Executive Function Is Associated With Off-Line Motor Learning in People With Chronic Stroke

Relationships Between Cognitive Impairments and Motor Learning After Stroke: A Scoping Review

BACKGROUND

Stroke is one of the leading causes of chronic disability worldwide. Sensorimotor recovery relies on principles of motor learning for the improvement of movement and sensorimotor function after stroke. Motor learning engages several cognitive processes to effectively learn and retain new motor skills. However, cognitive impairments are common and often coexist with motor impairments after stroke. The specific relationships between poststroke cognitive impairments and motor learning have not been determined.

OBJECTIVES

To summarize the existing evidence related to cognitive impairments and motor learning after stroke. Specific goals were to determine: (1) how motor learning is studied in individuals with poststroke cognitive impairments; (2) how cognitive impairments are assessed; (3) which cognitive domains impact motor learning.

RESULTS

Over 400 studies were screened for specific inclusion criteria and 19 studies that related poststroke cognitive impairments to motor learning were included. Studies used a wide variety of experimental designs, sample sizes, and measures for cognitive evaluation. Cognitive impairments impacting motor improvement and learning capacity after stroke were reported in all but 4 studies. The most common domains impacting motor learning were attention, executive function, and memory.

CONCLUSION

Detailed cognitive assessments, retention testing, and a combination of clinical and kinematic outcomes are recommended for future studies. The presence of specific cognitive impairments measured with sensitive instruments should be considered when designing effective training interventions for patients with stroke to maximize sensorimotor recovery.

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.

The Importance of Sleep for Successful Neurorehabilitation after Stroke

Sleep has important clinical implications for neurorehabilitation after stroke. We aimed to systematically explore sleep (including naps) as an essential factor in the neurorehabilitation of patients after stroke. After titles and abstracts were screened, 49 full texts were reviewed, and 7 were included in this review. Data were extracted and assessed for quality and risk of bias. We looked at any neurorehabilitation setting, and compared sleep with no sleep and explored these factors in stroke patients versus healthy individuals. Rehabilitation is critical for many activities that may need to be learned or re-learned following stroke and for returning to everyday life. In this context, sleep is essential in neurorehabilitation and physical therapy practice as it supports neuroplasticity, memory, and learning. The available data suggest that sleep should be considered in the treatment plan for successfully targeted physiotherapy to optimize cognitive and motor learning. Physical therapists should advise about sleep hygiene and therapies to improve sleep, both quality and quantity.

Sensitivity of conventional cognitive tests in multiple sclerosis: Application of item response theory

BACKGROUND

Cognitive impairment (CI) is common in Multiple Sclerosis (MS), and its prevalence rate ranges between 22% and 70%. Because CI significantly impacts vocational status, caregiver burden, and quality of life, an accurate neuropsychological assessment is required. Three widely used and validated batteries for MS-associated CI are the Brief Repeatable Neuropsychological Battery (BRN-B), the Minimal Assessment of Cognitive Function (MACFIMS), and the Brief International Cognitive Assessment (BICAMS). Although similar, these batteries differ in time-consuming and in specific tests employed. This study aims to assess the sensitivity of cognitive tests included in these batteries through an Item Response Theory approach.

METHODS

Ninety-seven patients with MS and 91 demographically matched controls (HC) were consecutively assessed using the three neuropsychological batteries (i.e., BRN-B, MACFIMS, and BICAMS). Continuous Response Model (CRM) was used to identify the cognitive test(s) that best discriminate patients with MS from HC. Receiver Operating Characteristic (ROC) curve analysis was used to determine the accuracy of the CRM results.

RESULTS

Cognitive tests loaded on two different latent variables: the 'higher-order executive functioning,' consisting of tests assessing concept formation, problem-solving, and inhibitory control, and the 'memory and information processing speed,' comprising tests assessing long-term, working memory, and information processing speed. The Delis Kaplan Executive Functioning System-Sorting Test and the Stroop Test were the most sensitive tests in differentiating cognitive functioning between MS and HC.

CONCLUSIONS

This study confirms the importance of including a more extensive executive assessment in MS clinical practice since higher-order executive functions (e.g., abstraction and inhibitory control) significantly impact patients' quality of life and functional autonomy. Clinical implications of careful dissection of executive functioning in MS neuropsychological assessment are discussed.

