Hillel Finestone

Background: Commercial markerless motion capture (MMC) systems show promise for use in rehabilitation and have been validated for the assessment of various parameters. However, no prior studies have evaluated MMC systems to detect stance asymmetry. Objective: The objective of this study was to assess the accuracy and variability of the Jintronix Weight Shift Tool MMC system to estimate the percentage of weight borne on each foot. Methods: Twelve healthy younger adults, 12 healthy older adults, and 12 people living with stroke were recruited for this cross-sectional study. The percentage of weight borne on each foot was simultaneously recorded by the Weight Shift Tool and a validated pressure mat during 2 series (raising the arm to capture the recording and without arm raise) with left lean, right lean, and equal stance. Agreement between the Weight Shift Tool and the pressure mat was assessed using Bland-Altman analyses. Results: Bias was greatest for older adults for all stances except for right lean without arm raise. Variability was greatest for people living with stroke for all stances except for left lean with arm raise. On average, the limits of agreement were narrower during equal stance. Although bias between the Weight Shift Tool and the pressure mat was small to moderate (0.0%-11.7%), the limits of agreement were wide (12.8%-33.6% above and below the bias). Conclusions: The Weight Shift Tool is not clinically acceptable for the estimation of the percentage of weight on each foot due to high variability. Investigation of other MMC systems is required to confirm the validity of MMC for clinical assessment.

Background: Nonimmersive virtual reality training (NIVRT) can be used to continue rehabilitative exercise for stroke recovery at home after discharge from inpatient or outpatient therapy. Objective: The objectives of this randomized controlled feasibility trial were to assess home-based NIVRT as telerehabilitation with patients living with stroke, and its potential to improve standing function and gait. Methods: Patients approaching discharge from inpatient or outpatient stroke rehabilitation were randomly allocated to NIVRT or iPad interventions. NIVRT provided interactive games and exercises designed to improve balance, stepping, and aerobic capacity. iPad apps addressed cognition and fine motor skills. Participants were visited in their homes by a physiotherapist, taught to use the program, and asked to do 30 minutes of exercise 5 days a week for 6 weeks, asynchronously. Feasibility was assessed by measuring recruitment, adherence, ability to set up and learn NIVRT, enjoyment, intent to continue, perception of impact, and safety. Participants completed assessments of standing balance, gait, and general function, before and after the intervention, by a blinded assessor. Results: NIVRT participants (n=11; 10 male participants; mean age 64, SD 12 years) did an average of 26 sessions (total 700 minutes), while iPad participants (n=9; 6 male participants; mean age 61, SD 20 years) did an average of 33 sessions (total 1241 minutes). Space was tight in 5 homes. All but 1 participant learned NIVRT and progressed. Most enjoyed it and felt that it improved their recovery. There were no serious adverse events. Most assessments showed improvement over time for both groups. Conclusions: Home-based NIVRT is safe and feasible to continue rehabilitative exercise after discharge. More research on efficacy and effectiveness in this population is required. Trial Registration: ClinicalTrials.gov NCT03261713; https://clinicaltrials.gov/study/NCT03261713 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-019-3438-9

BACKGROUND Commercial markerless motion capture (MMC) systems show promise for use in rehabilitation and have been validated for the assessment of various parameters. However, no prior studies have evaluated MMC systems to detect stance asymmetry. OBJECTIVE The objective of this study was to assess the accuracy and variability of the Jintronix Weight Shift Tool MMC system to estimate the percentage of weight borne on each foot. METHODS Twelve healthy younger adults, 12 healthy older adults, and 12 people living with stroke were recruited for this cross-sectional study. The percentage of weight borne on each foot was simultaneously recorded by the Weight Shift Tool and a validated pressure mat during 2 series (raising the arm to capture the recording and without arm raise) with left lean, right lean, and equal stance. Agreement between the Weight Shift Tool and the pressure mat was assessed using Bland-Altman analyses. RESULTS Bias was greatest for older adults for all stances except for right lean without arm raise. Variability was greatest for people living with stroke for all stances except for left lean with arm raise. On average, the limits of agreement were narrower during equal stance. Although bias between the Weight Shift Tool and the pressure mat was small to moderate (0.0%-11.7%), the limits of agreement were wide (12.8%-33.6% above and below the bias). CONCLUSIONS The Weight Shift Tool is not clinically acceptable for the estimation of the percentage of weight on each foot due to high variability. Investigation of other MMC systems is required to confirm the validity of MMC for clinical assessment.

