Cognitive Reserve Modifies the Relationship Between Neural Function, Neural Injury and Upper-Limb Recovery After Stroke.

OBJECTIVE: To investigate whether cognitive reserve modifies the relationship between functional connectivity, lesion volume, stroke severity and upper-limb motor impairment and recovery in stroke survivors. METHODS: Ten patients with first-ever ischemic middle cerebral artery stroke completed the Cognitive Reserve Index Questionnaire at baseline. Upper-limb motor impairment and functional connectivity were assessed using the Fugl-Meyer Assessment and electroencephalography respectively at baseline and 3-months post-stroke. A debiased weighted phase lag index was computed to estimate functional connectivity between electrodes. Partial least squares (PLS) regression identified a connectivity model that maximally predicted variance in the degree of upper-limb impairment. Regression models were generated to determine whether cognitive reserve modified the relationship between neural function (functional connectivity), neural injury (lesion volume), stroke severity (National Institutes of Health Stroke Scale) and upper-limb motor impairment at baseline and recovery at 3-months (Fugl-Meyer Assessment). RESULTS: The addition of cognitive reserve to a regression model with a dependent variable of upper-limb motor recovery and independent variables of functional connectivity between the ipsilesional motor cortex and parietal cortex, stroke severity and lesion volume improved model efficiency (∆BIC=-7.07) despite not reaching statistical significance (R2=0.90, p=0.07). Cognitive reserve did not appear to improve regression models examining motor impairment at baseline. CONCLUSIONS: Preliminary observations suggest cognitive reserve might modify the relationship between neural function, neural injury, stroke severity and upper-limb motor recovery. Further investigation of cognitive reserve in motor recovery post-stroke appears warranted.

Consumer engagement in health care policy, research and services: A systematic review and meta-analysis of methods and effects.

To assess the effects of consumer engagement in health care policy, research and services. We updated a review published in 2006 and 2009 and revised the previous search strategies for key databases (The Cochrane Central Register of Controlled Trials; MEDLINE; EMBASE; PsycINFO; CINAHL; Web of Science) up to February 2020. Selection criteria included randomised controlled trials assessing consumer engagement in developing health care policy, research, or health services. The International Association for Public Participation, Spectrum of Public Participation was used to identify, describe, compare and analyse consumer engagement. Outcome measures were effects on people; effects on the policy/research/health care services; or process outcomes. We included 23 randomised controlled trials with a moderate or high risk of bias, involving 136,265 participants. Most consumer engagement strategies adopted a consultative approach during the development phase of interventions, targeted to health services. Based on four large cluster-randomised controlled trials, there is evidence that consumer engagement in the development and delivery of health services to enhance the care of pregnant women results in a reduction in neonatal, but not maternal, mortality. From other trials, there is evidence that involving consumers in developing patient information material results in material that is more relevant, readable and understandable for patients, and can improve knowledge. Mixed effects are reported of consumer-engagement on the development and/or implementation of health professional training. There is some evidence that using consumer interviewers instead of staff in satisfaction surveys can have a small influence on the results. There is some evidence that consumers may have a role in identifying a broader range of health care priorities that are complementary to those from professionals. There is some evidence that consumer engagement in monitoring and evaluating health services may impact perceptions of patient safety or quality of life. There is growing evidence from randomised controlled trials of the effects of consumer engagement on the relevance and positive outcomes of health policy, research and services. Health care consumers, providers, researchers and funders should continue to employ evidence-informed consumer engagement in their jurisdictions, with embedded evaluation. Systematic review registration: PROSPERO CRD42018102595.

Synthesis of clinical practice guideline recommendations for the primary health care of chronic musculoskeletal pain.

