Factors Influencing the Delivery of Intensive Rehabilitation in Stroke: Patient Perceptions Versus Rehabilitation Therapist Perceptions

Background Despite increasing evidence on intensive task-specific practice and aerobic exercise in stroke rehabilitation, implementation remains difficult. The factors influencing implementation have been explored from therapists’ perspectives; however, despite an increased emphasis on patient involvement in research, patients’ perceptions have not yet been investigated. Objective The study aimed to investigate factors influencing implementation of higher intensity activity in people with stroke and to compare this with therapists’ perspectives. Design The design was a cross-sectional qualitative study. Methods The study used semi-structured interviews with people with stroke who were part of a randomized clinical trial, the Determining Optimal post-Stroke Exercise (DOSE) study, which delivered a higher intensity intervention. An interview guide was developed and data analyzed using implementation frameworks. Factors emerging from people with stroke were compared and contrasted to factors perceived by rehabilitation therapists. Results Ten people with stroke were interviewed before data saturation was reached. Participants had a positive attitude regarding working hard, and were satisfied with the graded exercise test, high intensity intervention, and the feedback monitoring devices. Therapists and patients had contrasting perceptions about their beliefs of intensive exercise and the content of the intervention, with therapists more focused on the methods and patients more focused on the personal interactions stemming from the therapeutic relationship. Conclusions People with stroke perceived no barriers regarding the implementation of higher intensity rehabilitation in practice and were positive towards working at more intense levels. Contrastingly, from the therapists’ perspective, therapists’ beliefs about quality of movement and issues around staffing and resources were perceived to be barriers. In addition, therapists and people with stroke perceived the contents of the intervention differently, highlighting the importance of involving patients and clinicians in the development and evaluation of rehabilitation interventions

Delivering intensive rehabilitation in stroke: factors influencing implementation

Background The evidence-base for stroke rehabilitation recommends intensive and repetitive task-specific practice, as well as aerobic exercise. However, translating these evidence-based interventions from research into clinical practice remains a major challenge. Objective To investigate factors influencing implementation of higher intensity activity in stroke rehabilitation settings Design A cross-sectional qualitative study. Methods Semi-structured interviews with rehabilitation therapists who had experience of delivering a higher intensity intervention as part of a clinical trial (DOSE), from four sites, across two provinces, in Canada. An interview guide was developed and data analysed using implementation frameworks. Results Fifteen therapists were interviewed before data saturation was reached. Therapists and patients generally had positive experiences regarding high intensity interventions. However, therapists felt they would adapt the protocol to accommodate their beliefs about ensuring movement quality. The requirement for all patients to have a graded exercise test, and the use of sensors, e.g. heart rate monitors, gave therapists confidence to push patients harder than they normally would. Paradoxically, a system that enables routine graded exercise testing, and the availability of staff and equipment contribute challenges for implementation in everyday practice. Conclusions Even therapists involved in delivering a high intensity intervention as part of a trial wanted to adapt it for clinical practice. Hence it is imperative that researchers are explicit regarding key intervention components and what can be adapted to help ensure implementation fidelity. Changes in therapist’s beliefs and system level changes (staffing and resources) are likely to be required to facilitate higher intensity rehabilitation in practice

Higher intensity walking improves global cognition during inpatient rehabilitation: A secondary analysis of a randomized control trial

Cognitive deficits are common poststroke. Cognitive rehabilitation is typically used to improve cognitive deficits. It is unknown whether higher doses of exercise to promote motor recovery influence cognitive outcomes. Our recent trial, Determining Optimal Post-Stroke Exercise (DOSE), shows more than double the steps and aerobic minutes can be achieved during inpatient rehabilitation versus usual care, and translates to improved long-term walking outcomes. Thus, the secondary analysis aim was to determine the effect of the DOSE protocol on cognitive outcomes over 1-year poststroke. The DOSE protocol progressively increased step number and aerobic minutes during inpatient stroke rehabilitation over 20 sessions. The Montreal Cognitive Assessment (MoCA), Digit Symbol Substitution Test (DSST), and Trail Making Test B were completed at baseline, post-intervention, and 6- and 12-months poststroke, administered using standardized guidelines. Using the DOSE data, we used mixed-effect spline regression to model participants\u27 trajectories of cognitive recovery, controlling for relevant covariates. Participants (Usual Car

