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

Quantitative EEG abnormalities in major depressive disorder with basal ganglia stroke with lesions in different hemispheres

BACKGROUND

This study aimed to examine the aberrant EEG oscillation in major depressive subjects with basal ganglia stroke with lesions in different hemispheres.

METHODS

Resting EEG of 16 electrodes in 58 stroke subjects, 26 of whom had poststroke depression (13 with left-hemisphere lesion and 13 with right) and 32 of whom did not (18 with left lesion and 14 with right), was recorded to obtain spectral power analysis for several frequency bands. Multiple analysis of variance and receiver operating characteristic (ROC) curves were used to identify differences between poststroke depression (PSD) and poststroke non-depression (PSND), treating the different lesion hemispheres separately. Moreover, Pearson linear correlation analysis was conducted to test the severity of depressive symptoms and EEG indices.

RESULTS

PSD with left-hemisphere lesion showed increased beta2 power in frontal and central areas, but PSD with right-hemisphere lesion showed increased theta and alpha power mainly in occipital and temporal regions. Additionally, for left-hemisphere lesions, beta2 power in central and right parietal regions provided high discrimination between PSD and PSND, and for right-hemisphere lesions, theta power was similarly discriminative in most regions, especially temporal regions. We also explored the association between symptoms of depression and the power of abnormal bands, but we found no such relationship.

LIMITATIONS

The sample size was relatively small and included subjects with different lesions of the basal ganglia.

CONCLUSIONS

The aberrant EEG oscillation in subjects with PSD differs between subjects with lesions of the left and right hemispheres, suggesting a complex association between depression and lesion location in stroke patients.

Gait training with Hybrid Assistive Limb enhances the gait functions in subacute stroke patients: A pilot study

BACKGROUND

The robotic Hybrid Assistive Limb (HAL) provides motion according to the wearer's voluntary activity. HAL training effects on walking speed and capacity have not been clarified in subacute stroke.

OBJECTIVES

To determine improvement in walking ability by HAL and the most effective improvement measure for use in future large-scale trials.

METHODS

Sixteen first-ever hemiplegic stroke patients completed at least 20 sessions over 5 weeks. Per session, the experimental group received no more than 20 min of gait training with HAL (HT) and 40 min of conventional physiotherapy, whereas the control group received at least 60 min of conventional physiotherapy. Primary outcome was maximum walking speed (MWS).

RESULTS

The change in MWS from baseline at week 5 was 11.6±10.6 m/min (HAL group) and 2.2±4.1 m/min (control group) (adjusted mean difference = 9.24 m/min, 95% confidence interval 0.48-18.01, P = 0.040). In HAL subjects there were significant increases in Self-selected walking speed (SWS; a secondary outcome) and in step length (a secondary outcome) at MWS and SWS compared with controls.

CONCLUSIONS

HT improved walking speed in hemiplegic sub-acute stroke patients. In future, randomized controlled trials are needed to confirm the utility of HT.

Neurofeedback as a form of cognitive rehabilitation therapy following stroke: A systematic review

Neurofeedback therapy (NFT) has been used within a number of populations however it has not been applied or thoroughly examined as a form of cognitive rehabilitation within a stroke population. Objectives for this systematic review included: i) identifying how NFT is utilized to treat cognitive deficits following stroke, ii) examining the strength and quality of evidence to support the use of NFT as a form of cognitive rehabilitation therapy (CRT) and iii) providing recommendations for future investigations. Searches were conducted using OVID (Medline, Health Star, Embase + Embase Classic) and PubMed databases. Additional searches were completed using the Cochrane Reviews library database, Google Scholar, the University of Toronto online library catalogue, ClinicalTrials.gov website and select journals. Searches were completed Feb/March 2015 and updated in June/July/Aug 2015. Eight studies were eligible for inclusion in this review. Studies were eligible for inclusion if they: i) were specific to a stroke population, ii) delivered CRT via a NFT protocol, iii) included participants who were affected by a cognitive deficit(s) following stroke (i.e. memory loss, loss of executive function, speech impairment etc.). NFT protocols were highly specific and varied within each study. The majority of studies identified improvements in participant cognitive deficits following the initiation of therapy. Reviewers assessed study quality using the Downs and Black Checklist for Measuring Study Quality tool; limited study quality and strength of evidence restricted generalizability of conclusions regarding the use of this therapy to the greater stroke population. Progression in this field requires further inquiry to strengthen methodology quality and study design. Future investigations should aim to standardize NFT protocols in an effort to understand the dose-response relationship between NFT and improvements in functional outcome. Future investigations should also place a large emphasis on long-term participant follow-up.

Design and test of an automated version of the modified Jebsen test of hand function using Microsoft Kinect

Background

The present paper describes the design and evaluation of an automated version of the Modified Jebsen Test of Hand Function (MJT) based on the Microsoft Kinect sensor.

Methods

The MJT was administered twice to 11 chronic stroke subjects with varying degrees of hand function deficits. The test times of the MJT were evaluated manually by a therapist using a stopwatch, and automatically using the Microsoft Kinect sensor. The ground truth times were assessed based on inspection of the video-recordings. The agreement between the methods was evaluated along with the test-retest performance.

Results

The results from Bland-Altman analysis showed better agreement between the ground truth times and the automatic MJT time evaluations compared to the agreement between the ground truth times and the times estimated by the therapist. The results from the test-retest performance showed that the subjects significantly improved their performance in several subtests of the MJT, indicating a practice effect.

Conclusions

The results from the test showed that the Kinect can be used for automating the MJT.

Robotic Characterization of Ipsilesional Motor Function in Subacute Stroke

BACKGROUND

Poststroke impairments of the ipsilesional arm are often discussed, but rarely receive focused rehabilitation. Ipsilesional deficits may affect daily function and although many studies have investigated them in chronic stroke, few characterizations have been made in the subacute phase. Furthermore, most studies have quantified ipsilesional deficits using clinical measures that can fail to detect subtle, but important deficits in motor function.

OBJECTIVE

We aimed to quantify reaching deficits of the contra- and ipsilesional limbs in the subacute phase poststroke.

METHODS

A total of 227 subjects with first-time, unilateral stroke completed a unilateral assessment of motor function (visually guided reaching) using a KINARM robot. Subjects completed the task with both the ipsi- and contralesional arms. Subjects were assessed on a variety of traditional clinical measures (Functional Independence Measure, Chedoke-McMaster Stroke Assessment, Purdue Pegboard, Behavioral Inattention Test) to compare with robotic measures of motor function.

RESULTS

Ipsilesional deficits were common and occurred in 37% (n = 84) of subjects. Impairments of the ipsilesional and contralesional arm were weakly to moderately correlated on robotic measures. Magnitude of impairment of the contralesional arm was similar for subjects with and without ipsilesional deficits. Furthermore, we found that a higher percentage of subjects with right-hemisphere stroke had ipsilesional deficits and more subjects with left-hemisphere subcortical strokes did not have ipsilesional deficits.

CONCLUSIONS

Magnitude of contralesional impairment and lesion location may be poor predictors of individuals with ipsilesional impairments after stroke. Careful characterization of ipsilesional deficits could identify individuals who may benefit from rehabilitation of the less affected arm.

