A translational roadmap for transcranial magnetic and direct current stimulation in stroke rehabilitation: Consensus-based core recommendations from the third stroke recovery and rehabilitation roundtable.

BACKGROUND AND AIMS: The purpose of this Third Stroke Recovery and Rehabilitation Roundtable (SRRR3) was to develop consensus recommendations to address outstanding barriers for the translation of preclinical and clinical research using the non-invasive brain stimulation (NIBS) techniques Transcranial Magnetic Stimulation (TMS) and Transcranial Direct Current Stimulation (tDCS) and provide a roadmap for the integration of these techniques into clinical practice. METHODS: International NIBS and stroke recovery experts (N = 18) contributed to the consensus process. Using a nominal group technique, recommendations were reached via a five-stage process, involving a thematic survey, two priority ranking surveys, a literature review and an in-person meeting. RESULTS AND CONCLUSIONS: Results of our consensus process yielded five key evidence-based and feasibility barriers for the translation of preclinical and clinical NIBS research, which were formulated into five core consensus recommendations. Recommendations highlight an urgent need for (1) increased understanding of NIBS mechanisms, (2) improved methodological rigor in both preclinical and clinical NIBS studies, (3) standardization of outcome measures, (4) increased clinical relevance in preclinical animal models, and (5) greater optimization and individualization of NIBS protocols. To facilitate the implementation of these recommendations, the expert panel developed a new SRRR3 Unified NIBS Research Checklist. These recommendations represent a translational pathway for the use of NIBS in stroke rehabilitation research and practice.

A translational roadmap for transcranial magnetic and direct current stimulation in stroke rehabilitation: Consensus-based core recommendations from the third stroke recovery and rehabilitation roundtable.

BACKGROUND AND AIMS: The purpose of this Third Stroke Recovery and Rehabilitation Roundtable (SRRR3) was to develop consensus recommendations to address outstanding barriers for the translation of preclinical and clinical research using the non-invasive brain stimulation (NIBS) techniques Transcranial Magnetic Stimulation (TMS) and Transcranial Direct Current Stimulation (tDCS) and provide a roadmap for the integration of these techniques into clinical practice. METHODS: International NIBS and stroke recovery experts (N = 18) contributed to the consensus process. Using a nominal group technique, recommendations were reached via a five-stage process, involving a thematic survey, two priority ranking surveys, a literature review and an in-person meeting. RESULTS AND CONCLUSIONS: Results of our consensus process yielded five key evidence-based and feasibility barriers for the translation of preclinical and clinical NIBS research, which were formulated into five core consensus recommendations. Recommendations highlight an urgent need for (1) increased understanding of NIBS mechanisms, (2) improved methodological rigor in both preclinical and clinical NIBS studies, (3) standardization of outcome measures, (4) increased clinical relevance in preclinical animal models, and (5) greater optimization and individualization of NIBS protocols. To facilitate the implementation of these recommendations, the expert panel developed a new SRRR3 Unified NIBS Research Checklist. These recommendations represent a translational pathway for the use of NIBS in stroke rehabilitation research and practice.

Supporting post-stroke access to services and resources for individuals with low income: understanding usual care practices in acute care and rehabilitation settings.

PURPOSE: Following stroke, individuals who live in a low-income or are at risk of living in a low-income situation face challenges with timely access to social services and community resources. Understanding the usual care practices of stroke teams, specifically, how they support this access to services and resources, is an important first step in promoting the implementation of practice change. METHOD: A qualitative multiple-case study of acute care, inpatient, and outpatient rehabilitation stroke teams in an urban area of Canada. Semi-structured interviews and questionnaires about the workplace context were conducted with 19 professionals (social workers, occupational therapists, physiotherapists, speech-language pathologists) at four sites. RESULTS: In their usual practice, stroke teams prioritized immediate care needs. The stroke team professionals did not address income or resources unless it directly affected discharge. Usual care was influenced by factors such as time constraints, lack of knowledge about services and resources, and social service system limitations. CONCLUSION: To better support post-stroke access to social services and resource for low-income individuals, a multidisciplinary approach, with actions beginning earlier on and extending throughout the continuum of care, is recommended, in addition to system-level advocacy.

