How active are patients in setting goals during rehabilitation after stroke? A qualitative study of clinician perceptions

Purpose: We investigated stroke rehabilitation clinician’s perceptions of the patient as an active partner in setting goals within stroke rehabilitation and factors that influence patient engagement.

Methods: Semi-structured interviews, subject to general inductive analysis with 20 Clinicians’ working in three UK based stroke rehabilitation teams (one in-patient ward and two community based rehabilitation teams).

Results: There were three key themes that impacted on the patients active involvement in setting goals for rehabilitation after stroke: Patient barriers to goal setting (knowledge of the patient and family, who is the patient and the stroke’s impact); How we work as a team (the role of the patient in setting goals, the effect of clinician attributes on goal setting); and How systems impact goal setting (goal-setting practice, home versus hospital, and professional/funder expectations of clinicians’).

Conclusions: Goal setting served a range of different, sometimes conflicting, functions within rehabilitation. Clinicians’ identified the integral nature of goals to engage and motivate patients and to provide direction and purpose for rehabilitation. Further, there was an identified need to consider the impact of prioritizing clinician-derived goals at the expense of patient-identified goals. Lastly the reliance on the SMART goal format requires further consideration, both in terms of the proposed benefits and whether they disempower the patient during rehabilitation.

• Implications for rehabilitation

• Goal setting is often promoted as a relatively simple, straightforward way to structure interactions with patients

• Patient-related factors together with resourcing constraints are significant barriers to patient-centered goal setting, particularly during inpatient rehabilitation

• Clinicians need to have pragmatic tools that can be integrated into practice to ensure that goal-setting practice can be maximized for patients with different intrinsic characteristics

     

The development of a patient-specific method for physiotherapy goal setting: a user-centered design

Purpose: To deliver client-centered care, physiotherapists need to identify the patients’ individual treatment goals. However, practical tools for involving patients in goal setting are lacking. The purpose of this study was to improve the frequently used Patient-Specific Complaints instrument in Dutch physiotherapy, and to develop it into a feasible method to improve physiotherapy goal setting.

Methods: An iterative user-centered design was conducted in co-creation with the physiotherapists and patients, in three phases. Their needs and preferences were identified by means of group meetings and questionnaires. The new method was tested in several field tests in physiotherapy practices.

Results: Four main objectives for improvement were formulated: clear instructions for the administration procedure, targeted use across the physiotherapy process, client-activating communication skills, and a client-centered attitude of the physiotherapist. A theoretical goal-setting framework and elements of shared decision making were integrated into the new-called, Patient-Specific Goal-setting method, together with a practical training course.

Conclusions: The user-centered approach resulted in a goal-setting method that is fully integrated in the physiotherapy process. The new goal-setting method contributes to a more structured approach to goal setting and enables patient participation and goal-oriented physiotherapy. Before large-scale implementation, its feasibility in physiotherapy practice needs to be investigated.

• Implications for rehabilitation

• Involving patients and physiotherapists in the development and testing of a goal-setting method, increases the likelihood of its feasibility in practice.

• The integration of a goal-setting method into the physiotherapy process offers the opportunity to focus more fully on the patient’s goals.

• Patients should be informed about the aim of every step of the goal-setting process in order to increase their awareness and involvement.

• Training physiotherapists to use a patient-specific method for goal setting is crucial for a correct application.