Caregivers: Do They Make a Difference to Patient Recovery in Subacute Stroke?

OBJECTIVE

To evaluate the relationship between caregiver nature and availability, and rehabilitation outcomes in subacute stroke.

DESIGN

Retrospective cohort study.

SETTING

Four community rehabilitation hospitals.

PARTICIPANTS

Patients with subacute, first-time stroke (N=4042; 48.5% men; mean age ± SD, 70.12±10.4y; 51.5% women; mean age ± SD, 72.54 ±10.0y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehabilitation effectiveness, defined as the percentage of potential improvement eventually achieved with rehabilitation; and rehabilitation efficiency, defined as the rate of functional improvement during rehabilitation.

RESULTS

In our cohort, 96.7% had available caregiver(s), of which 42.0% were primarily supported by foreign domestic workers (FDWs), 25.9% by spouses, 19.3% by first-degree relatives, 7.8% by other relatives, and 5.1% by other caregivers. Using quantile regression, we found that having a caregiver was independently associated with rehabilitation efficiency (β=-3.83; 95% confidence interval [CI], -6.99 to -0.66; P=.018). The relationship between caregiver availability and rehabilitation effectiveness was modified by patient sex in that the negative association was significantly greater in men (β=-22.81; 95% CI, -32.70 to -12.94; P<.001) than women (β=-5.64; 95% CI, -14.72 to 3.44; P=.223). Having a FDW as a caregiver compared with a spousal caregiver was negatively associated with rehabilitation effectiveness (β=-3.95; 95% CI, -6.94 to -0.95; P=.01) and rehabilitation efficiency (β=-1.83; 95% CI, -3.14 to -0.53; P=.006). The number of potential caregivers was only significantly associated with rehabilitation effectiveness at the bivariate level (P=.006).

CONCLUSIONS

Caregiver identity, and possibly availability, appears to negatively affect rehabilitation outcomes in subacute stroke. A better understanding of these relationships has potential implications on clinical practice and policy directions.

Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis

BACKGROUND

Stroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.

METHODS

Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

RESULTS

Twenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [-0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD -0.10; CI [-0.59, 0.38], n = 35). Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.

CONCLUSIONS

FES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.

TRIAL REGISTRATION

PROSPERO: CRD42015025162 , Date:11/08/2015.

Atypical anticipatory postural adjustments during gait initiation among individuals with sub-acute stroke

Anticipatory postural adjustments, executed prior to gait initiation, help preserve lateral stability when stepping. Atypical patterns of anticipatory activity prior to gait initiation may occur in individuals with unilateral impairment (e.g., stroke). This study aimed to determine the prevalence, correlates, and consequences of atypical anticipatory postural adjustment patterns prior to gait initiation in a sub-acute stroke population. Forty independently-ambulatory individuals with sub-acute stroke stood on two force plates and initiated gait at a self-selected speed. Medio-lateral centre of pressure displacement was calculated and used to define anticipatory postural adjustments (shift in medio-lateral centre of pressure >10mm from baseline). Stroke severity, motor recovery, and functional balance and mobility status were also obtained. Three patterns were identified: single (typical), absent (atypical), and multiple (atypical) anticipatory postural adjustments. Thirty-five percent of trials had atypical anticipatory postural adjustments (absent and multiple). Frequency of absent anticipatory postural adjustments was negatively correlated with walking speed. Multiple anticipatory postural adjustments were more prevalent when leading with the non-paretic than the paretic limb. Trials with multiple anticipatory postural adjustments had longer duration of anticipatory postural adjustment and time to foot-off, and shorter unloading time than trials with single anticipatory postural adjustments. A high prevalence of atypical anticipatory control prior to gait initiation was found in individuals with stroke. Temporal differences were identified with multiple anticipatory postural adjustments, indicating altered gait initiation. These findings provide insight into postural control during gait initiation in individuals with sub-acute stroke, and may inform interventions to improve ambulation in this population.

Unexpected Improvement of Hand Motor Function with a Left Temporoparietal Low-Frequency Repetitive Transcranial Magnetic Stimulation Regime Suppressing Auditory Hallucinations in a Brainstem Chronic Stroke Patient

We here report paradoxical hand function recovery in a 61-year-old male tetra-paretic chronic patient following a stroke of the brainstem (with highly degraded right and abolished left-hand finger flexion/extension disabling him to manipulate objects) who experienced insidious auditory hallucinations (AHs) 4 years after such event. Symptomatic treatment for AHs was provided with periodical double sessions of low-frequency repetitive transcranial magnetic stimulation (rTMS) (daily 1 Hz, 2 × 1,200 pulses interleaved by 1 h interval) delivered to the left temporoparietal junction across two periods of 5 and 3 weeks, respectively. At the end of each stimulation period, AHs disappeared completely. Most surprisingly and totally unexpectedly, the patient experienced beneficial improvements of long-lasting impairments in his right-hand function. Detailed examination of onset and offset of rTMS stimulation regimes strongly suggests a temporal relation with the remission and re-appearance of AHs and also with a fragile but clinically meaningful improvements of right (but not left) hand function contingent to the accrual of stimulation sessions. On the basis of post-recovery magnetic resonance imaging structural and functional evidence, mechanistic hypotheses that could subtend such unexpected motor recovery are critically discussed.

Arterial Stiffness in Subacute Stroke: Changing Pattern and Relationship with Functional Recovery

BACKGROUND

To examine changing patterns in arterial stiffness and functional outcome in patients with subacute stroke, and to determine which parameter shows a strong correlation with the reversal of arterial stiffness, during a 3-month period of comprehensive rehabilitation therapy.

METHODS

This descriptive, observational cohort study enrolled 60 patients (43 male and 17 female; average age, 62.7 years), and all received conventional rehabilitation therapy, during a 3-month period. Brachial-ankle pulse wave velocity (baPWV) was measured as an index of arterial stiffness. Functional assessments included the 6-minute walk test (6MWT), Fugl-Meyer Assessment of hemiparetic upper and lower limbs, the functional ambulatory category, the Berg balance scale, the Korean Mini-Mental Status Examination, and the Korean-Modified Barthel Index. All measurements were conducted at baseline and 1 and 3 months after stroke onset.

RESULTS

Rehabilitation therapy resulted in a statistically significant improvement in baPWV since 3 months post stroke. Another functional outcome measure showed statistically significant improvements since 1 month after rehabilitation. Multivariable linear regression analysis revealed that a change in baPWV was significantly correlated with changes in the 6MWT.

CONCLUSIONS

Three months of comprehensive rehabilitation therapy led to statistically significant improvements in arterial stiffness and functional outcomes during the subacute phase of stroke. Thus, the comprehensive rehabilitation focused on improving gait endurance would be warranted in subacute stroke patients.

Caregiver-mediated exercises for improving outcomes after stroke

BACKGROUND

Stroke is a major cause of long-term disability in adults. Several systematic reviews have shown that a higher intensity of training can lead to better functional outcomes after stroke. Currently, the resources in inpatient settings are not always sufficient and innovative methods are necessary to meet these recommendations without increasing healthcare costs. A resource efficient method to augment intensity of training could be to involve caregivers in exercise training. A caregiver-mediated exercise programme has the potential to improve outcomes in terms of body function, activities, and participation in people with stroke. In addition, caregivers are more actively involved in the rehabilitation process, which may increase feelings of empowerment with reduced levels of caregiver burden and could facilitate the transition from rehabilitation facility (in hospital, rehabilitation centre, or nursing home) to home setting. As a consequence, length of stay might be reduced and early supported discharge could be enhanced.

