Stroke survivors' views on their priorities for upper-limb recovery and the availability of therapy services after stroke: a longitudinal, phenomenological study.

PURPOSE: Forty percent of stroke survivors have a persistent lack of function in the upper limb, causing significant disability. Most personal-care tasks and meaningful activities require bi-manual function of both upper limbs. However, lower-limb mobility is often viewed as the priority in stroke services. Perspectives of stroke survivors on priorities for upper-limb recovery and therapy have not been investigated in detail. Therefore, this study aimed to explore their views. MATERIALS AND METHODS: Thirteen stroke survivors each engaged in up to four semi-structured interviews over 18 months. A phenomenological approach guided the research. RESULTS: Three themes were identified. Priorities change on coming home: recovery of walking is a priority early after stroke but upper-limb recovery becomes equally important over time, particularly once living at home. Limited therapy services: therapy has a short duration, prioritizes lower-limb mobility, and is short-lived in the community; people feel abandoned by services. Active partners in recovery: stroke survivors want intermittent access to review and advice so they can be active partners with therapists to manage their upper-limb recovery. CONCLUSION: Therapy services should recognize stroke survivors' changing priorities and work with them as active partners in upper-limb recovery. Intermittent access to review and advice should be included in service design.Implications for rehabilitationStroke survivors' priorities may change over time from recovery of walking toward upper-limb recovery.Post-stroke services can be perceived as insufficient to meet the needs of stroke survivors who want to participate actively in rehabilitation of their upper limb.Stroke survivors may prefer services that are more flexible to provide regular review of their progress, access to guidance and support to self-manage their recovery.

Interventions for perceptual disorders following stroke.

BACKGROUND: Perception is the ability to understand information from our senses. It allows us to experience and meaningfully interact with our environment. A stroke may impair perception in up to 70% of stroke survivors, leading to distress, increased dependence on others, and poorer quality of life. Interventions to address perceptual disorders may include assessment and screening, rehabilitation, non-invasive brain stimulation, pharmacological and surgical approaches. OBJECTIVES: To assess the effectiveness of interventions aimed at perceptual disorders after stroke compared to no intervention or control (placebo, standard care, attention control), on measures of performance in activities of daily living.  SEARCH METHODS: We searched the trials registers of the Cochrane Stroke Group, CENTRAL, MEDLINE, Embase, and three other databases to August 2021. We also searched trials and research registers, reference lists of studies, handsearched journals, and contacted authors. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of adult stroke survivors with perceptual disorders. We defined perception as the specific mental functions of recognising and interpreting sensory stimuli and included hearing, taste, touch, smell, somatosensation, and vision. Our definition of perception excluded visual field deficits, neglect/inattention, and pain. DATA COLLECTION AND ANALYSIS: One review author assessed titles, with two review authors independently screening abstracts and full-text articles for eligibility. One review author extracted, appraised, and entered data, which were checked by a second author. We assessed risk of bias (ROB) using the ROB-1 tool, and quality of evidence using GRADE.  A stakeholder group, comprising stroke survivors, carers, and healthcare professionals, was involved in this review update. MAIN RESULTS: We identified 18 eligible RCTs involving 541 participants. The trials addressed touch (three trials, 70 participants), somatosensory (seven trials, 196 participants) and visual perception disorders (seven trials, 225 participants), with one (50 participants) exploring mixed touch-somatosensory disorders. None addressed stroke-related hearing, taste, or smell perception disorders. All but one examined the effectiveness of rehabilitation interventions; the exception evaluated non-invasive brain stimulation. For our main comparison of active intervention versus no treatment or control, one trial reported our primary outcome of performance in activities of daily living (ADL):  Somatosensory disorders: one trial (24 participants) compared an intervention with a control intervention and reported an ADL measure.  Touch perception disorder: no trials measuring ADL compared an intervention with no treatment or with a control intervention.  Visual perception disorders: no trials measuring ADL compared an intervention with no treatment or control.  In addition, six trials reported ADL outcomes in a comparison of active intervention versus active intervention, relating to somatosensation (three trials), touch (one trial) and vision (two trials).   AUTHORS' CONCLUSIONS: Following a detailed, systematic search, we identified limited RCT evidence of the effectiveness of interventions for perceptual disorders following stroke. There is insufficient evidence to support or refute the suggestion that perceptual interventions are effective. More high-quality trials of interventions for perceptual disorders in stroke are needed. They should recruit sufficient participant numbers, include a 'usual care' comparison, and measure longer-term functional outcomes, at time points beyond the initial intervention period. People with impaired perception following a stroke should continue to receive neurorehabilitation according to clinical guidelines.

