PURPOSE:Robot-assisted lower limb rehabilitation (RALLR) may be an effective adjunct to conventional therapy for those with neurological conditions. Robot-assisted rehabilitation is emerging in Western Australia (WA) and local perspectives on this technology have not been explored. This study aimed to explore perspectives of WA clinicians on RALLR, to inform further implementation. METHODS:This was a cross-sectional survey of neurorehabilitation clinicians across metropolitan WA. A subset of respondents completed semi-structured interviews. Transcripts were analysed thematically. RESULTS:Fifty-six clinicians (across four professions) completed the survey. Eleven participated in an interview. The majority of clinicians expressed interest in upskilling in rehabilitation robotics (87.5%, n = 49) and incorporating robotics into their clinical practice (78.6%, n = 44). Access to devices, device practicality and clinician confidence using technology were identified as barriers to RALLR implementation. Comprehensive experiential learning, ongoing technical support and knowledge sharing were identified as key implementation facilitators. Suggestions for an optimised RALLR service in WA were discussed. CONCLUSION:Most clinicians supported broader implementation of RALLR in WA. Successful integration will require coordinated clinician, organisational and health-system wide collaboration. Sustainable funding models, comprehensive workforce training, accessible technical support and consultation with clinicians and people with neurological conditions are priorities for RALLR optimisation.

PURPOSE:Explore perspectives of people living with neurological conditions in Western Australia (WA) on robot-assisted lower limb neurorehabilitation (RALLR), and implementation requirements. MATERIALS AND METHODS:This co-designed, qualitative descriptive study included people living with neurological conditions. In-person semi-structured focus groups (FGs) were facilitated by a person with lived experience of stroke. FGs were recorded, data were transcribed, and thematically analysed using a reflexive approach. RESULTS:Five FGs included 24 participants (54.2% women, median age 50 years). Of these, thirteen participants had RALLR experience. Primary neurological conditions represented among participants comprised spinal cord injury (n = 11), stroke (n = 3), multiple sclerosis (n = 2), and other conditions (n = 8). Three main themes were established: perceived benefits (physiological, psychosocial, therapy, ambulation, independence, and pain), barriers (awareness, access, cost, psychological challenges, and device limitations), and recommendations for future implementation in WA (access, design, and purpose of robotic devices). CONCLUSIONS:This study highlights the desire for improved access to RALLR among people living with neurological conditions in WA. Participants acknowledged multiple benefits of RALLR; however, addressing financial, design, and availability barriers of RALLR are necessary for successful adoption. Future efforts should prioritise accessibility in both metropolitan and regional areas, optimise device usability, and foster interdisciplinary collaboration in RALLR integration.

Background Post-stroke lateropulsion is prevalent and associated with poor rehabilitation outcomes; however, data regarding long-term function associated with lateropulsion are lacking. Objectives This study aimed to explore lateropulsion resolution and associations between lateropulsion, functional outcomes, and fall occurrence up to 12 months post-stroke. Methods Participants for this prospective, longitudinal cohort study were recruited from a Stroke Rehabilitation Unit (SRU). Assessments were conducted at SRU admission, at discharge, and at three, six, nine, and twelve months post-stroke. Outcomes included the Four-Point Pusher Score (4PPS), Functional Independence Measure (FIM), and fall occurrence. Longitudinal outcomes were modeled using generalized linear mixed-effects models. Results The final analyses included data from 144 participants. Eighty-two participants (56.9) had lateropulsion (4PPS >= 1) on admission. Odds of resolved lateropulsion (4PPS = 0) increased longitudinally from discharge for people who participated in rehabilitation physiotherapy (OR: 9.7, 28.1, 43.1, 81.3: <0.001 at three, six, nine, and twelve months respectively). The greatest FIM improvement among participants in all 4PPS categories occurred during the SRU inpatient phase. The probability of falls post-discharge was greatest among participants with 4PPS = 1 at three months, when compared with 4PPS = 0 (p= 0.022). Conclusions This study showed that lateropulsion can continue to resolve up to one year post-stroke. Earlier lateropulsion resolution was associated with ongoing rehabilitation physiotherapy participation. Long-term functional gains were maintained among people discharged home, whereas functional status deteriorated after six months among those in residential care. Study findings will allow rehabilitation and service providers to better plan for and accommodate the long-term rehabilitation and care needs of people with post-stroke lateropulsion.

