Accelerometer and global positioning system measurement of recovery of community ambulation across the first 6 months after stroke: an exploratory prospective study

Objective: To characterize community ambulation and determine if it changes across the first 6 months after discharge from hospital after stroke

Identifying factors associated with sedentary time after stroke. Secondary analysis of pooled data from nine primary studies.

<p><b>Background</b>: High levels of sedentary time increases the risk of cardiovascular disease, including recurrent stroke.</p> <p><b>Objective</b>: This study aimed to identify factors associated with high sedentary time in community-dwelling people with stroke.</p> <p><b>Methods</b>: For this data pooling study, authors of published and ongoing trials that collected sedentary time data, using the activPAL monitor, in community-dwelling people with stroke were invited to contribute their raw data. The data was reprocessed, algorithms were created to identify sleep-wake time and determine the percentage of waking hours spent sedentary. We explored demographic and stroke-related factors associated with total sedentary time and time in uninterrupted sedentary bouts using unique, both univariable and multivariable, regression analyses.</p> <p><b>Results</b>: The 274 included participants were from Australia, Canada, and the United Kingdom, and spent, on average, 69% (SD 12.4) of their waking hours sedentary. Of the demographic and stroke-related factors, slower walking speeds were significantly and independently associated with a higher percentage of waking hours spent sedentary (p = 0.001) and uninterrupted sedentary bouts of <i>>30</i> and <i>>60 min</i> (p = 0.001 and p = 0.004, respectively). Regression models explained 11–19% of the variance in total sedentary time and time in prolonged sedentary bouts.</p> <p><b>Conclusion</b>: We found that variability in sedentary time of people with stroke was largely unaccounted for by demographic and stroke-related variables. Behavioral and environmental factors are likely to play an important role in sedentary behavior after stroke. Further work is required to develop and test effective interventions to address sedentary behavior after stroke.</p

High-intensity treadmill training and self-management for stroke patients undergoing rehabilitation : A feasibility study

Background Physical activity undertaken by stroke survivors is generally low. This trial investigated the feasibility of delivering a high-intensity treadmill and self-management program to people with stroke undergoing inpatient rehabilitation and determine whether physical activity, walking ability and cardiorespiratory fitness could be increased. Method A phase I, single-group, pre-post intervention study was conducted with stroke survivors undergoing inpatient rehabilitation who could walk. Participants undertook a high-intensity treadmill and self-management program for up to 30 min, three times a week for 8 weeks under the supervision of their usual physiotherapist. Feasibility was determined by examining compliance, satisfaction and adverse events. Clinical outcomes were amount of physical activity, walking ability, and cardiorespiratory fitness collected pre-training (week 0), post-training (week 8), and at follow-up (week 26). Results Forty stroke survivors participated, completing 10 (SD 6) sessions, 94% at the specified training intensity, with high satisfaction and no adverse events related to the intervention. At week 8, participants completed 2749 steps/day (95% CI 933 to 4564) more physical activity than at week 0. Walking distance increased by 110 m (95% CI 23 to 196), walking speed by 0.24 m/s (95% CI 0.05 to 0.42), and VO2 peak by 0.29 ml/kg/min (95% CI 0.03 to 0.56). At week 26, increases in physical activity, walking distance and speed, and cardiorespiratory fitness were maintained. Conclusions A high-intensity treadmill training program embedded within a self-management approach during inpatient rehabilitation appears feasible and potentially may offer sustained improvements in physical activity, walking ability, fitness, and quality of life. A randomised trial is warranted. Trial registration This feasibility study was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12613000764730)

Additional Saturday occupational therapy for adults receiving inpatient physiotherapy rehabilitation : A prospective cohort study