Access to social services and community resources for people with stroke and living in a low-income situation is not consistently addressed in acute care or rehabilitation settings.Supporting access to social services and community resources is influenced by the professionals' availability of time and resources, as well as knowledge about services and resources and the limitations of the social service system.Using a multidisciplinary approach, extending over the continuum of care from acute care to rehabilitation program may be a way forward to better support people with stroke and low income to access services and resources.

Identification and description of telerehabilitation assessments for individuals with neurological conditions: A scoping review.

Background: The clinical adoption of telerehabilitation accelerated rapidly over the last few years, creating opportunities for clinicians and researchers to explore the use of digital technologies and telerehabilitation in the assessment of deficits related to neurological conditions. The objectives of this scoping review were to identify outcome measures used to remotely assess the motor function and participation in people with neurological conditions and report, when available, the psychometric data of these remote outcome measures. Methods: MEDLINE (Ovid), CINAHL, PubMed, PsychINFO, EMBASE, and Cochrane databases were searched between December 13, 2020, and January 4, 2021, for studies investigating the use of remote assessments to evaluate motor function and participation in people with neurological conditions. An updated search was completed on May 9, 2022, using the same databases and search terms. Two reviewers independently screened each title and abstract, followed by full-text screening. Data extraction was completed using a pre-piloted data extraction sheet where outcome measures were reported as per the International Classification of Functioning, Disability and Health. Results: Fifty studies were included in this review. Eighteen studies targeted outcomes related to body structures and 32 targeted those related to activity limitation and participation restriction. Seventeen studies reported psychometric data; of these, most included reliability and validity data. Conclusion: Clinical assessments of motor function of people living with neurological conditions can be completed in a telerehabilitation or remote context using validated and reliable remote assessment measures.

Implementation of increased physical therapy intensity for improving walking after stroke: Walk 'n watch protocol for a multisite stepped-wedge cluster-randomized controlled trial.

RATIONALE: Clinical practice guidelines support structured, progressive protocols for improving walking after stroke. Yet, practice is slow to change, evidenced by the little amount of walking activity in stroke rehabilitation units. Our recent study (n = 75) found that a structured, progressive protocol integrated with typical daily physical therapy improved walking and quality-of-life measures over usual care. Research therapists progressed the intensity of exercise by using heart rate and step counters worn by the participants with stroke during therapy. To have the greatest impact, our next step is to undertake an implementation trial to change practice across stroke units where we enable the entire unit to use the protocol as part of standard of care. AIMS: What is the effect of introducing structured, progressive exercise (termed the Walk 'n Watch protocol) to the standard of care on the primary outcome of walking in adult participants with stroke over the hospital inpatient rehabilitation period? Secondary outcomes will be evaluated and include quality of life. METHODS AND SAMPLE SIZE ESTIMATES: This national, multisite clinical trial will randomize 12 sites using a stepped-wedge design where each site will be randomized to deliver Usual Care initially for 4, 8, 12, or 16 months (three sites for each duration). Then, each site will switch to the Walk 'n Watch phase for the remaining duration of a total 20-month enrolment period. Each participant will be exposed to either Usual Care or Walk 'n Watch. The trial will enroll a total of 195 participants with stroke to achieve a power of 80% with a Type I error rate of 5%, allowing for 20% dropout. Participants will be medically stable adults post-stroke and able to take five steps with a maximum physical assistance from one therapist. The Walk 'n Watch protocol focuses on completing a minimum of 30 min of weight-bearing, walking-related activities (at the physical therapists' discretion) that progressively increase in intensity informed by activity trackers measuring heart rate and step number. STUDY OUTCOME(S): The primary outcome will be the change in walking endurance, measured by the 6-Minute Walk Test, from baseline (T1) to 4 weeks (T2). This change will be compared across Usual Care and Walk 'n Watch phases using a linear mixed-effects model. Additional physical, cognitive, and quality of life outcomes will be measured at T1, T2, and 12 months post-stroke (T3) by a blinded assessor. DISCUSSION: The implementation of stepped-wedge cluster-randomized trial enables the protocol to be tested under real-world conditions, involving all clinicians on the unit. It will result in all sites and all clinicians on the unit to gain expertise in protocol delivery. Hence, a deliberate outcome of the trial is facilitating changes in best practice to improve outcomes for participants with stroke in the trial and for the many participants with stroke admitted after the trial ends.