OBJECTIVES

To determine if caregiver-mediated exercises (CME) improve functional ability and health-related quality of life in people with stroke, and to determine the effect on caregiver burden.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (October 2015), CENTRAL (the Cochrane Library, 2015, Issue 10), MEDLINE (1946 to October 2015), Embase (1980 to December 2015), CINAHL (1982 to December 2015), SPORTDiscus (1985 to December 2015), three additional databases (two in October 2015, one in December 2015), and six additional trial registers (October 2015). We also screened reference lists of relevant publications and contacted authors in the field.

SELECTION CRITERIA

Randomised controlled trials comparing CME to usual care, no intervention, or another intervention as long as it was not caregiver-mediated, aimed at improving motor function in people who have had a stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials. One review author extracted data, and assessed quality and risk of bias, and a second review author cross-checked these data and assessed quality. We determined the quality of the evidence using GRADE. The small number of included studies limited the pre-planned analyses.

MAIN RESULTS

We included nine trials about CME, of which six trials with 333 patient-caregiver couples were included in the meta-analysis. The small number of studies, participants, and a variety of outcome measures rendered summarising and combining of data in meta-analysis difficult. In addition, in some studies, CME was the only intervention (CME-core), whereas in other studies, caregivers provided another, existing intervention, such as constraint-induced movement therapy. For trials in the latter category, it was difficult to separate the effects of CME from the effects of the other intervention.We found no significant effect of CME on basic ADL when pooling all trial data post intervention (4 studies; standardised mean difference (SMD) 0.21, 95% confidence interval (CI) -0.02 to 0.44; P = 0.07; moderate-quality evidence) or at follow-up (2 studies; mean difference (MD) 2.69, 95% CI -8.18 to 13.55; P = 0.63; low-quality evidence). In addition, we found no significant effects of CME on extended ADL at post intervention (two studies; SMD 0.07, 95% CI -0.21 to 0.35; P = 0.64; low-quality evidence) or at follow-up (2 studies; SMD 0.11, 95% CI -0.17 to 0.39; P = 0.45; low-quality evidence).Caregiver burden did not increase at the end of the intervention (2 studies; SMD -0.04, 95% CI -0.45 to 0.37; P = 0.86; moderate-quality evidence) or at follow-up (1 study; MD 0.60, 95% CI -0.71 to 1.91; P = 0.37; very low-quality evidence).At the end of intervention, CME significantly improved the secondary outcomes of standing balance (3 studies; SMD 0.53, 95% CI 0.19 to 0.87; P = 0.002; low-quality evidence) and quality of life (1 study; physical functioning: MD 12.40, 95% CI 1.67 to 23.13; P = 0.02; mobility: MD 18.20, 95% CI 7.54 to 28.86; P = 0.0008; general recovery: MD 15.10, 95% CI 8.44 to 21.76; P < 0.00001; very low-quality evidence). At follow-up, we found a significant effect in favour of CME for Six-Minute Walking Test distance (1 study; MD 109.50 m, 95% CI 17.12 to 201.88; P = 0.02; very low-quality evidence). We also found a significant effect in favour of the control group at the end of intervention, regarding performance time on the Wolf Motor Function test (2 studies; MD -1.72, 95% CI -2.23 to -1.21; P < 0.00001; low-quality evidence). We found no significant effects for the other secondary outcomes (i.e.

PATIENT

motor impairment, upper limb function, mood, fatigue, length of stay and adverse events; caregiver: mood and quality of life).In contrast to the primary analysis, sensitivity analysis of CME-core showed a significant effect of CME on basic ADL post intervention (2 studies; MD 9.45, 95% CI 2.11 to 16.78; P = 0.01; moderate-quality evidence).The methodological quality of the included trials and variability in interventions (e.g. content, timing, and duration), affected the validity and generalisability of these observed results.

AUTHORS' CONCLUSIONS

There is very low- to moderate-quality evidence that CME may be a valuable intervention to augment the pallet of therapeutic options for stroke rehabilitation. Included studies were small, heterogeneous, and some trials had an unclear or high risk of bias. Future high-quality research should determine whether CME interventions are (cost-)effective.

Outcomes of repetitive facilitation exercises in convalescent patients after stroke with impaired health status

OBJECTIVE

To investigate the impact of stroke on health status and the effects of repetitive facilitation exercises (RFEs) for convalescent patients after stroke.

METHODS

The study was a prospective observational study of patients enrolled in an RFE programme. Between April 2008 and March 2012, 468 patients with stroke were enrolled in an intensive, comprehensive RFE programme. Patients participated in this interdisciplinary programme for 12 weeks, for an average of 5 hours per week. Before and immediately after the programme, several measures of rehabilitation outcomes and health-related quality-of-life were evaluated.

RESULTS

At baseline, most patients (95.4%) had modified Rankin scale scores of 3-5. Their health-related quality-of-life was significantly impaired, with physical and mental component summary scores on the Short Form 36-item questionnaire (SF-36) of 30.7 and 35.8, respectively. After the RFE programme, all outcome measures improved significantly.

CONCLUSIONS

The results demonstrate that convalescent patients after stroke may benefit substantially from RFE programmes in stroke rehabilitation centres, even when patients have impaired health status or high levels of healthcare utilization. Thus, an RFE programme is a simple yet highly effective means to improve rehabilitation outcomes and health-related quality-of-life, with a relatively low dropout rate.

Wearable tubing assistive walking device immediately enhances gait parameters in subjects with stroke: A randomized controlled study

BACKGROUND

Stroke patients develop compensatory movements due to limitations of ankle dorsiflexion and knee flexion. To solve the limitations, there are many adjustable walking assistive devices such as robotic devices, ankle-foot orthoses, and functional electric stimulation in rehabilitation session. However, these assistive devices have some disadvantages, including expense and discomforts. Therefore, the development of a new assistive device for stroke patients is needed to assist ankle dorsiflexion and knee flexion.

OBJECTIVE

This study investigated the effects of a wearable tubing assistive walking device (WTAWD) on gait parameters (gait speed, cadence, and step length and stride length on affected and less affected sides) in patients with stroke.

METHODS

Gait parameters were measured using the GAITRite system. One-way repeated measures analysis of variance was used to determine gait differences under three conditions (WTAWD, barefoot, and conventional elastic band orthosis).

RESULTS

Gait speed, cadence, and step length and stride length on both affected and less affected sides were significantly greater with WTAWD, compared to barefoot and conventional elastic band orthosis conditions.

CONCLUSION

WTAWD could be effective for patients with stroke.

Ischemic Stroke and Risk of Venous Thromboembolism in the General Population: The Tromsø Study

Background

Even though clinical data support a relation between ischemic stroke and venous thromboembolism (VTE), the strength and time dependence of the association remain to be settled at the population level. We therefore aimed to investigate the association between ischemic stroke and VTE in a prospective population‐based cohort.

