What influences provision of information about recovery on stroke units? A focused ethnographic case study.

OBJECTIVE: Patients and carers frequently report dissatisfaction with post-stroke information provision. This study aimed to develop an in-depth understanding of the factors influencing provision of information about recovery in stroke units. METHODS: Focused ethnographic case-studies in two UK stroke units, including non-participant observations and semi-structured interviews with professionals, patients and carers, and documentary analysis. A Framework approach to analysis was undertaken. RESULTS: Twenty patients, 17 carers and 47 professionals participated. The unpredictable recovery trajectory led professionals to present prognostic estimates as uncertain possibilities. The need to maintain patients' motivation limited sharing of negative predictions, and generic information over-emphasised the importance of therapy in recovery. A structured multidisciplinary team approach to delivering information improved consistency. Complex clinical reasoning was required to identify and meet patients' needs. Hospital environments and routines restricted opportunities for dialogue, particularly with carers. CONCLUSIONS: The process of providing information about post-stroke recovery is complex, requiring enhanced clinical reasoning and communication. The challenges faced by professionals are numerous and if not addressed can result in suboptimal provision. PRACTICE IMPLICATIONS: Professionals should develop a co-ordinated multidisciplinary approach to information provision; and engage in dialogue to ensure a tailored approach to identifying and meeting patients' and carers' information needs.

Exploring the delivery of remote physiotherapy during the COVID-19 pandemic: UK wide service evaluation.

INTRODUCTION: During the Coronavirus (Covid-19) pandemic, physiotherapists changed rapidly to working remotely. Research demonstrates the benefits of remote physiotherapy, but little is known about its implementation in practice. PURPOSE: Explore the take-up and delivery of remote physiotherapy during the pandemic in the United Kingdom. METHODS: Sequential mixed methods evaluation with physiotherapists leading remote physiotherapy delivery. Two-stage approach included online survey (2020) and semi-structured interviews with documentary/data analysis (2021). RESULTS: There were 1620 physiotherapists who completed the survey. The most used devices were telephone (n = 942,71.0%) and the AttendAnywhere platform (n = 511, 38.5%). Remote consultations were frequently used for initial assessment (n = 1105, 83%), screening/triage (n = 882, 67%), or to review, monitor, and progress treatment (n = 982-1004, 74%-76%). Qualitative survey responses reflected respondents' response to COVID-19 and delivery of remote physiotherapy. Twelve remote physiotherapy leads were then purposively sampled across clinical areas. Three main themes emerged from interviews: response to Covid-19, delivery of remote physiotherapy, and future of remote physiotherapy. CONCLUSION: Remote physiotherapy was safe, feasible, and acceptable for those who accessed it. There were patients for which it was deemed unsuitable across clinical areas. In practice, it should be combined with in-person consultation based on patients' needs/preferences. Further research should explore post-pandemic maintenance of remote delivery.

Development and validation of the MAnchester Needs Tool for Injured Children (MANTIC).

OBJECTIVE: To develop a measure of the needs injured children and their families' needs throughout recovery; The MAnchester Needs Tool for Injured Children (MANTIC). DESIGN: Tool development, psychometric testing. SETTING: Five children's major trauma centres in England. PARTICIPANTS: Children aged 2 to 16 years with any type of moderate/severe injury(ies) treated in a major trauma centre within 12 months of injury, plus their parents. METHODS: Stage 1a (Item generation): Interviews with injured children and their parents to generate draft items. Stage 1b (Co-production): Feedback about item clarity, relevance and appropriate response options was provided by parents and the patient and public involvement group. Stage 2 (Psychometric development): Completion of the prototype MANTIC by injured children and their parents with restructuring (as necessary) to establish construct validity. Concurrent validity was assessed by correlation with quality of life (EQ-5D-Y). MANTICs were repeated 2 weeks later to assess test-retest reliability. RESULTS: Stages 1a,b: Interviews (13 injured children, 19 parents) generated 64 items with semantic differential four-point response scale (strongly disagree, disagree, agree, strongly agree). Stage 2: One hundred and forty-four participants completed MANTIC questionnaires (mean age 9.8 years, SD 3.8; 68.1% male). Item responses were strong requiring only minor changes to establish construct validity. Concurrent validity with quality of life was moderate (r = 0.55, P < 0.01) as was test-retest reliability (ICC = 0.46 and 0.59, P < 0.001). Uni-dimensionality was strong (Cronbach's α > 0.7). CONCLUSION: The MANTIC is a feasible, acceptable, valid self-report measure of the needs of injured children and their families, freely available for clinical or research purposes.

