Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen Stroke Study

Advancing motor rehabilitation for adults with chronic neurological conditions through increased involvement of kinesiologists: a perspective review

Many people with neurological conditions experience challenges with movement. Although rehabilitation is often provided acutely and sub-acutely following the onset of a condition, motor deficits commonly persist in the long-term and are exacerbated by disuse and inactivity. Notably, motor rehabilitation approaches that incorporate exercise and physical activity can support gains in motor function even in the chronic stages of many neurological conditions. However, delivering motor rehabilitation on a long-term basis to people with chronic neurological conditions is a challenge within health care systems, and the onus is often placed on patients to find and pay for services. While neurological motor rehabilitation is largely the domain of physical and occupational therapists, kinesiologists may be able to complement existing care and support delivery of long-term neurological motor rehabilitation, specifically through provision of supported exercise and physical activity programs. In this perspective style review article, we discuss potential contributions of kinesiologists to advancing the field through exercise programming, focusing on community-based interventions that increase physical activity levels. We conclude with recommendations on how kinesiologists' role might be further optimized towards improving long-term outcomes for people with chronic neurological conditions, considering issues related to professional regulation and models of care.

Increased Provision of Bioavailable Mg through Vegetables Could Significantly Reduce the Growing Health and Economic Burden Caused by Mg Malnutrition

Magnesium (Mg) is an essential mineral nutrient for human health and its deficiency associated with many diseases, including stroke, heart failure, and type 2 diabetes. Vegetables are an important source of dietary Mg for humans. In this study, we quantified vegetable Mg content by a global meat analysis, analyzed human health, and economic impact caused by Mg deficiency. Results revealed that vegetable Mg content showed a large variation with an average value of 19.3 mg 100 g⁻¹ FW. Variation in per capita vegetable-Mg supply in different continents is largely ascribed to continental difference in the amount and the type of vegetables produced. The health and economic loss attributed to Mg deficiency are estimated to be 1.91 million disability-adjusted life years (DALYs) and 15.8 billion dollars (0.14% of GDP), respectively. A scenario analysis indicated that the increasing vegetable production (increased by 8.9% and 20.7% relative to 2017 in 2030 and 2050) and vegetable Mg content (increased by 22% through biofortification) could significantly reduce DALYs (1.24 million years) and economic burden (0.09% of GDP). This study could guide a major re-balance of production practices, species cultivated, and Mg biofortification to provide sufficient vegetable Mg for better human Mg nutrition.

Intracerebral transplantation of autologous adipose-derived stem cells for chronic ischemic stroke: A phase I study

Current therapy does not provide significant benefits for patients with chronic stroke. Pre-clinical studies suggested that autologous adipose-derived stem cells have benefits for the treatment of chronic stroke. This Phase I open-label study was conducted to demonstrate the safety and efficacy of autologous adipose-derived stem cells (GXNPC1) in chronic stroke. Three patients with chronic stroke were treated with stereotactic implantation of autologous adipose-derived stem cells (1 × 10⁸ cells). The primary endpoints of safety evaluation included adverse events, over a 6 months post-implantation period. The secondary endpoints included improvements in neurological functions. Evolutional change of brain parenchyma was also followed with magnetic resonance imaging (MRI). All three participants improved significantly at 6 months follow-up. The extent of improvement from pre-treatment was: National Institutes of Health Stroke Scale improved 5-15 points, Barthel Index: 25-50 points, Berg balance scale 0-21 points and Fugl-Meyer modified sensation 3-28 points. All three patients had signal change along the implantation tract on MRI one month after surgery. There is no related safety issue through 6 months observation. Clinical measures of neurological symptoms of these patients with chronic stroke improved at 6 months without adverse effects after implantation of autologous adipose-derived stem cells (GXNPC1), which might be correlated with post-implantation changes on brain MRI. Clinical Trial Registration-URL: https://clinicaltrials.gov/ct2/show/NCT02813512?term=ADSC&cond=Stroke&cntry=TW&draw=2&rank=1 Unique identifier: NCT02813512.

Timing and Dose of Upper Limb Motor Intervention After Stroke: A Systematic Review

This systematic review aimed to investigate timing, dose, and efficacy of upper limb intervention during the first 6 months poststroke. Three online databases were searched up to July 2020. Titles/abstracts/full-text were reviewed independently by 2 authors. Randomized and nonrandomized studies that enrolled people within the first 6 months poststroke, aimed to improve upper limb recovery, and completed preintervention and postintervention assessments were included. Risk of bias was assessed using Cochrane reporting tools. Studies were examined by timing (recovery epoch), dose, and intervention type. Two hundred and sixty-one studies were included, representing 228 (n=9704 participants) unique data sets. The number of studies completed increased from one (n=37 participants) between 1980 and 1984 to 91 (n=4417 participants) between 2015 and 2019. Timing of intervention start has not changed (median 38 days, interquartile range [IQR], 22-66) and study sample size remains small (median n=30, IQR 20-48). Most studies were rated high risk of bias (62%). Study participants were enrolled at different recovery epochs: 1 hyperacute (<24 hours), 13 acute (1-7 days), 176 early subacute (8-90 days), 34 late subacute (91-180 days), and 4 were unable to be classified to an epoch. For both the intervention and control groups, the median dose was 45 (IQR, 600-1430) min/session, 1 (IQR, 1-1) session/d, 5 (IQR, 5-5) d/wk for 4 (IQR, 3-5) weeks. The most common interventions tested were electromechanical (n=55 studies), electrical stimulation (n=38 studies), and constraint-induced movement (n=28 studies) therapies. Despite a large and growing body of research, intervention dose and sample size of included studies were often too small to detect clinically important effects. Furthermore, interventions remain focused on subacute stroke recovery with little change in recent decades. A united research agenda that establishes a clear biological understanding of timing, dose, and intervention type is needed to progress stroke recovery research. Prospective Register of Systematic Reviews ID: CRD42018019367/CRD42018111629.

Critical Period After Stroke Study (CPASS): A phase II clinical trial testing an optimal time for motor recovery after stroke in humans

Restoration of postinjury brain function is a signal neuroscience challenge. Animal models of stroke recovery demonstrate time-limited windows of heightened motor recovery, similar to developmental neuroplasticity. However, no equivalent windows have been demonstrated in humans. We report a randomized controlled trial applying essential elements of animal motor training paradigms to humans, to determine the existence of an analogous sensitive period in adults. We found a similar sensitive or optimal period 60 to 90 d after stroke, with lesser effects ≤30 d and no effect 6 mo or later after stroke. These findings prospectively demonstrated the existence of a sensitive period in adult humans. We urge the provision of more intensive motor rehabilitation within 60 to 90 d after stroke onset.

Restoration of human brain function after injury is a signal challenge for translational neuroscience. Rodent stroke recovery studies identify an optimal or sensitive period for intensive motor training after stroke: near-full recovery is attained if task-specific motor training occurs during this sensitive window. We extended these findings to adult humans with stroke in a randomized controlled trial applying the essential elements of rodent motor training paradigms to humans. Stroke patients were adaptively randomized to begin 20 extra hours of self-selected, task-specific motor therapy at ≤30 d (acute), 2 to 3 mo (subacute), or ≥6 mo (chronic) after stroke, compared with controls receiving standard motor rehabilitation. Upper extremity (UE) impairment assessed by the Action Research Arm Test (ARAT) was measured at up to five time points. The primary outcome measure was ARAT recovery over 1 y after stroke. By 1 y we found significantly increased UE motor function in the subacute group compared with controls (ARAT difference = +6.87 ± 2.63, P = 0.009). The acute group compared with controls showed smaller but significant improvement (ARAT difference = +5.25 ± 2.59 points, P = 0.043). The chronic group showed no significant improvement compared with controls (ARAT = +2.41 ± 2.25, P = 0.29). Thus task-specific motor intervention was most effective within the first 2 to 3 mo after stroke. The similarity to rodent model treatment outcomes suggests that other rodent findings may be translatable to human brain recovery. These results provide empirical evidence of a sensitive period for motor recovery in humans.

Upper Limb Performance in Daily Life Approaches Plateau Around Three to Six Weeks Post-stroke

Background. Wearable sensors allow for direct measurement of upper limb (UL) performance in daily life. Objective. To map the trajectory of UL performance and its relationships to other factors post-stroke. Methods. Participants (n = 67) with first stroke and UL paresis were assessed at 2, 4, 6, 8, 12, 16, 20, and 24 weeks after stroke. Assessments captured UL impairment (Fugl-Meyer), capacity for activity (Action Research Arm Test), and performance of activity in daily life (accelerometer variables of use ratio and hours of paretic limb activity), along with other potential modifying factors. We modeled individual trajectories of change for each measurement level and the moderating effects on UL performance trajectories. Results. Individual trajectories were best fit with a 3-parameter logistic model, capturing the rapid growth early after stroke within the longer data collection period. Plateaus (90% of asymptote) in impairment (bootstrap mean ± SE: 32 ± 4 days post-stroke) preceded those in capacity (41 ± 4 days). Plateau in performance, as measured by the use ratio (24 ± 5 days), tended to precede plateaus in impairment and capacity. Plateau in performance, as measured by hours of paretic activity (41 ± 6 days), occurred at a similar time to that of capacity and slightly lagged impairment. Modifiers of performance trajectories were capacity, concordance, UL rehabilitation, depressive symptomatology, and cognition. Conclusions. Upper limb performance in daily life approached plateau 3 to 6 weeks post-stroke. Individuals with stroke started to achieve a stable pattern of UL use in daily life early, often before neurological impairments and functional capacity started to stabilize.

