Do Performance Measures of Strength, Balance, and Mobility Predict Quality of Life and Community Reintegration After Stroke?

Measures and Influencers of Reintegration for the Stroke Patient: A Systematic Review

ABSTRACT

BACKGROUND: Stroke survivors may experience continued difficulties with reintegration, including challenges participating in social roles and performing activities of daily living across settings (eg, home, work). This article assessed the reintegration measures currently used in this clinical population, defining factors that most influence reintegration for these persons. METHODS: A systematic review of PubMed, Scopus, and the Cumulative Index to Nursing and Allied Health Literature databases explored reintegration measures and factors influencing reintegration in stroke populations. Study inclusion criteria for this review were as follows: data-based articles (quantitative and qualitative), studies measuring reintegration or examining outcomes of reintegration, participants being adult stroke populations, and studies published in English. The resulting articles were critically analyzed, and common themes regarding barriers, facilitators, and influencers of reintegration were established. RESULTS: A total of 24 articles met the inclusion criteria and were synthesized for use in this systematic review. Across stroke populations, 13 reintegration tools were used. A few factors, including residual stroke impairments, unmet needs, social support, and sociodemographic characteristics, are currently known to influence reintegration for this population. CONCLUSION: Reintegration must be uniformly defined and measured to best support stroke survivors, and further investigation into influential factors is critical to advance this goal. This review defines current assessments and factors influencing reintegration within stroke populations. Achieving these goals is critical to optimizing reintegration efforts and designing quality-of-life-improving nursing interventions for affected persons.

The effects of mechanical hippotherapy riding on postural control, balance, and quality of life (QoL) in patients with stroke

PURPOSED

This study aimed to investigate the effects of exercises by mechanical hippotherapy devices on postural control, balance, mobility, and Quality of Life in patients with stroke.

MATERIAL AND METHODS

This was a randomized controlled clinical trial with a total of 30 which were randomly divided into two groups. The participants in the mechanical hippotherapy group (MHG) (n = 15) were given exercises with a mechanical hippotherapy device for 15 min in addition to intensive conventional treatments (45 min), while the control group (CG) (n = 15) received additional 15 min of postural control and balance exercises for five days per week for four consecutive weeks. The primary outcome was The Berg Balance Scale (BBS). Secondary outcomes were the Fugl-Meyer (FM) Rating Scale, Biodex Balance Measurement (BBM), Trunk Impairment Scale (TIS), the Timed Up and Go Test (TUG) and quality of Life Short Form (SF-36).

RESULTS

In the MHG, FM-Lower extremity score (-6.4, p = 0.024), FM-Upper extremity score (-12.87, p = 0.013), TIS (-5.87, p = 0.04) and TUG (5.73, p = 0.027) improved statistically significant compared to CG.

CONCLUSION

Exercises using mechanical hippotherapy devices could improve postural control, functional mobility and balance in patients with stroke. It may also improve the quality of life.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03528993IMPLICATIONS FOR REHABILITATIONNCT03528993It was concluded from our results that mechanical hippotherapy could be included in the treatment programs of stroke patients.

Impact of long-term white matter hyperintensity changes on mobility and dexterity

White matter hyperintensities (WMH), a common feature of cerebral small vessel disease, are related to worse clinical outcomes after stroke. We assessed the impact of white matter hyperintensity changes over 1 year after minor stroke on change in mobility and dexterity, including differences between the dominant and non-dominant hands and objective in-person assessment versus patient-reported experience. We recruited participants with lacunar or minor cortical ischaemic stroke, performed medical and cognitive assessments and brain MRI at presentation and at 1 year. At both time points, we used the timed-up and go test and the 9-hole peg test to assess mobility and dexterity. At 1 year, participants completed the Stroke Impact Scale. We ran two linear mixed models to assess change in timed-up and go and 9-hole peg test, adjusted for age, sex, stroke severity (National Institutes of Health Stroke Scale), dependency (modified Rankin Score), vascular risk factor score, white matter hyperintensity volume (as % intracranial volume) and additionally for 9-hole peg test: Montreal cognitive assessment, hand (dominant/non-dominant), National Adult Reading Test (premorbid IQ), index lesion side. We performed ordinal logistic regression, corrected for age and sex, to assess relations between timed-up and go and Stroke Impact Scale mobility, and 9-hole peg test and Stroke Impact Scale hand function. We included 229 participants, mean age 65.9 (standard deviation = 11.13); 66% male. 215/229 attended 1-year follow-up. Over 1 year, timed-up and go time increased with aging (standardized β [standardized 95% Confidence Interval]: 0.124[0.011, 0.238]), increasing National Institutes of Health Stroke Scale (0.106[0.032, 0.180]), increasing modified Rankin Score (0.152[0.073, 0.231]) and increasing white matter hyperintensity volume (0.176[0.061, 0.291]). Men were faster than women (-0.306[0.011, 0.238]). Over 1 year, slower 9-hole peg test was related to use of non-dominant hand (0.290[0.155, 0.424]), aging (0.102[0.012, 0.192]), male sex (0.182[0.008, 0.356]), increasing National Institutes of Health Stroke Scale (0.160 [0.094, 0.226]), increasing modified Rankin Score (0.100[0.032, 0.169]), decreasing Montreal cognitive assessment score (-0.090[-0.167, -0.014]) and increasing white matter hyperintensity volume (0.104[0.015, 0.193]). One year post-stroke, Stroke Impact Scale mobility worsened per second increase on timed-up and go, odds ratio 0.67 [95% confidence interval 0.60, 0.75]. Stroke Impact Scale hand function worsened per second increase on the 9-hole peg test for the dominant hand (odds ratio 0.79 [0.71, 0.86]) and for the non-dominant hand (odds ratio 0.88 [0.83, 0.93]). Decline in mobility and dexterity is associated with white matter hyperintensity volume increase, independently of stroke severity. Mobility and dexterity declined more gradually for stable and regressing white matter hyperintensity volume. Dominant and non-dominant hands might be affected differently. In-person measures of dexterity and mobility are associated with self-reported experience 1-year post-stroke.