Accuracy and effectiveness of teledentistry: a systematic review of systematic reviews.

Introduction The COVID-19 pandemic has urged healthcare systems to develop new ways to safely provide care. Telehealth has become a compelling alternative. Our purpose was to evaluate the accuracy and effectiveness of teledentistry for screening, diagnosis and therapeutic management of dental care in children and adults.Methods We conducted a systematic review (SR) of systematic reviews. Multiple databases, the grey literature and conference archives were searched. Eligible SRs included those reporting virtual screening, diagnostic investigations and therapeutic interventions. Two investigators independently reviewed abstracts, articles, critically appraised SRs and extracted the data.Results We identified 817 citations and included six SRs. The accepted SRs involved >7,000 participants, used primarily asynchronous communication for diagnostic/screening outcomes and used synchronous communication for treatment outcomes. SRs were of low quality and included 30 primary studies of our interest. Sensitivity and specificity for dental referrals and diagnostic treatment planning were higher than other index/reference tests, ranging from 80-88% and 73-95%, respectively. Treatment outcome measured patient compliance and professional supervision.Conclusion This SR provides the best existing evidence for clinical decision-making involving teledentistry. Current evidence supports teledentistry as an effective means for dental referrals, treatment planning and compliance and treatment viability. Asynchronous communication and the adoption of smartphones for image capturing are feasible and convenient for the implementation of teledentistry.

The Use of Home-Based Nonimmersive Virtual Reality to Encourage Physical and Cognitive Exercise in People With Mild Cognitive Impairment: A Feasibility Study.

Individuals with mild cognitive impairment are at risk of cognitive and physical decline. Virtual reality (VR) exercise may provide beneficial physical and cognitive exercise. The objectives of this study were to assess the feasibility and safety of home-based VR exercise and to provide pilot data for physical and cognitive efficacy. Eleven individuals with mild cognitive impairment (seven males/four females, average 78 years old, and average 3 years since diagnosis) performed a 30-min home-based VR exercise program 5 days a week for 6 weeks. The VR platform was successfully installed in participants' homes, and all participants were able to learn the VR program and progress. Participants completed 99% of the prescribed exercise. There were no major adverse events. Most participants enjoyed the VR program and reported physical benefits; fewer reported cognitive benefits. No physical or cognitive outcome measures showed change after 6 weeks. Home-based VR exercise is safe and feasible in individuals with mild cognitive impairment.

Impact of an artist-in-residence program in a complex continuing care hospital: a quality improvement investigation.

BACKGROUND: The objective was to assess the impact of an Artist-in-Residence (AiR) program on the quality of life of patients living at a complex continuing care hospital. METHODS: In the AiR program, a professional Artist facilitated the creation of community art projects by patients in groups (before COVID-19) and individually (during COVID-19). Four patients, four staff and one family member involved with the program were interviewed to assess their experiences. RESULTS: Themes identified included improvements in spiritual, mental and community health, creation of a sense of community, learning skills and knowledge surrounding art and culture, and the importance of the Artist's personal characteristics/personality. It was recommended to continue and expand the program. CONCLUSIONS: The patients deeply enjoyed the AiR program and working with the Artist. Non-patient participants also recognized benefits for the hospital community. Procurement of stable funding and expansion of the program are areas to focus on next.

Identification and Description of Balance, Mobility, and Gait Assessments Conducted via Telerehabilitation for Individuals With Neurological Conditions: Protocol for a Scoping Review.

