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Abstract Background Sleep disturbance and fatigue are common in individuals undergoing inpatient rehabilitation following stroke. Understanding the relationships between sleep, fatigue, motor performance, and key biomarkers of inflammation and neuroplasticity could provide valuable insight into stroke recovery, possibly leading to personalized rehabilitation strategies. This study aimed to investigate the influence of sleep quality on motor function following stroke utilizing wearable technology to obtain objective sleep measurements. Additionally, we aimed to determine if there were relationships between sleep, fatigue, and motor function. Lastly, the study aimed to determine if salivary biomarkers of stress, inflammation, and neuroplasticity were associated with motor function or fatigue post-stroke. Methods Eighteen individuals who experienced a stroke and were undergoing inpatient rehabilitation participated in a cross-sectional observational study. Following consent, participants completed questionnaires to assess sleep patterns, fatigue, and quality of life. Objective sleep was measured throughout one night using the wearable Philips Actiwatch. Upper limb motor performance was assessed on the following day and saliva was collected for biomarker analysis. Correlation analyses were performed to assess the relationships between variables. Results Participants reported poor sleep quality, frequent awakenings, and difficulties falling asleep following stroke. We identified a significant negative relationship between fatigue severity and both sleep quality (r=-0.539, p = 0.021) and participants experience of awakening from sleep (r=-0.656, p = 0.003). A significant positive relationship was found between grip strength on the non-hemiplegic limb and salivary gene expression of Brain-derived Neurotrophic Factor (r = 0.606, p = 0.028), as well as a significant negative relationship between grip strength on the hemiplegic side and salivary gene expression of C-reactive Protein (r=-0.556, p = 0.048). Conclusion The findings of this study emphasize the importance of considering sleep quality, fatigue, and biomarkers in stroke rehabilitation to optimize recovery and that interventions may need to be tailored to the individual. Future longitudinal studies are required to explore these relationships over time. Integrating wearable technology for sleep and biomarker analysis can enhance monitoring and prediction of outcomes following stroke, ultimately improving rehabilitation strategies and patient outcomes.

The present study aims to describe the chair, bed, and toilet heights in rehabilitation hospitals and home environments to challenge rehabilitation clinicians to better prepare stroke survivors for discharge home. This study uses analysis of secondary outcomes from a multicentre, phase II randomized controlled trial (HOME Rehab trial) and additional observation of hospital environment. Data were collected from six rehabilitation hospitals and the homes of two hundred first-time stroke survivors who were aged >45 years. Chair, bed and toilet heights were measured; we measured 936 chairs and beds in hospital (17%) and home (83%) environments. Mean chair height at home was 47 cm (SD 6), which was 2 cm (95% CI, 0-4) lower than in the hospital ward and 5 cm (95% CI, 3-7) lower than in the hospital gym. Mean toilet height at home was 42 cm (SD 3), which was 3 cm (95% CI, 2-4) lower than in the hospital. Study findings suggest a disparity in heights between hospitals and home. Although clinicians may be aware of this disparity, they need to ensure that chair and bed heights within the hospital environment are progressively made lower to better prepare stroke survivors for discharge home.

BackgroundFew individuals (

The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to select a set of measures to comprehensively predict and assess outcomes following moderate-to-severe traumatic brain injury (TBI) across Australia. The aim of this article was to report on the implementation and findings of an evidence-based consensus approach to develop AUS-TBI recommendations for outcome measures following adult and pediatric moderate-to-severe TBI. Following consultation with a panel of expert clinicians, Aboriginal and Torres Strait Islander representatives and a Living Experience group, and preliminary literature searches with a broader focus, a decision was made to focus on measures of mortality, everyday functional outcomes, and quality of life. Standardized searches of bibliographic databases were conducted through March 2022. Characteristics of 75 outcome measures were extracted from 1485 primary studies. Consensus meetings among the AUS-TBI Steering Committee, an expert panel of clinicians and researchers and a group of individuals with lived experience of TBI resulted in the production of a final list of 11 core outcome measures: the Functional Independence Measure (FIM); Glasgow Outcome Scale-Extended (GOS-E); Satisfaction With Life Scale (SWLS) (adult); mortality; EuroQol-5 Dimensions (EQ5D); Mayo-Portland Adaptability Inventory (MPAI); Return to Work /Study (adult and pediatric); Functional Independence Measure for Children (WEEFIM); Glasgow Outcome Scale Modified for Children (GOS-E PEDS); Paediatric Quality of Life Scale (PEDS-QL); and Strengths and Difficulties Questionnaire (pediatric). These 11 outcome measures will be included as common data elements in the AUS-TBI data dictionary. Review Registration PROSPERO (CRD42022290954).

The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to develop a health informatics approach to collect data predictive of outcomes for persons with moderate-severe TBI across Australia. Central to this approach is a data dictionary; however, no systematic reviews of methods to define and develop data dictionaries exist to-date. This rapid systematic review aimed to identify and characterize methods for designing data dictionaries to collect outcomes or variables in persons with neurological conditions. Database searches were conducted from inception through October 2021. Records were screened in two stages against set criteria to identify methods to define data dictionaries for neurological conditions (International Classification of Diseases, 11th Revision: 08, 22, and 23). Standardized data were extracted. Processes were checked at each stage by independent review of a random 25% of records. Consensus was reached through discussion where necessary. Thirty-nine initiatives were identified across 29 neurological conditions. No single established or recommended method for defining a data dictionary was identified. Nine initiatives conducted systematic reviews to collate information before implementing a consensus process. Thirty-seven initiatives consulted with end-users. Methods of consultation were ?roundtable? discussion (n?=?30); with facilitation (n?=?16); that was iterative (n?=?27); and frequently conducted in-person (n?=?27). Researcher stakeholders were involved in all initiatives and clinicians in 25. Importantly, only six initiatives involved persons with lived experience of TBI and four involved carers. Methods for defining data dictionaries were variable and reporting is sparse. Our findings are instructive for AUS-TBI and can be used to further development of methods for defining data dictionaries.

Abstract Background Unplanned hospital presentations may occur post-stroke due to inadequate preparation for transitioning from hospital to home. The Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke (ReCAPS) trial was designed to test the effectiveness of receiving a 12-week, self-management intervention, comprising personalised goal setting with a clinician and aligned educational/motivational electronic messages. Primary outcome is as follows: self-reported unplanned hospital presentations (emergency department/admission) within 90-day post-randomisation. We present the statistical analysis plan for this trial. Methods/design Participants are randomised 1:1 in variable block sizes, with stratification balancing by age and level of baseline disability. The sample size was 890 participants, calculated to detect a 10% absolute reduction in the proportion of participants reporting unplanned hospital presentations/admissions, with 80% power and 5% significance level (two sided). Recruitment will end in December 2023 when funding is expended, and the sample size achieved will be used. Logistic regression, adjusted for the stratification variables, will be used to determine the effectiveness of the intervention on the primary outcome. Secondary outcomes will be evaluated using appropriate regression models. The primary outcome analysis will be based on intention to treat. A p-value ≤ 0.05 will indicate statistical significance. An independent Data Safety and Monitoring Committee has routinely reviewed the progress and safety of the trial. Conclusions This statistical analysis plan ensures transparency in reporting the trial outcomes. ReCAPS trial will provide novel evidence on the effectiveness of a digital health support package post-stroke. Trial registration ClinicalTrials.gov ACTRN12618001468213. Registered on August 31, 2018. SAP version 1.13 (October 12 2023) Protocol version 1.12 (October 12, 2022) SAP revisions Nil

Objective: To investigate the concurrent validity of the KHMS with the FMA-UE. Design: The FMA-UE and the KHMS were administered to 50 adults with stroke to evaluate their concurrent validity. Setting: Three tertiary rehabilitation hospitals. Participants: Participants were aged ≥18 years, receiving stroke or rehabilitation services from a participating hospital, and had a confirmed diagnosis of stroke (ischemic or hemorrhagic) with upper limb involvement. Fifty patients were recruited to the study (20 women, 30 men, N=50) with a mean age of 71 (SD 13.4, range 35-90) years. Time since stroke varied from 2 days to 187 months, with a median of 0.8 months. Interventions: Not applicable. Main Outcome Measures: Concurrent validity of the KHMS with the FMA-UE. Results: A correlation of r=0.948 was found between the 2 scales (P=.0001). Moderate floor effects were noted in our sample (16%); however, significant ceiling effects were recorded (44%). Conclusion: The KHMS demonstrated a statistically strong correlation with the FMA-UE and holds promise for use, particularly in the clinical setting, to evaluate upper limb motor impairment after stroke.