BACKGROUND Nonimmersive virtual reality training (NIVRT) can be used to continue rehabilitative exercise for stroke recovery at home after discharge from inpatient or outpatient therapy. OBJECTIVE The objectives of this randomized controlled feasibility trial were to assess home-based NIVRT as telerehabilitation with patients living with stroke, and its potential to improve standing function and gait. METHODS Patients approaching discharge from inpatient or outpatient stroke rehabilitation were randomly allocated to NIVRT or iPad interventions. NIVRT provided interactive games and exercises designed to improve balance, stepping, and aerobic capacity. iPad apps addressed cognition and fine motor skills. Participants were visited in their homes by a physiotherapist, taught to use the program, and asked to do 30 minutes of exercise 5 days a week for 6 weeks, asynchronously. Feasibility was assessed by measuring recruitment, adherence, ability to set up and learn NIVRT, enjoyment, intent to continue, perception of impact, and safety. Participants completed assessments of standing balance, gait, and general function, before and after the intervention, by a blinded assessor. RESULTS NIVRT participants (n=11; 10 male participants; mean age 64, SD 12 years) did an average of 26 sessions (total 700 minutes), while iPad participants (n=9; 6 male participants; mean age 61, SD 20 years) did an average of 33 sessions (total 1241 minutes). Space was tight in 5 homes. All but 1 participant learned NIVRT and progressed. Most enjoyed it and felt that it improved their recovery. There were no serious adverse events. Most assessments showed improvement over time for both groups. CONCLUSIONS Home-based NIVRT is safe and feasible to continue rehabilitative exercise after discharge. More research on efficacy and effectiveness in this population is required. CLINICALTRIAL ClinicalTrials.gov NCT03261713; https://clinicaltrials.gov/study/NCT03261713 INTERNATIONAL REGISTERED REPORT RR2-10.1186/s13063-019-3438-9

Stroke is one of the leading causes of disability worldwide. The efficacy of stroke recovery is determined by various factors, including patient adherence to their rehabilitation program. Effective communication between healthcare providers and patients is crucial for promoting patients’ adherence to rehabilitation programs. Aiming to support patient-healthcare provider communication during inpatient stroke rehabilitation, we (1) conducted semi-structured interviews with healthcare providers with expertise in inpatient stroke recovery to extract design requirements for visualizing stroke recovery progress. Using these design requirements, we (2) designed a data visualization tool representing stroke recovery. We (3) sought feedback on the visualization designs from healthcare providers and patients and integrated their feedback into the designs. Informed by the results of our studies, we provided several considerations for designing future visualization tools for patients and providers to communicate during inpatient stroke rehabilitation.

Problem addressed Chronic noncancer pain is often excessively managed with medications (most notably opioids) instead of nonpharmacologic options or multidisciplinary care—the gold standards. Objective of program To offer an effective alternative to pharmacologic management of chronic noncancer pain in primary care. Program description Patients 18 years of age or older with chronic noncancer pain were referred by family physicians or nurse practitioners in a family health team (outpatient, multidisciplinary clinic) in Ottawa, Ont. A registered nurse used the Pain Explanation and Treatment Diagram with patients, taught self-management skills (related to habits [smoking, consumption of alcohol, diet], exercise, sleep, ergonomics, and psychosocial factors), and referred patients to relevant resources. Conclusion A nurse-led chronic pain program, initiated without extra funding, was successfully integrated into a primary care setting. Among the participating patients in the pilot project, outcomes related to pain intensity, pain interference with daily living, and opioid use were encouraging. This program could serve as a model for improving chronic noncancer pain management in primary care. Résumé Problème à l’étude La douleur chronique non cancéreuse est souvent gérée à l’excès au moyen de médicaments (surtout des opioïdes) plutôt qu’en ayant recours à des options non pharmacologiques ou à des soins multidisciplinaires, qui sont les normes d’excellence. Objectif du programme Offrir une alternative efficace à la prise en charge pharmacologique de la douleur chronique non cancéreuse en soins primaires. Description du programme Des patients de 18 ans et plus souffrant de douleur chronique non cancéreuse ont été aiguillés par des médecins de famille ou des infirmières praticiennes vers une équipe de santé familiale (clinique multidisciplinaire en consultation externe) à Ottawa (Ontario). Une infirmière autorisée a utilisé avec les patients le Pain Explanation and Treatment Diagram (diagramme d’explication et de traitement de la douleur), leur a transmis des compétences en autogestion (liées aux habitudes [tabagisme, consommation d’alcool, alimentation], à l’activité physique, à l’hygiène du sommeil, à l’ergonomie et aux facteurs psychosociaux) et a demandé pour eux des consultations auprès des ressources pertinentes. Conclusion Un programme d’autogestion de la douleur chronique, dirigé par une infirmière et mis sur pied sans financement supplémentaire, a été intégré avec succès dans un milieu de soins primaires. Chez les participants au projet pilote, les résultats relatifs à l’intensité de la douleur, à l’interférence de la douleur avec les activités de la vie quotidienne et à l’usage d’opioïdes étaient encourageants. Ce programme pourrait servir de modèle pour améliorer la gestion de la douleur chronique non cancéreuse en soins primaires.

