Rehabilitation therapy services for stroke patients living at home: systematic review of randomised trials

Barriers to self-administered home-based task-oriented practice post-stroke: development and content validity of a new instrument

PURPOSE

To develop a new instrument to identify barriers to self-administered home-based task-oriented practice post-stroke and test its content validity.

MATERIALS AND METHODS

The sample consisted of individuals with stroke and neurological rehabilitation professionals. The study consisted of two steps: (1) Instrument development, involving three processes; a data search in the literature, interviews with the target population and an open questionnaire (online) sent to professionals; and (2) Testing the content validity of the instrument by asking individuals with stroke and professionals about the comprehensiveness and relevance of the items and additionally asking individuals with stroke about the comprehensibility of the items. For each item in the instrument, the threshold validity scores were ≥0.80 in the Content Validity Index and ≥0.75 for the Kappa agreement.

RESULTS

The preliminary version was developed with 46 items. The content validation was performed in three rounds. The last version of the instrument Barriers to self-administered home-based task-oriented practice post-stroke (BASH-TOP-Stroke) contained 34 items in five response categories, in which the higher the value presented, the greater the number of barriers. The content validity for the items was excellent.

CONCLUSIONS

The study provides a new instrument to help identify barriers to self-administered home-based task-oriented practice post-stroke.

Study of the Possibility of Using Virtual Reality Application in Rehabilitation among Elderly Post-Stroke Patients

Thanks to medical advances, life expectancy is increasing. With it comes an increased incidence of diseases, of which age is a risk factor. Stroke is among these diseases, and is one of the causes of long-term disability. The opportunity to treat these patients is via rehabilitation. A promising new technology that can enhance rehabilitation is virtual reality (VR). However, this technology is not widely used by elderly patients, and, moreover, the elderly often do not use modern technology at all. It therefore becomes a legitimate question whether elderly people will be able to use virtual reality in rehabilitation. This article presents a rehabilitation application dedicated to patients with upper limb paresis and unilateral spatial neglect (USN). The application was tested on a group of 60 individuals including 30 post-stroke patients with an average age of 72.83 years. The results of the conducted study include a self-assessment by the patients, the physiotherapist's evaluation, as well as the patients' performance of the exercise in VR. The study showed that elderly post-stroke patients are able to use virtual reality applications, but the ability to correctly and fully perform an exercise in VR depends on several factors. One of them is the ability to make logical contact (p = 0.0001 < 0.05). However, the study presented here shows that the ability to use VR applications does not depend on age but on mental and physical condition, which gives hope that virtual reality applications can be used in post-stroke rehabilitation among patients of all ages.

Upper-Limb Functional Recovery in Chronic Stroke Patients after COVID-19-Interrupted Rehabilitation: An Observational Study

Background/Objectives: Upper-limb function of chronic stroke patients declined when outpatient rehabilitation was interrupted and outings restricted, owing to the novel coronavirus infection (COVID-19) pandemic. We investigated whether these patients recovered upper-limb function post-resumption of outpatient rehabilitation. Methods: In this observational study, 43 chronic stroke hemiparesis patients with impaired upper extremity function were scored for limb function via the Fugl-Meyer assessment of the upper extremity (FMA-UE) and the Action Research Arm Test (ARAT) after a structured interview, evaluation, and intervention. Scores at 6 and 3 months pre- and 3 months post-rehabilitation interruption were examined retrospectively; scores immediately and at 3 and 6 months post-resumption of care were examined prospectively. The amount of change for each time period and an analysis of covariance were performed with time as a factor, changes in the FMA-UE and the ARAT scores as dependent variables, and statistical significance at 5%. Results: The time of evaluation significantly impacted the total score, as well as part C and part D of FMA-UE and total, pinch, and gross movement of the ARAT. Post-hoc tests showed that the magnitude of change in limb-function scores from immediately to 3 months post-resumption was significantly higher than the change from 3 months pre- to immediately post-interruption for the total score and part D of the FMA-UE, as well as grip and gross movement of the ARAT (p < 0.05). Conclusions: Upper-limb functional decline in chronic stroke patients, caused by the COVID-19 pandemic-related therapy interruption and outing restrictions, was resolved approximately 3 months post-resumption of rehabilitation therapy. Our data can serve as reference standards for planning and evaluating treatment for chronic stroke patients with inactivity-related impaired upper-limb function.

Occupational Therapy Practice: Time From Stroke Onset to Outpatient Upper Limb Rehabilitation

Upper limb stroke rehabilitation has been understudied in usual occupational therapy. The study's purpose was to describe the timing and amount of usual occupational therapy in the stroke population for hospital-based outpatient upper limb rehabilitation. A multi-site study of timing and amount of occupational therapy was calculated for mild and moderate upper limb stroke impairments using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE). Mild stroke participants (n = 58) had a mean of 164.25 days, and the moderate stroke participants (n = 64) had a mean of 106.75 days from the date of stroke onset to first treatment which was significantly different (p = .047). There were no significant differences in the amount of therapy between mild or moderate stroke patients. Mild stroke patients experience a longer delay in receiving outpatient occupational therapy compared with moderate impairments which may be attributed to the subtlety of the impairments that impact participation in daily activities.

Home-based rehabilitation versus hospital-based rehabilitation for stroke patients in post-acute care stage: Comparison on the quality of life

BACKGROUND

This study focused on the integrated post-acute care (PAC) stage of stroke patients, and employed a retrospective study to examine the satisfaction with life quality in two groups, one that received home-based rehabilitation and one that received hospital-based rehabilitation. A secondary purpose was to analyze the correlations among the index and components concerning their quality of life (QOL) and compare the advantages and disadvantages of these two approaches to PAC.

METHODS

This research was a retrospective study of 112 post-acute stroke patients. The home-based group received rehabilitation for one to two weeks, and two to four sessions per week. The hospital-based group received the rehabilitation for three to six weeks, and 15 sessions per week. The home-based group mainly received the training and guidance of daily activities at the patients' residence. The hospital-based group mainly received physical facilitation and functional training in the hospital setting.

RESULTS

The mean scores of QOL assessment for both groups were found to be significantly improved after intervention. Between-group comparisons showed that the hospital-based group had better improvement than the home-based group in mobility, self-care, pain/discomfort and depression/anxiety. In the home-based group, the MRS score and the participant's age can explain 39.4% of the variance of QOL scores.

CONCLUSION

The home-based rehabilitation was of lower intensity and duration than the hospital-based one, but it still achieved a significant improvement in QOL for the PAC stroke patients. The hospital-based rehabilitation offered more time and treatment sessions. Therefore hospital-based patients responded with better QOL outcomes than the home-based patients.

Contralateral seventh cervical nerve transfer for central spastic arm paralysis: a systematic review and meta-analysis

Objectives

The specific benefits of a contralateral cervical 7 nerve transplant in people with spastic paralysis of the upper extremity caused by cerebral nerve injury are unclear. To evaluate the efficacy and safety of contralateral C7 nerve transfer for central spastic paralysis of the upper extremity, we conducted a comprehensive literature search and meta-analysis.

Materials and methods

PRISMA guidelines were used to search the databases for papers comparing the efficacy of contralateral cervical 7 nerve transfer vs. rehabilitation treatment from January 2010 to August 2022. The finishing indications were expressed using SMD ± mean. A meta-analysis was used to assess the recovery of motor function in the paralyzed upper extremity.

Results

The meta-analysis included three publications. One of the publications offers information about RCTs and non-RCTs. A total of 384 paralyzed patients were included, including 192 who underwent CC7 transfer and 192 who received rehabilitation. Results from all patients were combined and revealed that patients who had CC7 transfer may have regained greater motor function in the Fugl-Meyer score (SMD 3.52, 95% CI = 3.19-3.84, p < 0.00001) and had superior improvement in range of motion compared to the rehabilitation group (SMD 2.88, 95% CI = 2.47-3.29, p < 0.00001). In addition, the spasticity in the paralyzed upper extremity significantly improved in patients with CC7 transfer (SMD -1.42, 95% CI = -1.60 to -1.25, p < 0.00001).

Conclusion

Our findings suggested that a contralateral C7 nerve transfer, which has no additional adverse effects on the healthy upper limb, is a preferable method to restore motor function.