Background:: Understanding the risk factors for incontinence after acute stroke allows for early identification and treatment of patients who are likely to experience this complication. Objectives:: The purpose of this study was to estimate the incidence of urinary and fecal incontinence (UI and FI) after stroke in adults and examine the association of risk factors. Methods:: Screening data from a prospective study were analyzed. Included were 652 consecutive patients admitted to an acute stroke unit over a 15-month period beginning May 2021. Those with pre-existing UI or FI were excluded from the analysis. Bivariate analyses examined unadjusted relationships between both UI and FI and age, sex, stroke severity, premorbid disability, stroke type, and stroke anatomical site. Regression analyses were performed to build iterative models. Results:: A total of 418 patients had an acute stroke without pre-existing incontinence. The median age of stroke survivors was 76 years (IQR 66–84), 58% were men, and 76% had an ischemic stroke. Within the first 7 days after stroke, 128 (29%) had UI and 115 (26%) had FI. Increasing age, premorbid disability, and stroke severity increased the risk of both new-onset UI and FI after stroke. Those with intraventricular hemorrhage were 2.9 times more likely to develop UI. Women were 1.7 times more likely to have UI after stroke than men. Intraventricular hemorrhage increased the risk of new-onset FI after stroke by 2.9 times, while lobar hemorrhage increased the risk by 2.2 times. Conclusions:: Urinary and fecal incontinence continue to be relatively common after acute stroke, although incidence rates are lower than 20th century estimates. Patients are more likely to require incontinence assessment, monitoring and care if they are older, had higher premorbid disability, and have experienced more severe stroke or intraventricular hemorrhage. Given that more than a quarter of stroke patients develop incontinence following stroke, continence care and rehabilitation programs remain essential components of stroke services.

Objectives: To determine whether allied health interventions delivered using telehealth provide similar or better outcomes for patients compared with traditional face-to-face delivery modes. Study design: A rapid systematic review using the Cochrane methodology to extract eligible randomized trials. Eligible trials: Trials were eligible for inclusion if they compared a comparable dose of face-to-face to telehealth interventions delivered by a neuropsychologist, occupational therapist, physiotherapist, podiatrist, psychologist, and/or speech pathologist; reported patient-level outcomes; and included adult participants. Data sources: MEDLINE, CENTRAL, CINAHL, and EMBASE databases were first searched from inception for systematic reviews and eligible trials were extracted from these systematic reviews. These databases were then searched for randomized clinical trials published after the date of the most recent systematic review search in each discipline (2017). The reference lists of included trials were also hand-searched to identify potentially missed trials. The risk of bias was assessed using the Cochrane Risk of Bias Tool Version 1. Data Synthesis: Fifty-two trials (62 reports, n = 4470) met the inclusion criteria. Populations included adults with musculoskeletal conditions, stroke, post-traumatic stress disorder, depression, and/or pain. Synchronous and asynchronous telehealth approaches were used with varied modalities that included telephone, videoconferencing, apps, web portals, and remote monitoring, Overall, telehealth delivered similar improvements to face-to-face interventions for knee range, Health-Related Quality of Life, pain, language function, depression, anxiety, and Post-Traumatic Stress Disorder. This meta-analysis was limited for some outcomes and disciplines such as occupational therapy and speech pathology. Telehealth was safe and similar levels of satisfaction and adherence were found across modes of delivery and disciplines compared to face-to-face interventions. Conclusions: Many allied health interventions are equally as effective as face-to-face when delivered via telehealth. Incorporating telehealth into models of care may afford greater access to allied health professionals, however further comparative research is still required. In particular, significant gaps exist in our understanding of the efficacy of telehealth from podiatrists, occupational therapists, speech pathologists, and neuropsychologists. Protocol Registration Number: PROSPERO (CRD42020203128).

Abstract Background Health Service implementation projects are often guided by theoretical implementation frameworks. Little is known about the effectiveness of these frameworks to facilitate change in processes of care and patient outcomes within the inpatient setting. The aim of this review was to assess the effectiveness of the application of theoretical implementation frameworks in inpatient healthcare settings to change processes of care and associated patient outcomes. Method We conducted a search in CINAHL, MEDLINE, EMBASE, PsycINFO, EMCARE and Cochrane Library databases from 1st January 1995 to 15th June 2021. Two reviewers independently applied inclusion and exclusion criteria to potentially eligible studies. Eligible studies: implemented evidence-based care into an in-patient setting using a theoretical implementation framework applied prospectively; used a prospective study design; presented process of care or patient outcomes; and were published in English. We extracted theoretical implementation frameworks and study design against the Workgroup for Intervention Development and Evaluation Research (WIDER) Checklist and implementation strategies mapped to the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy. We summarised all interventions using the Template for Intervention Description and Replication (TIDieR) checklist. We appraised study quality using the Item bank on risk of bias and precision of observational studies and the revised Cochrane risk of bias tool for cluster randomised trials. We extracted process of care and patient outcomes and described descriptively. We conducted meta-analysis for process of care and patient outcomes with reference to framework category. Results Twenty-five studies met the inclusion criteria. Twenty-one used a pre-post (no comparison), two a pre-post with a comparison, and two a cluster randomised trial design. Eleven theoretical implementation frameworks were prospectively applied: six process models; five determinant frameworks; and one classic theory. Four studies used two theoretical implementation frameworks. No authors reported their justification for selecting a particular framework and implementation strategies were generally poorly described. No consensus was reached for a preferred framework or subset of frameworks based on meta-analysis results. Conclusions Rather than the ongoing development of new implementation frameworks, a more consistent approach to framework selection and strengthening of existing approaches is recommended to further develop the implementation evidence base. Trial registration CRD42019119429.

Abstract Background Planning discharges from subacute care facilities is becoming increasingly complex due to an ageing population and a high demand on services. The use of non-standardised assessments to determine a patient’s readiness for discharge places a heavy reliance on a clinician’s judgement which can be influenced by system pressures, past experiences and team dynamics. The current literature focusses heavily on discharge-readiness from clinicians’ perspectives and in the acute care setting. This paper aimed to explore the perceptions of discharge-readiness from the perspectives of key stakeholders in subacute care: inpatients, family members, clinicians and managers. Methods A qualitative descriptive study was conducted, exploring the views of inpatients (n = 16), family members (n = 16), clinicians (n = 17) and managers (n = 12). Participants with cognitive deficits and those who did not speak English were excluded from this study. Semi-structured interviews and focus groups were conducted and audio-recorded. Following transcription, inductive thematic analysis was completed. Results Participants identified that there are both patient-related and environmental factors that influence discharge-readiness. Patient-related factors discussed included continence, functional mobility, cognition, pain and medication management skills. Environmental factors centred around the discharge (home) environment, and were suggested to include a safe physical environment alongside a robust social environment which was suggested to assist to fill any gaps in functional capabilities (i.e. patient-related factors). Conclusions These findings make a unique contribution to the literature by providing a thorough exploration of determining discharge-readiness as a combined narrative from the perspectives from key stakeholders. Findings from this qualitative study identified key personal and environmental factors influencing patients’ discharge-readiness, which may allow health services to streamline the determination of discharge-readiness from subacute care. Understanding how these factors might be assessed within a discharge pathway warrants further attention.

Abstract Background Pulmonary rehabilitation (PR) is a core component of management people with chronic obstructive pulmonary disease (COPD); yet, people with COPD face significant barriers to attending centre-based PR programs. The emergence of new models of PR, remotely delivered directly into people’s homes, has the potential to improve rehabilitation access and completion by providing patients with a choice of rehabilitation location (centre or home). However, offering patients a choice of rehabilitation model is not usual practice. We are undertaking a 14-site cluster randomised controlled trial to determine whether offering choice of PR location improves rehabilitation completion rates resulting in reduced all-cause unplanned hospitalisation over 12 months. The aim of this paper is to describe the protocol for the process evaluation of the HomeBase2 trial. Methods A mixed methods process evaluation, to be undertaken in real time, has been developed in accordance with UK Medical Research Council (MRC) recommendations on process evaluation of complex interventions. This protocol describes the intended use of two theoretical frameworks (RE-AIM framework (Reach; Effectiveness; Adoption; Implementation; Maintenance) and Theoretical Domains Framework (TDF)) to synthesise findings and interpret data from a combination of qualitative (semi-structured interviews) and quantitative (questionnaires, clinical outcome data, intervention fidelity) methodologies. Data will be collected at an intervention, patient and clinician level. Qualitative and quantitative data will be used to derive context-specific potential and actual barriers and facilitators to offering patients choice of rehabilitation location. Acceptability and sustainability of the intervention will be evaluated for future scale-up. Discussion The process evaluation described here will appraise the clinical implementation of offering a choice of rehabilitation program location for people with COPD. It will identify and evaluate key factors for future scale-up and sustainability and scale-up of offering choice of pulmonary rehabilitation program model for people. Trial registration ClinicalTrials.gov NCT04217330 Registration date: January 3 2020.

