Very early versus delayed mobilisation after stroke

Overview of Acute Ischemic Stroke Evaluation and Management

Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.

Cultural and linguistic adaptation of the Oxford Cognitive Screen to the Spanish population

INTRODUCTION

Stroke is the sixth leading cause of disability in Spain. Patients may present motor, sensory, or cognitive sequelae, which can be minimised with early treatment. To this end, there is a need for quick-to-administer assessment tools to evaluate deficits in these areas. The Oxford Cognitive Screen (OCS) is a brief test specifically designed to assess cognitive function in patients with stroke. Our aim in this study is to report the linguistic and cultural adaptation of a Spanish-language version of the test (OCS-S).

METHODS

The linguistic validation was conducted with a process of double translation and 10 consensus meetings of the multidisciplinary research team. We also performed 3 pilot studies, with 5 potential users, 23 healthy individuals, and 23 patients with stroke (ischaemic in 61% of cases and haemorrhagic in 39%), respectively; participants were aged between 31 and 88 years.

RESULTS

The OCS-S includes the 10 subtests, the coding of responses, and the scoring system from the original version. We modified and extended the instructions for administration in order to ensure the reliability of the content and its application. Five tasks were modified (images, numbers, and sentences) and the praxis subtest was modified to evaluate both hands. The pilot studies confirmed comprehension in the target population, independently of any cognitive problems.

CONCLUSION

The OCS-S is conceptually and linguistically equivalent to the original test, enabling psychometric assessment and application of the test in the Spanish population. The OCS-S may be a useful screening tool for quickly assessing cognitive function after stroke.

Cultural and linguistic adaptation of the Oxford Cognitive Screen to the Spanish population

INTRODUCTION

Stroke is the sixth leading cause of disability in Spain. Patients may present motor, sensory, or cognitive sequelae, which can be minimised with early treatment. To this end, there is a need for quick-to-administer assessment tools to evaluate deficits in these areas. The Oxford Cognitive Screen (OCS) is a brief test specifically designed to assess cognitive function in patients with stroke. Our aim in this study is to report the linguistic and cultural adaptation of a Spanish-language version of the test (OCS-S).

MATERIAL AND METHODS

The linguistic validation was conducted with a process of double translation and 10 consensus meetings of the multidisciplinary research team. We also performed 3 pilot studies, with 5 potential users, 23 healthy individuals, and 23 patients with stroke (ischaemic in 61% of cases and haemorrhagic in 39%), respectively; participants were aged between 31 and 88 years.

RESULTS

The OCS-S includes the 10 subtests, the coding of responses, and the scoring system from the original version. We modified and extended the instructions for administration in order to ensure the reliability of the content and its application. Five tasks were modified (images, numbers, and sentences) and the praxis subtest was modified to evaluate both hands. The pilot studies confirmed comprehension in the target population, independently of any cognitive problems.

CONCLUSIONS

The OCS-S is conceptually and linguistically equivalent to the original test, enabling psychometric assessment and application of the test in the Spanish population. The OCS-S may be a useful screening tool for quickly assessing cognitive function after stroke.

Therapist-Guided Tablet-Based Telerehabilitation for Patients With Aphasia: Proof-of-Concept and Usability Study

BACKGROUND

Aphasia is the loss or impairment of language functions and affects everyday social life. The disorder leads to the inability to understand and be understood in both written and verbal communication and affects the linguistic modalities of auditory comprehension, verbal expression, reading, and writing. Due to heterogeneity of the impairment, therapy must be adapted individually and dynamically to patient needs. An important factor for successful aphasia therapy is dose and intensity of therapy. Tablet computer-based apps are a promising treatment method that allows patients to train independently at home, is well accepted, and is known to be beneficial for patients. In addition, it has been shown to ease the burden of therapists.

OBJECTIVE

The aim of this project was to develop an adaptive multimodal system that enables aphasic patients to train at home using language-related tasks autonomously, allows therapists to remotely assign individualized tasks in an easy and time-efficient manner, and tracks the patient's progress as well as creation of new individual exercises.

METHODS

The system consists of two main parts: (1) the patient's interface, which allows the patient to exercise, and (2) the therapist's interface, which allows the therapist to assign new exercises to the patient and supervise the patient's progress. The pool of exercises is based on a hierarchical language structure. Using questionnaires, therapists and patients evaluated the system in terms of usability (ie, System Usability Scale) and motivation (ie, adapted Intrinsic Motivation Inventory).

RESULTS

A total of 11 speech and language therapists (age: mean 28, SD 7 years) and 15 patients (age: mean 53, SD 10 years) diagnosed with aphasia participated in this study. Patients rated the Bern Aphasia App in terms of usability (scale 0-100) as excellent (score >70; Z=-1.90; P=.03) and therapists rated the app as good (score >85; Z=-1.75; P=.04). Furthermore, patients enjoyed (scale 0-6) solving the exercises (score>3; mean 3.5, SD 0.40; Z=-1.66; P=.049).

CONCLUSIONS

Based on the questionnaire scores, the system is well accepted and simple to use for patients and therapists. Furthermore, the new tablet computer-based app and the hierarchical language exercise structure allow patients with different types of aphasia to train with different doses and intensities independently at home. Thus, the novel system has potential for treatment of patients with aphasia as a supplement to face-to-face therapy.