Testing the psychometric properties of the Chinese (Cantonese) version of SATIS-Stroke in people with chronic stroke

PURPOSE

To culturally adapt and examine the psychometric properties of the Chinese (Cantonese) version of SATIS-Stroke (C-SATIS-Stroke) in people with chronic stroke.

MATERIALS AND METHODS

Forward and backward translations were performed in accordance with available guidelines. We administered the C-SATIS-Stroke to 101 people with stroke and 50 healthy older adults. We assessed the test-retest and internal reliability, measurement error, known-group validity, correlations with other outcome measures, optimal cut-off score and ceiling and floor effects.

RESULTS

C-SATIS-Stroke demonstrated excellent internal consistency (Cronbach's α = 0.959) and good test-retest reliability (intraclass correlation coefficient3,1 = 0.913). Compared with healthy controls, people with chronic stroke had lower C-SATIS-Stroke scores. The mean C-SATIS-Stroke score was significantly correlated with the mean scores of the Activities-specific Balance Confidence Scale, Stroke Impact Scale, Community Integration Measure and Survey of Activities and Fear of Falling in the Elderly. The cut-off score to distinguish the levels of satisfaction with activity and participation between people with chronic stroke and healthy older adults was 80 out of 108 (sensitivity: 77%; specificity: 72%). C-SATIS-Stroke exhibited ceiling effects but not floor effects.

CONCLUSIONS

C-SATIS-Stroke is a reliable and valid measure for assessing satisfaction with social participation among Chinese people with chronic stroke.IMPLICATIONS FOR REHABILITATIONSatisfactory semantic, idiomatic, cultural, and conceptual equivalence of the C-SATIS-Stroke are in line with those of the original English version of the SATIS-StrokeExcellent reliability and validity of the C-SATIS-Stroke are also in line with those of the original English version of the SATIS-StrokeThe C-SATIS-Stroke can be used to assess the subjective satisfaction feeling in terms of social participation among Chinese people with chronic stroke.

Stroke survivors' views on their priorities for upper-limb recovery and the availability of therapy services after stroke: a longitudinal, phenomenological study

PURPOSE

Forty percent of stroke survivors have a persistent lack of function in the upper limb, causing significant disability. Most personal-care tasks and meaningful activities require bi-manual function of both upper limbs. However, lower-limb mobility is often viewed as the priority in stroke services. Perspectives of stroke survivors on priorities for upper-limb recovery and therapy have not been investigated in detail. Therefore, this study aimed to explore their views.

MATERIALS AND METHODS

Thirteen stroke survivors each engaged in up to four semi-structured interviews over 18 months. A phenomenological approach guided the research.

RESULTS

Three themes were identified. Priorities change on coming home: recovery of walking is a priority early after stroke but upper-limb recovery becomes equally important over time, particularly once living at home. Limited therapy services: therapy has a short duration, prioritizes lower-limb mobility, and is short-lived in the community; people feel abandoned by services. Active partners in recovery: stroke survivors want intermittent access to review and advice so they can be active partners with therapists to manage their upper-limb recovery.

CONCLUSION

Therapy services should recognize stroke survivors' changing priorities and work with them as active partners in upper-limb recovery. Intermittent access to review and advice should be included in service design.Implications for rehabilitationStroke survivors' priorities may change over time from recovery of walking toward upper-limb recovery.Post-stroke services can be perceived as insufficient to meet the needs of stroke survivors who want to participate actively in rehabilitation of their upper limb.Stroke survivors may prefer services that are more flexible to provide regular review of their progress, access to guidance and support to self-manage their recovery.

Development of a predictive risk stratification tool to identify the population over age 45 at risk for new-onset stroke within 7 years

Background and purpose

With the acceleration of the aging process of society, stroke has become a major health problem in the middle-aged and elderly population. A number of new stroke risk factors have been recently found. It is necessary to develop a predictive risk stratification tool using multidimensional risk factors to identify people at high risk for stroke.

Methods

The study included 5,844 people (age ≥ 45 years) who participated in the China Health and Retirement Longitudinal Study in 2011 and its follow-up up to 2018. The population samples were divided into training set and validation set according to 1:1. A LASSO Cox screening was performed to identify the predictors of new-onset stroke. A nomogram was developed, and the population was stratified according to the score calculated through the X-tile program. Internal and external verifications of the nomogram were performed by ROC and calibration curves, and the Kaplan-Meier method was applied to identify the performance of the risk stratification system.

Results

The LASSO Cox regression screened out 13 candidate predictors from 50 risk factors. Finally, nine predictors, including low physical performance and the triglyceride-glucose index, were included in the nomogram. The nomogram's overall performance was good in both internal and external validations (AUCs at 3-, 5-, and 7-year periods were 0.71, 0.71, and 0.71 in the training set and 0.67, 0.65, and 0.66 in the validation set, respectively). The nomogram was proven to excellently discriminate between the low-, moderate-, and high-risk groups, with a prevalence of 7-year new-onset stroke of 3.36, 8.32, and 20.13%, respectively (P < 0.001).

Conclusion

This research developed a clinical predictive risk stratification tool that can effectively identify the different risks of new-onset stroke in 7 years in the middle-aged and elderly Chinese population.

Current physical therapy practice and implementation factors regarding the evidence-based 'Rehabilitation of Mobility after Stroke (ReMoS)' guideline in Germany: a cross-sectional online survey

BACKGROUND

Evaluation of the current physical therapy practice for German stroke rehabilitation with respect to the 'Rehabilitation of Mobility after Stroke (ReMoS)' guideline recommendations and the associated implementation factors.

