Rehabilitation Current Awareness Bulletin March 2020

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Title: Group-based music intervention in Parkinson's disease - findings from a mixed-methods study.

Citation: Clinical rehabilitation; Feb 2020 ; p. 269215520907669 Author(s): Pohl, Petra; Wressle, Ewa; Lundin, Fredrik; Enthoven, Paul; Dizdar, Nil

Objective: To evaluate a group-based music intervention in patients with Parkinson's disease.

Design: Parallel group randomized controlled trial with qualitative triangulation.

Setting: Neurorehabilitation in primary care.

Subjects: Forty-six patients with Parkinson's disease were randomized into intervention group (n = 26), which received training with the music-based intervention, and control group (n = 20) without training.

Interventions: The intervention was delivered twice weekly for 12 weeks.

Main Measures: Primary outcome was Timed-Up-and-Go subtracting serial 7's (dual-task ability). Secondary outcomes were cognition, balance, concerns about falling, freezing of gait, and quality of life. All outcomes were evaluated at baseline, post-intervention, and three months post-intervention. Focus groups and individual interviews were conducted with the intervention group and with the delivering physiotherapists.

Results: No between-group differences were observed for dual-task ability. Between-group differences were observed for Falls Efficacy Scale (mean difference (MD) = 6.5 points; 95% confidence interval (CI) = 3.0 to 10.0, P = 0.001) and for Parkinson Disease Questionnaire-39 items (MD = 8.3; 95% CI = 2.7 to 13.8, P = 0.005) when compared to the control group post-intervention, but these were not maintained at three months post-intervention. Three themes were derived from the interviews: Expectations versus Results, Perspectives on Treatment Contents, and Key Factors for Success.

Conclusion: Patient-reported outcomes and interviews suggest that the group-based music intervention adds value to mood, alertness, and quality of life in patients with Parkinson's disease. The study does not support the efficacy in producing immediate or lasting gains in dual-tasking, cognition, balance, or freezing of gait.

Title: Exploring the relationship between resilience and practice education placement success in occupational therapy students.

Citation: Australian Occupational Therapy Journal; Feb 2020; vol. 67 (no. 1); p. 49-61

Author(s): Brown, Ted; Yu, Mong-Lin; Hewitt, Alana E.; Isbel, Stephen T.; Bevitt, Thomas; Etherington, Jamie

Introduction: Practice education is a fundamental component of health professional students' education and many personal, social and professional factors impact on students' performance. This study investigated the relationship between measures of resilience and practice education performance in occupational therapy students.

Methods: A quantitative cross-sectional study was used to collect the data. In all, 149 occupational therapy students completed a self-report questionnaire comprised of demographic questions and two standardised scales: Resilience at University (RAU) and Resilience Scale for Adults (RSA). Students' practice education performance was measured by the Student Practice Evaluation Form–Revised (SPEF–R). Multi-linear regression analyses with bootstrapping were completed to identify resilience factors that were predictive of occupational therapy students' practice performance.

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Results: Overall, occupational therapy students reported high levels of resilience based on the RAU and RSA subscale scores. "Managing Stress," "Find Your Calling" and "Living Authentically" were strong predictors of a range of key fieldwork performance SPEF–R factors, including "Professional Behaviours," "Self-management Skills," "Co-worker Communication" and "Communication Skills."

Conclusion: The resilience factors identified as being significant predictors of practice education performance outcomes in occupational therapy students represent notable findings. They suggest that students' capabilities in managing their stress levels, finding meaning in their chosen profession, and engaging self-care daily activities outside of the work environment that are meaningful, authentic and fit with one's personal values and beliefs can act as buffers against the challenges experienced by students who are completing practice education placements. The findings will assist academic and practice educators in identifying and targeting vulnerable students and strengthening resilience strategies through proactive pre-practice placement initiatives. Qualitative studies are recommended to further explore the relationship between resilience and practice education performance in occupational therapy students.

Title: Quality of life: A universal or a disability specific concept?

Citation: The Canadian Journal of Occupational Therapy; Feb 2020; vol. 87 (no. 1); p. 4

Author(s): Asnat Bar-Haim Erez; Gal, Eynat Background: Quality of life (QoL) is an important outcome of occupational therapy practice. Autism spectrum disorder (ASD) is a neurodevelopmental disorder that impacts the individual throughout their lifespan and may substantially affect QoL. Measuring QoL of people with ASD presents a challenge and a debate whether to use general versus disability-specific adapted measures.

Purpose: This paper aims to (a) revisit the construct of QoL and discuss specific dilemmas pertaining to its measurement, and (b) discuss implications to the assessment of QoL in individuals with ASD while highlighting the potential contribution of occupational therapy to the development of measures.

Key Issues: We suggest adding the domain of accessibility into QoL assessments, including, physical, sensory, social, and cognitive aspects, and to use disability-specific QoL measures.

Implications: The paper presents a call for occupational therapists to be involved in developing specific ASD disability-oriented measures that consider the unique characteristics of the disorder and environmental supports.

Title: Does training in a top-down approach influence recorded goals and treatment plans?

Citation: The Canadian Journal of Occupational Therapy; Feb 2020; vol. 87 (no. 1); p. 42

Author(s): Jutzi, Katelyn S R; Linkewich, Elizabeth; Hunt, Anne W; McEwen, Sara

Background: Five stroke rehabilitation teams were supported in the implementation of Cognitive Orientation to daily Occupational Performance (CO-OP) as part of a knowledge translation (KT) project called CO-OP KT. Medical record auditors noted there was occasionally a disconnect between client goals and treatment plans, revealing a need to better understand the characteristics of each and their relationship to each other.

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Purpose: This study aimed to examine the characteristics of goals and treatment plans in occupational therapy before and after CO-OP KT.

Method: A descriptive secondary analysis of medical record data was employed.

Findings: Post intervention, there was a change in goal specificity (p = .04) and therapist-client goal alignment (p = .05). Occupation-based goals were often paired with a bottom-up, impairment-based treatment. Top-down treatments, when present, lacked the same detail given to bottom-up plans.

Implications: CO-OP KT seemed to lead to more specific goals, but matching top-down treatment plans were not found.

Title: To what extent does therapy of chronic stroke patients address participation? A content analysis of ambulatory physical and occupational therapy based on the International Classification of Functioning, Disability, and Health framework.

Citation: Disability & Rehabilitation; Feb 2020; vol. 42 (no. 4); p. 545-551

Author(s): Tetzlaff, Britta; Barzel, Anne; Stark, Anne; Ketels, Gesche; Scherer, Martin

Purpose: The study aim was to analyze whether ambulatory therapy of chronic stroke patients contains elements that specifically address "Activity and participation", and to what extent participation as a major goal in rehabilitation is realized in ambulatory care.

Method: Qualitative and quantitative content analysis of standard therapy of 71 chronic stroke patients with upper limb impairment. 469 statements on therapy of 34 therapists were analyzed using data-driven and concept-driven coding based on the International Classification of Functioning, Disability and Health framework.