High Intensity Physical Rehabilitation Later Than 24 h Post Stroke Is Beneficial in Patients: A Pilot Randomized Controlled Trial (RCT) Study in Mild to Moderate Ischemic Stroke

Objective: Very early mobilization was thought to contribute to beneficial outcomes in stroke-unit care, but the optimal intervention strategy including initiation time and intensity of mobilization are unclear. In this study, we sought to confirm the rehabilitative effects of different initiation times (24 vs. 48 h) with different mobilization intensities (routine or intensive) in ischemic stroke patients within three groups. Materials and Methods: We conducted a randomized and controlled trial with a blinded follow-up assessment. Patients with ischemic stroke, first or recurrent, admitted to stroke unit within 24 h after stroke onset were recruited. Eligible subjects were randomly assigned (1:1:1) to 3 groups: Early Routine Mobilization in which patients received < 1.5 h/d out-of-bed mobilization within 24-48 h after stroke onset, Early Intensive Mobilization in which patients initiated ≥3 h/d mobilization at 24-48 h after the stroke onset, and Very Early Intensive Mobilization in which patients received≥3 h/d mobilization within 24 h. The modified Rankin Scale score of 0-2 was used as the primary favorable outcome. Results: We analyzed 248 of the 300 patients (80 in Early Routine Mobilization, 82 in Very Early Intensive Mobilization and 86 in Early Intensive Mobilization), with 52 dropping out (20 in Early Routine Mobilization, 18 in Very Early Intensive Mobilization and 14 in Early Intensive Mobilization). Among the three groups, the Early Intensive Mobilization group had the most favorable outcomes at 3-month follow-up, followed by patients in the Early Routine Mobilization group. Patients in Very Early Intensive Mobilization received the least odds of favorable outcomes. At 3 month follow up, 53.5%, (n = 46) of patients with Early Intensive Mobilization showed a favorable outcome (modified Rankin Scale 0-2) (p = 0.041) as compared to 37.8% (n = 31) of patients in the Very Early Intensive Mobilization. Conclusions: Post-stroke rehabilitation with high intensity physical exercise at 48 h may be beneficial. Very Early Intensive Mobilization did not lead to a favorable outcome at 3 months. Clinical Trial Registration: www.chictr.org.cn, identifier ChiCTR-ICR-15005992.

Very early versus delayed mobilisation after stroke

BACKGROUND

Very early mobilisation (VEM) is performed in some stroke units and recommended in some acute stroke clinical guidelines. However, it is unclear whether very early mobilisation independently improves outcome after stroke.

OBJECTIVES

To determine whether very early mobilisation (started as soon as possible, and no later than 48 hours after onset of symptoms) in people with acute stroke improves recovery (primarily the proportion of independent survivors) compared with usual care.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched 31 July 2017). We also systematically searched 19 electronic databases including; CENTRAL; 2017, Issue 7 in the Cochrane Library (searched July 2017), MEDLINE Ovid (1950 to August 2017), Embase Ovid (1980 to August 2017), CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to August 2017) , PsycINFO Ovid (1806 to August 2017), AMED Ovid (Allied and Complementary Medicine Database), SPORTDiscus EBSCO (1830 to August 2017). We searched relevant ongoing trials and research registers (searched December 2016), the Chinese medical database, Wanfangdata (searched to November 2016), and reference lists, and contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of people with acute stroke, comparing an intervention group that started out-of-bed mobilisation within 48 hours of stroke, and aimed to reduce time-to-first mobilisation, with or without an increase in the amount or frequency (or both) of mobilisation activities, with usual care, where time-to-first mobilisation was commenced later.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, assessed risk of bias, and applied the GRADE approach to assess the quality of the evidence. The primary outcome was death or poor outcome (dependency or institutionalisation) at the end of scheduled follow-up. Secondary outcomes included death, dependency, institutionalisation, activities of daily living (ADL), extended ADL, quality of life, walking ability, complications (e.g. deep vein thrombosis), patient mood, and length of hospital stay. We also analysed outcomes at three-month follow-up.