Abstract Objective Epilepsy is associated with an increased risk of cardiovascular disease and mortality. Whether cardiac structure and function are altered in epilepsy remains unclear. To address this, we conducted a systematic review and meta‐analysis of studies evaluating cardiac structure and function in patients with epilepsy. Methods We searched the electronic databases MEDLINE, PubMed, COCHRANE, and Web of Science from inception to 31 December 2021. Primary outcomes of interest included left ventricular ejection fraction (LVEF) for studies reporting echocardiogram findings and cardiac weight and fibrosis for postmortem investigations. Study quality was assessed using the National Heart, Lung, and Blood Institute (NHLBI) assessment tools. Results Among the 10 case‐control studies with epilepsy patients (n = 515) and healthy controls (n = 445), LVEF was significantly decreased in epilepsy group compared with controls (MD: −1.80; 95% confidence interval [CI]: −3.56 to −0.04; P = 0.045), whereas A‐wave velocity (MD: 4.73; 95% CI: 1.87‐7.60; P = 0.001), E/e' ratio (MD: 0.39; 95% CI: 0.06‐0.71; P = 0.019), and isovolumic relaxation time (MD: 10.18; 95% CI: 2.05‐18.32; P = 0.014) were increased in epilepsy, compared with controls. A pooled analysis was performed in sudden unexpected death in epilepsy (SUDEP) cases with autopsy data (n = 714). Among SUDEP cases, the prevalence of cardiac hypertrophy was 16% (95% CI: 9%–23%); cardiac fibrosis was 20% (95% CI: 15%–26%). We found no marked differences in cardiac hypertrophy, heart weight, or cardiac fibrosis between SUDEP cases and epilepsy controls. Significance Our findings suggest that epilepsy is associated with altered diastolic and systolic echocardiogram parameters compared with healthy controls. Notably, SUDEP does not appear to be associated with a higher incidence of structural cardiac abnormalities, compared with non‐SUDEP epilepsy controls. Longitudinal studies are needed to understand the prognostic significance of such changes. Echocardiography may be a useful noninvasive diagnostic test in epilepsy population.

People with neurological conditions may face barriers to meal preparation. Culinary nutrition interventions aim to facilitate the building of knowledge and skills for meal preparation. This scoping review aims to map the available evidence for culinary nutrition interventions for people with neurological conditions and evaluate the quality of these interventions based on program design, delivery and evaluation. After a systematic search of online databases (MEDLINE, CINAHL, Embase, Scopus and Proquest) and reference lists, a total of ten publications describing nine interventions were included. Most interventions were designed for people with stroke and/or Transient Ischemic Attack (n = 3) and Multiple Sclerosis (n = 3); others were for traumatic brain injury (n = 1), mild dementia (n = 1) and Parkinson’s Disease (n = 1). Overall, the included culinary nutrition interventions had good program delivery (inclusion of motivational experiences, delivered by appropriate health providers) but needed improvements in program design (lack of consumer engagement and neurological symptom accommodations) and evaluation (lack of complete process, outcome and impact evaluations). In conclusion, the evidence base for culinary nutrition interventions for people with neurological conditions remains sparse. To bridge the gap between theory and practice, it is important to consider the following aspects in culinary nutrition intervention planning/improvement: (I) the involvement of consumers; (II) the accommodation/tailoring for post-condition effects; and (III) the coverage of all disease-specific culinary nutrition aspects.

Objective: This implementation study aimed to enhance the key elements of clinical practice goal-setting across 5 rehabilitation services. Design: This study followed a participatory action research approach guided by the Knowledge to Action framework. Methods: Medical record audits and structured client interviews were conducted prior to and following 12 weeks of implementation, in order to evaluate the success of the goal-setting implementation package. Results: Medical record audits and interviews conducted pre-implementation (audits n = 132, interviews n = 64), post-implementation (audits n = 130, interviews n = 56) and at 3-month follow-up (audits n = 30) demonstrated varied success across sites. Following implementation 2 sites significantly improved their common goal focus (site 1 p ≤ 0.001, site 2 p = 0.005), these sites also demonstrated a significant increase in clients reporting that they received copies of their rehabilitation goals (site 1 p ≤ 0.001, site 2 p ≤ 0.001). Four sites improved client action planning, feedback and review, and 3 sites enhanced their specificity of goal-setting. At 3-month follow-up 4 sites had continued to improve their common goal focus; however, all sites decreased the specificity of their goal-setting. Conclusion: Elements of the implementation package were successful at enhancing the goal-setting process; however, how the package is implemented within the team may impact outcomes. LAY ABSTRACT There are 4 important elements of goal-setting in rehabilitation: including the client; having a team focus on common goals; setting specific and meaningful goals; and including action planning feedback and review of goals. A goal-setting package was developed to assist healthcare workers to complete all important elements of goal-setting. This study aimed to evaluate the use of the goal-setting package in 5 rehabilitation services. Client medical records were reviewed and interviews with clients were undertaken to evaluate the success of the goal-setting package. In 2 sites, using the goal-setting package resulted in a significant increase in establishing common goals among the client and team and providing written information to clients about their goals. More action plans were developed to assist clients to work towards goals at 4 sites, whilst 3 sites improved in terms of setting more specific goals.

Abstract Background Evidence for digital health programmes to support people living with stroke is growing. We assessed the feasibility of a protocol and procedures for the Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke (ReCAPS) trial. Methods We conducted a mixed-method feasibility study. Participants with acute stroke were recruited from three hospitals (Melbourne, Australia). Eligibility: Adults with stroke discharged from hospital to home within 10 days, modified Rankin Score 0–4 and prior use of Short Message System (SMS)/email. While in hospital, recruited participants contributed to structured person-centred goal setting and completed baseline surveys including self-management skills and health-related quality of life. Participants were randomised 7–14 days after discharge via REDCap® (1:1 allocation). Following randomisation, the intervention group received a 12-week programme of personalised electronic support messages (average 66 messages sent by SMS or email) aligned with their goals. The control group received six electronic administrative messages. Feasibility outcomes included the following: number of patients screened and recruited, study retainment, completion of outcome measures and acceptability of the ReCAPS intervention and trial procedures (e.g. participant satisfaction survey, clinician interviews). Protocol fidelity outcomes included number of goals developed (and quality), electronic messages delivered, stop messages received and engagement with messages. We undertook inductive thematic analysis of interview/open-text survey data and descriptive analysis of closed survey questions. Results Between November 2018 and October 2019, 312 patients were screened; 37/105 (35%) eligible patients provided consent (mean age 61 years; 32% female); 33 were randomised (17 to intervention). Overall, 29 (88%) participants completed the12-week outcome assessments with 12 (41%) completed assessments in the allocated timeframe and 16 also completing the satisfaction survey (intervention=10). Overall, trial participants felt that the study was worthwhile and most would recommend it to others. Six clinicians participated in one of three focus group interviews; while they reported that the trial and the process of goal setting were acceptable, they raised concerns regarding the additional time required to personalise goals. Conclusion The study protocol and procedures were feasible with acceptable retention of participants. Consent and goal personalisation procedures should be centralised for the phase III trial to reduce the burden on hospital clinicians. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12618001468213 (date 31/08/2018); Universal Trial Number: U1111-1206-7237

Abstract Introduction Despite digital health tools being popular for supporting self‐management of chronic diseases, little research has been undertaken on stroke. We developed and pilot tested, using a randomized controlled design, a multicomponent digital health programme, known as Inspiring Virtual Enabled Resources following Vascular Events (iVERVE), to improve self‐management after stroke. The 4‐week trial incorporated facilitated person‐centred goal setting, with those in the intervention group receiving electronic messages aligned to their goals, versus limited administrative messages for the control group. In this paper, we describe the participant experience of the various components involved with the iVERVE trial. Methods Mixed method design: satisfaction surveys (control and intervention) and a focus group interview (purposively selected intervention participants). Experiences relating to goal setting and overall trial satisfaction were obtained from intervention and control participants, with feedback on the electronic message component from intervention participants. Inductive thematic analysis was used for interview data and open‐text responses, and closed questions were summarized descriptively. Triangulation of data allowed participants' perceptions to be explored in depth. Results Overall, 27/54 trial participants completed the survey (13 intervention: 52%; 14 control: 48%); and 5/8 invited participants in the intervention group attended the focus group. Goal setting: The approach was considered comprehensive, with the involvement of health professionals in the process helpful in developing realistic, meaningful and person‐centred goals. Electronic messages (intervention): Messages were perceived as easy to understand (92%), and the frequency of receipt was considered appropriate (11/13 survey; 4/5 focus group). The content of messages was considered motivational (62%) and assisted participants to achieve their goals (77%). Some participants described the benefits of receiving messages as a ‘reminder’ to act. Overall trial satisfaction: Messages were acceptable for educating about stroke (77%). Having options for short message services or email to receive messages was considered important. Feedback on the length of the intervention related to specific goals, and benefits of receiving the programme earlier after stroke was expressed. Conclusion The participant experience has indicated acceptance and utility of iVERVE. Feedback from this evaluation is invaluable to inform refinements to future Phase II and III trials, and wider research in the field. Patient or Public Contribution Two consumer representatives sourced from the Stroke Foundation (Australia) actively contributed to the design of the iVERVE programme. In this study, participant experiences directly contributed to the further development of the iVERVE intervention and future trial design.