Results: Almost half of therapy provided to stroke patients was related to "Upper extremity" (47.5%), as one out of seven identified main categories. Regarding International Classification of Functioning, Disability, and Health framework, 75.1% of therapeutic practices in ambulatory therapy covered "Body functions," but only 13.2% addressed "Activities and participation". Some statements contained specific therapeutic concepts (9.4%) or isolated notes (2.1%) and were not linkable to the International Classification of Functioning, Disability and Health framework.

Conclusions: Ambulatory therapy of chronic stroke patients is related, in part, to participation. There is potential for an increase in participation by applying therapeutic approaches, which actively involve the patients in goal-setting and therapeutic exercises to specifically address activities and participation. To realize participation as a major goal in the rehabilitation process ambulatory therapy of chronic stroke patients, one should focus on therapeutic approaches and exercises that specifically address activities and participation. Structured goal-setting, which actively involve patients, can be used to identify goals relevant to individual activities and participation.

Title: Doing what's right: A grounded theory of ethical decision-making in occupational therapy.

Citation: Scandinavian Journal of Occupational Therapy; Feb 2020; vol. 27 (no. 2); p. 98-111

Author(s): VanderKaay, Sandra; Letts, Lori; Jung, Bonny; Moll, Sandra E.

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Background: Ethical decision-making is an important aspect of reasoning in occupational therapy practice. However, the process of ethical decision-making within the broader context of reasoning is yet to be clearly explicated.

Objective: The purpose of this study was to advance a theoretical understanding of the process by which occupational therapists make ethical decisions in day-to-day practice.

Method: A constructivist grounded theory approach was adopted, incorporating in-depth semi-structured interviews with 18 occupational therapists from a range of practice settings and years of experience. Initially, participants nominated as key informants who were able to reflect on their decision-making processes were recruited. Theoretical sampling informed subsequent stages of data collection. Participants were asked to describe their process of ethical decision-making using scenarios from clinical practice. Interview transcripts were analyzed using a systematic process of initial then focused coding, and theoretical categorization to construct a theory regarding the process of ethical decision-making.

Findings: An ethical decision-making prism was developed to capture three main processes: Considering the Fundamental Checklist, Consulting Others, and Doing What's Right. Ethical decision-making appeared to be an inductive and dialectical process with the occupational therapist at its core.

Conclusion: Study findings advance our understanding of ethical decision-making in day-to-day clinical practice.

Title: Occupational therapist use of the 'Timed Up and Go' test in a Memory Clinic to compare performance between cognitive diagnoses and screen for falls risk.

Citation: Australian Occupational Therapy Journal; Feb 2020; vol. 67 (no. 1); p. 13-21

Author(s): Harper, Kristie J.; Riley, Vera; Petta, Antonio; Jacques, Angela; Spendier, Nicholas; Ingram, Katharine

Introduction: Occupational therapists assess older patients attending Memory Clinics to address multiple facets, including memory, activities of daily living function, mobility and falls risk. Identifying deficits in motor and functional abilities represents a crucial and necessary component of cognitive diagnosis. The aim of this research was to compare performance on the TUG between patients with normal (NC), mild cognitive impairment (MCI) and dementia.

Methods: A prospective single-blind single-centre cohort study was conducted in a Memory Clinic. Patients underwent comprehensive medical assessment, including the Mini Mental Status Examination (MMSE) to determine a cognitive diagnosis. The occupational therapist, blinded to any diagnosis, completed the TUG.

Results: A total of 158 patients aged 60 years and older were recruited. The average TUG was 15.4 s, which was similar between men and women (p =.87). A TUG greater than ≥14 s was significantly associated with the use of a walking aid (p ≤.001). The TUG increased with age and a slower TUG was associated with a greater number of previous falls (p =.023). The TUG did not significantly differ between patients with dementia, MCI and NC (p =.095). However, there was a significant difference comparing patients with NC and MCI (14.3 s) to those with dementia (16.4 s) (p =.048). There was a significant weak negative correlation between the MMSE and the TUG of −0.253 (p =.003). Univariate models showed that a patient's ability to ambulate independently contributed to 33% of the variance in the TUG, whereas previous falls contributed to 4%, highlighting the importance of physical function and intervention to target this.

Conclusion: A simple TUG test should be considered for use by occupational therapists in a Memory Clinic to screen patients at risk of falling. Patients diagnosed with dementia have

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a significantly slower TUG. However, this tool cannot assist with the early detection of patients with MCI.

Title: Making connections between school and home: Exploring therapists' perceptions of their relationships with families in partnering for change.

Citation: British Journal of Occupational Therapy; Feb 2020; vol. 83 (no. 2); p. 98-106

Author(s): Kennedy, Jennifer N; Missiuna, Cheryl A; Pollock, Nancy A; Sahagian Whalen, Sandra; Dix, Leah; Campbell, Wenonah N

Introduction: A recently developed service delivery model, called Partnering for Change, encourages collaboration between occupational therapists, educators and families, and aims to improve children's participation across school, home and community settings. Partnering for Change has been successful in facilitating equitable access to services and eliminating wait lists; however, it could have a more significant impact through improved capacity-building with families. The purpose of this study is to describe the factors that therapists view as influencing the development of family–therapist relationships in Partnering for Change, and to explore their ideas to improve relationship-building.

Methods: Focus groups were completed with 15 occupational therapists who provided Partnering for Change school-based services. Qualitative description methodology and directed content analysis were utilized.

Results: Several factors were identified that influenced the development of family–therapist relationships including competing demands; consistency and availability; awareness, readiness and commitment; relationships with schools and educators; and sociodemographic characteristics. Increasing in-person interactions and awareness of occupational therapy services were suggested to improve relationship-building.

Conclusions: Therapists should consider innovative ways of overcoming competing demands, utilizing relationships with schools and educators, and participating in mentorship and communities of practice to address the current barriers of family–therapist relationships, and create better opportunities for collaboration.

Title: Reasons for and outcome of occupational therapy consultation and treatment in the context of multidisciplinary cancer rehabilitation; a historical cohort study.

Citation: Australian occupational therapy journal; Feb 2020

Author(s): Rijpkema, Corine; Duijts, Saskia F A; Stuiver, Martijn M

Introduction: The aim of this study was to investigate reasons why people consulted an occupational therapist following cancer treatment, and to examine the outcome of occupational therapy interventions, in the context of multidisciplinary rehabilitation.

Methods: Data from 181 patients were collected retrospectively. The International Classification of Human Functioning and Health (ICF) was used to describe the reasons for occupational therapy consultation. Patients had completed the Canadian Occupational Performance Measurement (COPM) before and after the occupational therapy intervention. Change scores were calculated with a 95% confidence interval and a two-sided p-value obtained from a paired t-test.