Background The first aim of this study was to investigate the impact of providing an additional four hours of Saturday occupational therapy to patients receiving Saturday physiotherapy in an inpatient setting on length of stay, functional independence, gait and balance. The second aim was to conduct an economic evaluation to determine if the introduction of a Saturday occupational therapy service in addition to physiotherapy resulted in a net cost savings for the rehabilitation facility. Methods A prospective cohort study with a historical control was conducted in an Australian private mixed rehabilitation unit from 2015–2017. Clinical outcomes included the Functional Independence Measure (Motor, Cognitive, Total), gait speed (10 Meter Walk test) and five balance measures (Timed Up and Go test, Step test, Functional Reach, Feet Together Eyes Closed and the Balance Outcome Measure of Elder Rehabilitation). Economic outcomes were rehabilitation unit length of stay and additional treatment costs. Results A total of 366 patients were admitted to the rehabilitation unit over two 20-week periods. The prospective cohort (receiving Saturday occupational therapy and physiotherapy) had 192 participants and the historical control group (receiving Saturday physiotherapy only) had 174 participants. On admission, intervention group participants had higher cognitive (p < 0.01) and total (p < 0.01) Functional Independence Measure scores. Participation in weekend therapy by the intervention group was 11% higher, attending more sessions (p < 0.01) for a greater length of time (p < 0.01) compared to the historical control group. After controlling for differences in admission Functional Independence Measure scores, rehabilitation length of stay was estimated to be reduced by 1.39 (p = 0.08) days. The economic evaluation identified potential cost savings of AUD1,536 per patient. The largest potential savings were attributed to neurological patients AUD4,854. Traumatic and elective orthopaedic patients realised potential patient related cost savings per admission of AUD2,668 and AUD2,180, respectively. Conclusions Implementation of four hours of Saturday occupational therapy in addition to physiotherapy results in a more efficient service, enabling a greater amount of therapy to be provided on a Saturday over a shorter length of stay. Provision of multidisciplinary Saturday rehabilitation is potentially cost reducing for the treating hospital

Injuries in New Zealand Army Recruits

Musculoskeletal injuries are a major concern for the military resulting in substantial burdens for both recruits and the service. Recruits report high incidence of musculoskeletal injuries with the majority occurring to the lower limbs. Consequences of recruit injuries can be considerable for the individual including reduced participation, injury chronicity, training time loss and career pathway change due to backsquad or discharge. For the military, recruit injuries can result in increased health care expenditure, additional costs related to training, and recruitment and retention to replace injured recruits. Potentially, deployment capability may be impacted as fewer recruits progress from basic training to trade training or operational units, whereby they gain essential skills to become deployable. Injury incidence data were limited for New Zealand Army recruits with a current understanding of the recruit injury problem unknown. It was unknown whether recruits present for basic training with pre-existing injuries or risk factors that could predispose them to injury, and if a prevention program using neuromuscular training could lower recruit injury incidence. The aim of the current program of research was to establish the extent of the New Zealand Army recruit injury problem, the profile and aetiology of recruit injuries and the effect of six weeks neuromuscular training compared to usual training on incidence of lower limb injury of New Zealand Army recruits undertaking basic training. Additionally, this program of research investigated if baseline personal, lifestyle and physical performance characteristics could predict actual injury sustained during training. This program of research comprised four studies based on the sequence of injury prevention model. The first study explored the extent of the New Zealand Army recruit injury problem through surveillance of four years of physiotherapy provisions for injuries sustained during basic training. Commencing basic training were 1896 recruits (1697 males, 199 females), who required 1683 physiotherapy provisions for injury sustained during training, across four years. Lower limb injuries accounted for more than 75% (n = 1285) of the total demand for physiotherapy service and injuries sustained at the knee and below accounted for 67% of all injury presentations. Studies 2, 3 and 4 investigated injury risk and injury outcomes in 248 New Zealand Army recruits (228 male, 20 female). Study 2 investigated personal profiles, lifestyle and physical performance characteristics of recruits presenting to basic training to identify if pre-existing conditions or risk factors for injury existed at the commencement of training. Recruits were predominantly male (91.9%) with an average age of 20.3 ± 2.8 years. Approximately 30% of recruits reported injury in the year prior to training commencing, with 44.8% of those injuries in the lower limbs. Approximately one fifth of recruits were self-reported current smokers. Recruits who passed the 2.4 km timed run for distance were 53.8% of males and 28.6% of females. Weight-bearing dorsiflexion lunge test performance was within a normal range (left = 10.2 ± 3.2 cm); although, 30.9% of recruits had limb asymmetry (>1.5 cm). Outcomes of the Y Balance TestTM for dynamic lower limb stability, found 70% of female recruits had high posterolateral reach asymmetry (8.1 ± 6.0 cm), while normalised composite reach scores were low (right) for male (92.2 ± 8.1%) and female recruits (89.0 ± 7.5%). Findings from Studies 1 and 2 informed the development of a neuromuscular injury prevention intervention program for army recruit injuries occurring at the knee and below. Study 3, a cluster randomised controlled trial design, was used to investigate if a six-week neuromuscular training program led to fewer lower limb injuries in basic training army recruits, across two intakes compared to usual training. Neuromuscular exercises did not change recruit injury incidence but did lower health care encounters for overall lower limb per recruit (control 4.83 ±7.58, intervention 3.45 ± 5.79, p = 0.041), and overall number of knee injuries (control 262, intervention 120) (p < 0.010) during basic training. Additionally, more intervention recruits completed training on time (p = 0.026). Study 4 considered whether personal, lifestyle, and physical performance characteristics can predict actual injuries sustained by recruits during training. From 248 participants commencing basic training, 46 (18.5%) recruits had missing data, which resulted in 202 (81.5%) remaining for the regression analysis. Backwards stepwise logistic regression had two variables associated with injury risk in the final model: passing the 2.4 km timed run and right Y Balance TestTM posterolateral reach. This model accurately predicted 60.9% of recruits with 36 correctly assigned as not injured and 87 correctly assigned as injured. Findings support the use of physical performance injury screening to identify recruits at risk of injury at entry to training so that mitigation measures could be taken to reduce this risk. This program of research identified several clinical implications and recommendations for future directions. Firstly, knee injuries are common in army recruits and need to be targeted by prevention programs. Secondly, recruits enter training with injury risk factors and therefore screening is important to identify individuals at higher risk so that measures could be taken to lower this risk. Thirdly, neuromuscular training reduces health care burdens associated with common lower limb injuries. Future recommendations include investigation of recruit injury risk factors and neuromuscular training over longer study durations and with larger samples. Investigation of the effectiveness of neuromuscular training delivered prior to basic training or as part of a recruit preconditioning program to lower injury and associated burdens requires consideration. Finally, injury consensus statements are required to improve consistency and accuracy reporting military recruit injury and to improve comparability of findings across military recruit research