Development of a Set of Indicators for Measuring and Improving Quality of Rehabilitation Care after Ischemic Stroke

Stroke is the leading global cause of permanent disability and the second leading cause of dementia within the first year of the event. Systematic quality improvement interventions such as Audit & Feedback (A&F) can monitor and improve the performance of post-stroke care in conjunction with the use of quality indicators (QIs). The scientific literature shows limited studies on quality improvement and QIs design for poststroke rehabilitation. In Italy, the National Outcomes Evaluation Programme (PNE) annually provides several QIs concerning the acute wards. On the contrary, indicators for quality assessment of post-acute stroke rehabilitation are not available nationwide. In recent years, the Italian Ministry of Health has funded a national network project, the aim of which is to provide and evaluate the effectiveness of A&F strategies in healthcare improvement. Part of this project is the development of a set of IQs for ischemic stroke rehabilitation used to conduct an A&F. In this study, we describe the design and development process of these QIs from administrative databases and report the results of the pilot test conducted on a small sample of Sicilian rehabilitation facilities, comparing them from 2019 to 2021. Feedback from the participating centers was mainly positive, and the quality indicators were found to be comprehensible and appreciated. However, the study highlighted the need for better adherence to indicators measuring processes of rehabilitation care. The set of quality indicators presented in this study, relevant to inpatient settings, could be considered a starting point on which to base quality improvement initiatives both nationally and internationally.

Rehabilitation Therapy Doses Are Low After Stroke and Predicted by Clinical Factors

BACKGROUND

Stroke is a leading cause of long-term disability. Greater rehabilitation therapy after stroke is known to improve functional outcomes. This study examined therapy doses during the first year of stroke recovery and identified factors that predict rehabilitation therapy dose.

METHODS

Adults with new radiologically confirmed stroke were enrolled 2 to 10 days after stroke onset at 28 acute care hospitals across the United States. Following an initial assessment during acute hospitalization, the number of physical therapy, occupational therapy, and speech therapy sessions were determined at visits occurring 3, 6, and 12 months following stroke. Negative binomial regression examined whether clinical and demographic factors were associated with therapy counts. False discovery rate was used to correct for multiple comparisons.

RESULTS

Of 763 patients enrolled during acute stroke admission, 510 were available for follow-up. Therapy counts were low overall, with most therapy delivered within the first 3 months; 35.0% of patients received no physical therapy; 48.8%, no occupational therapy, and 61.7%, no speech therapy. Discharge destination was significantly related to cumulative therapy; the percentage of patients discharged to an inpatient rehabilitation facility varied across sites, from 0% to 71%. Most demographic factors did not predict therapy dose, although Hispanic patients received a lower cumulative amount of physical therapy and occupational therapy. Acutely, the severity of clinical factors (grip strength and National Institutes of Health Stroke Scale score, as well as National Institutes of Health Stroke Scale subscores for aphasia and neglect) predicted higher subsequent therapy doses. Measures of impairment and function (Fugl-Meyer, modified Rankin Scale, and Stroke Impact Scale Activities of Daily Living) assessed 3 months after stroke also predicted subsequent cumulative therapy doses.

CONCLUSIONS

Rehabilitative therapy doses during the first year poststroke are low in the United States. This is the first US-wide study to demonstrate that behavioral deficits predict therapy dose, with patients having more severe deficits receiving higher doses. Findings suggest directions for identifying groups at risk of receiving disproportionately low rehabilitation doses.

An optimal model of long-term post-stroke care

Stroke is a major healthcare challenge that is increasing worldwide. The burden of stroke is significant for the affected individuals as well as for the general population; high-quality care is needed to reduce its negative impacts. This article synthesized information from systematic reviews, guidelines, and primary literature on stroke care and post-stroke rehabilitation and proposes an optimal strategy for long-term post-stroke care. It also highlights the unmet needs of patients who experienced a stroke in terms of early diagnosis of complications and adequate, comprehensive therapy.

Understanding the facilitators and barriers of stroke survivors' adherence to recovery-oriented self-practice: a thematic synthesis

PURPOSE

Stroke survivors receive considerable rehabilitation efforts as inpatients, but one-on-one therapy decreases after discharge. The gap between the amount of required therapy and the lack of its availability in this phase of care may be partly overcome by self-practice. However, patient's adherence to prescribed programs is often low. While single studies have examined factors affecting adherence in this specific case, they have not been reviewed and synthesised previously.

METHODS

A thematic synthesis of qualitative studies explored factors affecting stroke survivors' adherence to prescribed, recovery-oriented self-practice. Five databases were systematically searched for references: Medline, Psycinfo, CINAHL, Embase, and ASSIA. Quality assessment was undertaken using the CASP tool.

RESULTS

From 1308 references, 68 potential papers were read in full, and 12 were included in the review. An overarching theme was identified as: "Tailoring and personalization rather than standardization." It was informed by the following three analytical themes: "The meaning of 'self' in self-practice," "Identifying self-practice as a team effort," and "Self-practice that is grounded in one's reality."

CONCLUSION

To have a positive effect on adherence to self-practice, clinicians are advised to spend time learning about each individual's life circumstances, so they can tailor proposed exercise programs to patients' personal situations, preferences, and needs.IMPLICATIONS FOR REHABILITATIONThe topic of patient's adherence to self-practice of prescribed exercise is a common concern, often voiced by frustrated rehabilitation health professionals. Bridging the gap between the patient's needs for post-discharge intensive therapy and the inability of healthcare systems to provide it could be filled partly by self-practice.Adherence to self-practice has become even more essential since the COVID 19 pandemic and the decrease in face-to-face delivery of rehabilitation due to social distancing requirements.Adherence to exercise is a broad topic. Reasons for poor adherence differ between patient populations and the exercises they are prescribed. This study focuses on post-discharge stroke survivors' adherence to recovery targeted exercise that could be described as repetitive and less physically demanding movements and functions.Reviewed studies were qualitative and usually included a relatively small number of participants within a specific context. Using thematic synthesis, we combined these small pieces of the puzzle into a larger picture, to produce recommendations that could be drawn on by clinicians to improve self-practice adherence.

A Cadaver Feasibility Study of Extradural Contralateral C7 Ventral Root Transfer Technique for Treating Upper Extremity Paralysis

STUDY DESIGN

A total of 6 formalin-fixed cadavers were included in the cadaver feasibility study.

OBJECTIVE

The aim was to ascertain the anatomical feasibility of extradural contralateral C7 ventral root transfer technique by cervical posterior.

SUMMARY OF BACKGROUND DATA

Upper limb spastic hemiplegia is a common sequela after stroke. In our previous study, the authors established a method by transferring contralateral C7 dorsal and ventral roots to the corresponding C7 dorsal and ventral roots on the affected side in the cervical posterior.

METHODS

In the present study, six formalin-fixed cadavers were dissected to confirm the anatomical feasibility. Experimental anastomosis in cadavers was conducted. The pertinent lengths of the extradural nerve roots were measured. The tissue structures surrounding regions between the extradural CC7 nerve roots and the vertebral artery were observed. The cervical magnetic resonance imaging scans of 60 adults were used to measure the distance between the donor and recipient nerves.

RESULTS

Experimental anastomosis showed that the distance between the donor and recipient nerves was approximately 1 cm; the short segment of the sural nerve needed bridging. The distance between both exit sites of the exit of the extradural dura mater was 33.57±1.55 mm. The length of the extradural CC7 ventral root was 22.00±0.98 mm. The ventral distance (vd) and the dorsal distance (dd) in males were 23.98±1.72 mm and 30.85±2.22 mm ( P <0.05), while those in females were 23.28±1.51 mm and 30.03±2.16 mm, respectively. C7 vertebral transverse process, ligaments, and other soft tissues were observed between the vertebral artery and the extradural C7 nerve root.

CONCLUSION

Under the premise of less trauma, our study shows that the extradural contralateral C7 ventral root transfer technique, in theory, yields better surgical results, including better recovery of motor function and complete preservation of sensory function.

LEVEL OF EVIDENCE

5.

Development of strategies to support home-based exercise adherence after stroke: a Delphi consensus

OBJECTIVE

To develop a set of strategies to enhance adherence to home-based exercises after stroke, and an overarching framework to classify these strategies.

METHOD

We conducted a four-round Delphi consensus (two online surveys, followed by a focus group then a consensus round). The Delphi panel consisted of 13 experts from physiotherapy, occupational therapy, clinical psychology, behaviour science and community medicine. The experts were from India, Australia and UK.

RESULTS

In round 1, a 10-item survey using open-ended questions was emailed to panel members and 75 strategies were generated. Of these, 25 strategies were included in round 2 for further consideration. A total of 64 strategies were finally included in the subsequent rounds. In round 3, the strategies were categorised into nine domains-(1) patient education on stroke and recovery, (2) method of exercise prescription, (3) feedback and supervision, (4) cognitive remediation, (5) involvement of family members, (6) involvement of society, (7) promoting self-efficacy, (8) motivational strategies and (9) reminder strategies. The consensus from 12 experts (93%) led to the development of the framework in round 4.

CONCLUSION

We developed a framework of comprehensive strategies to assist clinicians in supporting exercise adherence among stroke survivors. It provides practical methods that can be deployed in both research and clinical practices. Future studies should explore stakeholders' experiences and the cost-effectiveness of implementing these strategies.