Effects of Different Intervention Time Points of Early Rehabilitation on Patients with Acute Ischemic Stroke: A Single-Center, Randomized Control Study

Objective

To investigate effects of different intervention time points of early rehabilitation on patients with acute ischemic stroke.

Methods

We enrolled patients diagnosed with acute ischemic stroke in our hospital's rehabilitation ward from November 2013 to December 2015. Patients were randomly assigned to an ultraearly rehabilitation program (started within 72 hours of onset) or an early rehabilitation program (started from 72 hours to 7 days after onset). The efficacy was assessed by the NIH Stroke Scale (NIHSS) International, Barthel Index, and Fugl-Meyer Assessment at one and three months after rehabilitation. Data were analyzed by variance analysis of two-factor repeated measurement. Covariance analysis was used to adjust confounding factors for the determination of statistical differences.

Results

41 patients were enrolled in the ultraearly rehabilitation group, while 45 patients were in the early rehabilitation group. There were no differences between the two groups at baseline data. Compared with the early rehabilitation group, patients in the ultraearly rehabilitation group have significantly improved NIHSS score, BMI score, and FMA score at one month and three months (P < 0.001). After adjusting for confounding factors (gender, age, severity of NIHSS score, location of stroke, hypertension, diabetes, atrial fibrillation, and coronary heart disease), the significant difference still existed between the two groups at one month and three months (P < 0.001).

Conclusion

Our study indicated a higher efficacy in the ultraearly rehabilitation group than the early rehabilitation group. The result suggests an important practical significance in favor of the clinical treatment of stroke.

Role of Cerebrolysin® in Rehabilitation in Ischemic Stroke: A Case Report

Patient: Male, 71-year-old

Final Diagnosis: Stroke

Symptoms: Hemiplegia

Medication: —

Clinical Procedure: —

Specialty: Rehabilitation

Scalp acupuncture enhances local brain regions functional activities and functional connections between cerebral hemispheres in acute ischemic stroke patients

This study aimed to explore the changes in functional connections between cerebral hemispheres and local brain regions functional activities in patients with acute ischemic stroke (AIS) treated with International Standard Scalp Acupuncture (ISSA). Thirty patients with middle cerebral artery AIS in the dominant hemisphere were selected and randomly divided into two groups such as the control group and the scalp acupuncture group, with 15 patients in each group. Patients in the control group were treated with conventional Western medicine, while patients in the scalp acupuncture group received ISSA (acupuncture at the parietal midline [MS5], acupuncture at the left anterior parietotemporal oblique line [MS6] and acupuncture at the left posterior parietotemporal oblique line [MS7]) for one course of treatment. All patients were evaluated for treatment efficacy and received whole brain resting state functional magnetic resonance imaging (Rs‐fMRI) scan before and after treatment. The observational indicators included: (a) the National Institutes of Health Stroke Scale (NIHSS) scores and the simplified Fugl‐Meyer Assessment (SFMA) scores; (b) analyses of the amplitude of low‐frequency fluctuation (ALFF), regional homogeneity (ReHo) and voxel‐mirrored homotopic connectivity (VMHC). The results showed a significant difference in the NIHSS scores before and after treatment in the scalp acupuncture group compared with the control group (p < .05), indicating that patients improved better after scalp acupuncture treatment. Compared with the control group, the VMHC, ALFF and ReHo values in the scalp acupuncture group increased after treatment. The VMHC values increased in the brain regions dominated by bilateral BA6 and BA8; the ALFF values increased in the left BA39 and the adjacent superior temporal gyrus and middle temporal gyrus; and the ReHo values increased in the brain regions extending from left middle temporal gyrus (including BA21) to BA37, and the brain regions extending from the left BA40 and angular gyrus to BA7. The present study indicated that scalp acupuncture can specifically strengthen the functional activities of the brain regions related to sensory integration, language processing and motor coordination in the middle aged and elderly patients with AIS of the dominant cerebral hemisphere, and can strengthen bilateral frontal lobe motor control. This study may provide a scientific basis for the clinical application of ISSA treatment in patients with AIS, and may also provide a preliminary research basis for further animal experiments.

A prospective cohort study on longitudinal trajectories of cognitive function after stroke

The study aimed to determine longitudinal trajectories of cognitive function during the first year after stroke. The Montreal Cognitive Assessment (MoCA) was used to screen cognitive function at 36-48 h, 3-months, and 12-months post-stroke. Individuals who shared similar trajectories were classified by applying the group-based trajectory models. Data from 94 patients were included in the analysis. Three cognitive functioning groups were identified by the trajectory models: high [14 patients (15%)], medium [58 (62%)] and low [22 (23%)]. For the high and medium groups, cognitive function improved at 12 months, but this did not occur in the low group. After age, sex and education matching to the normative MoCA from the Swedish population, 52 patients (55%) were found to be cognitively impaired at baseline, and few patients had recovered at 12 months. The impact on memory differs between cognitive functioning groups, whereas the impact on activities of daily living was not different. Patients with the poorest cognitive function did not improve at one-year poststroke and were prone to severe memory problems. These findings may help to increase focus on long-term rehabilitation plans for those patients, and more accurately assess their needs and difficulties experienced in daily living.

Pushing the Rehabilitation Boundaries: Hand Motor Impairment Can Be Reduced in Chronic Stroke

Background. Stroke is one of the most common causes of physical disability worldwide. The majority of survivors experience impairment of movement, often with lasting deficits affecting hand dexterity. To date, conventional rehabilitation primarily focuses on training compensatory maneuvers emphasizing goal completion rather than targeting reduction of motor impairment. Objective. We aim to determine whether finger dexterity impairment can be reduced in chronic stroke when training on a task focused on moving fingers against abnormal synergies without allowing for compensatory maneuvers. Methods. We recruited 18 chronic stroke patients with significant hand motor impairment. First, participants underwent baseline assessments of hand function, impairment, and finger individuation. Then, participants trained for 5 consecutive days, 3 to 4 h/d, on a multifinger piano-chord-like task that cannot be performed by compensatory actions of other body parts (e.g., arm). Participants had to learn to simultaneously coordinate and synchronize multiple fingers to break unwanted flexor synergies. To test generalization, we assessed performance in trained and nontrained chords and clinical measures in both the paretic and the nonparetic hands. To evaluate retention, we repeated the assessments 1 day, 1 week, and 6 months post-training. Results. Our results showed that finger impairment assessed by the individuation task was reduced after training. The reduction of impairment was accompanied by improvements in clinical hand function, including precision pinch. Notably, the effects were maintained for 6 months following training. Conclusion. Our findings provide preliminary evidence that chronic stroke patient can reduce hand impairment when training against abnormal flexor synergies, a change that was associated with meaningful clinical benefits.

Translation and validation of the stroke impact scale 3.0 into urdu for Pakistan

BACKGROUND

The Stroke Impact Scale version 3.0 (SIS 3.0) is a self-reported outcome measure designed to assess quality of life (QoL) following a stroke. Although the psychometric properties of the SIS 3.0 are identified as superior to the generic QoL scales, it has not been translated and tested in Pakistan.

OBJECTIVE

To validate the Urdu version of the SIS 3.0 (USIS 3.0) for Pakistan.

METHODS

A prospective cohort of 116 patients with mild to moderate stroke reported their recovery using the USIS 3.0. The patients were concurrently assessed on the established tools to assess the validity and were re-evaluated to determine the test-retest reliability, precision, minimal detectable change (MDC), and minimal clinically important difference (MCID).

RESULTS

The reliability and internal consistency of USIS were satisfactory except for the emotion domain. The correlations of USIS with the established tools were strong. The discriminant validity was also significant across the levels of the modified Rankin scale (MRS). Only hand function and communication domains exhibited significant floor and ceiling effects, respectively. Regarding weighted K, values ranged from 0.53 to 0.88.

CONCLUSIONS

The USIS 3.0 has satisfactory psychometric properties and can be used in clinical and research settings for stroke survivors.

From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke

Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond.

Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT.

Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability.

Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.

Examination of Rehabilitation Intensity According to Severity of Acute Stroke: A Retrospective Study

OBJECTIVES

To investigate the intensity and effectiveness of rehabilitation in acute stroke patients according to the severity of functional impairments in them.

MATERIALS AND METHODS

This retrospective cohort study included 294 patients with acute hemispheric stroke admitted to three acute-care hospitals who subsequently underwent an inpatient rehabilitation program. Stroke severity was classified according to neurological deficits and trunk dysfunction. The following data were obtained from medical records: age, sex, stroke type, lesion side, hospitalization duration, initial functional status determined using the National Institutes of Health Stroke Scale, rehabilitation start date, first day out of bed after admission, total treatment duration, total number of treatment sessions, rehabilitation implementation rate between start of rehabilitation and discharge, trunk control test and Barthel Index score on the first day out of bed after admission and discharge, and post-discharge outcomes. Hierarchical cluster analysis was performed with clusters categorized using the National Institutes of Health Stroke Scale and trunk control test scores. Variables were compared using the Kruskal-Wallis test, and Dunn's nonparametric comparison test was performed for post-hoc analysis to determine differences between clusters.

RESULTS

The National Institutes of Health Stroke Scale and trunk control test showed a significant correlation (r = -0.816, p < 0.01) using which cluster analysis identified three clusters. Rehabilitation showed a ceiling effect in patients with mild stroke and a floor effect in patients with severe stroke.

CONCLUSION

These results may guide the determination of rehabilitation intensity with reference to the severity of neurological deficits and trunk dysfunction.

Moderate-intensity exercise versus high-intensity interval training to recover walking post-stroke: protocol for a randomized controlled trial

Background

Stroke results in neurologic impairments and aerobic deconditioning that contribute to limited walking capacity which is a major barrier post-stroke. Current exercise recommendations and stroke rehabilitation guidelines recommend moderate-intensity aerobic training post-stroke. Locomotor high-intensity interval training is a promising new strategy that has shown significantly greater improvements in aerobic fitness and motor performance than moderate-intensity aerobic training in other populations. However, the relative benefits and risks of high-intensity interval training and moderate-intensity aerobic training remain poorly understood following stroke. In this study, we hypothesize that locomotor high-intensity interval training will result in greater improvements in walking capacity than moderate-intensity aerobic training.

Methods

Using a single-blind, 3-site randomized controlled trial, 50 chronic (> 6 months) stroke survivors are randomly assigned to complete 36 locomotor training sessions of either high-intensity interval training or moderate-intensity aerobic training. Main eligibility criteria are age 40–80 years, single stroke for which the participant received treatment (experienced 6 months to 5 years prior to consent), walking speed ≤ 1.0 m/s, able to walk at least 3 min on the treadmill at ≥ 0.13 m/s (0.3 mph), stable cardiovascular condition (American Heart Association class B), and the ability to walk 10 m overground without continuous physical assistance. The primary outcome (walking capacity) and secondary outcomes (self-selected and fast gait speed, aerobic fitness, and fatigue) are assessed prior to initiating training and after 4 weeks, 8 weeks, and 12 weeks of training.

Discussion

This study will provide fundamental new knowledge to inform the selection of intensity and duration dosing parameters for gait recovery and optimization of aerobic training interventions in chronic stroke. Data needed to justify and design a subsequent definitive trial will also be obtained. Thus, the results of this study will inform future stroke rehabilitation guidelines on how to optimally improve walking capacity following stroke.

Trial registration

ClinicalTrials.govNCT03760016. Registered on November 30, 2018.

The rehabilitation of physical function after severely disabling stroke: a survey of UK therapist practice

Background/aims

Individuals who are severely disabled from stroke (survivors of severely disabling stroke) experience poorer outcomes compared to those who are less disabled from stroke. However, there is a paucity of evidence describing current therapy practice in the management of severely disabling stroke. The aim of the study was to describe intervention and outcome measure use by physiotherapists and occupational therapists in the rehabilitation of physical function of survivors of severely disabling stroke.

Methods

A mixed-methods survey was conducted, involving an online questionnaire and follow-up interviews. Survey participants were UK-based physiotherapists and occupational therapists with experience treating stroke. Questionnaire data were analysed with descriptive and inferential statistics. Interview data were analysed using content analysis.

Results

A total of 452 therapists (59% physiotherapists) responded to the questionnaire. Out of the respondents, 18 self-selected therapists participated in follow-up interviews to explain questionnaire data. Whole body positioning, training of upper limb handling and positioning, and sitting balance practice were the most frequently used interventions. Inpatient-based therapists performed more active rehabilitation interventions, whereas community-based therapists performed more training and education. The Barthel Index, Modified Rankin Scale and National Institutes for Health Stroke Scale were the most frequently used outcome measures. Outcome measure use was generally low and was more likely to be completed when it was part of a national audit. Reasons for low outcome measure use were perceived lack of time and insensitivity to detect clinical change.

Conclusions

A variety of interventions and outcome measures are used in the rehabilitation of survivors of severely disabling stroke. There is a need to evaluate the effectiveness of frequently used interventions and identify outcome measures that are sensitive to the needs of survivors of severely disabling stroke.

Efficacy and Safety Study of Wearable Cyborg HAL (Hybrid Assistive Limb) in Hemiplegic Patients With Acute Stroke (EARLY GAIT Study): Protocols for a Randomized Controlled Trial

We hypothesized that gait treatment with a wearable cyborg Hybrid Assistive Limb (HAL) would improve the walking ability of patients with hemiparesis after stroke. This study aims to evaluate the efficacy and safety of gait treatment using HAL versus conventional gait training (CGT) in hemiplegic patients with acute stroke and establish a protocol for doctor-initiated clinical trials for acute stroke. We will enroll patients with acute stroke at the University of Tsukuba Hospital. This study is a single-center, randomized, parallel-group, controlled trial (HAL group, n = 20; control group, n = 20) that will include three phases: (1) pre-observation phase (patient enrollment, baseline assessment, and randomization); (2) treatment phase (nine sessions, twice or thrice per week over 3−4 weeks; the HAL and control groups will perform gait treatment using HAL or CGT, respectively, and finally (3) post-treatment evaluation phase. The Functional Ambulation Category score will be the primary outcome measure, and the following secondary outcome measures will be assessed: Mini-Mental State Examination, Brunnstrom recovery stage of lower limbs, Fugl–Meyer assessment of lower limbs, 6-min walking distance, comfortable gait speed, step length, cadence, Barthel Index, Functional Independence Measure, gait posture, motion analysis (muscle activity), amount of activity (evaluated using an activity meter), stroke-specific QOL, and modified Rankin Scale score. The baseline assessment, post-treatment evaluation, and follow-up assessment will evaluate the overall outcome measures; for other evaluations, physical function evaluation centered on walking will be performed exclusively, excluding ADL and QOL scores. This study is a randomized controlled trial that aims to clarify the efficacy and safety of gait treatment using HAL compared with CGT in hemiplegic patients with acute stroke. In addition, we aim to establish a protocol for doctor-initiated clinical trials for acute stroke based on the study results. If our results demonstrate the effectiveness of the proposed treatment regarding outcomes of patients with hemiplegic acute stroke, this study will promote the treatment of these patients using the HAL system as an effective tool in future stroke rehabilitation programs. The study protocol was registered with the Japan Registry of Clinical Trials on October 14, 2020 (jRCTs032200151).

Efficacy of lateral stair walking training in patients with chronic stroke: A pilot randomized controlled study

BACKGROUND

Patients with chronic stroke have reduced capacity for performing activities of daily living (ADLs) and are at increased risk for falls during walking due to long-term changes to muscle tone and force, as well as movement control.

RESEARCH QUESTION

To investigate the efficacy of lateral stair walking training on muscle strength of affected lower extremities, balance, ADLs, and gait ability in patients with chronic stroke.

METHODS

The experimental group received 15 min of lateral stair walking exercise along with 15 min of traditional physiotherapy, whereas the control group received only traditional physiotherapy for 30 min. Both groups received the intervention once a week for 12 weeks. Outcome measurements included muscle strength, postural assessment scale for stroke patients (PASS), Fugal-Meyer assessment for lower extremity (FMA-LE), Barthel index (BI), timed up and go test (TUG), and the gait parameters which were determined by the Reha-Watch system.

RESULTS

A total of 24 participants completed the study. The experimental group showed significant improvements in hip extensor, flexor, and abductor strength of the affected limb, FMA-LE, BI, TUG, and gait parameters of stride length, velocity, and cadence. Significant differences in affected limb ankle plantar strength (p = 0.024), PASS (p = 0.017), BI (p = 0.039), TUG (p = 0.049), and gait velocity (p < 0.001) were observed between the 2 groups.

SIGNIFICANCE

Lateral stair walking training alongside physical therapy resulted in significant improvements in hip muscle strength and gait parameters in patients with chronic stroke. Our results support the incorporation of lateral stair walking training into clinical rehabilitation programs. Lateral stair walking training in patients with chronic stroke can be used as an effective treatment to improve gait, balance performance, and ADLs.