Methods and Results

Participants (n=30 002) were recruited from 3 surveys of the Tromsø study (conducted in 1994–1995, 2001, and 2007–2008) and followed through 2010. All incident events of ischemic stroke and VTE during follow‐up were recorded. Cox‐regression models with age as time scale and ischemic stroke as a time‐dependent variable were used to calculate hazard ratios (HR) of VTE adjusted for cardiovascular risk factors. During a median follow‐up time of 15.7 years, 1360 participants developed ischemic stroke and 722 had a VTE. The risk of VTE was highest the first month (HR 19.7; 95% CI, 10.1–38.5) and from 1 to 3 months after the stroke (HR 10.6; 95% CI 5.0–22.5), but declined rapidly thereafter. The risk estimates were approximately the same for deep vein thrombosis (HR 19.1; 95% CI, 7.8–38.5), and pulmonary embolism (HR 20.2; 95% CI, 7.4–55.1). Stroke was associated with higher risk for provoked (HR 22.6; 95% CI, 12.5–40.9) than unprovoked VTE (HR 7.4; 95% CI, 2.7–20.1) the first 3 months.

Conclusions

The risk of VTE increased during the first 3 months after an ischemic stroke. The particularly high risk of provoked VTE suggests that additional predisposing factors, such as immobilization, potentiate the VTE risk in patients with ischemic stroke.

Delayed gait recovery with recovery of an injured corticoreticulospinal tract in a chronic hemiparetic patient: A case report

OBJECTIVES

We report on a chronic hemiparetic patient whose gait recovery was delayed until healing of an injured corticoreticulospinal tract (CRT), which was demonstrated on diffusion tensor tractography (DTT).

CASE PRESENTATION

A 71-year-old female presented with complete paralysis of the right extremities resulting from a spontaneous intracerebral hemorrhage. At 5 months after onset, when she was admitted for rehabilitation after undergoing rehabilitation at the previous university hospital, she presented with severe weakness of the right leg (manual muscle test: 0 ∼ 2- score) and could not even stand. She received comprehensive rehabilitative therapy for 32 months after the onset. Motor weakness of her right leg improved to the point that she was able to extend her knee on gravity-eliminated position at 11 months and against some resistance at 30 months after onset. She was able to walk independently at 30 months after onset.

RESULTS

The left CRT was discontinuous at the basal ganglia level on 5-month DTT. This discontinuation elongated to the cerebral cortex on 32-month DTT, whereas on 32-month DTT, the right CRT had become thicker compared with that on 5-month DTT.

CONCLUSIONS

An injured CRT healed in a patient who was able to walk independently after approximately 2 years of rehabilitation starting 5 months after the onset of intracerebral hemorrhage.

Variability, frequency composition, and temporal regularity of submaximal isometric elbow flexion force in subacute stroke

We compared variability, frequency composition, and temporal regularity of submaximal isometric elbow flexion force at 10, 20, 35, and 50 % of peak torque between 34 stroke subjects (5-48 days post-onset, both arms) and 24 age-matched controls (dominant arm), and related the findings in the paretic arm to motor impairment. Force variability was quantified by the coefficient of variation (CV), frequency composition by the median frequency and relative power in 0-3-, 4-6-, and 8-12-Hz bands, and regularity by the sample entropy (SampEn). The paretic elbow flexors showed significantly increased CV and relative power in 0-3-Hz band, decreased power in 4-6- and 8-12-Hz bands, and decreased SampEn compared to both the non-paretic and control elbow flexors (P ≤ 0.0002), with no differences between the latter two (P ≥ 0.012). With increasing contraction intensity, the relative power in different frequency bands was insufficiently modulated and SampEn excessively decreased in the paretic elbow flexors. Also, CV in the paretic elbow flexors was non-linearly related to the relative power in different frequency bands and SampEn across contraction intensities (rectangular hyperbolic fit, 0.21 ≤ R ² ≤ 0.55, P ≤ 0.006), whereas no force parameter correlated with arm motor impairment. These results largely extend our previous findings in the paretic knee extensors to the elbow flexors in subacute stroke, except that here force variability was increased only in the paretic elbow flexors and modulation of force regularity with increasing contraction intensity showed the opposite, decreasing pattern, which was considerably exaggerated in the paretic muscles.

Factors Influencing the Efficacy of Aerobic Exercise for Improving Fitness and Walking Capacity After Stroke: A Meta-Analysis With Meta-Regression

OBJECTIVE

To assess the influence of dosing parameters and patient characteristics on the efficacy of aerobic exercise (AEX) poststroke.

DATA SOURCES

A systematic review was conducted using PubMed, MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Physiotherapy Evidence Database, and Academic Search Complete.

STUDY SELECTION

Studies were selected that compared an AEX group with a nonaerobic control group among ambulatory persons with stroke.

DATA EXTRACTION

Extracted outcome data included peak oxygen consumption (V˙o₂peak) during exercise testing, walking speed, and walking endurance (6-min walk test). Independent variables of interest were AEX mode (seated or walking), AEX intensity (moderate or vigorous), AEX volume (total hours), stroke chronicity, and baseline outcome scores.

DATA SYNTHESIS

Significant between-study heterogeneity was confirmed for all outcomes. Pooled AEX effect size estimates (AEX group change minus control group change) from random effects models were V˙o₂peak, 2.2mL⋅kg^-1⋅min^-1 (95% confidence interval [CI], 1.3-3.1mL⋅kg^-1⋅min^-1); walking speed, .06m/s (95% CI, .01-.11m/s); and 6-minute walk test distance, 29m (95% CI, 15-42m). In meta-regression, larger V˙o₂peak effect sizes were significantly associated with higher AEX intensity and higher baseline V˙o₂peak. Larger effect sizes for walking speed and the 6-minute walk test were significantly associated with a walking AEX mode. In contrast, seated AEX did not have a significant effect on walking outcomes.

CONCLUSIONS

AEX significantly improves aerobic capacity poststroke, but may need to be task specific to affect walking speed and endurance. Higher AEX intensity is associated with better outcomes. Future randomized studies are needed to confirm these results.

Scalp acupuncture and electromagnetic convergence stimulation for patients with cerebral infarction: study protocol for a randomized controlled trial

BACKGROUND

Scalp acupuncture (SA) and repetitive transcranial magnetic stimulation (rTMS) are effective for treating cerebral infarction. This study aims to examine the efficacy and safety of SA and electromagnetic convergence stimulation (SAEM-CS), which was developed through collaboration between conventional medical physicians and doctors who practice traditional Korean medicine. SAEM-CS was designed to improve function in patients with cerebral infarction, compared to the improvement after conventional stroke rehabilitation, SA, and rTMS therapeutic approaches.