Changes in motor paralysis involving upper extremities of outpatient chronic stroke patients from temporary rehabilitation interruption due to spread of COVID-19 infection: An observational study on pre- and post-survey data without a control group

Background

Outpatient rehabilitation was temporarily suspended because of coronavirus disease (COVID-19), and there was a risk that patients’ activities of daily living (ADLs) would decrease and physical functions unmaintained. Therefore, we investigated the ADLs and motor functions of chronic stroke patients whose outpatient rehabilitation was temporarily interrupted.

Methods

In this observational study, the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE), Action Research Arm Test (ARAT), and Barthel Index (BI) scores of 49 stroke hemiplegic patients at 6 and 3 months before rehabilitation interruptions were retrospectively determined and were prospectively investigated on resumption of outpatient rehabilitation. Presence or absence of symptoms and difficulties caused by the interruption period (IP) was investigated using a binomial method. Deltas were analyzed using a generalized linear model (GLM) according to the survey period. Age, sex, severity of FMA-UE immediately post-resumption and post-onset period were used as covariates. For survey items showing significant model fit, the 95% confidence interval of minimum detectable change (MDC₉₅) was calculated, and the amount of change was compared. Questionnaire responses were tested via proportion ratio. Statistical significance was set at 5%.

Results

The FMA-UE part A and total scores were significantly model fit depending on periods. The estimated FMA-UE total score decreased by 1.64 (z = −2.38, p = 0.02) during the 3-month IP. No fits were observed by GLM in other parts of the FMA-UE, ARAT, or BI. The calculated MDC₉₅ was 3.58 for FMA-UE part A and 4.50 for FMA-UE overall. Answers to questions regarding sleep disturbance and physical pain were significantly biased toward “no” in the psychosomatic function items (p<0.05). There was no bias in the distribution of answers to questions regarding joint stiffness, muscle weakness, muscle stiffness, and difficulty in moving arms and hands. All 16 questions regarding activities and participation items were significantly biased toward answers “no” (p<0.05).

Conclusions

The FMA-UE part A and total scores were affected. Patients complained of subjective symptoms related to upper limb paralysis after the IP. Since ADLs of patients were maintained, the therapist can recommend that patients not receiving outpatient treatments be evaluated in relation to the shoulder, elbow, and forearm and instructed on self-training to maintain motor function.

Cross-sectional survey of rehabilitation service availability for stroke and hip fracture in Australian public hospitals

OBJECTIVE

To describe the rehabilitation services available for people with stroke and hip fracture across New South Wales/Australian Capital Territory metropolitan and rural/regional public hospitals in Australia.

DESIGN

A cross-sectional study design was used.

SETTING

New South Wales/Australian Capital Territory public hospital providing rehabilitation services for stroke and hip fracture.

PARTICIPANTS

Delegates from 59 eligible hospitals.

INTERVENTION

Information about the type, number and availability of inpatient and outpatient rehabilitation services at each hospital was collected via survey.

MAIN OUTCOME MEASURES

Counts, percentages, mean (SD), median (IQR) were used to quantify the number and type of inpatient and outpatient services available.

RESULTS

Across inpatient rehabilitation units, reduced availability was noted in the number of clinical disciplines available, availability of neuropsychology and social work in rural units. Across outpatient rehabilitation services, reduced availability was noted in the number of disciplines available, availability of occupational therapy, psychology, rehabilitation physicians, specialist nursing, geriatricians, and podiatry in rural services. Five rural hospitals had no access to outpatient rehabilitation.

CONCLUSION

There was reduced availability of rehabilitation services and health disciplines in rural/regional settings. A follow-up study is underway investigating relationships between reduced outpatient service availability and inpatient length of stay in rural/regional versus metropolitan hospitals.

Effect of opposing needling on motor cortex excitability in healthy participants and in patients with post-stroke hemiplegia: study protocol for a single-blind, randomised controlled trial

Background

Opposing needling has an obvious curative effect in the treatment of post-stroke hemiplegia; however, the mechanism of the opposing needling in the treatment of post-stroke hemiplegia is still not clear. The purpose of this study is to investigate the effect of opposing needling on the excitability of primary motor cortex (M1) of healthy participants and patients with post-stroke hemiplegia, which may provide insight into the mechanisms of opposing needling in treating post-stroke hemiplegia.

Methods

This will be a single-blind, randomised, sham-controlled trial in which 80 healthy participants and 40 patients with post-stroke hemiplegia will be recruited. Healthy participants will be randomised 1:1:1:1 to the 2-Hz, 50-Hz, 100-Hz, and sham electroacupuncture groups. Patients with post-stroke hemiplegia will be randomised 1:1 to the opposing needling or conventional treatment groups. The M1 will be located in all groups by using neuroimaging-based navigation. The stimulator coil of transcranial magnetic stimulation (TMS) will be moved over the left and right M1 in order to identify the TMS hotspot, followed by a recording of resting motor thresholds (RMTs) and motor-evoked potentials (MEPs) of the thenar muscles induced by TMS before and after the intervention. The primary outcome measure will be the percent change in the RMTs of the thenar muscles at baseline and after the intervention. The secondary outcome measures will be the amplitude (μV) and latency (ms) of the MEPs of the thenar muscles at baseline and after the intervention.

Discussion

The aim of this trial is to explore the effect of opposing needling on the excitability of M1 of healthy participants and patients with post-stroke hemiplegia.

Trial registration

Chinese Clinical Trial Registry ChiCTR1900028138. Registered on 13 December 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05443-x.

A Feasibility Study of Expanded Home-Based Telerehabilitation After Stroke

Introduction: High doses of activity-based rehabilitation therapy improve outcomes after stroke, but many patients do not receive this for various reasons such as poor access, transportation difficulties, and low compliance. Home-based telerehabilitation (TR) can address these issues. The current study evaluated the feasibility of an expanded TR program. Methods: Under the supervision of a licensed therapist, adults with stroke and limb weakness received home-based TR (1 h/day, 6 days/week) delivered using games and exercises. New features examined include extending therapy to 12 weeks duration, treating both arm and leg motor deficits, patient assessments performed with no therapist supervision, adding sensors to real objects, ingesting a daily experimental (placebo) pill, and generating automated actionable reports. Results: Enrollees (n = 13) were median age 61 (IQR 52-65.5), and 129 (52-486) days post-stroke. Patients initiated therapy on 79.9% of assigned days and completed therapy on 65.7% of days; median therapy dose was 50.4 (33.3-56.7) h. Non-compliance doubled during weeks 7-12. Modified Rankin scores improved in 6/13 patients, 3 of whom were >3 months post-stroke. Fugl-Meyer motor scores increased by 6 (2.5-12.5) points in the arm and 1 (-0.5 to 5) point in the leg. Assessments spanning numerous dimensions of stroke outcomes were successfully implemented; some, including a weekly measure that documented a decline in fatigue (p = 0.004), were successfully scored without therapist supervision. Using data from an attached sensor, real objects could be used to drive game play. The experimental pill was taken on 90.9% of therapy days. Automatic actionable reports reliably notified study personnel when critical values were reached. Conclusions: Several new features performed well, and useful insights were obtained for those that did not. A home-based telehealth system supports a holistic approach to rehabilitation care, including intensive rehabilitation therapy, secondary stroke prevention, screening for complications of stroke, and daily ingestion of a pill. This feasibility study informs future efforts to expand stroke TR. Clinical Trial Registration: Clinicaltrials.gov, # NCT03460587.

Cerebellar Transcranial Direct Current Stimulation for Motor Learning in People with Chronic Stroke: A Pilot Randomized Controlled Trial

Cerebellar transcranial direct current stimulation (ctDCS) is a non-invasive brain stimulation technique that alters neural plasticity through weak, continuous, direct currents delivered to the cerebellum. This study aimed to evaluate the feasibility of conducting a randomized controlled trial (RCT) delivering three consecutive days of ctDCS during split-belt treadmill training (SBTT) in people with chronic stroke. Using a double-blinded, parallel-group RCT design, eligible participants were randomly allocated to receive either active anodal ctDCS or sham ctDCS combined with SBTT on three consecutive days. Outcomes were assessed at one-week follow-up, using step length symmetry as a measure of motor learning and comfortable over-ground walking speed as a measure of walking capacity. The feasibility of the RCT protocol was evaluated based on recruitment, retention, protocol deviations and data completeness. The feasibility of the intervention was assessed based on safety, adherence and intervention fidelity. Of the 26 potential participants identified over four months, only four were enrolled in the study (active anodal ctDCS n = 1, sham ctDCS n = 3). Both the inclusion criteria and the fidelity of the SBTT relied upon the accurate estimation of step length asymmetry. The method used to determine the side of the step length asymmetry was unreliable and led to deviations in the protocol. The ctDCS intervention was well adhered to, safe, and delivered as per the planned protocol. Motor learning outcomes for individual participants revealed that treadmill step length symmetry remained unchanged for three participants but improved for one participant (sham ctDCS). Comfortable over-ground walking speed improved for two participants (sham ctDCS). The feasibility of the planned protocol and intervention was limited by intra-individual variability in the magnitude and side of the step length asymmetry. This limited the sample and compromised the fidelity of the SBTT intervention. To feasibly conduct a full RCT investigating the effect of ctDCS on locomotor adaptation, a reliable method of identifying and defining step length asymmetry in people with stroke is required. Future ctDCS research should either optimize the methods for SBTT delivery or utilize an alternative motor adaptation task.

