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Objective: To explore the experiences of children and families after a child’s traumatic injury (Injury Severity Score >8). Design: Qualitative interview study. Setting: Two children’s major trauma centres in England. Participants: 32 participants: 13 children with traumatic injuries, their parents/guardians ( n = 14) and five parents whose injured child did not participate. Methods: Semi-structured interviews exploring the emotional, social, practical and physical impacts of children’s injuries, analysed by thematic analysis. Results: Interviews were conducted a median of 8.5 months (IQR 9.3) post-injury. Injuries affected the head, chest, abdomen, spine, limbs or multiple body parts. Injured children struggled with changes to their appearance, physical activity restrictions and late onset physical symptoms, which developed after hospital discharge when activity levels increased. Social participation was affected by activity restrictions, concerns about their appearance and interruptions to friendships. Psychological impacts, particularly post-traumatic stress type symptoms often affected both children and parents. Parents’ responsibilities suddenly increased, which affected family relationships and roles, their ability to work and carry out daily tasks. Rapid hospital discharge was wanted, but participants often felt vulnerable on return home. They valued continued contact with a healthcare professional and practical supports from family and friends, which enabled resumption of their usual lives. Conclusions: Injured children experience changes to their appearance, friendships, physical activity levels and develop new physical and mental health symptoms after hospital discharge. Such challenges can be addressed by the provision of advice about potential symptoms, alternative activities during recovery, strategies to build resilience and how to access services after hospital discharge.

Objective: To create a classification system based on stroke-related impairments. Data source: All adults with stroke admitted for at least 72 hours in England, Wales and Northern Ireland from July 2013 to July 2015 extracted from the Sentinel Stroke National Audit Programme Analysis: Impairments were defined using the National Institute of Health Stroke Scale scores at admission. Common combinations of impairments were identified based on geometric coding and expert knowledge. Validity of the classification was assessed using standard descriptive statistics to report and compare patients’ characteristics, therapy received and outcomes in each group. Results: Data from 94,905 patients were extracted. The items of the National Institute of Health Stroke Scale (on admission) were initially grouped into four body systems: Cognitive, Motor, Sensory and Consciousness. Seven common combinations of these impairments were identified (in order of stroke severity); Patients with Loss of Consciousness ( n = 6034, 6.4%); those with Motor + Cognitive + Sensory impairments ( n = 28,226, 29.7%); Motor + Cognitive impairments ( n = 16,967, 17.9%); Motor + Sensory impairments ( n = 9882, 10.4%); Motor Only impairments ( n = 20,471, 21.6%); Any Non-Motor impairments ( n = 7498, 7.9%); and No Impairments ( n = 5827, 6.1%). There was a gradation of age, premorbid disability, mortality and disability on discharge. People with the most and least severe categories were least likely to receive therapy, and received least therapy (−20 minutes/day of stay) compared to −35 minutes/day of stay for the moderately severe categories. Conclusions: A classification system of seven Stroke Impairment Categories has been presented.

Question In adults with stroke, does Bobath therapy improve lower limb activity performance, strength or co-ordination when compared with no intervention or another intervention? Design Systematic review of randomised trials with meta-analyses. Participants Adults after stroke. Intervention Bobath therapy compared with another intervention or no intervention. Outcome measures Lower limb activity performance (eg, sit to stand, walking, balance), lower limb strength and lower limb co-ordination. Trial quality was assessed using the PEDro scale. Results Twenty-two trials were included in the review and 17 in the meta-analyses. The methodological quality of the trials varied, with PEDro scale scores ranging from 2 to 8 out of 10. No trials compared Bobath therapy to no intervention. Meta-analyses estimated the effect of Bobath therapy on lower limb activities compared with other interventions, including: task-specific training (nine trials), combined interventions (four trials), proprioceptive neuromuscular facilitation (one trial) and strength training (two trials). The pooled data indicated that task-specific training has a moderately greater benefit on lower limb activities than Bobath therapy (SMD 0.48), although the true magnitude of the benefit may be substantially larger or smaller than this estimate (95% CI 0.01 to 0.95). Bobath therapy did not clearly improve lower limb activities more than a combined intervention (SMD −0.06, 95% CI −0.73 to 0.61) or strength training (SMD 0.35, 95% CI −0.37 to 1.08). In one study, Bobath therapy was more effective than proprioceptive neuromuscular facilitation for improving standing balance (SMD −1.40, 95% CI −1.92 to −0.88), but these interventions did not differ on any other outcomes. Bobath therapy did not improve strength or co-ordination more than other interventions. Conclusions Bobath therapy was inferior to task-specific training and not superior to other interventions, with the exception of proprioceptive neuromuscular facilitation. Prioritising Bobath therapy over other interventions is not supported by current evidence. Registration PROSPERO CRD42019112451.

The objective of this review was to synthesise studies which address the views of healthcare professionals (HCPs) towards patients with functional neurological disorder (FND).An interpretive systematised review was conducted. Seven databases were searched using a comprehensive search strategy (MEDLINE, EMBASE, AMED, CINAHL, PsychINFO, ProQuest Nursing and Allied Health, and Scopus). Qualitative studies and those using survey methods were included. An inductive approach to thematic analysis was used to identify concepts from the data and to synthesise the results.The views of 2769 HCPs were represented in 11 included articles. The overarching theme across the articles was uncertainty: about making the diagnosis of FND, about professional roles, and about optimum management. Fear was also a common theme: of saying the wrong thing, of offending patients, or of breaking the therapeutic relationship.If all HCPs felt uncertain about how to manage patients with FND and avoided them by passing them on to another discipline, then a "vicious cycle" is formed in which patients are passed from one professional to another but without receiving clear, honest information, or effective treatment. HCPs would benefit from increased training on FND and clear clinical pathways to alleviate feelings of uncertainty.Implications for rehabilitationEvidence-based or, at the very least, consensus-based multi-disciplinary care pathways for the assessment and treatment of patients with functional neurological disorder are required to improve equitability of services.Training packages for healthcare professionals need to be developed, evaluated and implemented in order to improve confidence of making and explaining the diagnosis and to reduce stigma of functional neurological disorders.Improved input for patients with functional neurological disorder is likely to occur if healthcare professionals are open, honest and use effective communication skills, both with their patients and fellow healthcare professionals.

Objectives: To understand why most stroke patients receive little therapy. We investigated the factors associated with the amount of stroke therapy delivered. Methods: Data regarding adults admitted to hospital with stroke for at least 72 hours (July 2013–July 2015) were extracted from the UK’s Sentinel Stroke National Audit Programme. Descriptive statistics and multilevel mixed effects regression models explored the factors that influenced the amount of therapy received while adjusting for confounding. Results: Of the 94,905 patients in the study cohort (mean age: 76 (SD: 13.2) years, 78% had a mild or moderate severity stroke. In all, 92% required physiotherapy, 87% required occupational therapy, 57% required speech therapy but only 5% were considered to need psychology. The average amount of therapy ranged from 2 minutes (psychology) to 14 minutes (physiotherapy) per day of inpatient stay. Unmodifiable characteristics (such as stroke severity) dominated the variation in the amount of therapy. However important, modifiable organizational factors were the day and time of admission, type of stroke team, timely therapy assessments, therapy and nursing staffing levels (qualified and support staff), and presence of weekend or early supported discharge services. Conclusion: The amount of stroke therapy is associated with unmodifiable patient-related characteristics and modifiable organizational factors in that more therapy was associated with higher therapy and nurse staffing levels, specialist stroke rehabilitation services, timely therapy assessments, and the presence of weekend and early discharge services.

Perceptual control theory (PCT) proposes that perceptual inputs are controlled to intentional 'reference' states by hierarchical negative feedback control, evidence for which comes from manual tracking experiments in humans. We reviewed these experiments to determine whether tracking is a process of perceptual control, and to assess the state-of-the-evidence for PCT. A systematic literature search was conducted of peer-review journal and book chapters in which tracking data were simulated with a PCT model (13 studies, 53 participants). We report a narrative review of these studies and a qualitative assessment of their methodological quality. We found evidence that individuals track to individual-specific endogenously-specified reference states and act against disturbances, and evidence that hierarchical PCT can simulate complex tracking. PCT's learning algorithm, reorganization, was not modelled. Limitations exist in the range of tracking conditions under which the PCT model has been tested. Future PCT research should apply the PCT methodology to identify control variables in real-world tasks and develop hierarchical PCT architectures for goal-oriented robotics to test the plausibility of PCT model-based action control.