Results: The reasons for occupational therapy consultation were predominantly within the ICF domain "Activities and Participation". On average, patients improved 3.0 points (95% CI

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2.8-3.2) on the performance scale of the COPM, and 3.4 points (95% CI 3.2-3.7) on the satisfaction scale (both: p = <.001).

Conclusion: The result of this study supports the added value of occupational therapy to cancer rehabilitation, and emphasise the positive effect of occupational therapy on everyday functioning. Controlled clinical studies are needed to strengthen the evidence.

Title: Doing, being, becoming and belonging at the heart of occupational therapy: An analysis of theoretical ways of knowing.

Citation: Scandinavian journal of occupational therapy; Feb 2020 ; p. 1-13

Author(s): Hitch, Danielle; Pepin, Genevieve

Background: Theoretical ways of knowing in occupational therapy include paradigms, conceptual practice models and related knowledge. Despite the diversity of models available to guide practice, there are few examples of analyses which compare and contrast their respective core concepts.

Aims: The aims of this paper are to describe how the dimensions of occupation described in the Pan Occupational Paradigm pervade conceptual practice models, and are embedded within case reports of occupational therapy.

Materials and Methods: A framework analysis was undertaken, using the dimensions of occupation - doing, being, becoming and belonging - as core concepts. The alignment of concepts from four widely utilised occupational therapy conceptual practice models with these dimensions were investigated and described. Four case reports developed in reference to these specific conceptual practice models were also analysed, and their expression of the core concepts and dimensions discussed.

Results: The dimensions of occupation were embedded in all reviewed conceptual practice models and case reports. The dimensions are explained in discrete, relational and embedded forms, with each conceptual practice model adopting a specific terminology and structure to describe them.

Conclusions and Significance: The presence of all four dimensions of occupation, regardless of form, terminology or structural arrangement, is proposed as a hallmark of an occupational therapy conceptual practice model.

Title: Increasing the delivery of upper limb constraint-induced movement therapy post-stroke: A feasibility implementation study.

Citation: Australian occupational therapy journal; Feb 2020

Author(s): McCluskey, Annie; Massie, Louise; Gibson, Gillian; Pinkerton, Lisa; Vandenberg, Ana

Introduction: Few stroke survivors receive upper limb constraint-induced movement therapy (CIMT). The aims of this study were to evaluate whether a behaviour change program for occupational therapists increased the number of stroke survivors receiving CIMT, describe the time and process involved in delivering the first program, any adverse events, fidelity and dose of CIMT provided, and upper limb outcomes.

Methods: A feasibility pre-post implementation study design was used, with intervention and measures for therapists and stroke survivors. Intervention for occupational therapists was informed by the Behaviour Change Wheel and included CIMT training, barrier identification, mentoring and a community of practice. Therapists delivered 2-week CIMT programs with

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1:1 supervision, first assisting stroke survivors to identify upper limb goals using the Canadian Occupational Performance Measure. The primary outcome was change in the number of stroke survivors receiving CIMT (program reach). Hours associated with program delivery, adverse events and participant repetitions were recorded (program fidelity and dose). Change in motor function was measured (fidelity) using the Motor Assessment Scale (Upper Limb), Box and Block Test, Nine Hole Peg Test and Motor Activity Log at baseline, program completion (2 weeks), 1 and 12 months.

Results: Program reach: Sixteen stroke participants were recruited (mean 15.3 months post-stroke, SD 11.9) and six CIMT programs conducted over 24 months, compared to none pre-implementation. The first CIMT program required a mean of 242 hours for preparation and delivery. All programs were student-assisted. Fidelity and dose: Stroke participants completed a mean of 360.6 repetitions/hour (SD 183.7), and 12,719.6 repetitions/program (SD 6,872.8). Statistically significant changes in upper limb motor function were recorded; some changes were clinically important.

Conclusions: The behaviour change program resulted in multiple CIMT programs being delivered safely and with fidelity. Capacity building and skill development took many hours, as did preparation for the first CIMT program.

Title: Institutional context: What elements shape how community occupational therapists think about their clients' care?

Citation: Health & social care in the community; Jan 2020

Author(s): Carrier, Annie; Freeman, Andrew; Desrosiers, Johanne; Levasseur, Mélanie

Abstract: Clinical reasoning (CR) is the cognitive process that therapists use to plan, direct, perform and reflect on client care. Linked to intervention efficiency and quality, CR is a core competency that occurs within an institutional context (legal, regulatory, administrative and organisational elements). Because this context can shape how community therapists think about their clients' care, its involvement in their CR could have a major impact on the interventions delivered. However, little is known about this involvement. Our study thus aimed to describe the elements of the institutional context involved in community therapists' CR. From March 2012 to June 2014, we conducted an institutional ethnography (IE) inquiry in three Health and Social Services Centres in Québec (Canada). We observed participants and conducted semi-structured interviews with 10 occupational therapists. We also interviewed 12 secondary key informants (colleagues and managers) and collected administrative documents (n = 50). We analysed data using the IE process. Of the 13 elements of the institutional context identified, we found that four are almost constantly involved in participants' CR. These four elements, that is, institutional procedures, organisation's basket of services, occupational therapists' mandate and wait times for their services, restrictively shape CR. Specifically, occupational therapists restrict their representation of the client's situation and exploration of potential solutions to what is possible within the bounds of these four elements. In light of such restrictions on the way they think about their clients' care, therapists should pay close attention to the elements of their own institutional context and how they are involved in their CR. Because of its potentially important impact on the future of professions (e.g. further restrictions on professionals' role, reduced contribution to population health and well-being), this involvement of the institutional context in CR concerns all professionals, be they clinicians, educators, researchers or regulatory college officers.

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Title: Motivational interviewing to promote health outcomes and behaviour change in multiple sclerosis: a systematic review.

Citation: Clinical Rehabilitation; Mar 2020; vol. 34 (no. 3); p. 299-309

Author(s): Dorstyn, Diana S.; Mathias, Jane L.; Bombardier, Charles H.; Osborn, Amanda J.

Objective: To examine the evidence for motivational interviewing when used to assist individuals with multiple sclerosis manage their healthcare.

Data sources: The Cochrane, Embase, PsycINFO and PubMed databases were searched for studies published between 1983 and December 2019. The reference lists of included studies were additionally examined and Scopus citation searches conducted.

Review methods: Study screening and data extraction were independently completed by two reviewers. Randomised controlled trials comparing motivational interviewing interventions for multiple sclerosis to usual care, wait-list or other active intervention controls were examined. Studies were assessed using the Cochrane Risk of Bias tool. Standardised mean differences (Hedges' g), 95% confidence intervals and P values were calculated for all health and behavioural outcomes.

