Associations between executive function and physical function poststroke: a pilot study

Association between the executive dysfunction and balance function in patients with stroke

INTRODUCTION

A previous study has shown an association between executive dysfunction (ED) and balance function in patients with stroke. However, it is unclear what factors mediate the association between ED and balance function. Therefore, the aim of this study was to investigate the association between ED and balance function and to identify mediating factors using mediation analysis.

METHODS

This study had a cross-sectional design. The study included 107 patients with stroke. This study was divided into two groups (ED and non-ED) using trail making test (TMT) part B. Two groups were compared for balance function (timed up and go test [TUGT] and Berg balance scale [BBS]) and other variables using paired test. In addition, partial correlation analysis with age, cognitive function as a control factor, and mediation analysis were also performed.

RESULTS

The ED group (N = 55) had significantly lower TUGT and BBS scores than the non-ED group (N = 52). TMT part B correlated with TUGT (ρ = 0.41), BBS (ρ = -0.33), and Brunnstrom recovery stage (BRS) lower limb (ρ = -0.22). The TUGT model of mediation analysis showed a significant indirect effect as a result of mediation of the BRS lower limb between TMT part B and TUGT. The BBS model showed a significant indirect effect as a result of mediation of the activities of daily living (ADL) motor function between TMT part B and BBS.

CONCLUSIONS

ED and balance function were associated, and the degree of paralysis and ADL motor function were associated with them in patients with stroke.

Intervention and assessment of executive dysfunction in patients with stroke: A scoping review

Rehabilitation methods for executive dysfunction were focused on cognitive rehabilitation in patients with stroke and traumatic brain injury. However, no reviews have focused on the various rehabilitation methods and assessment of executive function in patients with only stroke and included various study designs. This study aimed to identify various interventions and assessments in patients with stroke and executive dysfunction via a scoping review. We searched for articles using the PubMed, Web of Science, and CINAHL databases. Two reviewers independently screened the articles based on the inclusion and exclusion criteria using the title, abstract, and full text. We subsequently determined the study design, sample size, time since stroke, intervention, and assessment. We extracted 1131 articles, of which 27 articles were selected. The study designs were randomized controlled trials (81.5%), pilot studies (11.1%), and feasibility studies (7.4%), with a total of 599 participants. Interventions varied from cognitive training (22.2%), virtual reality (22.2%), noninvasive brain stimulation (14.8%), and dual-task training (11.1%), with consistent results. The assessments used were the Trail Making Test Part B (70.4%), Stroop Color and Word Test (44.4%), Digit Symbol Test, Frontal Assessment Battery, and Tower of London test (11.1%). In conclusion, this scoping review provided various interventions and assessments in patients with stroke with executive dysfunction.

Processing Speed and Attentional Shift/Mental Flexibility in Patients with Stroke: A Comprehensive Review on the Trail Making Test in Stroke Studies

The Trail Making Test (TMT) is one of the most commonly administered tests in clinical and research neuropsychological settings. The two parts of the test (part A (TMT-A) and part B (TMT-B)) enable the evaluation of visuoperceptual tracking and processing speed (TMT-A), as well as divided attention, set-shifting and cognitive flexibility (TMT-B). The main cognitive processes that are assessed using TMT, i.e., processing speed, divided attention, and cognitive flexibility, are often affected in patients with stroke. Considering the wide use of TMT in research and clinical settings since its introduction in neuropsychological practice, the purpose of our review was to provide a comprehensive overview of the use of TMT in stroke patients. We present the most representative studies assessing processing speed and attentional shift/mental flexibility in stroke settings using TMT and applying scoring methods relying on conventional TMT scores (e.g., time-to-complete part A and part B), as well as derived measures (e.g., TMT-(B-A) difference score, TMT-(B/A) ratio score, errors in part A and part B). We summarize the cognitive processes commonly associated with TMT performance in stroke patients (e.g., executive functions), lesion characteristics and neuroanatomical underpinning of TMT performance post-stroke, the association between TMT performance and patients' instrumental activities of daily living, motor difficulties, speech difficulties, and mood statue, as well as their driving ability. We also highlight how TMT can serve as an objective marker of post-stroke cognitive recovery following the implementation of interventions. Our comprehensive review underscores that the TMT stands as an invaluable asset in the stroke assessment toolkit, contributing nuanced insights into diverse cognitive, functional, and emotional dimensions. As research progresses, continued exploration of the TMT potential across these domains is encouraged, fostering a deeper comprehension of post-stroke dynamics and enhancing patient-centered care across hospitals, rehabilitation centers, research institutions, and community health settings. Its integration into both research and clinical practice reaffirms TMT status as an indispensable instrument in stroke-related evaluations, enabling holistic insights that extend beyond traditional neurological assessments.