A scoping review of the feasibility, acceptability, and effects of physiotherapy delivered remotely.

PURPOSE: To review the feasibility, acceptability, and effects of physiotherapy when delivered remotely. MATERIALS AND METHODS: CINAHL, MEDLINE, EBM Reviews, and Cochrane Library databases (January 2015-February 2022) were searched and screened for papers (of any design) investigating remote physiotherapy. Data were extracted by two independent raters. Methodological quality of the identified papers was not assessed. Thematic content analysis drew out the key issues. RESULTS: Forty-one papers (including nine systemic reviews and six with meta-analyses) were selected involving musculoskeletal, stroke and neurological, pulmonary, and cardiac conditions. The most commonly delivered intervention was remote exercise provision, usually following assessment which was completed in-person. All studies, which assessed it, found that remote physiotherapy was comparably effective to in-person delivery at lower cost. Patient satisfaction was high, they found remote physiotherapy to be more accessible and convenient. It boosted confidence and motivation by reminding patients when and how to exercise but adherence was mixed. No adverse events were reported. Barriers related to access to the technology; technical problems and concerns about therapists' workload. CONCLUSIONS: Remote physiotherapy is safe, feasible, and acceptable to patients. Its effects are comparable with traditional care at lower cost.IMPLICATIONS FOR REHABILITATIONRemote physiotherapy is safe, feasible, and acceptable to patients with comparable effects to in-person care.Remote delivery increases access to physiotherapy especially for those who cannot travel to a treatment facility whether due to distance or disability.Remote physiotherapy may increase adherence to exercise by reminding patients when and how to exercise.Remote physiotherapy does not suit everyone, thus a hybrid system with both in-person and remote delivery may be most effective.

Bobath therapy is inferior to task-specific training and not superior to other interventions in improving arm activity and arm strength outcomes after stroke: a systematic review.

QUESTION: What is the effect of Bobath therapy on arm activity and arm strength compared with a dose-matched comparison intervention or no intervention after stroke? DESIGN: Systematic review of randomised trials with meta-analysis. PARTICIPANTS: Adults after stroke. INTERVENTION: Bobath therapy compared with no intervention or other interventions delivered at the same dose as the Bobath therapy. OUTCOME MEASURES: Arm activity outcomes and arm strength outcomes. Trial quality was assessed with the PEDro scale. RESULTS: Thirteen trials were included; all compared Bobath with another intervention, which were categorised as: task-specific training (five trials), arm movements (five trials), robotics (two trials) and mental practice (one trial). The PEDro scale scores ranged from 5 to 8. Pooled data from five trials indicated that Bobath therapy was less effective than task-specific training for improving arm activities (SMD -1.07, 95% CI -1.59 to -0.55). Pooled data from five trials indicated that Bobath therapy was similar to or less effective than arm movements for improving arm activities (SMD -0.18, 95% CI -0.44 to 0.09). One trial indicated that Bobath therapy was less effective than robotics for improving arm activities and one trial indicated similar effects of Bobath therapy and mental practice on arm activities. For strength outcomes, pooled data from two trials indicated a large benefit of task-specific training over Bobath therapy (SMD -1.08); however, this estimate had substantial uncertainty (95% CI -3.17 to 1.01). The pooled data of three trials indicated that Bobath therapy was less effective than task-specific training for improving Fugl-Meyer scores (MD -7.84, 95% CI -12.99 to -2.69). The effects of Bobath therapy relative to other interventions on strength outcomes remained uncertain. CONCLUSIONS: After stroke, Bobath therapy is less effective than task-specific training and robotics in improving arm activity and less effective than task-specific training on the Fugl-Meyer score. REGISTRATION: PROSPERO CRD42021251630.

Evaluation of the Individual Activity Descriptors of the mMRC Breathlessness Scale: A Mixed Method Study.