Results: Ten randomised controlled trials, involving a pooled sample of 987 adults with relapsing–remitting or progressive multiple sclerosis and mild to moderate impairment, were identified. Most trials had a low or unclear risk of methodological bias. Motivational interviewing, when used in conjunction with other counselling or rehabilitation techniques, resulted in significant immediate medium-to-very large improvements in multiple physical, psychological, social and behavioural outcomes (range: g =.34–2.68). Maintenance effects were promising (range: g =.41–1.11), although less frequently assessed (N studies = 5) and of limited duration (1–7 months). Individual and group-based interventions, delivered in-person or by telephone, were all effective.

Conclusions: Motivational interviewing is a flexible counselling technique that may improve rehabilitation care for multiple sclerosis. However, evidence for persisting benefits to health outcomes and behaviour is currently limited.

Title: A qualitative study on user acceptance of a home-based stroke telerehabilitation system.

Citation: Topics in Stroke Rehabilitation; Mar 2020; vol. 27 (no. 2); p. 81-92

Author(s): Chen, Yu; Chen, Yunan; Zheng, Kai; Dodakian, Lucy; See, Jill; Zhou, Robert; Chiu, Nina; Augsburger, Renee; McKenzie, Alison; Cramer, Steven C.

Objective: This paper reports a qualitative study of a home-based stroke telerehabilitation system. The telerehabilitation system delivers treatment sessions in the form of daily guided rehabilitation games, exercises, and stroke education in the patient's home. The aims of the current report are to investigate patient perceived benefits of and barriers to using the telerehabilitation system at home.

Methods: We used a qualitative study design that involved in-depth semi-structured interviews with 13 participants who were patients in the subacute phase after stroke and had completed a six-week intervention using the home-based telerehabilitation system. Thematic analysis was conducted to analyze the data.

Results: Participants mostly reported positive experiences with the telerehabilitation system. Benefits included observed improvements in limb functions, cognitive abilities, and emotional

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well-being. They also perceived the system easy to use due to the engaging experience and the convenience of conducting sessions at home. Meanwhile, participants pointed out the importance of considering technical support and physical environment at home. Further, family members' support helped them sustain in their rehabilitation. Finally, adjusting difficulty levels and visualizing patients' rehabilitation progress might help them in continued use of the telerehabilitation system.

Conclusion: Telerehabilitation systems can be used as an efficient and user-friendly tool to deliver home-based stroke rehabilitation that enhance patients' physical recovery and mental and social-emotional wellbeing. Such systems need to be designed to offer engaging experience, display of recovery progress, and flexibility of schedule and location, with consideration of facilitating and social factors.

Title: "Connecting patients and therapists remotely using technology is feasible and facilitates exercise adherence after stroke".

Citation: Topics in Stroke Rehabilitation; Mar 2020; vol. 27 (no. 2); p. 93-102

Author(s): Simpson, Dawn B.; Bird, Marie-Louise; English, Coralie; Gall, Seana L; Breslin, Monique; Smith, Stuart; Schmidt, Matthew; Callisaya, Michele L.

Purpose: Repetitive task practice after stroke is important to improve function, yet adherence to exercise is low. The aim of this study was to determine whether using the internet, a tablet application, and a chair sensor that connected to a therapist was feasible in monitoring adherence and progressing a functional exercise at home.

Methods: Ten participants with stroke completed a 4-week sit-to-stand exercise using the technology at home (ACTRN12616000051448). A therapist remotely monitored exercise adherence, progressed goals, and provided feedback via the app. Measures of feasibility (design, recruitment/withdrawals, adherence, safety, participant satisfaction and estimates of effect on function) were collected.

Results: Participants' mean age was 73.6 years [SD 9.9 years]. The system was feasible to deliver and monitor exercise remotely. All participants completed the study performing a mean 125% of prescribed sessions and 104% of prescribed repetitions. Participants rated the system usability (78%), enjoyment (70%) and system benefit (80%) as high. No adverse events were reported. The mean pre- and post-intervention difference in the total short performance physical battery score was 1.4 (95% CI 0.79, 2.00).

Conclusions: It was feasible and safe to prescribe and monitor exercises using an app and sensor-based system. A definitive trial will determine whether such technology could facilitate greater exercise participation after stroke.

Title: Factors Influencing the Delivery of Intensive Rehabilitation in Stroke: Patient Perceptions Versus Rehabilitation Therapist Perceptions.

Citation: Physical Therapy; Feb 2020; vol. 100 (no. 2); p. 307-316

Author(s): Janssen, Jessie; Klassen, Tara D; Connell, Louise A; Eng, Janice J

Background: Despite increasing evidence regarding the benefit of intensive task-specific practice and aerobic exercise in stroke rehabilitation, implementation remains difficult. The factors influencing implementation have been explored from therapists' perspectives; however, despite an increased emphasis on patient involvement in research, patients' perceptions have not yet been investigated.

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Objective: The study aimed to investigate factors influencing implementation of higher intensity activity in people with stroke and to compare this with therapists' perspectives.

Design: The design was a cross-sectional qualitative study.

Methods: The study used semistructured interviews with people with stroke who were part of a randomized clinical trial, the Determining Optimal post-Stroke Exercise study, which delivered a higher intensity intervention. An interview guide was developed and data analyzed using implementation frameworks. Factors emerging from interviews with people with stroke were compared and contrasted with factors perceived by rehabilitation therapists.

Results: Ten people with stroke were interviewed before data saturation was reached. Participants had a positive attitude regarding working hard and were satisfied with the graded exercise test, high intensity intervention, and the feedback-monitoring devices. Therapists and patients had contrasting perceptions about their beliefs regarding intensive exercise and the content of the intervention, with therapists more focused on the methods and patients more focused on the personal interactions stemming from the therapeutic relationship.

Conclusions: People with stroke perceived no barriers regarding the implementation of higher intensity rehabilitation in practice and were positive towards working at more intense levels. Contrastingly, from the therapists' perspective, therapists' beliefs about quality of movement and issues around staffing and resources were perceived to be barriers. In addition, therapists and people with stroke perceived the contents of the intervention differently, highlighting the importance of involving patients and clinicians in the development and evaluation of rehabilitation interventions.

Title: Spasticity and Range of Motion Over Time in Stroke Patients Who Received Multiple-Dose Botulinum Toxin Therapy.

Citation: Journal of Stroke & Cerebrovascular Diseases; Jan 2020; vol. 29 (no. 1)

Author(s): Ro, Takanori; Ota, Tetsuo; Saito, Tsukasa; Oikawa, Ou

Objective: This study examined how the effects of botulinum toxin therapy changed over time by sequential evaluation of clinical improvements in spasticity and contracture in 24 chronic-stage stroke patients on repeated botulinum toxin therapy who were receiving fewer rehabilitation interventions.

Methods: Botulinum toxin injection was administered into the spastic muscle of the paralyzed upper or lower limb 5 times with at least 3-month intervals. Modified Ashworth Scale and range of motion were measured before and 2 weeks after each dose in the extremities to compare the first measurement value with subsequent values. Each predose value was also compared with the first predose value.