Objective: To map and describe how patients pass through stroke services. Methods: Data from 94,905 stroke patients (July 2013–July 2015) who were still inpatients 72 hours after hospital admission were extracted from a national stroke register and were used to identify the routes patients took through hospital and community stroke services. We sought to categorize these routes through iterative consultations with clinical experts and to describe patient characteristics, therapy provision, outcomes and costs within each category. Results: We identified 874 routes defined by the type of admitting stroke team and subsequent transfer history. We consolidated these into nine distinct routes and further summarized these into three overlapping ‘pathways’ that accounted for 99% of the patients. These were direct discharge (44%), community rehabilitation (47%) and inpatient transfer (19%) with 12% of the patients receiving both inpatient transfer and community rehabilitation. Patients with the mildest and most severe strokes were more likely to follow the direct discharge pathway. Those perceived to need most therapy were more likely to follow the inpatient transfer pathway. Costs were lowest and mortality was highest for patients on the direct discharge pathway. Outcomes were best for patients on the community rehabilitation pathway and costs were highest where patients underwent inpatient transfers. Conclusion: Three overarching stroke care pathways were identified which differ according to patient characteristics, therapy needs and outcomes. This pathway mapping provides a benchmark to develop and plan clinical services, and for future research.

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To assess the effects of AFOs for improving walking in adults with calf muscle weakness due to slowly progressive NMD.

Purpose: To assess the feasibility and acceptability of the Howz smart home system for stroke survivors.Materials: Howz uses smart home technology to monitor users' activity in the home and machine learning algorithms to detect when their activity changes. This information made available to the user and a named contact (usually a family member) via the Howz app. If activity changes, an alert is then sent to the user and the named contact.Methods: Howz was installed in the homes of 19 stroke survivors who lived alone. The sensors installed; the number and nature of alerts; adverse events; any technical difficulties and how Howz was used were recorded. We also interviewed participants and their named contacts about their views and experiences of using Howz eight weeks after installation.Results: Installation was effective; no technological problems or adverse events were reported. All participants chose alerts regarding "getting up" and activity during the day and at night. There was a mean of 1.1 (sd 1.2) alerts/person. Participants found the system unobtrusive and were positive about it. They found it easy to use and would recommend it to others with stroke. The most frequently reported benefit was that Howz gave peace of mind for the users and/or the family/named contact that help would be at hand if needed.Conclusions: The Howz system was feasible and acceptable for stroke survivors. It gave users and their family an enhanced sense of security and peace of mind that help would be at hand if needed.Implications for rehabilitationAlthough most stroke survivors are elderly and often suffer physical, visual and cognitive disabilities which are often considered as barriers to using smart home technology, this project has demonstrated the well-developed smart home technology is feasible and acceptable.Users were able and willing to engage with the technology (to varying degrees) and had no concerns about invasion of privacy.The main benefit of the Howz system is an enhanced sense of security for the user and their family that help is at hand if needed.

Background\ud Limitations in upper limb functioning are common in Musculoskeletal disorders and the Disabilities of the Arm, Shoulder and Hand scale (DASH) has gained widespread use in this context. However, various concerns have been raised about its construct validity and so this study seeks to examine this and other psychometric aspects of both the DASH and QuickDASH from a modern test theory perspective.\ud \ud Methods\ud Participants in the study were eligible if they had a confirmed diagnosis of Rheumatoid Arthritis (RA). They were mailed a questionnaire booklet which included the DASH. Construct validity was examined by fit to the Rasch measurement model. The degree of precision of both the DASH and QuickDASH were considered through their Standard Error of Measurement (SEM).\ud \ud Results\ud Three hundred and thirty-seven subjects with confirmed RA took part, with a mean age of 62.0 years (SD12.1); 73.6% (n = 252) were female. The median standardized score on the DASH was 33 (IQR 17.5–55.0). Significant misfit of the DASH and QuickDASH was observed but, after accommodating local dependency among items in a two-testlet solution, satisfactory fit was obtained, supporting the unidimensionality of the total sets and the sufficiency of the raw (ordinal or standardized) scores.\ud \ud Conclusion\ud Having accommodated local response dependency in the DASH and QuickDASH item sets, their total scores are shown to be valid, given they satisfy the Rasch model assumptions. The Rasch transformation should be used whenever all items are used to calculate a change score, or to apply parametric statistics within an RA population.\ud \ud Significance and innovations\ud \ud Most previous modern psychometric analyses of both the DASH and QuickDASH have failed to fully address the effect of a breach of the local independence assumption upon construct validity.\ud \ud Accommodating this problem by creating ‘super items’ or testlets, removes this effect and shows that both versions of the scale are valid and unidimensional, as applied with a bi-factor equivalent solution to an RA population.\ud \ud The Standard Error of Measurement of a scale can be biased by failing to take into account the local dependency in the data which inflates reliability and thus making the SEM appear better (i.e. smaller) than the true value without bias.\ud

ObjectiveTo review and synthesise qualitative literature relating to the views, perceptions and experiences of patients with acquired neurological conditions and their caregivers about the process of receiving information about recovery; as well as the views and experiences of healthcare professionals involved in delivering this information.DesignSystematic review of qualitative studies.Data sourcesMEDLINE, Embase, AMED, CINAHL, PsycINFO, Web of Science and the Cochrane library were searched from their inception to July 2019.Data extraction and synthesisTwo reviewers extracted data from the included studies and assessed quality using an established tool. Thematic synthesis was used to synthesise the findings of included studies.ResultsSearches yielded 9105 titles, with 145 retained for full-text screening. Twenty-eight studies (30 papers) from eight countries were included. Inductive analysis resulted in 11 descriptive themes, from which 5 analytical themes were generated: the right information at the right time; managing expectations; it’s not what you say, it’s how you say it; learning how to talk about recovery and manage emotions; the context of uncertainty.ConclusionsOur findings highlight the inherent challenges in talking about recovery in an emotional context, where breaking bad news is a key feature. Future interventions should focus on preparing staff to meet patients’ and families’ information needs, as well as ensuring they have the skills to discuss potential recovery and break bad news compassionately and share the uncertain trajectory characteristic of acquired neurological conditions. An agreed team-based approach to talking about recovery is recommended to ensure consistency and improve the experiences of patients and their families.

The study explored the acceptability of high repetition arm training as part of a randomised controlled trial, early after stroke, when fatigue levels and emotional strain are often high. 36 sub-acute stroke survivors (61 years+/-15) attended for assessment sessions at 3, 6, and 12 weeks after stroke. Individuals were randomised to receive 6 high repetition arm training sessions between 3 and 6 weeks (intervention) or the control group. Semi-structured interviews were conducted at trial completion. Interview transcripts were analysed through framework analysis conducted independently by 2 researchers. Stroke survivors participated despite high levels of fatigue because they hoped for personal benefit or to potentially benefit future patients. Benefits reported from participation included physical improvements, psychological benefit, improved understanding of their condition as well as a feeling of hope and distraction. The arm training at three weeks after stroke, aiming for 420 movement repetitions was not considered to be too intensive or too early, and most individuals felt lucky to have been, or would have preferred to be in the early training group. High repetition arm training early after stroke was acceptable to participants. Study participation was generally viewed as a positive experience, suggesting that early intervention may not only be physically beneficial but also psychologically.Implications for rehabilitationStroke survivors report that high repetition arm training early after stroke is acceptable.Participation in rehabilitation research early after stroke provides stroke survivors with hope and meaning despite the high prevalence of fatigue.Complex information needs to be repeated and provided in a number of formats early after stroke. Stroke survivors report that high repetition arm training early after stroke is acceptable. Participation in rehabilitation research early after stroke provides stroke survivors with hope and meaning despite the high prevalence of fatigue. Complex information needs to be repeated and provided in a number of formats early after stroke.