Prevalence and risk factors for chronic lower limb oedemain the older population – A community cohort study

Older people are at risk of chronic oedema that increases morbidity and reduces quality of life. This retrospective study aimed to explore the prevalence, characteristics, and risk factors for chronic oedema in older community-dwelling people. Methods Non-health professionals completed routine screening of older people receiving community-age care between 2020 and 2022, including a 10-second pitting test to detect foot and ankle oedema, age, gender, comorbidities, mobility and care levels. Participant characteristics were described, and unadjusted analyses and logistic regression were completed to explore factors associated with oedema. Results There were 459 older adults receiving community care with a mean age of 80.3 years (SD 7.4), and 68.6% were female. Prevalence of chronic oedema was 38.1% (n=175) and 85.4% (n=147) had bilateral oedema. An increased risk of oedema was associated with having chronic heart failure (OR:3.73, CI 2.41, 5.79) and using a mobility aid (OR: 2.38, CI 1.51, 3.75). Conclusion Older people are at risk of chronic oedema and early detection may prevent complications. Non-health professionals can perform screening, boosting workforce capacity

Does the use of store-and-forward telehealth systems improve outcomes for clinicians managing diabetic foot ulcers? A pilot study

Diabetic foot ulcers are one of the most hospitalised diabetes complications and contribute to many leg amputations.\ud Trained diabetic foot teams and specialists managing diabetic foot ulcers have demonstrated reductions in amputations and hospitalisation by up to 90%. Few such teams exist in Australia. Thus, access is limited for all geographical populations and may somewhat explain the high rates of hospitalisation.\ud Aim: This pilot study aims to analyse if local clinicians managing diabetic foot complications report improved access to diabetic foot specialists and outcomes with the introduction of a telehealth store-and-forward system.\ud Method: A store-and-forward telehealth system was implemented in six different Queensland locations between August 2009 and February 2010. Sites were offered ad hoc and/or fortnightly telehealth access to a diabetic foot speciality service. A survey was sent six months following commencement of the trial to the 14 eligible clinicians involved in the trial to gauge clinical perception of the telehealth system.\ud Results: Eight participants returned the surveys. The majority of responding clinicians reported that the telehealth system was easy to use (100%), improved their access to diabetic foot speciality services (75%), improved upskilling of local diabetes service staff (100%), and improved patient outcomes (100%).\ud Conclusion: This pilot study suggests that clinicians found the use of a telehealth store-and-forward system very useful in improving access to speciality services, clinical skills and patient outcomes. This study supports the recommendation that telehealth systems should be made available for diabetic foot ulcer management

Predictors of self-perceived cultural responsiveness in entry-level physiotherapy students in Australia and Aotearoa New Zealand