METHODS/DESIGN

This study is a prospective, outcome assessor-blinded, randomized controlled clinical trial with a 1:1:1:1 allocation ratio. Participants with motion or sensory disabilities caused by a first-time cerebral infarction (n = 60) that had occurred within 1 month of the study onset will be randomly assigned to control, SA, rTMS, or SAEM-CS groups. All groups will receive two sessions of conventional rehabilitation treatment per day. The SA group will receive SA on the upper limb area of MS6 and MS7 (at the lesional hemisphere) for 20 min, the rTMS group will receive low-frequency rTMS (LF-rTMS) treatment on the hot spot of the M1 region (motor cortex at the contralesional hemisphere) for 20 min, and the SAEM-CS group will receive LF-rTMS over the contralesional M1 region hot spot while receiving simultaneous SA stimulation on the lesional upper limb area of MS6 and MS7 for 20 min. SA, rTMS, and SAEM-CS treatments will be conducted once/day, 5 days/week (excluding Saturdays and Sundays) for 3 weeks, for a total of 15 sessions. The primary outcome will be evaluated using the Fugl-Meyer Assessment, while other scales assessing cognitive function, activities of daily living, walking, quality of life, and stroke severity are considered secondary outcome measures. Outcome measurements will be conducted at baseline (before intervention), 3 weeks after the first intervention (end of intervention), and 4 weeks after intervention completion.

DISCUSSION

This study aims to explore the efficacy and safety of SAEM-CS on cerebral infarction. Collaborative research combined traditional Korean and conventional medicines, which can be useful in developing new treatment technologies.

TRIAL REGISTRATION

KCT0001768 . Registered on 14 January 2016.

Community-based Rehabilitation Training after stroke: protocol of a pilot randomised controlled trial (ReTrain)

INTRODUCTION

The Rehabilitation Training (ReTrain) intervention aims to improve functional mobility, adherence to poststroke exercise guidelines and quality of life for people after stroke. A definitive randomised controlled trial (RCT) is required to assess the clinical and cost-effectiveness of ReTrain, which is based on Action for Rehabilitation from Neurological Injury (ARNI). The purpose of this pilot study is to assess the feasibility of such a definitive trial and inform its design.

METHODS AND ANALYSIS

A 2-group, assessor-blinded, randomised controlled external pilot trial with parallel mixed-methods process evaluation and economic evaluation. 48 participants discharged from clinical rehabilitation despite residual physical disability will be individually randomised 1:1 to ReTrain (25 sessions) or control (exercise advice booklet). Outcome assessment at baseline, 6 and 9 months include Rivermead Mobility Index; Timed Up and Go Test; modified Patient-Specific Functional Scale; 7-day accelerometry; Stroke Self-efficacy Questionnaire, exercise diary, Fatigue Assessment Scale, exercise beliefs and self-efficacy questionnaires, SF-12, EQ-5D-5L, Stroke Quality of Life, Carer Burden Index and Service Receipt Inventory. Feasibility, acceptability and process outcomes include recruitment and retention rates; with measurement burden and trial experiences being explored in qualitative interviews (20 participants, 3 intervention providers). Analyses include descriptive statistics, with 95% CI where appropriate; qualitative themes; intervention fidelity from videos and session checklists; rehearsal of health economic analysis.

ETHICS AND DISSEMINATION

National Health Service (NHS) National Research Ethics Service approval granted in April 2015; recruitment started in June. Preliminary studies suggested low risk of serious adverse events; however (minor) falls, transitory muscle soreness and high levels of postexercise fatigue are expected. Outputs include pilot data to inform whether to proceed to a definitive RCT and support a funding application; finalised Trainer and Intervention Delivery manuals for multicentre replication of ReTrain; presentations at conferences, public involvement events; internationally recognised peer-reviewed journal publications, open access sources and media releases.

TRIAL REGISTRATION NUMBER

NCT02429180; Pre-results.

Persistence of reduced neuromotor noise in long-term motor skill learning

It is well documented that variability in motor performance decreases with practice, yet the neural and computational mechanisms that underlie this decline, particularly during long-term practice, are little understood. Decreasing variability is frequently examined in terms of error corrections from one trial to the next. However, the ubiquitous noise from all levels of the sensorimotor system is also a significant contributor to overt variability. While neuromotor noise is typically assumed and modeled as immune to practice, the present study challenged this notion. We investigated the long-term practice of a novel motor skill to test whether neuromotor noise can be attenuated, specifically when aided by reward. Results showed that both reward and self-guided practice over 11 days improved behavior by decreasing noise rather than effective error corrections. When the challenge for obtaining reward increased, subjects reduced noise even further. Importantly, when task demands were relaxed again, this reduced level of noise persisted for 5 days. A stochastic learning model replicated both the attenuation and persistence of noise by scaling the noise amplitude as a function of reward. More insight into variability and intrinsic noise and its malleability has implications for training and rehabilitation interventions.

Delayed regaining of gait ability in a patient with brain injury: A case report

BACKGROUND

Little is known about delay in regaining gait ability at a chronic stage after brain injury. In this study, we report on a single patient who regained the gait ability during 2 months of intensive rehabilitation starting 2 years after a brain injury.

METHODS AND RESULTS

A 40-year-old male patient diagnosed with viral encephalitis underwent comprehensive rehabilitation until 2 years after onset. However, he could not even sit independently and presented with severe physical deconditioning and severe ataxia. To understand his neurological state, 4 neural tracts related to gait function were reconstructed, and based on the state of these neural tracts, we decided that the patient had the neurological potential to walk independently. Therefore, we assumed that the main reasons for gait inability in this patient were severe physical deconditioning and truncal ataxia. Consequently, the patient underwent the following intensive rehabilitative therapy: administration of drugs for control of ataxia (topiramate, clonazepam, and propranolol) and movement therapy for physical conditioning and gait training. As a result, after 2 months of rehabilitation, he was able to walk independently on an even floor, with improvement of severe physical deconditioning and truncal ataxia.

CONCLUSION

We described the rehabilitation program in a single patient who regained the gait ability during 2 months of intensive rehabilitation starting 2 years after a brain injury.

Quantifying Change During Outpatient Stroke Rehabilitation: A Retrospective Regression Analysis

OBJECTIVE

To examine change and individual trajectories for balance, upper extremity motor capacity, and mobility in people poststroke during the time they received outpatient therapies.

DESIGN

Retrospective analyses of an observational cohort using hierarchical linear modeling.

SETTING

Outpatient rehabilitation.

PARTICIPANTS

Persons poststroke (N=366).

INTERVENTIONS

Usual outpatient physical and occupational therapy.

MAIN OUTCOMES MEASURES

Berg Balance Scale (BBS), Action Research Arm Test (ARAT), and walking speed were used to assess the 3 domains. Initial scores at the start of outpatient therapy (intercepts), rate of change during outpatient therapy (slopes), and covariance between slopes and intercepts were modeled as random effects. Additional variables modeled as fixed effects were duration (months of outpatient therapy), time (days poststroke), age (y), and inpatient status (if the patient went to an inpatient rehabilitation facility [IRF]).

RESULTS

A patient with average age and time started at 37 points on the BBS with a change of 1.8 points per month, at 35 points on the ARAT with a change of 2 points per month, and with a walking speed of .59m/s with a change of .09m/s per month. When controlling for other variables, patients started with lower scores on the BBS and ARAT or had slower walking speeds at admission if they started outpatient therapy later than average or went to an IRF.

CONCLUSIONS

Patients generally improved over the course of outpatient therapy, but there was considerable variability in individual trajectories. Average rates of change across all 3 domains were small.