Abstract Background Hospital-based stroke rehabilitation for stroke survivors in developing countries may be limited by staffing ratios and length of stay that could hamper recovery potential. Thus, a home-based, gamified rehabilitation system (i.e., IntelliRehab) was tested for its ability to increase cerebral blood flow (CBF), and the secondary impact of changes on the upper limb motor function and functional outcomes. Objective To explore the effect of IntelliRehab on CBF in chronic stroke patients and its correlation with the upper limb motor function. Methods Two-dimensional pulsed Arterial Spin Labelling (2D-pASL) was used to obtain CBF images of stable, chronic stroke subjects (n = 8) over 3-months intervention period. CBF alterations were mapped, and the detected differences were marked as regions of interest. Motor functions represented by Fugl-Meyer Upper Extremity Assessment (FMA) and Stroke Impact Scale (SIS) were used to assess the primary and secondary outcomes, respectively. Results Regional CBF were significantly increased in right inferior temporal gyrus and left superior temporal white matter after 1-month (p = 0.044) and 3-months (p = 0.01) of rehabilitation, respectively. However, regional CBF in left middle fronto-orbital gyrus significantly declined after 1-month of rehabilitation (p = 0.012). Moreover, SIS-Q7 and FMA scores significantly increased after 1-month and 3-months of rehabilitation. There were no significant correlations, however, between CBF changes and upper limb motor function. Conclusions Participants demonstrated improved motor functions, supporting the benefit of using IntelliRehab as a tool for home-based rehabilitation. However, within-participant improvements may have limited potential that suggests the need for a timely administration of IntelliRehab to get the maximum capacity of improvement.

Implementation of evidence-informed rehabilitation of the upper limb is variable, and outcomes for stroke survivors are often suboptimal. We established a national partnership of clinicians, survivors of stroke, researchers, healthcare organizations, and policy makers to facilitate change. The objectives of this study are to increase access to best-evidence rehabilitation of the upper limb and improve outcomes for stroke survivors. This prospective pragmatic, knowledge translation study involves four new specialist therapy centers to deliver best-evidence upper-limb sensory rehabilitation (known as SENSe therapy) for survivors of stroke in the community. A knowledge-transfer intervention will be used to upskill therapists and guide implementation. Specialist centers will deliver SENSe therapy, an effective and recommended therapy, to stroke survivors in the community. Outcomes include number of successful deliveries of SENSe therapy by credentialled therapists; improved somatosensory function for stroke survivors; improved performance in self-selected activities, arm use, and quality of life; treatment fidelity and confidence to deliver therapy; and for future implementation, expert therapist effect and cost-effectiveness. In summary, we will determine the effect of a national partnership to increase access to evidence-based upper-limb sensory rehabilitation following stroke. If effective, this knowledge-transfer intervention could be used to optimize the delivery of other complex, evidence-based rehabilitation interventions.

Predicting and optimizing outcomes after traumatic brain injury (TBI) remains a major challenge because of the breadth of injury characteristics and complexity of brain responses. AUS-TBI is a new Australian Government?funded initiative that aims to improve personalized care and treatment for children and adults who have sustained a TBI. The AUS-TBI team aims to address a number of key knowledge gaps, by designing an approach to bring together data describing psychosocial modulators, social determinants, clinical parameters, imaging data, biomarker profiles, and rehabilitation outcomes in order to assess the influence that they have on long-term outcome. Data management systems will be designed to track a broad range of suitable potential indicators and outcomes, which will be organized to facilitate secure data collection, linkage, storage, curation, management, and analysis. It is believed that these objectives are achievable because of our consortium of highly committed national and international leaders, expert committees, and partner organizations in TBI and health informatics. It is anticipated that the resulting large-scale data resource will facilitate personalization, prediction, and improvement of outcomes post-TBI.

Abstract Background Several active ingredients contribute to the purposes and mechanisms of goal-setting in rehabilitation. Active ingredients in the goal-setting process include, interdisciplinary teamworking, shared decision-making, having meaningful and specific goals, and including action planning, coping planning, feedback, and review. Clinicians have expressed barriers and enablers to implementing these active ingredients in rehabilitation teams. Interventions designed to improve goal-setting practices need to be tailored to address context specific barriers and enablers. Attempts to understand and enhance goal-setting practices in rehabilitation settings should be supported using theory, process models and determinant frameworks. Few studies have been undertaken to enhance goal-setting practices in varied case-mix rehabilitation settings. Methods This study is part of a larger program of research guided by the Knowledge to Action (KTA) framework. A multisite, participatory, codesign approach was used in five sites to address three stages of the KTA. (1) Focus groups were conducted to understand barriers and enablers to implementing goal-setting at each site. Following the focus groups three staff co-design workshops and one consumer workshop were run at each site to (2) adapt knowledge to local context, and to (3) select and tailor interventions to improve goal-setting practices. Focus groups were analysed using the Theoretical Domains Framework (TDF) and informed the selection of behaviour change techniques incorporated into the implementation plan. Results Barriers and enablers identified in this study were consistent with previous research. Clinicians lacked knowledge and understanding of the differences between a goal and an action plan often confusing both terms. Clinicians were unable to demonstrate an understanding of the importance of comprehensive action planning and review processes that extended beyond initial goal-setting. Interventions developed across the sites included staff training modules, a client held workbook, educational rehabilitation service flyers, interdisciplinary goal-based case conference templates, communication goal boards and a key worker model. Implementation plans were specifically established for each site. Conclusions Rehabilitation teams continue to struggle to incorporate a truly client-centred, interdisciplinary model of goal-setting in rehabilitation. Whilst clinicians continue to lack understanding of how they can use aspects of goal-setting to enhance client outcomes and autonomy in rehabilitation settings.

Abstract Background It is common for people with persistent spasticity due to a stroke to receive an injection of botulinum toxin-A in the upper limb, however post-injection intervention varies. Aim To determine the long-term effect of additional upper limb rehabilitation following botulinum toxin-A in chronic stroke. Method An analysis of long-term outcomes from national, multicenter, Phase III randomised trial with concealed allocation, blinded measurement and intention-to-treat analysis was carried out. Participants were 140 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 greater than 3 months ago, who had completed formal rehabilitation and had no significant cognitive impairment. Experimental group received botulinum toxin-A plus 3 months of evidence-based movement training while the control group received botulinum toxin-A plus a handout of exercises. Primary outcomes were goal attainment (Goal Attainment Scale) and upper limb activity (Box and Block Test) at 12 months (ie, 9 months beyond the intervention). Secondary outcomes were spasticity, range of motion, strength, pain, burden of care, and health-related quality of life. Results By 12 months, the experimental group scored the same as the control group on the Goal Attainment Scale (MD 0 T-score, 95% CI -5 to 5) and on the Box and Block Test (MD 0.01 blocks/s, 95% CI -0.01 to 0.03). There were no differences between groups on any secondary outcome. Conclusion Additional intensive upper limb rehabilitation following botulinum toxin-A in chronic stroke survivors with a disabled upper limb is not more effective in the long-term. Trial Registration ACTRN12615000616572 (12/06/2015).

Background and Purpose Changes to hospital systems were implemented from March 2020 in Australia in response to the coronavirus disease 2019 pandemic, including decreased resources allocated to stroke units. We investigate changes in the quality of acute care for patients with stroke or transient ischemic attack during the pandemic according to patients’ treatment setting (stroke unit or alternate ward). Methods We conducted a retrospective cohort study of patients admitted with stroke or transient ischemic attack between January 2019 and June 2020 in the Australian Stroke Clinical Registry (AuSCR). The AuSCR monitors patients’ treatment setting, provision of allied health and nursing interventions, prescription of secondary prevention medications, and discharge destination. Weekly trends in the quality of care before and during the pandemic period were assessed using interrupted time series analyses. Results In total, 18,662 patients in 2019 and 8,850 patients in 2020 were included. Overall, 75% were treated in stroke units. Before the pandemic, treatment in a stroke unit was superior to alternate wards for the provision of all evidence-based therapies assessed. During the pandemic period, the proportion of patients receiving a swallow screen or assessment, being discharged to rehabilitation, and being prescribed secondary prevention medications decreased by 0.58% to 1.08% per week in patients treated in other ward settings relative to patients treated in stroke units. This change represented a 9% to 17% increase in the care gap between these treatment settings during the period of the pandemic that was evaluated (16 weeks). Conclusions During the first 6 months of the pandemic, widening care disparities between stroke units and alternate wards have occurred.

Objective To examine the frequency and timing of inpatient engagement in meaningful activities within rehabilitation (within and outside of structured therapy times) and determine the associations between activity type, goal awareness, and patient affect. Methods This prospective observational study performed behavioral mapping in a 42-bed inpatient brain injury rehabilitation unit by recording patient activity every 15 minutes (total 42 hours). The participants were randomly selected rehabilitation inpatients with acquired brain injury; all completed the study. The main outcome measures included patient demographics, observation of activity, participation, goal awareness, and affect. Results The inpatients spent 61% of the therapeutic day (8:30 to 16:30) in their single room and were alone 49% of the time. They were physically socially inactive for 76% and 74% of their awake time, respectively, with neutral affect observed for about half of this time. Goal-related activities were recorded for only 25% of the inpatients’ awake time. The odds of physical activity were 10.3-fold higher among in patients receiving support to address their goals within their rehabilitation program (odds ratio=10.3; 95% confidence interval, 5.02–21.16). Conclusion Inpatients in a mixed brain injury rehabilitation unit spent a large amount of their awake hours inactive and only participated in goal-related activities for a quarter of their awake time. Rehabilitation models that increase opportunities for physical, cognitive, and social activities outside of allied health sessions are recommended to increase overall activity levels during inpatient rehabilitation.