Development and Clinical Evaluation of a Web-Based Upper Limb Home Rehabilitation System Using a Smartwatch and Machine Learning Model for Chronic Stroke Survivors: Prospective Comparative Study

Background

Recent advancements in wearable sensor technology have shown the feasibility of remote physical therapy at home. In particular, the current COVID-19 pandemic has revealed the need and opportunity of internet-based wearable technology in future health care systems. Previous research has shown the feasibility of human activity recognition technologies for monitoring rehabilitation activities in home environments; however, few comprehensive studies ranging from development to clinical evaluation exist.

Objective

This study aimed to (1) develop a home-based rehabilitation (HBR) system that can recognize and record the type and frequency of rehabilitation exercises conducted by the user using a smartwatch and smartphone app equipped with a machine learning (ML) algorithm and (2) evaluate the efficacy of the home-based rehabilitation system through a prospective comparative study with chronic stroke survivors.

Methods

The HBR system involves an off-the-shelf smartwatch, a smartphone, and custom-developed apps. A convolutional neural network was used to train the ML algorithm for detecting home exercises. To determine the most accurate way for detecting the type of home exercise, we compared accuracy results with the data sets of personal or total data and accelerometer, gyroscope, or accelerometer combined with gyroscope data. From March 2018 to February 2019, we conducted a clinical study with two groups of stroke survivors. In total, 17 and 6 participants were enrolled for statistical analysis in the HBR group and control group, respectively. To measure clinical outcomes, we performed the Wolf Motor Function Test (WMFT), Fugl-Meyer Assessment of Upper Extremity, grip power test, Beck Depression Inventory, and range of motion (ROM) assessment of the shoulder joint at 0, 6, and 12 months, and at a follow-up assessment 6 weeks after retrieving the HBR system.

Results

The ML model created with personal data involving accelerometer combined with gyroscope data (5590/5601, 99.80%) was the most accurate compared with accelerometer (5496/5601, 98.13%) or gyroscope data (5381/5601, 96.07%). In the comparative study, the drop-out rates in the control and HBR groups were 40% (4/10) and 22% (5/22) at 12 weeks and 100% (10/10) and 45% (10/22) at 18 weeks, respectively. The HBR group (n=17) showed a significant improvement in the mean WMFT score (P=.02) and ROM of flexion (P=.004) and internal rotation (P=.001). The control group (n=6) showed a significant change only in shoulder internal rotation (P=.03).

Conclusions

This study found that a home care system using a commercial smartwatch and ML model can facilitate participation in home training and improve the functional score of the WMFT and shoulder ROM of flexion and internal rotation in the treatment of patients with chronic stroke. This strategy can possibly be a cost-effective tool for the home care treatment of stroke survivors in the future.

Trial Registration

Clinical Research Information Service KCT0004818; https://tinyurl.com/y92w978t

A Systematic Review of the Effectiveness of Telerehabilitation Interventions for Therapeutic Purposes in the Elderly

BACKGROUND

Many elderly people suffer from chronic health conditions and mobility limitations. Therefore, they may benefit from traditional rehabilitation or telerehabilitation interventions as an alternative for this type of services.

OBJECTIVE

The purpose of this study was to compare the effectiveness of telerehabilitation interventions with traditional rehabilitation services for therapeutic purposes in the elderly.

METHODS

This systematic review was conducted in 2018. The searched databases were Cochrane Library, PubMed, Scopus, Web of Science, Embase, and ProQuest. The search was conducted with no time or language limitation. The selected papers included the randomized clinical trial studies in which elderly people aged 60 and over used telerehabilitation services for treatment purposes. The quality of the studies was evaluated by using the physiotherapy evidence database (PEDro) scale. Data were extracted by using a data extraction form and findings were narratively synthesized.

RESULTS

After screening the retrieved papers, eight articles were selected to be included in the study. According to the findings, telerehabilitation was used for the elderly after stroke, chronic obstructive pulmonary disease (COPD), total knee replacement, and in patients with the comorbidity of COPD and chronic heart failure. Overall, in most studies, there was no significant difference between the intervention and control groups and the level of improvements was similar for most outcomes.

CONCLUSION

Telerehabilitation services can be regarded as an alternative to traditional rehabilitation approaches to reduce outpatient resource utilization and improve quality of life. However, more rigorous studies are suggested to investigate the effectiveness of telerehabilitation services for specific diseases or health conditions.

Changes in social participation and life-space mobility in newly enrolled home-based rehabilitation users over 6 months

[Purpose] This study aimed to examine whether we were able to measure changes in social participation and life-space mobility of newly enrolled home-based rehabilitation (HR) users by using the activities and participation components of the International Classification of Functioning, Disability and Health (ICF) and Life-Space Assessment (LSA) over a 6-months period. [Participants and Methods] We enrolled 47 HR users who had suffered from a stroke or other condition within the previous year. A 6-month prospective cohort study was conducted. The performance qualifiers “d6 domestic life” and “d9 community, social and civic life” in the activities and participation components of the ICF and LSA were used. [Results] We observed significant improvements in the performance qualifier “d9 community, social and civic life” of the ICF over 3 months, and the LSA over a 6-months period. We also identified significant improvements in “d910 community life” and “d920 recreation and leisure” of the ICF. The LSA results showed that HR users had more frequent mobility within the neighborhood. [Conclusion] This study showed that newly enrolled HR users improved their social activities in the community, recreational activities, and life-space mobility over a 6-months period. These were measured using performance qualifiers from the ICF and LSA.

How do patients pass through stroke services? Identifying stroke care pathways using national audit data

Objective:

To map and describe how patients pass through stroke services.

Methods:

Data from 94,905 stroke patients (July 2013–July 2015) who were still inpatients 72 hours after hospital admission were extracted from a national stroke register and were used to identify the routes patients took through hospital and community stroke services. We sought to categorize these routes through iterative consultations with clinical experts and to describe patient characteristics, therapy provision, outcomes and costs within each category.

Results:

We identified 874 routes defined by the type of admitting stroke team and subsequent transfer history. We consolidated these into nine distinct routes and further summarized these into three overlapping ‘pathways’ that accounted for 99% of the patients. These were direct discharge (44%), community rehabilitation (47%) and inpatient transfer (19%) with 12% of the patients receiving both inpatient transfer and community rehabilitation. Patients with the mildest and most severe strokes were more likely to follow the direct discharge pathway. Those perceived to need most therapy were more likely to follow the inpatient transfer pathway. Costs were lowest and mortality was highest for patients on the direct discharge pathway. Outcomes were best for patients on the community rehabilitation pathway and costs were highest where patients underwent inpatient transfers.

Conclusion:

Three overarching stroke care pathways were identified which differ according to patient characteristics, therapy needs and outcomes. This pathway mapping provides a benchmark to develop and plan clinical services, and for future research.

Translating concepts of neural repair after stroke: Structural and functional targets for recovery

Stroke is among the most common causes of adult disability worldwide, and its disease burden is shifting towards that of a long-term condition. Therefore, the development of approaches to enhance recovery and augment neural repair after stroke will be critical. Recovery after stroke involves complex interrelated systems of neural repair. There are changes in both structure (at the molecular, cellular, and tissue levels) and function (in terms of excitability, cortical maps, and networks) that occur spontaneously within the brain. Several approaches to augment neural repair through enhancing these changes are under study. These include identifying novel drug targets, implementing rehabilitation strategies, and developing new neurotechnologies. Each of these approaches has its own array of different proposed mechanisms. Current investigation has emphasized both cellular and circuit-based targets in both gray and white matter, including axon sprouting, dendritic branching, neurogenesis, axon preservation, remyelination, blood brain barrier integrity, blockade of extracellular inhibitory signals, alteration of excitability, and promotion of new brain cortical maps and networks. Herein, we review for clinicians recovery after stroke, basic elements of spontaneous neural repair, and ongoing work to augment neural repair. Future study requires alignment of basic, translational, and clinical research. The field continues to grow while becoming more clearly defined. As thrombolysis changed stroke care in the 1990 s and thrombectomy in the 2010 s, the augmentation of neural repair and recovery after stroke may revolutionize care for these patients in the coming decade.

