[Show abstract][Hide abstract] ABSTRACT: Background: Virtual reality (VR) systems are promising treatment options in stroke rehabilitation because they can incorporate motor learning strategies (MLS) supporting motivating task oriented practice. However, clinicians lack motor learning-based training for VR use. The objectives of this study were to design, implement and evaluate the effectiveness of a knowledge translation (KT) strategy to support therapists in acquiring proficiency using the GestureTek VR system while emphasizing integration of MLS. Methods: Participants were four physical therapists
and three occupational therapists from a stroke rehabilitation unit, who provided VR-based therapy to 24 clients with stroke. The KT intervention included newly created e-learning modules, group and individual practice, and audit and feedback. Content covered practicalities of VR system operation with a focus on integrating MLS. Using a pre-post design, the ADOPT-VR was used to evaluate changes in therapists’ attitudes, social influences and perceived behavioural control (PBC) regarding VR use. Summative and self-evaluation of e-learning objectives provided information about knowledge acquisition. The MLS Rating Instrument (MLSRI-20) examined MLS use during videotaped VR sessions. Video-stimulated recall evaluated decision-making related to VR and MLS use. Therapists’ experiences were explored through a focus group. Results: Significant pre-post change in therapists’ PBC (p=0.034), but not attitudes or social influences, were observed at post-test. However, therapists used few MLS, with no significant improvement in MLS use over time. While therapists reported increased knowledge about motor learning and understanding of the VR system, difficulties with VR system operation seemingly hindered assimilation of learning in these domains. Managing technical aspects of VR appeared to be prioritized over integrating MLS. Conclusions: The KT strategy yielded increased knowledge in motor learning and VR system use but limited integration of MLS into practice. Future KT strategies should consider a phased approach whereby proficiency in VR system operation precedes integration of a theoretical approach to treatment.
5th Canadian Stroke Congress, Vancouver, BC Canada; 10/2014
[Show abstract][Hide abstract] ABSTRACT: Background: Although task-related walking training has been recommended after stroke, the theoretical basis, content, and impact of interventions vary across the literature. There is a need for a comparison of different approaches to task-related walking training after stroke. Objective: To compare the impact of a motor-learning-science-based overground walking training program with body-weight-supported treadmill training (BWSTT) in ambulatory, community-dwelling adults within 1 year of stroke onset. Methods: In this rater-blinded, 1:1 parallel, randomized controlled trial, participants were stratified by baseline gait speed. Participants assigned to the Motor Learning Walking Program (MLWP) practiced various overground walking tasks under the supervision of 1 physiotherapist. Cognitive effort was encouraged through random practice and limited provision of feedback and guidance. The BWSTT program emphasized repetition of the normal gait cycle while supported on a treadmill and assisted by 1 to 3 therapy staff. The primary outcome was comfortable gait speed at postintervention assessment (T2). Results: In total, 71 individuals (mean age = 67.3; standard deviation = 11.6 years) with stroke (mean onset = 20.9 [14.1] weeks) were randomized (MLWP, n = 35; BWSTT, n = 36). There was no significant between-group difference in gait speed at T2 (0.002 m/s; 95% confidence interval [CI] = −0.11, 0.12; P > .05). The MLWP group improved by 0.14 m/s (95% CI = 0.09, 0.19), and the BWSTT group improved by 0.14 m/s (95% CI = 0.08, 0.20). Conclusions: In this sample of community-dwelling adults within 1 year of stroke, a 15-session program of varied overground walking-focused training was not superior to a BWSTT program of equal frequency, duration, and in-session step activity.