BackgroundPost-stroke lateropulsion is prevalent and has been associated with varied lesion locations, but existing imaging studies are limited by small participant cohorts. Evidence to guide lateropulsion rehabilitation is also limited. Improved understanding of lesion localization associated with lateropulsion post-stroke may inform more targeted intervention approaches.ObjectivesThis study investigated the associations between stroke neuroimaging data and presence of lateropulsion at inpatient rehabilitation admission.MethodsThis prospective, observational study included participants aged >= 65 years, admitted for inpatient stroke rehabilitation. Using routinely collected clinical neuroimaging data, stroke type, location, and volume were reported, and their association with lateropulsion presence (Four-Point Pusher Score - 4PPS) at admission was explored.ResultsOf 144 included participants, 82 (56.9%) had lateropulsion (4PPS >= 1). Lateropulsion presence was univariately associated with hemorrhagic stroke (p = 0.002), frontal cortical involvement (OR = 2.17, 95%CI 1.02-6.46), and white matter involvement (OR = 2.45, 95%CI 1.24-4.85), particularly frontal white matter (p = 0.021). Lesions involving the posterior limb of the internal capsule (OR = 2.88, 95% CI 1.14-7.27) and those involving the entire thalamus (OR = 1.0, p = 0.03) were associated with lateropulsion presence. When stratified by stroke type, no specific location was significantly associated with lateropulsion presence in hemorrhagic strokes. Among participants with ischemic stroke, involvement of the pre-central gyrus (OR = 2.45, 95%CI 1.05-5.76), post-central gyrus (OR = 2.76, 95%CI 1.15-6.60), inferior parietal cortex (OR = 3.95, 95%CI 1.43-10.90), and supramarginal gyrus (OR = 3.73, 95%CI 1.25-11.13) were associated with lateropulsion presence. The stroke laterality and size were not significantly associated with lateropulsion presence.ConclusionsThe findings indicate a role of network disconnection in the post-stroke lateropulsion presence. Future, larger-cohort lesion-network mapping studies are recommended.

BackgroundPost-stroke lateropulsion is prevalent and associated with poor rehabilitation outcomes, but evidence to guide rehabilitation of affected stroke survivors is limited. Current post-stroke lateropulsion rehabilitation practice across Australia and New Zealand has not been previously described.ObjectivesThis study aimed to describe lateropulsion rehabilitation practice in Australia and New Zealand, determine clinicians,' educators' and researchers' opinions about the need for educational resources to guide best-practice, and to identify current barriers to, and enablers of, optimal rehabilitation delivery.MethodsThis cross-sectional survey was distributed to stroke rehabilitation clinicians, educators and researchers across Australia and New Zealand using Qualtrics. Data were described using frequency distributions and Chi-squared tests. Responses to open-ended questions were summarized for reporting.ResultsThe final analyses included 127 surveys. Most participants (93%) were physiotherapists. The importance of identifying and assessing post-stroke lateropulsion was noted by 97.6% of participants; however routine lateropulsion assessment was reported by only 60.6% of respondents. About 93.6% of participants indicated that lateropulsion should be targeted as a rehabilitation priority. Limitations in knowledge and skill among clinicians and insufficient evidence to guide rehabilitation were noted as barriers to best-practice rehabilitation delivery. Most respondents (95.2%) indicated that lateropulsion management should be included in stroke rehabilitation guidelines.ConclusionsA sample of clinicians, educators, and researchers involved in stroke rehabilitation across Australia and New Zealand have indicated that lateropulsion should be targeted as a rehabilitation priority. Knowledge and skill were identified as barriers to best-practice rehabilitation implementation, which could be improved by addressing lateropulsion in clinical practice guidelines.