BACKGROUND: The COVID-19 global pandemic pushed many rehabilitation practitioners to pivot their in-person practice to adopt telerehabilitation as their main method of delivery. In addition to documenting information on interventions used with clients, it is best practice for therapists to use reliable and validated outcome measures to inform their interventions. OBJECTIVE: Through this scoping review, we aim to identify (1) which outcomes are being used remotely to assess balance, mobility, and gait in patients with neurological conditions, and (2) what psychometric data (validity, reliability, etc.) for remotely administered outcomes are available. METHODS: Three main concepts will be included in our search: (1) neurological conditions; (2) administration by telerehabilitation; and (3) outcome measures for balance, mobility, and gait. Studies reporting remote assessment of neurological conditions published since 1990 will be included. The database search will be completed in MEDLINE (Ovid), CINAHL, PubMed, PsycINFO, EMBASE, and Cochrane. Gray literature including dissertations, conference papers, and protocol papers will also be sourced. Two reviewers will independently screen each title and abstract using pre-established inclusion and exclusion criteria. Manuscripts that appear to meet the criteria will be subject to further review, and full-text extraction using a pre-piloted extraction sheet if all criteria are met. The data will be categorized by assessment types describing impairments (such as balance, strength, and mobility) or activity limitations or participation restriction (such as functional mobility, ambulatory functions, and activities of daily living). RESULTS: This scoping review will document outcome measures currently used in the remote assessment of neurological conditions. To date, 235 titles and abstracts were screened. We are in the process of finalizing the full text screening for the inclusion of articles. We expect the full screening to be completed in November 2021 and data analysis in January 2022. Our results are expected to be published in early 2022. CONCLUSIONS: The optimal use of telerehabilitation as a mode to deliver rehabilitation intervention should be coupled with the completion of validated outcome measures. Therefore, it is crucial to further our knowledge on remote outcome measures and therapeutic assessments. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/27186.

Health, social care and technological interventions to improve functional ability of older adults living at home: An evidence and gap map.

Background: By 2030, the global population of people older than 60 years is expected to be higher than the number of children under 10 years, resulting in major health and social care system implications worldwide. Without a supportive environment, whether social or built, diminished functional ability may arise in older people. Functional ability comprises an individual's intrinsic capacity and people's interaction with their environment enabling them to be and do what they value. Objectives: This evidence and gap map aims to identify primary studies and systematic reviews of health and social support services as well as assistive devices designed to support functional ability among older adults living at home or in other places of residence. Search Methods: We systematically searched from inception to August 2018 in: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL, PsycINFO, AgeLine, Campbell Library, ASSIA, Social Science Citation Index and Social Policy & Practice. We conducted a focused search for grey literature and protocols of studies (e.g., ProQuest Theses and Dissertation Global, conference abstract databases, Help Age, PROSPERO, Cochrane and Campbell libraries and ClinicalTrials.gov). Selection Criteria: Screening and data extraction were performed independently in duplicate according to our intervention and outcome framework. We included completed and on-going systematic reviews and randomized controlled trials of effectiveness on health and social support services provided at home, assistive products and technology for personal indoor and outdoor mobility and transportation as well as design, construction and building products and technology of buildings for private use such as wheelchairs, and ramps. Data Collection and Analysis: We coded interventions and outcomes, and the number of studies that assessed health inequities across equity factors. We mapped outcomes based on the International Classification of Function, Disability and Health (ICF) adapted categories: intrinsic capacities (body function and structures) and functional abilities (activities). We assessed methodological quality of systematic reviews using the AMSTAR II checklist. Main Results: After de-duplication, 10,783 records were screened. The map includes 548 studies (120 systematic reviews and 428 randomized controlled trials). Interventions and outcomes were classified using domains from the International Classification of Function, Disability and Health (ICF) framework. Most systematic reviews (n = 71, 59%) were rated low or critically low for methodological quality.The most common interventions were home-based rehabilitation for older adults (n = 276) and home-based health services for disease prevention (n = 233), mostly delivered by visiting healthcare professionals (n = 474). There was a relative paucity of studies on personal mobility, building adaptations, family support, personal support and befriending or friendly visits. The most measured intrinsic capacity domains were mental function (n = 269) and neuromusculoskeletal function (n = 164). The most measured outcomes for functional ability were basic needs (n = 277) and mobility (n = 160). There were few studies which evaluated outcome domains of social participation, financial security, ability to maintain relationships and communication.There was a lack of studies in low- and middle-income countries (LMICs) and a gap in the assessment of health equity issues. Authors' Conclusions: There is substantial evidence for interventions to promote functional ability in older adults at home including mostly home-based rehabilitation for older adults and home-based health services for disease prevention. Remotely delivered home-based services are of greater importance to policy-makers and practitioners in the context of the COVID-19 pandemic. This map of studies published prior to the pandemic provides an initial resource to identify relevant home-based services which may be of interest for policy-makers and practitioners, such as home-based rehabilitation and social support, although these interventions would likely require further adaptation for online delivery during the COVID-19 pandemic. There is a need to strengthen assessment of social support and mobility interventions and outcomes related to making decisions, building relationships, financial security, and communication in future studies. More studies are needed to assess LMIC contexts and health equity issues.

