Development and preliminary evaluation of a novel low cost VR-based upper limb stroke rehabilitation platform using Wii technology.

Abstract Purpose: This paper proposes a novel system (using the Nintendo Wii remote) that offers customised, non-immersive, virtual reality-based, upper-limb stroke rehabilitation and reports on promising preliminary findings with stroke survivors. Method: The system novelty lies in the high accuracy of the full kinematic tracking of the upper limb movement in real-time, offering strong personal connection between the stroke survivor and a virtual character when executing therapist prescribed adjustable exercises/games. It allows the therapist to monitor patient performance and to individually calibrate the system in terms of range of movement, speed and duration. Results: The system was tested for acceptability with three stroke survivors with differing levels of disability. Participants reported an overwhelming connection with the system and avatar. A two-week, single case study with a long-term stroke survivor showed positive changes in all four outcome measures employed, with the participant reporting better wrist control and greater functional use. Activities, which were deemed too challenging or too easy were associated with lower scores of enjoyment/motivation, highlighting the need for activities to be individually calibrated. Conclusions: Given the preliminary findings, it would be beneficial to extend the case study in terms of duration and participants and to conduct an acceptability and feasibility study with community dwelling survivors. Implications for Rehabilitation Low-cost, off-the-shelf game sensors, such as the Nintendo Wii remote, are acceptable by stroke survivors as an add-on to upper limb stroke rehabilitation but have to be bespoked to provide high-fidelity and real-time kinematic tracking of the arm movement. Providing therapists with real-time and remote monitoring of the quality of the movement and not just the amount of practice, is imperative and most critical for getting a better understanding of each patient and administering the right amount and type of exercise. The ability to translate therapeutic arm movement into individually calibrated exercises and games, allows accommodation of the wide range of movement difficulties seen after stroke and the ability to adjust these activities (in terms of speed, range of movement and duration) will aid motivation and adherence - key issues in rehabilitation. With increasing pressures on resources and the move to more community-based rehabilitation, the proposed system has the potential for promoting the intensity of practice necessary for recovery in both community and acute settings.The National Health Service (NHS) London Regional Innovation Fund

Inside the black box : creating excellence in stroke care through a community of practice.

This thesis looked inside the black box of stroke care, so called because its contents are not clearly defined. This case study of success illustrated how a new inpatient stroke unit (SU) was created in an inner London teaching hospital, transforming treatment for patients with stroke. Whilst it is known that good stroke care results in improved patient outcomes, it is not fully understood how or why. As stroke is the second major cause of death in adults worldwide, and a leading cause of adult disability in the UK, it is essential more is known about how evidence translates into practical knowledge for use in mainstream practice. This action research study, through the systematic documentation and evaluation of the processes and outcomes, has unpacked and illuminated factors that enabled development of success, and provides the first empirical account of its kind. This study adds to the knowledge of knowing how. A variety of qualitative and quantitative methods were used to generate data between January 2001 and November 2002. Findings were analysed using Immersion I Crystallization and descriptive statistics. When the black box of stroke unit care was opened, four key interrelated themes emerged from the process findings: building a multidisciplinary stroke team; developing practice based knowledge and skills in stroke; valuing the central role of the nurse in stroke care and creating an organisational climate for supporting improvement. Analyses of findings suggest the creation of excellence in stroke care was linked to the development of a Community of Practice (CoP), which combines three elements; domain, community and practice, into a conceptual framework of learning that fundamentally places the acquisition of knowledge into a social process of learning. Whilst improvement initiatives have recently been linked in the literature to CoPs, no guidance is available on how this should be done. This thesis makes an original contribution to the body of knowledge by providing the first empirical evidence of not only on how a CoP was created, but shows how it developed into a functional multidisciplinary CoP, a concept identified in the literature as difficult to accomplish. In concluding, issues related to practice, research, education and policy are raised for future considerations

From dictatorship to a reluctant democracy: Stroke therapists talking about self-management

This article is made available through the Brunel Open Access Publishing Fund.Purpose: Self-management is being increasingly promoted within chronic conditions including stroke. Concerns have been raised regarding professional ownership of some programmes, yet little is known of the professional’s experience. This paper aims to present the views of trained therapists about the utility of a specific self-management approach in stroke rehabilitation. Method: Eleven stroke therapists trained in the self-management approach participated in semi-structured interviews. These were audio recorded, transcribed verbatim and analysed thematically. Results: Two overriding themes emerged. The first was the sense that in normal practice therapists act as ‘‘benign dictators’’, committed to help their patients, but most comfortable when they, the professional, are in control. Following the adoption of the self-management approach therapists challenged themselves to empower stroke survivors to take control of their own recovery. However, therapists had to confront many internal and external challenges in this transition of power resulting in the promotion of a somewhat ‘‘reluctant democracy’’. Conclusions: This study illustrates that stroke therapists desire a more participatory approach to rehabilitation. However, obstacles challenged the successful delivery of this goal. If self-management is an appropriate model to develop in post stroke pathways, then serious consideration must be given to how and if these obstacles can be overcome