MAIN RESULTS

We included nine RCTs with 2958 participants; one trial provided most of the information (2104 participants). The median (range) delay to starting mobilisation after stroke onset was 18.5 (13.1 to 43) hours in the VEM group and 33.3 (22.5 to 71.5) hours in the usual care group. The median difference within trials was 12.7 (4 to 45.6) hours. Other differences in intervention varied between trials; in five trials, the VEM group were also reported to have received more time in therapy, or more mobilisation activity.Primary outcome data were available for 2542 of 2618 (97.1%) participants randomized and followed up for a median of three months. VEM probably led to similar or slightly more deaths and participants who had a poor outcome, compared with delayed mobilisation (51% versus 49%; odds ratio (OR) 1.08, 95% confidence interval (CI) 0.92 to 1.26; P = 0.36; 8 trials; moderate-quality evidence). Death occurred in 7% of participants who received delayed mobilisation, and 8.5% of participants who received VEM (OR 1.27, 95% CI 0.95 to 1.70; P = 0.11; 8 trials, 2570 participants; moderate-quality evidence), and the effects on experiencing any complication were unclear (OR 0.88; 95% CI 0.73 to 1.06; P = 0.18; 7 trials, 2778 participants; low-quality evidence). Analysis using outcomes collected only at three-month follow-up did not alter the conclusions.The mean ADL score (measured at end of follow-up, with the 20-point Barthel Index) was higher in those who received VEM compared with the usual care group (mean difference (MD) 1.94, 95% CI 0.75 to 3.13, P = 0.001; 8 trials, 9 comparisons, 2630/2904 participants (90.6%); low-quality evidence), but there was substantial heterogeneity (93%). Effect sizes were smaller for outcomes collected at three-month follow-up, rather than later.The mean length of stay was shorter in those who received VEM compared with the usual care group (MD -1.44, 95% CI -2.28 to -0.60, P = 0.0008; 8 trials, 2532/2618 participants (96.7%); low-quality evidence). Confidence in the answer was limited by the variable definitions of length of stay. The other secondary outcome analyses (institutionalisation, extended activities of daily living, quality of life, walking ability, patient mood) were limited by lack of data.Sensitivity analyses by trial quality: none of the outcome conclusions were altered if we restricted analyses to trials with the lowest risk of bias (based on method of randomization, allocation concealment, completeness of follow-up, and blinding of final assessment), or information about the amount of mobilisation.Sensitivity analysis by intervention characteristics: analyses restricted to trials where the mean VEM time-to-first mobilisation was less than 24 hours, showed an odds of death of 1.35 (95% CI 0.99 to 1.83; P = 0.06; I² = 25%; 5 trials). Analyses restricted to the trials that clearly reported a more prolonged out-of-bed activity showed a similar primary outcome (OR 1.14; 0.96 to 1.35; P = 0.13; I² = 28%; 5 trials), and odds of death (OR 1.27; 0.93 to 1.73; P = 0.13; I² = 0%; 4 trials) to the main analysis.Exploratory network meta-analysis (NMA): we were unable to analyze by the amount of therapy, but low-quality evidence indicated that time-to-first mobilisation at around 24 hours was associated with the lowest odds of death or poor outcome, compared with earlier or later mobilisation.

AUTHORS' CONCLUSIONS

VEM, which usually involved first mobilisation within 24 hours of stroke onset, did not increase the number of people who survived or made a good recovery after their stroke. VEM may have reduced the length of stay in hospital by about one day, but this was based on low-quality evidence. Based on the potential hazards reported in the single largest RCT, the sensitivity analysis of trials commencing mobilisation within 24 hours, and the NMA, there was concern that VEM commencing within 24 hours may carry an increased risk, at least in some people with stroke. Given the uncertainty around these effect estimates, more detailed research is still required.

An examination of current stroke rehabilitation practice in Peru: Implications for interprofessional education

This study aimed to better understand current clinical practice of rehabilitation professionals in Lima, Peru, and to explore the existence of and potential for interprofessional collaboration. A secondary purpose was to assess rehabilitation professionals' agreement with evidence-based stroke rehabilitation statements and confidence performing stroke rehabilitation tasks prior to and following an interprofessional stroke rehabilitation training. Current clinical practice for rehabilitation professionals in Peru differs from high-income counties like the United States, as physical therapists work with dysphagia and feeding, prosthetist orthotists serve a strictly technical role, and nurses have a limited role in rehabilitation. Additionally, while opportunity for future interprofessional collaboration within stroke rehabilitation exists, it appears to be discouraged by current health system policies. Pre- and post-training surveys were conducted with a convenience sample of 107 rehabilitation professionals in Peru. Survey response options included endorsement of professionals for rehabilitation tasks and a Likert scale of agreement and confidence. Training participants largely agreed with evidence-based stroke rehabilitation statements. Differences in opinion remained regarding the prevalence of dysphagia and optimal frequency of therapy post-stroke. Substantially increased agreement post-training was seen in favour of early initiation of stroke rehabilitation and ankle foot orthosis use. Participants were generally confident performing traditional profession-specific interventions and educating patients and families. Substantial increases were seen in respondents' confidence to safely and independently conduct bed to chair transfers and determine physiological stability. Identification of key differences in rehabilitation professionals' clinical practice in Peru is a first step toward strengthening the development of sustainable rehabilitation systems and interprofessional collaboration.

Efficacy and Safety of Very Early Mobilization in Patients with Acute Stroke: A Systematic Review and Meta-analysis

Whether very early mobilization (VEM) improves outcomes in stroke patients and reduces immobilization-related complications (IRCs) is currently unknown. The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of VEM in acute stroke patients following admission. Medline, Embase, and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) that examined the efficacy or safety of VEM in patients with acute stroke. VEM was defined as out of bed activity commencing within 24 or 48 hours after the onset of stroke. A total of 9 RCTs with 2,803 participants were included. Upon analysis, VEM was not associated with favorable functional outcomes (modified Ranking Scale: 0–2) at 3 months [relative risk (RR): 0.96; 95% confidence interval (CI): 0.86–1.06]; VEM did not reduce the risk of IRCs during follow up. With respect to safety outcomes, VEM was not associated with a higher risk of death (RR: 1.04; 95% CI: 0.52–2.09) and did not increase the risk of neurological deterioration or incidence of falls with injury. In conclusion, pooled data from RCTs concluded that VEM is not associated with beneficial effects when carried out in patients 24 or 48 hours after the onset of a stroke.