Purpose: The modified-Medical Research Council (mMRC) breathlessness scale consists of five grades that contain of a description of different activities. It has wide utility in the assessment of disability due to breathlessness but was originally developed before the advent of modern psychometric methodology and, for example contains more than one activity per grade. We conducted an evaluation of the mMRC structure. Patients and Methods: Cognitive debriefing was conducted with COPD patients to elicit their understanding of each mMRC activity. In a cross-sectional study, patients completed the mMRC scale (grades 0-4) and an MRC-Expanded (MRC-Ex) version consisting of 10-items, each containing one mMRC activity. Each activity was then given a 4-point response scale (0 "not at all" to 4 "all of the time") and all 10 items were given to 203 patients to complete Rasch analysis and assess the pattern of MRC item severity and its hierarchical structure. Results: Cognitive debriefing with 36 patients suggested ambiguity with the term "strenuous exercise" and perceived severity differences between mMRC activities. 203 patients completed the mMRC-Ex. Strenuous exercise was located third on the ascending severity scale. Rasch identified the mildest term was "walking up a slight hill" (logit -2.76) and "too breathless to leave the house" was the most severe (logit 3.42). Conclusion: This analysis showed that items that were combined into a single mMRC grade may be widely separated in terms of perceived severity when assessed individually. This suggests that mMRC grades as a measure of individual disability related to breathlessness contain significant ambiguity due to the combination of activities of different degrees of perceived severity into a single grade.

Investigating the association between inpatient stroke therapy and disability, destination on discharge, length of stay and mortality: a prospective cohort study using the Sentinel Stroke National Audit Programme.

OBJECTIVE: 'More is better' is a recognised mantra within stroke therapy, however, this has been developed in patients receiving long term rehabilitation. We investigated the relationship between amount of therapy received (from therapists and psychologists) and key patient outcomes during inpatient care. DESIGN: A secondary analysis of data from a prospective cohort study was performed. Multilevel mixed models adjusting for measured confounders (eg, severity), explored the relationship between therapy dose (average minutes per day of stay) and outcomes (disability, length of stay, home at discharge and mortality). Therapy was explored using simple linear terms and flexible natural cubic splines to allow for more complex relationships. SETTING: Data from the Sentinel Stroke National Audit Programme, covering England, Wales and Northern Ireland between July 2013 and July 2015 contained 94 905 adults with a stroke and still an inpatient after 72 hours. These patients received 92% (physiotherapy), 88% (occupational therapy), 57% (speech and language therapy) and 5% (clinical psychology), respectively. RESULTS: The average amount of therapy, for individual and 'any' therapy combined per day of stay was low. Overall, 41% were discharged with an 'independent' modified Rankin Scale (≤2), 14% died, 44% were discharged home, and the median length of stay was 16 days. We observed complex relationships between amount of therapy received and outcomes. An additional minute of 'any' therapy, occupational therapy, speech and language therapy and clinical psychology was associated with improved outcomes. Conversely, more physiotherapy was also associated with lower mortality and shorter length of stay, but also lower independence and discharge home. CONCLUSIONS: Our findings suggest for stroke inpatients requiring therapy, 'More is better' may be overly simplistic. Strong limitations associated with analysis of routine data restrict further robust investigation of the therapy-response relationship. Robust prospective work is urgently needed to further investigate the relationships observed here.

Stroke survivors' perceptions of participating in a high repetition arm training trial early after stroke.

PURPOSE: The study explored the acceptability of high repetition arm training as part of a randomised controlled trial, early after stroke, when fatigue levels and emotional strain are often high. MATERIALS AND METHODS: 36 sub-acute stroke survivors (61 years+/-15) attended for assessment sessions at 3, 6, and 12 weeks after stroke. Individuals were randomised to receive 6 high repetition arm training sessions between 3 and 6 weeks (intervention) or the control group. Semi-structured interviews were conducted at trial completion. Interview transcripts were analysed through framework analysis conducted independently by 2 researchers. RESULTS: Stroke survivors participated despite high levels of fatigue because they hoped for personal benefit or to potentially benefit future patients. Benefits reported from participation included physical improvements, psychological benefit, improved understanding of their condition as well as a feeling of hope and distraction. The arm training at three weeks after stroke, aiming for 420 movement repetitions was not considered to be too intensive or too early, and most individuals felt lucky to have been, or would have preferred to be in the early training group. CONCLUSION: High repetition arm training early after stroke was acceptable to participants. Study participation was generally viewed as a positive experience, suggesting that early intervention may not only be physically beneficial but also psychologically.Implications for rehabilitationStroke survivors report that high repetition arm training early after stroke is acceptable.Participation in rehabilitation research early after stroke provides stroke survivors with hope and meaning despite the high prevalence of fatigue.Complex information needs to be repeated and provided in a number of formats early after stroke.