Levelling the playing field: Exploring inequalities and exclusions with a community‐based football league for people with experience of mental distress

Introduction Sport workforce strategy in the United Kingdom (UK) has identified the occupational therapy profession as being ideally positioned to contribute to public health agendas relating to tackling physical inactivity amongst marginalised populations, such as disabled people and people with experience of mental distress. However, a robust understanding of the enablers, restrictions, and exclusions such groups encounter when seeking to participate in sport and physical activity is currently lacking. Methods This study aimed to gain an in-depth understanding of the different ways people with experience of mental distress talked about their participation in a community-based football league in England, in the UK. Nine people took part in this strand of a larger participatory action research (PAR) study, which used go-along interviews as the method of data collection. In alignment with PAR seeking to address power imbalances, the data from the go-along interviews were analysed through a Foucauldian lens using a collaboratively produced analytic framework. Findings Participants constructed the community-based football league as fostering feelings of purpose and belonging, against a backdrop of them describing experiencing stigma and exclusion when seeking to be active in their wider communities. They used the concept of occupational marginalisation to further interpret their situation. Conclusion Understanding why and how people participate in football extends beyond seeing it as an individual exercise to shared social lives and occupations. With this perspective, occupational therapists could address occupational marginalisation in partnership with community sports organisations, collaborating for wider social change beyond specialist services

Enhanced clarity and holism: The outcome of implementing the ICF with an acute stroke multidisciplinary team in England

This article is made available through the Brunel Open Access Publishing Fund.Purpose: Although it is recommended that the ICF (International Classification of Functioning, Disability and Health) should be implemented to aid communication within multidisciplinary stroke services, there is no empirical evidence to demonstrate the outcomes of such implementation. Working with one stroke service, this project aimed to address this gap and sought to evaluate the outcomes of implementing an ICF-based clinical tool into practice. Method: Using an action research framework with mixed methods, data were collected from individual interviews, a focus group, questionnaires, email communications, minutes from relevant meetings and field notes. Thematic analysis was undertaken, using immersion and crystallisation, to define overall themes. Descriptive statistics were used to analyse quantitative data. Data from both sources were combined to create key findings. Results: Three findings were determined from the data analysis. The ICF (1) fosters communication within and beyond the multidisciplinary stroke team; (2) promotes holistic thinking; and (3) helps to clarify team roles. Conclusions: The ICF enhanced clarity of communication and team roles within the acute stroke multidisciplinary team as well as with other clinicians, patients and their relatives. In addition, the ICF challenged stroke clinicians to think holistically, thereby appropriately extending their domain of concern beyond their traditional remit. Implications for Rehabilitation: (1) The ICF is a globally accepted framework to describe functioning and is in use in a variety of clinical settings. Yet, the outcomes of using it in clinical practice have yet to be fully explored. (2) This study found that the ICF enhanced clarity of communication and team roles within an acute stroke multidisciplinary team and to others beyond the team, including clinicians, patients and their relatives. (3) Using the ICF also challenged clinicians to think holistically about patient needs following a stroke.The Elizabeth Casson Trus

Doing together: reflections on facilitating the co-production of participatory action research with marginalised populations

Recognising the limited literature detailing the practical application of co-production principles and practices within sport, exercise and health research, critical reflections on co-production principles and practice are shared here, drawing on two participatory action research (PAR) projects in the United Kingdom (UK). Co-production and PAR are distinguished, and their commonalities discussed. Both projects were facilitated by occupational therapists and concerned with health inequities and social justice. The Voices for Inclusive Activity project brought disabled people together online to explore more accessible and inclusive approaches to evaluate disability sport and physical activity. The Positive Mental Attitude project took place with a community-based football league for people with experience of mental distress and explored the nature and value of participation. Both projects involved researching with people who are often excluded from research. Addressing power imbalances can function to engage marginalised people in processes of knowledge production and enable social justice. Co-production offers useful principles that are democratic, inclusive, collaborative, and participatory, but the process is not straightforward. The reflections within this paper focus on the challenges and opportunities the first and second authors faced as facilitators of co-produced research. Participant and co-researcher quotes reveal how participatory methods and approaches address gaps in experiential knowledge of exclusion and marginalisation. The potential for co-produced research to influence policy and practice is outlined

Developing theory and practice: Creation of a Community of Practice through Action Research produced excellence in stroke care