[Show abstract][Hide abstract] ABSTRACT: Unlabelled:
: This special interest article provides a historical framework with a contemporary case example that traces the infusion of the science of motor learning into neurorehabilitation practice. The revolution in neuroscience provided the first evidence for learning-dependent neuroplasticity and presaged the role of motor learning as critical for restorative therapies after stroke. The scientific underpinnings of motor learning have continued to evolve from a dominance of cognitive or information processing perspectives to a blend with neural science and contemporary social-cognitive psychological science. Furthermore, advances in the science of behavior change have contributed insights into influences on sustainable and generalizable gains in motor skills and associated behaviors, including physical activity and other recovery-promoting habits. For neurorehabilitation, these insights have tremendous relevance for the therapist-patient interactions and relationships. We describe a principle-based intervention for neurorehabilitation termed the Accelerated Skill Acquisition Program that we developed. This approach emphasizes integration from a broad set of scientific lines of inquiry including the contemporary fields of motor learning, neuroscience, and the psychological science of behavior change. Three overlapping essential elements-skill acquisition, impairment mitigation, and motivational enhancements-are integrated.
Video abstract available:
(See Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A71) for more insights from the authors.
[Show abstract][Hide abstract] ABSTRACT: Objective:To investigate the contributions of physiotherapy and occupational therapy to self-management interventions and the theoretical models used to support these interventions in chronic disease.Data sources:We conducted two literature searches to identify studies that evaluated self-management interventions involving physiotherapists and occupational therapists in MEDLINE, the Cochrane Library, CINAHL, EMBASE, AMED (Allied and Complementary Medicine), SPORTdiscus, and REHABDATA databases.Study selection:Four investigator pairs screened article title and abstract, then full text with inclusion criteria. Selected articles (n = 57) included adults who received a chronic disease self-management intervention, developed or delivered by a physiotherapist and/or an occupational therapist compared with a control group.Data extraction:Four pairs of investigators performed independent reviews of each article and data extraction included: (a) participant characteristics, (b) the self-management intervention, (c) the comparison intervention, (d) outcome measures, construct measured and results.Data synthesis:A total of 47 articles reported the involvement of physiotherapy in self-management compared with 10 occupational therapy articles. The type of chronic condition produced different yields: arthritis n = 21 articles; chronic obstructive pulmonary disease and chronic pain n = 9 articles each. The theoretical frameworks most frequently cited were social cognitive theory and self-efficacy theory. Physical activity was the predominant focus of the self-management interventions. Physiotherapy programmes included disease-specific education, fatigue, posture, and pain management, while occupational therapists concentrated on joint protection, fatigue, and stress management.Conclusions:Physiotherapists and occupational therapists make moderate contributions to self-management interventions. Most of these interventions are disease-specific and are most frequently based on the principles of behaviour change theories.
[Show abstract][Hide abstract] ABSTRACT: Virtual reality (VR) systems are promising treatment options for physical therapists (PTs) and occupational therapists (OTs) in stroke rehabilitation because they incorporate motor learning principles of task-oriented, challenging, and motivating practice. However, clinicians face challenges when integrating VR into clinical practice, including limited availability of training that supports the implementation of VR-based therapy with a motor learning focus. Untrained therapists may deliver sub-optimal intervention as they are unprepared to use VR systems effectively. Training support is required if therapists are to become competent at transferring gains made in VR-based therapy to better functioning in the real world. This poster describes the methods of an ongoing knowledge translation (KT) study to develop, implement and evaluate a KT strategy to promote motor learning-based integration of GestureTek’s Interactive Rehabilitation Exercise (IREX) and Gesture Xtreme (GX) systems into clinical practice in two stroke rehabilitation units. The KT initiative includes e-learning modules, experiential workshops, and audit and feedback. The 3 e-learning modules provide foundational knowledge about evidence for VR use in neuro-rehabilitation, neuroplasticity, motor learning principles, IREX/GX game characteristics, setting SMART goals, and implementing motor learning strategies. The format includes pre- and post-module confidence logs, interactive knowledge checks, and video clips. Experiential learning with the GestureTek system occurs in
group and individual formats. Audit and feedback is provided to participants through individual practice sessions and video stimulated recall sessions. Outcome measures evaluate participant knowledge and skills and the feasibility of both KT methods and VR implementation. This is the first study to evaluate a KT strategy focusing on motor learning-based VR interventions. The KT strategy is generalizable to other VR systems and can be implemented on a wide scale. The goal is to provide clinicians with skills to utilize VR to yield high quality evidence and enhanced outcomes for stroke rehabilitation clients.