The vicious cycle of functional neurological disorders: a synthesis of healthcare professionals' views on working with patients with functional neurological disorder.

PURPOSE: The objective of this review was to synthesise studies which address the views of healthcare professionals (HCPs) towards patients with functional neurological disorder (FND). METHODS: An interpretive systematised review was conducted. Seven databases were searched using a comprehensive search strategy (MEDLINE, EMBASE, AMED, CINAHL, PsychINFO, ProQuest Nursing and Allied Health, and Scopus). Qualitative studies and those using survey methods were included. An inductive approach to thematic analysis was used to identify concepts from the data and to synthesise the results. RESULTS: The views of 2769 HCPs were represented in 11 included articles. The overarching theme across the articles was uncertainty: about making the diagnosis of FND, about professional roles, and about optimum management. Fear was also a common theme: of saying the wrong thing, of offending patients, or of breaking the therapeutic relationship. CONCLUSIONS: If all HCPs felt uncertain about how to manage patients with FND and avoided them by passing them on to another discipline, then a "vicious cycle" is formed in which patients are passed from one professional to another but without receiving clear, honest information, or effective treatment. HCPs would benefit from increased training on FND and clear clinical pathways to alleviate feelings of uncertainty.Implications for rehabilitationEvidence-based or, at the very least, consensus-based multi-disciplinary care pathways for the assessment and treatment of patients with functional neurological disorder are required to improve equitability of services.Training packages for healthcare professionals need to be developed, evaluated and implemented in order to improve confidence of making and explaining the diagnosis and to reduce stigma of functional neurological disorders.Improved input for patients with functional neurological disorder is likely to occur if healthcare professionals are open, honest and use effective communication skills, both with their patients and fellow healthcare professionals.

The management of patients with functional stroke: speech and language therapists' views and experiences.

PURPOSE: Patients with functional stroke can present with functional speech, language or swallowing symptoms, which are managed by speech and language therapists (SLTs). The aim of this study was to explore SLTs' views and experiences of working with patients with functional stroke. METHODS: Constructivist grounded theory approach was used. Semi-structured interviews were the method of data collection. Constant comparative analysis was used to analyse data. Participants were eligible if they were SLTs who thought they had experience of working with functional stroke. RESULTS: 12 participants were interviewed. Patients with functional stroke were a common occurrence on participants' caseloads; yet they felt patients do not receive optimum care. All participants wanted to help their patients, yet felt they were working within a multitude of barriers to effective input. These included: stigma about the diagnosis, lack of pre-qualification training, quick discharge from inpatient settings, lack of access to mental health services and lack of clinical guidelines and care pathways. CONCLUSIONS: As healthcare professionals, participants were keen to help their patients. However, they felt they did not have the skills or knowledge to help which caused professional turmoil. Reducing stigma and increasing awareness and knowledge of functional stroke are required to improve patient outcomes.

A scoping review of design requirements for a home-based upper limb rehabilitation robot for stroke.

