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

Factors Influencing the Use of Mobile Applications for Driving Rehabilitation After Stroke: Exploring the Perspectives of Occupational Therapists

This study describes factors influencing occupational therapists' implementation of mobile applications into driving rehabilitation post-stroke. A qualitative descriptive design was used to analyze interview data from twenty (n = 20) occupational therapists working in stroke rehabilitation. Key factors include awareness of emerging applications, workplace technology policies, patient impairment levels and technological proficiency, and the involvement of caregivers in patient training. The ability to observe cognitive-perceptual abilities when utilizing mobile applications provided key insights into patient progress. Further investigation is necessary to explore methods for remotely monitoring outcomes in driving rehabilitation.

Understanding and enhancing post-stroke recovery: Insights from a nested qualitative study within the MindFit Project randomized clinical trial

BACKGROUND

Stroke survivors experience a wide range of physical, cognitive, and emotional challenges. In the MindFit Project, a randomized clinical trial, 141 chronic stroke patients were divided into three groups: mindfulness-based stress reduction (MBSR) with computerized cognitive training (CCT), physical exercise (PE) with CCT, and CCT alone. The interventions were conducted remotely over 12 weeks, including online group and individual sessions.

OBJECTIVE

This exploratory nested qualitative study aimed to investigate chronic stroke survivors' experiences, opinions, and perceived changes due to the interventions within the MindFit Project. The secondary objective was to describe the broader experience of their recovery journey.

METHODS

Twenty-seven participants were recruited through purposive sampling and engaged in semi-structured one-on-one interviews. Twelve received MBSR+CCT, nine received PE+CCT, and six received CCT-only. The interviews were recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Participants shared insights into their lives after stroke, including emotional and physical challenges, coping mechanisms, and the impact of societal perceptions. The interventions were generally positively valued, with MBSR aiding in emotional regulation, PE enhancing physical capabilities, and CCT improving cognition. The group setting provided valuable peer support and motivation, although some participants noted challenges owing to the heterogeneity. The telematic format was also appreciated for its accessibility, although it posed challenges to personal interaction and intervention supervision.

CONCLUSIONS

Our study emphasizes the complexity of stroke recovery and the importance of holistic, patient-centered rehabilitation approaches. It also highlights the value of combining physical and non-physical interventions in a group setting, along with the potential of remote platforms to enhance the accessibility of rehabilitation programs. These findings generate hypotheses for future randomized clinical trials aimed at improving post-stroke recovery.

Healthcare professionals' knowledge and perceptions of post-stroke rehabilitation in the peripandemic period: an online cross-sectional survey

The COVID-19 pandemic has profoundly affected healthcare systems, particularly post-stroke rehabilitation centers. The elevated severity of strokes and delayed hospital admissions caused numerous hurdles to rehabilitation administration during the peri-pandemic period. This study surveyed healthcare professionals' knowledge and perceptions of post-stroke rehabilitation during this period. An online cross-sectional survey was administered from September 17, 2023 to February 23, 2024, utilizing the SurveyMonkey platform. The questionnaire included 30 questions addressing participant baseline characteristics, knowledge of definitions and experiences, post-stroke rehabilitation procedures, obstacles encountered during the peri-pandemic period, and the utilization of telerehabilitation. Only complete responses from health professionals were considered. This report utilized convenience sampling. Data were analyzed via descriptive statistics and chi-square tests, with a significance threshold of p < 0.05. A total of 79 health professionals, predominantly physiatrists, neurologists, and physiotherapists, from eight countries participated in the study. Over half of the participants (64.6%) indicated the existence of a dedicated department for post-stroke rehabilitation. Significant obstacles comprised an absence of advanced rehabilitative treatments (60.8%), inadequately skilled workers (50.6%), and restricted space for rehabilitation (46.8%). Telerehabilitation was regarded as a feasible option by 45.6% of participants; nonetheless, obstacles, including patients' telecommunication proficiency and the possibility of diagnostic inaccuracies, were acknowledged. Complementary therapies, such as music and dance therapy, received favorable evaluations from 67.1% to 63.3% of respondents, respectively. The pandemic reduced rehabilitation admissions due to infection concerns (75.9%) and increased multimorbidity cases among patients (48.1%). The study underscores the pandemic's negative effect on post-stroke rehabilitation, emphasizing the necessity for multidisciplinary, customized therapy and enhanced integration of telerehabilitation to overcome access barriers. Addressing obstacles regarding infrastructure, training, and access to advanced approaches, particularly in a post-pandemic context, is essential to improving rehabilitation outcomes.

