Upper limb sensorimotor recovery in Asian stroke survivors: a study protocol for the development and implementation of a Technology-Assisted dIgitaL biOmaRker (TAILOR) platform.

Background: Stroke is a leading cause of lifelong disability worldwide, partially driven by a reduced ability to use the upper limb in daily life causing increased dependence on caregivers. However, post-stroke functional impairments have only been investigated using limited clinical scores, during short-term longitudinal studies in relatively small patient cohorts. With the addition of technology-based assessments, we propose to complement clinical assessments with more sensitive and objective measures that could more holistically inform on upper limb impairment recovery after stroke, its impact on upper limb use in daily life, and on overall quality of life. This paper describes a pragmatic, longitudinal, observational study protocol aiming to gather a uniquely rich multimodal database to comprehensively describe the time course of upper limb recovery in a representative cohort of 400 Asian adults after stroke. Particularly, we will characterize the longitudinal relationship between upper limb recovery, common post-stroke impairments, functional independence and quality of life. Methods: Participants with stroke will be tested at up to eight time points, from within a month to 3 years post-stroke, to capture the influence of transitioning from hospital to community settings. We will perform a battery of established clinical assessments to describe the factors most likely to influence upper limb recovery. Further, we will gather digital health biomarkers from robotic or wearable sensing technology-assisted assessments to sensitively characterize motor and somatosensory impairments and upper limb use in daily life. We will also use both quantitative and qualitative measures to understand health-related quality of life. Lastly, we will describe neurophysiological motor status using transcranial magnetic stimulation. Statistics: Descriptive analyses will be first performed to understand post-stroke upper limb impairments and recovery at various time points. The relationships between digital biomarkers and various domains will be explored to inform key aspects of upper limb recovery and its dynamics using correlation matrices. Multiple statistical models will be constructed to characterize the time course of upper limb recovery post-stroke. Subgroups of stroke survivors exhibiting distinct recovery profiles will be identified. Conclusion: This is the first study complementing clinical assessments with technology-assisted digital biomarkers to investigate upper limb sensorimotor recovery in Asian stroke survivors. Overall, this study will yield a multimodal data set that longitudinally characterizes post-stroke upper limb recovery in functional impairments, daily-life upper limb use, and health-related quality of life in a large cohort of Asian stroke survivors. This data set generates valuable information on post-stroke upper limb recovery and potentially allows researchers to identify different recovery profiles of subgroups of Asian stroke survivors. This enables the comparisons between the characteristics and recovery profiles of stroke survivors in different regions. Thus, this study lays out the basis to identify early predictors for upper limb recovery, inform clinical decision-making in Asian stroke survivors and establish tailored therapy programs. Clinical trial registration: ClinicalTrials.gov, identifier: NCT05322837.

Singapore KneE osTeoarthritis CoHort (SKETCH): protocol for a multi-centre prospective cohort study.

BACKGROUND: Knee osteoarthritis (OA) is a leading cause of global disability. The understanding of the role of psychosocial factors in knee OA outcomes is still evolving particularly in an Asian context. The primary aim of this study is to explore psychosocial factors that prognosticate short and long-term clinical outcomes, productivity, and healthcare utilization in patients with knee OA. Secondary aims are to explore the mediation and directional relationships and the role it plays in predicting the discordance between self-reported measures (SRM), physical-performance measures (PPMs) and objective clinical parameters. METHODS: A multi-centre prospective cohort study of community ambulant knee OA patients seeking treatment in the tertiary healthcare institutions in Singapore will be conducted. Patients with secondary arthritis, significant cognitive impairment, severe medical comorbidities or previous knee arthroplasty will be excluded. Primary clinical outcome measure is the Knee injury and OA Outcome Score-12 (KOOS-12). Baseline characteristics include sociodemographic status, arthritis status including symptom duration and radiographic severity, comorbidities and functional status through Charlson Comorbidities Index (CCI), Barthel Index (BI) and Parker Mobility Score (PMS). Psychosocial variables include social support, kinesiophobia, negative affect, self-efficacy, injustice, chronic illness shame and the built environment. Clinical outcomes include quality of life, physical performance, global assessment, satisfaction and physical activity levels. Productivity and healthcare utilization will be assessed by a modified OA Cost and Consequences Questionnaire (OCC-Q) and the Work Productivity and Activity Impairment Questionnaire (WPAI). Variables will be collected at baseline, 4, 12 months and yearly thereafter. Regression, mediation and structural equation modelling will be used for analysis. DISCUSSION: Results will allow contextualization, identification, and phenotyping of the critical (and potentially modifiable) psychosocial parameters that predict positive clinical outcomes in the OA population to guide optimization and refinement of healthcare and community. This will facilitate: 1. identification of high-risk knee OA subpopulations that will likely experience poor outcomes and 2. formulation of targeted multidisciplinary comprehensive approaches to address these psychosocial factors to optimize non-surgical treatment care, maximize functional outcomes and create more value-based care model for knee OA. ETHICS AND DISSEMINATION: The study has been registered under clinicaltrials.gov registry (Identifier: NCT04942236).