Objective People exhibiting post-stroke lateropulsion actively push their body across the midline to the more affected side and/or resist weight shift toward the less affected side. Despite its prevalence and associated negative rehabilitation outcomes, no clinical practice guidelines exist for the rehabilitation of post-stroke lateropulsion. We aimed to develop consensus-based clinical practice recommendations for managing post-stroke lateropulsion using an international expert panel. Design This Delphi panel process conformed with Guidance on Conducting and Reporting Delphi Studies recommendations. Participants Panel members had demonstrated clinical and/or scientific background in the rehabilitation of people with post-stroke lateropulsion. Main Measures The process consisted of four electronic survey rounds. Round One consisted of 13 open questions. Subsequent rounds ascertained levels of agreement with statements derived from Round One. Consensus was defined a priori as ≥75% agreement (agree or strongly agree), or ≥70% agreement after excluding ‘unsure’ responses. Results Twenty participants completed all four rounds. Consensus was achieved regarding a total of 119 recommendations for rehabilitation approaches and considerations for rehabilitation delivery, positioning, managing fear of falling and fatigue, optimal therapy dose, and discharge planning. Statements for which ‘some agreement’ (50%–74% agreement) was achieved and those for which recommendations remain to be clarified were recorded. Conclusions These recommendations build on existing evidence to guide the selection of interventions for post-stroke lateropulsion. Future research is required to elaborate specific rehabilitation strategies, consider the impact of additional cognitive and perceptual impairments, describe positioning options, and detail optimal therapy dose for people with lateropulsion.

Background: Acquired brain injury (ABI) can result in severe physical impairment causing difficulty with moving which, if not actively managed, can lead to contracture and deformity. Delayed access to rehabilitation may result in more contracture, with potential to increase duration of rehabilitation, cost and therapy time required. Objective: Describe the amount of therapy input for patients undergoing specialist in-patient rehabilitation following ABI, the differences in the type of therapy received by people with and without contracture and/or spasticity, and the impacts on functional outcomes including care needs and cost of care. Materials and Methods: A cohort analysis of prospectively collected data from 426 patients with ABI in a UK tertiary inpatient rehabilitation program. The Neurological impairment Scale (NIS) was used to identify the presence of spasticity or contracture. The Northwick Park Therapy Dependency Assessment (NPTDA) was used to calculate the therapy hours and type of treatment provided to people with and without spasticity and/or contracture. Outcomes (change in function and independence) were compared including the UK Functional Assessment Measure (UK FIM+FAM). Results: The Male/Female ratio was 63:37% with a mean age: 44.0(SD 13) years and a mean length of stay in specialist inpatient rehabilitation: 103 (SD 49) days. Aetiology: Stroke (63%), Trauma (20%); Hypoxia (7%): Other (10%). Patients with contractures were significantly more dependent than those without, both on admission and discharge. They stayed on average 31 days longer (95%CI 21.1, 40.5) (P=0.001) with an additional mean episode cost of £25,588 (95%CI £18.085, 34,043) (P<0.001). Despite this, they made similar overall functional gains resulting in similar long-term savings in the cost of ongoing care. Conclusion: Routine collection of the NPTDA supported quantification of the impact of spasticity and contracture on therapy inputs, length of stay, functional gains, and costs. People with contractures following ABI require more therapy time in rehabilitation to achieve similar functional gains, but nevertheless were cost-efficient to treat.