RATIONALE AND AIMS: The prevalence of chronic musculoskeletal pain (CMSP) is high and rising. The multidimensional impact of CMSP on individuals necessitates multidisciplinary evidence-based strategies to prevent and manage chronic pain. Primary health care (PHC) is the first point of care in many healthcare systems and evidence implementation at this point is important. We aim to describe the process of development of a comprehensive list of evidence-based recommendations derived from different high-quality clinical practice guidelines (CPGs) to inform the PHC healthcare of adults with CMSP. METHOD: A systematic review was conducted of CPGs that focussed on PHC management of CMSP in adults. CPGs were identified by searching 13 guideline clearinghouses and five online databases. Eligible CPGs were critically appraised using Appraisal of Guidelines Research and Evaluation, Version II (AGREE II). A stepwise systematic process was followed to identify a core set of recommendations. This process comprised the following: extract recommendations; analyze recommendations; synthesize recommendations by assimilating similar recommendations; determine the strength of the body of evidence underpinning the recommendations and produce a list of synthesized recommendations. RESULTS: Six high-quality CPGs were identified, providing 156 recommendations. These were condensed to 42 statements covering topics about the approach to care, assessment, advice and education, referral, pharmacological management, physical therapy, electrotherapy, psychological therapy, complementary therapy and self-management. The set of recommendations encompasses a person-centered approach, collaborative decision making, a biopsychosocial approach, patient education and empowerment towards self-management. CONCLUSION: The process of developing composite recommendations from multiple CPGs enables end-users to access comprehensive information on managing CMSP in PHC settings that is not available from one singular CPG. The content and evidence base for recommendations varied between CPGs. A similar stepwise process may be used to develop a core set of recommendations for other health conditions, where multiple, diverse CPGs exist.

Spatial Neglect Subtypes, Definitions and Assessment Tools: A Scoping Review.

Objective: The objective of this scoping review was to capture the reported definitions for the subtypes of neglect post stroke and map the range of assessment tools employed for each neglect subtype. Methods: EMBASE, Emcare, Medline, and psychINFO were searched from database inception. Searching included all allied terms and mesh headings for stroke, spatial neglect, measurement, screening tools, psychometric properties. Two reviewers independently screened studies for inclusion. Primary studies with documented protocols of a spatial neglect tool for adults post stroke, with some aspect of validity or reliability were included. Two reviewers independently reviewed the documented protocols of each tool to determine the underlying subtypes and disagreements were resolved through discussion. Results: There were 371 articles included with 292 tools used for the screening or diagnosis of neglect. The majority of studies (67%) included a tool that did not specify the neglect subtype being assessed, therefore an analysis of the underlying subtypes for each tool is presented. Conclusions: There is no consistency with the terms used to refer to the syndrome of spatial neglect with over 200 different terms used within the included studies to refer to the syndrome as a whole or one of its subtypes. It is essential to unify the terminology and definition for each neglect subtype. There are hundreds of neglect tools available, however many are not able to differentiate presenting subtypes. It is important for clinicians and researchers to critically evaluate the neglect tools being used for the screening and diagnosis of neglect.

Cognitive Reserve as an Emerging Concept in Stroke Recovery.

Stroke is a leading cause of death and disability. It is a complex and largely heterogeneous condition. Prognosis for variations in impairment and recovery following stroke continues to be challenging and inaccurate, highlighting the need to examine the influence of other currently unknown variables to better predict and understand interindividual differences in stroke impairment and recovery. The concept of "cognitive reserve," a feature of brain function said to moderate the relationship between brain pathology and clinical outcomes, might provide a partial explanation. This review discusses the potential significance of cognitive reserve in the context of stroke, with reference to reduced burden of disability poststroke, health promotion, intervention and secondary prevention of cognitive impairment, ease and challenges of translation into clinical practice, prognosis and prediction of recovery, and clinical decisions and trial stratification. Discussions from the review aim to encourage stroke clinicians and researchers to better consider the role of premorbid, lifestyle-related variables, such as cognitive reserve, in facilitating successful neurological outcomes and recovery following stroke.

The evidence for services to avoid or delay residential aged care admission: a systematic review.