Utilization of Rehabilitation Services in Stroke: A Study Utilizing the Health and Retirement Study With Linked Medicare Claims Data

OBJECTIVES

To describe Medicare fee-for-service beneficiaries who used poststroke rehabilitation services and identified the strongest predictors of utilization after the initial stroke care episode.

DESIGN

Pooled, cross-sectional design using data from 1998 to 2010 from the Health and Retirement Study (HRS) with linked Medicare claims data.

SETTING

NA.

PARTICIPANTS

Stroke survivors who were Medicare fee-for-service beneficiaries and participated in the HRS were included (N=515).

MAIN OUTCOME MEASURE

Utilization of rehabilitation services up to 10 years poststroke was the primary outcome with logistic regression used to predict utilization. Covariates included demographic factors, baseline functional status, health conditions, personal lifestyle factors, and social support.

RESULTS

Rehabilitation service utilization was 21.6%, 6.8%, 15.8%, 16.5%, and <16% in years 2, 4, 6, 8, and 10, respectively. Age was the primary factor predicting use of rehabilitation in the first 10 years poststroke (odds ratio: 1.14; P=.001). Recurrent stroke (odds ratio: 1.64; P=.051) was also significantly associated with utilization, whereas unspecified incident stroke at incident trended toward significance (odds ratio: 2.17; P=.077). None of the other factors was a significant predictor of participation in rehabilitation services in this period.

CONCLUSION

A small number of Medicare fee-for-service beneficiaries who are stroke survivors utilize rehabilitation services in the first 10 years poststroke. Of those who do, age is the primary driver of utilization. We analyzed a multitude of factors that might influence utilization, but other factors not available in these data also need to be explored.

Educational and Exercise Intervention to Prevent Falls and Improve Participation in Subjects With Neurological Conditions: The NEUROFALL Randomized Controlled Trial

Background: Falls, mobility impairments and lack of social support lead to participation restrictions in people with neurological conditions. The aim of this multicenter, single blinded randomized controlled trial was to test whether an educational program focusing on fall prevention and safe mobility reduces falls and increases social participation among people with neurological conditions. Methods: Ninety people with Stroke (n = 25), multiple sclerosis (n = 33) and Parkinson disease (n = 32), median age 63 (31-89), were randomized. A permuted block algorithm stratified by field center was used to allocate participants to an education group (EG, n = 42) consisting of an educational program focused on fall prevention and tailored balance exercises and a control group (CG, n = 48) receiving usual treatments. After baseline assessment, each participants was followed for 6 months with telephone contacts by blinded interviewers. Being fallers (>1 fall) and time to become a faller were used as primary outcomes. Community Integration Questionnaire (CIQ) and Instrumental Activities of Daily Living (IADL) scales assessed treatment effects on social integration and daily living activities. Results: Over a median (Interquartile Range) follow-up of 189 (182-205) days, [EG = 188 (182-202), CG = 189 (182-209)] fallers were 10 in the CG and 11 in the EG (hazard ratio 0.95, 95% confidence interval (CI) 0.45 to 2.5; P = 0.94). At follow-up the EG scored significantly better than CG on the CIQ (+1.7 points, CI: 0.1 to 3.3) and IADL (+2.2 points, CI: 0.4 to 4.0). Conclusions: This educational program did not reduce the risk of falls but it improved the ability to carry out activities of daily living and decreased participation restrictions in people with neurological conditions.

Relearning functional and symmetric walking after stroke using a wearable device: a feasibility study

BACKGROUND

Gait impairment is a common consequence of stroke and typically involves a hemiparetic or asymmetric walking pattern. Asymmetric gait patterns are correlated with decreased gait velocity and efficiency as well as increased susceptibility to serious falls and injuries.

RESEARCH QUESTION

This paper presents an innovative device worn on a foot for gait rehabilitation post stroke. The device generates a backward motion to the foot, which is designed to exaggerate the existing step length asymmetry while walking over ground. We hypothesize this motion will decrease gait asymmetry and improve functional walking in individuals with chronic stroke.

METHODS

Six participants with chronic stroke, more than one year post stroke, received four weeks of gait training with three sessions per week. Each session included 30 min of walking over ground using the wearable device. Gait symmetry and functional walking were assessed before and after training.

RESULTS

All participants improved step length symmetry, and four participants improved double limb support symmetry. All participants improved on all three functional outcomes (gait velocity, Timed Up and Go Test, and 6-Minute Walk Test), and five participants improved beyond the minimal detectable change or meaningful change in at least one functional outcome.

CONCLUSION

The results indicate that the presented device may help improve stroke patients' walking ability and warrant further study. A gait training approach using this new device may enable and expand long-term continuous gait rehabilitation outside the clinic following stroke.

TRIAL REGISTRATION

NCT02185404. Registered July 9, 2014, https://clinicaltrials.gov/ct2/show/NCT02185404.

Effects of combining modern recovery techniques with neurotrophic medication and standard treatment in stroke patients

Stroke is the main cause of disability after age 65, leaving survivors with sequels that require care and recovery treatment lasting years. It is estimated that by the year 2030 this pathology will be leading cause of mortality. To determine the efficacy of Lokomat training combined with neurotrophic medication and balneo-physiotherapeutic treatment in rehabilitation of post-stroke patients, a prospective study of 3 parallel groups was conducted: Group I (n = 22) - Lokomat, balneo-physiotherapy, and Cerebrolysin; Group II (n = 18) - Lokomat associated with balneo-physiotherapy; and Group III (n = 30) - balneo-physiotherapy alone (Control group). Patients were evaluated physically, neurologically, and functionally, according to the evolution of their motor deficiency, spasticity, functional independence and health-related quality of life. Patient improvement is significantly better (p < 0.05) in the group with associated therapies, especially during the first 6 months. Evolution was significantly better in all groups at 12 months than initially (p < 0.05), for all studied parameters and with the best effects in Group I (the three therapies combined). Association of Lokomat training with neurotrophic factors and classic recovery techniques improves the rehabilitation process in stroke patients.

Quality Management Program of Stroke Rehabilitation Using Adherence to Guidelines: A Nationwide Initiative in Japan

BACKGROUND AND AIM

In recent years, interest in the quality of medical care has rapidly increased worldwide. However, quality indicators that contribute to establishing standard treatment in stroke medicine, especially rehabilitation, are not well-developed in Japan. Japan has established Kaifukuki (convalescent) rehabilitation wards, and the development of quality indicators for stroke rehabilitation in the convalescent phase is an urgent issue.

METHODS

We first reviewed the literature regarding quality indicators for stroke rehabilitation. Next, we extracted candidate indicators from identified reports and guidelines and surveyed educational hospitals certified by the Japanese Association of Rehabilitation Medicine. On the basis of the survey results, we reevaluated the suitability of the proposed indicators in discussions with an expert panel.

RESULTS

The questionnaire survey highlighted several important items that revealed there is room for improvement in adherence. For stroke rehabilitation in the convalescent phase, we adopted 15 indicators that were feasible as indicators to be used for comparisons between facilities, based on scoring by and opinions of the expert panel. These indicators measured structure (2 indicators), process (5 indicators), and outcome (8 indicators).

CONCLUSION

This is the first study to establish quality indicators to standardize stroke rehabilitation in Japan. We developed this set of 15 indicators using an evidence-based approach. However, many tasks remain for continuous quality improvement.

A shape-memory and spiral light-emitting device for precise multisite stimulation of nerve bundles

We previously demonstrated that for long-term spastic limb paralysis, transferring the seventh cervical nerve (C7) from the nonparalyzed side to the paralyzed side results in increase of 17.7 in Fugl-Meyer score. One strategy for further improvement in voluntary arm movement is selective activation of five target muscles innervated by C7 during recovery process. In this study, we develop an implantable multisite optogenetic stimulation device (MOSD) based on shape-memory polymer. Two-site stimulation of sciatic nerve bundles by MOSD induces precise extension or flexion movements of the ankle joint, while eight-site stimulation of C7 nerve bundles induce selective limb movement. Long-term implant of MOSD to mice with severed and anastomosed C7 nerve is proven to be both safe and effective. Our work opens up the possibility for multisite nerve bundle stimulation to induce highly-selective activations of limb muscles, which could inspire further applications in neurosurgery and neuroscience research.

Optogenetic stimulation of damaged peripheral nerves has advantages over electrical stimulation but it’s limited to single-site stimulation. Here the authors develop a spiral-shaped LED implant for precise optogenetic stimulation of peripheral nerve bundles at multiple sites and use it to induce distinct limb movements in mice.