Background: Home-based robotic therapy is a trend of post-stroke upper limb rehabilitation. Although home-based upper limb rehabilitation robots have been developed over several decades, no design specification has been published. Objectives: To identify and synthesize design requirements considering user and technology needs for a home-based upper limb rehabilitation robot through a scoping review. Method: Studies published between 1 January 2000 and 10 June 2020 in Scopus, Web of Science and PubMed database regarding design requirements for upper limb rehabilitation robots from of stroke survivors or therapists were identified and analyzed. We use 'requirement' as something that is needed or wanted. Two physiotherapists ranked the requirements identified from literature review. Results: Nine studies were selected for review. They identified 42 requirements regarding functionality (n = 11, 26.2% of total requirements), usability (n = 16, 38.0% of total requirements), software (n = 14, 33.3% of total requirements) and safety (n = 1, 2.4% of total requirements). The main implementation barriers with respect to adherence and monitoring were space, operation, and cost. Conclusion: This is the first research to summarize the design requirements for home-based upper limb rehabilitation robots for stroke survivors. The need for a safe, comfortable, easy to use device which can be individualized and promote specific movements and tasks emerged. The result of this paper captures the design requirements that can be used in future for the development of a design specification. It provides designers and researchers guidance about the real-world needs for home-based upper limb rehabilitation robots for stroke.

Background The Valued Life Activities Scale (VLAs) measures difficulty in daily activities and social participation. With various versions involving a different number of items, we have linguistically and culturally adopted the full VLAs (33-items) and psychometrically tested it in adults with rheumatic and musculoskeletal diseases in the United Kingdom. Methods Participants with Rheumatoid Arthritis, Ankylosing Spondylitis, Chronic Pain/ Fibromyalgia, Chronic Hand/ Upper Limb Conditions, Osteoarthritis, Systemic Lupus, Systemic Sclerosis and Primary Sjogren’s Syndrome were recruited from out-patient clinics in National Health Service Hospitals, General Practice and patient organisations in the UK. Phase1 involved linguistic and cultural adaptation: forward translation to British English; synthesis; expert panel review and cognitive debriefing interviews. In Phase2 participants completed postal questionnaires to assess internal construct validity using (i) Confirmatory Factor Analysis (CFA) (ii) Mokken scaling and (iii) Rasch model. Results Responders (n = 1544) had mean age of 59 years (SD13.3) and 77.2% women. A CFA failed to support a total score from the 33-items (Chi Square 3552:df 464: p Conclusions The UK version of the VLAs failed to satisfy classical and modern psychometric standards for complete item sets. However, as the scale is not usually applied in complete format, an item bank approach calibrated 25 items with fit to the Rasch model. Suitable Computer Adaptive Testing (CAT) software could implement the item set, giving patients the choice of whether an item applies to them, or not.

The Evaluation of Daily Activity Questionnaire (EDAQ) is a detailed patient-reported outcome measure of activity ability. The objective of this research was to assess the linguistic and cross-cultural validity and psychometric properties of the EDAQ in rheumatoid arthritis for Dutch and German speakers. The EDAQ was translated into Dutch and German using standard methods. A total of 415 participants (Dutch n = 252; German n = 163) completed two questionnaires about four weeks apart. The first included the EDAQ, Health Assessment Questionnaire (HAQ) and 36-item Short-Form v2 (SF-36v2) and the second, the EDAQ only. We examined construct validity using Rasch analysis for the two components (Self-Care and Mobility) of the Dutch and German EDAQ. Language invariance was also tested from the English version. We examined internal consistency, concurrent and discriminant validity and test–retest reliability in the 14 EDAQ domains. The Self-Care and Mobility components satisfied Rasch model requirements for fit, unidimensionality and invariance by language. Internal consistency for all 14 domains was mostly good to excellent (Cronbach’s alpha ≥ 0.80). Concurrent validity was mostly strong: HAQ rs = 0.65–0.87; SF36v2 rs = − 0.61 to − 0.87. Test–retest reliability was excellent [ICC (2,1) = 0.77–0.97]. The EDAQ has good reliability and validity in both languages. The Dutch and German versions of the EDAQ can be used as a measure of daily activity in practice and research in the Netherlands and German- speaking countries.

Objective:To evaluate the feasibility of a multicentre randomized controlled trial of ReaDySpeech, an online speech therapy programme for people with dysarthria.Design:Feasibility randomized controlled trial, 2:1 minimization procedure.Setting:Four UK NHS services across hospital and community.Participants:Forty participants with dysarthria at least one week post-stroke.Interventions/comparator:ReaDySpeech with usual care ( n = 26) versus usual care only ( n = 14).Main outcomes:Feasibility measures included the following: recruitment and retention rate, time taken to carry out assessments, success of outcome assessor blinding, fidelity and adherence. Participant baseline and outcome measures collected before and after 8–10 weeks of intervention were the Frenchay Dysarthria Assessment II, Therapy Outcome Measure, Communication Outcomes After Stroke Scale, EQ-5D-5L and Dysarthria Impact Profile.Results:Recruited 40 participants out of 74 eligible people, 1–13 weeks post stroke and mean age 69 years (37–99). Retention was very high (92%). Assessor blinding was not achieved with intervention allocation correctly guessed for 70% of participants (26/37). Time to carry out assessments was acceptable to participants. ReaDySpeech was delivered to 16 of 26 allocated participants, who completed 55% of prescribed activities, but both interventions were delivered at low intensity (mean 6.6 face-to-face sessions of 40-minute duration).Conclusion:Recruitment and retention in this randomized controlled trial of computerized therapy for dysarthria is feasible for acute stroke. However, further feasibility work is needed to evaluate whether it is possible to recruit chronic stroke; increase intervention delivery, intensity and adherence; achieve outcome assessor blinding by video-recording and to determine sample size for a larger trial of effectiveness.

Computational models that simulate individuals’ movements in pursuit tracking tasks have been used to elucidate mechanisms of human motor control. Whilst there is evidence that individuals demonstrate idiosyncratic control tracking strategies, it remains unclear whether models can be sensitive to these idiosyncrasies. Perceptual control theory (PCT; Powers, 1973) provides a unique model architecture with an internally set reference value parameter, and can be optimized to fit an individual’s tracking behavior. The current study investigated whether PCT models could show temporal stability and individual-specificity over time. Twenty adults completed three blocks of 15 one-minute, pursuit-tracking trials. Two blocks (training and post-training) were completed in one session and the third was completed after one week (follow-up). The target moved in a one-dimensional, pseudorandom pattern. PCT models were optimized to the training data using a least-mean-squares algorithm, and validated with data from post-training and follow-up. We found significant inter-individual variability (partial η2: .464-.697) and intra-individual consistency (Cronbach’s α: .880-.976) in parameter estimates. Polynomial regression revealed that all model parameters, including the reference value parameter, contribute to simulation accuracy. Participants’ tracking performances were significantly more accurately simulated by models developed from their own tracking data than by models developed from other participants’ data. We conclude that PCT models can be optimized to simulate the performance of an individual and that the test-retest reliability of individual models is a necessary criterion for evaluating computational models of human performance.

We established spatial neglect prevalence, disease profile and amount of therapy that inpatient stroke survivors received, and outcomes at discharge using Sentinel Stroke National Audit Programme (SSNAP) data. We used data from 88,664 National Health Service (NHS) admissions in England, Wales and Northern Ireland (July 2013&ndash, July 2015), for stroke survivors still in hospital after 3 days with a completed baseline neglect National Institute for Health Stroke Scale (NIHSS) score. Thirty percent had neglect (NIHSS item 11 &ge, 1) and they were slightly older (78 years) than those without neglect (75 years). Neglect was observed more commonly in women (33 vs. 27%) and in individuals with a premorbid dependency (37 vs. 28%). Survivors of mild stroke were far less likely to present with neglect than those with severe stroke (4% vs. 84%). Those with neglect had a greatly increased length of stay (27 vs. 10 days). They received a comparable amount of average daily occupational and physiotherapy during their longer inpatient stay but on discharge a greater percentage of individuals with neglect were dependent on the modified Rankin scale (76 vs. 57%). Spatial neglect is common and associated with worse clinical outcomes. These results add to our understanding of neglect to inform clinical guidelines, service provision and priorities for future research.

