- Implications for rehabilitation
Immersive virtual reality may be used in rehabilitation to simulate natural environments to practice and develop communication skills.
The sense of immersion that can be achieved using virtual reality may promote the generalization of skills learnt during clinical rehabilitation to real-world situations.
Ethical and safety considerations, including cybersecurity and cybersickness, must be carefully monitored during all virtual reality research.
Methods: Semi-structured interviews were conducted in Singapore with community-dwelling stroke survivors with a previous fall (n?=?9), family caregivers (n?=?4), and domestic helpers (n?=?4) who have cared for a stroke survivor with a previous fall. Purposive sampling was used for recruitment; all interviews were audio-recorded with permission and transcribed. Thematic analysis was conducted using NVivo (v10) software.
Results: All participants shared their self-perceived intrinsic and extrinsic fall risk factors and main challenges after a fall. For stroke participants and family caregivers, motivational factors in developing safety strategies after a previous fall(s) include social connectedness, independent living and community participation. For family caregivers and domestic helpers, the stroke survivor’s safety is their top priority, however this can also lead to over-protective behavior outside of the rehabilitation process.
Conclusions: Reducing the risk of falls in community-dwelling stroke survivors seems to be more important than promoting community participation among caregivers. The study findings highlight that a structured and client-centered fall prevention program targeting stroke survivors and caregivers is needed in Singapore.
- Implications for rehabilitation
Falls after stroke can lead to functional decline in gait and mobility and restricted self-care activities.
Community-dwelling stroke survivors develop adaptive safety strategies after a fall and want to be socially connected. However, caregivers see the safety of the stroke survivors as their top priority and demonstrate over-protective behaviors.
Fall prevention programs for community-dwelling stroke survivors should target both stroke survivors and their caregivers.
A structured and client-centered fall prevention program targeting at multiple risk factors post-stroke is needed for community-living stroke survivors.
Methods: A single-blind randomized controlled study was conducted with 10 subjects for each group. The VRAI was conducted with the Nintendo Wii Fit Plus, whilst the TRI was conducted with a series of exercises with theraband. The muscle strength change of the two groups and the difference between pre and post interventions for each group were compared.
Results: The VRAI group had less improvement in the muscle strength of all ankle motions than did the TRI group (p > .05). The VRAI group had a greater improvement in muscle strength of plantar flexion than other motions, whilst the TRI group had an improvement in muscle strength of all ankle motions (p < .05).
Conclusions: The effects of VR training for the condition of FAI were not comparable to conventional training. However, VR training may be added to the conventional training programme as an optional for the condition of FAI.
- Implications for Rehabilitation
Functional ankle instability (FAI) is subjective feelings of ankle instability resulting from proprioceptive and neuromuscular deficits in which individuals may experience “giving way” condition of the ankle.
Therapeutic applications of virtual reality (VR) may be comparable to traditional rehabilitation interventions (TRI) in the rehabilitation of individuals with FAI. However, there is no definitive evidence for the issue.
Integrating low-cost VR into functional rehabilitation programme can provide insight into an issue of whether it can be replaced with traditional therapeutic approaches.
Although, the efficacy of VR application on strengthening muscles is unable to compare to traditional strengthening programmes, it may be considered an optional treatment based on the proprioceptive improvements.
Methods: We collected data on CSRT clients from January 2012 to February 2013. Comparator data were derived from a study of stroke survivors with limited access to specialised stroke rehabilitation. Literature-derived values were used to inform a long-term projection. Using Markov modelling, we projected the model for 35?years in six-month cycles. One-way, two-way, and probabilistic sensitivity analyses were performed. Results were discounted at 3% per year.
Results: Results demonstrated that the CSRT programme has a net monetary benefit (NMB) of $43,655 over Usual Care, and is both less costly and more effective (incremental cost?=??$17,255; incremental effect?=?1.65 Quality Adjusted Life Years [QALYs]). Results of the probabilistic sensitivity analysis revealed that incremental cost-effectiveness of the CSRT programme is superior in 100% of iterations when compared to Usual Care.
Conclusions: The study shows that CSRT model of care is cost-effective, and should be considered when evaluating potential stroke rehabilitation delivery methods.