Exploring stroke survivors' and physiotherapists' perspectives of the potential for markerless motion capture technology in community rehabilitation

INTRODUCTION

Many stroke survivors do not receive optimal levels of personalised therapy to support their recovery. Use of technology for stroke rehabilitation has increased in recent years to help minimise gaps in service provision. Markerless motion capture technology is currently being used for musculoskeletal and occupational health screening and could offer a means to provide personalised guidance to stroke survivors struggling to access rehabilitation.

AIMS

This study considered context, stakeholders, and key uncertainties surrounding the use of markerless motion capture technology in community stroke rehabilitation from the perspectives of stroke survivors and physiotherapists with a view to adapting an existing intervention in a new context.

METHODS

Three focus groups were conducted with eight stroke survivors and five therapists. Data were analysed using reflexive thematic analysis.

RESULTS

Five themes were identified: limited access to community care; personal motivation; pandemic changed rehabilitation practice; perceptions of technology; and role of markerless technology for providing feedback.

CONCLUSIONS

Participants identified problems associated with the access of community stroke rehabilitation, exacerbated by Covid-19 restrictions. Participants were positive about the potential for the use of markerless motion capture technology to support personalised, effective stroke rehabilitation in the future, providing it is developed to meet stroke survivor specific needs.

Impact of the COVID-19 Pandemic on Acute Stroke Rehabilitation in Japanese Primary Stroke Centers: A Nationwide Cross-Sectional Study Using a Web-Based Questionnaire Survey

INTRODUCTION

Acute stroke rehabilitation is crucial for achieving good functional recovery, even during the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to clarify the impact of the COVID-19 pandemic on acute stroke rehabilitation and identify which components in the acute stroke rehabilitation provision system were susceptible to the pandemic.

METHODS

A web-based questionnaire survey was conducted in all primary stroke centers (PSCs) in Japan between February 7 and April 21, 2022. The survey included questions about the current status of acute stroke rehabilitation and the influence of the pandemic. We classified the influences and investigated the relationship between the influence of the pandemic and the provision of rehabilitation. Additionally, we investigated a group of prefectures divided according to the grade of the pandemic.

RESULTS

The survey response rate was 67% (639 of 959 PSCs). Among them, 387 PSCs (61%) reported that the COVID-19 pandemic affected acute stroke rehabilitation. In PSCs affected by the pandemic, more rehabilitation-related staff were working, and the proportion of weekend/holiday rehabilitation implementation was higher compared to those unaffected. In PSCs from highly infected prefectures, no significant relationship was observed between the influence of the pandemic and the rehabilitation provision system.

CONCLUSIONS

PSCs that provide denser acute stroke rehabilitation may be affected to a greater extent by the pandemic. We conclude that stroke hospitals should formulate infection control procedures for acute stroke rehabilitation in advance, depending on the conditions of the region and facility.

Improving post-acute stroke follow-up care by adopting telecare consultations in a nurse-led clinic: Study protocol of a hybrid implementation-effectiveness trial

AIM

To evaluate the clinical effectiveness and implementation strategies of telecare consultations in post-stroke nurse-led clinics.

BACKGROUND

Telecare consultations could be an alternative to conventional in-person consultations and improve continuity of care for stroke survivors following their discharge from hospital. Previous studies utilizing telecare consultations only focused on testing their clinical effectiveness on stroke survivors; the appropriateness and feasibility of adopting this new delivery modality in a real-world setting were not examined.

DESIGN

A Type II hybrid effectiveness-implementation design will be adopted.

METHODS

Eligible stroke survivor participants will be randomly assigned to the intervention group (telecare consultation) or control group (usual in-person clinic consultation). Both groups will receive the same nursing intervention but delivered through different channels. The Reach, Effectiveness, Adoption, Implementation, Maintenance framework will be used to evaluate the clinical effectiveness and implementation outcomes. The primary outcome is the non-inferiority of the degree of disability between the two groups at 3 months into the intervention and at 3 months post-intervention. The paper complies with the SPIRIT guidelines for study protocols adapted for designing and reporting parallel group randomized trials.

CONCLUSION

The findings of this study will provide key insights into the processes for implementing and adopting telecare consultations into long-term services for post-stroke patients.

IMPACT

This study contributes to the translation of telecare consultations for stroke survivors into real-life settings. If effective, this program may provide guidance for expanding telecare consultations to other post-stroke nurse-led clinics or to patients with other chronic diseases.