Neurorehabilitation From a Distance: Can Intelligent Technology Support Decentralized Access to Quality Therapy?

Current neurorehabilitation models primarily rely on extended hospital stays and regular therapy sessions requiring close physical interactions between rehabilitation professionals and patients. The current COVID-19 pandemic has challenged this model, as strict physical distancing rules and a shift in the allocation of hospital resources resulted in many neurological patients not receiving essential therapy. Accordingly, a recent survey revealed that the majority of European healthcare professionals involved in stroke care are concerned that this lack of care will have a noticeable negative impact on functional outcomes. COVID-19 highlights an urgent need to rethink conventional neurorehabilitation and develop alternative approaches to provide high-quality therapy while minimizing hospital stays and visits. Technology-based solutions, such as, robotics bear high potential to enable such a paradigm shift. While robot-assisted therapy is already established in clinics, the future challenge is to enable physically assisted therapy and assessments in a minimally supervized and decentralized manner, ideally at the patient's home. Key enablers are new rehabilitation devices that are portable, scalable and equipped with clinical intelligence, remote monitoring and coaching capabilities. In this perspective article, we discuss clinical and technological requirements for the development and deployment of minimally supervized, robot-assisted neurorehabilitation technologies in patient's homes. We elaborate on key principles to ensure feasibility and acceptance, and on how artificial intelligence can be leveraged for embedding clinical knowledge for safe use and personalized therapy adaptation. Such new models are likely to impact neurorehabilitation beyond COVID-19, by providing broad access to sustained, high-quality and high-dose therapy maximizing long-term functional outcomes.

An Asian-centric human movement database capturing activities of daily living.

Assessment of human movement performance in activities of daily living (ADL) is a key component in clinical and rehabilitation settings. Motion capture technology is an effective method for objective assessment of human movement. Existing databases capture human movement and ADL performance primarily in the Western population, and there are no Asian databases to date. This is despite the fact that Asian anthropometrics influence movement kinematics and kinetics. This paper details the protocol in the first phase of the largest Asian normative human movement database. Data collection has commenced, and this paper reports 10 healthy participants. Twelve tasks were performed and data was collected using Qualisys motion capture system, force plates and instrumented table and chair. In phase two, human movement of individuals with stroke and knee osteoarthritis will be captured. This can have great potential for benchmarking with the normative human movement captured in phase one and predicting recovery and progression of movement for patients. With individualised progression, it will offer the development of personalised therapy protocols in rehabilitation.

Family members' experiences of driving disruption after acquired brain injury.

PRIMARY OBJECTIVE: 1) To explore family members' lived experiences of driving disruption at early and later stages of the recovery continuum following acquired brain injury (ABI). 2) To describe health-related quality of life of family members of individuals with ABI who are experiencing driving disruption. RESEARCH DESIGN: Mixed methods phenomenological research approach. METHODS AND PROCEDURES: Semi-structured interviews and health-related quality of life questionnaires were conducted with 15 family members of individuals with ABI (early group: 1-12 months post-injury, n = 6; later group: >1 year post-injury, n = 9). RESULTS: Two main themes were identified: Different for everyone: how driving disruption affects families, and Making it harder: context of driving disruption. The challenges of driving disruption were reported more frequently and with a more intense focus by family members who were caring for their relative for more than 1 year post-injury. This group also reported higher caregiver strain and poorer health-related quality of life. Reduced satisfaction with life, poor mental health and affected family functioning were reported by both groups. CONCLUSIONS: Driving disruption impacts on family members and has long-lasting consequences. It is important for clinicians to work with family members to manage these challenges even years after ABI and consider individual contextual factors.