ObjectiveTo identify the main drivers of inpatient stroke care resource use, estimate the influence of stroke teams on the length of stay (LoS) of its patients and analyse the variation in relative performance across teams.DesignFor each of four types of stroke care teams, a two-level count data model describing the variation in LoS and identifying the team influence on LoS purged of patient and treatment characteristics was estimated. Each team effect was interpreted as a measure of stroke care relative performance and its variation was analysed.SettingThis study used data from 145 396 admissions in 256 inpatient stroke care teams between June 2013 and July 2015 included in the national stroke register of England, Wales and Northern Ireland—Sentinel Stroke National Audit Programme.ResultsThe main driver of LoS, and thus resource use, was the need for stroke therapy even after stroke severity was taken into account. Conditional on needing the therapy in question, an increase in the average amount of therapy received per inpatient day was associated with shorter LoS. Important variations in stroke care performance were found within each team category.ConclusionsResource use was strongly associated with stroke severity, the need for therapy and the amount of therapy received. The variations in stroke care performance were not explained by measurable patient or team characteristics. Further operational and financial analyses are needed to unmask the causes of this unexplained variation.

Background: Despite advances in the acute care of subarachnoid haemorrhage, longer-term services remain under-developed. Clinical measures are commonly used to assess outcome and quality of life, b...

ObjectiveTo describe the demographics, mechanisms, presentation, injury patterns and outcomes for children with traumatic injuries.SettingData collected from the UK’s Trauma and Audit Research Network.Design and patientsThe demographics, mechanisms of injury and outcomes were described for children with moderate and severe injuries admitted to the Major Trauma Network in England between 2012 and 2017.ResultsData regarding 9851 children were collected. Most (69%) were male. The median age was 6.4 (SD 5.2) years, but infants aged 0.1 year (36.5 days) were the most frequently injured of all ages (0–15 years); 447 (36.0%) of injuries in infants aged ConclusionsA common age of injury and mortality was infants aged

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.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).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').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.

Objective: To identify the barriers and facilitators to goal-setting during rehabilitation for stroke and other acquired brain injuries. Data sources: AMED, Proquest, CINAHL and MEDLINE. Review methods: Two reviewers independently screened, extracted data and assessed study quality using the Mixed Methods Appraisal Tool and undertook thematic content analysis for papers examining the barriers and facilitators to goal-setting during stroke/neurological rehabilitation (any design). Last searches were completed in May 2016. Results: Nine qualitative papers were selected, involving 202 participants in total: 88 patients, 89 health care professionals and 25 relatives of participating patients. Main barriers were: Differences in staff and patients perspectives of goal-setting; patient-related barriers; staff-related barriers, and organisational level barriers. Main facilitators were: individually tailored goal-setting processes, strategies to promote communication and understanding, and strategies to avoid disappointment and unrealistic goals. In addition, patients’ and staff’s knowledge, experience, skill, and engagement with goal-setting could be either a barrier (if these aspects were absent) or a facilitator (if they were present). Conclusion: The main barriers and facilitators to goal-setting during stroke rehabilitation have been identified. They suggest that current methods of goal-setting during inpatient/early stage stroke or neurological rehabilitation are not fit for purpose.

ObjectiveTo explore the needs of children and their families after a child’s traumatic injury.DesignSemi-structured qualitative interviews with purposeful sampling for different types of injuries and a theoretical thematic analysis.Participants32 participants; 13 children living at home after a traumatic injury, their parents/guardians (n=14) and five parents whose injured child did not participate.SettingTwo Children’s Major Trauma Centres (hospitals) in England.ResultsInterviews were conducted a median 8.5 months (IQR 9.3) postinjury. Injuries affected the limbs, head, chest, abdomen, spine or multiple body parts. Participants highlighted needs throughout their recovery (during and after the hospital stay). Education and training were needed to help children and families understand and manage the injury, and prepare for discharge. Information delivery needed to be timely, clear, consistent and complete, include the injured child, but take into account individuals’ capacity to absorb detail. Similarly, throughout recovery, services needed to be timely and easily accessible, with flexible protocols and eligibility criteria to include injured children. Treatment (particularly therapy) needed to be structured, goal directed and of sufficient frequency to return injured children to their full function. A central point of contact is required after hospital discharge for advice, reassurance and to coordinate ongoing care. Positive partnerships with professionals helped injured children and their families maintain a sense of hope and participate in joint decision making about their care.ConclusionThroughout the full trajectory of recovery injured children and their families need family centred, accessible, flexible, coordinated health services, with more effective harmonious, communication between professionals, the child and their family. There is a requirement for support from a single point of contact and a system that monitors the needs of the injured child and their family after hospital discharge.

Background: Developed in the Norway, the Measure of Activity Performance of the Hand (MAP-Hand) assesses 18 activities performed using the hands. It was developed for people with rheumatoid arthritis (RA) using patient generated items, which are scored on a 0-3 scale and summarised into a total score range (0 to 54). This study reports the development and psychometric testing of the British English MAP-Hand in a UK population of people with RA.\ud \ud Methods: Recruitment took place in the National Health Service (NHS) through 17 Rheumatology outpatient clinics. Phase 1 (cross-cultural adaptation) involved: forward translation to British English; synthesis; expert panel review and cognitive debriefing interviews with people with RA. Phase 2 (psychometric testing) involved postal completion of the MAP-Hand, Health Assessment Questionnaire (HAQ), Upper Limb HAQ (ULHAQ), Short-Form 36 (SF-36v2) and Disabilities of the Arm Shoulder Hand (DASH) to measure internal consistency (Cronbach’s alpha); concurrent validity (Spearman’s correlations) and Minimal Detectable Difference (MDC95). The MAP-Hand was repeated three-weeks later to assess test-retest reliability (linear weighted kappa and Intra-Class Correlations (ICC (2,1)). Unidimensionality (internal construct validity) was assessed using (i) Confirmatory Factor Analysis (CFA) (ii) Mokken scaling and (iii) Rasch model. The RUMM2030 software was used, applying the Rasch partial credit model.\ud \ud Results: In Phase 1, 31 participants considered all items relevant. In Phase 2, 340 people completed Test-1 and 273 (80%) completed Test-2 questionnaires. Internal consistency was excellent (α=0.96). Test-retest reliability was good (ICC (2,1) = 0.96 (95% CI 0.94, 0.97)). The MAP-Hand correlated strongly with HAQ20 (rs=.88), ULHAQ (rs=.91), SF-36v2 Physical Functioning (PF) Score (rs=-.80) and DASH (rs=.93), indicating strong concurrent validity. CFA failed to support unidimensionality (Chi-Square 236.0 (df 120; p \ud Conclusions: The British English version of the MAP-Hand has good validity and reliability in people with RA and can be used in both research and clinical practice.\ud Keywords: PROMS; Patient Reported Outcome Measures; hand activity performance; hand function; hand pain; psychometric testing; Rasch analysis; validity; reliability

Objective: To describe the dose, intensity and context of physiotherapy for balance and mobility problems after stroke. Design: Process mapping to describe the context and non-participant observation of therapy sessions to describe the dose and content of therapy. Setting: Four inpatient stroke units in North-West England. Participants: Therapy staff and previously mobile stroke survivors who were treating, or receiving treatment for balance and mobility problems in the participating units. Results: Two units were stand-alone rehabilitation units; two offered a service at the weekends. One had no access to community-based rehabilitation. All had dedicated treatment facilities but often did not use them because of lack of space and difficulty transporting patients. Twenty-two patients participated and 100 treatment sessions were observed. Practicing walking, sit-to-stand and transfers were the most frequent objectives and interventions usually with the therapist(s) physically facilitating the patient’s movements. The dose of practise was low; mean repetitions of sit-to-stand per session was 5 (SD 6.4); mean time spent upright per session was 11.24 (SD = 7) minutes, and mean number of steps per session was 202 (SD 118). The mean number of staff per patient was 2.1 (SD = 0.6, mode = 2), usually involving two qualified therapists. Falls prevention or management, wheelchair skills and bed mobility were not practised. Conclusion: Stroke physiotherapy for balance and mobility problems features low-dose, low-intensity therapist-led practice, mainly of walking and sit-to-stand. Staff:patient ratios were high. Therapists need to organize treatment sessions to maximize the intensity of functional task practice.