The minimal clinically important difference in Berg Balance Scale scores among patients with early subacute stroke: a multicenter, retrospective, observational study

Background: Balance dysfunction is common in stroke patients. The Berg Balance Scale (BBS) is useful for evaluating the balance function of stroke patients, and it can estimate the minimal clinically important difference (MCID) in balance. BBS scores differ among stroke patients depending on whether they require walking assistance. The MCID should thus be estimated separately for patients who require assistance and those who do not.Objectives: To estimate the MCID of individuals who have had an early subacute stroke and require a walking aid and those who do not, to assist the clinical determination of the effectiveness of therapy.Methods: This was a retrospective clinical analysis of 80 early subacute stroke patients. We estimated the MCID by using the Functional Ambulation Categories (FAC) as anchors for changes in BBS scores during a 1-month period. The MCID was estimated based on a cutoff score for separating the patients who achieved a FAC change ≥1 point on receiver operator characteristic curves. The area under the curve (AUC) was used to measure the discrimination accuracy. The MCID was estimated for the patients who needed walking assistance and those who did not.Results: The estimated MCID of BBS scores in the assisted-walking group was 5 points and the AUC was 0.84 (p < .01); the corresponding values in the unassisted-walking group were 4 points and 0.62 (p = .26).Conclusions: For early subacute stroke patients who require assistance to walk, a 5-point improvement in the BBS score is a useful indicator for reducing the amount of assistance.

Why Are Stroke Rehabilitation Trial Recruitment Rates in Single Digits?

Background: Recruitment of patients in early subacute rehabilitation trials (<30 days post-stroke) presents unique challenges compared to conventional stroke trials recruiting individuals >6 months post-stroke. Preclinical studies suggest treatments be initiated sooner after stroke, thus requiring stroke rehabilitation trials be conducted within days post-stroke. How do specific inclusion and exclusion criteria affect trial recruitment rates for early stroke rehabilitation trials?

Objectives: Provide estimates of trial recruitment based on screening and enrollment data from a phase II early stroke rehabilitation trial.

Methods: CPASS, a phase II intervention trial screened ischemic stroke patients in acute care (18-months, N = 395) and inpatient rehabilitation (22-months, N = 673). Patients were stratified by upper extremity (UE) impairment into mild (NIHSS motor arm = 0, 1); moderate (NIHSS = 2, 3); severe (NIHSS = 4) and numbers of patients disqualified due to CPASS exclusion criteria determined. We also examined if a motor-specific evaluation (Action Research Arm Test, ARAT) increases the pool of eligible patients disqualified by the NIHSS motor arm item.

Results: CPASS recruitment in acute care (5.3%) and inpatient rehabilitation (5%) was comparable to prior trials. In acute care, a short stay (7–17-days), prior stroke (13.5% in moderately; 13.2% in severely impaired) disqualified the majority. In inpatient rehabilitation, the majority (40.8%) were excluded for “too mild” impairment. The next majority were disqualified for reaching inpatient rehabilitation “too late” to participate in an early stroke trial (15% in moderately; 24% in severely impaired). Mean ARAT in the “too mild” showed significant impairment and potential to benefit from participation in select UE rehabilitation trials.

Conclusions: Screening of ischemic stroke patients while they are still in acute care is crucial to successful recruitment for early stroke rehabilitation trials. A significant proportion of eligible patients are lost to “short length of stay” in acute care, and arrive to inpatient rehabilitation “too late” for an early rehabilitation trial. Additional screening of mildly impaired patients using a motor function specific scale will benefit the trial recruitment and generalizability.

Trial Registration Number:http://www.clinicaltrials.gov Identifier: NCT02235974.

The Berg Balance Scale at Admission Can Predict Community Ambulation at Discharge in Patients with Stroke

Background and Objectives: To regain the ability of community ambulation is a meaningful goal for stroke patients. Recent research recommended that the distance accomplished during the six-minute walk test (≥205 m in 6MWT) is the fittest for defining community ambulation. Until now, there are few studies that have used the updated definition to investigate the related predictors. The aim of this study was to investigate the association between the admission clinical parameters and community ambulation measured by the 6MWT at discharge. The other aim was to find the admission Berg Balance Scale (BBS) cut-off score to discriminate between household or community ambulators. Materials and Methods: This cohort study collected the data of patients who entered the post-acute Care Cerebrovascular Diseases program. Multivariate logistic regression was used to identify significant predictors measured at admission that are associated with community ambulation, and a receiver operating characteristic was adopted to calculate the cut-off value for admission status. There were 120 participants included in this study, and 25% (n = 30) of them regained the ability of community ambulation at discharge. The BBS on admission was identified as the only significant predictor for community ambulation (odds ratio 1.06). Results: The optimal cut-off score for the BBS at admission was 29, and the area under the curve for BBS scores on admission when discriminating between household and community ambulators at discharge was 0.74. Conclusions: The admission BBS scores could be used to predict household and community ambulators at discharge in stroke patients. The results of this study could help clinical physicians set appropriate discharge goals early.

International stroke genetics consortium recommendations for studies of genetics of stroke outcome and recovery

Numerous biological mechanisms contribute to outcome after stroke, including brain injury, inflammation, and repair mechanisms. Clinical genetic studies have the potential to discover biological mechanisms affecting stroke recovery in humans and identify intervention targets. Large sample sizes are needed to detect commonly occurring genetic variations related to stroke brain injury and recovery. However, this usually requires combining data from multiple studies where consistent terminology, methodology, and data collection timelines are essential. Our group of expert stroke and rehabilitation clinicians and researchers with knowledge in genetics of stroke recovery here present recommendations for harmonizing phenotype data with focus on measures suitable for multicenter genetic studies of ischemic stroke brain injury and recovery. Our recommendations have been endorsed by the International Stroke Genetics Consortium.

The Effectiveness of Verbal-Gestural Treatment on Verb Naming in Acute Inpatient Rehabilitation

Purpose The purpose of this study was to investigate the effectiveness of verbal-gestural treatment on verb production in patients with acute aphasia. Method Treatment was delivered during inpatient stay to four participants using a single-subject design. Results All patients demonstrated improvements in verbal expression. Some patients' improvements generalized to untrained verbs and nouns. Conclusions This study indicates verbal-gestural treatment can be an effective treatment model for acute aphasia in a hospital environment. Concurrent deficits resulting from stroke may impact the success with verbal-gestural treatment at this acute phase of recovery.

Reliability and validity of Japanese version of Fugl-Meyer assessment for the lower extremities

Background: Understanding the degree of motor paralysis in stroke patients is important for assessing the severity of functional impairment and predicting functional prognosis. Fugl-MeyerAssessment for the lower extremities (FMA-LE)is a commonly used measure with high reliability and validity, but there is no official translated Japanese version of FMA-LE.Objectives: This study aimed to develop Japanese FMA-LE and verify its reliability and validity in patients with acute stroke.Methods: The Japanese FMA-LE was developed following a standardized translation process. The reliability and validity were evaluated in 50 stroke patients at an acute care hospital. Validity was examined by determining the correlation between FMA-LEand Brunnstrom Recovery Stage (BRS), as well as Short Physical Performance Battery (SPPB). Intra-raterand inter-raterrelative reliabilities were evaluated by calculating intra-classcorrelation coefficients (ICCs). Absolute reliability was assessed by determining the standard error of the measurement and minimum detectible change (MDC). Systematic error was also assessed.Results: FMA-LEtotal score was high correlated with BRS (ρ = 0.73,p < .01) and moderately correlated with SPPB (ρ = 0.69,p < .01). For intra-raterreliability, ICC was 0.98 (p < .01), only fixed systematic error was observed (p < .01), and MDC of the FMA-LEtotal score was 1.24. For inter-raterreliability, ICC was 0.98 (p < .01), no systematic error was observed, and MDC of the FMA-LEtotal score was 3.23.Conclusions: The Japanese FMA-LE was reliable, valid, and useful for evaluating lower extremity function of acute stroke patients.

Effectiveness of walking training on balance, motor functions, activity, participation and quality of life in people with chronic stroke: a systematic review with meta-analysis and meta-regression of recent randomized controlled trials

PURPOSE

To review and quantify the effects of walking training for the improvement of various aspects of physical function of people with chronic stroke.

METHODS

We conducted a systematic search and meta-analysis of randomized controlled trials (RCTs) of chronic stroke rehabilitation interventions published from 2008 to 2020 in English or French. Of the 6476-screened articles collated from four databases, 15 RCTs were included and analyzed. We performed a meta-regression with the total training time as dependent variable in order to have a better understanding of how did the training dosage affect the effect sizes.

RESULTS

Treadmill walking training was more effective on balance and motor functions (standardized mean difference (SMD)=0.70[0.02, 1.37], p = 0.04) and 0.56[0.15, 0.96], p = 0.007 respectively). Overground walking training improved significantly walking endurance (SMD = 0.38[0.16, 0.59], p < 0.001), walking speed (MD = 0.12[0.05, 0.18], p < 0.001), participation (SMD = 0.35[0.02, 0.68], p = 0.04) and quality of life (SMD = 0.46[0.12, 0.80], p = 0.008). Aquatic training improved balance (SMD = 2.41[1.20, 3.62], p < 0.001). The Meta-regression analysis did not show significant effect of total training time on the effect sizes.