BACKGROUND: Interventions that enable people to remain in their own home as they age are of interest to stakeholders, yet detailed information on effective interventions is scarce. Our objective was to systematically search and synthesise evidence for the effectiveness of community-based, aged care interventions in delaying or avoiding admission to residential aged care. METHOD: Nine databases were searched from January 2000 to February 2018 for English publications. Reference lists of relevant publications were searched. The databases yielded 55,221 citations and 50 citations were gleaned from other sources. Where there was sufficient homogeneity of study design, population, intervention and measures, meta-analyses were performed. Studies were grouped by the type of intervention: complex multifactorial interventions, minimal/single focus interventions, restorative programs, or by the target population (e.g. participants with dementia). RESULTS: Data from 31 randomised controlled trials (32 articles) that met our inclusion criteria were extracted and analysed. Compared to controls, complex multifactorial interventions in community aged care significantly improved older adults' ability to remain living at home (risk difference - 0.02; 95% CI -0.03, - 0.00; p = 0.04). Commonalities in the 13 studies with complex interventions were the use of comprehensive assessment, regular reviews, case management, care planning, referrals to additional services, individualised interventions, frequent client contact if required, and liaison with General Practitioners. Complex interventions did not have a significantly different effect on mortality. Single focus interventions did not show a significant effect in reducing residential aged care admissions (risk difference 0, 95% CI -0.01, 0.01; p = 0.71), nor for mortality or quality of life. Subgroup analysis of complex interventions for people with dementia showed significant risk reduction for residential aged care admissions (RD -0.05; 95% CI -0.09, -0.01; p = 0.02). Compared to controls, only interventions targeting participants with dementia had a significant effect on improving quality of life (SMD 3.38, 95% CI 3.02, 3.74; p < 0.000001). CONCLUSIONS: Where the goal is to avoid residential aged care admission for people with or without dementia, there is evidence for multifactorial, individualised community programs. The evidence suggests these interventions do not result in greater mortality and hence are safe. Minimal, single focus interventions will not achieve the targeted outcomes. TRIAL REGISTRATION: PROSPERO Registration CRD42016050086 .

A Modular Hybrid Exoskeletal-Soft Glove for High Degree of Freedom Monitoring Capability.

In this paper, we present a hybrid exoskeletal-soft glove for the application of on-axis angle sensors that can be placed close to the center of rotation of the digit joints. 3D printed exoskeletal digit segments that run medially on most digits connect to low friction bearings. Exoskeletal segments and bearings provide rigid fixation points for a variety of traditional angle sensors, while a combination of textile and rigid structure fixate exoskeletal digits to the digits and hand. Exoskeletal digits are designed modularly so that only required digits are used and to reduce difficulty in donning and doffing. On-axis measurement may prove useful in control or assessment tasks in rehabilitation. The articulation of the digits while wearing the glove is demonstrated, albeit without sensors, showing little restriction at an early stage of the design process. Exoskeletal metacarpophalangeal joints of the 3rd and 4th digits require more work as the flexion/extension joint axis is inaccessible and moves when he digits are articulated. The proposed device must be customized for an individual and will facilitate an alternative approach to existing hand posture monitoring techniques.

Does Sensory Retraining Improve Sensation and Sensorimotor Function Following Stroke: A Systematic Review and Meta-Analysis.

Background: Reduced sensation is experienced by one in two individuals following stroke, impacting both the ability to function independently and overall quality of life. Repetitive activation of sensory input using active and passive sensory-based interventions have been shown to enhance adaptive motor cortical plasticity, indicating a potential mechanism which may mediate recovery. However, rehabilitation specifically focusing on somatosensory function receives little attention. Objectives: To investigate sensory-based interventions reported in the literature and determine the effectiveness to improve sensation and sensorimotor function of individuals following stroke. Methods: Electronic databases and trial registries were searched from inception until November 2018, in addition to hand searching systematic reviews. Study selection included randomized controlled trials for adults of any stroke type with an upper and/or lower limb sensorimotor impairment. Participants all received a sensory-based intervention designed to improve activity levels or impairment, which could be compared with usual care, sham, or another intervention. The primary outcomes were change in activity levels related to sensorimotor function. Secondary outcomes were measures of impairment, participation or quality of life. Results: A total of 38 study trials were included (n = 1,093 participants); 29 explored passive sensory training (somatosensory; peripheral nerve; afferent; thermal; sensory amplitude electrical stimulation), 6 active (sensory discrimination; perceptual learning; sensory retraining) and 3 hybrid (haptic-based augmented reality; sensory-based feedback devices). Meta-analyses (13 comparisons; 385 participants) demonstrated a moderate effect in favor of passive sensory training on improving a range of upper and lower limb activity measures following stroke. Narrative syntheses were completed for studies unable to be pooled due to heterogeneity of measures or insufficient data, evidence for active sensory training is limited however does show promise in improving sensorimotor function following stroke. Conclusions: Findings from the meta-analyses and single studies highlight some support for the effectiveness of passive sensory training in relation to sensory impairment and motor function. However, evidence for active sensory training continues to be limited. Further high-quality research with rigorous methods (adequately powered with consistent outcome measures) is required to determine the effectiveness of sensory retraining in stroke rehabilitation, particularly for active sensory training.