4th Canadian Stroke Congress, Montreal, QC; 10/2013
[Show abstract][Hide abstract] ABSTRACT: PURPOSE:: To evaluate and compare the interrater reliability of the Motor Learning Strategy Rating Instrument (MLSRI) within usual and virtual reality (VR) interventions for children with acquired brain injury. METHODS:: Two intervention sessions for each of 11 children (total, 22) were videotaped; sessions were provided by 4 physical therapists. Videotapes were divided into usual and VR components and rated by 2 observers using the MLSRI. A generalizability theory approach was used to determine interrater reliability for each intervention. RESULTS:: Interrater reliability for usual interventions was high for the MLSRI total score (g-coefficient, 0.81), whereas it was low for the VR total score (g-coefficient, 0.28); MLSRI category g-coefficients varied from 0.35 to 0.65 for usual and from 0.17 to 0.72 for VR interventions. CONCLUSION:: Adequate reliability was achieved within ratings of usual interventions; however, challenges related to MLSRI use to rate VR-based interventions require further evaluation.
Pediatric physical therapy: the official publication of the Section on Pediatrics of the American Physical Therapy Association 11/2012; 25(1). DOI:10.1097/PEP.0b013e3182750c28 · 1.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A "review of reviews" was undertaken to assess methodological issues in studies evaluating nondrug rehabilitation interventions in stroke patients.
MEDLINE, CINAHL, PsycINFO, and the Cochrane Database of Systematic Reviews were searched from January 2000 to January 2008 within the stroke rehabilitation setting. Electronic searches were supplemented by reviews of reference lists and citations identified by experts. Eligible studies were systematic reviews; excluded citations were narrative reviews or reviews of reviews. Review characteristics and criteria for assessing methodological quality of primary studies within them were extracted.
The search yielded 949 English-language citations. We included a final set of 38 systematic reviews. Cochrane reviews, which have a standardized methodology, were generally of higher methodological quality than non-Cochrane reviews. Most systematic reviews used standardized quality assessment criteria for primary studies, but not all were comprehensive. Reviews showed that primary studies had problems with randomization, allocation concealment, and blinding. Baseline comparability, adverse events, and co-intervention or contamination were not consistently assessed. Blinding of patients and providers was often not feasible and was not evaluated as a source of bias.
The eligible systematic reviews identified important methodological flaws in the evaluated primary studies, suggesting the need for improvement of research methods and reporting.
[Show abstract][Hide abstract] ABSTRACT: To review the reporting of key design features in studies of stroke rehabilitation therapies.
We used purposive sampling to examine English-language, human-subject, comparative studies focusing on stroke rehabilitation therapy provided the effect of therapy was evaluated in at least one of the following six outcome domains: ambulation, cognition, quality of life, daily activities, dysphagia, or communication. We searched MEDLINE®, CINAHL®, PsycINFO®, and the Cochrane Database of Systematic Reviews (date range: January 2000 through late-January 2008) and extracted data from included studies using standardized forms. We depicted the extracted data in tables and summarized the findings qualitatively in the text.
We retrieved 1,674 citations in the literature search and extracted data from 99 studies. Authors' reporting of key design features in stroke rehabilitation studies was lacking in four areas, that is, the background of persons delivering therapy, timing of therapy, subjects' receipt of prior or concomitant treatment, and psychometric properties of outcome measurement instruments.
Except for four areas, reporting of key design features in studies of stroke rehabilitation therapies was quite comprehensive. Researchers should pay particular attention to reporting blinding, and they should rationalize the number of outcome measurement instruments used in their studies.
[Show abstract][Hide abstract] ABSTRACT: Although task-oriented training has been shown to improve walking outcomes after stroke, it is not yet clear whether one task-oriented approach is superior to another. The purpose of this study is to compare the effectiveness of the Motor Learning Walking Program (MLWP), a varied overground walking task program consistent with key motor learning principles, to body-weight-supported treadmill training (BWSTT) in community-dwelling, ambulatory, adults within 1 year of stroke.