Background Lateropulsion is a common impairment after stroke. Regardless of stroke severity, functional recovery is slower in people with lateropulsion, resulting in requirement for longer rehabilitation duration. In Australia, inpatient rehabilitation funding is determined via the Australian National Sub-Acute and Non-Acute Patient Classification (AN-SNAP). AN-SNAP class is determined using age, diagnosis, weighted Functional Independence Measure (FIM) motor score, and FIM cognitive score. Objectives To explore accuracy of the AN-SNAP to predict length of stay (LOS) for people with poststroke lateropulsion. Methods A retrospective database audit was undertaken. AN-SNAP predicted LOS for each participant was calculated based on 2019 calendar year national benchmarks. A multivariable linear regression model estimated mean differences in reported LOS and AN-SNAP predicted LOS after adjusting for lateropulsion severity (Four Point Pusher Score). A separate logistic regression model assessed whether FIM change during admission was associated with reported LOS exceeding AN-SNAP predicted LOS. Results Data were available from 1126 admissions. Reported LOS exceeding AN-SNAP predicted LOS was associated with greater lateropulsion severity on admission. Where AN-SNAP predicted LOS was longer, those with no lateropulsion on admission showed shorter reported than predicted LOS. Greater improvement in FIM during rehabilitation was associated with increased odds of reported LOS exceeding AN-SNAP predicted LOS (OR 1.02, 95%CI 1.01-1.03, p < .001). Conclusions Inclusion of a measure of poststroke lateropulsion in the AN-SNAP classification model would result in more accurate LOS predictions to inform funding. Costs of longer rehabilitation LOS may be countered by optimized long-term physical function, reducing requirement for ongoing care.

Purpose A person with post-stroke lateropulsion pushes their body toward their hemiparetic side and/or resists accepting weight onto their nonparetic side. Research findings regarding long-term persistence of lateropulsion and its association with function are lacking. This study reports associations between lateropulsion severity (Four Point Pusher Score - 4PPS) and functional outcome (Functional Independence Measure - FIM) at three months after discharge. Methods This prospective cohort study included 41 consecutive admissions to a stroke rehabilitation unit. Lateropulsion severity and FIM were measured at admission, discharge and three-month follow-up. Lateropulsion status at discharge, stroke laterality, ongoing physiotherapy after discharge, and demographic variables (age and sex) were tested for association with FIM change over the follow-up period. Results Complete data were available for 38 participants. Among these, 17 (44.7%) showed lateropulsion (4PPS ≥ 1) on admission, 9 (23.7%) showed persistent lateropulsion on discharge, and 7 (18.4%) showed persistent lateropulsion at three month follow-up. Improved functional status (FIM score) was seen at follow-up in those discharged with lateropulsion who had right-sided lesions but not in those with left-sided lesions. Conclusions Lateropulsion can continue to resolve after discharge from inpatient rehabilitation. Larger cohort studies are needed to further explore associations between persistent lateropulsion and long-term outcomes.

Post-stroke lateropulsion is prevalent. The global inconsistency in terminology used to describe the condition presents obstacles in accurately comparing research results, reaching consensus on use of measurement tools, agreeing upon a consistent approach to rehabilitation, and translating research to clinical practice. Commencing in 2021, 20 international experts undertook a Delphi Process that aimed to compile clinical practice recommendations for the rehabilitation of lateropulsion. As a part of the process, the panel agreed to aim to reach consensus regarding terminology used to describe the condition. Improved understanding of the condition could lead to improved management, which will enhance patient outcomes after stroke and increase efficiency of healthcare resource utilisation. While consensus was not reached, the panel achieved some agreement that 'lateropulsion' is the preferred term to describe the phenomenon of 'active pushing of the body across the midline toward the more affected side, and / or actively resisting weight shift toward the less affected side'. This group recommends that 'lateropulsion' is used in future research and in clinical practice.