Reliability and validity of a mobile tablet for assessing left/right judgements.

BACKGROUND: Left/right judgement (LRJ) of body parts is commonly used to assess the ability to perform implicit motor imagery and the integrity of brain-grounded maps of the body. Clinically, LRJ are often undertaken using a mobile tablet, but the concurrent validity and reliability of this approach has not yet been established. OBJECTIVES: To evaluate the concurrent validity and test-retest reliability of a mobile tablet for assessing LRJ. METHOD: Participants completed LRJ for 50 hand images (Experiment 1), and 40 back, foot, or neck images (Experiment 2) using a mobile tablet and desktop computer in random order. Participants in Experiment 2 performed a repeat test the following day to assess test-retest reliability. Accuracy and response time (RT) were recorded. RESULTS: Twenty participants aged 55.3 (±6.7) years in Experiment 1, and 37 participants aged 38.2 (±12.3) years in Experiment 2, were recruited. Concurrent validity of the mobile tablet was good to excellent for hand judgements (ICC3,1 = 0.836 for RT; ICC = 0.909 for accuracy), and was good for back, foot, and neck judgements (ICC = 0.781 for accuracy; ICC = 0.880 for RT). Test-retest reliability of the mobile tablet was good to excellent (ICC = 0.824 for accuracy; ICC = 0.903 for RT). CONCLUSIONS: The mobile tablet demonstrated good to excellent concurrent validity with the desktop computer in two separate samples. The mobile tablet also demonstrated good to excellent test-retest reliability. The mobile tablet for LRJ is a valid alternative to the original desktop version.

Access to rehabilitation for patients with stroke in Australia.

OBJECTIVE: To identify factors associated with receiving acute goal-directed treatment, being assessed for ongoing rehabilitation, and receiving post-acute rehabilitation after having a stroke. DESIGN: Retrospective analysis of National Stroke Audit data for patients with acute stroke treated at Australian hospitals during 1 September 2014 - 28 February 2015. SETTING, PARTICIPANTS: 112 Australian hospitals that admit adults with acute stroke. MAIN OUTCOMES: Associations between patient-related and organisational factors and the provision of rehabilitation interventions. RESULTS: Data for 3462 patients were eligible for analysis; their median age was 74 years, 1962 (57%) were men, and 2470 (71%) had received care in a stroke unit. 2505 patients (72%) received goal-directed treatment during their acute admission; it was not provided to 364 patients (10.5%) who were responsive, had not fully recovered, and did not refuse treatment. Factors associated with higher odds of receiving goal-directed treatment included goal-setting with the patient and their family (odds ratio [OR], 6.75; 95% CI, 5.07-8.90) and receiving care in a stroke unit (OR, 2.08; 95% CI, 1.61-2.70). 1358 patients (39%) underwent further rehabilitation after discharge from acute care; factors associated with receiving post-acute rehabilitation included care in a stroke unit (OR, 1.73; 95% CI, 1.34-2.22) and having an arm or speech deficit. Dementia was associated with lower odds of receiving acute goal-directed treatment (OR, 0.49; 95%, 0.33-0.73) and post-acute rehabilitation (OR, 0.43; 95%, 0.30-0.61). CONCLUSIONS: Access to stroke units and to early and ongoing rehabilitation for patients after stroke can be improved in Australia, both to optimise outcomes and to reduce the burden of care on underresourced community and primary care providers.

Teaching of Manual Clinical Skills in Podiatric Medicine Theory and Recommendations.

In the podiatric medicine profession, there are a variety of manual tasks that require precision and skill beyond what would be usually expected in everyday living. It is the expectation of employers, regulatory bodies, and the public that graduating podiatric physicians sufficiently meet certain minimum competencies for that profession, including those for manual skills. However, teaching and evaluation methods seem to be inconsistent between countries, institutions, and programs. This may be the consequence of uncertainty regarding the safest and most effective methods to do so. A review of available international literature pertaining to psychomotor learning across a range of health professions was undertaken. As a result of this broad review, we present herein the available evidence and make recommendations for the teaching of psychomotor skills in the podiatric medicine profession. Specific aspects considered important include methods of teaching, practice, and feedback.