METHODS

A descriptive cross-sectional study employing an online survey was performed among German physical therapists in 2019. The survey consisted of three sections with open and closed questions: 1) self-reported use of ReMoS recommendations, 2) barriers of guideline use and 3) socio-demographic characteristics. The benchmark level for guideline adherent physical therapy was set at > 80%.

RESULTS

Data from 170 questionnaires were eligible for analysis. Participants' mean age was 41.6 years, 69.4% were female, while 60.1% had no academic degree. The ReMoS guideline was unknown to 52.9% of the responders. Out of all the 46 ReMoS guideline recommendations, only 'intensive walking training without a treadmill' was reported to be performed in a guideline adherent manner. Respondents usually denied any personal limitations, such as limited knowledge, or that the ReMoS guideline did not fit their routine practice.

CONCLUSIONS

Among German physical therapists, the ReMoS guideline is not well-known and many interventions are not performed as recommended, illustrating the discrepancies between the ReMoS guideline recommendations and current physical therapy practice. Interventions aimed at overcoming this gap should consider both knowledge of existing barriers and facilitators of guideline usage.

TRIAL REGISTRATION

The study was retrospectively registered to the German Clinical Trials Register ( DRKS00026681 ).

A 6-Month Home-Based Functional Electrical Stimulation Program for Foot Drop in a Post-Stroke Patient: Considerations on a Time Course Analysis of Walking Performance

Foot drop is a common disability in post-stroke patients and represents a challenge for the clinician. To date, ankle foot orthosis (AFO) combined with conventional rehabilitation is the gold standard of rehabilitation management. AFO has a palliative mechanical action without actively restoring the associated neural function. Functional electrical stimulation (FES), consisting of stimulation of the peroneal nerve pathway, represents an alternative approach. By providing an FES device (Bioness L-300, BIONESS, Valencia, CA, USA) for 6 months to a post-stroke 22-year-old woman with a foot drop, our goal was to quantify its potential benefit on walking capacity. The gait parameters and the temporal evolution of the speed were collected with a specific connected sole device (Feet Me^®) during the 10-m walking, the time up and go, and the 6-minute walking tests with AFO, FES, or without any device (NO). As a result, the walking speed changes on 10-m were clinically significant with an increase from the baseline to 6 months in AFO (+0.14 m.s⁻¹), FES (+0.36 m.s⁻¹) and NO (+0.32 m.s⁻¹) conditions. In addition, the speed decreased at about 4-min in the 6-minute walking test in NO and AFO conditions, while the speed increased in the FES conditions at baseline and after 1, 3, and 6 months. In addition to the walking performance improvement, monitoring the gait speed in an endurance test after an ecological rehabilitation training program helps to examine the walking performance in post-stroke patients and to propose a specific rehabilitation program.

Tailored GuideLine Implementation in STrokE Rehabilitation (GLISTER) in Germany. Protocol of a Mixed Methods Study Using the Behavior Change Wheel and the Theoretical Domains Framework

Objective

Evidence-based guidelines are important for informing clinical decision-making and improving patient outcomes. There is inconsistent usage of guidelines among physical therapists involved in stroke rehabilitation, suggesting the existence of a gap between theory and practice. Addressing the German guideline "evidence-based rehabilitation of mobility after stroke (ReMoS)," the aims of this project are (1) to describe the current physical therapy practice within the context of stroke rehabilitation in Germany, (2) to evaluate barriers and facilitators of guideline usage, (3) to develop, and (4) to pilot test a theory-based, tailored implementation intervention for the benefit of guideline recommendations.

Materials and Methods

This study uses a stepwise mixed methods approach for implementing a local guideline. A self-reported online questionnaire will be used to survey the current physical therapy practice in stroke rehabilitation. The same survey and systematic-mixed methods review will be used to evaluate the barriers and facilitators of guideline usage quantitatively. Semi-structured interviews will add a qualitative perspective on factors that influence ReMoS guideline implementation. The Behavior Change Wheel and Theoretical Domains Framework will be used to support the development of a tailored implementation intervention which will be pilot tested in a controlled study. Patient and physical therapy-related outcomes, as well as the appropriateness, such as acceptance and feasibility of the tailored implementation intervention, will be analyzed.

Conclusion

This will be the first endeavor to implement a guideline in German stroke rehabilitation with a focus on changing care provider behavior based on the knowledge of current practice and determining factors using a tailored and theory-based intervention.

Stroke Recovery During the COVID-19 Pandemic: A Position Paper on Recommendations for Rehabilitation

Health care delivery shifted and adapted with the COVID-19 pandemic caused by the novel severe acute respiratory syndrome coronavirus 2. Stroke care was negatively affected across the care continuum and may lead to poor community living outcomes in those who survived a stroke during the ongoing pandemic. For instance, delays in seeking care, changes in length of stays, and shifts in discharge patterns were observed during the pandemic. Those seeking care were younger and had more severe neurologic effects from stroke. Increased strain was placed on caregivers and public health efforts, and community-wide lockdowns, albeit necessary to reduce the spread of COVID-19, had detrimental effects on treatment and recommendations to support community living outcomes. The American Congress of Rehabilitation Medicine Stroke Interdisciplinary Special Interest Group Health and Wellness Task Force convened to (1) discuss international experiences in stroke care and rehabilitation and (2) review recently published literature on stroke care and outcomes during the pandemic. Based on the findings in the literature, the task force proposes recommendations and interdisciplinary approaches at the (1) institutional and societal level; (2) health care delivery level; and (3) individual and interpersonal level spanning across the care continuum and into the community.