Background: Contraversive lateropulsion is a common post-stroke impairment. Rehabilitation outcomes in stroke survivors exhibiting lateropulsion may differ from those without lateropulsion.Objectives: To systematically review evidence regarding associations between:1. Presence/severity of lateropulsion after stroke and functional outcome, rehabilitation length of stay, and discharge destination;2. Stroke-related factors and resolution of lateropulsion, functional outcome, rehabilitation length of stay, and discharge destination in affected stroke survivors.Methods: Medline, CINAHL, and Embase databases were searched. Journal articles published in English reporting on resolution of lateropulsion, length of stay, functional outcome, and/or discharge destination associated with post-stroke lateropulsion were included for review. Studies that did not include a comparison group (stroke survivors without lateropulsion, or sub-groups of participants with lateropulsion based on stroke-related factors), animal studies, and studies reporting only on ipsiversive lateropulsion and/or lateral medullary syndrome were excluded. Two authors independently assessed studies for inclusion. Included studies were evaluated using the Risk of Bias Assessment Tool for Nonrandomized Studies.Results: Screening identified 133 articles. Seven articles met inclusion criteria. People with contraversive lateropulsion after stroke can achieve similar improvements in function as those without lateropulsion, increasing likelihood of discharge home, but require longer rehabilitation durations to do so.Conclusions: The finding that longer rehabilitation durations are required for people with post-stroke lateropulsion to achieve their functional potential and increase likelihood of discharge home has implications for resourcing rehabilitation services. Given an additional three to four weeks in rehabilitation, people with post-stroke lateropulsion can achieve functional improvements function similar to those without lateropulsion.

Abstract Purpose A person with post-stroke lateropulsion actively pushes themselves toward their hemiplegic side, or resists moving onto their non-hemiplegic side. This study aimed to determine the association of lateropulsion severity with: • Change in function (Functional Independence Measure – FIM) and lateropulsion severity (Four-Point Pusher Score – 4PPS) during inpatient rehabilitation; • Inpatient rehabilitation length of stay (LOS); • Discharge destination from inpatient rehabilitation. Methods Retrospective data for 1,087 participants (aged ≥65 years) admitted to a stroke rehabilitation unit (2005–2018) were analysed using multivariable regression models. Results Complete resolution of lateropulsion was seen in 69.4% of those with mild lateropulsion on admission (n = 160), 49.3% of those with moderate lateropulsion (n = 142), and 18.8% of those with severe lateropulsion (n = 181). Average FIM change was lower in those with severe lateropulsion on admission than those with no lateropulsion (p < 0.001). Higher admission 4PPS was associated with reduced FIM efficiency (p < 0.001), longer LOS (p < 0.001), (adjusted mean LOS: 35.6 days for those with severe lateropulsion versus 27.0 days for those without), and reduced likelihood of discharge home (p < 0.001). Conclusion Post-stroke lateropulsion is associated with reduced functional improvement and likelihood of discharge home. However, given a longer rehabilitation duration, most stroke survivors with moderate to severe lateropulsion can achieve important functional improvement. Implications for Rehabilitation While people with post-stroke lateropulsion can be difficult to treat and require more resources than those without lateropulsion, the majority of those affected, even in severe cases, can make meaningful recovery with appropriate rehabilitation. Although those with moderate to severe post-stroke lateropulsion may have poorer outcomes (longer LOS and reduced likelihood of discharge home) it is still important to advocate for access to rehabilitation for this patient group to give them the opportunity for optimal functional recovery.

Purpose: To explore factors influencing physical activity (PA) reported by people living in rural/semi-rural communities in the south of England post-stroke, and to understand relationships between personal, interpersonal and environmental barriers and self-reported levels of PA. Method: A survey was mailed to patients of NHS Trusts who were identified as potential participants. Self-reported PA levels, type, and frequency of reported barriers were tabulated. Spearman's rank correlation coefficient was used to explore associations between self-reported PA level and: age, gender, level of physical function, fear of falling, beliefs regarding PA, available supports, and socioeconomic status. Results: Seventy-six of 322 questionnaires distributed were returned (24%). Only 55.2% of respondents reported undertaking PA of sufficient intensity to meet current guidelines. Personal barriers included fear of falling, stroke-related disability, pain, and fatigue. Interpersonal and environmental barriers included lack of social support, transport, and inclement weather. Significant relationships existed between self-reported PA and fear of falling, functional mobility, and beliefs relating to PA. Conclusions: Almost half of the survey cohort reported PA levels insufficient to meet current guidelines. Similar to barriers reported in previous studies in USA and other parts of the UK, numerous interlinking and overlapping personal, interpersonal, and environmental barriers to undertaking PA were identified.

