Posts Tagged practice

[BLOG POST] Talking About Your Injury

First, let’s review some general ideas. Many survivors initially think that few people know about their injury. After all, if the survivors did not tell others, how would they know? The reality is usually different. Sometimes, the injury event was on the news. For instance, if a survivor was in a major car accident or shooting, it generally made the news. Also, following an injury, family members may make prayer requests through social media or religious institutions. In this case, everyone who is connected via social media or anyone is part of the religions institution is aware of the injury event. Moreover, a brain injury is a big piece of news. Once one person hears about it, they are likely to “share the news” with friends from work, school or other social environments. Overall, information often makes the rounds to people you know quite quickly. However, the information is often piecemeal and occasionally, inaccurate.

With this in mind, the guiding principle when talking to others about your injury should that you give honest information in a manner that will engender others to have appropriate confidence in you. In some cases, people may be truly confused or concerned how you are doing and are using questions as a sort of gauge of health. The better you handle the situation, the more likely the other person will walk away with confidence in you.

Here are a few pieces of advice regarding talking about your injury:

  1. Always keep in mind who the person is that you are speaking with. For instance, is this a friend or an acquaintance? Is this person trustworthy to keep information private or likely to share it with everyone? Do I have a personal relationship or a professional relationship with this person? These factors will influence what you will share (or not share) with the other person.
  2. Whenever possible, keep information short and with limited detail. Remember, once you have said something, you cannot take back the information and the person you are speaking with may share that information with many others. Also, the less details you give, the less opportunity you are giving the other person to ask probing, sometimes uncomfortable, questions.
  3. Be sure to have a good exit/”no thank you” line. Not everyone has a right to your information and there are times you will not want to talk about your injury. A good exit line usually involves saying something nice, making your request and ending with something nice. For example: “Thank you for your concern but I really don’t enjoy talking about my recent health issues. However, I really appreciate that you cared so much to check on me.”
  4. Always tell the truth. If you tell a lie, there are two possible unpleasant outcomes. One, if the other person finds out that you deliberately lied, this can ruin the relationship. Second, if you tell a lie and the other person realizes the information is wrong but falsely thinks that you actually believe the lie, the other person will assume that you are quite confused.
  5. Be aware that you know a lot of medical/health terms that other people will not know, will not understand or even misunderstand. The average person on the street does not know terms such as “hemiplegia” or ” homonymous hemianopsia .” Using terms that other people do not understand may overwhelm the other person. Also, there are some terms that others may misunderstand. For instance, if you say that you are in “rehabilitation”, other people may falsely assume that you have a substance abuse problem. It may be better to say, “I have been working on my recovery from my injury” or “I have been in injury rehabilitation” rather than saying “I have been in rehabilitation.”
  6. Do not exaggerate or embellish your injury experience. Your story is already powerful and does not need any help. Also, exaggerating or embellishing may make the experience seem worse and cause other people to lose confidence in you.
  7. Be careful about using humor. Many people will not find much humor in your injury experience and may take too much humor to mean that you do not appreciate the seriousness of your injury. Again this could lead to a loss in confidence in your skills.
  8. Always ask questions of the other person. If the other person gets to ask all of the questions and you have to give all of the answers, eventually the friendly conversation may feel like an interrogation. The best way to balance the power is to ask questions of the other person, such as how are things going for their spouse, children or job.
  9. Practice your responses. When you are asked questions, the way to engender confidence is to have great responses. The best method to ensure you have great responses is to practice, out loud, your responses. This way, you can hear how your answers actually sound when coming from your mouth (which often sound different than how you imagine them in your mind) and practice different potential responses. It is often helpful to practice with a trusted loved one and/or to record and review your responses. This will help you find the best and most natural responses to questions.

These were just a few ideas and suggestions when talking to other about your injury. Always remember the key principle of giving honest responses that engender confidence!

Learn about brain injury treatment services at the Transitional Learning Center! Visit us at:


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[ARTICLE] In inpatient rehabilitation, large amounts of practice can occur safely without direct therapist supervision: an observational study – Full Text



When a hospital gymnasium used for inpatient rehabilitation is set up to allow semi-supervised practice: what percentage of practice is performed as semi-supervised practice, what percentage of patients in the gym are actively engaged in practice at one time, and is the semi-supervised practice that occurs safe?


