Rosalyn Stanton

Biofeedback improves activities of the lower limb after stroke: a systematic review

QUESTION Is biofeedback during the practice of lower limb activities after stroke effective in improving performance of those activities, and are any benefits maintained after intervention ceases? DESIGN Systematic review with meta-analysis of randomised trials. PARTICIPANTS People who have had a stroke. INTERVENTION Biofeedback during practice of sitting, standing up, standing, or walking. OUTCOME MEASURES Continuous measures of activity congruent with the activity trained. RESULTS 22 trials met the inclusion criteria and 19 contained data suitable for analysis. Effect sizes were calculated as standardised mean differences because different outcome measures were used. Since inclusion of all trials produced substantial statistical heterogeneity, only trials with a PEDro score >4 (11 trials) were included in the final analysis (mean PEDro score 5.7). In the short-term, biofeedback improved lower limb activities compared with usual therapy/placebo (SMD=0.49, 95% CI 0.22 to 0.75). Lower limb activities were still improved compared with usual therapy/placebo 1 to 5 months after the cessation of intervention (SMD=0.41, 95% CI 0.06 to 0.75). CONCLUSION Augmenting feedback through the use of biofeedback is superior to usual therapy/placebo at improving lower limb activities in people following stroke. Furthermore, these benefits are largely maintained in the longer term. Given that many biofeedback machines are relatively inexpensive, biofeedback could be utilised more widely in clinical practice.

What is the probability of patients who are nonambulatory after stroke regaining independent walking? A systematic review

Patients after stroke who are nonambulatory require resources, and independent walking becomes a major determinant of the ability to participate in activities of daily living. Our objective was to determine the probability of walking for patients who are nonambulatory in the first month after stroke. We performed a systematic review and meta-analysis of consecutive, prospective studies of nonambulatory patients within the first month after stroke in rehabilitation and acute units. The outcomes were the probability of achieving independent walking at three-, six- and 12 months after stroke. Twenty-six studies were included in the review. Seventeen studies comprising 2856 participants were entered into meta-analyses. For initially nonambulatory stroke patients managed in a rehabilitation unit, the probability of independent walking was 0·60 (95% CI 0·47–0·74, 1373 participants) at three-months, 0·65 (95% CI 0·53–0·77, 444 participants) at six-months and 0·91 (95% CI 0·81–1·00, 24 participants) at 12 months. For patients managed in an acute unit, the probability of independent walking was 0·39 (95% CI 0·27–0·52, 634 participants) at three-months, 0·69 (95% CI 0·46–0·92, 405 participants) at six-months and 0·74 (95% CI 0·59–0·88, 34 participants) at 12 months. 60% of patients managed in a rehabilitation unit who are nonambulatory in the first month after stroke will regain independent walking compared with 39% of those managed in an acute unit. This information can be used clinically to make decisions about allocation of rehabilitation resources, education of patients and carers, and for discharge planning.

The Physiotherapy eSkills Training Online resource improves performance of practical skills: a controlled trial

BackgroundE-learning is a common and popular mode of educational delivery, but little is known about its effectiveness in teaching practical skills. The aim of this study was to determine whether the Physiotherapy eSkills Training Online resource in addition to usual teaching improved the performance of practical skills in physiotherapy students.MethodThis study was a non-randomised controlled trial. The participants were graduate entry physiotherapy students enrolled in consecutive semesters of a neurological physiotherapy unit of study. The experimental group received the Physiotherapy eSkills Training Online resource as well as usual teaching. The Physiotherapy eSkills Training Online resource is an online resource incorporating (i) video-clips of patient-therapist simulations; (ii) supportive text describing the aim, rationale, equipment, key points, common errors and methods of progression; and (iii) a downloadable PDF document incorporating the online text information and a still image of the video-clip for each practical skill. The control group received usual teaching only. The primary outcomes were the overall performance of practical skills as well as their individual components, measured using a practical examination.ResultsThe implementation of the Physiotherapy eSkills Training Online resource resulted in an increase of 1.6 out of 25 (95% CI −0.1 to 3.3) in the experimental group compared with the control group. In addition, the experimental group scored 0.5 points out of 4 (95% CI 0 to 1.1) higher than the control group for ‘effectiveness of the practical skill’ and 0.6 points out of 4 (95% CI 0.1 to 1.1) higher for ‘rationale for the practical skill’.ConclusionThere was improvement in performance of practical skills in students who had access to the Physiotherapy eSkills Training Online resource in addition to usual teaching. Students considered the resource to be very useful for learning.