     

Oriented nanofibrous silk as a natural scaffold for ocular epithelial regeneration

The aim of this study was to develop nanofibrous silk substrates for limbal stem cell expansion that can serve as a potential alternative substrate to replace human amniotic membrane. The human limbal stem cell was used to evaluate the biocompatibility of substrates (random and oriented nanofibrous mats, and human amniotic membrane) based on their phenotypic profile, viability, proliferation, and attachment ability. Biocompatibility results indicated that all substrates were highly biocompatible, as limbal stem cells could favorably attach and proliferate on the nanofibrous surfaces. Microscopic figures showed that the human limbal stem cells were firmly anchored to the substrates and were able to retain a normal corneal stem cell phenotype. Microscopic analyses illustrated that cells infiltrated the nanofibers and successfully formed a three-dimensional corneal epithelium, which was viable for 15 days. Immunocytochemistry and real-time PCR results revealed no change in the expression profile of limbal stem cells grown on nanofibrous substrates when compared to those grown on human amniotic membrane. In addition, electrospun nanofibrous silk substrates especially oriented mat provides not only a milieu supporting limbal stem cells expansion, but also serve as a useful alternative carrier for ocular surface tissue engineering and could be used as an alternative substrate to amniotic membrane.     

Cross‐sex shifts in two brain imaging phenotypes and their relation to polygenic scores for same‐sex sexual behavior: A study of 18,645 individuals from the UK Biobank

Genetic and hormonal factors have been suggested to influence human sexual orientation. Previous studied proposed brain differences related to sexual orientation and that these follow cross‐sex shifted patterns. However, the neurobiological correlates of sexual orientation and how genetic factors relate to brain structural variation remains largely unexplored. Using the largest neuroimaging‐genetics dataset available on same‐sex sexual behavior (SSB) (n = 18,645), we employed a data‐driven multivariate classification algorithm (PLS) on magnetic resonance imaging data from two imaging modalities to extract brain covariance patterns related to sex. Through analyses of latent variables, we tested for SSB‐related cross‐sex shifts in such patterns. Using genotype data, polygenic scores reflecting the genetic predisposition for SSB were computed and tested for associations with neuroimaging outcomes. Patterns important for classifying between males and females were less pronounced in non‐heterosexuals. Predominantly in non‐heterosexual females, multivariate brain patterns as represented by latent variables were shifted toward the opposite sex. Complementary univariate analyses revealed region specific SSB‐related differences in both males and females. Polygenic scores for SSB were associated with volume of lateral occipital and temporo‐occipital cortices. The present large‐scale study demonstrates multivariate neuroanatomical correlates of SSB, and tentatively suggests that genetic factors related to SSB may contribute to structural variation in certain brain structures. These findings support a neurobiological basis to the differences in human sexuality.     

Relationship between radiographic measurements and knee adduction moment using 3D gait analysis

BackgroundRadiographic factors estimate the state of the static knee joint, and it is questionable how well these parameters reflect the dynamic knee condition. The external knee adduction moment (KAM) during gait is known to be a kinetic variable contributing to osteoarthritis progression. This study aims to investigate the effects of static radiographic parameters on the dynamic KAM during gait.MethodsOverall, 123 patients (mean age, 65.7 years; standard deviation, 8.1 years; 34 men and 89 women) were included. Seven radiographic parameters including the mechanical tibiofemoral angle (mTFA), Kellgren-Lawrence grade, and ankle joint line orientation (AJLO) were measured on radiographs, and the maximum KAM and KAM-time integral in the stance phase were obtained using three-dimensional gait analysis. The correlation and multiple regression analyses were performed for identifying significant radiographic measurements associated with the KAM.ResultsMost of the radiographic measurements correlated with the maximum KAM and KAM-time integral. As a result of multiple regression analysis, the mTFA (p < 0.001) and AJLO (p = 0.003) were identified as significant factors associated with the KAM-time integral (R² = 0.450); the mTFA (p < 0.001) and AJLO (p = 0.003) were identified as a significant factor associated with the maximum KAM (R² = 0.352) in multiple regression analysis. The discriminant validity of KAM was highest at varus 5.7 degree of the mTFA and 7.5 degree of the AJLO.SignificanceThe mTFA and AJLO were significantly associated with the KAM. However, to be used as a surgical indication for corrective osteotomy, a longitudinal study is needed to validate whether the mTFA and AJLO values directly cause osteoarthritis progression as we have suggested.Level of evidenceIII.     