Background: The Evaluation of Daily Activity Questionnaire (EDAQ) is a patient reported outcome (PRO) of activity limitations. The English EDAQ is reliable, valid and a comprehensive measure of the commonest problems experienced by people with rheumatoid arthritis (RA) and musculoskeletal conditions [1,2]. It includes 138 items in 14 ‘domains’ (Eating/ Drinking; Personal Care; Dressing; Bathing; Cooking; Moving Indoors; House Cleaning; Laundry; Moving and Transfers; Moving Outdoors; Gardening/Household Maintenance; Caring; Leisure/ Social Activities). All items are scored on a 0-3 scale (no difficulty to unable to do). There is no similar measure available in German. PROs must be tested in target languages and conditions, prior to use, to ensure validity and reliability. Objectives: To linguistically validate a German EDAQ and test it’s reliability and validity in German-speaking people with RA. Methods: The English EDAQ was forward-backward translated to German. Cognitive debriefing interviews were conducted and the German EDAQ developed. Participants from a Rheumatology clinic (Switzerland) and arthritis patient organizations (Switzerland, Germany, Austria) then completed postal questionnaires including: demographic questions, German EDAQ, Health Assessment Questionnaire (HAQ), SF36v2, RA Quality of Life scale (RAQOL), and a hand pain numeric rating scale (NRS). Three weeks later, the EDAQ was mailed again. Test-retest reliability of domain scores, and validity of the 14 German EDAQ domains against the other measures, were evaluated using nonparametric correlations. Internal consistency was tested using Cronbach’s alpha. Results: Six German-speaking people with RA were interviewed, recommended changes reviewed by the expert panel and the German EDAQ agreed. 163 people then completed questionnaires: 145 women and 18 men; mean age = 52.84 (SD14.94) years; mean RA duration = 15.73 years (SD12.12). 85(45%) were employed; 21 had children

Objective: To develop an intervention and undertake a proof-of-concept evaluation of its feasibility, acceptability, and impact on recorded patient activity levels during inpatient stroke rehabilitation. Design: A longitudinal cohort design. Setting: Three inpatient stroke rehabilitation services. Subjects: Stroke survivors receiving inpatient rehabilitation. Intervention: A programme designed to increase patient activity, including individualised patient timetables, independent practice, therapeutic group work, and structured social activities was developed and implemented without additional resource. Main measures: Patients’ recorded activity levels were compared for two weeks before and after implementation of the programme. Data regarding the estimated time spent in different types of activity were extracted from patient treatment records, patients’ and therapists’ diaries, or timetables (if used) to measure patient activity levels Results: At baseline, recorded activity levels were low; patients undertook a mean of 61 minutes (SD = 39) of activity per day. After implementation of the programme, recorded activity levels significantly increased to a mean of 123 minutes (SD = 88) per day ( p = 0.0001). The time spent in all types of recorded activity increased ( p = 0.0001–0.002), except psychology where the increase did not reach significance ( p = 0.670). Conclusions: A structured programme can significantly increase recorded patient activity levels during inpatient stroke rehabilitation without additional resource.

Background: Although the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is widely used in the UK, no British English version is available. The aim of this study was to linguistically validate the DASH into British English and then test the reliability and validity of the British English DASH, (including the Work and Sport/Music DASH) and QuickDASH, in people with rheumatoid arthritis (RA). \ud \ud Methods: The DASH was forward translated, reviewed by an expert panel and cognitive debriefing interviews undertaken with 31 people with RA. Content validity was evaluated using the ICF Core Set for RA. Participants with RA (n=340) then completed the DASH, Health Assessment Questionnaire (HAQ), Short Form Health Survey v2 (SF36v2) and Measure of Activity Performance of the Hand (MAPHAND). We examined internal consistency and concurrent validity for the DASH, Work and Sport/Music DASH modules and QuickDASH. Participants repeated the DASH to assess test-retest reliability.\ud \ud \ud Results: Minor wording changes were made as required. The DASH addresses a quarter of Body Function and half of Activities and Participation codes in the ICF RA Core Set. Internal consistency for DASH scales were consistent with individual use (Cronbach’s alpha = 0.94-0.98). Concurrent validity was strong with the HAQ (rs = 0.69-0.91), SF36v2 Physical Function (rs = -0.71 - -0.85), Bodily Pain (rs = -0.71 - -0.74) scales and MAPHAND (rs =0.71-0.93). Test-retest reliability was good (rs = 0.74-0.95).\ud \ud \ud Conclusions: British English versions of the DASH, QuickDASH and Work and Sport/Music modules are now available to evaluate upper limb disabilities in the UK. The DASH, QuickDASH, Work and Sport/Music modules are reliable and valid to use in clinical practice and research with British people with RA.

Background Dysarthria, a disordered speech production resulting from neuro-muscular impairment, is a common symptom after stroke. It causes significant problems for patients’ speech intelligibility, communication, psychological well-being, social engagement and stroke recovery. Rehabilitation for dysarthria is variable in quality, intensity and duration, which may be, in part, due to the lack of good quality evidence. An online therapy programme, ReaDySpeech, has the potential to improve quality, intensity and duration of speech rehabilitation and was considered in a proof-of-concept study to be acceptable to speech and language therapists and patients which warranted further evaluation. The present study aims to examine the feasibility of running a trial using the ReaDySpeech intervention. Methods/design A feasibility, randomised controlled trial, will recruit a minimum of 36 people with post-stroke dysarthria who are more than 1 week post stroke. Participants will be externally randomised in a 2:1 ratio to receive either ReaDySpeech and usual care (24 participants) or usual care only (12 participants). This study is single blind with the researcher carrying out the baseline and outcome measures while blinded to treatment allocation. The primary objective is to assess the feasibility of conducting a larger Phase III trial. The specific objectives are to determine the following: recruitment rate and reasons for non-recruitment; loss of participants to follow-up; acceptability of randomisation; adherence to the intervention; delivery of ReaDySpeech and content; acceptability of outcome measures; success of blinding strategies; defining ‘usual’ care; and the implications of the intervention for the patient/family/carer. Discussion This study will involve a regional, multi-centre, randomised controlled feasibility trial of a complex intervention in order to evaluate whether a Phase III randomised controlled trial is feasible. Trial registration Current Controlled Trials, ISRCTN84996500 Electronic supplementary material The online version of this article (doi:10.1186/s40814-017-0169-0) contains supplementary material, which is available to authorized users.