BACKGROUND: Home-based robotic therapy is a trend of post-stroke upper limb rehabilitation. Although home-based upper limb rehabilitation robots have been developed over several decades, no design specification has been published. OBJECTIVES: To identify and synthesize design requirements considering user and technology needs for a home-based upper limb rehabilitation robot through a scoping review. METHOD: Studies published between 1 January 2000 and 10 June 2020 in Scopus, Web of Science and PubMed database regarding design requirements for upper limb rehabilitation robots from of stroke survivors or therapists were identified and analyzed. We use 'requirement' as something that is needed or wanted. Two physiotherapists ranked the requirements identified from literature review. RESULTS: Nine studies were selected for review. They identified 42 requirements regarding functionality (n = 11, 26.2% of total requirements), usability (n = 16, 38.0% of total requirements), software (n = 14, 33.3% of total requirements) and safety (n = 1, 2.4% of total requirements). The main implementation barriers with respect to adherence and monitoring were space, operation, and cost. CONCLUSION: This is the first research to summarize the design requirements for home-based upper limb rehabilitation robots for stroke survivors. The need for a safe, comfortable, easy to use device which can be individualized and promote specific movements and tasks emerged. The result of this paper captures the design requirements that can be used in future for the development of a design specification. It provides designers and researchers guidance about the real-world needs for home-based upper limb rehabilitation robots for stroke.

Educational support needs of injured children and their families: A qualitative study.

OBJECTIVE: To explore the educational support needs of injured children and families. PATIENTS: Thirteen injured children and/or their parents (n = 19) discharged from a major trauma centre within 12 months.  Methods: Semi-structured interviews analysed with thematic analysis.  Results: Theme 1: communication and information needs. Schools need help to understand the effects of children's injuries and the adjustments required for their return to school, such as how to involve chil-dren in the more active elements of the curriculum. Thus, effective communication between the injur-ed child, their family, health and education professionals and outside agencies is needed. A specialist key-worker could co-ordinate communication and school return. Theme 2: Educational support needs. Injured children experience changes to their appearance, new symptoms, and altered physical and cognitive abilities. Their absence from school often adversely affects their friendships. Consequently, injured children need continued access to education throughout recovery, support with learning, a flexible timetable, opportunities for social integration, involvement in all aspects of the curriculum, and environmen-tal adaptations to maintain their health and safety.  Conclusion: Children with different types of injuries have similar needs for flexible learning and environmental accommodations. Social integration and participation in physical activity should be specific goals for school return.

The Strength of the Corticospinal Tract Not the Reticulospinal Tract Determines Upper-Limb Impairment Level and Capacity for Skill-Acquisition in the Sub-Acute Post-Stroke Period.

Background. Upper-limb impairment in patients with chronic stroke appears to be partly attributable to an upregulated reticulospinal tract (RST). Here, we assessed whether the impact of corticospinal (CST) and RST connectivity on motor impairment and skill-acquisition differs in sub-acute stroke, using transcranial magnetic stimulation (TMS)-based proxy measures. Methods. Thirty-eight stroke survivors were randomized to either reach training 3-6 weeks post-stroke (plus usual care) or usual care only. At 3, 6 and 12 weeks post-stroke, we measured ipsilesional and contralesional cortical connectivity (surrogates for CST and RST connectivity, respectively) to weak pre-activated triceps and deltoid muscles with single pulse TMS, accuracy of planar reaching movements, muscle strength (Motricity Index) and synergies (Fugl-Meyer upper-limb score). Results. Strength and presence of synergies were associated with ipsilesional (CST) connectivity to the paretic upper-limb at 3 and 12 weeks. Training led to planar reaching skill beyond that expected from spontaneous recovery and occurred for both weak and strong ipsilesional tract integrity. Reaching ability, presence of synergies, skill-acquisition and strength were not affected by either the presence or absence of contralesional (RST) connectivity. Conclusion. The degree of ipsilesional CST connectivity is the main determinant of proximal dexterity, upper-limb strength and synergy expression in sub-acute stroke. In contrast, there is no evidence for enhanced contralesional RST connectivity contributing to any of these components of impairment. In the sub-acute post-stroke period, the balance of activity between CST and RST may matter more for the paretic phenotype than RST upregulation per se.

Experiences and views of receiving and delivering information about recovery in acquired neurological conditions: a systematic review of qualitative literature.