An Implanted Vestibular Prosthesis Improves Spatial Orientation in Animals with Severe Vestibular Damage

Gravity is a pervasive environmental stimulus, and accurate graviception is required for optimal spatial orientation and postural stability. The primary graviceptors are the vestibular organs, which include angular velocity (semicircular canals) and linear acceleration (otolith organs) sensors. Graviception is degraded in patients with vestibular damage, resulting in spatial misperception and imbalance. Since minimal therapy is available for these patients, substantial effort has focused on developing a vestibular prosthesis or vestibular implant (VI) that reproduces information normally provided by the canals (since reproducing otolith function is very challenging technically). Prior studies demonstrated that angular eye velocity responses could be driven by canal VI-mediated angular head velocity information, but it remains unknown whether a canal VI could improve spatial perception and posture since these behaviors require accurate estimates of angular head position in space relative to gravity. Here, we tested the hypothesis that a canal VI that transduces angular head velocity and provides this information to the brain via motion-modulated electrical stimulation of canal afferent nerves could improve the perception of angular head position relative to gravity in monkeys with severe vestibular damage. Using a subjective visual vertical task, we found that normal female monkeys accurately sensed the orientation of the head relative to gravity during dynamic tilts, that this ability was degraded following bilateral vestibular damage, and improved when the canal VI was used. These results demonstrate that a canal VI can improve graviception in vestibulopathic animals, suggesting that it could reduce the disabling perceptual and postural deficits experienced by patients with severe vestibular damage.SIGNIFICANCE STATEMENT Patients with vestibular damage experience impaired vision, spatial perception, and balance, symptoms that could potentially respond to a vestibular implant (VI). Anatomic features facilitate semicircular canal (angular velocity) prosthetics but inhibit approaches with the otolith (linear acceleration) organs, and canal VIs that sense angular head velocity can generate compensatory eye velocity responses in vestibulopathic subjects. Can the brain use canal VI head velocity information to improve estimates of head orientation (e.g., head position relative to gravity), which is a prerequisite for accurate spatial perception and posture? Here we show that a canal VI can improve the perception of head orientation in vestibulopathic monkeys, results that are highly significant because they suggest that VIs mimicking canal function can improve spatial orientation and balance in vestibulopathic patients.     

Long-term coordinated microstructural disruptions of the developing neocortex and subcortical white matter after early postnatal systemic inflammation

Severe postnatal systemic infection is highly associated with persistent disturbances in brain development and neurobehavioral outcomes in survivors of preterm birth. However, the contribution of less severe but prolonged postnatal infection and inflammation to such disturbances is unclear. Further, the ability of modern imaging techniques to detect the underlying changes in cellular microstructure of the brain in these infants remains to be validated. We used high-field ex-vivo MRI, neurohistopathology, and behavioral tests in newborn rats to demonstrate that prolonged postnatal systemic inflammation causes subtle, persisting disturbances in brain development, with neurodevelopmental delays and mild motor impairments. Diffusion-tensor MRI and neurite orientation dispersion and density imaging (NODDI) revealed delayed maturation of neocortical and subcortical white matter microstructure. Analysis of pyramidal neurons showed that the cortical deficits involved impaired dendritic arborization and spine formation. Analysis of oligodendrocytes showed that the white matter deficits involved impaired oligodendrocyte maturation and axonal myelination. These findings indicate that prolonged postnatal inflammation, without severe infection, may critically contribute to the diffuse spectrum of brain pathology and subtle long-term disability in preterm infants, with a cellular mechanism involving oligodendrocyte and neuronal dysmaturation. NODDI may be useful for clinical detection of these microstructural deficits.     