Mirror Therapy for Lower-Extremity Hemiparesis: A Knowledge Translation Study Using an Educational Module to Change Physiotherapists' Perceptions

Purpose: Despite growing evidence that mirror therapy (MT) is effective for improving lower-extremity (LE) function in patients with stroke, it is not commonly used by physiotherapists. The purpose of this study was to determine whether change would occur in physiotherapists' knowledge of, confidence in performing, and willingness to use MT for LE stroke rehabilitation after participating in a 1-hour educational module. Method: A convenience sample of physiotherapists working in neurorehabilitation was recruited for a single-group quasi-experimental pre-post study. Participants attended a 1-hour educational module on MT. Therapists' perceptions of the use of MT were assessed by questionnaire before and after they participated in the module. A follow-up telephone survey was conducted after 3 months to determine how many participants had actually used MT in their practice. Results: Nine physiotherapists participated in this study. Statistically significant increases were found in their perceived knowledge of, confidence in, and willingness to use MT. At the 3-month follow-up, three participants had used MT with patients with LE hemiparesis. Conclusions: Therapists' knowledge of and attitudes toward MT for LE stroke rehabilitation changed favourably after participating in a 1-hour educational module. The module also led some therapists to make a change in practice at 3 months.

Effect of whole-body vibration on obstacle clearance and stair negotiation time in chronic stroke patients; A randomized controlled trial

OBJECTIVE

To assess the effect of Whole-Body Vibration (WBV) and Routine Physiotherapy (RP) on obstacle crossing and stair negotiation time in chronic stroke patients.

METHODS

The current study was randomized, parallel-group, assessor-blinded, clinical trial conducted in Physiotherapy Department of Lahore General Hospital, involving 64 patients with chronic stroke. Patients were randomly allocated to 2 groups, i.e., the WBV group (n = 32) and the RP group (n = 32). The WBV group was given additional twelve sessions of vibration therapy (amplitude of 3 mm and frequency of 20 Hz), 6 days/week for 2 weeks. The outcome measures were change in score of height and depth of obstacles cleared, i.e., 6, 8, 10 & 12 inches height and 6, 8, 10 & 12 inches depth and stair negotiation time, i.e., Stair-Climb Test. Chi square test, Independent sample t-test and Paired sample t-test were used to analyze the data.

RESULTS

Results show that higher number of patients improved in crossing the maximum height and maximum depth of obstacles in the WBV group but improvement was significant only in height, i.e., (p < 0.05). In the WBV group, Stair Negotiation Time decreased significantly as compared to the RP group, i.e., (p < 0.05).

CONCLUSIONS

The present study concluded that both study groups, i.e., RP and WBV, improved despite better results for the latter. Speed of stair climbing and capacity to cross obstacles improved with the WBV therapy in chronic stroke survivors.

TRIAL REGISTRATION

IRCT, IRCT20190328043131N1. Registered 03 august 2019 - Retrospectively registered, https://www.irct.ir/user/trial/38832/view.

Rehabilitation Intensity and Patient Outcomes in Skilled Nursing Facilities in the United States: A Systematic Review

OBJECTIVE

Exponential increases in rehabilitation intensity in skilled nursing facilities (SNFs) motivated recent changes in Medicare reimbursement policies, which remove financial incentives for providing more minutes of physical therapy, occupational therapy, and speech therapy. Yet, there is concern that SNFs will reduce therapy provision and patients will experience worse outcomes. The purpose of this systematic review was to synthesize current evidence on the relationship between therapy intensity and patient outcomes in SNFs.

METHODS

PubMed, Medline, Scopus, Embase, CINAHL, PEDro, and COCHRANE databases were searched. English-language studies published in the United States between 1998 and February 14, 2020, examining the relationship between therapy intensity and community discharge, hospital readmission, length of stay (LOS), and functional improvement for short-stay SNF patients were considered. Data extraction and risk of bias were performed using the American Academy of Neurology Classification of Evidence scale for causation questions. American Academy of Neurology criteria were used to assess confidence in the evidence for each outcome.

RESULTS

Eight observational studies met inclusion criteria. There was moderate evidence that higher intensity therapy was associated with higher rates of community discharge and shorter LOS. One study provided very low-level evidence of associations between higher intensity therapy and lower hospital readmissions after total hip and knee replacement. There was low-level evidence indicating higher intensity therapy is associated with improvements in function.

CONCLUSIONS

This systematic review concludes with moderate confidence that higher intensity therapy in SNFs leads to higher community discharge rates and shorter LOS. Future research should improve quality of evidence on functional improvement and hospital readmissions.

IMPACT

This systematic review demonstrates that patients in SNFs may benefit from higher intensity therapy. Because new policies no longer incentivize intensive therapy, patient outcomes should be closely monitored to ensure patients in SNFs receive high-quality care.

Post-stroke fatigue level is significantly associated with mental health component of health-related quality of life: a cross-sectional study

PURPOSE

Individuals post-stroke might have high levels of post-stroke fatigue (PSF) which might affect their quality of life. This study aimed to investigate the prevalence of post-stroke fatigue in Jordan and to comprehensively identify its possible associated factors.

METHODS

A cross-sectional design was implemented through one-hour face-to-face assessment sessions. The modified fatigue impact scale, 12-item Short-Form Health Survey, Montreal Cognitive Assessment, Motor Assessment Log, Upper Extremity Fugl Meyer assessment, Nine Hole Peg Test, 10 Meter Walk Testing, active and passive goniometry, Hand-held dynamometry, and modified Ashworth scale were used as outcome measures. Prevalence of post-stroke fatigue and levels of quality of life were reported using descriptive analyses. Multiple variable linear regression analysis was used to identify PSF associated factors of post-stroke fatigue. P < 0.05 was considered significant for all statistical tests.

RESULTS

153 individuals with stroke participated in the study. A total of 117 participants (69.9%, 95% CI = 62.0-77.1%) were fatigued. Fatigue was significantly predicted by mental component of quality of life (β -0.42 [95% CI -0.53--0.31]; p < 0.001), cognition (β -0.69 [95% CI -1.08--0.29], p = 0.001), weekly sport hours (β -0.94 [95% CI -1.73--0.14], p = 0.022), and shoulder abduction spasticity (β -1.81 [95% CI -3.38--0.24], p = 0.024. The model explained 51% of the variation in the fatigue (F = 29.006, p < 0.001).

CONCLUSION

Jordanian individuals with stroke have a high prevalence of fatigue. Mental related quality of life was significantly associated with PSF levels. Other factors significantly associated with PSF included cognition status, sport participation, and spasticity. Healthcare practitioners working in neurorehabilitation should take PSF and its significant correlates into consideration when treating individuals with stroke.

Intensity of daily physical activity - a key component for improving physical capacity after minor stroke?

PURPOSE

Elucidating the complex interactions between physical activity (PA), a multidimensional concept, and physical capacity (PC) may reveal ways to improve rehabilitation interventions. This cross-sectional study aimed to explore which PA dimensions are related to PC in people after minor stroke.

MATERIALS AND METHODS

Community dwelling individuals >6 months after minor stroke were evaluated with a 10-Meter-Walking-Test (10MWT), Timed-Up & Go, and the Mini Balance Evaluation System Test. The following PA outcomes were measured with an Activ8 accelerometer: counts per minute during walking (CPM_walking; a measure of intensity), number of active bouts (frequency), mean length of active bouts (distribution), and percentage of waking hours in upright positions (duration). Multivariable linear regression models, adjusted for age, sex and BMI, were used to assess the relationships between PC and PA outcomes.

RESULTS

Sixty-nine participants [62.2 ± 9.8 years, 61% male, 20 months post onset (IQR 13.0-53.5)] were included in the analysis. CPM_walking was significantly associated to PC in the 10MWT (std. ß = 0.409, p = 0.002), whereas other associations between PA and PC were not significant.

CONCLUSIONS

The PA dimension intensity of walking is significantly associated with PC, and appears to be an important tool for future interventions in rehabilitation after minor stroke.Implications for rehabilitationIt is recommended to express physical activity after minor stroke in multiple dimensions such as intensity, frequency, duration and distribution.In particular, intensity of physical activity measured with accelerometer counts is most closely related to physical capacity.The findings of this study underline the importance of being physically active beyond a certain intensity.In future development of interventions and guidelines that aim to promote daily physical activity, intensity should be taken into account.

Task-Oriented Circuit Training for Mobility in Outpatient Stroke Rehabilitation in Germany and Austria: A Contextual Transferability Analysis

People with stroke cite mobility deficits as one of the most burdensome limitations. National and international stroke guidelines recommend physical therapy based on task-oriented practice, with high numbers of repetitions to improve mobility. In the outpatient setting in Germany and Austria, these principles have not yet been established. The purpose of this study was to identify an evidence-based intervention that could help reduce this research-practice gap. A stepwise approach proposed by Voigt-Radloff and colleagues and Cochrane Germany was used. First, the specific health service problem in the German and Austrian physical therapy outpatient context was identified. Second, a promising intervention was identified using a systematic search in the Cochrane Library and by grading the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation. Finally, the transferability of the promising intervention into the local context was evaluated using predefined questions from the Cochrane guide and reports from health insurances, professional organizations, and national stroke guidelines. Task-oriented circuit training reviewed by English and colleagues was chosen. The review showed clinically important improvements in walking distance and speed. The quality of the evidence was graded high for these 2 outcomes. We identified contextual challenges for implementation at the setting level (eg, insufficient reimbursement for group therapy by insurance companies), the participant and therapist level (eg, unknown motivation for group therapy due to the established 1:1 patient-therapist ratio), and the outcome measure level (eg, lack of standardized, cross-culturally translated manuals). Although task-oriented circuit training is scientifically well established, barriers to implementation into routine care in Germany and Austria can be expected. In a next step, research using knowledge translation methodology will focus on the detailed evaluation of barriers and facilitators with relevant stakeholders.

Modifiable Physical Factors Associated With Physical Functioning for Patients Receiving Dialysis: A Systematic Review

Background: Patients receiving dialysis have reduced physical function, which is associated with unfavorable clinical outcomes and decreased quality of life. The authors aimed to identify and explore modifiable physical factors associated with physical function for patients receiving dialysis. Methods: Searches were performed in MEDLINE, Embase, Ovid Emcare, and The Cochrane Library in October 2018. Etiological studies involving dialysis populations that report association or predictive statistics between a modifiable physical factor and physical function were eligible for inclusion. Predictor variables were (1) modifiable via exercise and (2) considered an impairment in the International Classification of Functioning, Disability and Health. Results: Of 5384 titles screened, 23 studies were included. Thirteen studies focused on physical activity levels and muscle strength and the relationship with physical function while 2 studies investigated sedentary behavior. Twenty-one studies focused on hemodialysis populations. Studies related to physical activity levels displayed a moderately strong relationship with physical function, whereas muscle strength displayed a predominantly weak to moderate relationship. Conclusions: Physical activity levels, sedentary behavior levels, and muscle strength are related to physical function status for patients receiving dialysis. There is a need for robust longitudinal data to confirm the results of this investigation and for more focus on populations receiving peritoneal dialysis.

Comparison between Erigo tilt-table exercise and conventional physiotherapy exercises in acute stroke patients: a randomized trial

Background

Stroke is a common, serious, and disabling health-care problem throughout the world. Although great advances have been made in acute stroke management, the most of post-stroke care to reduce a patient’s dependency relies on rehabilitation.