TRIAL REGISTRATION

This study has been registered at clinicaltrials.gov (identifier: NCT05183672). Registered on 10 January 2022.

An Interpretable Approach with Explainable AI for Heart Stroke Prediction

Heart strokes are a significant global health concern, profoundly affecting the wellbeing of the population. Many research endeavors have focused on developing predictive models for heart strokes using ML and DL techniques. Nevertheless, prior studies have often failed to bridge the gap between complex ML models and their interpretability in clinical contexts, leaving healthcare professionals hesitant to embrace them for critical decision-making. This research introduces a meticulously designed, effective, and easily interpretable approach for heart stroke prediction, empowered by explainable AI techniques. Our contributions include a meticulously designed model, incorporating pivotal techniques such as resampling, data leakage prevention, feature selection, and emphasizing the model's comprehensibility for healthcare practitioners. This multifaceted approach holds the potential to significantly impact the field of healthcare by offering a reliable and understandable tool for heart stroke prediction. In our research, we harnessed the potential of the Stroke Prediction Dataset, a valuable resource containing 11 distinct attributes. Applying these techniques, including model interpretability measures such as permutation importance and explainability methods like LIME, has achieved impressive results. While permutation importance provides insights into feature importance globally, LIME complements this by offering local and instance-specific explanations. Together, they contribute to a comprehensive understanding of the Artificial Neural Network (ANN) model. The combination of these techniques not only aids in understanding the features that drive overall model performance but also helps in interpreting and validating individual predictions. The ANN model has achieved an outstanding accuracy rate of 95%.

Variability in the Transition of Care to Poststroke Rehabilitation During the First Wave of COVID-19

OBJECTIVE

The aim of the study is to evaluate transitions of acute stroke and inpatient rehabilitation facility care during the first wave of COVID-19.

DESIGN

This is a retrospective observational study (3 comprehensive stroke centers with hospital-based inpatient rehabilitation facilities) between January 1, 2019, and May 31, 2019 (acute stroke = 584, inpatient rehabilitation facility = 210) and January 1, 2020, and May 31, 2020 (acute stroke = 534, inpatient rehabilitation facility = 186). Acute stroke characteristics included stroke type, demographics, and medical comorbidities. The proportion of patients admitted for acute stroke and inpatient rehabilitation facility care was analyzed graphically and using t test assuming unequal variances.

RESULTS

The proportion of intracerebral hemorrhage patients (28.5% vs. 20.5%, P = 0.035) and those with history of transient ischemic attack (29% vs. 23.9%; P = 0.049) increased during the COVID-19 first wave in 2020. Uninsured acute stroke admissions decreased (7.3% vs. 16.6%) while commercially insured increased (42.7% vs. 33.4%, P < 0.001).Acute stroke admissions decreased from 116.5 per month in 2019 to 98.8 per month in 2020 ( P = 0.008) with no significant difference in inpatient rehabilitation facility admissions (39 per month in 2019, 34.5 per month in 2020; P = 0.66).In 2019, monthly changes in acute stroke admissions coincided with inpatient rehabilitation facility admissions.In 2020, acute stroke admissions decreased 80.6% from January to February, while inpatient rehabilitation facility admissions remained stable. Acute stroke admissions increased 12.8% in March 2020 and remained stable in April, while inpatient rehabilitation facility admissions decreased by 92%.

CONCLUSIONS

Acute stroke hospitalizations significantly decreased per month during the first wave of COVID-19, with a delayed effect on the transition from acute stroke to inpatient rehabilitation facility care.

Current trends and future perspectives of stroke management through integrating health care team and nanodrug delivery strategy

Stroke is accounted as the second-most mortality and adult disability factor in worldwide, while causes the bleeding promptly and lifetime consequences. The employed functional recovery after stroke is highly variable, allowing to deliver proper interventions to the right stroke patient at a specific time. Accordingly, the multidisciplinary nursing team, and the administrated drugs are major key-building-blocks to enhance stroke treatment efficiency. Regarding the healthcare team, adequate continuum of care have been declared as an integral part of the treatment process from the pre-hospital, in-hospital, to acute post-discharge phases. As a curative perspective, drugs administration is also vital in surviving at the early step and reducing the probability of disabilities in later. In this regard, nanotechnology-based medicinal strategy is exorbitantly burgeoning. In this review, we have highlighted the effectiveness of current clinical care considered by nursing teams to treat stroke. Also, the advancement of drugs through synthesis of miniaturized nanodrug formations relating stroke treatment is remarked. Finally, the remained challenges toward standardizing the healthcare team and minimizing the nanodrugs downsides are discussed. The findings ensure that future works on normalizing the healthcare nursing teams integrated with artificial intelligence technology, as well as advancing the operative nanodrugs can provide value-based stroke cares.