The efficacy and safety of agomelatine, sertraline, and escitalopram for senile post-stroke depression: A randomized double-blind placebo-controlled trial

OBJECTIVES

This study aims to investigate the efficacy and safety of agomelatine, sertraline, and escitalopram for patients with senile post-stroke depression (SPSD, aged over 65 years).

PATIENTS AND METHODS

A total of 165 patients (aged over 65 years) with post-stroke depression (PSD) were recruited. These patients were randomly assigned to one of four groups and given an anti-depressant or a placebo as follows: group A (agomelatine in combination with conventional cerebrovascular disease medication) 48 patients; group B (sertraline in combination with conventional cerebrovascular disease medication) 47 patients; group C (escitalopram in combination with conventional cerebrovascular disease medication) 50 patients; and, a control group (conventional treatment alone) 20 patients. The efficacy of the different treatments was evaluated using the Hamilton Depression Scale (HAMD), the National Institute of Health Stroke Scale (NIHSS), and the Activities of Daily Living (ADL) Barthel index (BI) at one, two, four, and six weeks after treatment began.

RESULTS

According to the HAMD, NIHSS score, and BI index, the patients who received one of the three antidepressant treatments showed significant improvement compared with the control group (p < 0.05), but there was no significant difference between the three groups receiving anti-depressant medication (p > 0.05). Laboratory tests showed that the general adverse effects of the treatments were mild in all three groups, and patients generally tolerated the treatments.

CONCLUSION

A decrease of HAMD and NIHSS scores and an increase in the BI index could be observed in the patients receiving agomelatine, sertraline, or escitalopram treatment. Thus, it would appear that the condition of SPSD in older patients can be improved with the use of either agomelatine, sertraline, or escitalopram.

Effectiveness of theta and gamma electroacupuncture for post-stroke patients on working memory and electrophysiology: study protocol for a double-center, randomized, patient- and assessor-blinded, sham-controlled, parallel, clinical trial

BACKGROUND

Practitioners of complementary and alternative medicine have suggested that electroacupuncture (EA) could improve post-stroke cognitive impairment, based on the clinical evidence. This study protocol is aimed at showing the effectiveness of theta and gamma EA for post-stroke patients on working memory (WM) and electrophysiology.

METHODS

After assessing their eligibility, 66 patients with stroke will be enrolled from two Chinese medicine hospitals and randomly divided into theta frequency EA group, gamma frequency EA group, and sham-EA group according to the ratio of 1:1:1. All patients will receive 20 sessions of EA procedures for 4 weeks. Patients in three groups will receive EA at two same acupoints in the head: Baihui (GV20) and Shenting (GV24). The frequency of the three groups of EA is set as follows: 6 Hz (theta-EA group), 40 Hz (gamma-EA group), and no current through the electrodes (sham EA). Patients and assessors will be blinded throughout the entire study. The primary outcome is the performance accuracy of 1-back task which is a frequently used measure of WM in cognitive neuroscience research contexts. Secondary outcome measures will include the response time of 1-back task, the Rivermead Behavioral Memory Test, Trail Making Test, Loewenstein Occupational Therapy Cognitive Assessment Scale, modified Barthel Index, and electroencephalogram (EEG) signals during 1-back tasks. A blinding index will be assessed. Data will be statistically analyzed by one-way ANOVA, at 5% of significance level.

DISCUSSION

We expect this double-center, randomized, patient- and assessor-blinded, sham-controlled, parallel, clinical trial to explore the effectiveness of theta and gamma EA therapy, compared with sham EA, for post-stroke WM.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2000031995 . Registered on 17 April 2020.

Association of affected lower limb flexor muscle strength with swing phase duration and gait speed in elderly post-stroke patients

BACKGROUND

Although several studies have shown an association of muscle weakness with gait speed (GS), no study has explored the relationship of muscle strength with swing phase duration and GS after stroke among the elderly in Saudi Arabia.

OBJECTIVE

To examine the association of affected ankle dorsiflexor and hip flexor muscle strength with swing phase duration and GS in the elderly with different stroke chronicity.

METHODS

In this cross-sectional study, we included a total of 60 post-stroke patients aged ≥55 years who were admitted in neurorehabilitation units between May 2017 and August 2018. Linear regression was employed to examine the association of muscle strength (measured using a handheld dynamometer) with swing phase duration and GS (both measured using the computerized Zebris-Mat).