The study was funded by a grant from the Special Trustees of the Trust. Copyright @ 2010 Informa UK, Ltd.This article has been made available through the Brunel Open Access Publishing Fund.This article has been made available through the Brunel Open Access Publishing Fund.Much emphasis is placed on expert knowledge like evidence-based stroke guidelines, with insufficient attention paid to processes required to translate this into delivery of everyday good care. This paper highlights the worth of creating a Community of Practice (CoP) as a means to achieve this. Drawing on findings from a study conducted in 2000/2002 of processes involved in establishing a nationally lauded high quality Stroke Unit, it demonstrates how successful development of a new service was linked to creation of a CoP. Recent literature suggests CoPs have a key in implementing evidence-based practice; this study supports this claim whilst revealing for the first time the practical knowledge and skills required to develop this style of working. Findings indicate that participatory and democratic characteristics of Action Research are congruent with the collaborative approach required for developing a CoP. The study is an exemplar of how practitioner researchers can capture learning from changing practice, thus contributing to evidence-based healthcare with theoretical and practical knowledge. Findings are relevant to those developing stroke services globally but also to those interested in evidencebased practice.This article is available through the Brunel Open Access Publishing Fund

Rehabilitation using virtual gaming for Hospital and hOMe-Based training for the Upper limb post Stroke (RHOMBUS II): protocol of a feasibility randomised controlled trial

Introduction Upper limb (UL) rehabilitation is most effective early after stroke, with higher doses leading to improved outcomes. For the stroke survivor, the repetition may be monotonous. For clinicians, providing a clinically meaningful level of input can be challenging. As such, time spent engaged in UL activity among subacute stroke survivors remains inadequate. Opportunities for the stroke survivor to engage with UL rehabilitation in a safe, accessible and engaging way are essential to improving UL outcomes following stroke. The NeuroBall is a non-immersive virtual reality (VR) digital system designed for stroke rehabilitation, specifically for the arm and hand. The aim of the Rehabilitation using virtual gaming for Hospital and hOMe-Based training for the Upper limb post Stroke study is to determine the safety, feasibility and acceptability of the NeuroBall as a rehabilitation intervention for the UL in subacute stroke. Methods and analysis A feasibility randomised controlled trial (RCT) will compare the NeuroBall plus usual care with usual care only, in supporting UL rehabilitation over 7 weeks. Twenty-four participants in the subacute poststroke phase will be recruited while on the inpatient or early supported discharge (ESD) stroke pathway. Sixteen participants will be randomised to the intervention group and eight to the control group. Outcomes assessed at baseline and 7 weeks include gross level of disability, arm function, spasticity, pain, fatigue and quality of life (QoL). Safety will be assessed by recording adverse events and using pain, spasticity and fatigue scores. A parallel process evaluation will assess feasibility and acceptability of the intervention. Feasibility will also be determined by assessing fidelity to the intervention. Postintervention, semistructured interviews will be used to explore acceptability with 12 participants from the intervention group, four from the usual care group and with up to nine staff involved in delivering the intervention. Ethics and dissemination This trial has ethical approval from Brunel University London’s Research Ethics Committee 25257-NHS-Oct/2020-28121-2 and the Wales Research Ethics Committee 5 Bangor (Health and Care Research Wales) REC ref: 20/WA/0347. The study is sponsored by Brunel University London. Contact: Dr Derek Healy, Chair, University Research Ethics committee ([email protected]). Trial results will be submitted for publication in peer-reviewed journals, presented at national and international conferences and distributed to people with stroke. Trial registration number ISRCTN11440079; Pre-results

Management of the ataxias : towards best clinical practice

This document aims to provide recommendations for healthcare professionals on the diagnosis and management of people with progressive ataxia. The progressive ataxias are rare neurological conditions, and are often poorly understood by healthcare professionals. Diagnosis has generally been a long process because of the rarity and complexity of the different ataxias1. In addition, many healthcare professionals are unsure how best to manage the conditions and there is sometimes a feeling that little can be done for these patients1,2 Although there are no disease-modifying treatments for the majority of the progressive ataxias, there are many aspects of the conditions that are treatable and it is thus important that this is recognised by the relevant healthcare professionals. The diagnosis and management of the few treatable causes is also of paramount importance. All this highlights the importance of producing these guidelines: in order to increase awareness and understanding of these conditions, and lead to their improved diagnosis and management. With new developments in genetic technologies and the discovery of more genes, diagnosis is improving and has great scope to continue to do so. In addition, research is advancing and many human trials to test medications are taking place, making us more optimistic that disease-modifying treatments will be found for the progressive ataxias

Synthesising practice guidelines for the development of community-based exercise programmes after stroke

This is a freely-available open access publication. Please cite the published version which is available via the DOI link in this record.Multiple guidelines are often available to inform practice in complex interventions. Guidance implementation may be facilitated if it is tailored to particular clinical issues and contexts. It should also aim to specify all elements of interventions that may mediate and modify effectiveness, including both their content and delivery. We conducted a focused synthesis of recommendations from stroke practice guidelines to produce a structured and comprehensive account to facilitate the development of community-based exercise programmes after stroke.National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsul