BackgroundMotor impairment after stroke interferes with performance of everyday activities. Upper limb spasticity may further disrupt the movement patterns that enable optimal function; however, the specific features of these altered movement patterns, which differentiate individuals with and without spasticity, have not been fully identified. This study aimed to characterize the kinematic and proprioceptive deficits of individuals with upper limb spasticity after stroke using the Kinarm robotic exoskeleton.MethodsUpper limb function was characterized using two tasks: Visually Guided Reaching, in which participants moved the limb from a central target to 1 of 4 or 1 of 8 outer targets when cued (measuring reaching function) and Arm Position Matching, in which participants moved the less-affected arm to mirror match the position of the affected arm (measuring proprioception), which was passively moved to 1 of 4 or 1 of 9 different positions. Comparisons were made between individuals with (n = 35) and without (n = 35) upper limb post-stroke spasticity.ResultsStatistically significant differences in affected limb performance between groups were observed in reaching-specific measures characterizing movement time and movement speed, as well as an overall metric for the Visually Guided Reaching task. While both groups demonstrated deficits in proprioception compared to normative values, no differences were observed between groups. Modified Ashworth Scale score was significantly correlated with these same measures.ConclusionsThe findings indicate that individuals with spasticity experience greater deficits in temporal features of movement while reaching, but not in proprioception in comparison to individuals with post-stroke motor impairment without spasticity. Temporal features of movement can be potential targets for rehabilitation in individuals with upper limb spasticity after stroke.
Background Despite the growing prevalence of people with complex conditions and evidence of the positive impact of telemonitoring for single conditions, little research exists on telemonitoring for this population. Objective This randomized controlled trial and embedded qualitative study aims to evaluate the impact on and experiences of patients and health care providers (HCPs) using a telemonitoring system with decision support to manage patients with complex conditions, including those with multiple chronic conditions, compared with the standard of care. Methods A pragmatic, unblinded, 6-month randomized controlled trial sought to recruit 146 patients with ≥1 diagnosis of heart failure (HF), uncontrolled hypertension (HT), and insulin-requiring diabetes mellitus (DM) from outpatient specialty settings in Toronto, Ontario, Canada. Participants were randomized into the control and telemonitoring groups, with the latter being instructed to take readings relevant to their conditions. The telemonitoring system contained an algorithm that generated decision support in the form of actionable self-care directives to patients and alerts to HCPs. The primary outcome was health status (36-Item Short Form Health Survey questionnaire). Secondary outcomes included anxiety and depression, self-efficacy in chronic disease management, and self-reported health service use. HF-related quality of life and self-care measures were also collected from patients followed for HF. Within- and between-group change scores were analyzed for statistical significance (P<.05). A convenience sample of HCPs and patients in the intervention group was interviewed about their experiences. Results A total of 96 patients were recruited and randomized. Recruitment was terminated early because of implementation challenges and the onset of the COVID-19 pandemic. No significant within- and between-group differences were found for the main primary and secondary outcomes. However, a within-group analysis of patients with HF found improvements in self-care maintenance (P=.04) and physical quality of life (P=.046). Opinions expressed by the 5 HCPs and 13 patients who were interviewed differed based on the monitored conditions. Although patients with HF reported benefitting from actionable self-care guidance and meaningful interactions with their HCPs, patient and HCP users of the DM and HT modules did not think telemonitoring improved the clinical management of those conditions to the same degree. These differing experiences were largely attributed to the siloed nature of specialty care and the design of the decision support, whereby fluctuations in the status of HT and DM typically required less urgent interventions compared with patients with HF. Conclusions We recommend that future research conceive telemonitoring as a program and that self-management and clinical decision support are necessary but not sufficient components of such programs for patients with complex conditions and lower acuity. We conclude that telemonitoring for patients with complex conditions or within multidisciplinary care settings may be best operationalized through nurse-led models of care. Trial Registration ClinicalTrials.gov NCT03127852; https://clinicaltrials.gov/ct2/show/NCT03127852 International Registered Report Identifier (IRRID) RR2-10.2196/resprot.8367
Background Telemonitoring (TM) interventions have been designed to support care delivery and engage patients in their care at home, but little research exists on TM of complex chronic conditions (CCCs). Given the growing prevalence of complex patients, an evaluation of multi-condition TM is needed to expand TM interventions and tailor opportunities to manage complex chronic care needs. Objective This study aims to evaluate the feasibility and patients’ perceived usefulness of a multi-condition TM platform in a nurse-led model of care. Methods A pragmatic, multimethod feasibility study was conducted with patients with heart failure (HF), hypertension (HTN), and/or diabetes. Patients were asked to take physiological readings at home via a smartphone-based TM app for 6 months. The recommended frequency of taking readings was dependent on the condition, and adherence data were obtained through the TM system database. Patient questionnaires were administered, and patient interviews were conducted at the end of the study. An inductive analysis was performed, and codes were then mapped to the normalization process theory and Implementation Outcomes constructs by Proctor. Results In total, 26 participants were recruited, 17 of whom used the TM app for 6 months. Qualitative interviews were conducted with 14 patients, and 8 patients were interviewed with their informal caregiver present. Patient adherence was high, with patients with HF taking readings on average 76.6% (141/184) of the days they were asked to use the system and patients with diabetes taking readings on average 72% (19/26) of the days. The HTN adherence rate was 55% (29/52) of the days they were asked to use the system. The qualitative findings of the patient experience can be grouped into 4 main themes and 13 subthemes. The main themes were (1) making sense of the purpose of TM, (2) engaging and investing in TM, (3) implementing and adopting TM, and (4) perceived usefulness and the perceived benefits of TM in CCCs. Conclusions Multi-condition TM in nurse-led care was found to be feasible and was perceived as useful. Patients accepted and adopted the technology by demonstrating a moderate to high level of adherence across conditions. These results demonstrate how TM can address the needs of patients with CCCs through virtual TM assessments in a nurse-led care model by supporting patient self-care and keeping patients connected to their clinical team.