Results: Compared with predose scores, Modified Ashworth Scale significantly improved in all flexors after 2 weeks from the first to fifth doses. Range of motion significantly improved in wrist dorsiflexion and ankle dorsiflexion. Comparison of values before each dose versus the first predose value showed significant improvement both in the Modified Ashworth Scale score of wrist flexors, finger flexors, and ankle planter flexors, and the range of motion of elbow extension, wrist dorsiflexion, and ankle dorsiflexion.

Conclusion: The comparison of predose values versus 2-week postdose values indicated that the effect of botulinum toxin formulation would not lessen after repeated injections with continuous improvements of Modified Ashworth Scale and range of motion. The comparison of predose values versus the first predose value also suggested that multiple injections of botulinum toxin formulation could be more effective in reducing spasticity and increasing the range of motion than a single injection.

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Title: Home-based Upper Extremity Stroke Therapy Using a Multiuser Virtual Reality Environment: A Randomized Trial.

Citation: Archives of Physical Medicine & Rehabilitation; Feb 2020; vol. 101 (no. 2); p. 196-203

Author(s): Thielbar, Kelly O.; Triandafilou, Kristen M.; Barry, Alexander J.; Yuan, Ning; Nishimoto, Arthur; Johnson, Joelle; Stoykov, Mary Ellen; Tsoupikova, Daria; Kamper, Derek G.

Abstract: To compare participation and subjective experience of participants in both home-based multiuser virtual reality (VR) therapy and home-based single-user (SU) VR therapy. Crossover, randomized trial. Initial training and evaluations occurred in a rehabilitation hospital; the interventions took place in participants' homes. Survivors of stroke with chronic upper extremity impairment (N=20). Four weeks of in-home treatment using a custom, multiuser virtual reality system (VERGE): 2 weeks of both multiuser (MU) and SU versions of VERGE. The order of presentation of SU and MU versions was randomized such that participants were divided into 2 groups, First MU and First SU. We measured arm displacement during each session (m) as the primary outcome measure. Secondary outcome measures include time participants spent using each MU and SU VERGE and Intrinsic Motivation Inventory scores. Fugl-Meyer Assessment of Motor Recovery After Stroke Upper Extremity (FMA-UE) score and compliance with prescribed training were also evaluated. Measures were recorded before, midway, and after the treatment. Activity and movement were measured during each training session. Arm displacement during a session was significantly affected the mode of therapy (MU: 414.6m, SU: 327.0m, P =.019). Compliance was very high (99% compliance for MU mode and 89% for SU mode). Within a given session, participants spent significantly more time training in the MU mode than in the SU mode (P =.04). FMA-UE score improved significantly across all participants (Δ3.2, P =.001). Multiuser VR exercises may provide an effective means of extending clinical therapy into the home.

Title: The role of rehabilitation psychology in stroke care described through case examples.

Citation: NeuroRehabilitation; Feb 2020

Author(s): Perna, Robert; Harik, Lindsey

Background: A stroke event, sometimes referred to as a cerebrovascular accident (CVA), is a sudden and often traumatic life event that results in life-changing consequences with which affected people must cope. There are nearly 800,000 instances of stroke annually in the U.S. (American Heart Association, 2018). Stroke is the leading cause of disability in adults, and more than one-third of people who survive a stroke will have severe disability in the U.S. (Mayo, 2005). Between 35% and 75% of stroke survivors will have significant cognitive impairment (Tatemichi et al., 1994; Nys et al., 2007). An estimated one-third of people suffer depression after stroke (Hackett et al., 2005), about one-fourth experience significant anxiety (Barker-Collo, 2007), and about one-fifth suffer from insomnia (Leppavuoria et al., 2002). These and other stroke-related psychological issues negatively influence rehabilitation and outcomes through a variety of mechanisms. For example, post-stroke depression has been shown to be related to more negative functional consequences (Kneebone et al., 2000; Matsuzaki et al., 2015). Psychological disturbances may affect rehabilitation outcomes through a reduction in adherence to home exercise programs,

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reduced energy level, increased fatigue, reduced frustration tolerance, and potentially less motivation and hope about the future.

Objectives: This manuscript aims to identify and describe the role of rehabilitation psychology in treating these common post-stroke complaints and, ultimately, optimizing post-stroke outcomes via two case examples.

Methodology: This manuscript describes two cases of individuals in post-acute rehabilitation who had psychological issues which were negatively affecting outcomes.

Conclusion: Given the abrupt and significant life-changing nature of stroke, it is often necessary to manage a diverse array of psychological issues that often cannot be simply managed via psychotropic medications. Moreover, an understanding of the patients' emotional adjustment and issues can help them maximize their rehabilitation, recovery, and community integration. For the cases discussed, psychology consultations were central in helping optimize their rehabilitation and functional outcomes.

Title: Nutritional improvement is associated with better functional outcome in stroke rehabilitation: A cross-sectional study using controlling nutritional status.

Citation: Journal of rehabilitation medicine; Feb 2020

Author(s): Kishimoto, Hiroshi; Yodu, Arito; Kohno, Yutaka; Oose, Hirotaka

Objective: To investigate the relationship between changes in nutritional status and the functional outcome of adult post-stroke patients hospitalized for rehabilitation.

Design: A cross-sectional study Subjects: Post-stroke patients who were admitted to a convalescent rehabilitation ward.

Methods: On admission and discharge, the nutritional status of each subject was assessed using the "controlling nutritional status" system. Activities of daily living were assessed using the Functional Independence Measure (FIM). Patients were divided into 2 categories: (i) those whose nutritional status improved or remained normal during the rehabilitation; and (ii) all others.

Results: The median age of patients was 65.5 years. Although there were no significant differences between the 2 categories in most characteristics, the FIM efficiency was significantly higher (-0.230 in the improved category and 0.133 in the other; p < 0.001). Multiple linear regression analysis showed that the improved category as a variable was independently associated with greater FIM efficiency (p < 0.001).

Conclusion: Improvement or maintenance of nutritional status was associated with better functional recovery in post-stroke rehabilitation in adult patients of all ages.

Title: Virtual reality therapy for upper limb rehabilitation in patients with stroke: a meta-analysis of randomized clinical trials.

Citation: Brain injury; Feb 2020 ; p. 1-10

Author(s): Mekbib, Destaw B; Han, Jiawei; Zhang, Li; Fang, Shan; Jiang, Hongjie; Zhu, Junming; Roe, Anna W; Xu, Dongrong

Background: Stroke is a major cause of life-long disability in adults, associated with poor quality of life. Virtual reality (VR)-based therapy systems are known to be helpful in improving motor functions following stroke, but recent clinical findings have not been included in the previous publications of meta-analysis studies.

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Aims: This meta-analysis was based on the available literature to evaluate the therapeutic potential of VR as compared to dose-matched conventional therapies (CT) in patients with stroke.