Blood pressure trajectory of inpatient stroke rehabilitation patients from the Determining Optimal Post-Stroke Exercise (DOSE) trial over the first 12 months post-stroke

BackgroundHigh blood pressure (BP) is the primary risk factor for recurrent strokes. Despite established clinical guidelines, some stroke survivors exhibit uncontrolled BP over the first 12 months post-stroke. Furthermore, research on BP trajectories in stroke survivors admitted to inpatient rehabilitation hospitals is limited. Exercise is recommended to reduce BP after stroke. However, the effect of high repetition gait training at aerobic intensities (>40% heart rate reserve; HRR) during inpatient rehabilitation on BP is unclear. We aimed to determine the effect of an aerobic gait training intervention on BP trajectory over the first 12 months post-stroke.MethodsThis is a secondary analysis of the Determining Optimal Post-Stroke Exercise (DOSE) trial. Participants with stroke admitted to inpatient rehabilitation hospitals were recruited and randomized to usual care (n = 24), DOSE1 (n = 25; >2,000 steps, 40–60% HRR for >30 min/session, 20 sessions over 4 weeks), or DOSE2 (n = 25; additional DOSE1 session/day) groups. Resting BP [systolic (SBP) and diastolic (DBP)] was measured at baseline (inpatient rehabilitation admission), post-intervention (near inpatient discharge), 6- and 12-month post-stroke. Linear mixed-effects models were used to examine the effects of group and time (weeks post-stroke) on SBP, DBP and hypertension (≥140/90 mmHg; ≥130/80 mmHg, if diabetic), controlling for age, stroke type, and baseline history of hypertension.ResultsNo effect of intervention group on SBP, DBP, or hypertension was observed. BP increased from baseline to 12-month post-stroke for SBP (from [mean ± standard deviation] 121.8 ± 15.0 to 131.8 ± 17.8 mmHg) and for DBP (74.4 ± 9.8 to 78.5 ± 10.1 mmHg). The proportion of hypertensive participants increased from 20.8% (n = 15/72) to 32.8% (n = 19/58). These increases in BP were statistically significant: an effect [estimation (95%CI), value of p] of time was observed on SBP [0.19 (0.12–0.26) mmHg/week, p < 0.001], DBP [0.09 (0.05–0.14) mmHg/week, p < 0.001], and hypertension [OR (95%CI): 1.03 (1.01–1.05), p = 0.010]. A baseline history of hypertension was associated with higher SBP by 13.45 (8.73–18.17) mmHg, higher DBP by 5.57 (2.02–9.12) mmHg, and 42.22 (6.60–270.08) times the odds of being hypertensive at each timepoint, compared to those without.ConclusionBlood pressure increased after inpatient rehabilitation over the first 12 months post-stroke, especially among those with a history of hypertension. The 4-week aerobic gait training intervention did not influence this trajectory

Implementation of increased physical therapy intensity for improving walking after stroke: Walk 'n Watch protocol for a multi-site stepped-wedge cluster randomized controlled trial

Clinical practice guidelines support structured, progressive protocols for improving walking after stroke. Yet, practice is slow to change, evidenced by the little amount of walking activity in stroke rehabilitation units. Our recent study (n=75) found that a structured, progressive protocol integrated with typical daily physical therapy improved walking and quality of life measures over usual care. Research therapists progressed the intensity of exercise by using heart rate and step counters worn by the participants with stroke during therapy. To have the greatest impact, our next step is to undertake an implementation trial to change practice across stroke units where we enable the entire unit to use the protocol as part of standard of care. What is the effect of introducing structured, progressive exercise (termed the Walk 'n Watch protocol) to standard of care on the primary outcome of walking in adult participants with stroke over the hospital inpatient rehabilitation period? Secondary outcomes will be evaluated and include quality of life.Methods and sample size estimates: This national, multisite clinical trial will randomize 12 sites using a stepped-wedge design where each site will be randomized to deliver Usual Care initially for 4, 8, 12 or 16-months (three sites for each duration). Then, each site will switch to the Walk 'n Watch phase for the remaining duration of a total 20-month enrolment period. Each participant will be exposed to only one of Usual Care or Walk 'n Watch. The trial will enrol a total of 195 participants with stroke to achieve a power of 80% with a Type I error rate of 5%, allowing for 20% dropout. Participants will be medically stable adults post-stroke and able to take 5 steps with a maximum physical assistance from one therapist. The Walk 'n Watch protocol focuses on completing a minimum of 30-minutes of weight-bearing, walking-related activities (at the physical therapists' discretion) that progressively increases in intensity informed by activity trackers measuring heart rate and step number.Study outcome(s): The primary outcome will be the change in walking endurance, measured by the Six-Minute Walk Test, from Baseline (T1) to 4-weeks (T2). This change will be compared across Usual Care and Walk 'n Watch phases using a linear mixed-effects model. Additional physical, cognitive, and quality of life outcomes will be measured at T1, T2, and 12-months post-stroke (T3) by a blinded assessor. The implementation stepped-wedge cluster-randomized trial enables the protocol to be tested under real-world conditions, involving all clinicians on the unit. It will result in all sites and all clinicians on the unit to gain expertise in protocol delivery. Hence, a deliberate outcome of the trial is facilitating changes in best practice to improve outcomes for participants with stroke in the trial, and for the many participants with stroke admitted after the trial ends