Implementation of a randomized controlled trial on an inpatient stroke rehabilitation unit: Lessons learned.

BACKGROUND/AIMS: The objective of this manuscript is to present challenges and solutions that arose during a mid-sized single-site RCT of a rehabilitation intervention performed in an inpatient stroke rehabilitation setting. METHODS: Seventy-six participants from an inpatient stroke rehabilitation unit were randomized to experimental and control groups. All participants did 30-45 min of virtual reality (VR) daily for 10-12 sessions. The experimental group did VR targeting sitting balance while the control group did VR with limited arm movement. Challenges during the implementation of the RCT were documented and strategies to mitigate them were applied. RESULTS: Challenges were placed into five categories:1. Recruitment. Our recruitment procedures required multiple steps prior to initiating direct patient contact; one solution would be to have patients consent to be approached about research upon admission to the inpatient unit.2. Patient-specific Issues. Fatigue, pain, vision problems and engagement were managed through scheduling, increasing the workload slowly and personalized modifications to the VR.3./4. Scheduling and Staffing. Recruitment and attendance at VR sessions were maximized through good communication, flexibility and cooperation, between research staff, clinical staff, volunteers, students and participants.5. Technology. Because hospital internet service was poor, a mobile internet data plan was purchased to ensure the system's reliability. CONCLUSIONS: We have identified challenges in delivering a rehabilitation intervention on an inpatient stroke rehabilitation unit and some of the measures taken to surmount these challenges. Through good planning, flexibility and collaboration, almost all of the challenges were successfully addressed. CLINICAL TRIAL REGISTRATION NUMBER: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02285933.

Considerations for Postacute Rehabilitation for Survivors of COVID-19.

Coronavirus disease (COVID-19), the infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported on December 31, 2019. Because it has only been studied for just over three months, our understanding of this disease is still incomplete, particularly regarding its sequelae and long-term outcomes. Moreover, very little has been written about the rehabilitation needs of patients with COVID-19 after discharge from acute care. The objective of this report is to answer the question "What rehabilitation services do survivors of COVID-19 require?" The question was asked within the context of a subacute hospital delivering geriatric inpatient and outpatient rehabilitation services. Three areas relevant to rehabilitation after COVID-19 were identified. First, details of how patients may present have been summarized, including comorbidities, complications from an intensive care unit stay with or without intubation, and the effects of the virus on multiple body systems, including those pertaining to cardiac, neurological, cognitive, and mental health. Second, I have suggested procedures regarding the design of inpatient rehabilitation units for COVID-19 survivors, staffing issues, and considerations for outpatient rehabilitation. Third, guidelines for rehabilitation (physiotherapy, occupational therapy, speech-language pathology) following COVID-19 have been proposed with respect to recovery of the respiratory system as well as recovery of mobility and function. A thorough assessment and an individualized, progressive treatment plan which focuses on function, disability, and return to participation in society will help each patient to maximize their function and quality of life. Careful consideration of the rehabilitation environment will ensure that all patients recover as completely as possible.

Sitting Balance Exercise Performed Using Virtual Reality Training on a Stroke Rehabilitation Inpatient Service: A Randomized Controlled Study.

