NeuroRehabilitation OnLine: Description of a regional multidisciplinary group telerehabilitation innovation for stroke and neurological conditions using the Template for Intervention Description and Replication checklist.

Background: Providing recommended amounts of rehabilitation for stroke and neurological patients is challenging. Telerehabilitation is viable for delivering rehabilitation and an acceptable adjunct to in-person therapy. NeuroRehabilitation OnLine (NROL) was developed as a pilot and subsequently operationalised as a regional innovation embedded across four National Health Service (NHS) Trusts. Objective: To describe the NROL innovation to assist future implementation and replication efforts. Methods: The Template for Intervention Description and Replication (TIDieR) checklist, with guidance from the TIDieR-Telehealth extension, was used to describe NROL. The description was developed collaboratively by clinical academics, therapists, managers and researchers. Updated Consolidated Framework for Implementation Research domains were used to describe the context in which the innovation was delivered. Results: NROL delivers online group-based real-time neurorehabilitation with technology assistance. It incorporates multidisciplinary targeted therapy and peer support to complement existing therapy. Procedures, materials and structure are detailed to demonstrate how NROL is embedded within a healthcare system. NROL uses existing NHS therapy workforce alongside dedicated NROL roles, including an essential technology support role. Selection of NROL groups is dependent on patient needs. The NROL innovation is tailored over time in response to feedback. NROL described here is successfully integrated within a regional stroke and neurorehabilitation network, aligns with local and national strategies and capitalises on an existing clinical-academic partnership. Conclusion: This comprehensive description of a regional NROL innovation, and clarification of core components, should facilitate other healthcare settings to adapt and implement NROL for their context. Continuous evaluation alongside implementation will ensure maximal impact for neurorehabilitation.

Great expectations? A qualitative study of health professionals' perspectives on breaking bad news about rehabilitation potential after traumatic brain injury or spinal injury.

Background: Neurorehabilitation units play an important role in facilitating recovery for those with complex needs following a neurological event. National guidance highlights the importance of providing patients and their families with information and fostering realistic expectations. This may involve the breaking of bad news. The aim of this study is to explore health professionals' perspectives on breaking bad news in the neurorehabilitation setting.Method: 15 health professionals (physiotherapists, occupational therapists, nurses, speech therapists, psychologists and doctors) working at a 24 bedded neurorehabilitation unit in a National Health Service acute trust in England were recruited. A qualitative study was conducted using patient vignettes to facilitate discussions during semi-structured interviews and a focus group. The results were analyzed using thematic analysis.Results: Four major themes emerged: influencing factors, current approaches used, staff experiences, and strategies to improve breaking bad news. There was a need for better management of patients' and families' expectations. Breaking bad news was seen as emotionally demanding yet often unrecognized work.Conclusions: Breaking bad news in the neurorehabilitation setting is complex and under-recognized work, involving multiple health professionals. There is a need for both experience and training to improve skills and confidence in breaking bad news.Implications for RehabilitationExisting tools to support breaking bad news provide a structured step by step approach which may be helpful, but it is recognised there is also a need for experience, reflection, flexibility, and individualisation of the process.Discussing information about rehabilitation potential may be stressful for health professionals themselves and adversely affect their own well-being.Both novice and experienced staff require opportunities for reflective practice and training to develop the skills they need to discuss rehabilitation potential.

Current therapy for the upper limb after stroke: a cross-sectional survey of UK therapists.

OBJECTIVES: To survey the reported content, frequency and duration of upper limb treatment provided by occupational and physiotherapists for people after stroke in the UK. DESIGN: A cross-sectional online survey was used. Description and analysis of the data were based on items from the Template for Intervention Description and Replication (Who, Where, What and How much). SETTING: The online survey was distributed via professional and social networks to UK-based therapists. PARTICIPANTS: Respondents were occupational or physiotherapists currently working clinically in the UK with people after stroke. Over the 6 week data collection period, 156 respondents opened the survey, and 154 completed it. Respondents comprised 85 physiotherapists and 69 occupational therapists. RESULTS: Respondents reported treating the upper limb a median of three times a week (range: 1 to 7) for a mean of 29 min (SD: 18). Most (n=110) stated this was supplemented by rehabilitation assistants, family and/or carers providing additional therapy a median of three times a week (range 1 to 7). Functional training was the most commonly reported treatment for people with mild and moderate upper limb deficits (>40%). There was much less consistency in treatments reported for people with severe upper limb deficits with less than 20% (n=28) reporting the same treatments. CONCLUSIONS: This study provides a contemporaneous description of reported therapy in the UK for people with upper limb deficits after stroke and a detailed template to inform standard therapy interventions in future research. Several evidence-based therapies were reported to be used by respondents (eg, constraint induced movement therapy), but others were not (eg, mental imagery). The findings also highlight that the current reported provision of upper limb therapy is markedly less than what is likely to be effective. This underlines an urgent need to configure and fund services to empower therapists to deliver greater amounts of evidence-based treatment for people with upper limb deficits after stroke.

Influence of NOS1 on verbal intelligence and working memory in both patients with schizophrenia and healthy control subjects.

CONTEXT: Human and animal studies have implicated the gene NOS1 in both cognition and schizophrenia susceptibility. OBJECTIVE: To investigate whether a potential schizophrenia risk single-nucleotide polymorphism (rs6490121) identified in a recent genome-wide association study negatively influences cognition in patients with schizophrenia and healthy control subjects. DESIGN: A comparison of both cases and controls grouped according to NOS1 genotype (GG vs AG vs AA) on selected measures of cognition in 2 independent samples. We tested for association between NOS1 rs6490121 and cognitive functions known to be impaired in schizophrenia (IQ, episodic memory, working memory, and attentional control) in an Irish sample. We then sought to replicate the significant results in a German sample. SETTING: Unrelated patients from general adult psychiatric inpatient and outpatient services and unrelated healthy volunteers from the general population were ascertained. PARTICIPANTS: Patients with DSM-IV-diagnosed schizophrenia and healthy control subjects from independent samples of Irish (cases, n = 349; controls, n = 230) and German (cases, n = 232; controls, n = 1344) nationality. RESULTS: A main effect of NOS1 genotype on verbal IQ and working memory was observed in the Irish sample where the homozygous carriers of the schizophrenia risk G allele performed poorly compared with the other genotype groups. These findings were replicated in the German sample, again with the GG genotype carriers performing below other genotype groups. Post hoc analysis of additional IQ measures (full-scale and performance IQ) in the German sample revealed that NOS1 GG carriers underperformed on these measures also. CONCLUSIONS: NOS1 is associated with clinically significant variation in cognition. Whether this is a mechanism by which schizophrenia risk is increased (eg, via an influence on cognitive reserve) is yet to be confirmed.