Methods: We retrieved relevant articles in EMBASE, MEDLINE, PubMed, and Web of Science published between 2010 and February 2019. Peer-reviewed randomized controlled trials that compared VR with CT were included.

Results: A total of 27 studies met the inclusion criteria. The analysis indicated that the VR group showed statistically significant improvement in the recovery of UL function (Fugl-Meyer Upper Extremity [FM-UE]: n = 20 studies, Mean Difference [MD] = 3.84, P = .01), activity (Box and Block Test [BBT]: n = 13, MD = 3.82, P = .04), and participation (Motor Activity Log [MAL]: n = 6, MD = 0.8, P = .0001) versus the control group.

Conclusion: VR appears to be a promising therapeutic technology for UL motor rehabilitation in patients with stroke.

Title: What is the potential of virtual reality for post-stroke sensorimotor rehabilitation?

Citation: Expert review of neurotherapeutics; Feb 2020 ; p. 1-3

Author(s): Levin, Mindy F

Title: Post-stroke sleep disturbances and rehabilitation outcomes: a prospective cohort study.

Citation: Internal medicine journal; Feb 2020; vol. 50 (no. 2); p. 208-213

Author(s): Iddagoda, Mayura T; Inderjeeth, Charles A; Chan, Kien; Raymond, Warren D

Background: Poor sleep is common after stroke, and data regarding its effect on rehabilitation outcomes are limited. Controversial evidence was found concerning the effect of sedatives on improving sleep quality in poor sleepers after stroke.

Aim: To assess the prevalence of poor sleep in post-stroke patients and its effect on rehabilitation outcomes.

Method: A total of 104 stroke patients from two major stroke rehabilitation units in Western Australia was enrolled. Sleep quality was assessed using the Pittsburgh Sleep Quality Indexes at baseline and after stroke. The main outcome measures were Functional Independence Measure (FIM) change and length of stay (LOS). Sedative use during this period was also recorded.

Results: A total of 29.8% post-stroke patients suffered from poor sleep. There was no relationship between poor sleep and the stroke characteristics, such as severity, side and type, or demographics, such as age and gender. Poor sleep quality was inversely associated with rehabilitation outcomes measured by FIM (Rs. -0.317, P = 0.005). However, there was no significant association between sleep quality and LOS (P = 0.763). Sedatives were used in 18.2% of patients but had no impact on sleep quality or rehabilitation outcomes.

Conclusion: This research supported that poor sleep was frequent after stroke and had negative effects on rehabilitation outcomes. Use of sedatives was of limited benefit to improve sleep quality, and further studies are required to search for strategies to improve sleep problems after stroke.

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Title: Advances and challenges in stroke rehabilitation.

Citation: The Lancet. Neurology; Jan 2020

Author(s): Stinear, Cathy M; Lang, Catherine E; Zeiler, Steven; Byblow, Winston D

Abstract: Stroke remains a leading cause of adult disability and the demand for stroke rehabilitation services is growing. Substantial advances are yet to be made in stroke rehabilitation practice to meet this demand and improve patient outcomes relative to current care. Several large intervention trials targeting motor recovery report that participants' motor performance improved, but to a similar extent for both the intervention and control groups in most trials. These neutral results might reflect an absence of additional benefit from the tested interventions or the many challenges of designing and doing large stroke rehabilitation trials. Strategies for improving trial quality include new approaches to the selection of patients, control interventions, and endpoint measures. Although stroke rehabilitation research strives for better trials, interventions, and outcomes, rehabilitation practices continue to help patients regain independence after stroke.

Title: Stroke Inpatient Rehabilitation Team Conferences: Leadership and Structure Improve Patient Outcomes.

Citation: Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association; Feb 2020 ; p. 104622

Author(s): Kushner, David S; Strasser, Dale C

Abstract: Consensus on how rehabilitation teamwork and services are optimally coordinated continues to be a work in progress. One area of recent research has been inpatient-rehabilitation team conferences in stroke. The prevalence of Americans living with stroke is expected to gradually increase as the U.S. population ages, as will the related direct and indirect costs. Effective interdisciplinary team conferences during acute-stroke inpatient-rehabilitation are key to managing long-term costs while improving functional outcomes. Effective team conferences help to identify patients at risk for medical complications and institutionalization and help to determine interventions that will focus on patients' medical, physical, cognitive, emotional, and social barriers to recovery and barriers to a community/home disposition. This scoping review paper identifies and analyzes literature on theory and structure of effective teams with the focus on stroke interdisciplinary rehabilitation team conferences and offers suggestions for improvement. Potential flaws of commonly used team conference formats are described. Studies are outlined showing associations between stroke patient outcomes and better care coordination and leadership in medical teamwork; and 2 examples of successful interdisciplinary team conference models used in stroke inpatient-rehabilitation are provided that support a case for a proactive, conscious structure to team conferences. Given the complexity of many stroke patients' clinical care, greater attention to team functioning, and especially team conference leadership and structure, may be a promising area of focus to improve the quality of health care services for people with stroke.

Title: Systematic Review and Meta-Analysis of Home-Based Rehabilitation on Improving Physical Function Among Home-Dwelling Patients With a Stroke.

Citation: Archives of physical medicine and rehabilitation; Feb 2020; vol. 101 (no. 2); p. 359-373

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Author(s): Chi, Nai-Fang; Huang, Yi-Chieh; Chiu, Hsiao-Yean; Chang, Hsiu-Ju; Huang, Hui-Chuan

Objective: To evaluate the effects of home-based rehabilitation on improving physical function in home-dwelling patients after a stroke.

Data Sources: Various electronic databases, including PubMed, Cumulative Index to Nursing and Allied Health, Embase, the Cochrane Central Register of Controlled Trials, and 2 Chinese data sets (ie, Chinese Electronic Periodical Services and China Knowledge Resource Integrated) were searched for studies published before March 20, 2019.

Study Selection: Randomized controlled trials conducted to examine the effect of home-based rehabilitation on improving physical function in home-dwelling patients with a stroke and published in English or Chinese were included. In total, 49 articles in English (n=23) and Chinese (n=26) met the inclusion criteria.

Data Extraction: Data related to patient characteristics, study characteristics, intervention details, and outcomes were extracted by 2 independent reviewers.

Data Synthesis: A random-effects model with a sensitivity analysis showed that home-based rehabilitation exerted moderate improvements on physical function in home-dwelling patients with a stroke (g=0.58; 95% CI, 0.45∼0.70). Moderator analyses revealed that those patients with stroke of a younger age, of male sex, with a first-ever stroke episode, in the acute stage, and receiving rehabilitation training from their caregiver showed greater improvements in physical function.

Conclusions: Home rehabilitation can improve functional outcome in survivors of stroke and should be considered appropriate during discharge planning if continuation care is required.

Title: Nature-based rehabilitation to reduce post-stroke fatigue is not effective: A randomized controlled trial.

