Research in the Acute Rehabilitation Setting: a Bridge Too Far?

A Unified Model for Stroke Recovery and Rehabilitation: Why Now?

ABSTRACT

The current model of stroke care delivery in the United States and in many parts of the world is fragmented, resulting in lack of continuity of care, inability to track recovery meaningfully across the continuum, and lack of access to the frequency, intensity, and duration of high-quality rehabilitation necessary to optimally harness recovery processes. The process of recovery itself has been overshadowed by a focus on length of stay and the movement of patients across levels of care. Here, we describe the rationale behind the recent efforts at the Johns Hopkins Sheikh Khalifa Stroke Institute to define and coordinate an intensive, strategic effort to develop effective stroke systems of care across the continuum through the development of a unified Sheikh Khalifa Stroke Institute model of recovery and rehabilitation.

Developing a Framework for Designing and Deploying Technology-Assisted Rehabilitation After Stroke: A Qualitative Study

OBJECTIVE

Many unmet rehabilitation needs of patients with stroke can be addressed effectively using technology. However, technological solutions have not yet been seamlessly incorporated into clinical care. The purpose of this pilot study was to examine how to bridge the gaps between the recovery process, technology, and clinical practice to impact stroke rehabilitation meaningfully.

DESIGN

Semistructured interviews were performed using a grounded theory approach with purposive sampling of 17 diverse expert providers in acute care, inpatient, and outpatient stroke rehabilitation settings. Common themes were identified from qualitative analyses of the transcribed conversations to develop a guiding framework from the emerging concepts.

RESULTS

Four core themes emerged that addressed major barriers in stroke rehabilitation and technology-assisted solutions to overcome these barriers: (1) accessibility to quality rehabilitation, (2) adaptability to patient differences, (3) accountability or compliance with rehabilitation, and (4) engagement with rehabilitation.

CONCLUSIONS

The results suggest a four-pronged framework, the A3E framework that stands for Accessibility, Adaptability, Accountability, and Engagement, to comprehensively address existing barriers in providing rehabilitation services. This framework can guide technology developers and clinicians in designing and deploying technology-assisted rehabilitation solutions for poststroke rehabilitation, particularly using telerehabilitation.

Comparing a Novel Neuroanimation Experience to Conventional Therapy for High-Dose Intensive Upper-Limb Training in Subacute Stroke: The SMARTS2 Randomized Trial

BACKGROUND

Evidence from animal studies suggests that greater reductions in poststroke motor impairment can be attained with significantly higher doses and intensities of therapy focused on movement quality. These studies also indicate a dose-timing interaction, with more pronounced effects if high-intensity therapy is delivered in the acute/subacute, rather than chronic, poststroke period.

OBJECTIVE

To compare 2 approaches of delivering high-intensity, high-dose upper-limb therapy in patients with subacute stroke: a novel exploratory neuroanimation therapy (NAT) and modified conventional occupational therapy (COT).

METHODS

A total of 24 patients were randomized to NAT or COT and underwent 30 sessions of 60 minutes time-on-task in addition to standard care. The primary outcome was the Fugl-Meyer Upper Extremity motor score (FM-UE). Secondary outcomes included Action Research Arm Test (ARAT), grip strength, Stroke Impact Scale hand domain, and upper-limb kinematics. Outcomes were assessed at baseline, and days 3, 90, and 180 posttraining. Both groups were compared to a matched historical cohort (HC), which received only 30 minutes of upper-limb therapy per day.

RESULTS

There were no significant between-group differences in FM-UE change or any of the secondary outcomes at any timepoint. Both high-dose groups showed greater recovery on the ARAT (7.3 ± 2.9 points; P = .011) but not the FM-UE (1.4 ± 2.6 points; P = .564) when compared with the HC.

CONCLUSIONS

Neuroanimation may offer a new, enjoyable, efficient, and scalable way to deliver high-dose and intensive upper-limb therapy.