Contralateral hemi-fifth-lumbar nerve transfer for unilateral lower limb dysfunction due to incomplete traumatic spinal cord injury: A report of two cases

Current strategies for the chronic stage of spinal cord injury (SCI) had seen little progress. In this report, we present the use of contralateral L5 nerve transfer for the treatment of incomplete SCI patients with unilateral lower limb dysfunction in two male patients. One was diagnosed with L2 vertebral fracture and dislocation combined with coni medullaris injury 10 months prior, and the other was diagnosed with T6 and T7 vertebral fractures with SCI 24 months prior. The patients were treated with decompression surgery within 24 hr after injury. The patients reached a recovery plateau after 6-8 months of spontaneous recovery of locomotion and sustained paralysis in the right leg and were left confined to the wheelchair. The score on the lower-extremity Fugl-Meyer assessment (FMA-LE) was 7 for both patients. The patients were then enrolled, and they underwent half of the anterior root of the contralateral L5 transfer to S1 and S2 to improve lower limb motor function. A posterior approach was performed to expose the L5, S1, and S2 nerve roots. Half of the anterior root of the left L5 was cut, and end-to-end neurorrhaphy from the left L5 to the right S1 and S2 was performed subdurally. After the surgery, routine rehabilitation treatments were prescribed. Muscle strength decreased transiently in the donor-side before recovering within 12 months postoperatively. Muscle strength was significantly improved on the affected side 2 years postoperatively, when the FMA-LE scores increased to 14 and 15, respectively. The patients regained independent walking ability with crutches. This report suggests that contralateral hemi-5th-lumbar nerve transfer is safe and can benefit incomplete SCI patients with unilateral lower limb dysfunction.

Effectiveness of occupation-based interventions on performance's quality for hemiparetic stroke in community-dwelling: A randomized clinical trial study

BACKGROUND

Occupations define activities that people perform to occupy themselves and that people have meaning and value to them. The use of occupation-based intervention addresses activity daily of living performance.

OBJECTIVES

This study was to investigate the effects of occupation-based interventions on performance's quality for hemiparetic stroke in community-dwelling.

METHODS

Forty-three participants were enrolled in this study with a full understanding of the purpose and method of the research and had a diagnosis with hemiparetic stroke. Participants were randomized to one of two treatment groups: Experimental group (n = 23) or control groups (n = 20). The experimental group applied occupation-based intervention and control group applied action focusing intervention. All participants underwent ten treatment sessions during the study period and conducted pre- and post-assessment. Several instruments were used to measure quality of performance.

RESULTS

After the intervention training, the qualities of occupational performance were significantly higher in the experimental group applied occupation-based intervention than the control group applied action focusing intervention (p < 0.001).

CONCLUSIONS

Based on the results of this study, occupation-based intervention has positive effects on quality of performing daily activities and occupational activities independently in persons with hemiparetic stroke.

C7 transfer in a posterior intradural approach for treating hemiplegic upper-limbs: hypothesis and a cadaver feasibility study

Objective: Contralateral C7 nerve root transfer surgery has been successfully applied to rescue motor function of a hemiplegic upper extremity in patients with central neurological injury. This surgical technique is challenging, and limited anatomical space makes it difficult to manipulate tissues and may lead to higher complication rates. The authors hypothesis a new surgical route in which cervical nerve roots of both donor and recipient sides are exposed from a posterior intradural approach and neurorrhaphy is performed easily and clearly. The feasibility of this operation is tested in a cadaver model. Methods: A fresh cadaver was placed prone. After a standard midline incision and extensive cervical laminectomy, the dura and arachnoid were widely opened, and the spinal nerve roots of C6, C7, and C8 were exposed bilaterally. Nerve grafting was attempted between pairs of donor and recipient nerve roots on contralateral sides of the spinal cord. After completion of neurorrhaphy, the dura was closed. Results: Precise neurorrhaphy could be performed intradurally between posterior and anterior nerve roots of C7 on both sides. Multiple anastomoses of C7 to various nerve roots on the contralateral side could also be performed within the same surgical field with an interposition nerve graft. Conclusion: The posterior intradural repair idea affords many advantages, the pathway is shorter and more straightforward, which provides more access to multiple nerve roots repair in one surgical field, and is more familiar to many neurosurgeons and spine surgeons. It may potentially be adapted for clinical use.

Novel Uses of Nerve Transfers

Nerve transfer surgery involves using a working, functional nerve with an expendable or duplicated function as a donor to supply axons and restore function to an injured recipient nerve. Nerve transfers were originally popularized for the restoration of motor function in patients with peripheral nerve injuries. However, more recently, novel uses of nerve transfers have been described, including nerve transfers for sensory reinnervation, nerve transfers for spinal cord injury and stroke patients, supercharge end-to-side nerve transfers, and targeted muscle reinnervation for the prevention and treatment of postamputation neuroma pain. The uses for nerve transfers and the patient populations that can benefit from nerve transfer surgery continue to expand. Awareness about these novel uses of nerve transfers among the medical community is important in order to facilitate evaluation and treatment of these patients by peripheral nerve specialists. A lack of knowledge of these techniques continues to be a major barrier to more widespread implementation.

Application of motor learning in neurorehabilitation: a framework for health-care professionals

Learning motor skills is an essential part of most rehabilitation processes. Facilitating and supporting motor learning is particularly challenging in neurological rehabilitation: patients who suffer from neurological diseases experience both physical limitations and difficulties of cognition and communication that affect and/or complicate the motor learning process. Therapists (e.g. physiotherapists and occupational therapists) who work in neurorehabilitation are therefore continuously searching for the best way to facilitate patients during these intensive learning processes. To support therapists in the application of motor learning, a framework was developed, integrating knowledge from the literature and the opinions and experiences of international experts. This article presents the framework, illustrated by cases from daily practice. The framework may assist therapists working in neurorehabilitation in making choices, implementing motor learning in routine practice, and supporting communication of knowledge and experiences about motor learning with colleagues and students. The article discusses the framework and offers suggestions and conditions given for its use in daily practice.

A Usability Study of a Serious Game in Cognitive Rehabilitation: A Compensatory Navigation Training in Acquired Brain Injury Patients

Acquired brain injury patients often report navigation impairments. A cognitive rehabilitation therapy has been designed in the form of a serious game. The aim of the serious game is to aid patients in the development of compensatory navigation strategies by providing exercises in 3D virtual environments on their home computers. The objective of this study was to assess the usability of three critical gaming attributes: movement control in 3D virtual environments, instruction modality and feedback timing. Thirty acquired brain injury patients performed three tasks in which objective measures of usability were obtained. Mouse controlled movement was compared to keyboard controlled movement in a navigation task. Text-based instructions were compared to video-based instructions in a knowledge acquisition task. The effect of feedback timing on performance and motivation was examined in a navigation training game. Subjective usability ratings of all design options were assessed using questionnaires. Results showed that mouse controlled interaction in 3D environments is more effective than keyboard controlled interaction. Patients clearly preferred video-based instructions over text-based instructions, even though video-based instructions were not more effective in context of knowledge acquisition and comprehension. No effect of feedback timing was found on performance and motivation in games designed to train navigation abilities. Overall appreciation of the serious game was positive. The results provide valuable insights in the design choices that facilitate the transfer of skills from serious games to real-life situations.

Trial of Contralateral Seventh Cervical Nerve Transfer for Spastic Arm Paralysis

BACKGROUND

Spastic limb paralysis due to injury to a cerebral hemisphere can cause long-term disability. We investigated the effect of grafting the contralateral C7 nerve from the nonparalyzed side to the paralyzed side in patients with spastic arm paralysis due to chronic cerebral injury.

METHODS

We randomly assigned 36 patients who had had unilateral arm paralysis for more than 5 years to undergo C7 nerve transfer plus rehabilitation (18 patients) or to undergo rehabilitation alone (18 patients). The primary outcome was the change from baseline to month 12 in the total score on the Fugl-Meyer upper-extremity scale (scores range from 0 to 66, with higher scores indicating better function). Results The mean increase in Fugl-Meyer score in the paralyzed arm was 17.7 in the surgery group and 2.6 in the control group (difference, 15.1; 95% confidence interval, 12.2 to 17.9; P<0.001). With regard to improvements in spasticity as measured on the Modified Ashworth Scale (an assessment of five joints, each scored from 0 to 5, with higher scores indicating more spasticity), the smallest between-group difference was in the thumb, with 6, 9, and 3 patients in the surgery group having a 2-unit improvement, a 1-unit improvement, or no change, respectively, as compared with 1, 6, and 7 patients in the control group (P=0.02). Transcranial magnetic stimulation and functional imaging showed connectivity between the ipsilateral hemisphere and the paralyzed arm. There were no significant differences from baseline to month 12 in power, tactile threshold, or two-point discrimination in the hand on the side of the donor graft.