A quasi-randomised, controlled, feasibility trial of GLITtER (Green Light Imaging Interpretation to Enhance Recovery)-a psychoeducational intervention for adults with low back pain attending secondary care.

BACKGROUND: Although it is broadly accepted that clinicians should endeavour to reassure patients with low back pain, to do so can present a significant clinical challenge. Guidance for how to provide effective reassurance is scarce and there may be a need to counter patient concerns arising from misinterpretation of spinal imaging findings. 'GLITtER' (Green Light Imaging Intervention to Enhance Recovery) was developed as a standardised method of communicating imaging findings in a manner that is reassuring and promotes engagement in an active recovery. This feasibility study is an important step towards definitive testing of its effect. METHODS: This feasibility study was a prospective, quasi-randomised, parallel trial with longitudinal follow-up, involving sampling of patients attending a spinal outpatient clinic at a metropolitan hospital. English speaking adults (18-75 years) presenting to the clinic with low back pain and prior spinal imaging were considered for inclusion. Eligible patients were allocated to receive a GLITtER consultation or a standard consultation (as determined by appointment scheduling and clinician availability), and were blinded to their allocation. Full details of the GLITtER intervention are described in accordance with the Tidier template.Follow-up data were collected after 1 and 3 months. The primary outcome of this study was the fulfillment of specific feasibility criteria which were established a priori. Determination of a sample size for a definitive randomised controlled trial was a secondary objective. RESULTS: Two hundred seventy-six patients underwent preliminary screening and 31 patients met the final eligibility criteria for study inclusion. Seventeen participants were allocated to the intervention group and 14 were allocated to the control group. Three month follow-up data were available from 42% of the 31 enrolled participants (N = 13, six intervention, seven control). Feasibility indicators for consent, resource burden and acceptability of the GLITtER intervention were met, however participant recruitment was slower than anticipated and an acceptable follow-up rate was not achieved. CONCLUSIONS: Failure to achieve pre-specified recruitment and follow-up rates were important outcomes of this feasibility study. We attribute failure to issues that are likely to be relevant for other clinical trials with this population. It is realistic to consider that these challenges can be overcome through careful strategy, ample funding and continued partnership with health care providers. TRIAL REGISTRATION: The trial was registered on the Australian and New Zealand Clinical Trials Registry on 28/2/2017 (ACTRN12617000317392).

Rehabilitation Interventions for Upper Limb Function in the First Four Weeks Following Stroke: A Systematic Review and Meta-Analysis of the Evidence.

OBJECTIVE: To investigate the therapeutic interventions reported in the research literature and synthesize their effectiveness in improving upper limb (UL) function in the first 4 weeks poststroke. DATA SOURCES: Electronic databases and trial registries were searched from inception until June 2016, in addition to searching systematic reviews by hand. STUDY SELECTION: Randomized controlled trials (RCTs), controlled trials, and interventional studies with pre/posttest design were included for adults within 4 weeks of any type of stroke with UL impairment. Participants all received an intervention of any physiotherapeutic or occupational therapeutic technique designed to address impairment or activity of the affected UL, which could be compared with usual care, sham, or another technique. DATA EXTRACTION: Two reviewers independently assessed eligibility of full texts, and methodological quality of included studies was assessed using the Cochrane Risk of Bias Tool. DATA SYNTHESIS: A total of 104 trials (83 RCTs, 21 nonrandomized studies) were included (N=5225 participants). Meta-analyses of RCTs only (20 comparisons) and narrative syntheses were completed. Key findings included significant positive effects for modified constraint-induced movement therapy (mCIMT) (standardized mean difference [SMD]=1.09; 95% confidence interval [CI], .21-1.97) and task-specific training (SMD=.37; 95% CI, .05-.68). Evidence was found to support supplementary use of biofeedback and electrical stimulation. Use of Bobath therapy was not supported. CONCLUSIONS: Use of mCIMT and task-specific training was supported, as was supplementary use of biofeedback and electrical simulation, within the acute phase poststroke. Further high-quality studies into the initial 4 weeks poststroke are needed to determine therapies for targeted functional UL outcomes.