Estimation Error Consisting of Motor Imagery and Motor Execution in Patients with Stroke

Previous studies demonstrate that the difference between motor imagery and actual tasks (estimation error) is related to cognitive and physical functions and that a large estimation error (LE) is related to motor imagery ability, including cognitive and physical functions in healthy subjects. The purpose of this study investigated whether estimation error is related to physical and cognitive function in patients with stroke. The study included 60 patients with stroke. The Timed Up and Go Test (TUGT) was employed to assess estimation error. First, the imagined TUGT (iTUGT) was performed; thereafter, the actual TUGT was performed. The estimation error was calculated by subtracting TUGT from iTUGT, with conversion to the absolute value. The patients were classified into the small estimation error (SE) and LE groups, with comparisons of various clinical scores (Mini-Mental State Examination, Berg Balance Scale, 10-m walking speed, Brunnstrom Recovery Stage, and Functional Independence Measure). As a result, the estimation error was significantly larger in the LE group than in the SE group. Cognitive function and balance ability were significantly lower in the LE group than in the SE group. In conclusion, the estimation error was related to physical and cognitive functions in patients with stroke.

Walking Ability Associated with Executive Dysfunction in Patients with Stroke: A Cross-Sectional Study

Previous studies have shown an association between executive dysfunction and walking ability. However, it remains unclear whether the degree of executive dysfunction is associated with differences in walking ability in patients with stroke. The aim of this study was to investigate whether there are differences in walking ability according to executive dysfunction in patients with stroke. A total of 51 patients with stroke were enrolled in this study. Executive function was measured using the Trail Making Test (TMT) Part B, and walking ability was assessed using the 10 m walk test and the Timed Up and Go Test (TUGT). Cluster analysis was performed using the TMT Part B and compared within each cluster. TMT Part B was categorized into three groups (cluster 1: n = 20, cluster 2: n = 24, and cluster 3: n = 7). Cluster 1 was significantly better than clusters 2 and 3, and cluster 2 was significantly better than cluster 3. The 10 m walk time and TUGT of cluster 1 were significantly better than those of cluster 3. However, the 10 m walk time and TUGT of clusters 1 and 2 did not differ significantly. In conclusion, these findings may indicate differences in walking ability according to executive dysfunction.

Effects of Repetitive Transcranial Magnetic Stimulation on Gait and Postural Control Ability of Patients with Executive Dysfunction after Stroke

Objective: To assess the effects of repetitive transcranial magnetic stimulation (rTMS) on the gait and postural control ability of patients with executive dysfunction (ED) after stroke. Methods: A total of 18 patients with ED after stroke were randomly assigned into two groups, including an experimental group and a sham group. Patients in both groups received routine rehabilitation therapy, and patients in the experimental group underwent rTMS on the left dorsolateral prefrontal cortex (DLPFC) for 2 weeks (5 HZ, 80%MT, 1200 pulses). In the sham group, patients experienced sham stimulation treatment, in which the coil was placed vertically with the head. Before and after treatment, patients in both groups were subjected to Montreal cognitive assessment (MoCA) scoring, Fugl−Meyer assessment of lower extremity (L-FMA), Stroop color-word test (SCWT), gait analysis, foot plantar pressure test, 10-m walking test (10MWT), Berg balance scale (BBS), and timed up and go test (TUGT). In the SCWT, it was attempted to record the time of each card (SCWT-T), the correct number (SCWT-C), Stroop interference effect-time (SIE-T), and SIE correct count (SIE-C). The TUGT was categorized into four stages: getting up (GT), walking straight (WT), turning around (TT), and sitting down (ST), in which the total time of TUGT was calculated. Results: After two weeks of treatment, the evaluation indexes were improved in the two groups, some of which were statistically significant. In the experimental group, SCWT-T, SIE-T, SIE-C, GT, WT, TT, ST, and TUGT were significantly improved after treatment (p < 0.05). SCWT-C, L-FMA score, 10MWT, GT, WT, stride length, step width, foot plantar pressure, pressure center curve, and activities of daily living were not statistically different from those before treatment (p > 0.05). After treatment, SCWT-T, SIE-C, SIE-T, BBS score, TT, and ST in the experimental group were significantly shorter than those before treatment, with statistical differences (p < 0.05). Compared with the sham group, SCWT-C, L-FMA score, 10MWT, GT, WT, TUGT, stride length, step width, foot plantar pressure, pressure center curve, and motor skills were not significantly improved (p > 0.05). Conclusion: It was revealed that post-stroke rTMS treatment of patients with ED could improve executive function, improve postural control function, and reduce the risk of falling. In addition, rTMS of DLPFC could be a therapeutic target for improving postural control ability and reducing the risk of falling.