Citation: Journal of rehabilitation medicine; Feb 2020

Author(s): Pálsdóttir, Anna-María; Stigmar, Kjerstin; Norrving, Bo; Petersson, Ingemar F; Åström, Mikael; Pessah-Rasmussen, Hélène

Objective: To determine whether nature-based rehabilitation, as an add-on to standard care, has a long-term influence on post-stroke fatigue, perceived value of everyday occupations, disability, health-related quality of life, anxiety, and depression at follow-up 8 and 14 months after randomization.

Design: Single-blinded, 2-armed, randomized controlled trial.

Methods: Stroke survivors, identified through routine 3-month follow-up visit (sub-acute) or medical records (chronic stroke > 1 year previously), were randomized to standard care + nature-based rehabilitation (intervention group) or standard care alone (control group). Blinded evaluations were conducted at follow-up 8 and 14 months after randomization, for the following outcomes: post-stroke fatigue (Mental Fatigue Scale; MFS), perceived value of everyday occupations (Oval-pd), disability (modified Rankin Scale; mRS), health-related quality of life (EQ-5D), anxiety (Hospital Anxiety and Depression Scale; HAD) and depression (HAD).

Results: Approximately one-quarter of the screened patients were eligible for inclusion in the study; of these, half agreed to participate; a final total of 101 patients were randomized (mean age 67 years, 60% female). The patients with sub-acute stroke were highly compliant with the intervention. No statistically significant differences in improvement were found

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between the intervention and control groups for any of the outcome measures. Fatigue decreased to a value below the suggested cut-off for mental fatigue (< 10.5) in the intervention group, but not in the control group.

Conclusion: Nature-based rehabilitation is feasible and well tolerated. A larger randomized controlled trial is warranted.

Title: "Living in a foreign country": experiences of staff-patient communication in inpatient stroke settings for people with post-stroke aphasia and those supporting them.

Citation: Disability and rehabilitation; Feb 2020; vol. 42 (no. 3); p. 324-334

Author(s): Clancy, Louise; Povey, Rachel; Rodham, Karen

Purpose: Staff-patient communication in in-patient stroke settings is viewed as challenging for stroke survivors with aphasia and those supporting them. This study sought to explore these experiences from the perspectives of stroke survivors, their carers and healthcare professionals.

Methods: A qualitative study where stroke survivors with aphasia, carers and healthcare professionals were interviewed (audio-recorded) one-to-one or via focus group. Stroke survivors were at least 6 months post-stroke and had a self-reported mild to moderate level of post-stroke aphasia. Transcripts for each group were analysed separately using inductive thematic analysis; followed by an integrative analysis.

Results: Six stroke survivors with aphasia, 10 carers, and six healthcare professionals were recruited. Three overarching themes were identified: "being in a foreign country", "finding a voice", and "you're just a number". A dynamic model of communication is proposed offering a framework for understanding the relationships between "the context", "the people" and "the interactions".

Conclusions: Communication was viewed as important but challenging by all three groups. To maximise staff-patient interactions in the future, attention needs to be paid to: the psychosocial needs of stroke survivors and their carers, ongoing staff training and support for the healthcare professionals supporting them, and the provision of an aphasia-friendly and a communicatively stimulating ward environment.

Implications for Rehabilitation: Effective staff-patient communication is viewed as fundamental to stroke rehabilitation but challenging by patients with aphasia, their carers and the healthcare professionals supporting them. To maximise staff-patient communication three key areas must be considered and targeted: those involved/affected by staff-patient communication ("the people"), factors within the "hospital context", and "the interactions" between "the people". Tailoring and being consistent with communication and care is paramount to avoid repeated negative communication encounters which can result in disengagement from care. Stroke rehabilitation which currently focuses on the physical fails to address the psychological/emotional and social needs of the patients and those supporting them.

Title: Effect of Additional Rehabilitation After Botulinum Toxin-A on Upper Limb Activity in Chronic Stroke: The InTENSE Trial.

Citation: Stroke; Feb 2020; vol. 51 (no. 2); p. 556-562

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Author(s): Lannin, Natasha A; Ada, Louise; English, Coralie; Ratcliffe, Julie; Faux, Steven G; Palit, Mithu; Gonzalez, Senen; Olver, John; Cameron, Ian; Crotty, Maria; InTENSE Trial Group

Background and Purpose: The aim of this trial was to determine the effect of additional upper limb rehabilitation following botulinum toxin-A for upper limb activity in chronic stroke.

Methods: We conducted a multicenter phase III randomized trial with concealed allocation, blinded measurement, and intention-to-treat analysis. One hundred forty 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 >3 months ago, who had completed formal rehabilitation and had no significant cognitive impairment. Experimental group received botulinum toxin-A plus evidence-based movement training while the control group received botulinum toxin-A plus a handout of exercises. Primary outcomes were goal attainment (Goal Attainment Scaling) and upper limb activity (Box and Block Test) at 3 months (end of intervention). Secondary outcomes were spasticity, range of motion, strength, pain, burden of care, and health-related quality of life.

Results: In terms of goal attainment, the experimental group scored the same (mean difference, 2 T-score [95% CI, -2 to 7]) as the control group on the Goal Attainment Scale. In terms of upper limb activity, by 3 months the experimental group moved blocks at the same speed (mean difference, 0.00 blocks/s [95% CI, -0.02 to 0.01]) as the control group on the Box and Block Test. There were no differences between groups on any secondary outcome except strength, in favor of the experimental group (mean difference, 1.4 kg [95% CI, 0.2-2.7]).

Conclusions: Findings suggest that additional intensive upper limb rehabilitation following botulinum toxin-A in chronic stroke survivors with a disabled upper limb is not effective. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: ACTRN12615000616572.

Title: Acupuncture for stroke: perceptions and possibilities.

Citation: Acupuncture in medicine : journal of the British Medical Acupuncture Society; Jan 2020 ; p. 964528419901129

Author(s): Robinson, Nicola; Ye, Tian; Ronan, Patricia; Garbelli, Pietro Emanuele; Smithard, David

Objective: To investigate perceptions and acceptability of, and attitudes towards, acupuncture for post-acute stroke and rehabilitation care by exploring the views of different stakeholders.

Methods: Three electronic surveys were conducted to gauge the breadth of knowledge and acceptance of acupuncture in post-acute stroke and rehabilitation care among three stakeholder groups: (1) traditional acupuncturists registered with the British Acupuncture Council (BAcC); (2) National Health Service (NHS) professionals attending the 2017 UK Stroke Forum conference; and (3) the UK network of Stroke Club co-ordinators.

Results: Of 278 NHS respondents, 31% were doctors. Over half (52%) of all NHS respondents reported they had insufficient knowledge about acupuncture, its effectiveness (23%) or how to refer (21%). Only 12% had previously referred stroke patients for acupuncture but 46% thought that there was role for acupuncture in post-acute stroke care (50% were unsure). Two thirds of BAcC acupuncturist respondents had treated at least one stroke patient, with 70.1% having treated 1-5 stroke patients and 71% having provided treatment in the last year, most commonly for motor impairment (88.2%). Of 99 Stroke Club

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coordinators who responded, only seven had ever been asked about acupuncture by patients, but most felt there would be interest.