Effect of ligand orientation on hepatocyte attachment onto the poly(N p-vinylbenzyl-o-β-D-galactopyranosyl-D-gluconamide) as a model ligand of asialoglycoprotein

The orientation effect of galactose ligand on hepatocyte attachment was investigated. Poly(N-p-vinylbenzyl-o-β-D-galactopyranosyl-D-gluconamide)(PVLA, a β-galactose-carrying styrene homopolymer, was used as a model ligand for the asialoglycoprotein receptors on hepatocytes. PVLA was transferred onto the poly(γ-benzyl L-glutamate) (PBLG) or PBLG/poly(ethylene glycol) (PEG)PBLG Langmuir-Blodgett (LB) films as the monolayer level. The dichroic fluorescence values of the confocal microscope indicated that the PVLA transferred onto the LB films was located with a preferential orientation of its molecular axes with regard to the direction of the α-helix of polypeptide. Hepatocyte recognized well-oriented galactose moieties of the surface of PVLA through asialoglycoprotein receptors.     

Impact of joint line orientation on clinical outcomes in bilateral Oxford mobile-bearing unicompartmental knee arthroplasty

BackgroundJoint line orientation angle (JLOA) is the angle between the knee joint line and the floor. It has been reported to be related to postoperative outcome after TKA. Regarding unicompartmental knee arthroplasty (UKA), although it can be horizontal after UKA because it is a resurfacing surgery, there are few reports about the JLOA after UKA and its impact on clinical outcomes.PurposeThe purpose of this study was to reveal the relationship between JLOA and clinical outcome after UKA.MethodsThis study included 106 knees in 53 consecutive patients with osteoarthritis who underwent simultaneous bilateral mobile-bearing UKA. Their pre- and postoperative JLOAs were measured by full-leg-length standing coronal radiographs. We also evaluated the tibial component height (TCH) as the factor which we assumed could influence JLOA. We analyzed the patients’ JLOAs, TCHs and clinical outcomes.ResultsPre- and postoperative JLOA were 0.4 ± 2.4° and 2.7 ± 2.6°, respectively. The JLOA significantly tilted medially (P < 0.0001). The JLOA significantly negatively correlated with the improvement of the clinical outcomes (Oxford Knee Score (OKS): r = 0.40, P < 0.0001, Knee Society Knee Score (KSKS): r = 0.25, P < 0.01, Knee Society Function Score (KSFS): r = 0.22, P = 0.02). The TCH showed a positive correlation with postoperative JLOA and with the postoperative JLOA change (r = 0.45, P < 0.001; r = 0.25, P < 0.01, respectively).ConclusionThe JLOA significantly tilted medially after UKA. An excessive medial tilt of the JLOA was associated with poorer postoperative outcomes of UKA. It is therefore recommended to keep the JLOA horizontal and to avoid a lower tibial cut.     

The role of disclosure & perceptions about providers in health discussions among gay and bisexual young men

ObjectivesGay and bisexual men may feel discomfort discussing sensitive topics such as sexual behaviors and substance use with their health providers, which may prevent them from receiving important health information. This study investigates whether patients’ perceptions of their provider’s sexual orientation predicts patient-provider discussions of sexual and general health topics, and whether this relationship is moderated by patients’ disclosure of sexual orientation to providers.MethodsData were collected online from a sample of 576 gay and bisexual men living in the USA, aged 18–26. Adjusted risk ratios were estimated by using modified Poisson regression with robust error variance.ResultsParticipants who believed their providers were gay or bisexual were more likely to have discussed sexual health topics, but not general health topics; simple slopes analyses revealed that this effect was stronger among those who had not disclosed to their providers. Disclosure was also consistently associated with increased likelihood of discussing almost all topics.ConclusionsFindings highlight differences in communication based on disclosure and perceived sexual orientation of provider, suggesting the need to further explore how these differences influence young gay and bisexual men’s health.Practice implicationsDyads may be more likely to discuss sexual health topics when patients believe their providers are sexual minorities themselves. In addition, patient-provider dyads may be likelier to discuss various health topics when providers are aware of patients’ sexual minority statuses.