An observational study using periodic behaviour mapping.


Patients in general and stroke rehabilitation units of a metropolitan hospital.

Outcome measures

Observations in the rehabilitation gym quantified the number of patients in the gym and the numbers of patients practising and resting. In observations of patients practising, the condition of practice was recorded as being with a therapist, with a family member, or with no direct supervision. The number of adverse events during the data collection period was collected from the hospital Incident Information Management System.


The rehabilitation gym was observed on 113 occasions, resulting in 1319 individual patient observations. An average of 12 patients were in the gym during the observations. Practice was being performed with family supervision in 15% of observations and with no direct supervision in 26% of observations, resulting in semi-supervised practice accounting for 41% of all observations of practice. The percentage of observations that were of patients taking part in active practice was 78%. There were no adverse events in the gym.


In an inpatient setting, a large percentage of practice can be performed as semi-supervised practice. This does not appear to compromise the time spent in active practice or patient safety.


Following orthopaedic injury or stroke, there is clear evidence that people who do more practice in rehabilitation achieve better outcomes.12345 In stroke survivors, a pooled analysis of eight trials3 established that if the therapy dose provided is increased by more than two times, the effect size on activity outcomes is 0.59 (95% CI 0.23 to 0.94). Scrivener et al established that the number of lower limb repetitions achieved in the first week of rehabilitation after a stroke is a good clinical predictor of walking speed at discharge from rehabilitation.4 This dose-response relationship has also been shown in people with orthopaedic conditions. Inpatients having rehabilitation following a hip fracture achieved better functional outcomes if they were more active in therapy sessions.6 Inpatients with lower limb orthopaedic conditions achieved better functional outcomes and had a shorter length of stay if they were more active throughout the entire day.2

Despite the evidence that increased amounts of practice result in better outcomes, patientsin rehabilitation do not generally engage in large amounts of physical practice. The time spent in physiotherapy for stroke survivors in inpatient rehabilitation ranges from 24 to 87 minutes per day.78910111213141516 Similarly, the time spent in physiotherapy for patients with orthopaedic conditions is only 45 minutes per day.13 Additionally, the time spent in active practice during therapy sessions is low, with many studies reporting that less than half of a therapy session is spent in active practice.1117181920 The main reason for these short times spent in therapy and in active practice is that the most common mode of delivery of therapy in the gym area is one-to-one therapy (ie, the patient practises under direct supervision of one or more therapists, therapy students or therapy assistants). This results in a very limited number of patients being in the therapy area at one time, and high therapist to patient ratios. A recent study on inpatient stroke rehabilitation reported that the mean number of staff per patient was two, and patients were participating in less than 30 minutes of physiotherapy a day.21 One potential solution to this problem is to provide opportunities for ‘semi-supervised practice’, meaning that patients practise in the therapy area without the direct supervision of a therapist. This provides the opportunity for patients to spend much longer periods of the day in the gym area with the potential for achieving more time in active practice.

The following strategies can be used to facilitate the provision of semi-supervised practice for patients in rehabilitation. First, the environment of the therapy area can be structured to provide permanent practice areas.22 For example, all the required equipment for different exercises can be placed at workstations, allowing efficient set up for practice. Second, the environment at these workstations can be modified to provide safety when patients are practising without a therapist (eg, the use of adjacent walls, benches and plinths). Third, therapists or therapy assistants can supervise many patients at the same time in class or group settings.7 Additionally, members of the patient’s family can provide assistance with practice. Interestingly, when families are involved in therapy, this not only improves outcomes for stroke survivors but decreases the caregiver strain experienced by the family members.23

Currently, in the risk-averse setting of a hospital, semi-supervised practice is generally not provided24 and in some settings is actually not permitted. To date, it appears that the provision of semi-supervised practice has not been evaluated to establish what percentage of practice occurs as semi-supervised practice when that option is provided, whether patients continue to practise when they are not under direct supervision of a therapist, and whether semi-supervised practice can be provided without compromising patient safety. This information could help to change current clinical management to include more semi-supervised practice, thereby enabling patients in rehabilitation to achieve greater amounts of practice and spend more of their time active.