Purpose

To compare the effectiveness of exercises using an Erigo tilt-table and conventional physiotherapy in the rehabilitation of acute stroke patients.

Methods

A total of 110 acute stroke patients (age 51.08 ± 7.48 years, 8.69 ± 4.62 days after stroke) were assigned randomly into two groups, 55 in each for 30 days of conventional physiotherapy (Group A) or Erigo tilt-table (Group B) rehabilitation. The National Institutes of Health Stroke Scale (NIHSS), Mini-Mental Scale Examination (MMSE), Modified Ashworth Scale were used to measure muscle tone, quality of life (QOL) and muscle strength (MMT), Affected upper (UE) and lower limb (LE) outcomes were assessed at baseline (day 0), after day 30 of the intervention and on 90th day of follow up. Repeated measures ANOVA followed by a Bonferroni post-hoc test and independent Student’s t-test were used for statistical analysis to evaluate the improvement in outcome variables within and between the groups.

Results

Both the treatments were effective. Notably, Group B patients showed a significant improvement in both QOL (p < 0.001) and lower limb strength (p = 0.030) at day 90 and muscle tone (p = 0.011) at day 30 compared to Group A.

Conclusion

Both the groups improved with time but the Erigo tilt-table group experienced greater improvement in QOL, NIHSS and muscle strength of the lower limb. Thus, Erigo tilt-table can be used for early rehabilitation of acute hemiplegic patients and improving their quality of life and motor system, resulting in better functional performances.

Balance Training with Electromyogram-Triggered Functional Electrical Stimulation in the Rehabilitation of Stroke Patients

This study was conducted to investigate the effects of balance training with electromyogram-triggered functional electrical stimulation (EMG-triggered FES) to improve static balance, dynamic balance, and ankle muscle activation in stroke patients. Forty-nine participants (>6 months after stroke) were randomly assigned to the experimental group (n = 25) and the control group (n = 24). The experimental group underwent balance training with EMG-triggered FES for 40 min a day, 5 days a week, for a 6-week period in addition to general rehabilitation. The control group underwent balance training without EMG-triggered FES along with conventional therapy. Outcome measures included static balance ability, dynamic balance ability, and leg muscle activation. The static and dynamic balance abilities were significantly improved after intervention in both groups (p < 0.05), although the experimental group showed considerably greater improvement than the control group (p < 0.05). Leg muscle activation on the affected side resulted in significant improvements in the experimental group (p < 0.05) when compared with baseline but not in the control group. Balance training with EMG-triggered FES is an acceptable and effective intervention to improve the static balance, dynamic balance, and ankle muscle activation in stroke patients.

Effect of investigator observation on gait parameters in individuals with stroke

Improvements in gait speed following various training paradigms applied to patients post-stroke does not always lead to changes in walking performance, defined as gains in daily stepping activity. We hypothesized that testing conditions, specifically the presence of an observer, influences patient behaviors and resultant outcomes may overestimate their true walking capacity. This potential Hawthorne effect on spatiotemporal and biomechanical measures of locomotor function in individuals post-stroke has not been assessed previously. Fifteen ambulatory individuals with chronic stroke wore instrumented insoles and performed two separate normal-pace walking assessments, including unobserved conditions during which participants were unattended and unaware of data collection, and observed conditions with an investigator present. Gait analysis was conducted outside of a laboratory setting using instrumented insoles equipped with a 3D accelerometer and pressure sensors which captured the spatiotemporal kinematics, vertical ground reaction forces and foot acceleration. Data were compared using paired comparisons, with subsequent correlation and stepwise regression analyses to explore potential associations between Hawthorne-induced changes in walking strategies, gait speed and locomotor performance (daily stepping). Except for cadence, other measures of spatiotemporal parameters and swing kinematics (acceleration) were not significantly different between observed vs unobserved conditions. However, analyses of ground reaction forces revealed significantly greater paretic limb loading (Δ1^st peak = 1.5 ± 1.6 N/kg Δ2^nd peak = 1.4 ± 1.8 N/kg; p < 0.01) and increases in weight bearing symmetry (11-24%, p < 0.01) during observed vs unobserved conditions. This potential Hawthorne effect was greater in those with slower walking speeds and shorter stride lengths but was not related to daily stepping. The present findings suggest that biomechanical parameters of walking function may be related to the presence of an observer and highlight the need to separately measure locomotor capacity (gait speed) and performance (daily stepping).

Kinematic on Ankle and Knee Joint of Post-Stroke Elderly Patients by Wearing Newly Elastic Band-Type Ankle-Foot Orthosis in Gait

Purpose

The post-stroke elderly was increased caused by increasing stroke and advanced medical. However, ankle–foot orthoses (AFOs) can be uncomfortable for hemiplegic patients; therefore, the usability is not good. In this study, we analyzed ankle and knee joint angles in post-stroke elderly patients to assess the functional effectiveness (specifically prevention of back knee and drop-foot) of a new elastic band-type AFO (New Product: NP) during gait.

Patients and methods

Nine elderly post-stroke patients (eight males, one female; 55.7±8.4 years; 165.8±9.2 cm; 68.8±11.5 kg; five with right hemiplegia, four with left hemiplegia; onset period: 6.6 years) were selected for participation in this study. We captured gait motion using 12 cameras (MX-T20, Vicon, Inc., Oxford, UK) under three different conditions [wearing nothing (WI), using existing ordinary AFOs made from hard plastic material (EP), and using NP]. The angle variation and maximum–minimum angle of the lower body joints were analyzed during dorsi-plantar flexion of the ankle joint and flexion–extension of knee joint. A one-way ANOVA test for multiple comparisons was performed, followed by a Tukey’s b test to identify statistical significance, which was set at 0.005.

