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Background: Difficulty using the upper extremity in everyday activities is common after stroke. Constraint-induced movement therapy (CIMT) has been shown to be effective in both sub-acute and chronic phases of stroke recovery and is recommended in clinical practice guidelines for stroke internationally. Despite reports of equivalence of outcome when stroke rehabilitation interventions are delivered using telehealth, there has been limited evaluation of CIMT when using this mode of delivery. ReCITE will (a) evaluate the feasibility and acceptability of CIMT when delivered via telehealth to stroke survivors (TeleCIMT) and (b) explore therapists' experiences and use of an online support package inclusive of training, mentoring and resources to support TeleCIMT delivery in clinical practice., Methods: A prospective single-group, single blinded, study design with embedded process evaluation will be conducted. The study will be conducted at three outpatient services in Sydney, Australia. A multi-faceted therapist support package, informed by the Capabilities, Opportunity, Motivation- Behaviour model (COM-B), will be used to support occupational therapists to implement TeleCIMT as part of routine care to stroke survivors. Each service will recruit 10 stroke survivor participants ( n = 30) with mild to moderate upper extremity impairment. Upper extremity and quality of life outcomes of stroke survivor participants will be collected at baseline, post-intervention and at a 4 week follow-up appointment. Feasibility of TeleCIMT will be evaluated by assessing the number of stroke participants who complete 80% of intensive arm practice prescribed during their 3 week program (i.e., at least 24 h of intensive arm practice). Acceptability will be investigated through qualitative interviews and surveys with stroke survivors, supporter surveys and therapist focus groups. Qualitative interviews with therapists will provide additional data to explore their experiences and use of the online support package., Discussion: The COVID-19 pandemic resulted in a rapid transition to delivering telehealth. The proposed study will investigate the feasibility and acceptability of delivering a complex intervention via telehealth to stroke survivors at home, and the support that therapists and patients require for delivery. The findings of the study will be used to inform whether a larger, randomized controlled trial is feasible., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Christie, Fearn, McCluskey, Lannin, Shiner, Kilkenny, Boydell, Meharg, Howes, Churilov, Faux, Doussoulin and Middleton.)

Background: It is common for people with persistent spasticity due to a stroke to receive an injection of botulinum toxin-A in the upper limb, however post-injection intervention varies., Aim: To determine the long-term effect of additional upper limb rehabilitation following botulinum toxin-A in chronic stroke., Method: An analysis of long-term outcomes from national, multicenter, Phase III randomised trial with concealed allocation, blinded measurement and intention-to-treat analysis was carried out. Participants were 140 stroke survivors who were scheduled to receive botulinum toxin-A in any muscle(s) that cross the wrist because of moderate to severe spasticity after a stroke greater than 3 months ago, who had completed formal rehabilitation and had no significant cognitive impairment. Experimental group received botulinum toxin-A plus 3 months of evidence-based movement training while the control group received botulinum toxin-A plus a handout of exercises. Primary outcomes were goal attainment (Goal Attainment Scale) and upper limb activity (Box and Block Test) at 12 months (ie, 9 months beyond the intervention). Secondary outcomes were spasticity, range of motion, strength, pain, burden of care, and health-related quality of life., Results: By 12 months, the experimental group scored the same as the control group on the Goal Attainment Scale (MD 0 T-score, 95% CI -5 to 5) and on the Box and Block Test (MD 0.01 blocks/s, 95% CI -0.01 to 0.03). There were no differences between groups on any secondary outcome., Conclusion: Additional intensive upper limb rehabilitation following botulinum toxin-A in chronic stroke survivors with a disabled upper limb is not more effective in the long-term., Trial Registration: ACTRN12615000616572 (12/06/2015)., (© 2022. The Author(s).)

Background: Environmental enrichment involves organization of the environment and provision of equipment to facilitate engagement in physical, cognitive, and social activities. In animals with stroke, it promotes brain plasticity and recovery., Aims: To assess the feasibility and safety of a patient-driven model of environmental enrichment incorporating access to communal and individual environmental enrichment., Methods: A nonrandomized cluster trial with blinded measurement involving people with stroke ( n  = 193) in four rehabilitation units was carried out. Feasibility was operationalized as activity 10 days after admission to rehabilitation and availability of environmental enrichment. Safety was measured as falls and serious adverse events. Benefit was measured as clinical outcomes at three months, by an assessor blinded to group., Results: The experimental group ( n  = 91) spent 7% (95% CI -14 to 0) less time inactive, 9% (95% CI 0-19) more time physically, and 6% (95% CI 2-10) more time socially active than the control group ( n  = 102). Communal environmental enrichment was available 100% of the time, but individual environmental enrichment was rarely within reach (24%) or sight (39%). There were no between-group differences in serious adverse events or falls at discharge or three months or in clinical outcomes at three months., Conclusions: This patient-driven model of environmental enrichment was feasible and safe. However, the very modest increase in activity by people with stroke, and the lack of benefit in clinical outcomes three months after stroke do not provide justification for an efficacy trial.

Background and Purpose: Changes to hospital systems were implemented from March 2020 in Australia in response to the coronavirus disease 2019 pandemic, including decreased resources allocated to stroke units. We investigate changes in the quality of acute care for patients with stroke or transient ischemic attack during the pandemic according to patients' treatment setting (stroke unit or alternate ward)., Methods: We conducted a retrospective cohort study of patients admitted with stroke or transient ischemic attack between January 2019 and June 2020 in the Australian Stroke Clinical Registry (AuSCR). The AuSCR monitors patients' treatment setting, provision of allied health and nursing interventions, prescription of secondary prevention medications, and discharge destination. Weekly trends in the quality of care before and during the pandemic period were assessed using interrupted time series analyses., Results: In total, 18,662 patients in 2019 and 8,850 patients in 2020 were included. Overall, 75% were treated in stroke units. Before the pandemic, treatment in a stroke unit was superior to alternate wards for the provision of all evidence-based therapies assessed. During the pandemic period, the proportion of patients receiving a swallow screen or assessment, being discharged to rehabilitation, and being prescribed secondary prevention medications decreased by 0.58% to 1.08% per week in patients treated in other ward settings relative to patients treated in stroke units. This change represented a 9% to 17% increase in the care gap between these treatment settings during the period of the pandemic that was evaluated (16 weeks)., Conclusions: During the first 6 months of the pandemic, widening care disparities between stroke units and alternate wards have occurred.