- Implications for Rehabilitation
Ongoing rehabilitation following stroke is imperative for optimal recovery.
Home-based specialised stroke rehabilitation may be an option for individuals for whom ongoing rehabilitation is unavailable or inaccessible.
The results of this study demonstrated that home-based rehabilitation is a cost-effective means of providing ongoing rehabilitation to individuals who have experienced a stroke.
Method: Twelve stroke-survivors (nine females, mean age 58 years, [standard deviation 7.1], median stroke chronicity 42 months [interquartile range 34.7], Motricity index 14–25 for shoulder and elbow) were asked to complete nine, 40-min intervention sessions using two activities on the system over 3 weeks. Feasibility and acceptability were assessed through a semi-structured interview, recording of adverse effects, adherence, enjoyment (using an 11-point Likert scale), and perceived exertion (using the BORG scale). Assessments of impairment (Fugl–Meyer Assessment Upper extremity), activity (ABILHAND, Action Research Arm Test, Motor Activity Log-28), and participation (Subjective Index of Physical and Social Outcome) were completed at baseline, following intervention, and at 4-week follow-up. Data were analysed using Thematic Analysis of interview and intervention field-notes and Wilcoxon Signed Ranks. Side-by-side displays were used to integrate findings.
Results: Participants received between 175 and 336 min of intervention. Thirteen non-serious adverse effects were reported by five participants. Participants reported a high level of enjoyment (8.1 and 6.8 out of 10) and rated exertion between 11.6 and 12.9 out of 20. Themes of improvements in impairments and increased spontaneous use in functional activities were identified and supported by improvements in all outcome measures between baseline and post-intervention (p?<?0.05 for all measures).
Conclusions: Integrated findings suggested that the system is feasible and acceptable for use with a group of community-dwelling stroke-survivors including those with moderately-severe disability.
- Implications for rehabilitation
To ensure feasibility of use and maintenance of an appropriate level of challenge, gaming technologies for use in upper-limb stroke rehabilitation should be personalised, dependent on individual need.
Through the use of hands-free systems and personalisation, stroke survivors with moderate and moderately-severe levels of upper-limb impairment following stroke are able to use gaming technologies as a means of delivering upper-limb rehabilitation.
Future studies should address issues of acceptability, feasibility, and efficacy of personalised gaming technologies for delivery of upper-limb stroke rehabilitation in the home environment.
Findings from this study can be used to develop future games and activities suitable for use in stroke rehabilitation.
- Implications for Rehabilitation
??Use of a cognitive-motor low-cost virtual reality intervention designed to remediate arm motor impairments in sub-acute stroke is feasible, safe and perceived as useful by therapists and patients for stroke rehabilitation.
??Input from end-users (therapists and individuals with stroke) is critical for the development and implementation of a virtual reality intervention.
- Implications for rehabilitation
Being able to solve challenges with technology is empowering for the participants in vocational rehabilitation programmes, regardless of the frequency of use.
To be able to introduce concrete apps is a tool in the social workers counselling efforts to develop the participants’ ability to master life situations.
The process of introducing compensatory technology has had an inherent value in the individual participant’s empowerment process through the vocational rehabilitation programme.
- Implications for Rehabilitation
Although there is an increase in rehabilitation programmes geared towards those with chronic stroke, we must also consider the participants’ perception of those programmes.
Incorporating participant feedback may increase enjoyment and adherence to the rehabilitation programmes.
The VR experience, as well as provision of feedback and instruction, are important aspects to consider when developing a VR programme for stroke survivors.
VR for rehabilitation may be a feasible tool for increasing the survivors’ confidence in completing ADL post-stroke.
Materials and methods: In a qualitative study, 10 interviews with stroke patients were conducted, transcribed, and analysed using qualitative content analysis.
Results: The patients’ experiences with inpatient stroke rehabilitation and their perception of nurses’ and nurse assistants’ roles and functions during hospitalisation were found to be related to one overall theme derived from 10 categories. As a recurring motif in the patients’ interviews, they experienced existential thoughts, and these thoughts unquestionably affected their experiences within the rehabilitation unit. These thoughts enhanced their need for human contact, thereby affecting their relationships with and perceptions of the nursing staff.
