Verna Stavric

Background Measures of hemiparetic ankle dorsiflexor muscle strength and rate of force development (RFD) are often used to determine the efficacy of rehabilitation interventions after stroke. However, evidence supporting the reliability of these measures is limited. This brief report provides a secondary analysis investigating the between-session reliability of isometric ankle dorsiflexor muscle strength, rate of force development (RFD), and tibialis anterior electromyography (TA EMG), in people with chronic stroke. Method Participants (n=15) completed three maximal isometric contractions of the ankle dorsiflexor muscles as fast as possible using a rigid dynamometer. Tests were repeated seven days later. Outcomes included ankle dorsiflexor isometric maximal voluntary contraction (MVC), RFD in the first 200ms (RFD200ms), time to reach 90% MVC, and peak TA EMG. Data were analysed for 13 participants using intra-class correlation coefficients (ICC) and standard error of the measure percentage (SEM%). Results Reliability was higher when analysing the mean of three trials rather than the best of three trials. There was excellent reliability for isometric dorsiflexor MVC (ICC 0.97 [95% CI 0.92, 0.99], SEM% 7%). However, for other outcomes, while the ICC indicated good reliability, the lower bound of the 95% confidence interval of the ICC fell in the moderate range for TA EMG (ICC 0.86 [95% CI 0.60, 0.96], SEM% 25%) and time to reach 90% MVC (ICC 0.80 [95% CI 0.53, 0.93], SEM% 23%) and in the poor range for dorsiflexor RFD200ms (ICC 0.79 [95% CI 0.48, 0.92], SEM% 24%). Conclusion The findings raise concerns about the reliability of measures of rapid force production in the dorsiflexor muscles after stroke. Given the functional significance of the ankle dorsiflexors, larger studies should be conducted to further investigate these concerns and explore reliable methods for measuring rapid force production in the hemiparetic dorsiflexor muscles.

Shoulder pain is prevalent in people living with spinal cord injury. Technology and digital rehabilitation tools are increasingly available, but this has not yet included the provision of a self-guided exercise intervention focused on managing shoulder pain for people living with spinal cord injury. We drew on the person-based approach (PBA) to intervention development to design a Shoulder Pain Intervention delivered over the interNet (SPIN) to address this gap. However, in preparation for the design process, we found very few published examples of how the PBA had been operationalized. The aim of this paper is to provide a detailed explanation of our approach and how we operationalized the PBA in the design of SPIN to maximize relevance and engagement. Our design process followed the key PBA steps, combining additional evidence and theoretical components. Each step ensured that guiding principles were formulated and followed to maximize the probability that SPIN would be fit for purpose. We followed 3 steps: (1) we drew on themes from preparatory research (existing and primary) to identify the key behavioral issues, needs and challenges, and existing features to form the basis of SPIN design; (2) we formatted guiding principles that included articulating specific design objectives to provide a framework to identify system requirements; and (3) we selected and refined intervention features using existing literature, behavioral theory, and tools such as the “Behaviour Change Wheel.” We have designed SPIN by incorporating a deep understanding of the users’ needs and best available evidence to maximize engagement and positive outcomes. In this paper, we have made clear how we operationalized the PBA phases, including how existing evidence, theory, tools, and methods were leveraged to support the PBA process. In explicating our process, we have provided a blueprint to guide future researchers using this approach.

Study design: Development of a Clinical Practice Guideline (CPG). Objective: To develop a CPG for the physiotherapy management of people with Spinal Cord Injuries (SCI). Setting: Australia and New Zealand. Methods: Systematic reviews of randomised controlled trials (RCTs) of physiotherapy interventions for adults with SCI were conducted to address over 100 clinical questions. Questions were decided a priori and written in PICO format (Participant, Intervention, Comparison and Outcome). Meta-analyses were conducted across trials that made similar comparisons. A Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence certainty and formulate recommendations. A Guideline panel made evidence recommendations and consensus-based opinion statements based on a standardised process that included voting. Results: Seventy-six RCTs met the inclusion criteria for the systematic reviews. These RCTs informed 20 meta-analyses that were used in the development of the CPG. More than one hundred evidence recommendations and consensus-based opinion statements across 13 categories of physiotherapy interventions were made by the panel. Conclusion: The Australian and New Zealand CPG for the Physiotherapy Management of people with SCI provide clear and readily accessible guidance to physiotherapists based on evidence and consensus of clinical experts. The Guideline is available at www.sciptguide.com.

