing symptom scales; the Rivermead Post-concussion Symptom Questionnaire (RPQ) or the Sports Concussion Assessment Test (SCAT-5) symptom scale to determine concurrent validity. Participant responses to the BIST symptom scale items were used to determine scale reliability using Cronbach's alpha. A principal components analysis explored the underlying factor structure. Spearman's correlation coefficients determined concurrent validity with the RPQ and SCAT-5 symptom scales. The 15 items were found to require a reading age of 6-8 years old using readability statistics. High concurrent validity was shown against the RPQ (r = 0.91) and SCAT-5 (r = 0.90). The BIST total symptom scale (α = 0.94) and the three factors identified demonstrated excellent internal consistency: physical/emotional (α = 0.90), cognitive (α = 0.92) and vestibular-ocular (α = 0.80). This study provides evidence to support the utility, internal consistency, factor structure and concurrent validity of the BIST. Further research is warranted to determine the utility of the BIST scoring criteria and responsiveness to change in patients