Results

Regarding the ankle joint, the maximum plantar flexion (drop-foot) value decreased with the NP, and the maximum dorsiflexion value increased. Regarding the knee joint, the maximum extension (back knee) value decreased, and the maximum flexion value increased (p < 0.005).

Conclusion

Using analysis of the kinematics of the ankles and knees during walking, this research confirmed the effectiveness of the NP, an elastic band-type AFO, for use in ordinary post-stroke elderly patients.

Randomized Controlled Trial of the Lateral Push-Off Skater Exercise for High-Intensity Interval Training vs Conventional Treadmill Training

OBJECTIVE

To examine the therapeutic effects of the lateral push-off skater exercise vs conventional treadmill training on health-related quality of life, cardiorespiratory fitness (CRF), and balance.

DESIGN

Single-blinded, randomized controlled trial.

SETTING

Outpatient clinic at a tertiary hospital.

PARTICIPANTS

Patients after minor stroke (N=36) with National Institutes of Health Stroke Scale scores≤3 between 20 and 65 years of age were randomly assigned to the intervention group (n=18) or the control group (n=18).

INTERVENTIONS

Thirty-minute sessions of the skater exercise were performed 3 times weekly for 12 weeks in the intervention group. Conventional treadmill aerobic exercise was conducted in the control group at the same frequency and duration as the experimental group exercise.

MAIN OUTCOME MEASURES

The primary outcome was measured using the European Quality of Life-5 Dimension (EQ-5D). Secondary outcomes included CRF and balance indicators. Assessments were performed at baseline (T0), 12 weeks from T0 (T1), and 16 weeks from T0 (T2).

RESULTS

Significant improvements in EQ-5D, peak oxygen uptake (VO₂peak), peak oxygen pulse, peak minute ventilation (VE), Dynamic Gait Index (DGI), and Berg Balance Scale (BBS) were found in the intervention group after performing the skater exercise (P<.05, all), and these improvements were sustained at T2 (P<.05, all). Between-group comparisons demonstrated greater improvements in EQ-5D, VO₂peak, peak oxygen pulse, peak VE, DGI, and BBS in the intervention group than those in the control group at both T1 (P<.05, all) and T2 (P<0.05, all). Correlation analysis showed significant relationships between EQ-5D and VO₂peak, peak VE, DGI, and BBS (P<.05, all).

CONCLUSIONS

The skater exercise improved health-related quality of life, CRF, and balance in patients after minor stroke more effectively than conventional treadmill-based aerobic exercise. We recommend the skater exercise as a high-intensity interval training program for patients after minor stroke.

Voluntary control of wearable robotic exoskeletons by patients with paresis via neuromechanical modeling

BACKGROUND

Research efforts in neurorehabilitation technologies have been directed towards creating robotic exoskeletons to restore motor function in impaired individuals. However, despite advances in mechatronics and bioelectrical signal processing, current robotic exoskeletons have had only modest clinical impact. A major limitation is the inability to enable exoskeleton voluntary control in neurologically impaired individuals. This hinders the possibility of optimally inducing the activity-driven neuroplastic changes that are required for recovery.

METHODS

We have developed a patient-specific computational model of the human musculoskeletal system controlled via neural surrogates, i.e., electromyography-derived neural activations to muscles. The electromyography-driven musculoskeletal model was synthesized into a human-machine interface (HMI) that enabled poststroke and incomplete spinal cord injury patients to voluntarily control multiple joints in a multifunctional robotic exoskeleton in real time.

RESULTS

We demonstrated patients' control accuracy across a wide range of lower-extremity motor tasks. Remarkably, an increased level of exoskeleton assistance always resulted in a reduction in both amplitude and variability in muscle activations as well as in the mechanical moments required to perform a motor task. Since small discrepancies in onset time between human limb movement and that of the parallel exoskeleton would potentially increase human neuromuscular effort, these results demonstrate that the developed HMI precisely synchronizes the device actuation with residual voluntary muscle contraction capacity in neurologically impaired patients.

CONCLUSIONS

Continuous voluntary control of robotic exoskeletons (i.e. event-free and task-independent) has never been demonstrated before in populations with paretic and spastic-like muscle activity, such as those investigated in this study. Our proposed methodology may open new avenues for harnessing residual neuromuscular function in neurologically impaired individuals via symbiotic wearable robots.

People With Aneurysmal Subarachnoid Hemorrhage Have Low Physical Fitness and Can Be Predisposed to Inactive and Sedentary Lifestyles

BACKGROUND

Physical inactivity, sedentary lifestyles, and low functional outcome are thought to impact the level of physical fitness in patients with aneurysmal subarachnoid hemorrhage (a-SAH). However, changes in fitness over time and associated factors have not been studied in a-SAH.

OBJECTIVE

The objective was to evaluate the level of physical fitness in the first year after a-SAH and explore longitudinal relations with physical activity, sedentary behavior, and functional outcome. Additionally, we evaluated whether physical fitness could be predicted by disease-related characteristics (ie, severity of a-SAH, location of the aneurysm, treatment procedure, pituitary dysfunction, and complications).

DESIGN

This was a prospective 1-year follow-up study.

METHODS

Fifty-two participants performed exercise testing at 6 and 12 months after a-SAH. Cardiopulmonary exercise testing and isokinetic dynamometry were applied to determine the peak oxygen uptake $({\rm{\dot{V}}}{{\rm{o}}_{2{\rm{peak}}}})$ and the peak torque of the knee extensors (PText) and flexors (PTflex). In addition, physical activity and sedentary behavior were evaluated by accelerometer-based activity monitoring. The functional outcome was assessed by the Functional Independence Measure and Functional Assessment Measure. Disease-related characteristics were collected at hospital intake.