Utilization of physiotherapy in the continuum of stroke care at a tertiary hospital in Ibadan, Nigeria

OBJECTIVES

To investigate the pattern of referral for and utilisation of physiotherapy in the continuum of stroke care at a tertiary hospital in Ibadan, Nigeria.

METHODS

Referral notes and medical records of patients admitted in the University College Hospital, Ibadan with a clinical diagnosis of stroke between January, 2009 and December, 2013 were retrospectively reviewed. Information on age, sex, type of stroke, length of hospital stay, referral for physiotherapy and utilisation of physiotherapy were retrieved. Data were summarised using descriptive statistics and analysed using Chi-square test.

RESULTS

A total of 783 patients with stroke were admitted in the hospital during the period under study. The in-patient mortality rate was 37.2%. The mean Length of Hospital Stay (LoHS) was 16.17±12.34 days. Referral rate for physiotherapy was high (75.8%) and the mean time from admission to referral for physiotherapy was three days. Majority of patients referred utilised physiotherapy (63.4%) and mean number of physiotherapy sessions received during in-patient care was 8.69±6.45. There was a significant association between LoHS and utilisation of in-patientphysiotherapy (p=0.02).

CONCLUSION

The referral rate of stroke patients for physiotherapy was relatively high. Utilisation of in-patient physiotherapy reduced length of hospital stay among patients with stroke. Utilisation of out-patient physiotherapy was low. Strategies to enhance out-patient utilisation should be explored.

Design, Analysis, and Optimization of an Acute Stroke Gait Rehabilitation Device

Stroke is one of the leading causes of adult physical disability, and rehabilitation and hospitalization costs for stroke are among the highest for all injuries. Current rehabilitation techniques are labor intensive and time consuming for therapists and difficult to perform effectively. Research suggests that starting rehabilitation during the acute or subacute stage of recovery results in better outcomes than therapy delivered in the chronic stage. To improve the gait rehabilitation process, robot-assisted gait rehabilitation has gained much interest over the past years. However, many robot-assisted rehabilitation devices have limitations; one of which is being bulky and complex to handle. Large and expensive devices that require special training to operate are less attractive to clinics and therapists, and ultimately less likely to be available to patients especially at the early stage of stroke. To address these limitations, this research proposes a new gait rehabilitation device called the linkage design gait trainer (LGT). The device is based on a walking frame design with a simple four-bar linkage “end-effector” mechanism to generate normal gait trajectories during general walking and exercise. The design of the four-bar linkage mechanism was optimized for a particular gait pattern. A prototype of the device was developed and tested. The kinematics of the device itself and gait kinematics with and without assistance from the device were recorded and analyzed using an optical motion capture system. The results show the linkage mechanism is able to guide the leg of the user during over ground walking. There were some differences in the hip (20.5 deg RMS) and knee (14.8 deg RMS) trajectory between the person walking with and without the device assistance. The study demonstrated the concept and feasibility of this novel gait training device.

Dose and timing in neurorehabilitation: prescribing motor therapy after stroke

PURPOSE OF REVIEW

Prescribing the most appropriate dose of motor therapy for individual patients is a challenge because minimal data are available and a large number of factors are unknown. This review explores the concept of dose and reviews the most recent findings in the field of neurorehabilitation, with a focus on relearning motor skills after stroke.

RECENT FINDINGS

Appropriate dosing involves the prescription of a specific amount of an active ingredient, at a specific frequency and duration. Dosing parameters, particularly amount, are not well defined or quantified in most studies. Compiling data across studies indicates a positive, moderate dose-response relationship, indicating that more movement practice results in better outcomes. This relationship is confounded by time after stroke, however, wherein longer durations of scheduled therapy may not be beneficial in the first few hours, days, and/or weeks.

SUMMARY

These findings suggest that substantially more movement practice may be necessary to achieve better outcomes for people living with the disabling consequences of stroke. Preclinical investigations are needed to elucidate many of the unknowns and allow for a more biologically driven rehabilitation prescription process. Likewise, clinical investigations are needed to determine the dose-response relationships and examine the potential dose-timing interaction in humans.

Cerebrolysin and Recovery After Stroke (CARS): A Randomized, Placebo-Controlled, Double-Blind, Multicenter Trial

Supplemental Digital Content is available in the text.

The aim of this trial was to investigate whether stroke patients who receive Cerebrolysin show improved motor function in the upper extremities at day 90 compared with patients who receive a placebo.

Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial

BACKGROUND

Early mobilisation after stroke is thought to contribute to the effects of stroke-unit care; however, the intervention is poorly defined and not underpinned by strong evidence. We aimed to compare the effectiveness of frequent, higher dose, very early mobilisation with usual care after stroke.