Objective: Develop and test a person-centred goal-setting package for discharge care planning in acute and rehabilitation stroke units. Methods: A multidisciplinary, expert working group (n = 15), and consumer group (n = 4) was convened. A multistage iterative approach was used to develop and test the package. Stages included: (i) contextual understanding, (ii) package development, and (iii) clinician training and field-testing in acute and rehabilitation settings. Observational field notes were taken and clinicians' perspectives captured using semi-structured focus groups post-testing. Results: The final package included a 34-item menu aligned with a manual containing: guideline summaries; common goals; goal metrics based on the SMART Goal Evaluation Method (SMART-GEM); evidence-based strategies; and worked examples. Twenty-three clinicians attended training. Clinician observations (n = 5) indicated that: the package could be incorporated into practice; a range of person-centred goals were set; and opportunities provided to raise additional issues. Clinician feedback (n = 8) suggested the package was useful and facilitated person-centred goal-setting. Enablers included potential for incorporation into existing processes and beliefs that it promoted person-centred care. Barriers included additional time. Conclusion: The package demonstrated potential to facilitate comprehensive person-centred goal-setting for patients with stroke. Innovation: We developed an innovative approach to support structured person-centred goal setting in clinical and research settings.

BackgroundDifficulty using the upper extremity in everyday activities is common after stroke. Constraint-induced movement therapy (CIMT) has been shown to be effective in both sub-acute and chronic phases of stroke recovery and is recommended in clinical practice guidelines for stroke internationally. Despite reports of equivalence of outcome when stroke rehabilitation interventions are delivered using telehealth, there has been limited evaluation of CIMT when using this mode of delivery. ReCITE will (a) evaluate the feasibility and acceptability of CIMT when delivered via telehealth to stroke survivors (TeleCIMT) and (b) explore therapists' experiences and use of an online support package inclusive of training, mentoring and resources to support TeleCIMT delivery in clinical practice.MethodsA prospective single-group, single blinded, study design with embedded process evaluation will be conducted. The study will be conducted at three outpatient services in Sydney, Australia. A multi-faceted therapist support package, informed by the Capabilities, Opportunity, Motivation- Behaviour model (COM-B), will be used to support occupational therapists to implement TeleCIMT as part of routine care to stroke survivors. Each service will recruit 10 stroke survivor participants (n = 30) with mild to moderate upper extremity impairment. Upper extremity and quality of life outcomes of stroke survivor participants will be collected at baseline, post-intervention and at a 4 week follow-up appointment. Feasibility of TeleCIMT will be evaluated by assessing the number of stroke participants who complete 80% of intensive arm practice prescribed during their 3 week program (i.e., at least 24 h of intensive arm practice). Acceptability will be investigated through qualitative interviews and surveys with stroke survivors, supporter surveys and therapist focus groups. Qualitative interviews with therapists will provide additional data to explore their experiences and use of the online support package.DiscussionThe COVID-19 pandemic resulted in a rapid transition to delivering telehealth. The proposed study will investigate the feasibility and acceptability of delivering a complex intervention via telehealth to stroke survivors at home, and the support that therapists and patients require for delivery. The findings of the study will be used to inform whether a larger, randomized controlled trial is feasible.

Abstract Objective: We aim to report the accuracy of linking data from a non‐government‐held clinical quality registry to national claims data and identify associated sources of systematic bias. Methods: Patients with stroke or transient ischaemic attack admitted to hospitals participating in the Australian Stroke Clinical Registry (AuSCR) were linked with Medicare and medication dispensings through the Australian Medicare enrolment file (MEF). The proportion of registrants in the datasets was calculated and factors associated with a non‐merge assessed using multivariable analyses. Results: A total of 17,980 AuSCR registrants (January 2010 – July 2014) were submitted for linkage (median age 76 years; 46% female; 67% ischaemic stroke); the proportion merged was 97% MEF, 93% Medicare and 95% medication dispensings. Data from registrants born in Asia were less likely to link with the MEF (adjusted Odds Ratio [aOR]: 0.20; 95%Confidence Interval [CI]: 0.15, 0.27). Data for those aged 85‐plus compared to those under 65 years were less likely to merge with Medicare (aOR 0.25; 95%CI:0.21, 0.30) but more likely to merge with dispensing claims data (aOR: 2.15 (95%CI:1.71, 2.69). Implications for public health: Linkage between the AuSCR, a national clinical quality registry and Commonwealth datasets was achieved and potential sources of bias were identified.

Abstract Background Ensuring patients receive an effective dose of therapeutic exercises and activities is a significant challenge for inpatient rehabilitation. My Therapy is a self-management program which encourages independent practice of occupational therapy and physiotherapy exercises and activities, outside of supervised therapy sessions. Methods This implementation trial aims to determine both the clinical effectiveness of My Therapy on the outcomes of function and health-related quality of life, and cost-effectiveness per minimal clinically important difference (MCID) in functional independence achieved and per quality adjusted life year (QALY) gained, compared to usual care. Using a stepped-wedge cluster randomised design, My Therapy will be implemented across eight rehabilitation wards (inpatient and home-based) within two public and two private Australian health networks, over 54-weeks. We will include 2,160 patients aged 18 + years receiving rehabilitation for any diagnosis. Each ward will transition from the usual care condition (control group receiving usual care) to the experimental condition (intervention group receiving My Therapy in addition to usual care) sequentially at six-week intervals. The primary clinical outcome is achievement of a MCID in the Functional Independence Measure (FIM™) at discharge. Secondary outcomes include improvement in quality of life (EQ-5D-5L) at discharge, length of stay, 30-day re-admissions, discharge accommodation, follow-up rehabilitation services and adverse events (falls). The economic outcomes are the cost-effectiveness per MCID in functional independence (FIM™) achieved and per QALY gained, for My Therapy compared to usual care, from a health-care sector perspective. Cost of implementation will also be reported. Clinical outcomes will be analysed via mixed-effects linear or logistic regression models, and economic outcomes will be analysed via incremental cost-effectiveness ratios. Discussion The My Therapy implementation trial will determine the effect of adding self-management within inpatient rehabilitation care. The results may influence health service models of rehabilitation including recommendations for systemic change to the inpatient rehabilitation model of care to include self-management. Findings have the potential to improve patient function and quality of life, and the ability to participate in self-management. Potential health service benefits include reduced hospital length of stay, improved access to rehabilitation and reduced health service costs. Trial registration This study was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12621000313831; registered 22/03/2021, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380828&isReview=true ).

BackgroundResuming work after stroke is a common goal of working-age adults, yet there are few vocational rehabilitation programs designed to address the unique challenges faced following stroke. The Work intervention was developed to address these gaps. ObjectiveThis paper presents a protocol that outlines the steps that will be undertaken to pilot both the intervention and trial processes for the Work trial. MethodsThe Work trial is a 2-arm, prospective, randomized, blinded-assessor study with intention-to-treat analysis. A total of 54 adults of working age who have experienced a stroke

Abstract Background Brain injury rehabilitation is an expensive and long‐term endeavour. Very little published information or debate has underpinned policy for service delivery in Australia. Within the context of finite health budgets and the challenges associated with providing optimal care to persons with brain injuries, members of the public were asked ‘What considerations are important to include in a model of care of brain injury rehabilitation?’ Methods Qualitative study using the Citizen Jury method of participatory research. Twelve adult jurors from the community and seven witnesses participated including a health services funding model expert, peak body representative with lived experience of brain injury, carer of a person with a brain injury, and brain injury rehabilitation specialists. Witnesses were cross‐examined by jurors over two days. Results Key themes related to the need for a model of rehabilitation to: be consumer‐focused and supporting the retention of hope; be long‐term; provide equitable access to services irrespective of funding source; be inclusive of family; provide advocacy; raise public awareness; and be delivered by experts in a suitable environment. A set of eight recommendations were made. Conclusion Instigating the recommendations made requires careful consideration of the need for new models of care with flexible services; family involvement; recruitment and retention of highly skilled staff; and providing consumer‐focused services that prepare individuals and their carers for the long term. Patient and public contribution As jury members, the public deliberated information provided by expert witnesses (including a person with a head injury) and wrote the key recommendations.