Nursing Mothers' Experiences of Musculoskeletal Pain Attributed to Poor Posture During Breastfeeding: A Mixed Methods Study.

Background: Breastfeeding has various benefits for infants and mothers. However, if not performed in the correct posture, prolonged breastfeeding could cause musculoskeletal-related symptoms such as shoulder, neck, and upper back pain. In Jordan, nursing mothers do not have access to a breastfeeding midwifery team, a breastfeeding dietician, or a breastfeeding nurse for advice and education. The primary aim of this study was to explore nursing mothers' experiences of breastfeeding-related musculoskeletal pain; secondary aims were to explore nursing mothers' awareness of recommended breastfeeding postures and their experience of education and advice about breastfeeding postures. Methods: A cross-sectional mixed methods study was conducted with nursing mothers in Jordan who have breastfed their babies for 6 months or more following normal delivery, using an online survey questionnaire and semi-structured interviews. Participants were recruited through general practitioner clinics. Results: Four hundred ninety-three nursing mothers submitted the online questionnaire, and 12 interviews were completed. Nursing mothers reported experiencing nonspecific pain in lower back, neck, shoulder, and hand, attributed to breastfeeding. Pain in these joints affected mood, sleep, working ability, and quality of life by limiting activities of daily living. Findings showed that the majority of Jordanian nursing mothers did not receive education about safe or optimal breastfeeding positioning from health professionals. Conclusions: Nursing mothers in Jordan are not receiving appropriate education or advice about optimal postures for breastfeeding and have reported experiencing musculoskeletal pain, attributed to breastfeeding, that interferes with activities of daily living and affects quality of life. Postural education and advice should be provided to nursing mothers to prevent or avoid development of musculoskeletal pain.

World guidelines for falls prevention and management for older adults: a global initiative.

BACKGROUND: falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present. OBJECTIVES: to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries. METHODS: a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting. RECOMMENDATIONS: all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations. CONCLUSIONS: the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

Effectiveness of Somatosensory Stimulation for the Lower Limb and Foot to Improve Balance and Gait after Stroke: A Systematic Review.

This systematic review's purpose was to evaluate the effectiveness of lower-limb and foot somatosensory stimulation to improve balance and gait post-stroke. PRISMA reporting guidelines were followed. Included studies: randomized controlled trials (RCTs), published in English with ethical approval statement. Studies of conditions other than stroke, functional electrical stimulation, and interventions eliciting muscle contraction, were excluded. AgeLine, AMED, CINAHL PLUS, EMBASE, EMCARE MEDLINE, PEDro, PsycARTICLES, PsycINFO, SPORTDiscus, Web of Science and Cochrane central register of controlled trials were searched from 1 January 2002 to 31 March 2022. Two authors independently screened results, extracted data and assessed study quality using Cochrane Risk of Bias 2 tool; 16 RCTs (n = 638) were included. Four studies showed a medium or large standardized between-group effect size (Cohen's d) in favor of somatosensory stimulation, in relation to: customized insoles (d = 0.527), taping (d = 0.687), and electrical stimulation (two studies: d = 0.690 and d = 1.984). Although limited by study quality and heterogeneity of interventions and outcomes, with only one study's results statistically significant, several interventions showed potential for benefit, exceeding the minimally important difference for gait speed. Further research with larger trials is required. This unfunded systematic review was registered with PROSPERO (number CRD42022321199).

Perceptual Disorders After Stroke: A Scoping Review of Interventions.