BACKGROUND: Virtual reality training (VRT) is engaging and may enhance rehabilitation intensity. Only one previous study has looked at its use to improve sitting balance after stroke. OBJECTIVE: To determine if supplemental sitting balance exercises, administered via VRT, improve control of sitting balance and upper extremity function in stroke rehabilitation inpatients. DESIGN: Assessor-blinded, placebo-controlled randomized controlled trial. SETTING: Stroke inpatient rehabilitation unit. PARTICIPANTS: Seventy-six participants (out of 130 approached) with subacute stroke who could not stand independently were randomized to experimental and control groups. Sixty-nine completed the study. INTERVENTIONS: The experimental group did VRT that required leaning and reaching, whereas the control group had their trunk restrained and performed VRT that involved only small upper extremity movements to minimize trunk movement. Both groups performed 10-12 sessions of 30-45 minutes. Participants were assessed pre, post, and 1 month after the sessions by a blinded examiner. OUTCOME MEASURES: Function in Sitting Test (FIST, primary outcome measure); Ottawa Sitting Scale; Reaching Performance Scale; Wolf Motor Function Test (WMFT). RESULTS: Thirty-three participants completed the experimental intervention and 36 the control. Pre/post differences for FIST were 3.4 (confidence interval [CI] 0.5;6.3) for the experimental group and 5.3 (2.9;7.7) for the control group. There was a significant improvement over time (adjusted for multiple comparisons, P < .006) on most outcome measures except the WMFT Performance Time Scale (control group; P = .007) and grip strength (P = .008); there were no differences between groups (P > .006). CONCLUSIONS: Siting balance outcomes were similar for both groups; therefore, this study does not support the use of sitting balance exercises provided via VRT for the rehabilitation of sitting balance after stroke. However, because it is only the second study to investigate VRT for sitting balance and upper extremity function, more research, using more challenging exercises and a greater treatment intensity, is required before definitive conclusions are made.

Centre of pressure displacements produced in sitting during virtual reality training in younger and older adults and patients who have had a stroke.

Purpose: Poor sitting balance is common after stroke and makes leaning and reaching while sitting difficult and dangerous. Virtual reality training (VRT) uses computer hardware and software to track a person's movements and allow him or her to interact with a virtual environment. VRT games are available to train sitting balance after stroke; however, it is unknown how challenging they are. The objectives of this study were to characterize the centre of pressure displacements generated during the performance of VRT in stroke patients (ST) and compare their performance to that of young (YA) and older adults (OA).Materials and Methods: Eight ST participants who could stand for at least four minutes were recruited from an inpatient stroke rehabilitation unit for this cross-sectional, observational pilot study. Eight YA and eight OA were recruited from the community. Participants sat on a pressure mat and played 17 VRT game/difficulty combinations. The area, range and average velocity of centre of pressure displacement were determined for each game/difficulty.Results: Virtually manoeuvring a motorcycle around barriers and leaning to move a ball down a maze produced the greatest displacement of the centre of pressure, particularly in the mediolateral direction. OA moved further and faster in the mediolateral direction than YA. ST's performance was more variable.Conclusions: Some VRT games were more likely to push participants to challenge their limits of stability. Others required less displacement but more trunk stability. These results can guide which VRT games are used for the rehabilitation of sitting balance after stroke.Implications for rehabilitationSome virtual reality training games produce greater displacements of the centre of pressure in sitting than others, suggesting that careful matching between game challenge and desired therapeutic outcome is necessary when selecting games.Virtual reality training performed in sitting with feet on the floor challenges sitting balance in the frontal plane more so than in the sagittal plane.Older adults tend to lean more than younger adults while individuals with stroke move more or less than others, depending on the game.

Home-based virtual reality training after discharge from hospital-based stroke rehabilitation: a parallel randomized feasibility trial.