METHODS

We did this parallel-group, single-blind, randomised controlled trial at 56 acute stroke units in five countries. Patients (aged ≥18 years) with ischaemic or haemorrhagic stroke, first or recurrent, who met physiological criteria were randomly assigned (1:1), via a web-based computer generated block randomisation procedure (block size of six), to receive usual stroke-unit care alone or very early mobilisation in addition to usual care. Treatment with recombinant tissue plasminogen activator was allowed. Randomisation was stratified by study site and stroke severity. Patients, outcome assessors, and investigators involved in trial and data management were masked to treatment allocation. The primary outcome was a favourable outcome 3 months after stroke, defined as a modified Rankin Scale score of 0-2. We did analysis on an intention-to-treat basis. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12606000185561.

FINDINGS

Between July 18, 2006, and Oct 16, 2014, we randomly assigned 2104 patients to receive either very early mobilisation (n=1054) or usual care (n=1050); 2083 (99%) patients were included in the 3 month follow-up assessment. 965 (92%) patients were mobilised within 24 h in the very early mobilisation group compared with 623 (59%) patients in the usual care group. Fewer patients in the very early mobilisation group had a favourable outcome than those in the usual care group (n=480 [46%] vs n=525 [50%]; adjusted odds ratio [OR] 0·73, 95% CI 0·59-0·90; p=0·004). 88 (8%) patients died in the very early mobilisation group compared with 72 (7%) patients in the usual care group (OR 1·34, 95% CI 0·93-1·93, p=0·113). 201 (19%) patients in the very early mobilisation group and 208 (20%) of those in the usual care group had a non-fatal serious adverse event, with no reduction in immobility-related complications with very early mobilisation.

INTERPRETATION

First mobilisation took place within 24 h for most patients in this trial. The higher dose, very early mobilisation protocol was associated with a reduction in the odds of a favourable outcome at 3 months. Early mobilisation after stroke is recommended in many clinical practice guidelines worldwide, and our findings should affect clinical practice by refining present guidelines; however, clinical recommendations should be informed by future analyses of dose-response associations.

FUNDING

National Health and Medical Research Council, Singapore Health, Chest Heart and Stroke Scotland, Northern Ireland Chest Heart and Stroke, UK Stroke Association, National Institute of Health Research.

[The early post-stroke mobilization]

Early mobilization is an important prerequisite for the successful recovery after stroke. However, it is unclear at present how early mobilization should be started after stroke. Three randomized controlled trials were devoted to the comparison of the effectiveness and safety of very early (within the first day after stroke) and early (within two days after stroke) mobilization. The meta-analysis of the results of these studies did not reveal any advantages of very early mobilization over early mobilization. One randomized control study was designed to compare the consequences of mobilization within 3 and 7 days after stroke. It has demonstrated that earlier mobilization is associated with fewer complications and does not exert negative effect on cerebral haemodynamics. A number of observational studies confirmed the positive effect of early mobilization on the outcome of stroke. It is concluded that it may be justified to start mobilization on the second day after stroke provided there are no contraindications to such modality. The practicability of very early mobilization remains to be elucidated.

Stroke unit management and revascularisation in acute ischemic stroke

BACKGROUND

Stroke affects one in six people throughout their lifetimes and is the most frequent cause of disability in adults. Several recanalization therapies have emerged and the management of patients in stroke units has improved over the last decades.

SUMMARY

This article examines the current treatment options for stroke patients, summarizing the key clinical evidence, as well as listing the complications and practical issues related to each of these main treatment options.

KEY MESSAGES

Recent advances in the treatment of acute stroke include developments in intravenous thrombolysis (IVT), intra-arterial treatment and bridging therapies.

CLINICAL IMPLICATIONS

Treatment within a stroke unit reduces mortality and disability regardless of age, sex and stroke severity. IVT is widely available and reduces disability when initiated within 4.5 h after the onset of symptoms. The major limitations of IVT are the low recanalization rates and the narrow time frame. Intra-arterial treatment, especially when using newly developed stent-retrievers, achieves very high recanalization rates. It is restricted by its limited availability and by the longer time span required to initiate therapy. Bridging both therapies is a promising approach that combines the advantages of both therapies, but the superiority of this approach remains to be proven. Future strategies to reduce the burden of acute stroke in Europe should focus on immediate access to acute stroke care and dedicated stroke units for all patients.

2nd International Salzburg Conference on Neurorecovery (ISCN 2013) Salzburg/Austria|November 28th-29th, 2013

The 2nd International Salzburg Conference on Neurorecovery was held on the 28th and 29th of November, 2013, in Salzburg, one of the most beautiful cities in Austria, which is well known for its rich cultural heritage, world-famous music and beautiful surrounding landscapes. The aim of the conference was to discuss the progress in the field of neurorecovery. The conference brought together internationally renowned scientists and clinicians, who described the clinical and therapeutic relevance of translational research and its applications in neurorehabilitation.