The Lives Lost to Inequities: Avertable Deaths From Neurologic Diseases in the Past Decade

BACKGROUND AND OBJECTIVES

Mortality rates for neurologic diseases are increasing in the United States, with large disparities across geographical areas and populations. Racial and ethnic populations, notably the non-Hispanic (NH) Black population, experience higher mortality rates for many causes of death, but the magnitude of the disparities for neurologic diseases is unclear. The objectives of this study were to calculate mortality rates for neurologic diseases by race and ethnicity and-to place this disparity in perspective-to estimate how many US deaths would have been averted in the past decade if the NH Black population experienced the same mortality rates as other groups.

METHODS

Mortality rates for deaths attributed to neurologic diseases, as defined by the International Classification of Diseases, were calculated for 2010 to 2019 using death and population data obtained from the Centers for Disease Control and Prevention and the US Census Bureau. Avertable deaths were calculated by indirect standardization: For each calendar year of the decade, age-specific death rates of NH White persons in 10 age groups were multiplied by the NH Black population in each age group. A secondary analysis used Hispanic and NH Asian populations as the reference groups.

RESULTS

In 2013, overall age-adjusted mortality rates for neurologic diseases began increasing, with the NH Black population experiencing higher rates than NH White, NH American Indian and Alaska Native, Hispanic, and NH Asian populations (in decreasing order). Other populations with higher mortality rates for neurologic diseases included older adults, the male population, and adults older than 25 years without a high school diploma. The gap in mortality rates for neurologic diseases between the NH Black and NH White populations widened from 4.2 individuals per 100,000 in 2011 to 7.0 per 100,000 in 2019. Over 2010 to 2019, had the NH Black population experienced the neurologic mortality rates of NH White, Hispanic, or NH Asian populations, 29,986, 88,407, or 117,519 deaths, respectively, would have been averted.

DISCUSSION

Death rates for neurologic diseases are increasing. Disproportionately higher neurologic mortality rates in the NH Black population are responsible for a large number of excess deaths, making research and policy efforts to address the systemic causes increasingly urgent.

Protocol for a remote home-based upper extremity self-training program for community-dwelling individuals after stroke

Background

Half of all stroke survivors experience hemiparesis on the contralateral side, resulting in chronic upper extremity (UE) impairment. Remote rehabilitation is a promising approach to optimize the gains made in the clinic to maximize function and promote UE use at home. This paper describes the study protocol for a remote home-based UE self-training program.

Design

This was a feasibility study that used a convergent mixed methods approach.

Methods

We collected data on 15 community-dwelling individuals with UE hemiparesis after stroke. The study used motivational interviewing (MI) and ecological momentary assessments (EMA) to maximize engagement in a 4-week personalized UE self-training program. The study consisted of three phases: 1) training in MI for the interventionists 2) creating customized treatment plans using shared decision making, and 3) four weeks of UE self-training.

Measures and analysis

To evaluate feasibility, we will summarize recruitment and retention rates, intervention delivery, acceptance, adherence, and safety. Quantitative UE outcomes will measure change in UE status after the intervention (Fugl-Meyer Assessment, Motor Activity Log, Canadian Occupational Performance Measure, and bilateral magnitude ratio). Qualitative data (1:1 semi-structured interviews) will capture participants' perceptions and experience with the intervention. Quantitative and qualitative data will be integrated to gain a deeper understanding of the facilitators and barriers for engagement and adherence to UE self-training.

Conclusion

The results of this study will advance the scientific knowledge for use of MI and EMA as methods for enhancing adherence and engagement in UE self-training in stroke rehabilitation. The ultimate impact of this research will be to improve UE recovery for individuals with stroke transitioning back into community.

Clinical trials registration

NCT05032638.

Cerebro-/Cardiovascular Collateral Damage During the COVID-19 Pandemic: Fact or Fiction?