CONCLUSION

Treadmill and overground walking protocols consisting of ≥30 min sessions conducted at least 3 days per week for about 8 weeks are beneficial for improving motor impairments, activity limitations, participation, and quality of life in people with chronic stroke.Implications for rehabilitationTreadmill walking training is effective for improving balance and motor functions.Overground walking training improved significantly walking endurance, walking speed, participation and quality of life.Treadmill and overground walking protocols consisting of ≥30 min sessions conducted at least 3 days per week for about 8 weeks are beneficial for improving motor impairments, activity limitations, participation, and quality of life in patient with chronic stroke.

A First Step Toward the Operationalization of the Learned Non-Use Phenomenon: A Delphi Study

BACKGROUND

The negative discrepancy between residual functional capacity and reduced use of the contralesional hand, frequently observed after a brain lesion, has been termed Learned Non-Use (LNU) and is thought to depend on the interaction of neuronal mechanisms during recovery and learning-dependent mechanisms.

OBJECTIVE

Albeit the LNU phenomenon is generally accepted to exist, currently, no transdisciplinary definition exists. Furthermore, although therapeutic approaches are implemented in clinical practice targeting LNU, no standardized diagnostic routine is described in the available literature. Our objective was to reach consensus regarding a definition as well as synthesize knowledge about the current diagnostic procedures.

METHODS

We used a structured group communication following the Delphi method among clinical and scientific experts in the field, knowledge from both, the work with patient populations and with animal models.

RESULTS

Consensus was reached regarding a transdisciplinary definition of the LNU phenomenon. Furthermore, the mode and strategy of the diagnostic process, as well as the sources of information and outcome parameters relevant for the clinical decision making, were described with a wide range showing the current lack of a consistent universal diagnostic approach.

CONCLUSIONS

The need for the development of a structured diagnostic procedure and its implementation into clinical practice is emphasized. Moreover, it exists a striking gap between the prevailing hypotheses regarding the mechanisms underlying the LNU phenomenon and the actual evidence. Therefore, basic research is needed to bridge between bedside and bench and eventually improve clinical decision making and further development of interventional strategies beyond the field of stroke rehabilitation.

Clinical Neurorehabilitation: Using Principles of Neurological Diagnosis, Prognosis, and Neuroplasticity in Assessment and Treatment Planning

Neurorehabilitation aspires to restore a person to his or her fullest potential after incurring neurological dysfunction. In medical rehabilitation, diagnosis involves assessment of medical conditions and their effects on functioning. It is usually a team effort that involves an amalgam of diagnostic assessments by multiple disciplines, leading to a collection of rehabilitative treatment plans and goals. This article discusses a clinical neurological paradigm, using rigorous clinical assessment of neuropathological and clinical diagnosis, along with prognostication of natural history and recovery. In the context of the role of neuroplasticity in recovery, this paradigm can add significant value to rehabilitation team management and planning. It contributes to enhanced understanding of neurological impairments and syndromes as they relate to functional disability, aiding in targeting deficits and setting treatment goals. Rehabilitation strategies and goals should be informed by natural history and prognosis, and viewed in the framework of the stage of recovery. Prognostic formulations should suggest an emphasis on restorative versus compensatory strategies for functional problems. Treatment planning should be informed by evidence on how interventions modulate brain reorganization in promoting recovery. Strategies that promote adaptive neuroplasticity should be favored, especially with restorative efforts, and evidence supporting optimal techniques, timing, and dosing of rehabilitation should be considered in treatment planning.

The Kickstart Walk Assist System for improving balance and walking function in stroke survivors: a feasibility study

BACKGROUND

Compared with traditional physical therapy for stroke patients, lower extremity exoskeletons can provide patients with greater endurance and more repeatable and controllable training, which can reduce the therapeutic burden of the therapist. However, most exoskeletons are expensive, heavy or require active power to be operated. Therefore, a lighter, easy to wear, easy to operate, low-cost technology for stroke rehabilitation would be a welcome opportunity for stroke survivors, caregivers and clinicians. One such device is the Kickstart Walk Assist system and the purpose of this study was to determine feasibility of using this unpowered exoskeleton device in a sample of stroke survivors.

METHODS

Thirty stroke survivors were enrolled in the study and experienced walking with the Kickstart exoskeleton device that provided spring-loaded assistance during gait. After 5 days of wearing the exoskeleton, participants were evaluated in the two states of wearing and not wearing the exoskeleton. Outcome measures included: (a) spatio-temporal gait measures, (b) balance measures and (c) exoskeleton-use feedback questionnaire.

RESULTS

In comparison to not wearing the device, when participants wore the Kickstart walking system, weight bearing asymmetry was reduced. The time spent on the 10-m walk test was also reduced, but there was no difference in the timed-up-and-go test (TUGT). Gait analysis data showed reduction in step time and double support time. Stroke survivors were positive about the Kickstart walking system's ability to improve their balance, speed and gait. In addition, their confidence level and willingness to use the device was also positive.

CONCLUSIONS

These findings show the feasibility of using the Kickstart walking system for improving walking performance in stroke survivors. Our future goal is to perform a longer duration study with more comprehensive pre- and post-testing in a larger sample of stroke survivors. Trial registration Chinese Clinical Trial Registry, ChiCTR2000032665. Registered 5 May 2020-Retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=53288.

Intense Arm Rehabilitation Therapy Improves the Modified Rankin Scale Score: Association Between Gains in Impairment and Function

OBJECTIVE

To evaluate the effect of intensive rehabilitation on the modified Rankin Scale (mRS), a measure of activities limitation commonly used in acute stroke studies, and to define the specific changes in body structure/function (motor impairment) most related to mRS gains.

METHODS

Patients were enrolled >90 days poststroke. Each was evaluated before and 30 days after a 6-week course of daily rehabilitation targeting the arm. Activity gains, measured using the mRS, were examined and compared to body structure/function gains, measured using the Fugl-Meyer (FM) motor scale. Additional analyses examined whether activity gains were more strongly related to specific body structure/function gains.

RESULTS

At baseline (160 ± 48 days poststroke), patients (n = 77) had median mRS score of 3 (interquartile range, 2-3), decreasing to 2 [2-3] 30 days posttherapy (p < 0.0001). Similarly, the proportion of patients with mRS score ≤2 increased from 46.8% at baseline to 66.2% at 30 days posttherapy (p = 0.015). These findings were accounted for by the mRS score decreasing in 24 (31.2%) patients. Patients with a treatment-related mRS score improvement, compared to those without, had similar overall motor gains (change in total FM score, p = 0.63). In exploratory analysis, improvement in several specific motor impairments, such as finger flexion and wrist circumduction, was significantly associated with higher likelihood of mRS decrease.

CONCLUSIONS

Intensive arm motor therapy is associated with improved mRS in a substantial fraction (31.2%) of patients. Exploratory analysis suggests specific motor impairments that might underlie this finding and may be optimal targets for rehabilitation therapies that aim to reduce activities limitations.

CLINICAL TRIAL

Clinicaltrials.gov identifier: NCT02360488.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for patients >90 days poststroke with persistent arm motor deficits, intensive arm motor therapy improved mRS in a substantial fraction (31.2%) of patients.

Neuropsychiatric symptoms in a occipito-temporal infarction with remarkable long-term functional recovery

Posterior circulation infarctions (PCI) constitute 5-25% of ischemic strokes. PCI of the occipital lobe present with a panoply of symptoms including quadrantanopsia, topographical disorientation, and executive dysfunction. Long-term cognitive recovery after PCI is not well described. However, the adult brain is remarkably plastic, capable of adapting and remodeling. We describe a 43-year-old right-handed woman who complained of black spots in both eyes, headaches, photophobia, and a feeling she would faint. Initial neurological exam and a CT scan were normal; she was diagnosed with ocular migraine. A second neurological exam a week later showed left superior quadrantopsia; an MRI scan suggested right occipito-temporal infarct. In subsequent months, the patient complained of fatigue, quadrantanopsia, memory problems, and topographical disorientation. The patient participated in multi-modality treatment, and in self-directed arts projects and physical activities. Six years later, she reported noticeable improvements in cognition and daily functioning, which were documented on neurocognitive testing. Comparison between initial and subsequent MRIs using FreeSurfer 5.3 identified neuroplastic brain changes in areas serving similar functions to the areas injured from the stroke. The case illustrates the neuropsychiatric presentation after right occipito-temporal stroke, the value of formal and self-directed cognitive rehabilitation, the extended time to cognitive recovery, and the ability of the brain to undergo neuroplastic changes.