Feedback Received While Practicing Everyday Activities During Rehabilitation After Stroke: An Observational Study

BACKGROUND AND PURPOSE The provision of feedback is important for effective skill learning. The purpose of this study was to examine the nature of feedback provided during the practice of everyday activities (such as standing up, walking, and reaching and grasping objects) during stroke rehabilitation, both when the therapist was present and when the patient was practicing alone. METHOD DESIGN A cross-sectional observational study of the feedback received during rehabilitation by people who had had a stroke was conducted. Forty unique patient-therapist dyads were observed during 30 minutes of actual practice of everyday activities with data collected through behavioural mapping. The following was recorded: the activity practiced, whether the therapist was present, whether feedback was provided verbally or by equipment, and the content of feedback. PARTICIPANTS A sample of all therapists providing rehabilitation within one Australian health service and their patients who had had a stroke. MEASURES Quantity, frequency, mode (verbal or equipment) and content (information feedback, motivational statements, unrelated or none) of feedback during the practice of everyday activities were determined. RESULTS For 68% of the time that patients were practicing activities, they received ≥1 occasion of feedback/minute. When the therapist was present, the frequency of motivational statements was more than four times greater, at 1.32 (SD 0.6) occasions/minute, than information feedback. For 25% of the time, the therapist was not present, and no feedback was provided. CONCLUSION Given the importance of specific content for learning, therapists could replace some motivational statements with information feedback. When practicing alone, information feedback could be provided by commercially available biofeedback or customized equipment.

Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke: a systematic review

QUESTION Is biofeedback during the practice of lower limb activities after stroke more effective than usual therapy in improving those activities, and are any benefits maintained beyond the intervention? DESIGN Systematic review with meta-analysis of randomised trials with a PEDro score > 4. PARTICIPANTS People who have had a stroke. INTERVENTION Biofeedback (any type delivered by any signal or sense) delivered concurrently during practice of sitting, standing up, standing or walking compared with the same amount of practice without biofeedback. OUTCOME MEASURES Measures of activity congruent with the activity trained. RESULTS Eighteen trials including 429 participants met the inclusion criteria. The quality of the included trials was moderately high, with a mean PEDro score of 6.2 out of 10. The pooled effect size was calculated as a standardised mean difference (SMD) because different outcome measures were used. Biofeedback improved performance of activities more than usual therapy (SMD 0.50, 95% CI 0.30 to 0.70). CONCLUSION Biofeedback is more effective than usual therapy in improving performance of activities. Further research is required to determine the long-term effect on learning. Given that many biofeedback machines are relatively inexpensive, biofeedback could be utilised widely in clinical practice. [Stanton R, Ada L, Dean CM, Preston E (2016) Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke: a systematic review.Journal of Physiotherapy63: 11-16].

Promoting physical activity after stroke via self-management: a feasibility study

Abstract Background: Many people with mild disability after stroke are physically inactive despite the risk of recurrent stroke. A self-management program may be one strategy to increase physical activity in stroke survivors. Objectives: To investigate the feasibility of a self-management program, and determine whether self-management can increase daily physical activity levels and self-efficacy for exercise, decrease cardiovascular risk, and improve walking ability, participation, and quality of life in people with mild disability after stroke. Method: A Phase I, single-group, pre-post intervention study was carried out with twenty stroke survivors who had mild disability and were discharged directly home from acute stroke units. A self-management program was delivered via five home-based sessions over 3 months, incorporating: education, goal setting, barrier identification, self-monitoring, and feedback. Feasibility of the intervention was determined by examining adherence, duration, usefulness, and safety. Clinical outcomes were amount of physical activity (duration of moderate physical activity in min/day and counts of physical activity in steps/day), self-efficacy, cardiovascular risk, walking ability, participation, and quality of life. Results: The intervention was feasible with 96% of sessions being delivered, each taking less than an hour (41 min, SD 12). Participants perceived the self-management program to be useful and there were few adverse events. At 3 months, participants completed 27 min/day (95% CI 4–49) more moderate physical activity than at baseline and 16 min/day (95% CI −10 to 42) at 6 months. Conclusion: Self-management appears to be feasible and has the potential to increase physical activity in people with mild disability after stroke. A Phase II randomized trial is warranted.