Stroke

Stroke is a major cause of death and disability. International and national guidelines are available to help clinicians provide evidence-based care for stroke prevention, acute treatment, and rehabilitation. Stroke is a medical emergency and rapid assessment is needed to establish the diagnosis, identify the underlying cause, provide acute treatment, and prevent complications. Although stroke is a clinical diagnosis based upon a history of sudden onset of neurological symptoms, which include unilateral weakness or sensory loss, dysphasia, hemianopia, inattention, and reduced coordination, brain imaging with CT or MRI scan is needed to distinguish cerebral infarction from primary intracerebral haemorrhage. Stroke units are the cornerstones of stroke care and should be available to all stroke patients throughout their inpatient stay. Multidisciplinary stroke care should address the physical, psychological, and social consequences of stroke and consider the needs of both patients and carers. Good communication with patients and carers and between members of the multidisciplinary team is fundamental to quality care. Ongoing assessment and treatment may be needed for: dysphagia; nutrition and hydration; continence and skin care; mobility and upper limb function; comprehension and communication; concentration and memory; spatial awareness and inattention; mood; pain and spasticity. Patients and carers should be fully informed about the diagnosis, prognosis, treatment and available care. Discharge requires careful planning and consultation. Early supported discharge can improve outcome for carefully selected patients. It is important to recognize and address the long-term needs in order to maximize choice, independence, and wellbeing. Targeted rehabilitation to address issues such as mobility and leisure may be effective.

Noninvasive strategies to promote functional recovery after stroke

Stroke is a common and disabling global health-care problem, which is the third most common cause of death and one of the main causes of acquired adult disability in many countries. Rehabilitation interventions are a major component of patient care. In the last few years, brain stimulation, mirror therapy, action observation, or mental practice with motor imagery has emerged as interesting options as add-on interventions to standard physical therapies. The neural bases for poststroke recovery rely on the concept of plasticity, namely, the ability of central nervous system cells to modify their structure and function in response to external stimuli. In this review, we will discuss recent noninvasive strategies employed to enhance functional recovery in stroke patients and we will provide an overview of neural plastic events associated with rehabilitation in preclinical models of stroke.

Active and Progressive Exoskeleton Rehabilitation Using Multisource Information Fusion From EMG and Force-Position EPP

Although exoskeletons have received enormous attention and have been widely used in gait training and walking assistance in recent years, few reports addressed their application during early poststroke rehabilitation. This paper presents a healthcare technology for active and progressive early rehabilitation using multisource information fusion from surface electromyography and force-position extended physiological proprioception. The active-compliance control based on interaction force between patient and exoskeleton is applied to accelerate the recovery of the neuromuscular function, whereby progressive treatment through timely evaluation contributes to an effective and appropriate physical rehabilitation. Moreover, a clinic-oriented rehabilitation system, wherein a lower extremity exoskeleton with active compliance is mounted on a standing bed, is designed to ensure comfortable and secure rehabilitation according to the structure and control requirements. Preliminary experiments and clinical trial demonstrate valuable information on the feasibility, safety, and effectiveness of the progressive exoskeleton-assisted training.

NEUROExos: A powered elbow orthosis for post-stroke early neurorehabilitation

This paper presents the development of a portable version of the robotic elbow exoskeleton NEUROExos, designed for the treatment of stroke survivors in acute/sub-acute phases. The design was improved by a novel Series Elastic Actuation (SEA) system. The system implements two control modalities: a near-zero output impedance torque control and a passive-compliance position control.

Hand robotics rehabilitation: feasibility and preliminary results of a robotic treatment in patients with hemiparesis

Background. No strongly clinical evidence about the use of hand robot-assisted therapy in stroke patients was demonstrated. This preliminary observer study was aimed at evaluating the efficacy of intensive robot-assisted therapy in hand function recovery, in the early phase after a stroke onset. Methods. Seven acute ischemic stroke patients at their first-ever stroke were enrolled. Treatment was performed using Amadeo robotic system (Tyromotion GmbH Graz, Austria). Each participant received, in addition to inpatients standard rehabilitative treatment, 20 sessions of robotic treatment for 4 consecutive weeks (5 days/week). Each session lasted for 40 minutes. The exercises were carried out as follows: passive modality (5 minutes), passive/plus modality (5 minutes), assisted therapy (10 minutes), and balloon (10 minutes). The following impairment and functional evaluations, Fugl-Meyer Scale (FM), Medical Research Council Scale for Muscle Strength (hand flexor and extensor muscles) (MRC), Motricity Index (MI), and modified Ashworth Scale for wrist and hand muscles (AS), were performed at the beginning (T0), after 10 sessions (T1), and at the end of the treatment (T2). The strength hand flexion and extension performed by Robot were assessed at T0 and T2. The Barthel Index and COMP (performance and satisfaction subscale) were assessed at T0 and T2. Results. Clinical improvements were found in all patients. No dropouts were recorded during the treatment and all subjects fulfilled the protocol. Evidence of a significant improvement was demonstrated by the Friedman test for the MRC (P < 0.0123). Evidence of an improvement was demonstrated for AS, FM, and MI. Conclusions. This original rehabilitation treatment could contribute to increase the hand motor recovery in acute stroke patients. The simplicity of the treatment, the lack of side effects, and the first positive results in acute stroke patients support the recommendations to extend the clinical trial of this treatment, in association with physiotherapy and/or occupational therapy.