A parallel, randomized controlled trial with stratification by baseline gait speed will be conducted. Allocation will be controlled by a central randomization service and participants will be allocated to the two active intervention groups (1:1) using a permuted block randomization process. Seventy participants will be assigned to one of two 15-session training programs. In MLWP, one physiotherapist will supervise practice of various overground walking tasks. Instructions, feedback, and guidance will be provided in a manner that facilitates self-evaluation and problem solving. In BWSTT, training will emphasize repetition of the normal gait cycle while supported over a treadmill, assisted by up to three physiotherapists. Outcomes will be assessed by a blinded assessor at baseline, post-intervention and at 2-month follow-up. The primary outcome will be post-intervention comfortable gait speed. Secondary outcomes include fast gait speed, walking endurance, balance self-efficacy, participation in community mobility, health-related quality of life, and goal attainment. Groups will be compared using analysis of covariance with baseline gait speed strata as the single covariate. Intention-to-treat analysis will be used.
In order to direct clinicians, patients, and other health decision-makers, there is a need for a head-to-head comparison of different approaches to active, task-related walking training after stroke. We hypothesize that outcomes will be optimized through the application of a task-related training program that is consistent with key motor learning principles related to practice, guidance and feedback.
ClinicalTrials.gov # NCT00561405.
[Show abstract][Hide abstract] ABSTRACT: A goal of physical therapy interventions for children and youth with acquired brain injury (ABI) is the learning and relearning of motor skills. Therapists can apply theoretically derived and evidence-based motor learning strategies (MLSs) to structure the presentation of a task and organize the environment in ways that may promote effective, transfer-oriented practice. However, little is known about how MLSs are used in physical therapy interventions for children with ABI.
The purpose of this study was to develop and validate an observer-rated Motor Learning Strategy Rating Instrument (MLSRI) quantifying the application of MLSs in physical therapy interventions for children with ABI.
A multi-stage, iterative, item generation and reduction approach was used.
An initial list of MLS items was generated through literature review. Seven experts participated in face validation to confirm item comprehensiveness. In a content validation process, 12 physical therapists with pediatric ABI experience responded to a questionnaire evaluating feasibility and importance of items. Six physical therapy sessions with clients with ABI were videotaped at a children's rehabilitation center. The 12 physical therapists participated in a session where they: (1) rated session videos to test the MLSRI and (2) provided verbal feedback.
Revisions were made sequentially to the MLSRI based on these processes.
The MLSRI was scored during videotape observation rather than being given a live rating, which may be onerous in certain settings and may influence therapist or child behavior.
Further reliability investigations will determine whether the 33-item MLSRI is of help in documenting strategy use during intervention, as an evaluation tool in research, and as a knowledge transfer resource in clinical practice.
[Show abstract][Hide abstract] ABSTRACT: Evidence that the physical environment is a fall risk factor in older adults is inconsistent. The study evaluated and summarised evidence of the physical environment as a fall risk factor.
Eight databases (1985-2006) were searched. Investigators evaluated quality of two categories (cross-sectional and cohort) of studies, extracted and analysed data.
Cross-sectional: falls occur in a variety of environments; gait aids were present in approximately 30% of falls. COHORT: Home hazards increased fall risk (odds ratio (OR) = 1.15; 95% confidence interval (CI): 0.97-1.36) although not significantly. When only the high quality studies were included, the OR = 1.38 (95% CI: 1.03-1.87), which was statistically significant. Use of mobility aids significantly increased fall risk in community (OR = 2.07; 95% CI: 1.59-2.71) and institutional (OR = 1.77; 95% CI: 1.66-1.89) settings.
Home hazards appear to be a significant risk factor in older community-dwelling adults, although they may present the greatest risk for persons who fall repeatedly. Future research should examine relationships between mobility impairments, use of mobility aids and falls.