Abstract Background Electronic communication is used in various populations to achieve health goals, but evidence in stroke is lacking. We pilot tested the feasibility and potential effectiveness of a novel personalised electronic self-management intervention to support person-centred goal attainment and secondary prevention after stroke. Methods A phase I, prospective, randomised controlled pilot trial (1:1 allocation) with assessor blinding, intention-to-treat analysis, and a process evaluation. Community-based survivors of stroke were recruited from participants in the Australian Stroke Clinical Registry (AuSCR) who had indicated their willingness to be contacted for research studies. Inclusion criteria include 1–2 years following hospital admission for stroke and living within 50 km of Monash University (Melbourne). Person-centred goals were set with facilitation by a clinician using a standardised template. The intervention group received electronic support messages aligned to their goals over 4 weeks. The control group received only 2–3 electronic administrative messages. Primary outcomes were study retention, goal attainment (assessed using Goal Attainment Scaling method) and satisfaction. Secondary outcomes were self-management (Health Education Impact Questionnaire: 8 domains), quality of life, mood and acceptability. Results Of 340 invitations sent from AuSCR, 73 responded, 68 were eligible and 57 (84%) completed the baseline assessment. At the goal-setting stage, 54/68 (79%) were randomised (median 16 months after stroke): 25 to intervention (median age 69 years; 40% female) and 29 to control (median age 68 years; 38% female). Forty-five (83%) participants completed the outcome follow-up assessment. At follow-up, goal attainment (mean GAS-T score ≥ 50) in the intervention group was achieved for goals related to function, participation and environment (control: environment only). Most intervention participants provided positive feedback and reported that the iVERVE messages were easy to understand (92%) and assisted them in achieving their goals (77%). We found preliminary evidence of non-significant improvements between the groups for most self-management domains (e.g. social integration and support: β coefficient 0.34; 95% CI − 0.14 to 0.83) and several quality-of-life domains in favour of the intervention group. Conclusion These findings support the need for further randomised effectiveness trials of the iVERVE program to be tested in people with new stroke. Trial registration ANZCTR, ACTRN12618001519246 . Registered on 11 September 2018—retrospectively registered.

Introduction There is compelling evidence that either centre-based or home-based pulmonary rehabilitation improves clinical outcomes in chronic obstructive pulmonary disease (COPD). There are known health service and personal barriers which prevent potentially eligible patients from accessing the benefits of pulmonary rehabilitation. The aim of this hybrid effectiveness-implementation trial is to examine the effects of offering patients a choice of pulmonary rehabilitation locations (home or centre) compared with offering only the traditional centre-based model.Method and analysis This is a two-arm cluster randomised, controlled, assessor-blinded trial of 14 centre-based pulmonary rehabilitation services allocated to intervention (offering choice of home-based or centre-based pulmonary rehabilitation) or control (continuing to offer centre-based pulmonary rehabilitation only), stratified by centre-based programme setting (hospital vs non-hospital). 490 participants with COPD will be recruited. Centre-based pulmonary rehabilitation will be delivered according to best practice guidelines including supervised exercise training for 8 weeks. At intervention sites, the home-based pulmonary rehabilitation will be delivered according to an established 8-week model, comprising of one home visit, unsupervised exercise training and telephone calls that build motivation for exercise participation and facilitate self-management. The primary outcome is all-cause, unplanned hospitalisations in the 12 months following rehabilitation. Secondary outcomes include programme completion rates and measurements of 6-minute walk distance, chronic respiratory questionnaire, EQ-5D-5L, dyspnoea-12, physical activity and sedentary time at the end of rehabilitation and 12 months following rehabilitation.Direct healthcare costs, indirect costs and changes in EQ-5D-5L will be used to evaluate cost-effectiveness. A process evaluation will be undertaken to understand how the choice model is implemented and explore sustainability beyond the clinical trial.Ethics and dissemination Alfred Hospital Ethics Committee has approved this protocol. The trial findings will be published in peer-reviewed journals, submitted for presentation at conferences and disseminated to patients across Australia with support from national lung charities and societies.Trial registration number NCT04217330.

Abstract Background Assessment of the costs of care associated with chronic upper-limb spasticity following stroke in Australia and the potential benefits of adding intensive upper limb rehabilitation to botulinum toxin-A are key objectives of the InTENSE randomised controlled trial. Methods Recruitment for the trial has been completed. A total of 139 participants from 6 stroke units across 3 Australian states are participating in the trial. A cost utility analysis will be undertaken to compare resource use and costs over 12 months with health-related quality of life outcomes associated with the intervention relative to a usual care comparator. A cost effectiveness analysis with the main clinical measure of outcome, Goal Attainment Scaling, will also be undertaken. The primary outcome measure for the cost utility analysis will be the incremental cost effectiveness ratio (ICER) generated from the incremental cost of the intervention as compared to the incremental benefit, as measured in quality adjusted life years (QALYs) gained. The utility scores generated from the EQ-5D three level instrument (EQ-5D-3 L) measured at baseline, 3 months and 12 months will be utilised to calculate the incremental Quality Adjusted Life Year (QALY) gains for the intervention relative to usual care using area-under the curve methods. Discussion The results of the economic evaluation will provide evidence of the total costs of care for patients with chronic upper limb spasticity following stroke. It will also provide evidence for the cost-effectiveness of adding evidence-based movement therapy to botulinum toxin-A as a treatment, providing important information for health system decision makers tasked with the planning and provision of services.

Abstract Background Subgroups of older patients experience difficulty performing activities of daily living (ADL) following hospital discharge, as well as unplanned hospital readmissions and emergency department (ED) presentations. We examine whether these subgroups of “at-risk” older patients benefit more than their counterparts from an evidence-based discharge planning intervention, on the following outcomes: (1) independence in ADL, (2) participation in life roles, (3) unplanned re-hospitalizations, and (4) ED presentations. Trial design and methods This study used data from a randomized control trial involving 400 hospitalized older patients with acute and medical conditions, recruited through 5 sites in Australia. Participants receive either HOME, a patient-centered discharge planning intervention led by an occupational therapist; or a structured in-hospital consultation. HOME uses a collaborative approach for goal setting and includes pre and post-discharge home visits as well as telephone follow-up. Characteristics associated with higher risks of adverse outcomes were recorded and at-risk subgroups were created (mild cognitive impairment, walking difficulty, comorbidity, living alone and no support from family). Independence in ADL and participation in life roles were assessed with validated questionnaires. The number of unplanned re-hospitalizations and ED presentations were extracted from medical files. Linear regression models were conducted to detect variation in response to the intervention at 3-months, according to patients’ characteristics. Results Analyses revealed significant interaction effects for intervention by cognitive status for unplanned re-hospitalization (p = 0.003) and ED presentations (p = 0.021) at 3 months. Within the at-risk subgroup of mild cognitively impaired, the HOME intervention significantly reduced unplanned hospitalizations (p = 0.027), but the effect did not reach significance in ED visits. While the effect of HOME differed according to support received from family for participation in life roles (p = 0.019), the participation observed in HOME patients with no support was not significantly improved. Conclusions Findings show that hospitalized older adults with mild cognitive impairment benefit from the HOME intervention, which involves preparation and post-discharge support in the environment, to reduce unplanned re-hospitalizations. Improved discharge outcomes in this at-risk subgroup following an occupational therapist-led intervention may enable best care delivery as patients transition from hospital to home. Trial registration The trial was registered before commencement (ACTRN12611000615987).

Abstract Background There is a need to provide a large amount of extra practice on top of usual rehabilitation to adults after stroke. The purpose of this study was to determine if it is feasible to add extra upper limb practice to usual inpatient rehabilitation and whether it is likely to improve upper limb activity and grip strength. Method A prospective, single-group, pre- and post-test study was carried out. Twenty adults with upper limb activity limitations who had some movement in the upper limb completed an extra hour of upper limb practice, 6 days per week for 4 weeks. Feasibility was measured by examining recruitment, intervention (adherence, efficiency, acceptability, safety) and measurement. Clinical outcomes were upper limb activity (Box and Block Test, Nine-Hole Peg Test) and grip strength (dynamometry) measured at baseline (week 0) and end of intervention (week 4). Results Of the 212 people who were screened, 42 (20%) were eligible and 20 (9%) were enrolled. Of the 20 participants, 12 (60%) completed the 4-week program; 7 (35%) were discharged early, and 1 (5%) withdrew. Participants attended 342 (85%) of the possible 403 sessions and practiced for 324 (95%) of the total 342 h. In terms of safety, there were no study-related adverse events. Participants increased 0.29 blocks/s (95% CI 0.19 to 0.39) on the Box and Block Test, 0.20 pegs/s (95% CI 0.10 to 0.30) on the Nine-Hole Peg Test, and 4.4 kg (95% CI 2.9 to 5.9) in grip strength, from baseline to end of intervention. Conclusions It appears feasible for adults who are undergoing inpatient rehabilitation and have some upper limb movement after stroke to undertake an hour of extra upper limb practice. The magnitude of the clinical outcomes suggests that further investigation is warranted and this study provides useful information for the design of a phase II randomized trial. Trial registration Australian and New Zealand Clinical Trial Registry (ACTRN12615000665538).