OBJECTIVE: To review and synthesise qualitative literature relating to the views, perceptions and experiences of patients with acquired neurological conditions and their caregivers about the process of receiving information about recovery; as well as the views and experiences of healthcare professionals involved in delivering this information. DESIGN: Systematic review of qualitative studies. DATA SOURCES: MEDLINE, Embase, AMED, CINAHL, PsycINFO, Web of Science and the Cochrane library were searched from their inception to July 2019. DATA EXTRACTION AND SYNTHESIS: Two reviewers extracted data from the included studies and assessed quality using an established tool. Thematic synthesis was used to synthesise the findings of included studies. RESULTS: Searches yielded 9105 titles, with 145 retained for full-text screening. Twenty-eight studies (30 papers) from eight countries were included. Inductive analysis resulted in 11 descriptive themes, from which 5 analytical themes were generated: the right information at the right time; managing expectations; it's not what you say, it's how you say it; learning how to talk about recovery and manage emotions; the context of uncertainty. CONCLUSIONS: Our findings highlight the inherent challenges in talking about recovery in an emotional context, where breaking bad news is a key feature. Future interventions should focus on preparing staff to meet patients' and families' information needs, as well as ensuring they have the skills to discuss potential recovery and break bad news compassionately and share the uncertain trajectory characteristic of acquired neurological conditions. An agreed team-based approach to talking about recovery is recommended to ensure consistency and improve the experiences of patients and their families.

Professionals' Views and Experiences of Using Rehabilitation Robotics With Stroke Survivors: A Mixed Methods Survey.

Objective: To understand the reason for low implementation of clinical and home-based rehabilitation robots and their potential. Design: Online questionnaire (November 2020 and February 2021). Subjects: A total of 100 professionals in stroke rehabilitation area were involved (Physiotherapists n = 62, Occupation therapists n = 35). Interventions: Not applicable. Main Measures: Descriptive statistics and thematic content analysis were used to analyze the responses: 1. Participants' details, 2. Professionals' views and experience of using clinical rehabilitation robots, 3. Professionals' expectation and concerns of using home-based rehabilitation robots. Results: Of 100 responses, 37 had experience of rehabilitation robots. Professionals reported that patients enjoyed using them and they increased accessibility, autonomy, and convenience especially when used at home. The main emergent themes were: "aims and objectives for rehabilitation robotics," "requirements" (functional, software, and safety), "cost," "patient factors" (contraindications, cautions, and concerns), and "staff issues" (concerns and benefits). The main benefits of rehabilitation robots were that they provided greater choice for therapy, increased the amount/intensity of treatment, and greater motivation to practice. Professionals perceived logistical issues (ease of use, transport, and storage), cost and limited adaptability to patients' needs to be significant barriers to tier use, whilst acknowledging they can reduce staff workload to a certain extent. Conclusion: The main reported benefit of rehabilitation robots were they increased the amount of therapy and practice after stroke. Ease of use and adaptability are the key requirements. High cost and staffing resources were the main barriers.

The impact of injury: The experiences of children and families after a child's traumatic injury.

OBJECTIVE: To explore the experiences of children and families after a child's traumatic injury (Injury Severity Score >8). DESIGN: Qualitative interview study. SETTING: Two children's major trauma centres in England. PARTICIPANTS: 32 participants: 13 children with traumatic injuries, their parents/guardians (n = 14) and five parents whose injured child did not participate. METHODS: Semi-structured interviews exploring the emotional, social, practical and physical impacts of children's injuries, analysed by thematic analysis. RESULTS: Interviews were conducted a median of 8.5 months (IQR 9.3) post-injury. Injuries affected the head, chest, abdomen, spine, limbs or multiple body parts. Injured children struggled with changes to their appearance, physical activity restrictions and late onset physical symptoms, which developed after hospital discharge when activity levels increased. Social participation was affected by activity restrictions, concerns about their appearance and interruptions to friendships. Psychological impacts, particularly post-traumatic stress type symptoms often affected both children and parents. Parents' responsibilities suddenly increased, which affected family relationships and roles, their ability to work and carry out daily tasks. Rapid hospital discharge was wanted, but participants often felt vulnerable on return home. They valued continued contact with a healthcare professional and practical supports from family and friends, which enabled resumption of their usual lives. CONCLUSIONS: Injured children experience changes to their appearance, friendships, physical activity levels and develop new physical and mental health symptoms after hospital discharge. Such challenges can be addressed by the provision of advice about potential symptoms, alternative activities during recovery, strategies to build resilience and how to access services after hospital discharge.