Background: Usability has been touted as one determiner of success of mobile health (mHealth) interventions. Multiple systematic reviews of usability assessment approaches for different mHealth solutions for physical rehabilitation are available. However, there is a lack of synthesis in this portion of the literature, which results in clinicians and developers devoting a significant amount of time and effort in analyzing and summarizing a large body of systematic reviews. Objective: This study aims to summarize systematic reviews examining usability assessment instruments, or measurements tools, in mHealth interventions including physical rehabilitation. Methods: An umbrella review was conducted according to a published registered protocol. A topic-based search of PubMed, Cochrane, IEEE Xplore, Epistemonikos, Web of Science, and CINAHL Complete was conducted from January 2015 to April 2023 for systematic reviews investigating usability assessment instruments in mHealth interventions including physical exercise rehabilitation. Eligibility screening included date, language, participant, and article type. Data extraction and assessment of the methodological quality (AMSTAR 2 [A Measurement Tool to Assess Systematic Reviews 2]) was completed and tabulated for synthesis. Results: A total of 12 systematic reviews were included, of which 3 (25%) did not refer to any theoretical usability framework and the remaining (n=9, 75%) most commonly referenced the ISO framework. The sample referenced a total of 32 usability assessment instruments and 66 custom-made, as well as hybrid, instruments. Information on psychometric properties was included for 9 (28%) instruments with satisfactory internal consistency and structural validity. A lack of reliability, responsiveness, and cross-cultural validity data was found. The methodological quality of the systematic reviews was limited, with 8 (67%) studies displaying 2 or more critical weaknesses. Conclusions: There is significant diversity in the usability assessment of mHealth for rehabilitation, and a link to theoretical models is often lacking. There is widespread use of custom-made instruments, and preexisting instruments often do not display sufficient psychometric strength. As a result, existing mHealth usability evaluations are difficult to compare. It is proposed that multimethod usability assessment is used and that, in the selection of usability assessment instruments, there is a focus on explicit reference to their theoretical underpinning and acceptable psychometric properties. This could be facilitated by a closer collaboration between researchers, developers, and clinicians throughout the phases of mHealth tool development. Trial Registration: PROSPERO CRD42022338785; https://www.crd.york.ac.uk/prospero/#recordDetails

UNSTRUCTURED Shoulder pain is prevalent in people living with spinal cord injury (pwSCI). Technology and digital rehabilitation tools are increasingly available, but this has not yet included provision of a self-guided exercise intervention focused on managing shoulder pain for pwSCI. We drew on the person-based approach (PBA) to intervention development, to design a Shoulder Pain Intervention delivered over the interNet (SPIN) to address this gap. However, in preparation for the design process we found few published examples of how the PBA had been operationalized. The aim of this paper is to provide a detailed explanation of our approach and how we operationalized the PBA in the design of SPIN to maximize relevance and engagement. Our design process followed the key PBA steps, combining additional evidence and theoretical components. Each step ensured guiding principles were formulated and followed to maximize the probability that SPIN would be fit for purpose. We followed three steps: 1) we drew from themes from preparatory research (existing and primary) to identify the key behavioral issues, needs and challenges, and existing features to form the basis of SPIN design; 2) we formatted guiding principles that included articulating specific design objectives to provide a framework to identify system requirements; and 3) we selected and refined intervention features using existing literature, behavioral theory, and tools such as the ‘Behaviour Change Wheel’. We have designed SPIN by incorporating a deep understanding of the users’ needs and best available evidence, to maximize engagement and positive outcomes. In this paper we have made clear how we operationalized the PBA phases, including how existing evidence, theory, tools, and methods were leveraged to support the PBA process. In explicating our process, we have provided a blueprint to provide guidance to future researchers using this approach.

Background Measures of hemiparetic ankle dorsiflexor muscle strength and rate of force development (RFD) are often used to determine the efficacy of rehabilitation interventions after stroke. However, evidence supporting the reliability of these measures is limited. This brief report provides a secondary analysis investigating the between-session reliability of isometric ankle dorsiflexor muscle strength, rate of force development (RFD), and tibialis anterior electromyography (TA EMG), in people with chronic stroke. Method Participants (n=15) completed three maximal isometric contractions of the ankle dorsiflexor muscles as fast as possible using a rigid dynamometer. Tests were repeated seven days later. Outcomes included ankle dorsiflexor isometric maximal voluntary contraction (MVC), RFD in the first 200ms (RFD200ms), time to reach 90% MVC, and peak TA EMG. Data were analysed for 13 participants using intra-class correlation coefficients (ICC) and standard error of the measure percentage (SEM%). Results Reliability was higher when analysing the mean of three trials rather than the best of three trials. There was excellent reliability for isometric dorsiflexor MVC (ICC 0.97 [95% CI 0.92, 0.99], SEM% 7%). However, for other outcomes, while the ICC indicated good reliability, the lower bound of the 95% confidence interval of the ICC fell in the moderate range for TA EMG (ICC 0.86 [95% CI 0.60, 0.96], SEM% 25%) and time to reach 90% MVC (ICC 0.8 [95% CI 0.53, 0.93], SEM% 23%) and in the poor range for dorsiflexor RFD200ms (ICC 0.79 [95% CI 0.48, 0.92], SEM% 24%). Conclusion The findings raise concerns about the reliability of measures of rapid force production in the dorsiflexor muscles after stroke. Given the functional significance of the ankle dorsiflexors, larger studies should be conducted to further investigate these concerns and explore reliable methods for measuring rapid force production in the hemiparetic dorsiflexor muscles.