Methods for specifying the target difference in a randomised controlled trial : the Difference ELicitation in TriAls (DELTA) systematic review

Peer reviewedPublisher PD

Optimizing stroke rehabilitation : determining the therapeutic dose and intensity to maximize walking and functional recovery early after stroke

Background: Stroke is a serious health concern and a leading cause of disability worldwide. Up to two-thirds of stroke survivors will experience physical and/or cognitive deficits thus requiring ongoing rehabilitation. Determining the appropriate exercise intensity and dose to optimize recovery is one of the top priorities in stroke rehabilitation research. Purpose: To determine the feasibility and efficacy of higher exercise intensity and dose on walking and functional recovery, cognition, and quality of life in the early phase after stroke. Methods: Multiple studies were conducted to examine how exercise intensity and dose may influence recovery early after stroke. Two studies were completed to identify and assess the precision of a readily available monitoring device to accurately record step count, a measure of walking dose. The results of these studies contributed to the design and implementation of an ongoing national, multi-site, randomized clinical trial occurring during inpatient stroke rehabilitation, to investigate how higher exercise intensity and dose impact walking and functional recovery, cognition, and quality of life. Results: From the two studies examining measurement of walking dose, The Fitbit One was identified as a monitoring device that could accurately assess step count (< 10% error), when positioned at the ankle, with individuals post-stroke that had a walking speed greater than 0.4m/s. Preliminary data from the ongoing multi-site randomized clinical trial revealed that individuals who received a higher exercise intensity and dose within their inpatient stroke rehabilitation were able to walk a clinically meaningful longer distance on the six-minute walk test and had a higher perception of their health status compared to those individuals that received usual care physical therapy. Conclusions: Higher exercise intensity and dose can be accurately measured and safely delivered during inpatient stroke rehabilitation. Furthermore, although preliminary results suggest that higher exercise intensity and dose may be effective at improving walking recovery and quality of life in the early phase after stroke, further analysis will need to be conducted when the complete study population is recruited to verify these findings.Medicine, Faculty ofGraduat

Multiscale modeling in the clinic: diseases of the brain and nervous system

Abstract Computational neuroscience is a field that traces its origins to the efforts of Hodgkin and Huxley, who pioneered quantitative analysis of electrical activity in the nervous system. While also continuing as an independent field, computational neuroscience has combined with computational systems biology, and neural multiscale modeling arose as one offshoot. This consolidation has added electrical, graphical, dynamical system, learning theory, artificial intelligence and neural network viewpoints with the microscale of cellular biology (neuronal and glial), mesoscales of vascular, immunological and neuronal networks, on up to macroscales of cognition and behavior. The complexity of linkages that produces pathophysiology in neurological, neurosurgical and psychiatric disease will require multiscale modeling to provide understanding that exceeds what is possible with statistical analysis or highly simplified models: how to bring together pharmacotherapeutics with neurostimulation, how to personalize therapies, how to combine novel therapies with neurorehabilitation, how to interlace periodic diagnostic updates with frequent reevaluation of therapy, how to understand a physical disease that manifests as a disease of the mind. Multiscale modeling will also help to extend the usefulness of animal models of human diseases in neuroscience, where the disconnects between clinical and animal phenomenology are particularly pronounced. Here we cover areas of particular interest for clinical application of these new modeling neurotechnologies, including epilepsy, traumatic brain injury, ischemic disease, neurorehabilitation, drug addiction, schizophrenia and neurostimulation