A Feasibility Study of Expanded Home-Based Telerehabilitation After Stroke

Introduction: High doses of activity-based rehabilitation therapy improve outcomes after stroke, but many patients do not receive this for various reasons such as poor access, transportation difficulties, and low compliance. Home-based telerehabilitation (TR) can address these issues. The current study evaluated the feasibility of an expanded TR program. Methods: Under the supervision of a licensed therapist, adults with stroke and limb weakness received home-based TR (1 h/day, 6 days/week) delivered using games and exercises. New features examined include extending therapy to 12 weeks duration, treating both arm and leg motor deficits, patient assessments performed with no therapist supervision, adding sensors to real objects, ingesting a daily experimental (placebo) pill, and generating automated actionable reports. Results: Enrollees (n = 13) were median age 61 (IQR 52-65.5), and 129 (52-486) days post-stroke. Patients initiated therapy on 79.9% of assigned days and completed therapy on 65.7% of days; median therapy dose was 50.4 (33.3-56.7) h. Non-compliance doubled during weeks 7-12. Modified Rankin scores improved in 6/13 patients, 3 of whom were >3 months post-stroke. Fugl-Meyer motor scores increased by 6 (2.5-12.5) points in the arm and 1 (-0.5 to 5) point in the leg. Assessments spanning numerous dimensions of stroke outcomes were successfully implemented; some, including a weekly measure that documented a decline in fatigue (p = 0.004), were successfully scored without therapist supervision. Using data from an attached sensor, real objects could be used to drive game play. The experimental pill was taken on 90.9% of therapy days. Automatic actionable reports reliably notified study personnel when critical values were reached. Conclusions: Several new features performed well, and useful insights were obtained for those that did not. A home-based telehealth system supports a holistic approach to rehabilitation care, including intensive rehabilitation therapy, secondary stroke prevention, screening for complications of stroke, and daily ingestion of a pill. This feasibility study informs future efforts to expand stroke TR. Clinical Trial Registration: Clinicaltrials.gov, # NCT03460587.

Comparing Two Different Modes of Task Practice during Lower Limb Constraint-Induced Movement Therapy in People with Stroke: A Randomized Clinical Trial

Background

Constraint-induced movement therapy (CIMT) is used for the rehabilitation of motor function after stroke.

Objectives

The aim of this study was to compare the effects of lower limb CIMT that uses number of repetition of tasks with the one that uses number of hours of practice.

Method

The study was a randomized clinical trial approved by the Ethics Committee of Kano State Ministry of Health. Fifty-eight people with stroke participated in the study. Groups 1 and 2 performed daily 600 repetitions and 3 hours of task practice, respectively, 5 times weekly for 4 weeks. Motor impairment (primary outcome), balance, functional mobility, knee extensor spasticity, walking speed and endurance, and exertion before and after commencement of activities were assessed at baseline and postintervention. The data was analyzed using Friedmann and Mann-Whitney U tests.

Result

The results showed that there was only significant difference (p < 0.05) in knee extensor spasticity (group 1 (median = 0(0), mean rank = 27.50); group 2 (median = 0(0), mean rank = 31.64)), exertion before commencement of activities (group 1 (median = 0(0.5), mean rank = 21.90); group 2 (median = 1(0.5), mean rank = 37.64)), and exertion after commencement of activities (group 1 (median = 1(1), mean rank = 20.07); group 2 (median = 1(0), mean rank = 39.61) postintervention in favour of the experimental group (group 1)).

Conclusion

The group 1 protocol is more effective at improving outcomes after stroke.

Recovery process of respiratory muscle strength in patients following stroke: A Pilot Study

OBJECTIVE

To determine the recovery process of respiratory muscle strength during 3 months following stroke, and to investigate the association of change in respiratory muscle strength and physical functions. Additionally, we compared respiratory muscle strength with those of healthy subjects.

METHOD

In this prospective, observational study, 19 stroke patients and 19 healthy subjects were enrolled. Maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), motricity index, trunk control test, 6-minute walk test (6MWT) and functional independence measure were assessed at 1, 2, and 3 months from stroke onset in stroke patients. MIP and MEP were assessed at arbitrary times in healthy subjects. Repeated one-way analysis of variance with Bonferroni post-hoc test was used to compare the change in respiratory muscle strength in each period in stroke patients. Pearson's correlation coefficient was computed for changes in respiratory muscle strength and physical functions. Student's t-test was used to compare respiratory muscle strength between stroke patients at 3 months from onset and healthy subjects.

RESULTS

MIP was significantly increased at 3 months compared to 1 month. MEP was significantly increased in 2 months and 3 months, compared to 1 month. MIP changes associated with 6MWT changes. Compared to healthy subjects, MIP and MEP at 3 months were significantly lower in stroke patients.

CONCLUSION

Respiratory muscle strength significantly increased during 3 months following stroke. However, the trend of recovery may be different. MIP changes may associated with walking endurance changes. During 3 months following stroke, respiratory muscle strength did not recover to healthy subjects.

Canadian Platform for Trials in Noninvasive Brain Stimulation (CanStim) Consensus Recommendations for Repetitive Transcranial Magnetic Stimulation in Upper Extremity Motor Stroke Rehabilitation Trials

Objective. To develop consensus recommendations for the use of repetitive transcranial magnetic stimulation (rTMS) as an adjunct intervention for upper extremity motor recovery in stroke rehabilitation clinical trials. Participants. The Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim) convened a multidisciplinary team of clinicians and researchers from institutions across Canada to form the CanStim Consensus Expert Working Group. Consensus Process. Four consensus themes were identified: (1) patient population, (2) rehabilitation interventions, (3) outcome measures, and (4) stimulation parameters. Theme leaders conducted comprehensive evidence reviews for each theme, and during a 2-day Consensus Meeting, the Expert Working Group used a weighted dot-voting consensus procedure to achieve consensus on recommendations for the use of rTMS as an adjunct intervention in motor stroke recovery rehabilitation clinical trials. Results. Based on best available evidence, consensus was achieved for recommendations identifying the target poststroke population, rehabilitation intervention, objective and subjective outcomes, and specific rTMS parameters for rehabilitation trials evaluating the efficacy of rTMS as an adjunct therapy for upper extremity motor stroke recovery. Conclusions. The establishment of the CanStim platform and development of these consensus recommendations is a first step toward the translation of noninvasive brain stimulation technologies from the laboratory to clinic to enhance stroke recovery.

Robotic Assessment of Upper Limb Function in a Nonhuman Primate Model of Chronic Stroke

Stroke is a leading cause of death and disability worldwide and survivors are frequently left with long-term disabilities that diminish their autonomy and result in the need for chronic care. There is an urgent need for the development of therapies that improve stroke recovery, as well as accurate and quantitative tools to measure function. Nonhuman primates closely resemble humans in neuroanatomy and upper limb function and may be crucial in randomized pre-clinical trials for testing the efficacy of stroke therapies. To test the feasibility of robotic assessment of motor function in a NHP model of stroke, two cynomolgus macaques were trained to perform a visually guided reaching task and were also assessed in a passive stretch task using the Kinarm robot. Strokes were then induced in these animals by transiently occluding the middle cerebral artery, and their motor performance on the same tasks was assessed after recovery. Relative to pre-stroke performance, post-stroke hand movements of the affected limb became slower and less accurate. Regression analyses revealed both recovered and compensatory movements to complete movements in different spatial directions. Lastly, we noted decreased range of motion in the elbow joint of the affected limb post-stroke associated with spasticity during passive stretch. Taken together, these studies highlight that sensorimotor deficits in reaching movements following stroke in cynomolgus macaques resemble those in human patients and validate the use of robotic assessment tools in a nonhuman primate model of stroke for identifying and characterizing such deficits.

Wearable gait device for stroke gait rehabilitation at home

BACKGROUND

Hemiparesis is a common disabling consequence of stroke that leads to abnormal gait patterns marked by asymmetries in step length, stance, and swing phases. Asymmetric gait patterns are correlated with decreased gait velocity and increased susceptibility to falls that can lead to serious injuries and hospitalizations.

OBJECTIVE

In this single group, before and after study, treatment with the iStride^TM gait device, designed to improve the gait patterns of individuals with hemiparesis, is adapted to the home environment. Previously tested in clinical settings, this study investigates if using the iStride^TM gait device within the home environment can provide safe and effective gait treatment for individuals with hemiparetic gait impairments caused by stroke.

METHODS

Twelve 30-minute sessions of walking on the device were administered in each participant's home environment. Twenty-one participants who were more than one-year post-stroke received the treatment. The Ten-Meter Walk Test, Timed Up and Go Test, Berg Balance Scale, Functional Gait Assessment, and Stroke Specific Quality of Life Scale were performed before and one week after treatment. Safety, treatment plan compliance, and subjective responses were also recorded during the study period.

RESULTS

Results demonstrate statistically significant improvement on all five outcome measures from before treatment to one week after the last treatment session (p < 0.01) using two-tailed paired t-tests. 76% of participants improved beyond the small meaningful change or minimal detectable change on three or more outcome measures. 67% of participants improved clinically in gait speed and on at least one of the fall risk assessment inventories. 81% of the participants were able to perform the treatment in their home without assistance before the end of week three.

CONCLUSIONS

The results indicate that the iStride^TM gait device can facilitate effective, safe, and home-accessible gait treatment opportunities for individuals with hemiparesis from stroke.