Conclusion: Interest in the provision of acupuncture for post-acute stroke care was expressed by both NHS practitioners and acupuncturists. Further research is required on the acceptability of acupuncture to patients as well as evidence of its clinical and cost effectiveness.

Title: Telerehabilitation services for stroke.

Citation: The Cochrane database of systematic reviews; Jan 2020; vol. 1 ; p. CD010255

Author(s): Laver, Kate E; Adey-Wakeling, Zoe; Crotty, Maria; Lannin, Natasha A; George, Stacey; Sherrington, Catherine

Background: Telerehabilitation offers an alternate way of delivering rehabilitation services. Information and communication technologies are used to facilitate communication between the healthcare professional and the patient in a remote location. The use of telerehabilitation is becoming more viable as the speed and sophistication of communication technologies improve. However, it is currently unclear how effective this model of delivery is relative to rehabilitation delivered face-to-face or when added to usual care.

Objectives: To determine whether the use of telerehabilitation leads to improved ability to perform activities of daily living amongst stroke survivors when compared with (1) in-person rehabilitation (when the clinician and the patient are at the same physical location and rehabilitation is provided face-to-face); or (2) no rehabilitation or usual care. Secondary objectives were to determine whether use of telerehabilitation leads to greater independence in self-care and domestic life and improved mobility, balance, health-related quality of life, depression, upper limb function, cognitive function or functional communication when compared with in-person rehabilitation and no rehabilitation. Additionally, we aimed to report on the presence of adverse events, cost-effectiveness, feasibility and levels of user satisfaction associated with telerehabilitation interventions.

Search Methods: We searched the Cochrane Stroke Group Trials Register (June 2019), the Cochrane Central Register of Controlled Trials (the Cochrane Library, Issue 6, 2019), MEDLINE (Ovid, 1946 to June 2019), Embase (1974 to June 2019), and eight additional databases. We searched trial registries and reference lists.

Selection Criteria: Randomised controlled trials (RCTs) of telerehabilitation in stroke. We included studies that compared telerehabilitation with in-person rehabilitation or no rehabilitation. In addition, we synthesised and described the results of RCTs that compared two different methods of delivering telerehabilitation services without an alternative group. We included rehabilitation programmes that used a combination of telerehabilitation and in-person rehabilitation provided that the greater proportion of intervention was provided via telerehabilitation.

Data Collection and Analysis: Two review authors independently identified trials on the basis of prespecified inclusion criteria, extracted data and assessed risk of bias. A third review author moderated any disagreements. The review authors contacted investigators to ask for missing information. We used GRADE to assess the quality of the evidence and interpret findings.

Main Results: We included 22 trials in the review involving a total of 1937 participants. The studies ranged in size from the inclusion of 10 participants to 536 participants, and reporting quality was often inadequate, particularly in relation to random sequence generation and allocation concealment. Selective outcome reporting and incomplete outcome data were apparent in several studies. Study interventions and comparisons varied, meaning that, in many cases, it was inappropriate to pool studies. Intervention approaches included post-

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hospital discharge support programs, upper limb training, lower limb and mobility retraining and communication therapy for people with post-stroke language disorders. Studies were either conducted upon discharge from hospital or with people in the subacute or chronic phases following stroke.

Primary Outcome: We found moderate-quality evidence that there was no difference in activities of daily living between people who received a post-hospital discharge telerehabilitation intervention and those who received usual care (based on 2 studies with 661 participants (standardised mean difference (SMD) -0.00, 95% confidence interval (CI) -0.15 to 0.15)). We found low-quality evidence of no difference in effects on activities of daily living between telerehabilitation and in-person physical therapy programmes (based on 2 studies with 75 participants: SMD 0.03, 95% CI -0.43 to 0.48).

Secondary Outcomes: We found a low quality of evidence that there was no difference between telerehabilitation and in-person rehabilitation for balance outcomes (based on 3 studies with 106 participants: SMD 0.08, 95%CI -0.30 to 0.46). Pooling of three studies with 569 participants showed moderate-quality evidence that there was no difference between those who received post-discharge support interventions and those who received usual care on health-related quality of life (SMD 0.03, 95% CI -0.14 to 0.20). Similarly, pooling of six studies (with 1145 participants) found moderate-quality evidence that there was no difference in depressive symptoms when comparing post-discharge tele-support programs with usual care (SMD -0.04, 95% CI -0.19 to 0.11). We found no difference between groups for upper limb function (based on 3 studies with 170 participants: mean difference (MD) 1.23, 95% CI -2.17 to 4.64, low-quality evidence) when a computer program was used to remotely retrain upper limb function in comparison to in-person therapy. Evidence was insufficient to draw conclusions on the effects of telerehabilitation on mobility or participant satisfaction with the intervention. No studies evaluated the cost-effectiveness of telerehabilitation; however, five of the studies reported health service utilisation outcomes or costs of the interventions provided within the study. Two studies reported on adverse events, although no serious trial-related adverse events were reported.

Authors' Conclusions: While there is now an increasing number of RCTs testing the efficacy of telerehabilitation, it is hard to draw conclusions about the effects as interventions and comparators varied greatly across studies. In addition, there were few adequately powered studies and several studies included in this review were at risk of bias. At this point, there is only low or moderate-level evidence testing whether telerehabilitation is a more effective or similarly effective way to provide rehabilitation. Short-term post-hospital discharge telerehabilitation programmes have not been shown to reduce depressive symptoms, improve quality of life, or improve independence in activities of daily living when compared with usual care. Studies comparing telerehabilitation and in-person therapy have also not found significantly different outcomes between groups, suggesting that telerehabilitation is not inferior. Some studies reported that telerehabilitation was less expensive to provide but information was lacking about cost-effectiveness. Only two trials reported on whether or not any adverse events had occurred; these trials found no serious adverse events were related to telerehabilitation. The field is still emerging and more studies are needed to draw more definitive conclusions. In addition, while this review examined the efficacy of telerehabilitation when tested in randomised trials, studies that use mixed methods to evaluate the acceptability and feasibility of telehealth interventions are incredibly valuable in measuring outcomes.

Sources Used: The following databases are used in the creation of this bulletin: Amed, Cinahl & Medline. Disclaimer: The results of your literature search are based on the request that you made, and consist of a list of

references, some with abstracts. Royal United Hospital Bath Healthcare Library will endeavour to use the best, most appropriate and most recent sources available to it, but accepts no liability for the information retrieved, which is subject to the content and accuracy of databases, and the limitations of the search process. The library assumes no liability for the interpretation or application of these results, which are not intended to provide advice or recommendations on patient care.