Strategies to augment recovery after stroke

OPINION STATEMENT

The improvement of recovery after stroke remains one of the main priorities for patients with stroke. Acute de-occlusion of the artery should improve patient outcome and recovery. Recent data and meta-analysis confirmed the efficacy of IV thrombolysis when administered to selected patients less than 4.5 hours after the onset of ischemic stroke even in patients aged > 80 years. IV thrombolysis with rTPA is currently the only validated treatment for the acute phase of ischemic stroke. This has lead to a major public health effort to create stroke treatment units in developed countries. Mechanical thrombectomy is not yet validated despite major support from clinicians and the industry overall. Many other treatment options are currently being tested in various other therapeutic areas. Some data show clearly that some of these options are now close to clinical significance: specific and adapted rehabilitation procedures that will include a rationale in patients' care management, use of monoaminergic drugs like SSRIs with improvement of motor recovery through a specific action on cortical excitability, cortical stimulation or inhibition with magnetic or electric techniques with the aim of modifying functional inter cortical balance and connections, and clinical and bio markers of recovery that would help to ensure appropriate individual care of each patient. Finally, repair therapies with the aim of restoring the brain-damaged networks could be useful in patients with persistent severe deficits. Several classes are under study for brain repair, including the use of stem cells, growth factors, and small molecules, but these are still at a preclinical level of development.

Rehabilitation of gait after stroke: a review towards a top-down approach

This document provides a review of the techniques and therapies used in gait rehabilitation after stroke. It also examines the possible benefits of including assistive robotic devices and brain-computer interfaces in this field, according to a top-down approach, in which rehabilitation is driven by neural plasticity.The methods reviewed comprise classical gait rehabilitation techniques (neurophysiological and motor learning approaches), functional electrical stimulation (FES), robotic devices, and brain-computer interfaces (BCI).From the analysis of these approaches, we can draw the following conclusions. Regarding classical rehabilitation techniques, there is insufficient evidence to state that a particular approach is more effective in promoting gait recovery than other. Combination of different rehabilitation strategies seems to be more effective than over-ground gait training alone. Robotic devices need further research to show their suitability for walking training and their effects on over-ground gait. The use of FES combined with different walking retraining strategies has shown to result in improvements in hemiplegic gait. Reports on non-invasive BCIs for stroke recovery are limited to the rehabilitation of upper limbs; however, some works suggest that there might be a common mechanism which influences upper and lower limb recovery simultaneously, independently of the limb chosen for the rehabilitation therapy. Functional near infrared spectroscopy (fNIRS) enables researchers to detect signals from specific regions of the cortex during performance of motor activities for the development of future BCIs. Future research would make possible to analyze the impact of rehabilitation on brain plasticity, in order to adapt treatment resources to meet the needs of each patient and to optimize the recovery process.

Early mobilization out of bed after ischaemic stroke reduces severe complications but not cerebral blood flow: a randomized controlled pilot trial

Objective: To evaluate whether early mobilization after acute ischaemic stroke is better than delayed mobilization with regard to medical complications and if it is safe in relation to neurological function and cerebral blood flow.

Design: Randomized controlled pilot trial of early versus delayed mobilization out of bed with incidence of severe complications as the primary outcome.

Setting: Acute stroke unit in the neurology department of a University Hospital.

Participants: Fifty patients after ischaemic stroke with a National Institutes of Health Stroke Scale (NIHSS) score >6 were recruited.

Intervention: All patients were treated with physiotherapy immediately after their admission. In the early protocol patients were mobilized out of bed after 52 hours, in the delayed protocol after seven days.

Results: Eight out of 50 randomized patients were excluded from the per-protocol analysis because of early transfer to other hospitals. There were 2 (8%) severe complications in the 25 early mobilization patients and 8 (47%) in the 17 delayed mobilization patients ( P < 0.006). There were no differences in the total number of complications or in clinical outcome. In the 26 patients (62%) who underwent serial transcranial Doppler ultrasonography, no blood flow differences were found.

Conclusion: We found an apparent reduction in severe complications and no increase in total complications with an early mobilization protocol after acute ischaemic stroke. No influence on neurological three-month outcomes or on cerebral blood flow was seen. These results justify larger trials comparing mobilization protocols with possibly even faster mobilization out of bed than explored here.

Non-invasive optical imaging of stroke

The acute onset of a neurological deficit is the key clinical feature of stroke. In most cases, however, pathophysiological changes in the cerebral vasculature precede the event, often by many years. Persisting neurological deficits may also require long-term rehabilitation. Hence, stroke may be considered a chronic disease, and diagnostic and therapeutic efforts must include identification of specific risk factors, and the monitoring of and interventions in the acute and subacute stages, and should aim at a pathophysiologically based approach to optimize the rehabilitative effort. Non-invasive optical techniques have been experimentally used in all three stages of the disease and may complement the established diagnostic and monitoring tools. Here, we provide an overview of studies using the methodology in the context of stroke, and we sketch perspectives of how they may be integrated into the assessment of the highly dynamic pathophysiological processes during the acute and subacute stages of the disease and also during rehabilitation and (secondary) prevention of stroke.