Perceptual disorders relating to hearing, smell, somatosensation, taste, touch, and vision commonly impair stroke survivors' ability to interpret sensory information, impacting on their ability to interact with the world. We aimed to identify and summarize the existing evidence for perceptual disorder interventions poststroke and identify evidence gaps. We searched 13 electronic databases including MEDLINE and Embase and Grey literature and performed citation tracking. Two authors independently applied a priori-defined selection criteria; studies involving stroke survivors with perceptual impairments and interventions addressing those impairments were included. We extracted data on study design, population, perceptual disorders, interventions, and outcomes. Data were tabulated and synthesized narratively. Stroke survivors, carers, and clinicians were involved in agreeing definitions and organizing and interpreting data. From 91 869 records, 80 studies were identified (888 adults and 5 children); participant numbers were small (median, 3.5; range, 1-80), with a broad range of stroke types and time points. Primarily focused on vision (34/80, 42.5%) and somatosensation (28/80; 35.0%), included studies were often case reports (36/80; 45.0%) or randomized controlled trials (22/80; 27.5%). Rehabilitation approaches (78/93; 83.9%), primarily aimed to restore function, and were delivered by clinicians (30/78; 38.5%) or technology (28/78; 35.9%; including robotic interventions for somatosensory disorders). Pharmacological (6/93; 6.5%) and noninvasive brain stimulation (7/93; 7.5%) approaches were also evident. Intervention delivery was poorly reported, but most were delivered in hospital settings (56/93; 60.2%). Study outcomes failed to assess the transfer of training to daily life. Interventions for stroke-related perceptual disorders are underresearched, particularly for pediatric populations. Evidence gaps include interventions for disorders of hearing, taste, touch, and smell perception. Future studies must involve key stakeholders and report this fully. Optimization of intervention design, evaluation, and reporting is required, to support the development of effective, acceptable, and implementable interventions. Registration: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019160270.

The mutual benefits of patient and public involvement in research: an example from a feasibility study (MoTaStim-Foot).

BACKGROUND: Patient and public involvement (PPI) in research has increased steadily over the last two decades and is now both expected and appropriately resourced by many funding bodies, including the National Institute for Health Research (NIHR). However, PPI in research occurs in many different capacities and numerous frameworks exist for reporting or appraising patient involvement activities. The aim of this article is to describe processes involving PPI contributions to an NIHR-funded mixed-methods feasibility study (MoTaStim-Foot). Details of PPI advisors' input, from initial identification and prioritisation of research ideas, to research delivery and dissemination, are discussed. METHODS: Extensive PPI for MoTaStim-Foot is reported, with consideration of Research Design Service (RDS) advice for PPI for research, involving identifying and prioritising: design; grant proposal development; undertaking/managing research; analysing and interpreting; dissemination; implementation; monitoring and evaluation. Two PPI workshops were undertaken; success in meeting UK standards for public involvement was audited against specific success criteria by two researchers, with discussion and consideration regarding how well our PPI achieved inclusive opportunities, working together, support and learning, governance, communications and impact. How PPI can be improved for future trials was also considered. Although the advantages of PPI for researchers were considered, the benefits for PPI advisors were also analysed. RESULTS: UK standards for public involvement were achieved, along with seven relevant research processes suggested by the RDS. PPI advisor contributions: informed study design; contributed to successful funding; enhanced trial delivery by informing participant information sheets and daily diaries; added value through undertaking note-taker roles in focus groups and helping to analyse focus group transcripts; and assisted in dissemination. However, benefits were mutual with PPI advisors reporting feeling valued and respected, a sense of pride with renewed confidence and purpose in life. CONCLUSIONS: Importance and value of PPI, to researchers and patient advisors, have been highlighted, reinforcing the benefits of working in partnership with PPI advisors. Trial registration ISRCTN 13676183; Central Portfolio Management System ID 30449. Registered 02/01/2015, https://www.isrctn.com/ISRCTN13676183 .

This article reports and analyses our public involvement in the research processes for a study funded by the National Institute for Health Research, the MoTaStim-Foot feasibility study. MoTaStim-Foot explored whether it was feasible to deliver treatments to help people feel their foot better after stroke. The results of this study have been published elsewhere (1). Patient and Public Involvement (PPI) advisors played an important role. They worked voluntarily, actively advising the research team; the term 'PPI advisor' is used within this article, following consultation with our PPI advisors. They were involved during idea generation and discussions about whether the study was important to pursue. In addition, they advised the research team during the study setup helping to write the plain English summary, the participant information sheets and advised on other research activities. Following relevant training, PPI advisors were involved in delivering the research including note-taking during focus groups. One PPI advisor also helped analyse the focus group transcripts and attended the UK Stroke Forum to present the results of the study. Reflecting upon the impact of the PPI advisors' contributions to the MoTaStim-Foot study has evidenced that not only was there great benefit to the research team and process, but our PPI advisors gained satisfaction from being involved in the research, planning, design and delivery. It made them all feel valued and respected and helped one of them find a renewed purpose in life. It is important to understand there can be mutual benefit from PPI advisors' contributions to research.