BackgroundDysarthria is an acquired speech disorder following neurologic injury that reduces intelligibility of speech due to weak, imprecise, slow and/or uncoordinated muscle control. The impact of dysarthria goes beyond communication and affects psychosocial functioning. This is an update of a review previously published by another group in 2005 and has been broadened to include additional interventions.ObjectivesTo assess the effects of interventions to improve dysarthric speech following stroke and other non-progressive adult-acquired brain injury such as trauma, infection, tumour and surgery.Search methodsWe searched the Cochrane Stroke Group Trials Register (May 2016). We searched CENTRAL (2016, Issue 4 of 12) and we searched the following databases on May 6th 2016: MEDLINE, EMBASE, CINAHL. We searched LLBA (1976 to November 2016) andPsycINFO (searched 1800 - September 2016). To identify further published, unpublished and ongoing trials, we searched major trials registers WHO ICTRP (http://www.who.int/ictrp/search/en/), the ISRCTN registry (http://www.isrctn.com/), ClinicalTrials.gov (http://www.clinicaltrials.gov/) and the Stroke Trials Registry (www.strokecenter.org/trials/). We also handsearched the reference lists of relevant articles and contacted academic institutions and other researchers regarding other published, unpublished or ongoing trials.There were no language restrictions.Selection criteriaWe selected randomised controlled trials (RCTs) comparing dysarthria interventions with (1) no intervention, (2) another intervention for dysarthria (this intervention may differ in methodology, timing of delivery, duration, frequency or theory), (3) an attention control.Data collection and analysisOne author (CM) independently screened all titles, three authors (CM, AB, PC) then independently screened remaining abstracts, examined full text studies for possible inclusion and discussed these where necessary, extracted data and assessed risk of bias. We reconciled differences by discussion or through an independent arbitrator. No author reviewed their own study. We contacted study authors for clarification and missing data. We calculated a standardised mean difference (SMD) and 95% confidence interval (CI), using a random-effectsmodel and performed sensitivity analyses to assess the influence ofmethodological quality and planned subgroup analyses for underlying clinical condition.Main resultsWe retrieved 17,313 citations, identified two ongoing trials and included five small trials that randomised 234 participants. Two studies had low risk of bias and none of the included studies were adequately powered. Two studies used an attention control and three studies compared to an alternative intervention, which in all cases was one intervention versus usual care intervention. There are no trials of an intervention versus no intervention. There are no trials of the same intervention with variations in timing, dose, intensity of treatment. Four studies included only people with stroke, the fifth was predominantly stroke but also brain injury. Three studies delivered intervention in the first few months after stroke, the other two recruited people with chronic dysarthria. Three studies evaluated behavioural interventions, one included acupuncture and one included transcranialmagnetic stimulation.One study included dysarthria as a planned subgroup within a broader trial of impaired communication.Our primary analysis of a persisting (long lasting i.e. 3-9 months post intervention) effect at the activity level of measurement found no evidence in favour of dysarthria intervention compared to any control (three trials, 116 participants, SMD 0.18, 95% CI -0.18 to 0.55; GRADE: low quality) with zero heterogeneity between trials (I² = 0%). Sensitivity analysis of the studies with low risk of bias found similarly, with a slightly wider confidence interval and slight heterogeneity (two trials, 92 participants, SMD 0.21 (-0.30 to 0.73, I² = 32%; GRADE: low quality). Results of the subgroup analysis for stroke was unsurprisingly similar to the primary analysis as so few non-stroke participants have been recruited to trials (three trials, 106 participants, SMD 0.16, 95% CI -0.23 to 0.54, I² = 0%; GRADE: low quality).Similar results emerged from most of the secondary analyses. There was no evidence of a persisting effect at the impairment (two trials, 56 participants, SMD 0.07, 95% CI -0.91 to 1.06, I² = 70%; GRADE: very low quality) or participation level (two trials, 79 participants, SMD -0.11, 95% CI -0.56 to 0.33, I² = 0%; GRADE: low quality) but substantial heterogeneity on the former. Analyses of immediate post-intervention outcomes provided no evidence of any short -term benefit on activity (three trials, 117 participants, SMD 0.29, 95% CI -0.07 to 0.66, I² = 0%; GRADE: very low quality); or participation (one study, 32 participants, SMD -0.24, 95% CI -0.94 to 0.45) levels of measurement.There was a statistically significant effect favouring intervention at the immediate, impairment level of measurement (four trials, 99 participants, SMD 0.47, 95% CI 0.02 to 0.92, p = 0.04, I² = 0%; GRADE: very low quality) but only one of these four trials had a low risk of bias.Authors’ conclusionsThere are no definitive adequately powered randomised controlled trials of interventions for people with dysarthria. There is limited evidence that there may be an immediate beneficial effect on impairment level measures but more, higher quality research is needed to confirm this finding. So although this review evaluated five studies, the benefits and risks of intervention are still unknown and the emerging evidence justifies adequately powered clinical trials into this condition. People with dysarthria after stroke or brain injury should continue to receive rehabilitation according to clinical guidelines.

Objective:To review children’s and their families’ needs after a child’s traumatic injury and assessment tools to measure needs.Data sources:Medline, Embase, CINAHL and PsycINFO databases (2005–September 2017) were searched and screened for papers (of any design) investigating children’s and families’ needs after a child’s traumatic physical injury.Review methods:Data regarding children’s and families’ needs were extracted by two independent raters. Methodological quality of the identified papers was not assessed. Thematic content analysis drew out the key needs.Results:A total of 12 studies were identified, involving 932 participants including 105 injured adolescents and 827 family members or professionals. The needs of children under 12 years were identified indirectly from families or professionals. Most studies focussed on traumatic brain injuries. Two groups of needs were identified: person-related and service-related. Person-related needs were categorized into adolescent-specific needs, need for support with cognitive, emotional, social and physical problems and help with practical problems. Service-related needs were categorized into the need for information, educational needs and support during care transitions (specifically access to community-based services). These needs were largely unmet, particularly regarding information, emotional support and care transitions, which were compounded by professionals’ limited understanding of the children’s difficulties. We found no published measurement tools to assess children’s and families’ needs after a child’s traumatic injury.Conclusion:The evidence about children’s and families’ needs following a child’s traumatic injury was limited, but needs for information, emotional support and access to community-based services were consistently unmet.

Objective: To describe goal-setting during inpatient stroke rehabilitation. Design: There were two stages: an electronic questionnaire for multidisciplinary teams and an analysis of goal-setting documentation for rehabilitation patients. Setting: Five inpatient stroke units. Participants: Staff involved in goal-setting and patients undergoing stroke rehabilitation. Results: A total of 13 therapists and 49 patients were recruited, and 351 documented goals were examined. All units used therapist-led goal-setting (60% of goals were set by therapists). In total, 72% of goals were patient-focused but patients and families were rarely directly involved. Goals focussed on basic mobility and activities of daily living (~50% and ~25% of goals, respectively). Only 41% of documented goals met the SMART criteria. Review of progress was limited: 48% of goals were never reviewed and 24% of the remainder were merely marked as ‘ongoing’ without a date or plan for completion. New goals and actions were often documented without any connection to previous goals. Integration between goals and treatment/action plans was mixed. In two units, goals were unconnected to a treatment or action plan, but for the remainder it was 90%–100%. However, that connection was generally vague and amounted to suggestions of the type of treatment modality that staff might employ. Conclusion: Goal-setting during inpatient stroke rehabilitation is therapist-led but discussed with the multidisciplinary team. Therapists mainly identified patient-focussed mobility and activities of daily living goals. Monitoring progress and revising goals were often uncompleted. Links between goals and treatment, action plans and progress were patchy.

Background: It is suggested the anterior cruciate ligament (ACL) plays a significant role in knee proprioception, however, the effect of ACL injury on knee proprioception is unclear. Studies utilising the two most common measurement techniques, joint position sense and threshold to detect passive motion, have provided evidence both for and against a proprioceptive deficient following ACL injury.\ud \ud Objective: The objective of the study was to undertake a meta-analysis investigating the effects of ACL injury, treated conservatively or by reconstruction, on proprioception of the knee, measured using joint position sense and/or threshold to detect passive movement techniques.\ud \ud Data sources: Seven databases were searched from their inception to September 2013 using the subject headings ‘anterior cruciate ligament, proprioception, postural sway, joint position sense, balance, equilibrium or posture’ to identify relevant studies.\ud \ud Eligibility criteria: PRISMA guidelines were followed as much as possible. Studies that investigated the effect of ACL injury on either knee joint kinaesthesia or position sense were included in this review.\ud \ud Data extraction and synthesis: Two reviewers independently extracted data using a standardised assessment form. Comparisons were made using a fixed effect model with an inverse variance method using Review Manager Software (V5.1).\ud \ud Results: Patients with ACL injury have poorer proprioception than people without such injuries (SMD = 0.35°; P = 0.001 and SMD = 0.38°; P = 0.03) when measured using joint position sense and threshold to detect passive motion techniques respectively. Patients had poorer proprioception in the injured than uninjured leg (SMD = 0.52°; P

BackgroundRoutine mood screening is recommended after stroke. However, clinicians report difficulty selecting appropriate tools from the wide range available. We aimed to systematically review the psychometric properties and clinical utility of mood screening tools for stroke survivors.MethodElectronic databases (AMED, EMBASE, CINAHL, Medline and PsycINFO) were searched to identify studies assessing the sensitivity and specificity of mood screening tools. Tools that demonstrated at least 80% sensitivity and 60% specificity with stroke survivors with identifiable cut-off scores indicating major and/or any mood disorder in at least one study were selected and clinical utility was assessed. Those with high clinical utility (against predefined criteria) were selected for recommendation.ResultsThirty papers examining 27 screening tools were identified and 16 tools met the psychometric and clinical utility criteria: 10 were verbal self-report tools, four were observational and two incorporated visual prompts for those with communication problems. Only the Stroke Aphasic Depression Questionnaire –Hospital version (SADQ-H) met all the psychometric and utility criteria. The nine-item Patient Health Questionnaire (PHQ-9) can detect major depression and the 15-item Geriatric Depression Scale (GDS-15) can identify milder symptoms; both are feasible to use in clinical practice. The Hospital Anxiety and Depression Scale (HADS) was the only tool able to identify anxiety accurately, but clinical utility was mixed.ConclusionsValid and clinically feasible mood screening tools for stroke have been identified but methodological inconsistency prevented recommendations about the optimal cut-off scores.