Physical and Cognitive Function Assessment to Predict Postoperative Outcomes of Abdominal Surgery

BACKGROUND

Current evaluation methods to assess physical and cognitive function are limited and often not feasible in emergency settings. The upper-extremity function (UEF) test to assess physical and cognitive performance using wearable sensors. The purpose of this study was to examine the (1) relationship between preoperative UEF scores with in-hospital outcomes; and (2) association between postoperative UEF scores with 30-d adverse outcomes among adults undergoing emergent abdominal surgery.

METHODS

We performed an observational, longitudinal study among adults older than 40 y who presented with intra-abdominal symptoms. The UEF tests included a 20-sec rapid repetitive elbow flexion (physical function), and a 60-sec repetitive elbow flexion at a self-selected pace while counting backwards by threes (cognitive function), administered within 24-h of admission and within 24-h prior to discharge. Multiple logistic regression models assessed the association between UEF and outcomes. Each model consisted of the in-hospital or 30-d post-discharge outcome as the dependent variable, preoperative UEF physical and cognitive scores as hypothesis covariates, and age and sex as adjuster covariates.

RESULTS

Using UEF physical and cognitive scores to predict in-hospital outcomes, an area under curve (AUC) of 0.76 was achieved, which was 17% more sensitive when compared to age independently. For 30-d outcomes, the AUC increased to 0.89 when UEF physical and cognitive scores were included in the model with age and sex.

DISCUSSION

Sensor-based measures of physical and cognitive function enhance outcome prediction providing an objective practicable tool for risk stratification in emergency surgery settings among aging adults presenting with intra-abdominal symptoms.

Cognitive impairment before and after intracerebral haemorrhage: a systematic review

INTRODUCTION

There is increasing interest in understanding cognitive dysfunction before and after Intracerebral haemorrhage (ICH), given the higher prevalence of dementia reported (ranging from 5 to 44%) for this stroke type. Much of the evidence to date examining cognitive impairment associated with cerebrovascular disease has tended to focus more on ischaemic stroke. The aim of this review was to identify and quantify studies that focused on cognitive dysfunction pre and post ICH.

METHODS

We conducted a systematic search using databases PubMed, Science Direct, Scopus and PsycINFO to identify studies that exclusively assessed cognitive function pre and post ICH. Studies were included in the review if used a measure of global cognition and/or a neuropsychological battery to assess cognitive function. Nineteen studies were deemed relevant for inclusion, where n = 8 studies examined cognitive impairment pre ICH and n = 11 post ICH.

RESULTS

Prevalence of cognitive impairment ranged between 9-29% for pre ICH and 14-88% for post ICH. Predictive factors identified for pre and post ICH were previous stroke, ICH volume and location and markers of cerebral amyloid angiopathy (CAA). Most common cognitive domains affected post ICH were information processing speed, executive function, memory, language and visuo-spatial abilities. Most common cognitive assessments tools were the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) for pre-existing cognitive impairment and the Mini-Mental State Examination for global cognition post ICH and the Trail Making Test where neuropsychological tests were used.

CONCLUSION

Cognitive impairment and dementia affected almost one-third of patients, whether assessed pre or post ICH.

Associations between ApoE gene and psychological consequences post stroke in a Bahraini cohort

BACKGROUND

The contribution of genetic factors such as the presence of ApoE allele e4 and its association with psychological consequences post stroke remains unknown within Middle-Eastern regions. This study examined the association of ApoE genotype with cognitive impairment and mood in stroke patients and compare with healthy older adults in Bahrain.