RESULTS

The mean increase in Fugl-Meyer score in the paralyzed arm was 17.7 in the surgery group and 2.6 in the control group (difference, 15.1; 95% confidence interval, 12.2 to 17.9; P<0.001). With regard to improvements in spasticity as measured on the Modified Ashworth Scale (an assessment of five joints, each scored from 0 to 5, with higher scores indicating more spasticity), the smallest between-group difference was in the thumb, with 6, 9, and 3 patients in the surgery group having a 2-unit improvement, a 1-unit improvement, or no change, respectively, as compared with 1, 6, and 7 patients in the control group (P=0.02). Transcranial magnetic stimulation and functional imaging showed connectivity between the ipsilateral hemisphere and the paralyzed arm. There were no significant differences from baseline to month 12 in power, tactile threshold, or two-point discrimination in the hand on the side of the donor graft.

CONCLUSIONS

In this single-center trial involving patients who had had unilateral arm paralysis due to chronic cerebral injury for more than 5 years, transfer of the C7 nerve from the nonparalyzed side to the side of the arm that was paralyzed was associated with a greater improvement in function and reduction of spasticity than rehabilitation alone over a period of 12 months. Physiological connectivity developed between the ipsilateral cerebral hemisphere and the paralyzed hand. (Funded by the National Natural Science Foundation of China and others; Chinese Clinical Trial Registry number, 13004466 .).

No Racial Difference in Rehabilitation Therapy Across All Post-Acute Care Settings in the Year Following a Stroke

BACKGROUND AND PURPOSE

Black stroke survivors experience greater poststroke disability than whites. Differences in post-acute rehabilitation may contribute to this disparity. Therefore, we estimated racial differences in rehabilitation therapy utilization, intensity, and the number of post-acute care settings in the first year after a stroke.

METHODS

We used national Medicare data to study 186 168 elderly black and white patients hospitalized with a primary diagnosis of stroke in 2011. We tabulated the proportion of stroke survivors receiving physical, occupational, and speech and language therapy in each post-acute care setting (inpatient rehabilitation facility, skilled nursing facility, and home health agency), minutes of therapy, and number of transitions between settings. We then used generalized linear models to determine whether racial differences in minutes of physical therapy were influenced by demographics, comorbidities, thrombolysis, and markers of stroke severity.

RESULTS

Black stroke patients were more likely to receive each type of therapy than white stroke patients. Compared with white stroke patients, black stroke patients received more minutes of physical therapy (897.8 versus 743.4; P<0.01), occupational therapy (752.7 versus 648.9; P<0.01), and speech and language therapy (865.7 versus 658.1; P<0.01). There were no clinically significant differences in physical therapy minutes after adjustment. Blacks had more transitions (median, 3; interquartile range, 1-5) than whites (median, 2; interquartile range, 1-5; P<0.01).

CONCLUSIONS

There are no clinically significant racial differences in rehabilitation therapy utilization or intensity after accounting for patient characteristics. It is unlikely that differences in rehabilitation utilization or intensity are important contributors to racial disparities in poststroke disability.

Configurable, wearable sensing and vibrotactile feedback system for real-time postural balance and gait training: proof-of-concept

BACKGROUND

Postural balance and gait training is important for treating persons with functional impairments, however current systems are generally not portable and are unable to train different types of movements.

METHODS

This paper describes a proof-of-concept design of a configurable, wearable sensing and feedback system for real-time postural balance and gait training targeted for home-based treatments and other portable usage. Sensing and vibrotactile feedback are performed via eight distributed, wireless nodes or "Dots" (size: 22.5 × 20.5 × 15.0 mm, weight: 12.0 g) that can each be configured for sensing and/or feedback according to movement training requirements. In the first experiment, four healthy older adults were trained to reduce medial-lateral (M/L) trunk tilt while performing balance exercises. When trunk tilt deviated too far from vertical (estimated via a sensing Dot on the lower spine), vibrotactile feedback (via feedback Dots placed on the left and right sides of the lower torso) cued participants to move away from the vibration and back toward the vertical no feedback zone to correct their posture. A second experiment was conducted with the same wearable system to train six healthy older adults to alter their foot progression angle in real-time by internally or externally rotating their feet while walking. Foot progression angle was estimated via a sensing Dot adhered to the dorsal side of the foot, and vibrotactile feedback was provided via feedback Dots placed on the medial and lateral sides of the mid-shank cued participants to internally or externally rotate their foot away from vibration.

RESULTS

In the first experiment, the wearable system enabled participants to significantly reduce trunk tilt and increase the amount of time inside the no feedback zone. In the second experiment, all participants were able to adopt new gait patterns of internal and external foot rotation within two minutes of real-time training with the wearable system.

CONCLUSION

These results suggest that the configurable, wearable sensing and feedback system is portable and effective for different types of real-time human movement training and thus may be suitable for home-based or clinic-based rehabilitation applications.

Stem cell therapy for abrogating stroke-induced neuroinflammation and relevant secondary cell death mechanisms

Ischemic stroke is a leading cause of death worldwide. A key secondary cell death mechanism mediating neurological damage following the initial episode of ischemic stroke is the upregulation of endogenous neuroinflammatory processes to levels that destroy hypoxic tissue local to the area of insult, induce apoptosis, and initiate a feedback loop of inflammatory cascades that can expand the region of damage. Stem cell therapy has emerged as an experimental treatment for stroke, and accumulating evidence supports the therapeutic efficacy of stem cells to abrogate stroke-induced inflammation. In this review, we investigate clinically relevant stem cell types, such as hematopoietic stem cells (HSCs), mesenchymal stem cells (MSCs), endothelial progenitor cells (EPCs), very small embryonic-like stem cells (VSELs), neural stem cells (NSCs), extraembryonic stem cells, adipose tissue-derived stem cells, breast milk-derived stem cells, menstrual blood-derived stem cells, dental tissue-derived stem cells, induced pluripotent stem cells (iPSCs), teratocarcinoma-derived Ntera2/D1 neuron-like cells (NT2N), c-mycER(TAM) modified NSCs (CTX0E03), and notch-transfected mesenchymal stromal cells (SB623), comparing their potential efficacy to sequester stroke-induced neuroinflammation and their feasibility as translational clinical cell sources. To this end, we highlight that MSCs, with a proven track record of safety and efficacy as a transplantable cell for hematologic diseases, stand as an attractive cell type that confers superior anti-inflammatory effects in stroke both in vitro and in vivo. That stem cells can mount a robust anti-inflammatory action against stroke complements the regenerative processes of cell replacement and neurotrophic factor secretion conventionally ascribed to cell-based therapy in neurological disorders.

Addressing post-stroke care in rural areas with Peru as a case study. Placing emphasis on evidence-based pragmatism

Stroke is a major cause of death and disability, with most of its burden now affecting low- and middle-income countries (LMIC). People in rural areas of LMIC who have a stroke receive very little acute stroke care and local healthcare workers and family caregivers in these regions lack the necessary knowledge to assist them. Intriguingly, a recent rapid growth in cell-phone use and digital technology in rural areas has not yet been appropriately exploited for health care training and delivery purposes. What should be done in rural areas, at the community setting-level, where access to healthcare is limited remains a challenge. We review the evidence on improving post-stroke outcomes including lowering the risks of functional disability, stroke recurrence, and mortality, and propose some approaches, to target post-stroke care and rehabilitation, noting key challenges in designing suitable interventions and emphasizing the advantages mHealth and communication technologies can offer. In the article, we present the prevailing stroke care situation and technological opportunities in rural Peru as a case study. As such, by addressing major limitations in rural healthcare systems, we investigate the potential of task-shifting complemented with technology to utilize and strengthen both community-based informal caregivers and community healthcare workers.