Family members' needs and experiences of driving disruption over time following an acquired brain injury: an evolving issue.

PURPOSE: Family members often assume the role of driver for individuals who are not driving post-acquired brain injury (ABI). Given that return to driving can be unpredictable and uncertain, the impact of driving disruption on family members may vary at different stages post-injury. This study aims to understand the needs and experiences of family members over time during driving disruption following an ABI. METHOD: A qualitative prospective longitudinal research design was used with semi-structured interviews at recruitment to study, 3 and 6 months later. RESULTS: Fourteen family members completed 41 interviews. The longitudinal data revealed four phases of driving disruption: (1) Wait and see, (2) Holding onto a quick fix, (3) No way out, and (4) Resolution and adjustment. The phases described a process of building tension and a need for support and resolution over time. CONCLUSIONS: Holding onto a quick fix is a pivotal phase whereby supports, such as engagement in realistic goal setting, are essential to facilitate family members' resolution of driving disruption issues. Family members who see no way out might not actively seek help and these points to a need for long-term and regular follow-ups. Future research can explore ways to support family members at these key times. Implications for rehabilitation Health professionals need to facilitate the process of fostering hope in family members to set realistic expectations of return to driving and the duration of driving disruption. It is necessary to follow-up with family members even years after ABI as the issue of driving disruption could escalate to be a crisis and family members might not actively seek help. Health professionals can consider both practical support for facilitating transport and emotional support when addressing the issue of driving disruption with family members.

Arrows in Biology: Lack of Clarity and Consistency Points to Confusion for Learners.

In this article, we begin to unpack the phenomenon of representational competence by exploring how arrow symbols are used in introductory biology textbook figures. Out of 1214 figures in an introductory biology textbook, 632 (52%) of them contained arrows that were used to represent many different concepts or processes. Analysis of these figures revealed little correlation between arrow style and meaning. A more focused study of 86 figures containing 230 arrows from a second textbook showed the same pattern of inconsistency. Interviews with undergraduates confirmed that arrows in selected textbook figures were confusing and did not readily convey the information intended by the authors. We also present findings from an online survey in which subjects were asked to infer meaning of different styles of arrows in the absence of context. Few arrow styles had intrinsic meaning to participants, and illustrators did not always use those arrows for the meanings expected by students. Thus, certain styles of arrows triggered confusion and/or incorrect conceptual ideas. We argue that 1) illustrators need to be more clear and consistent when using arrow symbols, 2) instructors need to be cognizant of the level of clarity of representations used during instruction, and 3) instructors should help students learn how to interpret representations containing arrows.

Family members' narratives of lifespace: Mapping changes before and after a brain injury causing driving disruption.

BACKGROUND/AIM: Family members of a person with an acquired brain injury often provide transport assistance during driving disruption with potential impacts on their own travel and participation within the community. The geographic area in which people travel and conduct their activities is known as lifespace. This study aimed to describe the quantitative changes in family members' lifespace after brain injury and understand their subjective experiences through interacting with maps during narratives. METHODS: Mapping was embedded within in-depth semi-structured interviews with 15 family members. Two sets of maps were generated per participant showing the number of travel locations before and after brain injury. In the interviews, participants reflected on the perceived meaning of lifespace change. Qualitative data were analysed using a narrative approach. RESULTS: Quantitative data from the mapping revealed an increase in travel locations for nine participants, a decrease for five, and no change for one participant. Data analysis revealed four typologies which complemented and enriched the quantitative data: (i) I will do everything for him or her; (ii) Trying to fit all in; (iii) We spend all our time together now; (iv) I need to also care for myself. CONCLUSIONS: The findings describe the change in family members' lifespace after taking on the driver role following acquired brain injury. This study highlights the importance of understanding both quantitative and qualitative aspects of lifespace. The subjective experiences and consequences of lifespace changes are different from the impact on individuals with health conditions. Mapping in an interview as a tool has potential clinical utility.