Sensory Stimulation of the Foot and Ankle Early Post-stroke: A Pilot and Feasibility Study.

Background: Somatosensory stimulation of the lower extremity could improve motor recovery and walking post-stroke. This pilot study investigated the feasibility of a subsequent randomized controlled trial (RCT) to determine whether task-specific gait training is more effective following either (a) intensive hands-on somatosensory stimulation or (b) wearing textured insoles. Objectives: Determine recruitment and attrition rates, adherence to intervention, acceptability and viability of interventions and outcome measures, and estimate variance of outcome data to inform sample size for a subsequent RCT. Methods: Design: randomized, single-blinded, mixed-methods pilot study. Setting: In-patient rehabilitation ward and community. Participants: n = 34, 18+years, 42-112 days following anterior or posterior circulation stroke, able to follow simple commands, able to walk independently pre-stroke, and providing informed consent. Intervention: Twenty 30-min sessions of task-specific gait training (TSGT) (delivered over 6 weeks) in addition to either: (a) 30-60 min mobilization and tactile stimulation (MTS); or (b) unlimited textured insole (TI) wearing. Outcomes: Ankle range of movement (electrogoniometer), touch-pressure sensory thresholds (Semmes Weinstein Monofilaments), motor impairment (Lower Extremity Motricity Index), walking ability and speed (Functional Ambulation Category, 5-m walk test, pressure insoles) and function (modified Rivermead Mobility Index), measured before randomization, post-intervention, and 1-month thereafter (follow-up). Adherence to allocated intervention and actual dose delivered (fidelity) were documented in case report forms and daily diaries. Focus groups further explored acceptability of interventions and study experience. Analysis: Recruitment, attrition, and dose adherence rates were calculated as percentages of possible totals. Thematic analysis of daily diaries and focus group data was undertaken. Standard deviations of outcome measures were calculated and used to inform a sample size calculation. Results: Recruitment, attrition, and adherence rates were 48.57, 5.88, and 96.88%, respectively. Focus groups, daily-diaries and case report forms indicated acceptability of interventions and outcome measures to participants. The 5-m walk was selected as primary outcome measure for a future trial [mean (SD) at end of intervention: 16.86 (11.24) MTS group and 21.56 (13.57) TI group]; sample size calculation indicated 60 participants are required per group. Conclusion: Recruitment, attrition and adherence rates and acceptability of interventions and outcomes justify a subsequent powered RCT of MTS+TSGT compared with TI+TSGT.

The experience of upper-limb dysfunction after stroke: a phenomenological study.

BACKGROUND: Stroke can bring about a profound disruption to people's lives, but what is less understood is the effect that specific dysfunctions can have. The aim of this study was to explore stroke survivors' experiences of upper-limb dysfunction over time. METHODS: 13 adult stroke survivors engaged in a series of up to four semi-structured interviews over an 18-month period after stroke. Data were interpreted through a method based on framework analysis. An interpretive phenomenological approach guided the research. RESULTS: Upper-limb dysfunction brought substantial challenges for people, identified in a main theme of an altered way of life. Subordinate themes that contributed to this alteration were challenges in personal care, participating in meaningful and valued activities, and managing life roles and relationships. The second main theme was the disrupted self, with subordinate themes of feeling devalued, disrupted self-image and changes in identity. CONCLUSION: The impact of upper-limb dysfunction on people's lives after stroke should be understood and acknowledged by rehabilitation professionals. Restoring some functional upper-limb activity could play an important role in enabling a person to regain a meaningful life and a coherent sense of self after stroke.IMPLICATIONS FOR REHABILITATIONUpper-limb dysfunction after stroke, and the loss of bimanual hand function, can profoundly alter a person's life, rendering them unable to manage simple tasks of personal care, participate in valued activities and fulfil important life roles.These functional and social limitations can then disrupt their sense of self, with feelings of low self-worth, and changes in self-image and identity.It is important that these changes in stroke survivors' lives are acknowledged and understood by rehabilitation professionals. More prolonged periods of therapy for recovery of upper-limb function, or for developing compensatory strategies, should be considered so that people can regain some meaning in life and maintain a coherent sense of self.