What's keeping people after stroke from walking outdoors to become physically active? A qualitative study, using an integrated biomedical and behavioral theory of functioning and disability

BACKGROUND

In general people after stroke do not meet the recommendations for physical activity to conduct a healthy lifestyle. Programs to stimulate walking activity to increase physical activity are based on the available insights into barriers and facilitators to physical activity after stroke. However, these programs are not entirely successful. The purpose of this study was to comprehensively explore perceived barriers and facilitators to outdoor walking using a model of integrated biomedical and behavioral theory, the Physical Activity for people with a Disability model (PAD).

METHODS

Included were community dwelling respondents after stroke, classified ≥ 3 at the Functional Ambulation Categories (FAC), purposively sampled regarding the use of healthcare. The data was collected triangulating in a multi-methods approach, i.e. semi-structured, structured and focus-group interviews. A primarily deductive thematic content analysis using the PAD-model in a framework-analysis' approach was conducted after verbatim transcription.

RESULTS

36 respondents (FAC 3-5) participated in 16 semi-structured interviews, eight structured interviews and two focus-group interviews. The data from the interviews covered all domains of the PAD model. Intention, ability and opportunity determined outdoor walking activity. Personal factors determined the intention to walk outdoors, e.g. negative social influence, resulting from restrictive caregivers in the social environment, low self-efficacy influenced by physical environment, and also negative attitude towards physical activity. Walking ability was influenced by loss of balance and reduced walking distance and by impairments of motor control, cognition and aerobic capacity as well as fatigue. Opportunities arising from household responsibilities and lively social constructs facilitated outdoor walking.

CONCLUSION

To stimulate outdoor walking activity, it seems important to influence the intention by addressing social influence, self-efficacy and attitude towards physical activity in the development of efficient interventions. At the same time, improvement of walking ability and creation of opportunity should be considered.

An interdisciplinary visual team in an acute and sub-acute stroke unit: Providing assessment and early rehabilitation

OBJECTIVE

To describe the work of an interdisciplinary visual team in a stroke unit providing early identification and assessment of patients with visual symptoms, and secondly to investigate frequency, type of visual deficits after stroke and self-evaluated impact on everyday life after stroke.

METHODS

For a period of three months, all stroke patients with visual or visuo-attentional deficits were registered, and data concerning etiology, severity and localization of the stroke and initial visual symptoms were registered. One month after discharge patients were contacted for follow-up.

RESULTS

Of 349 acute stroke admissions, 84 (24.1%) had visual or visuo-attentional deficits initially. Of these 84 patients, informed consent was obtained from 22 patients with a mean age of 67.7 years(SD 10.1), and the majority was female (59.1%). Based on the initial neurological examination, 45.4% had some kind of visual field defect, 27.2% had some kind of oculomotor nerve palsy, and about 31.8% had some kind of inattention or visual neglect. The patients were contacted for a phone-based follow-up one month after discharge, where 85.7% reported changes in their vision since their stroke.

CONCLUSION

In this consecutive sample, a quarter of all stroke patients had visual or visuo-attentional deficits initially. This emphasizes how professionals should have increased awareness of the existence of such deficits after stroke in order to provide the necessary interdisciplinary assessment and rehabilitation.

Ambulatory Status Protects against Venous Thromboembolism in Acute Mild Ischemic Stroke Patients

INTRODUCTION

Ischemic stroke patients are at high risk (up to 18%) for venous thromboembolism. We conducted a retrospective cross-sectional study to understand the predictors of acute postmild ischemic stroke patient's ambulatory status and its relationship with venous thromboembolism, hospital length of stay, and in-hospital mortality.

METHODS

We identified 522 patients between February 2006 and May 2014 and collected data about patient demographics, admission NIHSS (National Institutes of Health Stroke Scale), venous thromboembolism prophylaxis, ambulatory status, diagnosis of venous thromboembolism, and hospital outcomes (length of stay, mortality). Chi-square test, t-test and Wilcoxon rank-sum test, and binary logistic regression were used for statistical analysis as appropriate.

RESULTS

A total of 61 (11.7%), 48 (9.2%), and 23 (4.4%) mild ischemic stroke patients developed venous thromboembolism, deep venous thrombosis, and pulmonary embolism, respectively. During hospitalization, 281 (53.8%) patients were ambulatory. Independent predictors of in-hospital ambulation were being married (OR 1.64, 95% CI 1.10-2.49), being nonreligious (OR 2.19, 95% CI 1.34-3.62), admission NIHSS (per unit decrease in NIHSS; OR 1.62, 95% CI 1.39-1.91), and nonuse of mechanical venous thromboembolism prophylaxis (OR 1.62, 95% CI 1.02-2.61). After adjusting for confounders, ambulatory patients had lower rates of venous thromboembolism (OR .47, 95% CI .25-.89), deep venous thrombosis (OR .36, 95% CI .17-.73), prolonged length of hospital stay (OR .24, 95% CI .16-.37), and mortality (OR .43, 95% CI .21-.84).

CONCLUSIONS

Our findings suggest that for hospitalized acute mild ischemic stroke patients, ambulatory status is an independent predictor of venous thromboembolism (specifically deep venous thrombosis), hospital length of stay, and in-hospital mortality.

Interactive Voice Response-An Innovative Approach to Post-Stroke Depression Self-Management Support

Automated interactive voice response (IVR) call systems can provide systematic monitoring and self-management support to depressed patients, but it is unknown if stroke patients are able and willing to engage in IVR interactions. We sought to assess the feasibility and acceptability of IVR as an adjunct to post-stroke depression follow-up care. The CarePartner program is a mobile health program designed to optimize depression self-management, facilitate social support from a caregiver, and strengthen connections between stroke survivors and primary care providers (PCPs). Ischemic stroke patients and an informal caregiver, if available, were recruited during the patient's acute stroke hospitalization or follow-up appointment. The CarePartner program was activated in patients with depressive symptoms during their stroke hospitalization or follow-up. The 3-month intervention consisted of weekly IVR calls monitoring both depressive symptoms and medication adherence along with tailored suggestions for depressive symptom self-management. After each completed IVR call, informal caregivers were automatically updated, and, if needed, the subject's PCP was notified. Of the 56 stroke patients who enrolled, depressive symptoms were identified in 13 (23 %) subjects. Subjects completed 74 % of the weekly IVR assessments. A total of six subjects did not complete the outcome assessment, including two non-study-related deaths. PCPs were notified five times, including two times for suicidal ideation and three times for medication non-adherence. Stroke patients with depressive symptoms were able to engage in an IVR call system. Future studies are needed to explore the efficacy of an IVR approach for post-stroke self-management and monitoring of stroke-related outcomes.

Transcranial magnetic stimulation (TMS) in stroke: Ready for clinical practice?

The use of transcranial magnetic stimulation (TMS) in stroke research has increased dramatically over the last decade with two emerging and potentially useful functions identified. Firstly, the use of single pulse TMS as a tool for predicting recovery of motor function after stroke, and secondly, the use of repetitive TMS (rTMS) as a treatment adjunct aimed at modifying the excitability of the motor cortex in preparation for rehabilitation. This review discusses recent advances in the use of TMS in both prediction and treatment after stroke. Prediction of recovery after stroke is a complex process and the use of TMS alone is not sufficient to provide accurate prediction for an individual after stroke. However, when applied in conjunction with other tools such as clinical assessment and MRI, accuracy of prediction using TMS is increased. rTMS temporarily modulates cortical excitability after stroke. Very few rTMS studies are completed in the acute or sub-acute stages after stroke and the translation of altered cortical excitability into gains in motor function are modest, with little evidence of long term effects. Although gains have been made in both of these areas, further investigation is needed before these techniques can be applied in routine clinical care.