METHOD

A prospective sample of n = 62 stroke patients (case group) and n = 53 healthy ageing individuals (control group) were eligible to participate in the study. A neuropsychological battery of cognitive assessments were conducted on all participants, and then stratified by cognitive function: no cognitive impairment, mild cognitive impairment and moderate to severe cognitive impairment. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Most frequent ApoE genotype was e2/e3 in case (44%) and control groups (63%). ApoE allele e3 had the highest frequency for both groups with all stroke patients presenting with this allele and 86% for the control group (χ²  = 12.14, p < .0001). Stroke patients' non-carriers for ApoE allele e4 performed better on all cognitive measures but differences were not statistically significant (ns). Carriers of ApoE allele e2 in both groups had less mood symptoms compared to non-carriers.

DISCUSSION

ApoE genotype e3/e4 and e4/e4 was low in this Bahraini cohort explaining why there may been no significant associations found for this genotype variant with cognitive impairment. Further investigation of cognitive impairment and mood dysregulation with the different variants of the ApoE gene in general ageing and stroke populations is required from different ethno-cultural groups and geographical regions globally.

Association between executive and food functions in the acute phase after stroke

Purpose To investigate potential associations among executive, physical and food functions in the acute phase after stroke. Methods This is a cross-sectional study that evaluated 63 patients admitted to the stroke unit of a public hospital. The exclusion criteria were other neurological and/or psychiatric diagnoses. The tools for evaluation were: Mini-Mental State Examination and Frontal Assessment Battery for cognitive functions; Alberta Stroke Program Early CT Score for quantification of brain injury; National Institutes of Health Stroke Scale for neurological impairment; Modified Rankin Scale for functionality, and the Functional Oral Intake Scale for food function. Results The sample comprised 34 men (54%) and 29 women with a mean age of 63.6 years. The Frontal Assessment Battery was significantly associated with the other scales. In multivariate analysis, executive function was independently associated with the Functional Oral Intake Scale. Conclusion Most patients exhibited executive dysfunction that significantly compromised oral intake.

Predictors of Vascular Cognitive Impairment Poststroke in a Middle Eastern (Bahrain) Cohort: A Proposed Case-Control Comparison

BACKGROUND

Poststroke dementia and cognitive impairment are associated with poor long-term outcomes after stroke. The contribution of genetic factors such as the presence of apolipoprotein (ApoE) ɛ4 allele and its association with cognitive impairment poststroke remains inconclusive, particularly in Middle Eastern regions.

OBJECTIVE

The aim of this study is to examine all correlates and potential predictors of cognitive impairment including self-awareness and regulation deficits in stroke patients and compare these functions with healthy older adults from a Middle Eastern population.

METHODS

A prospective stroke sample of 200 patients (case group) and 100 healthy aging individuals (control group) will be recruited from the largest medical complex in Bahrain. A neuropsychological battery of cognitive assessments (global, executive, and metacognition) will be conducted on all participants. Participants will be categorized into 4 subgroups (nonvascular cognitive impairment, vascular cognitive impairment with no dementia, vascular dementia, and mixed dementia) using standardized cognitive assessment scores and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, dementia criteria. Biomarkers will include ApoE genotype, soluble form of receptor for advanced glycation end products, neprilysin, beta-secretase 1, biochemistry, and hematology measurements.

RESULTS

The primary study outcome is to determine early risk factors for cognitive impairment after stroke in a Bahraini cohort. The study has received full ethical approval from the Bahrain Ministry of Health and from the affiliated university.

CONCLUSIONS

With increasing stroke incidence rates in the Middle East, this research study will provide useful biological and epidemiological data for future development and planning of health policies and guidelines for stroke care within the Gulf region.

Association Between Metacognition and Mood Symptoms Poststroke

INTRODUCTION

The link between metacognition and mood has been well established, particularly in other conditions with psychological comorbidity, however, there is no evidence regarding this association in the area of stroke.

AIM

The aim of this study was to examine the association between metacognition, based on the Self-Regulatory Executive Function model, and mood symptoms in the acute phase after stroke.

METHODS

One hundred thirty patients were recruited to a prospective stroke study in Bahrain, and n = 64 were assessed for mood and cognition. A neuropsychological battery of cognitive assessments included the following measures: the Mini-Mental State Examination, the Trail Making Test (A+B), and the Metacognition Questionnaire 30 (MCQ-30) for metacognition. The Hospital Anxiety and Depression Scale assessed mood symptoms, and stroke severity was measured using the National Institute of Health Stroke Severity Scale.