Lap-tray and triangular sling are no more effective than a hemi-sling in preventing shoulder subluxation in those at risk early after stroke: a randomised trial.

BACKGROUND Shoulder subluxation is a common secondary impairment of the upper limb following stroke. A range of supportive devices are used in rehabilitation to prevent shoulder subluxation, including hemi-slings and firm supports, such as arm troughs, however, there is little evidence regarding their efficacy. AIM To determine whether a modified lap-tray during sitting and a triangular sling during standing is more effective than a hemi-sling in preventing shoulder subluxation, pain, contracture and upper limb activity limitation after stroke. DESIGN A prospective, randomized trial with concealed allocation, assessor blinding and intention-to-treat analysis. SETTING Three inpatient rehabilitation units in Australia and Norway. POPULATION Forty-six acute stroke survivors within 3 weeks of stroke who were at risk of subluxation. METHODS The experimental group used a modified lap-tray while sitting and a triangular sling while standing to support the affected arm for four weeks. The control group used a hemi-sling while sitting and standing. The primary outcome was amount of shoulder subluxation on X-ray. Secondary outcomes were upper limb activity, pain and contracture. RESULTS There was no significant difference between groups in terms of shoulder subluxation (MD -3 mm, 95% CI -8 to 3). There was a trend for the experimental group to develop less pain at rest (MD -0.7 out of 10, 95% CI -2.2 to 0.8) and during shoulder external rotation (MD -1.7 out of 10, 95% CI -3.7 to 0.3) and a trend towards having less contracture of shoulder external rotation (MD -10 deg, 95% CI -22 to 2). There was no significant difference between groups in terms of other contractures and activity of the upper limb. CONCLUSIONS A lap-tray during sitting combined with a triangular sling during standing is no more effective than a hemi-sling in preventing subluxation, pain, contracture and activity limitation in acute stroke survivors at risk of shoulder subluxation. CLINICAL REHABILITATION IMPACT The use of a lap-tray during sitting and triangular sling during standing is not indicated as an alternative to the hemi-sling to prevent shoulder subluxation in patients after stroke, so alternative strategies with proven efficacy, such as electrical stimulation, should be considered.

The effect of information feedback on training standing up following stroke: A feasibility study