Background/Aims: This study explored the applicability of the UK Bridges stroke self-management programme for use in an Australian health care context, and specifically, the need for any modification to the workbook tool. Methods: Data were collected via survey from Australian stroke professionals who had attended a 2-day Bridges training workshop and from focus groups with community-based stroke survivors across three different states. Findings: A total of 18 out of 30 workshop attendees (60%) completed the electronic survey. Most (94%) agreed that the training had advanced their practice with a stronger focus on self-management principles and that they would recommend the training to colleagues. The majority (71%) had incorporated some Bridges stroke self-management programme principles or strategies into their practice; although 81% reported a range of barriers to doing so. A total of 26 stroke survivors attended focus groups. The workbook was considered to be a useful tool to support self-management. Suggestions for change included the addition of some culturally contextualised patient stories and locally relevant stroke support resources. Conclusions: Stroke survivors and health professionals recognised the need for structured training, such as the Bridges stroke self-management programme, to develop self-management skills and knowledge post stroke. The Bridges stroke self-management programme workbook would be able to be used in Australia with minor modification.

This article describes the use of an activity worksheet and questionnaire to investigate the learning experience of students on clinical placement. The worksheet measures the amount of time students spend in different learning activities, and the questionnaire explores student satisfaction and preferred learning activities.

Aim: To explore the relationship between balance deficit, falls, and activities of daily living in a cohort with Charcot-Marie-Tooth disease. Method: A cohort survey of individuals with Charcot-Marie-Tooth disease attending a neurogenetic clinic was carried out. Surveys were sent to individuals on a database of a state-wide neurogenetic service located in Perth, Australia. Results: Out of 71 surveys, 40 were returned (56%). The cohort were predominantly male (68%), the average age was 55.5 years (range 18–84) and average age at symptom onset was 23 years (range 5–65). Excluding skeletal foot changes, balance deficits (87.5%) and loss of balance confidence (90%) were the most frequently rated symptoms and those most severely affecting physical functioning (71% and 64% respectively). Ankle splinting was frequently reported in this population (65%). The majority of participants (69%) had fallen at least once in the past year and 40% of fallers reported having never seen a physiotherapist. Conclusions: Despite balance deficits and loss of balance confidence being frequently reported to impact daily activities, and falls and near-falls being common in this cohort with Charcot-Marie-Tooth disease, more than a third had not seen a physiotherapist. Future management to reduce the disease burden should investigate the effects of a timely multidisciplinary approach to manage balance dysfunction, and strategies to reduce falls in this population.

Background/Aims: To explore the beliefs and attitudes of potential referrers and referrees regarding the possible utilisation of early supported discharge (ESD) prior to hospital discharge.Methods: Semi-standardised one-to-one interviews were conducted with nine consultants and ten dyads, comprising inpatients and corresponding treating staff members involved in referral of these patients to ESD. Content analysis was completed to identify key themes and to group the data into categories.Results: Rehabilitation consultants reported safety and the ability to manage at home were the primary considerations in ESD referral decision making. Most patients were extremely likely to agree to referral to ESD. Four main categories were identified in the responses from the patient/staff dyads, which were summarised as: positive and negative aspects of ESD, and barriers and enablers to early discharge. Patients were only willing to return home with ESD once they were ambulant in some capacity. Staff identified considerably more potential disadvantages, and fewer benefits than patients with regard to early discharge. However, there was no indication that staff beliefs had a negative influence on patient views regarding their participation in ESD.Conclusions: Patients and staff generally approved of ESD services; however, staff may need to place greater consideration on advantages, such as the potential emotional and mental benefits that some patients associate with returning home sooner with ESD.