BACKGROUND: Virtual reality training (VRT) uses computer software to track a user's movements and allow him or her to interact with a game presented on a television screen. VRT is increasingly being used for the rehabilitation of arm function, balance and walking after stroke. Patients often require ongoing therapy post discharge from inpatient rehabilitation. Outpatient therapy may be limited or inaccessible due to waiting lists, transportation issues, distance etc.; therefore, home-based VRT could provide the required therapy in a more convenient and accessible setting. The objectives of this parallel randomized feasibility trial are to determine (1) the feasibility of using VRT in the home post stroke and (2) the feasibility of a battery of quantitative and qualitative outcome measures of stroke recovery. METHODS: Forty patients who can stand for at least 2 min and are soon to be discharged from inpatient or outpatient rehabilitation post stroke are being recruited in Ottawa, Canada and being randomized to control and experimental groups. Participants in the experimental group use home-based VRT to do rehabilitative exercises for standing balance, stepping, reaching, strengthening and gentle aerobic fitness. Control group participants use an iPad with apps selected to rehabilitate cognition, hand fine motor skills and visual tracking/scanning. Both groups are instructed to perform 30 min of exercise 5 days a week for 6 weeks. VRT intensity and difficulty are monitored and adjusted remotely. Weekly telephone contact is made with all participants. Ability to recruit participants, ability to handle the technology and learn the activities, compliance, safety, enjoyment, perceived efficacy and cost of program delivery will be assessed. A battery of assessments of standing balance, gait and community integration will be assessed for feasibility of completion within this population and potential for improvement following the intervention. Effect sizes will be calculated. DISCUSSION: The results of this study will be used to support the creation of a definitive randomized controlled trial on the efficacy of home-based VRT for rehabilitation post stroke. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03261713 . Registered on 21 August 2017. Registration amended on 1 June 2018 to decrease enrollment from 40 to 20 due to a cut in study funding and difficulty recruiting participants.

PROTOCOL: Health, social care and technological interventions to improve functional ability of older adults: Evidence and gap map.

This is a protocol for a Campbell Evidence and Gap Map. The objectives are to identify and assess the available evidence on health, social care and technological interventions to improve functional ability among older adults.

Reliability of lower limb alignment measures using an established landmark-based method with a customized computer software program.

The objective of the study was to evaluate the reliability of frontal plane lower limb alignment measures using a landmark-based method by (1) comparing inter- and intra-reader reliability between measurements of alignment obtained manually with those using a computer program, and (2) determining inter- and intra-reader reliability of computer-assisted alignment measures from full-limb radiographs. An established method for measuring alignment was used, involving selection of 10 femoral and tibial bone landmarks. (1) To compare manual and computer methods, we used digital images and matching paper copies of five alignment patterns simulating healthy and malaligned limbs drawn using AutoCAD. Seven readers were trained in each system. Paper copies were measured manually and repeat measurements were performed daily for 3 days, followed by a similar routine with the digital images using the computer. (2) To examine the reliability of computer-assisted measures from full-limb radiographs, 100 images (200 limbs) were selected as a random sample from 1,500 full-limb digital radiographs which were part of the Multicenter Osteoarthritis Study. Three trained readers used the software program to measure alignment twice from the batch of 100 images, with two or more weeks between batch handling. Manual and computer measures of alignment showed excellent agreement (intraclass correlations [ICCs] 0.977-0.999 for computer analysis; 0.820-0.995 for manual measures). The computer program applied to full-limb radiographs produced alignment measurements with high inter- and intra-reader reliability (ICCs 0.839-0.998). In conclusion, alignment measures using a bone landmark-based approach and a computer program were highly reliable between multiple readers.

Mutations and polymorphisms in the human ornithine transcarbamylase gene.

Ornithine transcarbamylase (OTC) deficiency, an X-linked, semidominant disorder, is the most common inherited defect in ureagenesis resulting in hyperammonemia. The previous two mutation updates for the OTC gene were published in 1993 and 1995 and included 36 and 30 mutations respectively. This comprehensive update contains a compilation of 244 mutations including 13 polymorphisms. Twenty-four of the mutations are reported here for the first time. Forty-two percent of the disease-causing mutations are associated with acute neonatal hyperammonemia; 21% were found in patients with late onset disease and approximately 37% were found in manifesting heterozygous females, most of which are presumed to confer a neonatal phenotype in hemizygous males. Also included are residual enzyme activities and residual incorporation of ammonium nitrogen into urea and results of expression studies for a small proportion of the mutations. Most mutations in the OTC gene are "private" and are distributed throughout the gene with paucity of mutation in the sequence encoding the leader peptide (exon 1 and beginning of exon 2) and in exon 7. Almost all mutations in consensus splicing sites confer a neonatal phenotype. Thirteen polymorphisms have been found, several of which are useful for allele tracking in patients in whom the mutation can't be found. Even with sequencing of the entire reading frame and exon/intron boundaries, only about 80% of the mutations are detected in patients with proven OTC deficiency. The remaining probably occur within the introns or in regulatory domains.