Introduction Health care expenditure has rapidly increased in Australia. Effective management of occupational therapy services is required to meet clinical demand. Improving our understanding of factors which influence occupational therapy service delivery is a vital step to manage workload distribution and optimise service efficiency. This study aims to examine the influence of patient sociodemographic characteristics, diagnosis and functional independence on the utilisation of occupational therapy resources in hospital inpatients over 18 years old. Methods Prospective, cross-sectional, observational cohort study of 4549 inpatients from three hospital sites in Melbourne, Australia. Data extracted from organisational databases and included in this study were: patient demographics, diagnosis, functional level assessed using the SMAF (Functional Autonomy Measurement System) and occupational therapy time-use. Data were analysed using univariable and multivariable modelling. Results Occupational therapy time-use was significantly associated with all variables included in analysis ( p

Objective: Evaluate the implementation of Good Life with osteoArthritis from Denmark (GLA:D®) for knee osteoarthritis in Australia using the RE-AIM QuEST (Reach, Effectiveness, Adoption, Implementation, Maintenance Qualitative Evaluation for Systematic Translation) framework. Design: Physiotherapists completed surveys before and after GLA:D® training (2017–2020) to assess practices, and barriers and enablers to implementation. Patients completed online baseline, 3-month (post-treatment) and 12-month patient reported outcomes. Effective implementation was defined as within-participant moderate effect size (ES, ≥0.50) for average pain (100 ​mm VAS) and Knee Injury and Osteoarthritis Outcome Score quality of life scores (KOOS-QoL), and small effect size (≥0.20) for health-related quality of life (EQ-5D-5L). Results: Reach: 1064 physiotherapists and 1945 patients from all states and territories participated. Key barriers included out-of-pocket cost to patients, and program suitability for culturally and linguistically diverse communities. Effectiveness: Following training, more physiotherapists reported discussing treatment goals and weight management, and prescribing supervised, neuromuscular exercise. Patient outcomes at 3- and 12-months (n ​= ​1044 [54%] and 927 [48%]) reflected effective implementation, including reduced pain (ES, 95%CI ​= ​0.72, 0.62–0.84; and 0.65, 0.54–0.77) and improved KOOS-QoL (0.79, 0.69–0.90; and 0.93, 0.81–1.04) and EQ-5D-5L (0.43, 0.31–0.54; and 0.46, 0.35–0.58) scores. Adoption: 297 sites (264 private, 33 public) implemented GLA:D®. Implementation: Most patients completed at least one education (90%), and 10 exercise-therapy (78%) sessions. Adequate staffing to support program delivery was a key enabler. Maintenance: 99% of sites (293/297) continued offering the program in July 2020. Conclusion: Training changed practice and was associated with effective widespread implementation of GLA:D® in Australia.

Background: Discharge planning is recommended to optimise the transition from acute care to home for patients admitted with stroke. Despite this guideline recommendation, many patients do not receive a discharge care plan. Also, there is limited evidence on factors influencing the provision of discharge care plan post-stroke. We evaluated patient, clinical and system factors associated with receiving a care plan on discharge from hospital back to the community after stroke. Methods: This was an observational cohort study of patients with acute stroke who were discharged to the community between 2009–2013, using data from the Australian Stroke Clinical Registry linked to hospital administrative data. For this analysis, we used merged dataset containing information on patient demographics, clinical characteristics, and receipt of acute care processes. Multivariable logistic regression models were used to determine factors associated with receiving a discharge care plan. Results: Among 7812 eligible patients (39 hospitals, median age 73 years, 44.7% female, 56.9% ischaemic stroke), 47% received a care plan at discharge. The odds of receiving a discharge care plan increased over time (odds ratio [OR] 1.39 per year, 95% CI 1.37–1.48), and varied between hospitals. Factors associated with receiving a discharge care plan included greater socioeconomic position (OR 1.18, 95% CI 1.02–1.38), diagnosis of ischaemic stroke (OR 1.18, 95% CI 1.05–1.33), greater stroke severity (OR 1.15, 95% CI 1.01–1.31), or being discharged on antihypertensive medication (OR 3.07, 95% CI 2.69–3.50). In contrast, factors associated with a reduced odds of receiving a discharge care plan included being aged 85+ years (vs300 beds; OR 0.30, 95% CI 0.10–0.92). Conclusions: Implementing practices to target people who are older, discharged to residential aged care, or discharged on a weekend may improve discharge planning and post-discharge care after stroke.

Background: Australian Primary Care Practitioners are incentivised through Medicare funded policies to provide chronic disease management and facilitate multidisciplinary care. Little is known about how these policies are claimed in the long-term management of stroke. The objective of this study was to describe the use of funded primary care policies for people with stroke by impairment status. Methods: Linked Australian Stroke Clinical Registry (2010–2014) and Medicare data from adults with 90–180 days post-stroke EQ-5D health status survey data and admitted to one of 26 participating Australian hospitals were analysed. Medicare item claims for Primary Care Practitioner led chronic disease management and multidisciplinary care coordination policies, during the 18 months following stroke are described. Registrants were classified into impairment groups using their EQ-5D dimension responses through Latent Class Analysis. Associations between impairment and use of relevant primary care policies were explored using multivariable regression. Results: 5432 registrants were included (median age 74 years, 44% female, 86% ischaemic), 39% had a chronic disease management claim and 39% a multidisciplinary care coordination claim. Three latent classes emerged representing minimal, moderate and severe impairment. Compared to minimal, those with severe impairment were least likely to receive chronic disease management (adjusted Odds Ratio (aOR): 0.61, 95% Confidence Interval (CI): 0.49, 0.75) but were most likely to receive multidisciplinary care coordination. Podiatry was the commonest allied health service prescribed, regardless of impairment. Conclusions: Less than half of people living with stroke had a claim for primary care initiated chronic disease management, with mixed access for those with severe impairments.

Introduction After first stroke, the transition from rehabilitation to home can be confronting and fraught with challenges. Although stroke clinical practice guidelines recommend predischarge occupational therapy home visits to ensure safe discharge and provision of appropriate equipment, there is currently limited evidence to support this recommendation.Methods and analysis The HOME Rehab trial is a national, multicentre, phase III randomised controlled trial with concealed allocation, blinded assessment and intention-to-treat analysis being conducted in Australia. The trial aim is to determine the effect and potential cost-effectiveness of an enhanced occupational therapy discharge planning intervention that involves pre and postdischarge home visits, goal setting and occupational therapy in the home (the HOME programme) in comparison to an in-hospital predischarge planning intervention. Stroke survivors aged ≥45 years, admitted to a rehabilitation ward, expected to return to a community (private) dwelling after discharge, with no significant prestroke disability will be randomly allocated 1:1 to receive a standardised discharge planning intervention and the HOME programme or the standardised discharge planning intervention alone. The primary outcome is participation measured using the Nottingham Extended Activities of Daily Living. Secondary outcome areas include hospital readmission, disability, performance of instrumental activities of daily living, health-related quality of life, quality of care transition and carer burden. Resources used/costs will be collected for the cost-effectiveness analysis and hospital readmission. Recruitment commenced in 2019. Allowing for potential attrition, 360 participants will be recruited to detect a clinically important treatment difference with 80% power at a two-tailed significance level of 0.05.Ethics and dissemination This study is approved by the Alfred Health Human Research Ethics Committee and site-specific ethics approval has been obtained at all participating sites. Results of the main trial and the secondary endpoint of cost-effectiveness will be submitted for publication in peer-reviewed journalsTrial registration numberACTRN12618001360202

Abstract Background Improving upper limb (UL) motor recovery after stroke represents a major clinical and scientific goal. We aim to complete three systematic reviews to estimate the (1) association between time to start of UL therapy and motor recovery, (2) relative efficacy of different UL therapy approaches post-stroke and (3) cost-effectiveness of UL therapy interventions. Methods We have designed a systematic review protocol to address three systematic review questions that were each registered with PROSPERO. The search will be conducted in MEDLINE, EMBASE, and Cochrane Controlled Register of Trials. We will include randomised controlled trials, non-randomised clinical trials, before-after studies and observational studies of adult stroke survivors with an average stroke onset

Abstract Background Priority-setting partnerships between researchers and stakeholders (meaning consumers, health professionals and health decision-makers) may improve research relevance and value. The Cochrane Consumers and Communication Group (CCCG) publishes systematic reviews in ‘health communication and participation’, which includes concepts such as shared decision-making, patient-centred care and health literacy. We aimed to select and refine priority topics for systematic reviews in health communication and participation, and use these to identify five priority CCCG Cochrane Reviews. Methods Twenty-eight participants (14 consumers, 14 health professionals/decision-makers) attended a 1-day workshop in Australia. Using large-group activities and voting, participants discussed, revised and then selected 12 priority topics from a list of 21 previously identified topics. In mixed small groups, participants refined these topics, exploring underlying problems, who they affect and potential solutions. Thematic analysis identified cross-cutting themes, in addition to key populations and potential interventions for future Cochrane Reviews. We mapped these against CCCG’s existing review portfolio to identify five priority reviews. Results Priority topics included poor understanding and implementation of patient-centred care by health services, the fact that health information can be a low priority for health professionals, communication and coordination breakdowns in health services, and inadequate consumer involvement in health service design. The four themes underpinning the topics were culture and organisational structures, health professional attitudes and assumptions, inconsistent experiences of care, and lack of shared understanding in the sector. Key populations for future reviews were described in terms of social health characteristics (e.g. people from indigenous or culturally and linguistically diverse backgrounds, elderly people, and people experiencing socioeconomic disadvantage) more than individual health characteristics. Potential interventions included health professional education, interventions to change health service/health professional culture and attitudes, and health service policies and standards. The resulting five priority Cochrane Reviews identified were improving end-of-life care communication, patient/family involvement in patient safety, improving future doctors’ communication skills, consumer engagement strategies, and promoting patient-centred care. Conclusions Stakeholders identified priority topics for systematic reviews associated with structural and cultural challenges underlying health communication and participation, and were concerned that issues of equity be addressed. Priority-setting with stakeholders presents opportunities and challenges for review producers.

