Classification of Mild Stroke: A Mapping Review.

Persons with mild stroke experience motor and cognitive impairments that negatively affect their health and quality of life. To address these deficits, it is essential for clinicians and researchers to precisely identify mild stroke survivors. Despite the fact that half of all strokes are categorized as mild, no standards exist on what constitutes a "mild" stroke. The purpose of this study is to summarize the current classification of mild stroke using a mapping review approach. Strategies to categorize "mild stroke" severity were explored in 188 papers indexed in the PubMed database. The results indicate that there was substantial variability in the procedures and scoring criteria used to determine mild stroke. To identify persons with mild stroke, researchers have largely applied assessment instruments developed to inform acute stroke care (eg, National Institutes of Health Stroke Scale, Modified Rankin Scale, Barthel Index). Unfortunately, these approaches demonstrate floor effects and fail to detect the long-term disabling impairments that often limit the outcomes of mild stroke survivors. Additional research is warranted to suggest an evidence-based mild stroke categorization strategy that enhances diagnosis, treatment, and referral decisions to the benefit of mild stroke survivors.

Yoga led by a physical therapist for individuals with Essential Tremor: An explorative pilot study.

PURPOSE: The purpose of this pilot study is to evaluate the outcomes for individuals with Essential Tremor (ET) who participate in a community-based yoga class, led by a neurologic physical therapist. METHODS: Six subjects with ET completed an 8-week intervention consisting of weekly 1-h yoga classes (in the Vinyasa style) guided by an instructor (200-h registered yoga teacher, physical therapist, and neurological resident). RESULTS: Five subjects demonstrated improvements on the Tremor Research Group Essential Tremor Rating Scale (mean 15.3%, range 8.3-34.7%). The mean improvement on the Fullerton Advanced Balance Scale was 10.8% (range 2.5-20%). Five subjects maintained pre-intervention anxiety levels ("very low") while one reported increased anxiety secondary to a non-study related factor. Minimal improvements were noted in the McGill Quality of Life Questionnaire. CONCLUSION: This pilot study offers support for further examining the benefits of integration of yoga into an exercise program for individuals with ET and specific suggestions for future research are offered. There were no adverse events with participation in yoga.

Development of a community-based golf and exercise program for people with Parkinson's disease.

Individuals with Parkinson's disease (PD) typically display symptoms of rigidity, bradykinesia, and postural instability that can limit participation in recreational activities. The purpose of this clinical report is to describe the development, implementation, and outcomes of a novel and innovative community-based golf and exercise program for individuals with PD. In response to community interest, the program was developed through a unique partnership that blended the expertise of physical therapists and golf professionals. The 6-week program consisted of golf instruction and task-specific exercises. Improvements were noted in seven of eight participants for golf performance (driving distance and club head speed) and quality of life (PD Questionnaire-39) outcome measures. This report describes the design and implementation of a golf and exercise program for people with PD based on community need, evidence, and clinical expertise. Considerations and recommendations for future programs are discussed, such as program length, staffing, volunteers, funding, location, and resources.

A pilot study evaluating the association between physical activity and cognition among individuals with Parkinson's disease.

BACKGROUND: Few studies have examined the association between daily physical activity and cognitive function among older adults with Parkinson's disease (PD). OBJECTIVE: Here we evaluate the association between accelerometer-assessed physical activity and cognition among older patients with PD. METHODS: Cognition assessed via the Montreal Cognitive Assessment (MoCA). Moderate-to-vigorous physical activity (MVPA) was assessed via accelerometry over a 1-2 week monitoring period. RESULTS: After adjusting for motor impairment severity, for every 1 min/day increase in MVPA, participants had a 0.09 unit increase in MoCA-determined cognitive function (ß = 0.09; 95% CI: -0.003-0.19; P = 0.05). When further adjusting for motor impairment, age and gender, results were unchanged (ß = 0.09; 95% CI: 0.004-0.19; P = 0.04). CONCLUSION: The present study provides suggestive evidence of a favorable association between daily physical activity behavior and cognitive function among adults with PD.

A qualitative examination of physiotherapist led community-based yoga for individuals with Huntington's disease.