The reassuring potential of spinal imaging results: development and testing of a brief, psycho-education intervention for patients attending secondary care.

PURPOSE: To develop and test a standardised method of interpreting spinal imaging findings in a manner designed to reassure patients with low back pain and promote engagement in an active recovery. METHODS: A five-phase development and testing process involved collaborative working party contributions, informal and formal appraisal of the intervention content by clinicians and consumers, a two-stage online evaluation of the take-home patient resource, and onsite testing. RESULTS: A total of 12 health professionals and 77 consumers were included in formal evaluative processes at various stages of the development and testing process. Consumers assessed the revised iteration of the take-home resource to be clearer and easier to understand than the original version. We integrated all feedback and evaluation outcomes to develop the final intervention content, which was approved by experienced clinicians and considered safe. We devised a framework to guide delivery of the low-cost clinical intervention and a 10-15-min timeframe was demonstrated to be realistic. CONCLUSIONS: We have developed, modified, and tested a pragmatic framework for a brief, psychoeducational intervention. We have established face validity and acceptability from key stakeholders and engaged clinicians and are ready to proceed with a pilot feasibility trial.

The impact of choosing words carefully: an online investigation into imaging reporting strategies and best practice care for low back pain.

BACKGROUND: Low back pain clinical practice guidelines consistently recommend against the routine ordering of spinal imaging; however, imaging is frequently requested in primary care, without evidence of benefit. Imaging reports frequently identify degenerative features which are likely to be interpreted as 'abnormal', despite their high prevalence in symptom-free individuals. The aim of this study was to investigate whether post-imaging back-related perceptions are influenced by providing prior information about normal findings, and to compare the effect of receiving imaging results with best practice care (without imaging). The impact of introducing novel, 'enhanced' reporting strategies was also explored. METHODS: This study was a simulated-patient, randomised, multiple-arm experiment. Patient scenarios were presented to volunteer healthy adult participants via an online survey. In the scenarios, 'virtual' patients with low back pain were randomised to one of three groups. Group 1 received imaging and was pre-informed about normal findings. Group 2 received imaging (without pre-information). Group 3 received best practice care: quality information without imaging. Group 1 was further divided to receive either a standard report, or an 'enhanced' report (containing altered terminology and epidemiological information). The primary outcome was back-related perceptions (BRP), a composite score derived from three numeric rating scale scores exploring perceptions of spinal condition, recovery concerns and planned activity. The secondary outcomes were satisfaction and kinesiophobia. RESULTS: Full data were available from 660 participants (68% female). Analysis of covariance revealed a significant effect of group after controlling for baseline BRP scores [Formula: see text]. Pairwise comparisons indicated that receiving best practice care resulted in more positive BRPs than receiving imaging results, and receiving prior information about normal findings had no impact. Enhanced reporting strategies also positively impacted BRPs [Formula: see text]. Significant relationships between group allocation and both satisfaction [Formula: see text] and kinaesiophobia [Formula: see text] were found, with statistically significant pairwise comparisions again in favour of best-practice care. CONCLUSION: Intervention strategies such as enhanced reporting methods and the provision of quality information (without imaging) have the potential to improve the outcome of patients with recent-onset LBP and should be further considered by primary care providers.

Task-oriented interventions for children with developmental co-ordination disorder.