Conclusion: The findings deepen our understanding of how patients experience inpatient rehabilitation. The patients struggled with existential thoughts and concerns about the future and therefore called for human contact and support from the nursing staff. They perceived the nursing staff as mostly polite and helpful, but were unclear about the nursing staff’s function in rehabilitation which, in the patients’ perspective, equals physical training.
- Implications for Rehabilitation
Nursing staff need to pay attention to the patients’ needs, existential thoughts and concerns during inpatient rehabilitation.
Meaningful goals for the rehabilitation of stroke patients are crucial, and it is vital that the patients commit to the goals.
Patients expected polite and helpful nurses, but did not see them as therapeutic and active stakeholders, thus it is important that nursing staff present themselves as part of the interdisciplinary rehabilitation.
There is a need for training and education of nursing staff, both pre and post graduate.
Methods: Stroke survivors receiving in-patient rehabilitation were randomised to receive eight art participation sessions (n?=?41) or usual care (n?=?40). Recruitment, retention, preference for art participation and change in selected outcomes were evaluated at end of intervention outcome assessment and three-month follow-up.
Results: Of 315 potentially eligible participants 81 (29%) were recruited. 88% (n?=?71) completed outcome and 77% (n?=?62) follow-up assessments. Of eight intervention group non-completers, six had no preference for art participation. Outcome completion varied between 97% and 77%. Running groups was difficult because of randomisation timing. Effectiveness cannot be determined from this feasibility study but effects sizes suggested art participation may benefit emotional wellbeing, measured on the positive and negative affect schedule, and self-efficacy for Art (d?=?0.24–0.42).
Conclusions: Undertaking a RCT of art participation within stroke rehabilitation was feasible. Art participation may enhance self-efficacy and positively influence emotional wellbeing. These should be outcomes in a future definitive trial. A cluster RCT would ensure art groups could be reliably convened. Fewer measures, and better retention strategies are required.
- Implications for Rehabilitation
This feasibility randomised controlled trial (RCT) showed that recruiting and retaining stroke survivors in an RCT of a visual arts participation intervention within stroke rehabilitation was feasible.
Preference to participate in art activities may influence recruitment and drop-out rates, and should be addressed and evaluated fully.
Art participation as part of rehabilitation may improve some aspects of post-stroke wellbeing, including positive affect and self-efficacy for art.
A future definitive cluster RCT would facilitate full evaluation of the value art participation can add to rehabilitation.
Methods: This cross-sectional study was performed in a neurological rehabilitation hospital. We assessed unidimensionality, construct validity, internal consistency reliability, inter-rater reliability, minimal detectable change and possible floor and ceiling effects of the DEMMI in adult patients with sub-acute stroke.
Results: The study included a total sample of 121 patients with sub-acute stroke. We analysed validity (n?=?109) and reliability (n?=?51) in two sub-samples. Rasch analysis indicated unidimensionality with an overall fit to the model (chi-square = 12.37, p?=?0.577). All hypotheses on construct validity were confirmed. Internal consistency reliability (Cronbach’s alpha = 0.94) and inter-rater reliability (intraclass correlation coefficient = 0.95; 95% confidence interval: 0.92–0.97) were excellent. The minimal detectable change with 90% confidence was 13 points. No floor or ceiling effects were evident.
Conclusions: These results indicate unidimensionality, sufficient internal consistency reliability, inter-rater reliability, and construct validity of the DEMMI in patients with a sub-acute stroke. Advantages of the DEMMI in clinical application are the short administration time, no need for special equipment and interval level data. The de Morton Mobility Index, therefore, may be a useful performance-based bedside test to measure mobility in individuals with a sub-acute stroke across the whole mobility spectrum.
- Implications for Rehabilitation
The de Morton Mobility Index (DEMMI) is an unidimensional measurement instrument of mobility in individuals with sub-acute stroke.
The DEMMI has excellent internal consistency and inter-rater reliability, and sufficient construct validity.
The minimal detectable change of the DEMMI with 90% confidence in stroke rehabilitation is 13 points.
The lack of any floor or ceiling effects on hospital admission indicates applicability across the whole mobility spectrum of patients with sub-acute stroke.