PURPOSE: The purpose of this study is to examine community-based yoga, led by a physiotherapist, for individuals affected by Huntington's disease (HD). METHODS: Qualitative case study methodology was used to examine the Hatha yoga led by a certified yoga instructor who was a neurologic physiotherapist. Data collection included participant observations, semi-structured interviews with the instructor, and structured participant surveys. Data were coded and thematically analyzed. Strategies for rigor included field engagement, triangulation, member checks, and reflexivity. OUTCOMES: Five major themes emerged regarding the value and role of yoga for individuals affected by HD: [1] Emphasis on mindfulness, [2] Yoga is modifiable and accessible, [3] Precise communication, [4] Yoga fosters a sense of community, and [5] Poses tailored to HD-specific deficits. CONCLUSIONS: Yoga led by a physiotherapist can be tailored to enable participation by those affected by HD, addresses HD-specific deficits, and promotes a sense of community to supplement traditional physiotherapy.

Physical Therapy for a Patient with Essential Tremor and Prolonged Deep Brain Stimulation: A Case Report.

BACKGROUND: There is a lack of evidence examining the role of physical therapy (PT) to address movement dysfunction for individuals with essential tremor (ET). CASE REPORT: A 61-year-old male with ET and prolonged bilateral deep brain stimulation (DBS) completed 14 sessions of outpatient PT that emphasized balance, functional movements, and proximal stability training with an integration of principles of body awareness training and visual motor coordination. Improvements were noted in all outcome measures. DISCUSSION: This report describes a novel PT approach that offers a promising means of improving functional mobility and balance while decreasing falls risk in patients with ET.

Development of a community-based exercise program for people diagnosed and at-risk for Huntington's disease: A clinical report.

BACKGROUND: Given the neurodegenerative nature of Huntington's disease (HD), community-based exercise programs that meet the ongoing needs of those living with HD are needed. The genetic nature of HD warrants the inclusion of those at-risk for HD. The purpose of this clinical report is to describe an evidence-based approach to the design of a community-based exercise program to improve gait, balance, and fatigue for individuals diagnosed with and at-risk for HD. PROGRAM DESIGN: Based on the literature, clinical expertise and patient values, the program was designed to include four key features: (1) community-based group format for individuals with HD, caregivers, and those at-risk for HD; (2) individualized prescription within the group; (3) circuit training; and (4) use of outcome measures. PROGRAM IMPLEMENTATION AND OUTCOMES: The group met once weekly for 8 weeks for balance, strength, and cardiovascular fitness exercises. Three individuals participated, two diagnosed with HD and 1 considered "at-risk" for HD. Pre- and post- outcome measures included the 10 meter walk test, Berg Balance Scale, Fatigue Impact Scale, and the Timed Up and Go. Participants demonstrated improvement or maintenance of abilities in all measures with no adverse events. DISCUSSION: This clinical report describes the integration of the evidence, clinical expertise, and patient values to develop and implement individualized, community-based exercise groups, aimed to improve balance, gait speed, and fatigue measures for persons with HD and those at-risk. Post-program reflections and recommendations for those who are interested in developing similar programs in other communities are described.

"A Lot of Things Passed Me by": Rural Stroke Survivors' and Caregivers' Experience of Receiving Education From Health Care Providers.

PURPOSE: The purpose of this study is to examine rural Appalachian Kentucky stroke survivors' and caregivers' experiences of receiving education from health care providers with the long-term goal of optimizing educational interactions and interventions for an underserved population. METHODS: An interprofessional research team, representing nursing, occupational therapy, physical therapy, and speech language pathology, conducted a qualitative descriptive study involving semistructured interviews with 13 stroke survivors and 12 caregivers. Qualitative content analysis included predetermined and emerging coding. This article presents an in-depth analysis of a subset of data from the coding scheme of a larger study that examined the overall experience of stroke for participants. FINDINGS: Findings are presented within a developing model of patient and caregiver education constructs including providers and receivers of education and the content, timing, and delivery of information. CONCLUSIONS: Understanding the experience of receiving education for survivors and caregivers will help practitioners provide the right education, to the right people, at the right time, and in the right way to better support underserved groups. Improving patient and caregiver education is paramount to supporting health behavior change to optimize life poststroke and prevent future strokes. Our results suggest the need for improved access to educational providers, proactive identification of informational needs by providers, greater inclusion of caregivers in education, enhanced communication with information provision, and education from multiple providers using multiple delivery methods at multiple time points.

"Living with a ball and chain": the experience of stroke for individuals and their caregivers in rural Appalachian Kentucky.