Numerous observational studies have identified a decline in cerebro-/cardiovascular (CV) admissions during the initial phase of the COVID-19 pandemic. Recent studies and meta-analyses indicated that the overall decrease was smaller than that found in initial studies during the first months of 2020. Two years later we still do not have clear evidence about the potential causes and impacts of the reduction of CV hospitalizations during the COVID-19 pandemic. It has becoming increasingly evident that collateral damage (i.e., incidental damage to the public and patients) from the COVID-19 outbreak is the main underlying cause that at least somewhat reflects the effects of imposed measures such as social distancing and self-isolation. However, a smaller true decline in CV events in the community due to a lack of triggers associated with such acute syndromes cannot be excluded. There is currently indirect epidemiological evidence about the immediate impact that the collateral damage had on excess mortality, but possible late consequences including a rebound increase in CV events are yet to be observed. In the present narrative review, we present the reporting milestones in the literature of the rates of CV admissions and collateral damage during the last 2 years, and discuss all possible factors contributing to the decline in CV hospitalizations during the COVID-19 pandemic. Healthcare systems need to be prepared so that they can cope with the increased hospitalization rates for CV events in the near future.

Quality in stroke care during the early phases of the COVID-19 pandemic: A nationwide study

Introduction:

Evidence-based early stroke care as reflected by fulfillment of process performance measures, is strongly related to better patient outcomes after stroke and transient ischemic attack (TIA). Detailed data on the resilience of stroke care services during the COVID-19 pandemic are limited. We aimed to examine the quality of early stroke care at Danish hospitals during the early phases of the COVID-19 pandemic.

Materials and methods:

We extracted data from Danish national health registries in five time periods (11 March, 2020–27 January, 2021) and compared these to a baseline pre-pandemic period (13 March, 2019–10 March, 2020). Quality of early stroke care was assessed as fulfilment of individual process performance measures and as a composite measure (opportunity-based score).

Results:

A total of 23,054 patients were admitted with stroke and 8153 with a TIA diagnosis in the entire period. On a national level, the opportunity-based score (95% confidence interval [CI]) at baseline for ischemic patients was 81.1% (80.8–81.4), for intracerebral hemorrhage (ICH) 85.5% (84.3–86.6), and for TIA 96.0% (95.3–96.1). An increase of 1.1% (0.1–2.2) and 1.5% (0.3–2.7) in the opportunity-based score was observed during the first national lockdown period for AIS and TIA followed by a decline of −1.3% (−2.2 to −0.4) in the gradual reopening phase for AIS indicators. We found a significant negative association between regional incidence rates and quality-of-care in ischemic stroke patients implying that quality decreases when admission rates increase.

Conclusion:

The quality of acute stroke/TIA care in Denmark remained high during the early phases of the pandemic and only minor fluctuations occurred.

A case report: Upper limb recovery from stroke related to SARS-CoV-2 infection during an intervention with a brain-computer interface

COVID-19 may increase the risk of acute ischemic stroke that can cause a loss of upper limb function, even in patients with low risk factors. However, only individual cases have been reported assessing different degrees of hospitalization outcomes. Therefore, outpatient recovery profiles during rehabilitation interventions are needed to better understand neuroplasticity mechanisms required for upper limb motor recovery. Here, we report the progression of physiological and clinical outcomes during upper limb rehabilitation of a 41-year-old patient, without any stroke risk factors, which presented a stroke on the same day as being diagnosed with COVID-19. The patient, who presented hemiparesis with incomplete motor recovery after conventional treatment, participated in a clinical trial consisting of an experimental brain-computer interface (BCI) therapy focused on upper limb rehabilitation during the chronic stage of stroke. Clinical and physiological features were measured throughout the intervention, including the Fugl-Meyer Assessment for the Upper Extremity (FMA-UE), Action Research Arm Test (ARAT), the Modified Ashworth Scale (MAS), corticospinal excitability using transcranial magnetic stimulation, cortical activity with electroencephalography, and upper limb strength. After the intervention, the patient gained 8 points and 24 points of FMA-UE and ARAT, respectively, along with a reduction of one point of MAS. In addition, grip and pinch strength doubled. Corticospinal excitability of the affected hemisphere increased while it decreased in the unaffected hemisphere. Moreover, cortical activity became more pronounced in the affected hemisphere during movement intention of the paralyzed hand. Recovery was higher compared to that reported in other BCI interventions in stroke and was due to a reengagement of the primary motor cortex of the affected hemisphere during hand motor control. This suggests that patients with stroke related to COVID-19 may benefit from a BCI intervention and highlights the possibility of a significant recovery in these patients, even in the chronic stage of stroke.