Cardiopulmonary Function and Aerobic Exercise in Parkinson's: A Systematic Review of the Literature.

BACKGROUND: Cardiorespiratory impairments are considered the main cause of mortality in the late stages of Parkinson's. Aerobic exercise has been shown to improve pulmonary function in asthmatic patients and in healthy people. However, effects of aerobic exercise on cardiopulmonary function in people with Parkinson's have not been investigated. Therefore, this study aimed to review the effects of aerobic exercise on cardiopulmonary function in people with Parkinson's. METHODS: A systematic search was conducted using MEDLINE, AMED, CINHAL Plus, and relevant associated keywords, from January 1970 to January 2020. Inclusion criteria for the studies were: aerobic exercise as part of the intervention, pulmonary function test, and/or cardiopulmonary exercise test as outcome measures. RESULTS: In total, 329 citations were identified from the search, of which nine were included in this review. In general, aerobic exercise was found to have positive effects on cardiac function for people with Parkinson's, but there is a lack of studies on the effects of aerobic exercise on pulmonary function. CONCLUSION: People with early stages of Parkinson's may experience positive effects of aerobic exercise on cardiac fitness. Further research is needed in this area, particularly into the effects of aerobic exercise on pulmonary function in early stages of the disease.

Peg3 Deficiency Results in Sexually Dimorphic Losses and Gains in the Normal Repertoire of Placental Hormones.

Hormones from the fetally derived placenta signal to the mother throughout pregnancy to ensure optimal fetal growth and prepare the mother for her new role in nurturing her offspring. Through evolution, placental hormones have under gone remarkable diversification and species-specific expansions thought to be due to constant rebalancing of resource allocation between mother and offspring. Genomic imprinting, an epigenetic process in which parental germlines silence genes in the offspring, is thought to be the physical embodiment of a second conflicting interest, between the male and female mammal. Several genes silenced by paternal imprints normally function to limit the placental endocrine lineages of the mouse placenta. We hypothesized that paternal imprinting has adapted to overcome the rapid evolution of placental hormone gene families by directly regulating the lineages that express these hormones rather than individual hormones. This predicts the existence of genes maternally silenced in the offspring counteracting the influence of the paternal imprint. Here we report on the consequences of loss of function of Paternally expressed gene 3 (Peg3), on placental endocrine lineages. Mutant male placenta displayed a marked loss of the spongiotrophoblast, a key endocrine lineage of the placenta, and the glycogen cell lineage alongside reduced stores of placental glycogen and changes in expression of the normal repertoire of placental hormones. Peg3 is known to transcriptionally repress placental hormone genes. Peg3 consequently both positively and negatively regulates placental hormones through two independent and opposing mechanisms. Female placenta showed moderate response to loss of Peg3 with minor alterations to the junctional zone lineages and few changes in gene expression. These data highlight the important fact that female placenta compensate for the loss of Peg3 better than male placenta. This work lends further support to our novel hypothesis that the parental genomes are competing over the endocrine function of the mouse placenta and further suggests that a conflict between males and females begins in utero.

Functional Strength Training and Movement Performance Therapy for Upper Limb Recovery Early Poststroke-Efficacy, Neural Correlates, Predictive Markers, and Cost-Effectiveness: FAST-INdiCATE Trial.