Materials and methods: Electronic search was performed in PubMed and REHABDATA for studies published between 2000 and 2017.
Results: Eighty-six articles met the inclusion criteria. Results revealed a profound need for rehabilitation among different user groups with non-communicable diseases and injuries across countries. However, this need considerably outstripped the provision of services, which left many people with substantial unmet needs for rehabilitation. The main reasons for the unmet needs for rehabilitation were the absence of or unequal geographical distribution of services within a country, lack of transportation, and unaffordability of the services.
Conclusions: There are substantial unmet needs for rehabilitation and numerous barriers to accessing services. Efforts need to focus on building the capacity for rehabilitation research predominantly in low- and middle-income countries. The comprehensive data that this review provides is useful for raising awareness for the need of rehabilitation at policy level.
- Implications for rehabilitation
There is a profound need for rehabilitation services due to the ageing population and growing prevalence of non-communicable diseases.
This scoping review shows that the need for rehabilitation considerably outstrips the provision of services.
There are substantial unmet needs for rehabilitation and numerous barriers to accessing services.
Concerted global action to scale up quality rehabilitation services is needed, especially in low- and middle-income countries.
Methods: Ten visually impaired students at a South African university participated in one of two semi-structured focus group interviews (six and four in each group, respectively) wherein we explored their experience of informal helping relationships. Interpretive phenomenological analysis was used to make sense of the data.
Results: Help, according to the participants, can militate against visibility and complete acceptance, and has the potential to cause helpers to feel entrapped. By contrast, some students found that help offered benefits to relationships by boosting the helper’s self-esteem and affording disabled students the opportunity to make friends.
Conclusion: Decisions whether to accept help were mediated more by relationship factors than by the need for help. These findings are important for rehabilitation professionals, as deep relationship can come into being during the course of a rehabilitation process. Although this study was conducted in an informal setting, the relational dynamics that we explore are also applicable to clinical relationships between disabled persons and rehabilitation professionals.
- Implications for rehabilitation
In this paper, we provide an overview of the intricacies involved in care and helping relationships;
In order for rehabilitation to be successful, these relationships should ideally be real, trusting, and authentic;
Yet, authenticity and spontaneity often get lost in helping relationships, as help-recipients may deny help when they need it, and accept help when perfectly able to cope without it. These decisions are mediated more by relationship factors than by the need for help;
In their daily practice, it is essential for health professionals to be mindful of these relational intricacies within care relationships;
We recommend that professionals remain motivated to continuously reflect on their own actions and on the emotional investment they might have in their role as a helper;
Our last recommendation is for rehabilitation professionals to spend energy on exploring, through open and transparent discussions with their disabled patients, the relational dynamics in their relationship.
- Implications for rehabilitation
Integrating Ekso gait training into clinical practice during inpatient rehabilitation is feasible.
Overcoming barriers to implementation required administrative support and clinician persistence over several months.
Patients tolerated Ekso sessions well, without any complications or adverse incidents.
- Implications for rehabilitation
Semi-supervised machine learning applications may be a feasible approach for analyses of complex data sets in rehabilitation research.
Semi-supervised machine learning approaches uses a combination of labelled and unlabelled data to produce accurate predictive models, thereby requiring less user-input data than other machine learning approaches (i.e., supervised, unsupervised), reducing resource cost and user-burden.
Semi-supervised machine learning is an iterative process that, when applied to rehabilitation assessment and outcomes, could produce accurate personalized models for treatment.
Rehabilitation researchers and data scientists should collaborate to implement semi-supervised machine learning approaches in rehabilitation research, optimizing the power of large datasets that are becoming more readily available within the field (e.g., EEG signals, sensors, smarthomes).
Materials and methods: A qualitative study employing a phenomenological approach explored the lived experience of incurable cancer. A purposive sample of six people participated in semi-structured interviews. The data were analysed thematically at a semantic level to identify the functional difficulties experienced by people living with incurable cancer, the meanings of those difficulties, and participants perceived rehabilitation needs.