Habitat loss is viewed as a primary cause of pollinator population declines. Managed meadows and gardens provide benefits to wildlife, including pollinating insects. Given the interest in planting flowers for pollinators, lists of recommended varieties have been produced by professional organizations and amateurs alike. These lists serve as a good starting point but are often not grounded in empirical data. Coreopsis is a popular garden plant and a frequent component of commercial pollinator seed mixes. The aim of this study is to compare the ecological role of commercially available Coreopsis plants. It is hypothesized that pollinating insects exhibit preferences based on color and other floral traits. To address this question 4 species of wildtype Coreopsis and 13 cultivars were evaluated for their attractiveness to pollinating insects. Data was collected between June and August 2014 from Coreopsis plants in the Mount Cuba Center trial garden (Hockessin, Delaware). Flower visitors were observed and recorded to morphospecies. To assess which visual floral traits were correlated with pollinator visitation, inflorescence diameter, inflorescences per plant, inflorescence color and pattern, plant height, and number of flowers per inflorescence were measured. Correlating visitation with floral traits may explain the differential attraction of pollinators to Coreopsis flowers. David Ray The Nature Conservancy, MD/DC Chapter Atlantic White-Cedar Stand History and Rehabilitation Prospects Abstract: Efforts to understand the history and dynamics of Atlantic white-cedar (AWC) communities within the Nassawango Creek Watershed were undertaken to help inform various aspects of projects aimed at reestablishing and rehabilitating AWC across the ownership. We used a combination of local knowledge, aerial imagery and ancillary GIS layers (e.g. soils and wetlands), and extensive field transects to identify areas where AWC either currently exists or was known to have been present historically. This information has been assembled using GPS/GIS mapping and spatial analysis, through a dendrochronological study (analysis of tree rings), and observations of natural regeneration. Results presented in this poster suggest there is considerable potential to rehabilitate degraded AWC stands, an aspect of this effort that we have recently begun working on. Efforts to understand the history and dynamics of Atlantic white-cedar (AWC) communities within the Nassawango Creek Watershed were undertaken to help inform various aspects of projects aimed at reestablishing and rehabilitating AWC across the ownership. We used a combination of local knowledge, aerial imagery and ancillary GIS layers (e.g. soils and wetlands), and extensive field transects to identify areas where AWC either currently exists or was known to have been present historically. This information has been assembled using GPS/GIS mapping and spatial analysis, through a dendrochronological study (analysis of tree rings), and observations of natural regeneration. Results presented in this poster suggest there is considerable potential to rehabilitate degraded AWC stands, an aspect of this effort that we have recently begun working on. POSTER PRESENTATIONS Larry Murrell Air Infusion removes Biomat-Lining of Septic Stone-Filled Trench in less than Six Hours: New Protocol to Restore Impaired Septic System Function It is widely recognized that soil decline of residential properties in New Jersey follows a pattern of 1) waterlogging, 2) anaerobic-bacteria-generated toxins impairing plant health, 3) compaction, 4) rapid erosion, and 5) rising water tables. Use of pesticides and inorganic fertilizers accelerate the compaction and erosion in a vicious cycle. These negative impacts on soil health have a domino effect causing chronically high, usually perched water tables, contributing to water-logging and basement flooding. What is not widely recognized is that the soil surrounding the trenches of septic systems, also called drainfields or laterals, is highly susceptible to water-logging and the increasing water tables found all along the Eastern Seaboard. A high water table for septic fields promotes rapid formation of a 1-2” thick black biomat that forms in the surrounding soil. This biomat leads to compromised water flow from the stone-filled trench, or drainfield, into the septic field, and eventually to complete failure of the septic system. We have found that an effective way to attack the biomat of a septic system in a one-step procedure that destroys the biomat and allows the entrained waste water in the gravel train to surge into the soil of the septic field, literally saturating the soil of the field. Once this entrained waste water is transferred to the soil, natural aerobic bacteria digest the remains of the biomat and any toxins present in the field. This new protocol is effective because it saturates void spaces in the trench, and then saturates the entire septic field with aerated water. The restoration process is cost effective and takes only 6 8 hours to complete for each trench of a septic system. With our protocol, the entire biomat is destroyed by uniform air-infusion to the entire trench, and subsequently to the entire field. Samantha Nestory and Judy HoughGoldstein University of Delaware Entomology and Wildlife Ecology Mechanical control methods for Japanese stiltgrass (Microstegium vimineum) Abstract: Japanese stiltgrass (Microstegium vimineum) is an invasive grass that poses a major threat to native biodiversity and restoration efforts in invaded areas. While there are recommended control methods, few studies have scientifically quantified the efficacy of these control methods. A previous study determined that mowing any time after midsummer reduces the M. vimineum population, so we expanded upon this study to determine the effect of mowing height on M. vimineum populations. We established small plots at two sites that were dominated by M. vimineum. Vegetation surveys were conducted for each plot and then plots were mowed at one of three different heights (10 cm, 5 cm, 0 cm) in late summer before seed set. After 5 weeks, prior to senescence, all vegetation in the plots was harvested. Seed spikelets were counted, dried, and weighed. Vegetation was sorted into M. vimineum vegetation and all other vegetation, then dried and weighed. Results show that mowing at any of the three heights significantly reduced seed production and seed biomass of M. vimineum. Mowing at 10 cm reduced seed production by 85.9% and mowing at ground level reduced seed production by 99.5%. Seed biomass was reduced by 92.1% when plots were mowed 10 cm and by 99.5% when mowed at ground level. The results demonstrate that mowing below 10 cm before seeding occurs can significantly reduce M. vimineum reproductive output and could be integrated into an effective management program, which could increase the success of restoration efforts. Japanese stiltgrass (Microstegium vimineum) is an invasive grass that poses a major threat to native biodiversity and restoration efforts in invaded areas. While there are recommended control methods, few studies have scientifically quantified the efficacy of these control methods. A previous study determined that mowing any time after midsummer reduces the M. vimineum population, so we expanded upon this study to determine the effect of mowing height on M. vimineum populations. We established small plots at two sites that were dominated by M. vimineum. Vegetation surveys were conducted for each plot and then plots were mowed at one of three different heights (10 cm, 5 cm, 0 cm) in late summer before seed set. After 5 weeks, prior to senescence, all vegetation in the plots was harvested. Seed spikelets were counted, dried, and weighed. Vegetation was sorted into M. vimineum vegetation and all other vegetation, then dried and weighed. Results show that mowing at any of the three heights significantly reduced seed production and seed biomass of M. vimineum. Mowing at 10 cm reduced seed production by 85.9% and mowing at ground level reduced seed production by 99.5%. Seed biomass was reduced by 92.1% when plots were mowed 10 cm and by 99.5% when mowed at ground level. The results demonstrate that mowing below 10 cm before seeding occurs can significantly reduce M. vimineum reproductive output and could be integrated into an effective management program, which could increase the success of restoration efforts. POSTER PRESENTATIONS Monica Gagliardi Temple University School of Environmental Design ML Architect Student Oxford Wetland Sanctuary: What Nature Intended Abstract: In the era of global climate change, wetlands are a vital resource, providing the link to a resilient social, economic and environmental future. The Oxford Wetland Sanctuary goes beyond simply connecting people to nature, it uses a metric––the Evaluation for Planned Wetlands (EPW)––to restore a wetland, ensuring a highly impactful design based on science. The project incorporates creative social engagement, educational programming and economic opportunities. In the era of global climate change, wetlands are a vital resource, providing the link to a resilient social, economic and environmental future. The Oxford Wetland Sanctuary goes beyond simply connecting people to nature, it uses a metric––the Evaluation for Planned Wetlands (EPW)––to restore a wetland, ensuring a highly impactful design based on science. The project incorporates creative social engagement, educational programming and economic opportunities. Wetland mitigation banking represents an important economic component of the environmental sector, showcasing synergies between effective environmental protection and economic expansion while elevating the value of wetlands in society. The plan uses strategic micro grading and native re-vegetation to create a complex system that absorbs rainwater and slowly releases it to the aquifer; absorbs chem