BACKGROUND: Variation in physiological deficits underlying upper limb paresis after stroke could influence how people recover and to which physical therapy they best respond. OBJECTIVES: To determine whether functional strength training (FST) improves upper limb recovery more than movement performance therapy (MPT). To identify: (a) neural correlates of response and (b) whether pre-intervention neural characteristics predict response. DESIGN: Explanatory investigations within a randomised, controlled, observer-blind, and multicentre trial. Randomisation was computer-generated and concealed by an independent facility until baseline measures were completed. Primary time point was outcome, after the 6-week intervention phase. Follow-up was at 6 months after stroke. PARTICIPANTS: With some voluntary muscle contraction in the paretic upper limb, not full dexterity, when recruited up to 60 days after an anterior cerebral circulation territory stroke. INTERVENTIONS: Conventional physical therapy (CPT) plus either MPT or FST for up to 90 min-a-day, 5 days-a-week for 6 weeks. FST was "hands-off" progressive resistive exercise cemented into functional task training. MPT was "hands-on" sensory/facilitation techniques for smooth and accurate movement. OUTCOMES: The primary efficacy measure was the Action Research Arm Test (ARAT). Neural measures: fractional anisotropy (FA) corpus callosum midline; asymmetry of corticospinal tracts FA; and resting motor threshold (RMT) of motor-evoked potentials. ANALYSIS: Covariance models tested ARAT change from baseline. At outcome: correlation coefficients assessed relationship between change in ARAT and neural measures; an interaction term assessed whether baseline neural characteristics predicted response. RESULTS: 288 Participants had: mean age of 72.2 (SD 12.5) years and mean ARAT 25.5 (18.2). For 240 participants with ARAT at baseline and outcome the mean change was 9.70 (11.72) for FST + CPT and 7.90 (9.18) for MPT + CPT, which did not differ statistically (p = 0.298). Correlations between ARAT change scores and baseline neural values were between 0.199, p = 0.320 for MPT + CPT RMT (n = 27) and -0.147, p = 0.385 for asymmetry of corticospinal tracts FA (n = 37). Interaction effects between neural values and ARAT change between baseline and outcome were not statistically significant. CONCLUSIONS: There was no significant difference in upper limb improvement between FST and MPT. Baseline neural measures did not correlate with upper limb recovery or predict therapy response. TRIAL REGISTRATION: Current Controlled Trials: ISRCT 19090862, http://www.controlled-trials.com.

Using the TIDieR Checklist to Standardize the Description of a Functional Strength Training Intervention for the Upper Limb After Stroke.

BACKGROUND AND PURPOSE: Published reports of intervention in randomized controlled trials are often poorly described. The Template for Intervention Description and Replication (TIDieR) checklist has been recently developed to improve the reporting of interventions. The aim of this article is to describe a therapy intervention used in the stroke rehabilitation trial, "Clinical Efficacy of Functional Strength Training for Upper Limb Motor Recovery Early After Stroke: Neural Correlates and Prognostic Indicators" (FAST-INdICATE), using TIDieR. METHODS: The functional strength training intervention used in the FAST-INdICATE trial was described using TIDieR so that intervention can be replicated by both clinicians, who may implement it in practice, and researchers, who may deliver it in future research. The usefulness of TIDieR in the context of a complex stroke rehabilitation intervention was then discussed. RESULTS AND DISCUSSION: The TIDieR checklist provided a systematic way of describing a treatment intervention used in a clinical trial of stroke rehabilitation. Clarification is needed regarding several aspects of the TIDieR checklist, including in which section to report about the development of the intervention in pilot studies, results of feasibility studies; overlap between training and procedures for assessing fidelity; and where to publish supplementary material so that it remains in the public domain. CONCLUSIONS: TIDieR is a systematic way of reporting the intervention delivered in a clinical trial of a complex intervention such as stroke rehabilitation. This approach may also have value for standardizing intervention in clinical practice.Video abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A131).

FAST INdiCATE Trial protocol. Clinical efficacy of functional strength training for upper limb motor recovery early after stroke: neural correlates and prognostic indicators.