Results: People living with incurable cancer described cancer-related issues spanning all five domains of the International Classification of Functioning, Disability and Health (ICF). Although highly valued amongst study participants, rehabilitation services were difficult to access, poorly utilised, and referrals were sporadic and consequential; indicative of poor awareness of rehabilitation for people with incurable cancer amongst potential referrers.
Discussion: Participants valued a change in terminology away from “palliative” towards more positive language in line with enhanced supportive care movements. Validated tools such as the Palliative Care Therapy Outcome Measure, which align with the ICF, would allow rehabilitation professionals to demonstrate maintenance or improvement in participation and wellbeing.
- Implications for Rehabilitation
Incurable cancer leads to a fluctuating multifactorial disability.
People living with incurable cancer can benefit from rehabilitation input throughout their illness.
Offering flexible and varied rehabilitation options for people living with incurable cancer will increase physical and emotional well-being, function, and coping.
Allied health professionals should take and create opportunities to promote rehabilitation for people living with incurable cancer and their services to other potentially referring healthcare professionals to increase understanding of benefits and utilisation of available services for people living with incurable cancer.
Methods: We conducted a scoping review of the literature. Articles published between January 2001 and July 2017 were identified through Scopus, PubMed, CINAHL, and PsycINFO according to predefined inclusion and exclusion criteria.
Results: We identified 1791 articles through database and hand-searching strategies. Of the articles, 194 met inclusion criteria for full-text review, and 41 met inclusion criteria for study inclusion. The included studies used a variety of outcome measures encompassing domains within the ICF: body functions, activities, participation, and contextual factors across the time course of stroke recovery. We discovered disproportionate representation among racial/ethnic groups in the post-stroke disability disparities literature.
Conclusions: A wide variety of assessments are used to examine disparities in post-stroke disability across the time course of stroke recovery. Several studies have identified disparities through a variety of assessments; however, substantial problems abound from the assessments used including inconsistent use of assessments, lacking evidence on the validity of assessments among racial/ethnic groups, and inadequate representation among all racial/ethnic populations comprising the US.
- Implications for Rehabilitation
An enhanced understanding of racial/ethnic disparities in post-stroke disability outcomes is inherently important among rehabilitation practitioners who frequently engage with racial/ethnic minority populations across the time course of stroke recovery.
Clinicians should carefully consider the psychometric properties of assessment tools to counter potential racial bias.
Clinicians should be aware that many assessments used in stroke rehabilitation lack cultural sensitivity and could result in inaccurate assessment findings.
Objective: To assess the physical therapist’s adherence to structured stroke clinical practice guidelines in an active inpatient rehabilitation center in Qatar.
Setting: Department of Physical therapy in the stroke rehabilitation tertiary referral hospital in Qatar.
Method: A retrospective chart audit was performed on the clinical records of 216 stroke patients discharged from the active inpatient stroke rehabilitation unit with a diagnosis of stroke in 2016. The audit check list was structured to record the adherence of the assessment, goal settings and the management domains as per the “Physical Therapy After Acute Stroke” (PAAS) guideline.
Result: Of the 216 case files identified during the initial search, 127 files were ultimately included in the audit. Overall adherence to the clinical practice guideline was 71%, a comparable rate with the studies analyzing the same in various international health care facilities. Domains which were shared by interdisciplinary teams than managed by physical therapy alone and treatments utilizing sophisticated technology had lower adherence with the guideline. A detailed strength and weakness breakdown were then conducted.
Conclusion: This audit provides an initial picture of the current adherence of physical therapy assessment and management with the stroke physical therapy guideline at a tertiary rehabilitation hospital in the state of Qatar. An evaluation of the guideline adherence and practice variations helps to fine tune the physical therapy care to a highest possible standard of practice.
- Implications for Rehabilitation
???An evaluation of the guideline adherence and practice variations helps to fine tune the rehabilitation care to the highest possible standard of practice.
??Proper assessments of the relationship between the process of rehabilitation care and outcomes with a comprehensive set of process indicators will improve the quality of the care.
??An agreement needs to be established between rehabilitation teams engage in interdisciplinary stroke care regarding the shared responsibilities and team functioning.
??It is recommendable to develop a specialty based clinical practice guidelines that can be aligned at a higher ‘comprehensive rehabilitation level’ to provide the best possible and evidence based stroke care.