"The biggest problem we've ever had to face": how families manage driving cessation with people with dementia.

BACKGROUND: It is recognized that people with dementia are likely to need to stop driving at some point following diagnosis. Driving cessation can lead to negative outcomes for people with dementia and their family caregivers (FC), who often experience family conflict and tension throughout the process. Family experiences surrounding driving cessation have begun to be explored but warrant further examination. METHODS: Using a descriptive phenomenological approach, semi-structured interviews were undertaken with key stakeholders, including 5 retired drivers with dementia, 12 FC, and 15 health professionals (HP). Data were analyzed inductively to explore the needs and experiences of people with dementia and FC. RESULTS: The data revealed a range of possible interactions between people with dementia and FC. These were organized into a continuum of family dynamics according to levels of collaboration and conflict: in it together, behind the scenes, active negotiations, and at odds. At the in it together end of the continuum, people with dementia and FC demonstrated collaborative approaches and minimal conflict in managing driving cessation. At the at odds end, they experienced open conflict and significant tension in their interactions. Contextual factors influencing family dynamics were identified, along with the need for individualized approaches to support. CONCLUSIONS: The continuum of family dynamics experienced during driving cessation may help clinicians better understand and respond to complex family needs. Interventions should be tailored to families' distinctive needs with consideration of their unique contextual factors influencing dynamics, to provide sensitive and responsive support for families managing driving cessation.

Family members' needs and experiences of driving disruption due to health conditions or ageing.

PURPOSE: Family members often assume the caregiving role and provide practical assistance and emotional support when an individual is experiencing driving disruption due to health conditions or ageing. The purpose of this study was to understand the experiences, viewpoints and needs of family members with regards to an individual undergoing driving disruption across various population groups. METHOD: A scoping review was conducted through searching across six databases and hand searching articles published from 1985 to 2013. Findings from the articles specific to the aims of the review were extracted and summarised into common topics. RESULTS: Twenty-seven articles were included; dementia or cognitive impairment (16 articles), older adults (8 articles) and brain injury (3 articles). The most common topic raised was related to decisions and consequences for the individual. Other concerns were related to family members' occupational role changes, emotional and communication issues and support needs of family members and their recommendations for services. CONCLUSIONS: This review revealed the impact of driving disruption on family members but research is limited, especially in the area of brain injury. The majority of articles did not set out to explore family members' experiences and needs and this highlights an area that requires critical attention. IMPLICATIONS FOR REHABILITATION: Health professionals should be aware of the potential impact of driving disruption on family members. Family members frequently raise concerns regarding the decisions and consequences for their relative, but also bring up personal concerns such as changes to their own occupational roles and the communication and emotional issues they face during driving disruption. Unique challenges arise between family members of individuals of different health conditions, thus highlighting the importance of family caregiving research in various population groups.

A driving cessation program to identify and improve transport and lifestyle issues of older retired and retiring drivers.

BACKGROUND: This study explored the transport and lifestyle issues of older retired and retiring drivers participating in the University of Queensland Driver Retirement Initiative (UQDRIVE), a group program to promote adjustment to driving cessation for retired and retiring older drivers. METHODS: A mixed method research design explored the impact of UQDRIVE on the transport and lifestyle issues of 55 participants who were of mean age 77.9 years and predominantly female (n = 40). The participants included retired (n = 32) and retiring (n = 23) drivers. Transport and lifestyle issues were identified using the Canadian Occupational Performance Measure and rated pre- and post-intervention. RESULTS: Paired t-tests demonstrated a statistically significant improvement in performance (t = 10.5, p < 0.001) and satisfaction (t = 9.9, p < 0.001) scores of individual issues. Qualitative content analysis identified three categories of issues including: protecting my lifestyle; a better understanding of transport options; and being prepared and feeling okay. CONCLUSIONS: Participation in UQDRIVE had a positive and significant effect on the issues of the participants. The results highlight that although all participants stated issues related predominantly to practical concerns, there were trends in the issues identified by the drivers and retired drivers that were consistent with their current phase of the driving cessation process.