RATIONALE: Functional strength training in addition to conventional physical therapy could enhance upper limb recovery early after stroke more than movement performance therapy plus conventional physical therapy. AIMS: To determine (a) the relative clinical efficacy of conventional physical therapy combined with functional strength training and conventional physical therapy combined with movement performance therapy for upper limb recovery; (b) the neural correlates of response to conventional physical therapy combined with functional strength training and conventional physical therapy combined with movement performance therapy; (c) whether any one or combination of baseline measures predict motor improvement in response to conventional physical therapy combined with functional strength training or conventional physical therapy combined with movement performance therapy. DESIGN: Randomized, controlled, observer-blind trial. STUDY: The sample will consist of 288 participants with upper limb paresis resulting from a stroke that occurred within the previous 60 days. All will be allocated to conventional physical therapy combined with functional strength training or conventional physical therapy combined with movement performance therapy. Functional strength training and movement performance therapy will be undertaken for up to 1·5 h/day, five-days/week for six-weeks. OUTCOMES AND ANALYSIS: Measurements will be undertaken before randomization, six-weeks thereafter, and six-months after stroke. Primary efficacy outcome will be the Action Research Arm Test. Explanatory measurements will include voxel-wise estimates of brain activity during hand movement, brain white matter integrity (fractional anisotropy), and brain-muscle connectivity (e.g. latency of motor evoked potentials). The primary clinical efficacy analysis will compare treatment groups using a multilevel normal linear model adjusting for stratification variables and for which therapist administered the treatment. Effect of conventional physical therapy combined with functional strength training versus conventional physical therapy combined with movement performance therapy will be summarized using the adjusted mean difference and 95% confidence interval. To identify the neural correlates of improvement in both groups, we will investigate associations between change from baseline in clinical outcomes and each explanatory measure. To identify baseline measurements that independently predict motor improvement, we will develop a multiple regression model.

Observations of periwound skin protection in venous ulcers: a comparison of treatments.

OBJECTIVE: The objective of this study was to examine the effectiveness of 2 products on venous ulcer periwound skin. DESIGN: This was a descriptive comparative study. SETTING: An outpatient wound care clinic in a rural Midwestern area of the United States. PARTICIPANTS: Participants included a retrospective group of 50 patients and a prospective group of 28 patients. INTERVENTION: The intervention compared the experimental product (Remedy Nutrashield; Medline Industries, Mundelein, Illinois) versus Cavilon Moisturizing Lotion (3M, St Paul, Minnesota). OUTCOME MEASURES: The mean outcome measures were a decrease in periwound and ulcer size. MAIN RESULTS: For the periwound size, the estimated rates of change were as follows: 0.092 (SE, 0.021) cm/d and -0.026 (SE, 0.014) cm/d for products B and A groups, respectively. The decrease for the experimental group was significantly greater than the attenuated decrease for the retrospective cases (t297 = -2.57, P = .01), and the decrease for product B group was also significantly different from zero (t76 = -4.34, P < .0001). For the ulcer size model, the estimated rates of change were -0.272 (SE, 0.102) cm/d and -0.130 (SE, 0.067) cm/d for the experimental and retrospective groups, respectively. The rate for the experimental group was significantly less than zero (t76 = -2.67, P = .009), but there was no significant difference between prospective and retrospective cases in the rates of reduction in ulcer size (t308 = -1.16, P = .25). CONCLUSION: The results of this study illustrate how the integrity of the periwound skin may be an important determinant in decreasing periwound and ulcer size.

Planning, conducting, and interpreting prevalence and incidence for the wound practitioner.

Prevalence is a 1-time "snapshot" of cases present on a specific date, and incidence measures the new cases of a disease or condition in a given period. This article discusses prevalence and incidence and gives practical tips for wound care practitioners who plan and conduct prevalence/incidence audits.

Effects of mobilization and tactile stimulation on chronic upper-limb sensorimotor dysfunction after stroke.

OBJECTIVE: To explore the effects of Mobilization and Tactile Stimulation (MTS) and patterns of recovery in chronic stroke (>12mo) when upper limb (UL) "performance" has reached a clear plateau. DESIGN: Replicated single-system experimental study with 8 single cases using A-B-A design (baseline-intervention-withdrawal phases); length of baseline randomly determined; intervention phase involved 6 weeks of daily MTS to the contralesional UL. SETTING: Community setting, within participants' place of residence. PARTICIPANTS: Individual stroke survivors (N=8; male-to-female ratio, 3:1; age range, 49-76y; 4 with left hemiplegia, 4 with right hemiplegia) discharged from ongoing therapy, more than 1 year post stroke (range, 14-48mo). Clinical presentations were varied across the sample. INTERVENTIONS: Participants received up to 1 hour of daily (Monday to Friday) treatment with MTS to the UL for 6 weeks during the intervention (B) phase. MAIN OUTCOME MEASURES: Motor function (Action Research Arm Test [ARAT]) and motor impairment (Motricity Index [MI] arm section) of the UL. RESULTS: UL performance was stable during baseline for all participants. On visual analysis, improvements in motor impairment were seen in all participants, and clinically significant improvements in motor function were seen in 4 of 8 participants during the intervention phase. Latency between onset of intervention and improvement ranged from 5 to 31 days (ARAT) and from 0 to 28 days (MI). Improvements in performance were maintained on withdrawal of the intervention. Randomization tests were not significant. CONCLUSIONS: MTS appears to improve UL motor impairment and functional activity many months, even years, after stroke onset. Improvement can be immediate, but more often there is latency between the start of intervention and improvement; recovery can be distal to proximal.