Integrity of The Hand Fibers of The Corticospinal Tract Shown by Diffusion Tensor Imaging Predicts Hand Function Recovery After Hemorrhagic Stroke

BACKGROUND

Hand motor function is often severely affected in patients with hemorrhagic stroke. The present study aimed to investigate the feasibility of predicting hand function recovery after hypertensive intracerebral hemorrhage using diffusion tensor imaging (DTI).

METHODS

A total of 75 patients with hypertensive intracerebral hemorrhage were prospectively included. DTI of the corticospinal tract (CST) connecting the hand knob area of the precentral gyrus and the cerebral peduncle was performed at around 3 weeks after stroke. Integrity of the CST was evaluated as no disruption, partial disruption, and complete disruption. Hand function was compared by the Brunnstrom recovery stage of hand (BRS-H) at post-stroke 3 weeks and 3 months.

RESULTS

Degrees of integrity of the corticospinal cord was negatively correlated with the BRS-H at both post-stroke 3 weeks (r = -0.77, p < 0.01) and 3 months (r = -0.75, p < 0.01). Patients with intact CST or completely disrupted CST shown by DTI did not show significant improvement in the BRS-H at post-stroke 3 months. However, those with partially disrupted CST showed significant improvement in the BRS-H at post-stroke 3 months compared to 3 weeks (3.79 ± 1.36 vs 2.53 ± 1.58, p = 0.012).

CONCLUSIONS

DTI can be used to visualize the damage to the hand fibers of the CST. Patients with partially disrupted CST may benefit most from rehabilitation therapy for hand function recovery after hypertensive intracerebral hemorrhage.

Reliability and validity data to support the clinical utility of the Traumatic Brain Injury Caregiver Quality of Life (TBI-CareQOL)

OBJECTIVE

The Traumatic Brain Injury Caregiver Quality of Life (TBI-CareQOL) is a patient-reported outcome measurement system that is specific to caregivers of civilians and service members/veterans (SMVs) with traumatic brain injury (TBI). This measurement system includes 26 item banks that represent both generic (i.e., borrowed from existing measurement systems) and caregiver-specific components of health-related quality of life (HRQOL). This report provides reliability and validity data for measures within the TBI-CareQOL that have not previously been reported (i.e., 4 caregiver-specific and 7 generic measures of HRQOL).

DESIGN

Three hundred eighty-five caregivers of persons with TBI completed caregiver-specific computer adaptive tests (CATs) for Feelings of Loss-Self, Caregiver Strain, Caregiver-Specific Anxiety, and Feeling Trapped, as well as generic measures of HRQOL from complementary measurement systems (i.e., Neuro-QoL Positive Affect and Well-Being; PROMIS Sleep-Related Impairment; NIH Toolbox Perceived Stress, General Life Satisfaction, and Self Efficacy; TBI-QOL Resilience and Grief/Loss). Caregivers also completed several additional measures to establish convergent and discriminant validity, as well as the Mayo Portland Adaptability Index, 4th ed.

RESULTS

Findings support the internal consistency reliability (all alphas > .85) and test-retest stability (all alphas >.73) of the TBI-CareQOL measures. Convergent validity was supported by moderate to high correlations between the TBI-CareQOL measures and related measures, whereas discriminant validity was supported by low correlations between the TBI-CareQOL measures and unrelated constructs. Known-groups validity was also supported.

CONCLUSIONS

Findings support the reliability and validity of the item banks that comprise the TBI-CareQOL Measurement System. These measures should be considered for any standardized assessment of HRQOL in caregivers of civilians and SMVs with TBI. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The effect of transition care interventions incorporating health coaching strategies for stroke survivors: A systematic review and meta-analysis

OBJECTIVE

To systematically analyse health coaching strategies in transition care and synthesise the effect of these strategies on health care outcomes for stroke survivors.

METHODS

A systematic search of nine databases in two languages was conducted. Meta-analysis was conducted when data were available.

RESULTS

Twenty-five randomised controlled trials met the inclusion criteria. The meta-analysis revealed that health coaching strategies in transition care interventions significantly improve quality of life (QoL) (p < 0.001), activities of daily living (ADL) (p = 0.002) and reduce depression (p = 0.001) for stroke survivors at 3 months. Further subgroup analysis demonstrated that transition care interventions with a greater number of health coaching strategies are associated with a larger effect size on QoL (SMD=1.15) and ADL (SMD=1.177) at 3 months, and a medium effect size (SMD=0.674) on depression reduction. However, the effects of health coaching strategies on readmission, mortality and falls in stroke survivors remain inconclusive.

CONCLUSIONS

This review provides evidence that incorporating health coaching strategies in transitional care improves health outcomes of stroke survivors.

PRACTICE IMPLICATION

More trials of health coaching interventions to improve transition care with a rigorous study design are much needed to address the lack of support for stroke survivors and their caregivers in this crucial care period.

Persistent Effect of Gait Exercise Assist Robot Training on Gait Ability and Lower Limb Function of Patients With Subacute Stroke: A Matched Case-Control Study With Three-Dimensional Gait Analysis

Introduction

Gait exercise assist robot (GEAR), a gait rehabilitation robot developed for poststroke gait disorder, has been shown to improve walking speed and to improve the poststroke gait pattern. However, the persistence of its beneficial effect has not been clarified. In this matched case–control study, we assessed the durability of the effectiveness of GEAR training in patients with subacute stroke on the basis of clinical evaluation and three-dimensional (3D) gait analysis.

Methods

Gait data of 10 patients who underwent GEAR intervention program and 10 patients matched for age, height, sex, affected side, type of stroke, and initial gait ability who underwent conventional therapy were extracted from database. The outcome measures were walk score of Functional Independence Measure (FIM-walk), Stroke Impairment Assessment Set total lower limb motor function score (SIAS-L/E), and 3D gait analysis data (spatiotemporal factors and abnormal gait patter indices) at three time points: baseline, at the end of intervention, and within 1 week before discharge.

Results

In the GEAR group, the FIM-walk score, SIAS-L/E score, cadence, and single stance time of paretic side at discharge were significantly higher than those at post-training (p < 0.05), whereas the stance time and double support time of the unaffected side, knee extensor thrust, insufficient knee flexion, and external rotated hip of the affected side were significantly lower (p < 005). However, no significant differences in these respects were observed in the control group between the corresponding evaluation time points.

Conclusion

The results indicated significant improvement in the GEAR group after the training period, with respect to both clinical parameters and the gait pattern indices. This improvement was not evident in the control group after the training period. The results possibly support the effectiveness of GEAR training in conferring persistently efficient gait patterns in patients with poststroke gait disorder. Further studies should investigate the long-term effects of GEAR training in a larger sample.

Can kinematic parameters of 3D reach-to-target movements be used as a proxy for clinical outcome measures in chronic stroke rehabilitation? An exploratory study

BACKGROUND

Despite numerous trials investigating robot-assisted therapy (RT) effects on upper-extremity (UE) function after stroke, few have explored the relationship between three-dimensional (3D) reach-to-target kinematics and clinical outcomes. The objectives of this study were to 1) investigate the correlation between kinematic parameters of 3D reach-to-target movements and UE clinical outcome measures, and 2) examine the degree to which differences in kinematic parameters across individuals can account for differences in clinical outcomes in response to RT.

METHODS

Ten chronic stroke survivors participated in a pilot RT intervention (eighteen 1-h sessions) integrating cognitive skills training and a home-action program. Clinical outcome measures and kinematic parameters of 3D reach-to-target movements were collected pre- and post-intervention. The correlation between clinical outcomes and kinematic parameters was investigated both cross-sectionally and longitudinally (i.e., changes in response to the intervention). Changes in clinical outcomes and kinematic parameters were tested for significance in both group and subject-by-subject analyses. Potential associations between individual differences in kinematic parameters and differences in clinical outcomes were examined.

RESULTS

Moderate-to-strong correlation was found between clinical measures and specific kinematic parameters when examined cross-sectionally. Weaker correlation coefficients were found longitudinally. Group analyses revealed significant changes in clinical outcome measures in response to the intervention; no significant group changes were observed in kinematic parameters. Subject-by-subject analyses revealed changes with moderate-to-large effect size in the kinematics of 3D reach-to-target movements pre- vs. post-intervention. Changes in clinical outcomes and kinematic parameters varied widely across participants.

CONCLUSIONS

Large variability was observed across subjects in response to the intervention. The correlation between changes in kinematic parameters and clinical outcomes in response to the intervention was variable and not strong across parameters, suggesting no consistent change in UE motor strategies across participants. These results highlight the need to investigate the response to interventions at the individual level. This would enable the identification of clusters of individuals with common patterns of change in response to an intervention, providing an opportunity to use cluster-specific kinematic parameters as a proxy of clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02747433 . Registered on April 21st, 2016.