Abstract Background Organizational context is one factor influencing the translation of evidence into practice, but data pertaining to patients with acute stroke are limited. We aimed to determine the associations of organizational context in relation to four important evidence-based stroke care processes. Methods This was a mixed methods cross-sectional study. Among 19 hospitals in Queensland, Australia, a survey was conducted of the perceptions of stroke clinicians about their work using the Alberta Context Tool (ACT), a validated measure covering 10 concepts of organizational context, and with additional stroke-specific contextual questions. These data were linked to the Australian Stroke Clinical Registry (AuSCR) to determine the relationship with receipt of evidence-based acute stroke care (acute stroke unit admission, use of thrombolysis for those with acute ischemic stroke, receipt of a written care plan on discharge, and prescription of antihypertensive medications on discharge) using quantile regression. Exploratory cluster analysis was used to categorize hospitals into high and low context groups based on all of the 10 ACT concepts. Differences in adherence to care processes between the two groups were examined. Results A total of 215 clinicians completed the survey (50% nurses, 37% allied health staff, 10% medical practitioners), with 81% being in their current role for at least 1 year. There was good reliability (∞ 0.83) within the cohort to allow pooling of professional groups. Greater ACT scores, especially for social capital (μ 9.00, 95% confidence interval [CI] 4.86 to 13.14) and culture (μ 7.33, 95% CI 2.05 to 12.62), were associated with more patients receiving stroke unit care. There was no correlation between ACT concepts and other care processes. Working within higher compared to lower context environments was associated with greater proportions of patients receiving stroke unit care (88.5% vs. 69.0%) and being prescribed antihypertensive medication at discharge (62.5% vs. 52.0%). Staff from higher context hospitals were more likely to value medical and/or nursing leadership and stroke care protocols. Conclusions Overall organizational context, and in particular aspects of culture and social capital, are associated with the delivery of some components of evidence-based stroke care, offering insights into potential pathways for improving the implementation of proven therapies.

We present information on acute stroke care for the first wave of the COVID-19 pandemic in Australia using data from the Australian Stroke Clinical Registry (AuSCR). The first case of COVID-19 in Australia was recorded in late January 2020 and national restrictions to control the virus commenced in March. To account for seasonal effects of stroke admissions, patient-level data from the registry from January to June 2020 were compared to the same period in 2019 (historical-control) from 61 public hospitals. We compared periods using descriptive statistics and performed interrupted time series analyses. Perceptions of stroke clinicians were obtained from 53/72 (74%) hospitals participating in the AuSCR (80% nurses) via a voluntary, electronic feedback survey. Survey data were summarized to provide contextual information for the registry-based analysis. Data from the registry covered locations that had 91% of Australian COVID-19 cases to the end of June 2020. For the historical-control period, 9,308 episodes of care were compared with the pandemic period (8,992 episodes). Patient characteristics were similar for each cohort (median age: 75 years; 56% male; ischemic stroke 69%). Treatment in stroke units decreased progressively during the pandemic period (control: 76% pandemic: 70%, p < 0.001). Clinical staff reported fewer resources available for stroke including 10% reporting reduced stroke unit beds. Several time-based metrics were unchanged whereas door-to-needle times were longer during the peak pandemic period (March-April, 2020; 82 min, control: 74 min, p = 0.012). Our data emphasize the need to maintain appropriate acute stroke care during times of national emergency such as pandemic management.

IntroductionThis systematic review appraises the measurement quality of tools which assess activity and/or participation in adults with upper limb spasticity arising from neurological impairment, including methodological quality of the psychometric studies. Differences in the measurement quality of the tools for adults with a neurological impairment, but without upper limb spasticity, is also presented.Methods29 measurement tools identified in a published review were appraised in this systematic review. For each identified tool, we searched 3 databases (Medline, Embase, CINAHL) to identify psychometric studies completed with neurorehabilitation samples. Methodological quality of instrument evaluations was assessed with use of the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist. Synthesis of ratings allowed an overall rating of the psychometric evidence for each measurement tool to be calculated.Results149 articles describing the development or evaluation of psychometric properties of 22 activity and/or participation measurement tools were included. Evidence specific to tool use for adults with spasticity was identified within only 15 of the 149 articles and provided evidence for 9 measurement tools only. Overall, COSMIN appraisal highlighted a lack of evidence of measurement quality. Synthesis of ratings demonstrated all measures had psychometric weaknesses or gaps in evidence (particularly for use of tools with adults with spasticity).ConclusionsThe systematic search, appraisal and synthesis revealed that currently there is insufficient measurement quality evidence to recommend one tool over another. Notwithstanding this conclusion, newer tools specifically designed for use with people with neurological conditions who have upper limb spasticity, have emergent measurement properties that warrant further research.Systematic review registrationPROSPERO CRD42014013190.

Introduction Recent advances in Australia mean that it is possible to link national clinical registries with government held administrative datasets. However, formal evaluations of such activities and the potential impact for research are lacking. Objectives and Approach We aimed to assess the feasibility and accuracy of linking registrants from the Australian Stroke Clinical Registry (AuSCR) with the Medicare enrolment file. Following data custodian and ethics approvals, personal linkage identifiers were submitted to the Australian Institute of Health and Welfare (AIHW). De-identified data from AuSCR and the AIHW were submitted into the Secure Unified Research Environment and merged using project specific person-based IDs. We calculated the proportion of patients linked with the Medicare enrolment file that were present in the associated Medicare and medication dispensing datasets and the proportion with claims after their date of death. Logistic regression was used to identify factors associated with a non-merged patient. Results 17,980 AuSCR registrants (January 2010-July 2014) were submitted for linkage (median age 76 years; 46% female; 67% ischaemic stroke; 16% TIA). Of these, 93% were merged with Medicare (N=16,648) and 95% with subsidised medication dispensing claims data (N=17,079). In those who died, 127 (0.8%) had one or more Medicare claim and 411 (2.4%) had one or more medications dispensed after their death date. Asian born registrants were less likely to be merged with Medicare (adjusted Odds Ratio [aOR]: 0.54; 95% Confidence Interval [CI]: 0.40, 0.72) than Australian born registrants. Those aged ≥85 years were less likely to be merged with Medicare data than those aged

Background Hand and arm activity after stroke improves with evidence-based rehabilitation. Therapists face known barriers when providing evidence-based rehabilitation and require support to implement guidelines. The aim of this study was to investigate the feasibility of two implementation packages on guideline adherence by occupational therapists and physiotherapists, and explore effect on patient upper limb outcomes.Method This was a non-randomised clustered feasibility study of occupational and physiotherapy rehabilitation services (n=3 inpatient and n=3 outpatient services). Services were allocated to one of three groups: (group A) facilitator-mediated implementation package, (group B) self-directed implementation package or (group C) usual care (control); we recruited n=1 inpatient and n=1 outpatient service per group. Outcomes of feasibility, adherence to guidelines (medical file audits) and patient upper limb impairment (Fugl-Meyer Upper Extremity Assessment), activity (Box and Block Test) and practice (minutes/week) were collected at baseline and after 3 months of intervention.Results 29 therapists (8 in group A, 13 in groups B and 8 in group C) and 55 patients participated. Both the facilitator-mediated and the self-directed implementation packages were feasible to deliver in the rehabilitation setting. Therapists in group A improved with respect to guideline adherence (medical file audits; median within-group proportion difference of 0.29 (95% CI 0.22 to 0.36, p

Introduction: Despite an increase in the quality of clinical trials in stroke recovery, interventions have failed to markedly impact the trajectory of recovery after stroke. Failure may be due to the lack of consideration for the complexity of dose and its articulation within research trials. Prior to commencing the scoping review, we identified two research gaps to be addressed. Firstly, transparent application of a multidimensional definition of dose to clinical trial phases and secondly, the development of a quality tool to critique the articulation of dose across the pipeline. Building on this, we present the protocol for a scoping review that aims to synthesis what is known about dose articulation in stroke recovery in preclinical and clinical populations, and characterize research designs and statistical approaches used in dose articulation trials, and the associated advantages and disadvantages.Methods: The scoping review will apply Arksey and O'Malley's methodological framework. Two systematic searches that target preclinical and clinical literature will be run in Medline and Embase, which will be complimented by consultation with field experts and hand searching of included trials and relevant reviews. Search results will be imported into Covidence for transparent management. One reviewer will screen all abstracts and titles. Two reviewers will screen full text and a third reviewer included to resolve discrepancies. A standardized data charting form will be used to extract information and appraise the intervention description, risk of bias, and quality of both preclinical and clinical studies. Results will be summarized in tabular and narrative format to inform the development of recommendations for future research. Ethics approval is not required as data used will be secondary and de-identified.Conclusion: Development of a new quality tool to appraise the quality of both preclinical and clinical dose studies may serve to strengthen collaborative efforts between the fields. The findings from this review will advance the use of a discovery pipeline in stroke recovery research to ultimately inform clinical practice.