Background and PurposeCurrent approaches to upper limb rehabilitation are not sufficient to drive neural reorganization and maximize recovery after stroke. To address this evidence-practice gap, a knowledge translation intervention using the Behaviour Change Wheel was developed. The intervention involves collaboratively working with stroke therapy teams to change their practice and increase therapy intensity by therapists prescribing supplementary self-directed arm exercise. The purposes of this case series are: (1) to provide an illustrative example of how a research-informed process changed clinical practice and (2) to report on staff members' and patients' perceptions of the utility of the developed intervention.Case DescriptionsA participatory action research approach was used in 3 stroke rehabilitation units in the United Kingdom. The intervention aimed to change 4 therapist-level behaviors: (1) screening patients for suitability for supplementary self-directed arm exercise, (2) provision of exercises, (3) involving family and caregivers in assisting with exercises, and (4) monitoring and progressing exercises. Data on changes in practice were collected by therapy teams using a bespoke audit tool. Utility of the intervention was explored in qualitative interviews with patients and staff.OutcomesComponents of the intervention were successfully embedded in 2 of the 3 stroke units. At these sites, almost all admitted patients were screened for suitability for supplementary self-directed exercise. Exercises were provided to 77%, 70%, and 88% of suitable patients across the 3 sites. Involving family and caregivers and monitoring and progressing exercises were not performed consistently.ConclusionsThis case series is an example of how a rigorous research-informed knowledge translation process resulted in practice change. Research is needed to demonstrate that these changes can translate into increased intensity of upper limb exercise and affect patient outcomes.

Objective: To systematically review the psychometric properties and clinical utility of measures of pain in neurological conditions. Data sources: Electronic databases (AMED, CINAHL, MEDLINE, PEDro and Web of Knowledge) were searched from their inception to February 2013. Review methods: Studies investigating any measurement tool to assess pain in central nervous system conditions were systematically identified. Data about their psychometric properties and clinical utility were extracted and analysed independently. The strength of the psychometric properties and clinical utility were assessed. Results: A total of 13 articles met the selection criteria, which assessed 11 measurement tools; eight pain rating scales; one Neuropathic Pain Scale; and two measures of pain interference with every-day life. Most of the pain rating scales were specifically for hemiplegic shoulder pain. None had been sufficiently developed to recommend for use in clinical practice or research. Evaluation of reliability and the ability to detect change were particularly sparse. Reliability depended on the type of tools used. Patients with right hemisphere damage favoured verbal/written responses, while people with left hemisphere damage preferred and reported more effectively using visual/numeric responses. Validity between measures of pain intensity was moderate, while validity with mood or quality of life was weak to moderate. Conclusion: None of the selected measures of pain have been fully developed or evaluated to demonstrate that they provide accurate, relevant reproducible information.

Increases in the external knee adduction moment (EKAM) have been associated with increased mechanical load at the knee and progression of knee osteoarthritis. Valgus knee braces and lateral wedged insoles are common approaches to reducing this loading; however no study has directly compared the biomechanical and clinical effects of these two treatments in patients with medial tibiofemoral osteoarthritis. A cross-over randomised design was used where each intervention was worn by 28 patients for a two week period. Pre- and post-intervention gait kinematic/kinetic data and clinical outcomes were collected to evaluate the biomechanical and clinical effects on the knee joint. The valgus knee brace and the lateral wedged insole significantly increased walking speed, reduced the early stance EKAM by 7% and 12%, and the knee adduction angular impulse by 8.6 and 16.1% respectively. The lateral wedged insole significantly reduced the early stance EKAM compared to the valgus knee brace (p=0.001). The valgus knee brace significantly reduced the knee varus angle compared to the baseline and lateral wedged insole. Improvements in pain and function subscales were comparable for the valgus knee brace and lateral wedged insole. There were no significant differences between the two treatments in any of the clinical outcomes; however the lateral wedged insoles demonstrated greater levels of acceptance by patients. This is the first study to biomechanically compare these two treatments, and demonstrates that given the potential role of knee loading in osteoarthritis progression, that both treatments reduce this but lateral wedge insoles appear to have a greater effect.

Background Despite best evidence demonstrating the effectiveness of increased intensity of exercise after stroke, current levels of therapy continue to be below those required to optimise motor recovery. We developed and tested an implementation intervention that aims to increase arm exercise in stroke rehabilitation. The aim of this study was to illustrate the use of a behaviour change framework, the Behaviour Change Wheel, to identify the mechanisms of action that explain how the intervention produced change. Methods We implemented the intervention at three stroke rehabilitation units in the United Kingdom. A purposive sample of therapy team members were recruited to participate in semi-structured interviews to explore their perceptions of how the intervention produced change at their work place. Audio recordings were transcribed and imported into NVivo 10 for content analysis. Two coders separately analysed the transcripts and coded emergent mechanisms. Mechanisms were categorised using the Theoretical Domains Framework (TDF) (an extension of the Capability, Opportunity, Motivation and Behaviour model (COM-B) at the hub of the Behaviour Change Wheel). Results We identified five main mechanisms of action: ‘social/professional role and identity’, ‘intentions’, ‘reinforcement’, ‘behavioural regulation’ and ‘beliefs about consequences’. At the outset, participants viewed the research team as an external influence for whom they endeavoured to complete the study activities. The study design, with a focus on implementation in real world settings, influenced participants’ intentions to implement the intervention components. Monthly meetings between the research and therapy teams were central to the intervention and acted as prompt or reminder to sustain implementation. The phased approach to introducing and implementing intervention components influenced participants’ beliefs about the feasibility of implementation. Conclusions The Behaviour Change Wheel, and in particular the Theoretical Domains Framework, were used to investigate mechanisms of action of an implementation intervention. This approach allowed for consideration of a range of possible mechanisms, and allowed us to categorise these mechanisms using an established behaviour change framework. Identification of the mechanisms of action, following testing of the intervention in a number of settings, has resulted in a refined and more robust intervention programme theory for future testing. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1793-8) contains supplementary material, which is available to authorized users.

Connell LA, Tyson SF. Clinical reality of measuring upper-limb ability in neurologic conditions: a systematic review. Objective To review the psychometric properties and clinical utility of upper-limb measurement tools in people with neurologic conditions to provide recommendations for practice. Data Sources MEDLINE, CINAHL, EMBASE, PEDro, and AMED. Study Selection Independent reviewers searched, selected, and extracted data from articles that assessed reliability, validity, ability to detect change, and clinical utility of measures of the upper limb in adult neurologic conditions. Data Extraction Measures with good psychometrics and 8 or higher (out of 10) clinical utility scores were recommended. Data Synthesis The searches identified 31 measures of the upper limb. However, only 2 measures fulfilled all of the psychometric and clinical utility criteria; the Box and Block Test and the Action Research Arm Test. Conclusions The Box and Block and the Action Research Arm Tests produce robust data and are feasible for use in clinical practice. Future development of new or existing measures should ensure the construct and content validity of the measure is clearly identified, standardized guidelines are easily available, and ensure that it is individualized and contemporary. Attention to measures of upper-limb activity for people who are unable to grip objects is also needed.