Six-month functional recovery of stroke patients: a multi-time-point study

The aim of this study is to compare the time-course changes in neurologic impairments (trunk control, motor function, sensory, and cognition) and recovery in functional impairments (activity of daily livings and gait) simultaneously from initiating rehabilitation to 6 months after stroke. Consecutive stroke patients were recruited from the department of nervous surgery, and transferred into the department of rehabilitation medicine and continued on treatment during the acute stage. Outcome measures were examined at the initial rehabilitation baseline, 1, 2, and 4 weeks after rehabilitation treatment, and 3, 4, 5, and 6 months after stroke. Patients were assessed using the Trunk Impairment Scale, the Fugl-Meyer Motor and Sensory Assessments for the upper and lower limbs, Mini-Mental State Examination, Functional Ambulation Category, and Modified Barthel Index. Twenty consecutive patients were analyzed in the study with complete assessments. The recovery was relatively rapid during the 4 weeks after treatment (P value ranges from <0.001 to <0.007) and then to a lesser extent decelerated between 3 and 6 months after stroke (P value between <0.001 and 0.080). Statistical comparison by repeated measures analysis showed a significant interaction between time points and measures of all recovery variables (P<0.001). Significant differences in level of impairments and functional recovery were found at the different time points. In comparison with the lower leg and trunk control, the upper arm showed less recovery, with a significant difference. All variables except for leg motor function improved continuously over 6 months after stroke. Nevertheless, this study confirms the importance of the period within 3 months for recovery after stroke, during which most of the recovery occurred, ranging from 48 to 91%. Therefore, intensive treatment targeting motor and sensory functions early after stroke may be beneficial for recovery of impairments and functional performance.

New facilitation exercise using the vestibulo-ocular reflex for ophthalmoplegia: preliminary report

Objective: To study the effect of facilitation exercises using the vestibulo-ocular reflex on ophthalmoplegia due to brainstem injury.

Design: A single-baseline design (A–B: A without specific therapy, B with specific therapy) across individual subjects.

Setting: Inpatient rehabilitation facility.

Subjects: Eight patients with ophthalmoplegia (total of 15 affected muscles) due to brainstem injury.

Interventions: Basic rehabilitative treatment that included physical therapy, occupational therapy and/or speech therapy for impairments such as hemiplegia, ataxia or dysarthria was administered for two weeks (control treatment). Then, two facilitation exercise sessions (100 times/day, five days/week for two weeks) were administered in addition to the basic rehabilitative treatment for four weeks to the eight patients with ophthalmoplegia. Ophthalmoplegia was evaluated at study entry and at the end of each two-week session. The goal of the facilitation exercises is to facilitate voluntary eye movement using conjugated eye movements in the direction opposite to passive movements of the head.

Main measures: To assess ophthalmoplegia we measured the distance between the internal/external corneal margin and the canthus of the affected eye on images recorded on a video tape recorder.

Results: After the initial two-week basic rehabilitative treatment, the distance between the corneal margin and canthus decreased slightly. Subsequently, after each of the two facilitation exercise sessions, there were significant reductions in the distance between the corneal margin and canthus compared with that at the beginning of the respective facilitation exercise session.

Conclusion: Facilitation exercises significantly improved the horizontal movement of eyes with ophthalmoplegia due to brainstem injury.

Recovery of Grasp versus Reach in People with Hemiparesis Poststroke

Background and Objective. The authors recently found that grasping was not relatively more disrupted than reaching in people with acute hemiparesis. They now extend this work to the recovery of reach versus grasp.

Methods. Hemiparetic subjects were tested acutely, after 90 days, and then after 1 year poststroke, and a control group was evaluated once. Using kinematic techniques, subjects were studied performing reach and reach-to-grasp movements. The authors quantified 3 characteristics of performance for each movement: speed, accuracy, and efficiency, where an efficient movement was defined as a movement directly to the target without extraneous or abnormally circuitous movements. To evaluate the relative deficits and recovery in reach versus grasp, performance measures were converted to z scores using control group means and standard deviations.

Results. The authors’ results showed that, starting with small deficits in speed acutely, both reach speed and grasp speed improved over time. Deficits in accuracy were greater in the reach than the grasp acutely, and these deficits lessened such that by the 90-day time point, the relative accuracy of the 2 movements was the same. In contrast, deficits in efficiency were greater in the grasp than the reach acutely, and grasp efficiency did not recover. The majority of recovery in reaching and grasping occurred by the 90-day time point, with little change occurring between the 90-day and 1-year time points.

Conclusions. The authors hypothesize that, in chronic hemiparesis, purposeful movements requiring distal control may be more impaired than purposeful movements requiring proximal control, not because of the initial lesion, but because, over the course of recovery, spared components of the descending motor systems may be able to compensate for the accuracy deficits in reaching (proximal control) but not the efficiency deficits in grasping (distal muscular control).

Psychometric properties of the sensory scale of the Fugl-Meyer Assessment in stroke patients

Objective: To examine the psychometric properties of the sensory scale of the Fugl-Meyer Assessment (FMA-S) in stroke patients with a broad range of neurological and functional impairment at times from 14 to 180 days after stroke.

Subjects: A total of 176 first stroke patients consecutively admitted to a university based medical centre.

Design: This prospective, longitudinal investigation was based on data collected at 14, 30, 90 and 180 days after stroke.

Main outcome measures: Reliability (inter-rater reliability and internal consistency), validity (convergent and predictive validity) and responsiveness of the FMA-S were examined.

Results: The inter-rater agreement of the total score of the FMA-S was excellent, with an intraclass correlation coefficient of 0.93. The Cronbach's alphas of the FMA-S at four time points after stroke ranged from 0.94 to 0.98, indicating excellent internal consistency. However, the FMA-S showed a significant ceiling effect (more than 44.4% of the subjects achieving the highest score), poor to moderate inter-rater reliability for light touch items (weighted kappa ranging from 0.30 to 0.55), low to moderate validity (Spearman's rho ranging from 0.29 to 0.53), and low to moderate responsiveness (standardized response mean ranging from 0.27 to 0.67) at different post-stroke stages of recovery.

Conclusions: The psychometric properties of the FMA-S in measuring sensory function do not support its clinical use in stroke patients. Further studies on methods to improve the psychometric properties of the FMA-S are needed.