BACKGROUND: Developmental co-ordination disorder (DCD) is a common childhood disorder, which can persist into adolescence and adulthood. Children with DCD have difficulties in performing the essential motor tasks required for self-care, academic, social and recreational activities. OBJECTIVES: To assess the effectiveness of task-oriented interventions on movement performance, psychosocial functions, activity, and participation for children with DCD and to examine differential intervention effects as a factor of age, sex, severity of DCD, intervention intensity, and type of intervention. SEARCH METHODS: In March 2017, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, 13 other databases, and five trials registers. We also searched reference lists, and contacted members of the mailing list of the International Conference on DCD to identify additional studies. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) and quasi-RCTs that compared the task-oriented intervention with either an inactive control intervention or an active control intervention in children and adolescents aged four to 18 years with a diagnosis of DCD.Types of outcome measures included changes in motor function, as assessed by standardised performance outcome tests and questionnaires; adverse events; and measures of participation. DATA COLLECTION AND ANALYSIS: All review authors participated in study selection, data extraction, and assessments of risk of bias and quality, and two review authors independently performed all tasks. Specifically, two review authors independently screened titles and abstracts to eliminate irrelevant studies, extracted data from the included studies, assessed risk of bias, and rated the quality of the evidence using the GRADE approach. In cases of ambiguity or information missing from the paper, one review author contacted trial authors. MAIN RESULTS: This review included 15 studies (eight RCTs and seven quasi-RCTs). Study characteristicsThe trials included 649 participants of both sexes, ranging in age from five to 12 years.The participants were from Australia, Canada, China, Sweden, Taiwan, and the UK.Trials were conducted in hospital settings; at a university-based clinic, laboratory, or centre; in community centres; at home or school, or both at home and school.The durations of task-oriented interventions were mostly short term (less than six months), with the total number of sessions ranging from five to 50. The length of each session ranged from 30 to 90 minutes, and the frequencies ranged from once to seven times per week.We judged the risk of bias as moderate to high across the studies. Some elements were impossible to achieve (such as blinding of administering personnel or participants). KEY RESULTS: primary outcomesA meta-analysis of two RCTs and four quasi-RCTs found in favour of task-oriented interventions for improved motor performance compared to no intervention (mean difference (MD) -3.63, 95% confidence interval (CI) -5.88 to -1.39; P = 0.002; I2 = 43%; 6 trials, 169 children; very low-quality evidence).A meta-analysis of two RCTs found no effect of task-oriented interventions for improved motor performance compared to no intervention (MD -2.34, 95% CI -7.50 to 2.83; P = 0.38; I2 = 42%; 2 trials, 51 children; low-quality evidence).Two studies reported no adverse effects or events. Through personal correspondence, the authors of nine studies indicated that no injuries had occurred. KEY RESULTS: secondary outcomesDue to the limited number of studies with complete and consistent data, we were unable to perform any meta-analyses on our secondary measures or any subgroup analysis on age, sex, severity of DCD, and intervention intensity. AUTHORS' CONCLUSIONS: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect. The conclusions drawn from previous reviews, which unanimously reported beneficial effects of intervention, are inconsistent with our conclusions. This review highlights the need for carefully designed and executed RCTs to investigate the effect of interventions for children with DCD.

Inequities in access to inpatient rehabilitation after stroke: an international scoping review.

Background Inequities in accessing inpatient rehabilitation after stroke have been reported in many countries and impact on patient outcomes. Objective To explore variation in international recommendations regarding which patients should receive inpatient rehabilitation after stroke and to describe reported access to rehabilitation. Methods A scoping review was conducted to identify clinical guidelines with recommendations regarding which patients should access inpatient rehabilitation after stroke, and data regarding the proportion of patients accessing stroke rehabilitation. Four bibliographic databases and grey literature were searched. Results Twenty-eight documents were included. Selection criteria for post-acute inpatient rehabilitation were identified for 14 countries or regions and summary data on the proportion of patients receiving inpatient rehabilitation were identified for 14 countries. In Australia, New Zealand, and the United Kingdom, it is recommended that all patients with stroke symptoms should access rehabilitation, whereas guidelines from the United States, Canada, and Europe did not consistently recommend rehabilitation for people with severe stroke. Access to inpatient rehabilitation ranged from 13% in Sweden to 57% in Israel. Differences in availability of early supported discharge/home rehabilitation programs and variations in reporting methods may influence the ability to reliably compare access to rehabilitation between regions. Conclusion Recommendations regarding which patients with moderate and severe strokes should access ongoing rehabilitation are inconsistent. Clinical practice guidelines from different countries regarding post-stroke rehabilitation do not always reflect the evidence regarding the likely benefits to people with stroke. Inequity in access to rehabilitation after stroke is an international issue.

Circuit class therapy for improving mobility after stroke.