Background: Ensuring physiotherapy students are well prepared to work safely and effectively in culturally diverse societies upon graduation is vital. Therefore, determining whether physiotherapy programs are effectively developing the cultural responsiveness of students is essential. This study aimed to evaluate the level of self-perceived cultural responsiveness of entry level physiotherapy students during their training, and explore the factors that might be associated with these levels. Methods: A cross sectional study of physiotherapy students from nine universities across Australia and Aotearoa New Zealand was conducted using an online self-administered questionnaire containing three parts: The Cultural Competence Assessment tool, Altemeyer’s Dogmatism scale, and the Marlowe-Crowne social desirability scale- short form. Demographic data relating to university, program, and level of study were also collected. Data was analysed using one-way ANOVA, t-tests and multiple regression analysis. Results: A total of 817 (19% response rate) students participated in this study. Overall, students had a moderate level of self-perceived cultural responsiveness (Mean (SD) = 5.15 (0.67)). Fewer number of weeks of clinical placement attended, lower levels of dogmatism, and greater social desirability were related to greater self-perceived cultural responsiveness. Additionally, fourth year undergraduate students perceived themselves to be less culturally responsive than first and second year students (p < 0.05). Conclusions: These results provide educators with knowledge about the level of self-perceived cultural responsiveness in physiotherapy students, and the factors that may need to be assessed and addressed to support the development of culturally responsive practice

Effects of augmented exercise therapy on outcome of gait and gait-related activities in the first 6 months after stroke: a meta-analysis.

BACKGROUND AND PURPOSE-: The purpose of this study was to determine the effects of augmented exercise therapy on gait, gait-related activities, and (basic and extended) activities of daily living within the first 6 months poststroke. METHODS-: A systematic literature search in electronic databases from 1990 until October 2010 was performed. Randomized controlled trials were included in which the experimental group spent augmented time in lower-limb exercise therapy compared with the control group. Outcomes were gait, gait-related activities, and (extended) activities of daily living. Results from individual studies were pooled by calculating the summary effect sizes. Subgroup analyses were applied for a treatment contrast of ≥16 hours, timing poststroke, type of control intervention, and methodological quality. RESULTS-: Fourteen (N=725) of 4966 identified studies were included. Pooling resulted in small to moderate significant summary effect sizes in favor of augmented exercise therapy for walking ability, comfortable and maximum walking speed, and extended activities of daily living. No significant effects were found for basic activities of daily living. Subgroup analysis did not show a significant effect modification. CONCLUSIONS-: Dose-response trials in stroke rehabilitation are heterogeneous. The present meta-analysis suggests that increased time spent on exercise of gait and gait-related activities in the first 6 months poststroke results in significant small to moderate effects in terms of walking ability, walking speed, and extended activities of daily living. High-quality dose-response exercise therapy trials are needed with identical treatment goals but incremental levels of intensity. © 2011 American Heart Association, Inc

Using the Barthel Index and modified Rankin Scale as outcome measures for stroke rehabilitation trials; A comparison of minimum sample size requirements

Objectives Underpowered trials risk inaccurate results. Recruitment to stroke rehabilitation randomised controlled trials (RCTs) is often a challenge. Statistical simulations offer an important opportunity to explore the adequacy of sample sizes in the context of specific outcome measures. We aimed to examine and compare the adequacy of stroke rehabilitation RCT sample sizes using the Barthel Index (BI) or modified Rankin Scale (mRS) as primary outcomes. Methods We conducted computer simulations using typical experimental event rates (EER) and control event rates (CER) based on individual participant data (IPD) from stroke rehabilitation RCTs. Event rates are the proportion of participants who experienced clinically relevant improvements in the RCT experimental and control groups. We examined minimum sample size requirements and estimated the number of participants required to achieve a number needed to treat within clinically acceptable boundaries for the BI and mRS. Results We secured 2350 IPD (18 RCTs). For a 90% chance of statistical accuracy on the BI a rehabilitation RCT would require 273 participants per randomised group. Accurate interpretation of effect sizes would require 1000s of participants per group. Simulations for the mRS were not possible as a clinically relevant improvement was not detected when using this outcome measure. Conclusions Stroke rehabilitation RCTs with large sample sizes are required for accurate interpretation of effect sizes based on the BI. The mRS lacked sensitivity to detect change and thus may be unsuitable as a primary outcome in stroke rehabilitation trials