Therefore, the research questions for this observational study were as follows. When a hospital gymnasium used for inpatient rehabilitation is set up to facilitate semi-supervised practice:

  1. What percentage of practice is performed as semi-supervised practice?
  2. What percentage of patients in the gym are actively engaged in practice (as opposed to resting) at any time?
  3. Is the semi-supervised practice that occurs safe?


Continue —>  In inpatient rehabilitation, large amounts of practice can occur safely without direct therapist supervision: an observational study – ScienceDirect

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[ARTICLE] Advanced Robotic Therapy Integrated Centers (ARTIC): an international collaboration facilitating the application of rehabilitation technologies – Full Text



The application of rehabilitation robots has grown during the last decade. While meta-analyses have shown beneficial effects of robotic interventions for some patient groups, the evidence is less in others. We established the Advanced Robotic Therapy Integrated Centers (ARTIC) network with the goal of advancing the science and clinical practice of rehabilitation robotics. The investigators hope to exploit variations in practice to learn about current clinical application and outcomes. The aim of this paper is to introduce the ARTIC network to the clinical and research community, present the initial data set and its characteristics and compare the outcome data collected so far with data from prior studies.


ARTIC is a pragmatic observational study of clinical care. The database includes patients with various neurological and gait deficits who used the driven gait orthosis Lokomat® as part of their treatment. Patient characteristics, diagnosis-specific information, and indicators of impairment severity are collected. Core clinical assessments include the 10-Meter Walk Test and the Goal Attainment Scaling. Data from each Lokomat® training session are automatically collected.


At time of analysis, the database contained data collected from 595 patients (cerebral palsy: n = 208; stroke: n = 129; spinal cord injury: n = 93; traumatic brain injury: n = 39; and various other diagnoses: n = 126). At onset, average walking speeds were slow. The training intensity increased from the first to the final therapy session and most patients achieved their goals.


The characteristics of the patients matched epidemiological data for the target populations. When patient characteristics differed from epidemiological data, this was mainly due to the selection criteria used to assess eligibility for Lokomat® training. While patients included in randomized controlled interventional trials have to fulfill many inclusion and exclusion criteria, the only selection criteria applying to patients in the ARTIC database are those required for use of the Lokomat®. We suggest that the ARTIC network offers an opportunity to investigate the clinical application and effectiveness of rehabilitation technologies for various diagnoses. Due to the standardization of assessments and the use of a common technology, this network could serve as a basis for researchers interested in specific interventional studies expanding beyond the Lokomat®.


The number of technological devices that therapists can utilize to treat people with neurological impairments has grown substantially during the last decade. Alongside this growth in clinical use, research involving robotic therapy has grown rapidly. A search in Pubmed with the terms “robot” OR “robotic*” AND “rehabilitation” revealed 2225 hits (March 2017) with research markedly increasing after 2010. Despite this increase in research activity and clinical use, the effectiveness of robot-assisted interventions in neurorehabilitation is still in debate. While in some patient populations, for example adults with stroke, meta-analyses have shown that robotic interventions for the lower and upper extremity can be beneficial [12], current evidence is much less convincing in other patient groups, such as spinal cord injury (SCI), traumatic brain injury (TBI), multiple sclerosis (MS) and cerebral palsy (CP).

When comparing the effectiveness of robot-assisted gait training (RAGT) to conventional interventions of similar dosage in adult patients after SCI, it appears that neither intervention is superior [34]. In other populations, such as MS, a small number of pilot studies have been conducted, and a review [5] concluded that the evidence for the effectiveness remained inconclusive. In adult patients with TBI, to our knowledge, there is only one randomized controlled trial that investigated the effectiveness of RAGT [6]. While RAGT improved gait symmetry compared to manually assisted body-weight supported treadmill training, improvements in other gait parameters were not different between the interventions. In children with CP, the body of evidence is similarly small, as only two randomized trials were found [78]. To the authors’ knowledge, there are no randomized controlled trials in children with other diagnoses. Studies comparing effectiveness between different patient groups are lacking.