BACKGROUND: Circuit class therapy (CCT) offers a supervised group forum for people after stroke to practise tasks, enabling increased practice time without increasing staffing. This is an update of the original review published in 2010. OBJECTIVES: To examine the effectiveness and safety of CCT on mobility in adults with stroke. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched January 2017), CENTRAL (the Cochrane Library, Issue 12, 2016), MEDLINE (1950 to January 2017), Embase (1980 to January 2017), CINAHL (1982 to January 2017), and 14 other electronic databases (to January 2017). We also searched proceedings from relevant conferences, reference lists, and unpublished theses; contacted authors of published trials and other experts in the field; and searched relevant clinical trials and research registers. SELECTION CRITERIA: Randomised controlled trials (RCTs) including people over 18 years old, diagnosed with stroke of any severity, at any stage, or in any setting, receiving CCT. DATA COLLECTION AND ANALYSIS: Review authors independently selected trials for inclusion, assessed risk of bias in all included studies, and extracted data. MAIN RESULTS: We included 17 RCTs involving 1297 participants. Participants were stroke survivors living in the community or receiving inpatient rehabilitation. Most could walk 10 metres without assistance. Ten studies (835 participants) measured walking capacity (measuring how far the participant could walk in six minutes) demonstrating that CCT was superior to the comparison intervention (Six-Minute Walk Test: mean difference (MD), fixed-effect, 60.86 m, 95% confidence interval (CI) 44.55 to 77.17, GRADE: moderate). Eight studies (744 participants) measured gait speed, again finding in favour of CCT compared with other interventions (MD 0.15 m/s, 95% CI 0.10 to 0.19, GRADE: moderate). Both of these effects are considered clinically meaningful. We were able to pool other measures to demonstrate the superior effects of CCT for aspects of walking and balance (Timed Up and Go: five studies, 488 participants, MD -3.62 seconds, 95% CI -6.09 to -1.16; Activities of Balance Confidence scale: two studies, 103 participants, MD 7.76, 95% CI 0.66 to 14.87). Two other pooled balance measures failed to demonstrate superior effects (Berg Blance Scale and Step Test). Independent mobility, as measured by the Stroke Impact Scale, Functional Ambulation Classification and the Rivermead Mobility Index, also improved more in CCT interventions compared with others. Length of stay showed a non-significant effect in favour of CCT (two trials, 217 participants, MD -16.35, 95% CI -37.69 to 4.99). Eight trials (815 participants) measured adverse events (falls during therapy): there was a non-significant effect of greater risk of falls in the CCT groups (RD 0.03, 95% CI -0.02 to 0.08, GRADE: very low). Time after stroke did not make a difference to the positive outcomes, nor did the quality or size of the trials. Heterogeneity was generally low; risk of bias was variable across the studies with poor reporting of study conduct in several of the trials. AUTHORS' CONCLUSIONS: There is moderate evidence that CCT is effective in improving mobility for people after stroke - they may be able to walk further, faster, with more independence and confidence in their balance. The effects may be greater later after the stroke, and are of clinical significance. Further high-quality research is required, investigating quality of life, participation and cost-benefits, that compares CCT with standard care and that also investigates the influence of factors such as stroke severity and age. The potential risk of increased falls during CCT needs to be monitored.

A qualitative evaluation of scalpel skill teaching of podiatry students.

BACKGROUND: Degrees in health disciplines need a balance of theoretical knowledge and sufficient clinical practice to meet registration requirements, in particular those requiring specialist skills such as the use of scalpels and other small instruments, such as podiatry. However, despite this requirement there is a scarcity of literature and research to inform teaching of these particular manual clinical skills. Therefore, the aims of this study were to determine the current approaches being used to teach manual skills, in particular scalpel skills, in university podiatry programs in Australia and New Zealand, and to explore what issues, challenges and innovations exist. METHODS: A qualitative study, consisting of semi-structured interviews with staff at eight university podiatry programs in Australia and New Zealand was undertaken to determine how these skills are taught and evaluated, and how poor performers are managed. A conventional content analysis technique was used to analyse and code interview data, with the resultant categories reported. RESULTS: Approaches to teaching manual clinical skills, in particular scalpel skills, appear to be consistent between university programs in Australia and New Zealand in utilising didactic-style content, demonstration, physical practice on inanimate objects and real skin, and often the use of supplementary audio-visual material. The main reported differences between programs were in methods and processes of practice, with controversy regarding the use of inanimate objects versus real skin for practice. CONCLUSIONS: Despite a lack of research and literature surrounding this topic, the approach to teaching is relatively consistent between programs with greatest disparity being the structure and duration of practice. Key issues for teaching staff in teaching manual skills were students' clinical exposure, motivation, levels of anxiety and dexterity.