Dose-response study of mobilisation and tactile stimulation therapy for the upper extremity early after stroke: a phase I trial.

BACKGROUND: Physical therapy doses may need to be higher than provided in current clinical practice, especially for patients with severe paresis. The authors aimed to find the most effective and feasible dose of Mobilisation and Tactile Stimulation (MTS), which includes joint and soft-tissue mobilization and passive or active-assisted movement to enhance voluntary muscle contraction. METHODS: This 2-center, randomized, controlled, observer-blinded feasibility trial compared conventional rehabilitation but no extra therapy (group 1) with conventional therapy plus 1 of 3 daily doses of MTS, up to 30 (group 2), 60 (group 3), or 120 (group 4) minutes for 14 days. The 76 participants had substantial paresis (Motricity Index [MI] < 61) a mean of 30 days (standard deviation [SD] = 20 days) after anterior circulation stroke. MTS was delivered using a standardized schedule of techniques (eg, sensory input, active-assisted movement). The primary outcome was the Motricity Index (MI) and secondary outcome was the Action Research Arm Test (ARAT) tested on day 16. Adverse events were monitored daily. RESULTS: No difference was found in the change in control group MI compared with each of the 3 intervention groups (P = .593) or in the ARAT. Mean actual daily treatment time for all MTS groups was less than expected. The attrition rate was 1.3%. No adverse events related to overuse occurred. CONCLUSION: The authors were not able to deliver a maximum dose of 120 minutes of daily therapy each day. The mean daily dose of MTS feasible for subsequent evaluation is between 37 and 66 minutes.

Gene expression profiles during early differentiation of mouse embryonic stem cells.

BACKGROUND: Understanding the mechanisms controlling stem cell differentiation is the key to future advances in tissue and organ regeneration. Embryonic stem (ES) cell differentiation can be triggered by embryoid body (EB) formation, which involves ES cell aggregation in suspension. EB growth in the absence of leukaemia inhibitory factor (LIF) leads EBs to mimic early embryonic development, giving rise to markers representative of endoderm, mesoderm and ectoderm. Here, we have used microarrays to investigate differences in gene expression between 3 undifferentiated ES cell lines, and also between undifferentiated ES cells and Day 1-4 EBs. RESULTS: An initial array study identified 4 gene expression changes between 3 undifferentiated ES cell lines. Tissue culture conditions for ES differentiation were then optimized to give the maximum range of gene expression and growth. -Undifferentiated ES cells and EBs cultured with and without LIF at each day for 4 days were subjected to microarray analysis. -Differential expression of 23 genes was identified. 13 of these were also differentially regulated in a separate array comparison between undifferentiated ES cells and compartments of very early embryos. A high degree of inter-replicate variability was noted when confirming array results. Using a panel of marker genes, RNA amplification and RT-PCR, we examined expression pattern variation between individual -D4-Lif EBs. We found that individual EBs selected from the same dish were highly variable in gene expression profile. CONCLUSION: ES cell lines derived from different mouse strains and carrying different genetic modifications are almost invariant in gene expression profile under conditions used to maintain pluripotency. Tissue culture conditions that give the widest range of gene expression and maximise EB growth involve the use of 20% serum and starting cell numbers of 1000 per EB. 23 genes of importance to early development have been identified; more than half of these are also identified using similar studies, thus validating our results. EBs cultured in the same dish vary widely in terms of their gene expression (and hence, undoubtedly, in their future differentiation potential). This may explain some of the inherent variability in differentiation protocols that use EBs.