Effect of information feedback on training standing up following stroke: a pilot feasibility study

Background and objective: The ability to stand up is reduced following stroke. Traditional biofeedback is effective in improving the performance of lower limb activities. The aim of this study was to investigate the feasibility of and potential for information feedback from a simple inexpensive device to improve the ability to stand up from a chair in people following stroke. Methods: A single-group study with pre–post measures design was used. Twenty people with hemiplegic stroke in inpatient rehabilitation received 10 sessions over 2 weeks of information feedback about foot placement during training of standing up. Progression involved increasing repetitions, increasing difficulty and fading feedback. Feasibility was determined by adherence, time taken, acceptability and safety. Clinical outcomes were the time taken to stand up, quality and foot position measured using the 5-Times-Sit-To-Stand-Test and carryover into daily activities measured by covert observation. Results: The study was feasible with 97% of sessions completed, taking 19 (SD 6) to 25 (SD 10) minutes. Participants understood (4.6/5), found useful (4.6/5), challenging (4.4/5) and would recommend (4.7/5) the training. The time to stand up 5 times decreased by 24 (95% CI -48 to -1) s, and the quality of standing improved by 1.0/10.0 (95% CI 0.2 to 1.8). Carryover of the correct foot placement occurred to real life, with the beginning foot position correct 2.1/3.0 (95% CI 1.6 to 2.6) and end foot position correct 1.8/3.0 (95% CI 1.2 to 2.4) occasions. Conclusions: The training is feasible and has the potential to improve the ability to stand up.

The effect of specific feedback on training standing up following stroke: a feasibility study

Background: The time course of stroke recovery as well as the impact of exercise therapy on the pattern of (motor) recovery is poorly understood. Content: The present lecture will addresses the current knowledge about the predictability of the time course of body functions and activities post-stroke. There is growing evidence that the natural logarithmic pattern of functional recovery can be modified by early started, intensive task-oriented practice. However, the impact of practice on learningdependent and intrinsic, spontaneous mechanisms of neurological recovery is not well understood. Several, probably interrelated mechanisms, have been identified that drive recovery after stroke. These mechanisms underlying recovery are highly interactive and operate in different, sometimes limited time-windows after stroke. In this key note lecture, a hypothetical phenomenological model for understanding skill reacquisition after stroke will be presented. Subsequently, the longitudinal association of what and how patients learn when they show functional improvement after stroke will be discussed. Conclusions: There is growing evidence that the effects of neurorehabilitation are rather adaptive (substitution) than driven by mechanisms of ‘true neurological repair’ (restitution). Restitution is found to be limited to the time frame of spontaneous neurological recovery. Understanding functional recovery in terms of restitution and substitution should serve as a basis to optimize the timing, focus and intensity of evidence-based practice post stroke.