PURPOSE: Individuals in rural Appalachian Kentucky face health disparities and are at increased risk for negative health outcomes and poor quality of life secondary to stroke. The purpose of this study is to describe the experience of stroke for survivors and their caregivers in this region. A description of their experiences is paramount to developing tailored interventions and ultimately improving health care and support. METHODS: An interprofessional research team used a qualitative descriptive study design and interviewed 13 individuals with stroke and 12 caregivers, representing 10 rural Appalachian Kentucky counties. The transcripts were analyzed using qualitative content analysis. FINDINGS: A descriptive summary of the participants' experience of stroke is presented within the following structure: (1) Stroke onset, (2) Transition through the health care continuum (including acute care, inpatient rehabilitation, and community-based rehabilitation), and (3) Reintegration into life and rural communities. CONCLUSIONS: The findings provide insight for rural health care providers and community leaders to begin to understand the experience of stroke in terms of stroke onset, transition through the health care continuum, return to home, and community reintegration. An understanding of these experiences may lead to discussions of how to improve service provision, facilitate reintegration, support positive health outcomes, and improve quality of life for stroke survivors and their caregivers. The findings also indicate areas in need of future research including investigation of the effects of support groups, local health navigators to improve access to information and services, involvement of faith communities, proactive screening for management of mental health needs, and caregiver respite services.

Brain stimulation paired with novel locomotor training with robotic gait orthosis in chronic stroke: a feasibility study.

OBJECTIVES: 1) To investigate the feasibility of combining transcranial direct current stimulation (tDCS) to the lower extremity (LE) motor cortex with novel locomotor training to facilitate gait in subjects with chronic stroke and low ambulatory status, and 2) to obtain insight from study subjects and their caregivers to inform future trial design. METHODS: Double-blind, randomized controlled study with additional qualitative exploratory descriptive design. One-month follow-up.10 subjects with stroke were recruited and randomized to active tDCS or sham tDCS for 12 sessions. Both groups participated in identical locomotor training with a robotic gait orthosis (RGO) following each tDCS session. RGO training protocol was designed to harness cortical neuroplasticity. Data analysis included assessment of functional and participation outcome measures and qualitative thematic analysis. RESULTS: Eight subjects completed the study. Both groups demonstrated trends toward improvement, but the active tDCS group showed greater improvement than the sham group. Qualitative analyses indicated beneficial effects of this combined intervention. CONCLUSIONS: It is feasible to combine tDCS targeting the LE motor cortex with our novel locomotor training. It appears that tDCS has the potential to enhance the effectiveness of gait training in chronic stroke. Insights from participants provide additional guidance in designing future trials.

Perceived value of stroke outcome measures across the post-acute care continuum: a qualitative case study.

Connecting the continuum of post-acute care stroke services may be important for easing patients' transition between settings and facilitating recovery and community reintegration. The use of outcome measures is suggested as one means of connecting the continuum. The purpose of this qualitative case study is to describe administrators' and physiotherapists' perceived value of an outcomes program across the post-acute care stroke continuum at a rehabilitation hospital. Data were collected through individual interviews and focus groups with 18 participants. Three themes emerged on the value of the outcomes program: 1) enhanced communication; 2) supports clinical decision-making; and 3) value of objective data. These findings lend support for the use of standardized outcome measures by physiotherapists in stroke rehabilitation. Findings from this study may be useful for organizations and physiotherapists who wish to integrate outcome measures into practice.

Facilitating neurorehabilitation through principles of engagement.

A primary goal of neurorehabilitation is to guide recovery of functional skills after injury through evidence-based interventions that operate to manipulate the sensorimotor environment of the client. While choice of intervention is an important decision for clinicians, we contend it is only one part of producing optimal activity-dependent neuroplastic changes. A key variable in the rehabilitation equation is engagement. Applying principles of engagement may yield greater neuroplastic changes and functional outcomes for clients. We review the principles of neuroplasticity and engagement and their potential linkage through concepts of attention and motivation and strategies such as mental practice and enriched environments. Clinical applications and challenges for enhancing engagement during rehabilitation are presented. Engagement strategies, such as building trust and rapport, motivational interviewing, enhancing the client education process, and interventions that empower clients, are reviewed. Well-controlled research is needed to test our theoretical framework and suggested outcomes. Clinicians may enhance engagement by investing time and energy in the growth and development of the therapeutic relationship with clients, as this is paramount to maintaining clients' investment in continuing therapy and also may act as a driver of neuroplastic changes.