RESULTS

Total MCQ-30 scores were significantly associated with both anxiety (r = .47, P = .001) and depression (r = .54, P <. 0001). The MCQ-30 subscales' cognitive confidence, cognitive self-consciousness, and uncontrollability/danger were the specific factors to be associated with mood symptoms (P < .01). Global cognition (r =.32, P < .01), but not executive function, was significantly associated with depression only. Metacognition remained a statistically significant correlate with depression (β = .42, P < .0001) and anxiety (β = .51, P < .0001) after adjusting for education and global cognition.

DISCUSSION

Metacognition is a better determinant of mood symptoms after stroke, especially in regions where illiteracy levels are high in older populations, in comparison to executive function and global cognition.

Diversity of approaches in assessment of executive functions in stroke: limited evidence?

Stroke is a leading cause of disability worldwide. Cognitive functions and, in particular, executive function, are commonly affected after stroke, leading to impairments in performance of daily activities, decrease in social participation and in quality of life. Appropriate assessment and understanding of executive dysfunction are important, firstly to develop better rehabilitation strategies for executive functions per se and secondly to consider executive function abilities on rehabilitation strategies in general. The purpose of this review was to identify the most widely used assessment tools of executive dysfunction for patients with stroke, and their psychometric properties.

We systematically reviewed manuscripts published in English in databases from 1999 to 2015. We identified 35 publications. The most frequently used instruments were the Stroop, Digit Span and Trail making tests. Psychometric properties were described for the Executive Function Performance Test, Executive Clock Drawing Task, Chinese Frontal Assessment Battery and Virtual Action Planning — Supermarket, and two subtests of the Cambridge Cognitive Examination — Revised.

There is a paucity of tools to reliably measure executive dysfunction after stroke, despite the fact that executive dysfunction is frequent. Identification of the best tools for executive dysfunction assessment is necessary to address important gaps in research and in clinical practice.

Ecological validity and neuroanatomical correlates of the NIH EXAMINER executive composite score

Executive functions refer to a constellation of higher-level cognitive abilities that enable goal-oriented behavior. The NIH EXAMINER battery was designed to assess executive functions comprehensively and efficiently. Performance can be summarized by a single score, the "Executive Composite," which combines measures of inhibition, set-shifting, fluency, and working memory. We evaluated the ecological validity of the Executive Composite in a sample of 225 mixed neurological patients and controls using the Frontal Systems Behavior Scale (FrSBe), an informant-based measure of real-world executive behavior. In addition, we investigated the neuroanatomical correlates of the Executive Composite using voxel-based morphometry in a sample of 37 participants diagnosed with dementia, mild cognitive impairment, or as neurologically healthy. The Executive Composite accounted for 28% of the variance in Frontal Systems Behavior Scale scores beyond age. Even after including two widely used executive function tests (Trails B and Stroop) as covariates, the Executive Composite remained a significant predictor of real-world behavior. Anatomically, poorer scores on the Executive Composite were associated with smaller right and left dorsolateral prefrontal volumes, brain regions critical for good executive control. Taken together, these results suggest that the Executive Composite measures important aspects of executive function not captured by standard measures and reflects the integrity of frontal systems.

Stroke-related motor outcome measures: do they quantify the neurophysiological aspects of upper extremity recovery?

Various stroke rehabilitation outcome measures are used in clinical and research practice. Severe upper extremity paresis serves as a challenge for the selection of an appropriate outcome measure. No single measure is universally acceptable and sufficient to record the minute clinically important changes. The objectives of the present review were to explore the stroke-specific upper extremity motor outcome measures and to better understand those measures' ability to quantify upper extremity motor recovery. Seven outcome measures were selected for this review. The criteria used to select outcome measures for this review included performance-based tools that assessed the upper extremity's voluntary motor control and outcome measures which had been used for the past 10 years. A critical review that referred to motor recovery stages and volitional control was performed. The upper extremity components of each measure were compared with the neurophysiological aspects of recovery (Brunnstrom Recovery Stages) and analyzed for their clinical relevance. The concepts of minimal detectable change and minimal clinically important difference were also considered while examining the outcome measures. The findings of this review reveal that there were very few measures available to precisely assess the upper extremity motor components and volitional control. Most of the measures are functional and performance-based. Only Fugl-Meyer Assessment was found to explore the individual joint motor control as per the sequential recovery stages. Further, there is a need to develop stroke-specific upper extremity outcome measures. Scoring criteria of the acceptable measures may be modified to discern precise and progressive, but clinically significant motor changes.