Background: Measures of hemiparetic ankle dorsiflexor muscle strength and rate of force development (RFD) are often used to determine the efficacy of rehabilitation interventions after stroke. However, evidence supporting the reliability of these measures is limited. This brief report provides a secondary analysis investigating the between-session reliability of isometric ankle dorsiflexor muscle strength, rate of force development (RFD), and tibialis anterior electromyography (TA EMG), in people with chronic stroke. Method: Participants (n=15) completed three maximal isometric contractions of the ankle dorsiflexor muscles as fast as possible using a rigid dynamometer. Tests were repeated seven days later. Outcomes included ankle dorsiflexor isometric maximal voluntary contraction (MVC), RFD in the first 200ms (RFD200ms), time to reach 90% MVC, and peak TA EMG. Data were analysed for 13 participants using intra-class correlation coefficients (ICC) and standard error of the measure (SEM). Results: When the mean of three trials was analysed, there was excellent reliability for isometric dorsiflexor MVC (ICC 0.97 [95% CI 0.92-0.99]), moderate reliability for TA EMG (ICC 0.86 [0.60-0.96]) and time to reach 90% MVC (ICC 0.8 [0.53-0.93]) and poor reliability for dorsiflexor RFD200ms (ICC 0.79 [0.48-0.92]). Conclusion: Given the functional significance of the ankle dorsiflexors, future research should investigate more reliable methods for measuring rapid force production in the dorsiflexor muscles after stroke.

Study design: Qualitative study. Objectives: The benefits of exercise to reduce shoulder pain in people with spinal cord injury (SCI) are well documented. Digital health interventions offer a potential solution to overcome barriers to access rehabilitation support for exercise. The aim of this project was to gain people’s perspectives to inform the development of a self-guided web-based exercise intervention. Shoulder Pain Intervention delivered over the interNet (SPIN) is a self-guided web-based intervention to prescribe, monitor, and progress evidence-based exercises for people living with SCI and shoulder pain. Setting: Community in Auckland, New Zealand. Methods: The Person-Based Approach was used as the framework. Using an Interpretive Descriptive methodology, data were collected in individual and focus group interviews, exploring participants’ perceptions of this intervention idea. Data were analysed using conventional content analysis. Results: Sixteen participants took part and asked Is it right for me?. This had three main sub-themes. Should I use it?, whether I believe it will work for me right now; Can I use it?, whether I can operate the intervention competently and confidently and Will I use it?, whether it will be responsive to my unique needs, and keep me coming back. Conclusions: Participants expressed their expectations and tipping points when considering using an intervention like this. These findings will inform and guide design and development of an acceptable technology-based intervention to increase the likelihood of engagement with a self-guided web-based exercise programme. The model developed from these themes could be used to inform future self-guided intervention development.

Objective: The aim of this systematic review was to determine the effectiveness of self-guided digital physical activity (PA) and exercise interventions to improve physical activity and exercise (PA&E) outcomes for people living with chronic health conditions. Digital health interventions, especially those with minimal human contact, may offer a sustainable solution to accessing ongoing services and support for this population. Methods: A comprehensive and systematic search was conducted up to December 2021, through seven databases, for randomized trials that evaluated the effect of self-guided web- or internet-based PA interventions on physical activity or exercise outcomes. Included studies had to have interventions with minimal human contact and interaction with participants needed to be automatically generated. All studies were screened for eligibility and relevant data were extracted. Two independent reviewers assessed the risk of bias using the Cochrane risk of bias tool. Standardized mean differences and 95% confidence intervals (CI) were calculated. PA data were pooled, and forest plots were generated. Results: Sixteen studies met the eligibility criteria and included a total of 2,439 participants. There was wide variation in health conditions and intervention characteristics in mode and parameters of delivery, and in the application of theory and behavioral strategies. Self-reported PA in the intervention group was greater than controls at the end of the intervention [standardized mean difference (SMD) 0.2, 95% CI = 0.1, 0.3] and at follow up (SMD 0.3, 95% CI 0.2–0.5). The difference in objectively measured PA was small and non-significant (SMD 0.3, 95% CI −0.2 to 0.9). All interventions included behavioral strategies and ten of the sixteen were underpinned by theory. Conclusions: Self-guided digital PA&E interventions provided a positive effect on PA immediately after the intervention. An unexpected and positive finding was a sustained increase in PA at follow-up, particularly for interventions where the behavioral strategies were underpinned by a theoretical framework. Interventions with minimal contact have the potential to support sustained PA engagement at least as well as interventions with supervision. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42019132464.