RESULTS

At both 6 and 12 months, all fitness parameters were lower compared with predicted values (ranging from 18% to 28%). Physical activity is related to both ${\rm{\dot{V}}}{{\rm{o}}_{{\rm{2peak}}}}$ and PTflex. The Functional Independence Measure and Functional Assessment Measure scores was related to PText and PTflex. Further, participants who underwent surgical clipping had lower ${\rm{\dot{V}}}{{\rm{o}}_{{\rm{2peak}}}}$ and PTflex.

LIMITATIONS

Longitudinal observations cannot confirm causality.

CONCLUSIONS

Levels of physical fitness remain low over the first year after a-SAH. Participants who were physically more active had higher levels of physical fitness, whereas participants with impaired functional outcome or who were treated with surgical clipping were at risk of low physical fitness. Exercise interventions are warranted and should focus on the promotion of physical activity and target patients with impaired functional outcome or those who have been treated with surgical clipping.

Effect of Balance Training After Hip Fracture Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies

Background

Although balance impairment after hip fracture surgery (HFS) can constitute a long-term problem of limiting mobility and increasing the risk of falls in older adults, little is known about the effect of balance training (BT) on physical functioning after HFS. Thus, we performed a meta-analysis to evaluate whether BT improved the overall physical functioning of patients after HFS.

Methods

We searched the PubMed-Medline, Embase, and Cochrane Library databases in January 2018 and included all randomized controlled trials comparing BT with usual care after HFS. We performed a pairwise meta-analysis using fixed- and random-effects models.

Results

Eight randomized controlled trials including a total of 752 participants were retrieved. The BT group showed significantly improved overall physical functioning after HFS compared with the usual care group (overall standardized mean difference [SMD] = 0.390; 95% confidence interval [CI] = 0.114–0.667; p = .006). Both, balance and gait improved (SMD = 0.570; 95% CI = 0.149–0.992; p = .008 and SMD = 0.195; 95% CI = 0.043–0.347; p = .012, respectively) in the BT group. Lower limb strength, performance task, activity of daily living, and health-related quality of life also improved significantly in the BT group.

Conclusion

Our meta-analysis revealed that BT after HFS improved overall physical functioning. Positive effects on balance, gait, lower limb strength, performance task, activity of daily living, and health-related quality of life were evident. Therefore, BT should be specifically included in postoperative rehabilitation programs and balance must be thoroughly checked in elderly patients with hip fractures.

Gait Impairments in Patients Without Lower Limb Hypertonia Early Poststroke Are Related to Weakness of Paretic Knee Flexors

OBJECTIVE

To describe gait characteristics of patients without clinical evidence of lower limb hypertonia within 2 months of stroke and explore the relationship between gait and residual motor function.

DESIGN

Cohort study.

SETTING

Motion analysis laboratory in a tertiary-care free-standing rehabilitation hospital.

PARTICIPANTS

Consecutive sample of 73 eligible inpatients (first-known stroke <2 months postonset, walking independently, modified Ashworth score of 0 in the paretic lower limb) and 27 healthy controls (N=100).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Gait speed, stride and step lengths and cadences, stance time, single-support and double-support times, and associated symmetry measures in patients at self-selected normal speed and controls at very slow speed (51.1±32.6 cm/s and 61.9±21.8 cm/s, respectively, P=.115); Fugl-Meyer lower extremity motor score (FM-LE) and isometric knee flexion and extension strength in patients.

RESULTS

Except the stride/step cadence, all temporospatial parameters significantly differed between the stroke and control participants. Furthermore, significantly greater asymmetries were found in the patients for the overall stance time, initial double-support and single-support times, and step cadence, reflecting smaller values in the paretic than nonparetic limb. Most temporospatial parameters moderately to strongly correlated with the gait speed (|r|: .72-.94, P<.0001), FM-LE (|r|: .42-.62, P≤.0005), and paretic knee flexor strength (|r|: .47-.57, P≤.0004).

CONCLUSIONS

Gait of patients without clinical evidence of lower limb hypertonia within 2 months of stroke is characterized by many temporospatial deviations and asymmetries. The self-selected normal gait speed, FM-LE, and paretic knee flexor strength can discriminate gait impairments in these patients shortly before inpatient discharge. It remains to be determined whether the observed relationships between paretic knee flexor strength and gait measures warrant the development of interventions for strengthening of the paretic knee flexors in order to improve gait early poststroke.

The Efficacy of Lower Extremity Mirror Therapy for Improving Balance, Gait, and Motor Function Poststroke: A Systematic Review and Meta-Analysis

BACKGROUND

Mirror therapy is less commonly used to target the lower extremity after stroke to improve outcomes but is simple to perform. This review and meta-analysis aimed to evaluate the efficacy of lower extremity mirror therapy in improving balance, gait, and motor function for individuals with stroke.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database, and PsychINFO were searched from inception to May 2018 for randomized controlled trials (RCTs) comparing lower extremity mirror therapy to a control intervention for people with stroke. Pooled effects were determined by separate meta-analyses of gait speed, mobility, balance, and motor recovery.

RESULTS

Seventeen RCTs involving 633 participants were included. Thirteen studies reported a significant between-group difference favoring mirror therapy in at least one lower extremity outcome. In a meta-analysis of 6 trials that reported change in gait speed, a large beneficial effect was observed following mirror therapy training (standardized mean differences [SMD] = 1.04 [95% confidence interval [CI] = .43, 1.66], I² = 73%, and P < .001). Lower extremity mirror therapy also had a positive effect on mobility (5 studies, SMD = .46 [95% CI = .01, .90], I² = 43%, and P = .05) and motor recovery (7 studies, SMD = .47 [95% CI = .21, .74], I² = 0%, and P < .001). A significant pooled effect was not found for balance capacity.

CONCLUSIONS

Mirror therapy for the lower extremity has a large effect for gait speed improvement. This review also found a small positive effect of mirror therapy for mobility and lower extremity motor recovery after stroke.