Severe Disability After Stroke: Outcome After Inpatient Rehabilitation

Objective: To determine the functional outcome following acute rehabilitation of patients with severe and very severe stroke using the Functional Independence Mea sure (FIM). Background: Most patients with severe and very severe stroke are reported in the literature to have a poor functional outcome. However, there are few studies that specifically address severity and their conclusions are confounding. Methods: We retrospectively reviewed charts of 41 consecutive patients with the primary diag nosis of ischemic or hemorrhagic stroke admitted to an inpatient rehabilitation unit with a admission FIM score of <60. Outcome measures included discharge residence, length of stay, and FIM score. Results: Over 63 percent (26 patients) were discharged to home. Discharge mean FIM scores (61.24) were significantly improved over the admission mean FIM (34.12) for self-care, mobility, communication, and social cog nition. The FIM Efficiency score was 0.356/day (mean[FIMdis-FIMadm]/mean LOS) as compared with previous reports of FIM Efficiency of 0.97/day for all stroke. Con clusion: Patients with severe stroke can experience improvement during inpatient rehabilitation and be discharged to a home setting, although the rate of improvement is less than that of more moderate stroke.

Does Shorter Rehabilitation Limit Potential Recovery Poststroke?

Objective. To examine retrospectively the recovery of patients engaged in robotic research during a 6- to 7-week course of inpatient rehabilitation. Because timing of the Interim evaluation at 31/2 weeks was comparable to the present length of inpatient stroke rehabilitation, the authors assessed whether significant gains in motor abilities occurred after the time when most stroke patients today are discharged home. Methods. Fifty-six inpatients with a single, unilateral stroke were randomly assigned to a robot therapy or robot exposure group. Therapists blinded to group assignment administered the Fugl-Meyer, Motor Status Score, and MRC motor power test. Results. Significant improvements in upper-limb motor abilities occurred throughout a period approximately twice the present length of stay in inpatient rehabilitation. However, in the latter half of this period, patients who received conventional therapy showed little improvement, whereas patients who received robot training plus conventional therapy continued to improve. Conclusion. Further opportunities for recovery after stroke are possible by extending intensive therapy beyond present inpatient rehabilitation stays.

Synapse Loss and Regeneration: A Mechanism for Functional Decline and Recovery after Cerebral Ischemia?

Little is known of the mechanisms governing functional recovery after ischemic brain injury, and there is no clinical therapy established to restore neurologic function after ischemic injury is complete. Even so, pronounced spontaneous recovery of function is often observed in a subset of patients. Resolution of neurological deficits after ischemia must occur through replacement of lost tissue via production of new neurons, or through changes in the structure, function, or connectivity of surviving neurons. This review focuses on the neuronal synapse as a potential locus for functional recovery. Selective disruption of synaptic elements is a characteristic feature of hypoxic-ischemic brain injury, such as that seen in ischemic stroke or cardiac arrest. Ischemic damage to synapses occurs even in the absence of neuronal loss, and therefore might underlie the clinical disability observed in patients following mild or transient ischemia. We review evidence that recovery of lost synapses occurs after ischemic injury and that this recovery may be a necessary step for restoration of neurological function. The process of synapse loss and recovery can be examined in neuronal cultures and experimental stroke models. Such studies may help to gain a better understanding of the extracellular factors and intracellular cascades that facilitate recovery of synapses, and may result in therapeutic approaches to improve function after cerebral ischemia.

Validity and Reliability of the Activity Card Sort—Hong Kong Version

It is pertinent for occupational therapists to measure the changing patterns of activity engagement of older adults who might have undergone the process of aging, institutionalization, and illness. The Activity Card Sort was developed to measure the level of activity engagement in the main areas of occupational performance. This study examined the reliability, internal consistency, and construct validity of the Hong Kong version of the Activity Card Sort. Using expert panel reviews, 65 activities were identified as culturally appropriate for inclusion in the Hong Kong version. Sixty geriatric clients who had experienced a stroke participated in the evaluation. Results showed that the Hong Kong version of the Activity Card Sort was able to discriminate between clients with different levels of functioning ( t = −14.24; p = .00), and was positively associated with the Comprehensive Quality of Life Scale ( r = 0.86; p = .00). Excellent test—retest reliability ( r = 0.98) and internal consistency ( r = 0.89) were demonstrated. The findings suggest the Hong Kong version of the Activity Card Sort is a reliable and valid instrument to use with the Hong Kong Chinese elderly population.

Instrumental indices for upper limb function assessment in stroke patients: a validation study

Background

Robotic exoskeletons are increasingly being used in objective and quantitative assessment of upper limb (UL) movements. A set of instrumental indices computed during robot-assisted reaching tasks with the Armeo®Spring has been proven to assess UL functionality. The aim of this study was to test the construct validity of this indices-based UL assessment when used with patients who have had a stroke.

Methods

Forty-four 45- to 79-year-old stroke patients with a Wolf Motor Function Test ability score (WMFT-FAS) ranging from 10 to 75 and a Motricity Index (MI) ranging from 14 to 33 at shoulder and elbow were enrolled, thus covering a wide range of impairments. Residual UL function was assessed by both the WMFT-FAS and the WMFT-TIME, as well as by a set of 9 numerical indices assessing movement accuracy, velocity and smoothness computed from a 3D endpoint trajectory obtained during the “Vertical Capture” task of the Armeo®Spring device. To explore which variables better represented motor control deficits, the Mann-Whitney U Test was used to compare patients’ indices to those obtained from 25 healthy individuals. To explore the inner relationships between indices and construct validity in assessing accuracy, velocity and smoothness, a factor analysis was carried out. To verify the indices concurrent validity, they were compared to both WMFT-FAS and WMFT-TIME by the Spearman’s correlation coefficient.

Results

Seven indices of stroke subjects were significantly different from those of healthy controls, with effect sizes in the range 0.35–0.74. Factor analysis confirmed that specific subsets of indices belonged to the domains of accuracy, velocity and smoothness (discriminant validity). One accuracy index, both velocity indices and two smoothness indices were significantly correlated with WMFT-FAS and WMFT-TIME (|rho| = 0.31–0.50) (concurrent validity). One index for each of the assessed movement domains was proven to have construct validity (discriminant and concurrent) and was selected. Moreover, the indices were able to detect differences in accuracy, velocity and/or smoothness in patients with the same WMFT level.

Conclusions

The proposed index-based UL assessment can be used to integrate and support clinical evaluation of UL function in stroke patients.

Artistic Skills Recovery and Compensation in Visual Artists after Stroke

Background

Art is a characteristic of mankind, which requires superior central nervous processing and integration of motor functions with visual information. At the present time, a significant amount of information related to neurobiological basis of artistic creation has been derived from neuro-radiological cognitive studies, which have revealed that subsequent to tissue destruction, the artists continue to create art. The current study aims to review the most important cases of visual artists with stroke and to discuss artistic skills recovery and compensation as well as artistic style after stroke.

Methods

The role of various central nervous system regions in artistic creation was reviewed on the basis of previously published functional studies. Our PubMed search (1995–2015) has identified 10 famous artists with right cerebral stroke as well as 5 with left cerebral stroke who survived and continued to create art after stroke. As the artists included in this review lived at various times during the twentieth century and in different countries, clinical information related to their case was limited. However, it appears that artistic skills recovery and compensation appear within days after stroke. Some of the artists would subsequently change their artistic style. All these elements have been evaluated within the context of specific clinical cases.

Conclusion

The poststroke artistic skills recovery and compensation with development of a new style or the opposite, regaining the previous prestroke style, represents a significant element of clinical importance in medical rehabilitation as well as neuroesthetics, which requires further evaluation. At the present time, the molecular mechanisms of artistic creation are poorly understood, and more standardized clinical and experimental studies are needed.