One important factor leading to the lack of conclusive research is the relatively small number of available centers and participating patients and consequently the small statistical power of attempted studies. Multicenter collaborations are needed to achieve adequate number of participants. Several of the limitations in the evidence of the application of RAGT arise from patient selection criteria and use of different, poorly described and/or low-dosed training protocols. For example, when systematically reviewing the literature in children, we found no paper describing a training protocol on how to apply a robot for rehabilitation of gait [9]. Most of the systematic reviews mentioned that it is extremely difficult to pool results from studies due to the large variability in treatment duration and frequency, contents of the training and inclusion criteria of the patients. For children with CP, an expert team was created to formulate goals, inclusion criteria, training parameters and recommendations on including RAGT in the clinical setting, to assist therapists who train children with CP with the Lokomat® (Hocoma AG, Volketswil, Switzerland) [9]. Such information could be used as a first step in defining training protocols, but this information is missing for most other patient groups.

While randomized controlled trials are usually considered the “gold standard” in building solid evidence in the field of medicine, it is often difficult for rehabilitation specialists working in the clinical environment to interpret the findings with respect to the population of patients they treat on a daily basis. Randomized controlled trials require a specialized team, a controlled setting and a strict selection of patients according to well defined inclusion and exclusion criteria. These criteria often select individuals most likely to benefit based on specific parameters and lack of co-morbidities. These narrow criteria may impact the ecological validity, as results only apply to a minority of patients. This was recently investigated by Dörenkamp et al. [10] who reported that the majority of patients in primary care (40% at the age of 50 years and at least two-thirds of the octogenarian population [11]) simultaneously suffered from multiple medical problems. Further, improvements in function might be less comparable to results described in randomized controlled trials and the treatment regimens used may not be applicable to patients with multiple comorbidities.

To overcome these issues, we established the Advanced Robotic Therapy Integrated Centers (ARTIC) network to collect data from patients using RAGT in a wide variety of clinical settings. ARTIC hopes to develop guidelines for usage as well as to answer scientific questions concerning the use of RAGT. While the ARTIC network includes a general patient population, other research networks focus on a specific disorder or diagnostic group (see, for example [1213]). ARTIC focuses on a common technological intervention – currently the driven gait orthosis Lokomat® – and aims to gather evidence for the efficient and effective use of robotic therapy. Variation in practice among ARTIC members together with collection of common data and outcome measurements will enable the group to draw strong, generalizable conclusions. Further goals include establishing standardized treatment protocols and increasing medical and governmental acceptance of robotic therapy. The aims of this paper are to introduce the ARTIC network to the clinical and research community, present initial data on the characteristics of included patients and compare these to those known from existing epidemiological data and interventional studies.[…]


Continue —> Advanced Robotic Therapy Integrated Centers (ARTIC): an international collaboration facilitating the application of rehabilitation technologies | Journal of NeuroEngineering and Rehabilitation | Full Text

Fig. 1 Lokomat® system (of different generations) with (a) adult leg orthoses and (b) pediatric leg orthoses. Patients walk on a treadmill belt, are weight supported, and the exoskeleton device guides the legs through a physiological walking pattern

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[ARTICLE] Task-specific reach-to-grasp training after stroke: Development and description of a home-based intervention – UWE Research Repository


Objective: To describe and justify the development of a home-based, task-specific upper limb training intervention to improve reach-to-grasp after stroke and pilot it for feasibility and acceptability prior to a randomised controlled trial.

Intervention description: The intervention is based on intensive practice of whole reach-to-grasp tasks and part-practice of essential reach-to-grasp components. A ‘pilot’ manual of activities covering the domains of self-care, leisure and productivity was developed for the feasibility study. The intervention comprises 14 hours of therapist-delivered sessions over 6 weeks, with additional self-practice recommended for 42 hours (i.e. 1 hour every day). As part of a feasibility randomised controlled trial, 24 people with a wide range of upper limb impairment after stroke experienced the intervention to test adherence and acceptability. The median number of repetitions in 1-hour therapist-delivered sessions was 157 (IQR: 96-211). The amount of self-practice was poorly documented. Where recorded, median amount of practice was 30 minutes (IQR: 22-45) per day. Findings demonstrated that the majority of participants found the intensity, content and level of difficulty of the intervention acceptable, and the programme to be beneficial. Comments on the content and presentation of the self-practice material were incorporated in a revised ‘final’ intervention manual.

Discussion: A comprehensive training intervention to improve reach-to-grasp for people living at home after stroke has been described in accordance with the TIDieR reporting guidelines. The intervention has been piloted, found to be acceptable and feasible in the home setting.

Source: Task-specific reach-to-grasp training after stroke: Development and description of a home-based intervention – UWE Research Repository

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