Contralateral peripheral neurotization for a hemiplegic hindlimb after central neurological injury

OBJECTIVE Contralateral peripheral neurotization surgery has been successfully applied to rescue motor function of the hemiplegic upper extremity in patients with central neurological injury (CNI). It may contribute to strengthened neural pathways between the contralesional cortex and paretic limbs. However, the effect of this surgery in the lower extremities remains unknown. In the present study the authors explored the effectiveness and safety of contralateral peripheral neurotization in treating a hemiplegic lower extremity following CNI in adult rats. METHODS Controlled cortical impact (CCI) was performed on the hindlimb motor cortex of 36 adult Sprague-Dawley rats to create severe unilateral traumatic brain injury models. These CCI rats were randomly divided into 3 groups. At 1 month post-CCI, the experimental group (Group 1, 12 rats) underwent contralateral L-6 to L-6 transfer, 1 control group (Group 2, 12 rats) underwent bilateral L-6 nerve transection, and another control group (Group 3, 12 rats) underwent an L-6 laminectomy without injuring the L-6 nerves. Bilateral L-6 nerve transection rats without CCI (Group 4, 12 rats) and naïve rats (Group 5, 12 rats) were used as 2 additional control groups. Beam and ladder rung walking tests and CatWalk gait analysis were performed in each rat at baseline and at 0.5, 1, 2, 4, 6, 8, and 10 months to detect the skilled walking functions and gait parameters of both hindlimbs. Histological and electromyography studies were used at the final followup to verify establishment of the traumatic brain injury model and regeneration of the L6-L6 neural pathway. RESULTS In behavioral tests, comparable motor injury in the paretic hindlimbs was observed after CCI in Groups 1-3. Group 1 started to show significantly lower slip and error rates in the beam and ladder rung walking tests than Groups 2 and 3 at 6 months post-CCI (p < 0.05). In the CatWalk analysis, Group 1 also showed a higher mean intensity and swing speed after 8 months post-CCI and a longer stride length after 6 months post-CCI than Groups 2 and 3 (p < 0.05). Transection of L-6 resulted in transient skilled walking impairment in the intact hindlimbs in Groups 1 and 2 (compared with Group 3) and in the bilateral hindlimbs in Group 4 (compared with Group 5). All recovered to baseline level within 2 months. Histological study of the rat brains verified comparable injured volumes among Groups 1-3 at final examinations, and electromyography and toluidine blue staining indicated successful regeneration of the L6-L6 neural pathways in Group 1. CONCLUSIONS Contralateral L-6 neurotization could be a promising and safe surgical approach for improving motor recovery of the hemiplegic hindlimb after unilateral CNI in adult rats. Further investigations are needed before extrapolating the present conclusions to humans.

Description of an Occupational Therapy Intervention Aimed at Improving Outdoor Mobility

After a stroke people can find outdoor mobility difficult, but a targeted occupational therapy intervention has been shown to help people to get out of the house more often. This study describes the intervention.

The occupational therapists who provided the intervention kept records of the number and duration of therapy sessions, the goal of therapy and the activities undertaken. As part of the trial, functional and mobility outcome assessments were completed by the participants 4 and 10 months after recruitment and were used to compare the goals set with the goals achieved and the mobility performance.

Eighty-six participants were randomised to, and 78 received, the intervention. They received a median of 6 (mean 4.7, SD 1.9) sessions, with an average of 40 minutes per session. Sixty (77%) of the participants achieved their primary goal. Those who did not had greater functional limitations at the start of the study than those who did. Walking was the most common goal (17/78, 22%) and the most performed activity (135 times, 33%). Thirteen participants achieved walking and 12 of these were still walking outside at the 10-month assessment.

Three-quarters of people with stroke were therefore able to achieve their outdoor mobility goals after an occupational therapy intervention.

Results of the Belgian Sentinel Network of General Practitioners on the Involvement of Therapists in Stroke Rehabilitation

This study examines which therapists are involved in the rehabilitation of stroke survivors in Belgium at different points in time. A nationwide registration of stroke patients was provided by 199 and 189 family physicians working in sentinel practices for the years 2009 and 2010 respectively. 326 patients who were diagnosed with stroke were included. Patients with paralysis/paresis received significant more physiotherapy after one month (63%) compared to non-paralysed patients (38%) (P = 0.005). Residing in a nursing home was associated with higher proportions of patients receiving physiotherapy, both after one (P = 0.003) and six (P = 0.002) months. 31% of patients with aphasia were treated by a speech and language therapist after one month, which decreased after six months to 20%. After six months, the patients in a nursing home received significant more often speech and language therapy (P = 0.004), compared to patients living at home. The proportion of patients receiving stroke rehabilitation services provided by physiotherapists, speech/language therapists and occupational therapists is rather low, especially 6 months after the critical event.

Home-Based Physical Therapy for Individuals With Stroke in Thailand

In Thailand, individuals with stroke prefer to return home after being discharged from hospital and most of them have inconveniences to get to hospitals or clinics to receive physical therapy. Thus, home-based physical therapy (HBPT) might be an option. A retrospective pre-test and post-test study was conducted among 2,412 individuals with first stroke after receiving HBPT. It showed significant ( p < .0001) improvement in voluntary movement, postural balance, and activities of daily living (ADLs) in individuals with after-stroke duration of ≤20 years. Those with after-stroke duration of >20 years demonstrated significant development in voluntary movement ( p = .005) and postural balance ( p = .037), but not ADLs. In conclusion, HBPT improves voluntary movement, postural balance, and ADL in individuals following any period of first stroke, and might be an alternative service for them in Thailand.

Granulocyte Colony Stimulating Factor and Physiotherapy after Stroke: Results of a Feasibility Randomised Controlled Trial: Stem Cell Trial of Recovery EnhanceMent after Stroke-3 (STEMS-3 ISRCTN16714730)

Background

Granulocyte-colony stimulating factor (G-CSF) mobilises endogenous haematopoietic stem cells and enhances recovery in experimental stroke. Recovery may also be dependent on an enriched environment and physical activity. G-CSF may have the potential to enhance recovery when used in combination with physiotherapy, in patients with disability late after stroke.

Methods

A pilot 2 x 2 factorial randomised (1:1) placebo-controlled trial of G-CSF (double-blind), and/or a 6 week course of physiotherapy, in 60 participants with disability (mRS >1), at least 3 months after stroke. Primary outcome was feasibility, acceptability and tolerability. Secondary outcomes included death, dependency, motor function and quality of life measured 90 and 365 days after enrolment.

Results

Recruitment to the trial was feasible and acceptable; of 118 screened patients, 92 were eligible and 32 declined to participate. 60 patients were recruited between November 2011 and July 2013. All participants received some allocated treatment. Although 29 out of 30 participants received all 5 G-CSF/placebo injections, only 7 of 30 participants received all 18 therapy sessions. G-CSF was well tolerated but associated with a tendency to more adverse events than placebo (16 vs 10 patients, p = 0.12) and serious adverse events (SAE) (9 vs 3, p = 0.10). On average, patients received 14 (out of 18 planned) therapy sessions, interquartile range [12, 17]. Only a minority (23%) of participants completed all physiotherapy sessions, a large proportion of sessions (114 of 540, 21%) were cancelled due to patient (94, 17%) and therapist factors (20, 4%). No significant differences in functional outcomes were detected in either the G-CSF or physiotherapy group at day 90 or 365.

Conclusions

Delivery of G-CSF is feasible in chronic stroke. However, the study failed to demonstrate feasibility for delivering additional physiotherapy sessions late after stroke therefore a definitive study using this trial design is not supported. Future work should occur earlier after stroke, alongside on-going clinical rehabilitation.

Trial Registration

ISRCTN.com ISRCTN16714730

Moving Toward an Understanding of Disability in Older U.S. Stroke Survivors

OBJECTIVES

We test a comprehensive model of disability in older stroke survivors and determine the relative contribution of neighborhood, economic, psychological, and medical factors to disability.

METHOD

The sample consisted of 728 stroke survivors from the National Health and Aging Trends Study (NHATS), who were 65 years and older living in community settings or residential care. Confirmatory factor analysis and structural equation modeling were used to test relationships between neighborhood, socioeconomic, psychological, and medical factors, and disability.

RESULTS

Economic and medical context were associated with disability directly and indirectly through physical impairment. Neighborhood context was associated with disability, but was only marginally statistically significant ( p = .05). The effect of economic and neighborhood factors was small compared with that of medical factors.

DISCUSSION

Neighborhood and economic factors account for a portion of the variance in disability among older stroke survivors beyond that of medical factors.

Quantifying Change During Outpatient Stroke Rehabilitation: A Retrospective Regression Analysis

OBJECTIVE

To examine change and individual trajectories for balance, upper extremity motor capacity, and mobility in people poststroke during the time they received outpatient therapies.

DESIGN

Retrospective analyses of an observational cohort using hierarchical linear modeling.

SETTING

Outpatient rehabilitation.

PARTICIPANTS

Persons poststroke (N=366).

INTERVENTIONS

Usual outpatient physical and occupational therapy.

MAIN OUTCOMES MEASURES

Berg Balance Scale (BBS), Action Research Arm Test (ARAT), and walking speed were used to assess the 3 domains. Initial scores at the start of outpatient therapy (intercepts), rate of change during outpatient therapy (slopes), and covariance between slopes and intercepts were modeled as random effects. Additional variables modeled as fixed effects were duration (months of outpatient therapy), time (days poststroke), age (y), and inpatient status (if the patient went to an inpatient rehabilitation facility [IRF]).

RESULTS

A patient with average age and time started at 37 points on the BBS with a change of 1.8 points per month, at 35 points on the ARAT with a change of 2 points per month, and with a walking speed of .59m/s with a change of .09m/s per month. When controlling for other variables, patients started with lower scores on the BBS and ARAT or had slower walking speeds at admission if they started outpatient therapy later than average or went to an IRF.

CONCLUSIONS

Patients generally improved over the course of outpatient therapy, but there was considerable variability in individual trajectories. Average rates of change across all 3 domains were small.