Background Effective recruitment is an essential element of successful research but notoriously difficult to achieve. This article examines health care professionals’ views on the factors influencing decision-making regarding referral to a stroke rehabilitation trial. Methods Semi-structured interviews and a card-sorting task were undertaken with stroke service staff in acute and community hospital trusts. Data analysis used a thematic framework approach. Results Twenty-seven qualified health care professionals from 12 (6 acute and 6 community) hospital trusts and one charity participated. Four main factors emerged: patient-related, professional views, the organisation and research logistics, which all contributed to staff’s decision about whether to refer patients to a trial. Clinicians identified patient-related factors as the most frequent influence and considered themselves the patients’ advocate. They used their knowledge of the patient to anticipate the patients’ reaction to possible participation and tended to only refer those whom they perceived would respond positively. Participants also identified experience of research, a sense of ownership of the project and a positive view of the intervention being evaluated as factors influencing referral. The need to prioritise clinical matters, meet managerial demands and cope with constant change were organisational factors impacting negatively on referral. Staff often simply forgot about recruitment in the face of other higher priorities. Quick, simple, flexible research processes that were closely aligned with existing ways of working were felt to facilitate recruitment. Conclusions Patient- and professional-related factors were the most frequent influence on clinicians’ recruitment decisions, which often had a ‘gate-keeping’ effect. Managerial and clinical responsibility to juggle multiple (often higher) priorities was also an important factor. To facilitate recruitment, researchers need to develop strategies to approach potential participants as directly as possible to enable them to make their own decisions about participation; ensure that research processes are as quick and simple as possible; align with existing clinical pathways and systems; and give regular reminders and ongoing support to promote recruitment. Trial registration ISRCTN, 98287938. Registered 6 May 2015 Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1115-1) contains supplementary material, which is available to authorized users.

Upper limb orthotics, or splints, are widely advocated for people with stroke however opinion about whether, and how, they should be used is varied. We therefore systematically reviewed the literature on upper limb orthotics for people with stroke and other non-progressive brain lesions to establish whether an orthosis can improve function or/and impairments. Search strategy: the Cochrane library, MEDLINE, EMBASE, CINAHL, AMED, PsycINFO and RECAL were searched. We screened reference lists and contacted lead authors and other researchers in the field. Selection criteria: randomised controlled trials of upper limb orthoses in stroke survivors and other non-progressive brain lesions. Data collection and analysis: two reviewers independently identified trials, extracted data and assessed trial quality. Results for continuous outcomes were combined and analysed using mean difference or standardised mean difference, both with 95% confidence intervals and fixed-effect model. Main results: we analysed 4 trials with 126 participants. Upper limb orthoses showed no effect on upper limb function, range of movement at the wrist, fingers or thumb, nor pain. Conclusions: current evidence suggests that an upper limb orthosis does not effect upper limb function, range of movement at the wrist, fingers or thumb, nor pain.

Rationale: routine collection of outcome measures is advocated to improve quality of care. However, there has been scant investigation of how measurement tools are used in clinical practice and what impact they may have. This paper compares two neurorehabilitation teams, one which routinely used standardized measurement tools and the other which did not.We explore differences in communication and clinical decision making within multidisciplinary team (MDT) meetings to illuminate the influence measurement tools could have on clinical practice. Method: non-participant observation of MDT meetings in two neurological rehabilitation units in England. Semi-structured interviews were also carried out with at least one member of each profession in each team. Grounded theory techniques were used to analyse the data. Results: differences in team members’ communication within MDT meetings underscored differences in the process of clinical decision making within the teams. Using measurement tools provided a shared understanding to facilitate communication by focusing discussion on the patient’s abilities rather than individual professionals’ contributions. This led to differences in the way team members identified the nature and cause of patients’ problems, monitored their progress and planned for discharge. They provided a ‘neutral ground’ to reach a shared perspective between professionals, thereby avoiding conflict. Externally, use of the tools enabled objective discussion with patients and their families about their progress and was a vehicle to facilitate giving bad news. Conclusion Using standardized measurement tools can promote a patient-focused approach to care, thus facilitating treatment planning and clinical decision making.

Lateral wedge orthoses are often prescribed to correct varus deformity after stroke. Spasticity is implicated in varus deformity and is caused by velocity-related muscle length changes, so a lateral wedge may affect spasticity by manipulating foot and ankle kinematics which, in turn, may alter the length of these muscles. We sought to test this theory in healthy participants. Eight volunteers walked with no wedge and with lateral wedges of 5 and 8.5 degrees in both shoes. Qualysis motion capture system collected kinematic data and SIMM musculoskeletal modeling software calculated muscle tendon length of plantarflexor and peroneal muscle groups using 3-D ankle and knee joint angle data. The wedges increased ankle eversion (p < 0.0001) and total excursion of tibialis posterior, peroneus longus and brevis by 13-29% (p < 0.05). Muscle length of peroneus longus and brevis increased by

Objective: To investigate the content of acute stroke physiotherapy to treat postural control and mobility problems. Design: Stroke physiotherapists recorded the interventions used to treat postural control and mobility during treatment sessions. They recorded five sessions for at least five patients each. Descriptive statistics assessed the frequency with which the interventions were used. Setting: Hospital-based acute stroke care. Subjects: Thirty-six acute stroke physiotherapists recorded 2374 interventions in 364 treatment sessions for 76 patients. Main measures: The Stroke Physiotherapy Intervention Recording Tool. Results: Facilitation techniques were the most frequently used interventions (n = 1258, 53%) with exercise (n = 115, 5%), teaching others how to help the patient (n = 99, 4%) and provision of equipment (n = 63, 3%) the least frequently used. Conclusions: Acute stroke physiotherapists primarily use therapist-led ‘hands-on’ interventions to treat postural control and mobility problems. Interventions to promote activity or practice outside the treatment session are infrequently used.

Controlled laboratory study using a randomized crossover design.To determine the immediate effect of 3 common types of orthoses (2 elbow counterforce orthoses and a wrist splint) on grip strength in individuals with lateral epicondylosis.Lateral epicondylosis is a common cause of pain and upper limb dysfunction. Although the effectiveness of orthoses has been reported, comparisons of effectiveness among orthoses are limited.Fifty-two subjects with lateral epicondylosis were recruited (20 men, 32 women; mean +/- SD age, 41 +/- 8 years). Maximum and pain-free grip strength were assessed using a digital hand grip dynamometer immediately after the application of each orthosis. The 4 testing conditions included a placebo orthosis as a control condition, an elbow strap orthosis, an elbow sleeve orthosis, and a wrist splint. Data were analyzed using a 1-way analysis of variance for each outcome measure.Pain-free grip-strength was greater when using the elbow strap or the elbow sleeve orthosis compared to when using the placebo control orthosis or the wrist splint (P.02), but there was no difference between the elbow sleeve and strap orthoses (P.05), nor between the wrist splint and placebo orthosis (P.05). Maximum grip strength was less when using the wrist splint compared to when tested with the elbow sleeve or the elbow strap (Por =.003). Use of the elbow strap, elbow sleeve, or wrist splint did not change maximum grip strength compared to the control placebo orthosis condition (P.05). There was also no difference in maximum grip strength between the elbow strap and the elbow sleeve conditions (P.05).The use of the 2 types of elbow orthoses (strap and sleeve) resulted in an immediate increase in pain-free grip strength. No differences between the 2 orthoses were found, suggesting that either can be used. A wrist splint produced no immediate change in pain-free or maximum grip-strength, indicating that it should not be used as a first-choice orthosis based on those outcome measures.

Background: The optimal surgical treatment of early breast cancer in young women is not fully determined, while past reports indicate a trend to the increased use of breast-conserving surgery (BCS). This study aims to assess the trend in Australia and New Zealand of BCS use between 1999 and 2006 and to determine pathological factors associated with it. Methods: Data on cancer characteristics and surgical procedures in younger patients with early breast cancer reported to the National Breast Cancer Audit have been analysed. Results: There was little change in the rate of BCS over the last 7 years with an overall rate of 53%. The main factors associated with the use of BCS are low histological grade, absence of extensive intraductal carcinoma (EIC), negative lymph node involvement, unifocal tumour and small tumour size. Conclusion: Between 1999 and 2006, the use of BCS for early breast cancer treatment in younger women was stable. These results show that surgeons contributing data to the National Breast Cancer Audit appear to use pathological factors that are known to increase the risk of local recurrence after BCS, in selecting mastectomy for younger women.