BACKGROUND Despite the growing prevalence of people with complex conditions and evidence of the positive impact of telemonitoring for single conditions, little research exists on the use of telemonitoring in this population, particularly those with multiple chronic conditions (MCCs). OBJECTIVE This randomized controlled trial (RCT) and embedded qualitative study aimed to evaluate the impact and experiences of patients and healthcare providers (HCPs) using a telemonitoring system with decision support to manage complex patients, including those with MCCs, compared to the standard of care. METHODS A pragmatic 6-month RCT sought to recruit 146 patients with a diagnosis of heart failure (HF), uncontrolled hypertension (HT), and/or insulin requiring diabetes (DM) from outpatient specialty settings in Toronto, Canada. Participants were randomized into the control and telemonitoring groups with the latter being instructed to take readings relevant to their condition(s). The telemonitoring system contained an algorithm that generated decision support in the form of actionable self-care directives to patients and alerts to HCPs. The primary outcome was health status as measured by the SF-36. Secondary outcomes included anxiety and depression, self-efficacy in chronic disease management, and self-reported healthcare utilization. HF-related quality of life and self-care measures were also collected from patients followed for HF. Within- and between-group change scores were analyzed for statistical significance (P<.05). A convenience sample of HCPs and patients in the intervention group were interviewed about their experiences RESULTS A total of 96 patients were recruited and randomized. Recruitment was terminated early due to implementation challenges and the onset of COVID-19. No significant within- and between-group differences were found for the main primary and secondary outcomes. However, a within-group analysis of HF patients found improvements in self-care maintenance (P=.036) and physical quality of life (P= .046). Opinions expressed by the 5 HCPs and 13 patients interviewed differed based on the condition(s) monitored. Although HF patients reported benefitting from actionable self-care guidance and meaningful interactions with their HCPs, patient and HCP users of the DM and HT modules did not think telemonitoring improved the clinical management of those conditions to the same degree. These differing experiences were largely attributed to the siloed nature of specialty care, and the design of the decision support whereby it was indicated that fluctuations in HT and DM patient status typically required less urgent intervention compared to HF. CONCLUSIONS Consistent with previous studies, we recommend that future research conceive telemonitoring as a program and that self-management and clinical decision support are necessary, but not sufficient components of such programs for complex patients with lower acuity. We conclude that a multidisciplinary model of care that includes care coordination must accompany telemonitoring systems which may best be operationalized through novel models of care, such as nurse-led models. CLINICALTRIAL ClinicalTrials.gov NCT03127852, ISRCTN (41238563) INTERNATIONAL REGISTERED REPORT RR2-10.2196/resprot.8367
BACKGROUND Telemonitoring (TM) interventions have been designed to support care delivery and engage patients in their care at home, but little research exists on TM of complex chronic conditions (CCC). Given the growing prevalence of patients with CCC, an evaluation of multi-condition TM is needed to expand TM interventions, as well as tailor opportunities to manage complex chronic care needs. OBJECTIVE The objective of this study was to evaluate the feasibility and patients’ perceived usefulness of a multi-condition TM platform in a nurse-led model of care. METHODS A pragmatic, multi-method feasibility study was conducted with patients with heart failure (HF), hypertension (HTN), and/or diabetes (DM). Patients were asked to take physiological readings at home via a smartphone-based TM application for 6 months. The recommended frequency of taking readings was dependent on the condition, and adherence data was obtained through the TM system database. Patient questionnaires were administered and patient interviews were conducted at the end of the study. Inductive analysis was performed and codes were then mapped to Normalization Process Theory and Proctor’s Implementation Outcomes constructs. RESULTS Twenty-six participants were recruited, 17 of which used the TM system over 6 months. Qualitative interviews were conducted with 14 patients, and 8 were conducted with their informal caregiver present. Patient adherence was high, with patients with HF taking readings 76% of the days they were asked to use the system and patients with DM taking 72% of the readings. The HTN adherence rate was 55% of the days they were asked to use the system. The qualitative findings of the patient experience can be grouped into 4 main themes and 13 subthemes. The main themes were: (1) making sense of the purpose of TM, (2) engaging and investing in TM, (3) implementing and adopting TM, and (4) perceived usefulness and the perceived benefits of TM in CCC. CONCLUSIONS Multi-condition TM in nurse-led care was found to be feasible and was perceived as useful. Patients accepted and adopted the technology by demonstrating a moderate to high-level of adherence across conditions. These results demonstrate how TM can address the needs of patients with CCC through virtual TM assessments in a nurse-led care model by supporting patient self-care and keeping patients connected to their clinical team.
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