Background: Falls in the inpatient stroke population are common, resulting in increased morbidity and slow rehabilitation progress. Falls may result from stroke‐specific neurologic deficits; however, assessment of these deficits is lacking in many fall screening tools.Objective: To compare the ability to predict falls of the Stroke Assessment of Fall Risk (SAFR) tool, which includes items related to stroke‐specific neurologic deficits, and the commonly used Morse Fall Scale, which does not include these items.Design: Prospective cohort study.Setting: Inpatient tertiary stroke rehabilitation unit.Participants: Patients (N = 220) with acute stroke.Main Outcome Measures: Falls were captured by the medical records from January 2017 to September 2018. Logistic regression analysis evaluated both screening tools for predicting falls by calculating sensitivity, specificity, area under the receiver operating characteristic (AUC‐ROC) curve, and odds ratio (OR). We compared SAFR and Morse mean scores between fallers and non‐fallers using t‐tests.Results: Forty‐eight (21.8%) patients experienced ≥1 fall. SAFR, but not Morse, scores showed a statistically significant difference between fallers and non‐fallers (P = .001 vs P = .24, respectively). Higher SAFR score was associated with higher odds of falls (OR 1.36, 95% CI [1.12, 1.64]), whereas Morse was not (OR 1.04, 95% CI [0.97, 1.12]). SAFR showed a statistically significant difference in hemi‐neglect between fallers and non‐fallers (P = .03). Sensitivity and specificity of SAFR were 47.9% and 76.7%, vs 45.8% and 68.0% for Morse, respectively. SAFR positive predictive value and negative predictive value were 36.5% and 84.1%, respectively, similar to Morse (28.6% and 81.8%). The AUC‐ROC was 0.65 for SAFR and 0.56 for Morse.Conclusions: SAFR was significantly associated with fall risk and had better discrimination between fallers and non‐fallers than Morse. The neurologic‐specific hemi‐neglect component of SAFR, a component not present on the Morse, was a fall risk factor. Further research evaluating the predictive value of fall scales that include neurologic deficits is needed.

Background: Virtual reality training (VRT) is engaging and may enhance rehabilitation intensity. Only one previous study has looked at its use to improve sitting balance after stroke.Objective: To determine if supplemental sitting balance exercises, administered via VRT, improve control of sitting balance and upper extremity function in stroke rehabilitation inpatients.Design: Assessor‐blinded, placebo‐controlled randomized controlled trial.Setting: Stroke inpatient rehabilitation unit.Participants: Seventy‐six participants (out of 130 approached) with subacute stroke who could not stand independently were randomized to experimental and control groups. Sixty‐nine completed the study.Interventions: The experimental group did VRT that required leaning and reaching, whereas the control group had their trunk restrained and performed VRT that involved only small upper extremity movements to minimize trunk movement. Both groups performed 10‐12 sessions of 30‐45 minutes. Participants were assessed pre, post, and 1 month after the sessions by a blinded examiner.Outcome Measures: Function in Sitting Test (FIST, primary outcome measure); Ottawa Sitting Scale; Reaching Performance Scale; Wolf Motor Function Test (WMFT).Results: Thirty‐three participants completed the experimental intervention and 36 the control. Pre/post differences for FIST were 3.4 (confidence interval [CI] 0.5;6.3) for the experimental group and 5.3 (2.9;7.7) for the control group. There was a significant improvement over time (adjusted for multiple comparisons, P < .006) on most outcome measures except the WMFT Performance Time Scale (control group; P = .007) and grip strength (P = .008); there were no differences between groups (P > .006).Conclusions: Siting balance outcomes were similar for both groups; therefore, this study does not support the use of sitting balance exercises provided via VRT for the rehabilitation of sitting balance after stroke. However, because it is only the second study to investigate VRT for sitting balance and upper extremity function, more research, using more challenging exercises and a greater treatment intensity, is required before definitive conclusions are made.

Virtual reality training (VRT) uses computer software to track a user’s movements and allow him or her to interact with a game presented on a television screen. VRT is increasingly being used for the rehabilitation of arm function, balance and walking after stroke. Patients often require ongoing therapy post discharge from inpatient rehabilitation. Outpatient therapy may be limited or inaccessible due to waiting lists, transportation issues, distance etc.; therefore, home-based VRT could provide the required therapy in a more convenient and accessible setting. The objectives of this parallel randomized feasibility trial are to determine (1) the feasibility of using VRT in the home post stroke and (2) the feasibility of a battery of quantitative and qualitative outcome measures of stroke recovery. Forty patients who can stand for at least 2 min and are soon to be discharged from inpatient or outpatient rehabilitation post stroke are being recruited in Ottawa, Canada and being randomized to control and experimental groups. Participants in the experimental group use home-based VRT to do rehabilitative exercises for standing balance, stepping, reaching, strengthening and gentle aerobic fitness. Control group participants use an iPad with apps selected to rehabilitate cognition, hand fine motor skills and visual tracking/scanning. Both groups are instructed to perform 30 min of exercise 5 days a week for 6 weeks. VRT intensity and difficulty are monitored and adjusted remotely. Weekly telephone contact is made with all participants. Ability to recruit participants, ability to handle the technology and learn the activities, compliance, safety, enjoyment, perceived efficacy and cost of program delivery will be assessed. A battery of assessments of standing balance, gait and community integration will be assessed for feasibility of completion within this population and potential for improvement following the intervention. Effect sizes will be calculated. The results of this study will be used to support the creation of a definitive randomized controlled trial on the efficacy of home-based VRT for rehabilitation post stroke. ClinicalTrials.gov, NCT03261713 . Registered on 21 August 2017. Registration amended on 1 June 2018 to decrease enrollment from 40 to 20 due to a cut in study funding and difficulty recruiting participants.