Predictors for the use of traditional Chinese medicine among inpatients with first-time stroke: a population-based study

BACKGROUND

Stroke is one of the major causes of death and disability. The treatments that are provided to patients during hospitalization after an acute stroke are very important in stabilizing their medical condition and enabling the recovery of their motor functions. However, limited information is available regarding the use of traditional Chinese medicine (TCM) during hospitalization for first-time stroke patients. The researchers aimed to investigate the factors affecting TCM use and to provide clinicians with comprehensive information on TCM use among first-time stroke inpatients in Taiwan.

METHODS

The researchers collected and analyzed data, including patient characteristics, TCM use, and TCM prescription patterns, from the National Health Insurance Research Database in Taiwan for first-time stroke inpatients between 2006 and 2012.

RESULTS

Among the 89,162 first-time stroke patients, 7455 were TCM users, and 81,707 were TCM nonusers. The predictors for TCM use were as follows: age, 45-64 or < 45 years; men; living in a level 2, 4, or 7 urbanized area; insured amount ≥ 576 USD per month; ischemic stroke; hospitalized for first-time stroke for 8-14 days, 15-28 days, or ≥ 29 days; stroke severity index score 0-9 or 10-19; Charlson-Deyo comorbidity index score 0 or 1-2; hospitalization in a regional or community hospital; receiving rehabilitation; and previous experience with outpatient TCM use. An increase in the number of TCM users was observed from 2006 to 2012. Furthermore, 68.8-79.7% of TCM users used acupuncture only, while 17.8-26.1% used both acupuncture and Chinese herbal medicine.

CONCLUSIONS

An increasing number of first-time stroke patients have been choosing TCM as a complementary treatment during hospitalization. Moreover, TCM use is associated with demographic, clinical, and socioeconomic characteristics. These findings may help clinicians comprehensively understand the trend and the important factors affecting TCM utilization among patients who are hospitalized due to first-time stroke.

Effects of Exoskeletal Lower Limb Robot Training on the Activities of Daily Living in Stroke Patients: Retrospective Pre-Post Comparison Using Propensity Score Matched Analysis

PURPOSE

There is limited evidence of gait training using newly developed exoskeletal lower limb robot called Hybrid Assistive Limb (HAL) on the function and ability to perform ADL in stroke patients. In clinical settings, we frequently find it challenging to conduct a randomized controlled trial; thus, a large-scale observational study using propensity score analysis methods is a feasible alternative. The present study aimed to determine whether exoskeletal lower limb robot training improved the ability to perform ADL in stroke patients.

MATERIALS AND METHODS

Acute stroke patients who were admitted to our facility from April 2016 to March 2017 were evaluated in the conventional rehabilitation period (CRP) and those admitted from April 2017 to June 2019 were evaluated in the HAL rehabilitation period (HRP). We started a new gait rehabilitation program using HAL at the midpoint of these two periods. The functional outcomes or ADL ability outcomes of the patients in the CRP and the subsequent HRP were compared using propensity score matched analyses.

RESULTS

Propensity score matching analysis was performed for 108 stroke patients (63 from the CRP and 45 from the HRP), and 36 pairs were matched. The ADL ability, defined by the FIM scores and FIM score change, was significantly higher in patients admitted during the HRP. In addition, more stroke patients obtained practical walking ability during hospitalization in the HRP.

CONCLUSION

Gait training using HAL affects the ADL ability and obtaining of practical walking ability of stroke patients.

Late functional improvement and 5-year poststroke outcomes: a population-based cohort study

BACKGROUND

Late functional improvement between 3 and 12 months poststroke occurs in about one in four patients with ischaemic stroke, more commonly in lacunar strokes. It is unknown whether this late improvement is associated with better long-term clinical or health economic outcomes.

METHODS

In a prospective, population-based cohort of 1-year ischaemic stroke survivors (Oxford Vascular Study; 2002-2014), we examined changes in functional status (modified Rankin Scale (mRS), Rivermead Mobility Index (RMI), Barthel Index (BI)) from 3 to 12 months poststroke. We used Cox regressions adjusted for age, sex, 3-month disability and stroke subtype (lacunar vs non-lacunar) to examine the association of late improvement (by ≥1 mRS grades, ≥1 RMI points and/or ≥2 BI points between 3 and 12 months) with 5-year mortality and institutionalisation. We used similarly adjusted generalised linear models to examine association with 5-year healthcare/social-care costs.

RESULTS

Among 1288 one-year survivors, 1135 (88.1%) had 3-month mRS >0, of whom 319 (28.1%) demonstrated late functional improvement between 3 and 12 months poststroke. Late improvers had lower 5-year mortality (aHR per mRS=0.68, 95% CI 0.51 to 0.91, p=0.009), institutionalisation (aHR 0.48, 0.33 to 0.72, p<0.001) and healthcare/social care costs (margin US$17 524, -24 763 to -10 284, p<0.001). These associations remained on excluding patients with recurrent strokes during follow-up (eg, 5-year mortality/institutionalisation: aHR 0.59, 0.44 to 0.79, p<0.001) and on examining late improvement per RMI and/or BI (eg, 5-year mortality/institutionalisation with RMI/BI: aHR 0.73, 0.58 to 0.92, p=0.008).

CONCLUSION

Late functional improvement poststroke is associated with lower 5-year mortality, institutionalisation rates and healthcare/social care costs. These findings should motivate patients and clinicians to maximise late recovery in routine practice, and to consider extending access to proven rehabilitative therapies during the first year poststroke.

Health-related quality of life of patients after ischaemic stroke treated in a provincial hospital in Poland

BACKGROUND

Ischaemic stroke (IS) is a major cause of death and disability and affects the quality of life of patients. Previous studies focused on urban populations.

OBJECTIVE

To evaluate the health-related quality of life (QoL) of patients with history of IS and living in a rural area in Poland.

PATIENTS

Rural population of 172 patients discharged from a district hospital in Zakopane, Poland with a diagnosis of IS in the period from 01.01.2005 to 31.10.2006.

INTERVENTION

QoL was evaluated using the European Quality of Life Scale-5 Dimensions EQ-5D-3 L (EQ-5D) and the Short Form Health Survey - 12 version 2 (SF-12).

RESULTS

In the EQ-5D survey, 57.3% of patients had only some problems with mobility, 40.3% with usual activities, 63.2% with pain/discomfort, 59% with anxiety/depression, and 32.2% with self-care. In the SF-12 survey, both summary components (physical and psychological) were reduced compared to the population norm.

CONCLUSION

The quality of life in IS survivors is clearly reduced in the majority of domains assessed by the EQ-5D and SF-12 questionnaires. The most important factors affecting QoL were the functional state, depression and anxiety. A significant difference as compared to to urban and mixed populations was observed for a reduced SF-12 mental health component and for the EQ-5D visual analogue scale. We found no effect of gender, age or cognitive disorders on the outcomes of SF-12.

Predicting Longitudinal Progression in Functional Mobility After Stroke: A Prospective Cohort Study

Supplemental Digital Content is available in the text.

A majority of people with stroke remain impaired in their functional mobility. The aim of the study was to determine longitudinal changes in functional mobility after stroke.

Do emotional distress and functional problems in persons with traumatic brain injury contribute to perceived sleep-related impairment in caregivers?

OBJECTIVE

The goal of this study was to examine the association between characteristics of persons with traumatic brain injury (PwTBI) and perceived sleep-related impairment of the caregivers.

METHOD

Fifty-two dyads (n = 23 civilians, n = 29 service members/veterans [SMVs]) were enrolled. Caregivers completed the Patient-Reported Outcomes Measurement Information System Sleep-Related Impairment computer adaptive test, and PwTBI completed Quality of Life in Neurological Disorders measures of depression, anxiety, anger, cognitive functioning, and upper and lower extremity functioning. Hierarchical linear regression models, stratified by civilian/SMV group, were employed to assess prediction of caregiver-perceived sleep-related impairment from emotional distress of the PwTBI (anxiety, depressed mood, and anger) and perceived functional status of the PwTBI (cognitive, upper extremity, lower extremity functioning).

RESULTS

Compared with caregivers of civilians, caregivers of SMVs reported higher perceived sleep-related impairment. Regression results showed that characteristics of the PwTBI accounted for moderate amounts of variance in the sleep-related impairment of caregivers of both civilians and SMVs. Within-group analyses showed that the strongest predictor of sleep-related impairment of caregivers of civilians was self-reported cognitive function of the PwTBI (β = -0.82, p = .08); the strongest predictor of sleep-related impairment of caregivers of SMVs was self-reported anger of the PwTBI (β = 0.54, p = .07).

CONCLUSIONS

In both caregivers of civilians and SMVs with TBI, characteristics of the PwTBI were related to perceived caregiver sleep-related impairment. These preliminary data can inform future research with larger samples that examine the impact of multiple characteristics of the caregiver and care recipient on caregiver sleep. Findings highlight the potential importance of considering the dynamics of the dyad in rehabilitation programming not only for the PwTBI but for caregivers as well. (PsycInfo Database Record (c) 2020 APA, all rights reserved).