Physical activity in hospitalised stroke patients

The aim of this paper was to examine the amount and type of physical activity engaged in by people hospitalised after stroke. Method. We systematically reviewed the literature for observational studies describing the physical activity of stroke patients. Results. Behavioural mapping, video recording and therapist report are used to monitor activity levels in hospitalised stroke patients in the 24 included studies. Most of the patient day is spent inactive (median 48.1%, IQR 39.6%-69.3%), alone (median 53.7%, IQR 44.2%-60.6%) and in their bedroom (median 56.5%, IQR 45.2%-72.5%). Approximately one hour per day is spent in physiotherapy (median 63.2 minutes, IQR 36.0-79.5) and occupational therapy (median 57.0 minutes, IQR 25.1-58.5). Even in formal therapy sessions limited time is spent in moderate to high level physical activity. Low levels of physical activity appear more common in patients within 14 days post-stroke and those admitted to conventional care. Conclusions. Physical activity levels are low in hospitalised stroke patients. Improving the description and classification of post stroke physical activity would enhance our ability to pool data across observational studies. The importance of increasing activity levels and the effectiveness of interventions to increase physical activity after stroke need to be tested further.

Stroke rehabilitation

Stroke is a common, serious, and disabling global health-care problem, and rehabilitation is a major part of patient care. There is evidence to support rehabilitation in well coordinated multidisciplinary stroke units or through provision of early supported provision of discharge teams. Potentially beneficial treatment options for motor recovery of the arm include constraint-induced movement therapy and robotics. Promising interventions that could be beneficial to improve aspects of gait include fitness training, high-intensity therapy, and repetitive-task training. Repetitive-task training might also improve transfer functions. Occupational therapy can improve activities of daily living; however, information about the clinical effect of various strategies of cognitive rehabilitation and strategies for aphasia and dysarthria is scarce. Several large trials of rehabilitation practice and of novel therapies (eg, stem-cell therapy, repetitive transcranial magnetic stimulation, virtual reality, robotic therapies, and drug augmentation) are underway to inform future practice.

An exploration of the association between very early rehabilitation and outcome for the patients with acute ischaemic stroke in Japan: a nationwide retrospective cohort survey

BACKGROUND

Very early rehabilitation is expected to improve functional outcomes after stroke, although its effectiveness has not been fully evaluated. The purpose of this study was to investigate the association between very early intervention (VEI), and patient outcomes at discharge by using nationwide large data and statistical treatment for selection bias.

METHODS

In this study, we defined VEI as rehabilitation commencing within 3 days of stroke admission. The data were derived from a nationwide survey of acute-care hospitals conducted in 2007 for designing a reimbursement scheme and from a concurrent survey on rehabilitation services among a convenient subgroup of hospitals participating in the above survey. We included patients with a diagnosis code of ischaemic cerebrovascular disease with acute onset who underwent any rehabilitation services during hospitalisation. Surgery cases, those with no functional deficit, and those with a severe consciousness deficit upon admission were excluded. A total of 5,482 patients were enrolled from 294 hospitals. To correct for any potential selection bias, we used Friday admission as an instrumental variable (IV) and conducted a bivariate probit model analysis.

RESULTS

We found that VEI for acute stroke patients was significantly associated with a lesser degree of disability at discharge. Even after considering endogenous problems due to treatment selection, VEI improved the chance of reducing disability by 15.3% (p < 0.001). There was no significant association between VEI and in-hospital mortality, suggesting that VEI was not likely to lead to an adverse outcome.

CONCLUSIONS

These data suggest that VEI may lead to a better outcome with no increase in adverse events compared to delayed rehabilitation.

Stroke rehabilitation 2009: old chestnuts and new insights

The past year has continued to see growth in stroke rehabilitation literature, ranging from important insights into the basic science of stroke recovery to broader multidisciplinary aspects aimed at improving global quality of life in stroke survivors. The areas that particularly stand out include 1) new evidence on old treatment strategies in clinical rehabilitation; 2) developments in the treatment of "neglected" impairments, such as hemianopia and sensory loss; 3) evaluation of the use of technology in stroke rehabilitation; and 4) advances in neurorestorative treatments after stroke.

Very early mobilization following acute stroke: Controversies, the unknowns, and a way forward

Evidence that organized stroke-unit care results in better outcome has led to positive changes in stroke service delivery around the world. It is well accepted that stroke rehabilitation should commence as early as possible for optimal recovery to be achieved. Exactly how early rehabilitation should start is controversial. Early mobilization (getting up out of bed within 24 h of stroke onset) is a wellestablished feature of acute stroke care in many Scandinavian hospitals. Elsewhere in the world, stroke protocols enforce bed rest for the first few days or foster long periods of bed rest after stroke. This paper aims to provide an overview of the topic of very early mobilization (VEM). It is divided into three sections: section 1 reviews the effects of bed rest and outlines arguments both for and against enforced bed rest after stroke; in section 2, VEM as a treatment for stroke and the limitations of existing literature in the field are described; and section 3 outlines the systematic approach that has been taken by our team of clinical researchers to the study the effect of VEM after stroke.

Conclusion

VEM represents a simple, easy-to-deliver intervention, requiring little or no equipment. It is potentially deliverable to 85% of the acute stroke population and, if proven to be effective, may help reduce the significant personal and community burden of stroke. As current opinion about when mobilization should begin is divided, one way to move forward is through the conduct of a large high-quality clinical trial (such as A Very Early Rehabilitation Trial (AVERT)). Although some inroads have been made, further research in this field is clearly warranted.