RESULTS

The chronicity of the stroke was negatively associated (p < 0.05) with swing phase duration. The ankle dorsiflexor muscle strength was significantly associated with GS (β= 0.656, p = 0.041). In contrast, hip flexor muscle strength was significantly associated with GS (β= 0.574, p < 0.0001) even after adjusting for stroke chronicity (β= 0.561, p < 0.0001).

CONCLUSIONS

Stroke chronicity was the predictor that reduced swing phase duration. The ankle dorsiflexor muscle strength was associated with GS. However, the hip flexor muscle strength was associated with GS even after adjusting for stroke chronicity.

D-KEFS ST Failure Identifies Multiple Sclerosis Patients With Worse Objective and Self-Perceived Physical and Cognitive Disability

Background and Objectives: The Brief Repeatable Battery of Neuropsychological Test (BRB-NT) does not explore the executive functions. We combined BRB-NT and Delis-Kaplan Executive Function System Sorting Test (D-KEFS ST) to obtain a more comprehensive evaluation of cognitive impairment in Multiple Sclerosis (MS) patients.

Methods: 137 Relapsing Remitting MS (RRMS) patients underwent a detailed neuropsychological assessment including BRB-NT, D-KEFS ST and self-administrated questionnaires, namely the Multiple Sclerosis Neuropsychological Questionnaire (MSNQ), the Fatigue Severity Scale (FSS) and the Beck Depression Inventory-Second Edition (BDI-II).

Results: Fifty-four patients (39.4%) had normal scores in each item of both batteries (cognitive normal), while 64 patients (46.7%) failed in at least one test of BRB-NT but not of D-KEFS ST (BRB-NT impaired) and 18 (13.1%) failed in at least one test of both batteries (BRB-NT+D-KEFS ST impaired). Only one patient (0.7%) failed in D-KEFS ST, but not in BRB-NT and was excluded from further analysis. BRB-NT+D-KEFS ST impaired patients had a significant higher mean disease duration and median EDSS score (15.5 ± 13.6 years and 3.5, respectively) compared to those with only BRB-NT impaired (7.9 ± 9.2, p < 0.01 and 2.5, p < 0.05) and with cognitive normal patients (6.7 ± 9.4, p < 0.005 and 2.0, p < 0.01). SDMT was more frequently impaired in BRB-NT+D-KEFS ST impaired patients (77.8%) compared to only BRB-NT impaired ones (20.0%, p < 0.001). The failure in D-KEFS ST was associated with the number of failed BRB-NT items (OR 1.46, IC95% 1.07–1.99, p < 0.05) and with pathological SDMT z-value (OR 10.56, IC95% 2.50–44.66, p < 0.005). Compared to BRB-NT impaired patients and the cognitive normal ones, BRB-NT+D-KEFS ST impaired patients had significant higher MSNQ (p < 0.01) and BDI-II (p < 0.05) values.

Conclusion: D-KEFS ST did not increase the number of cognitively impaired MS patients identified by BRB-NT, but provided a more comprehensive evaluation of cognitive decline. D-KEFS ST identified a subgroup of patients with increased self-perception of cognitive decline, depression and higher physical disability.

A Game Changer: 'The Use of Digital Technologies in the Management of Upper Limb Rehabilitation'

Hemiparesis is a symptom of residual weakness in half of the body, including the upper extremity, which affects the majority of post stroke survivors. Upper limb function is essential for daily life and reduction in movements can lead to tremendous decline in quality of life and independence. Current treatments, such as physiotherapy, aim to improve motor functions, however due to increasing NHS pressure, growing recognition on mental health, and close scrutiny on disease spending there is an urgent need for new approaches to be developed rapidly and sufficient resources devoted to stroke disease. Fortunately, a range of digital technologies has led to revived rehabilitation techniques in captivating and stimulating environments. To gain further insight, a meta-analysis literature search was carried out using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) method. Articles were categorized and pooled into the following groups; pro/anti/neutral for the use of digital technology. Additionally, most literature is rationalised by quantitative and qualitative findings. Findings displayed, the majority of the inclusive literature is supportive of the use of digital technologies in the rehabilitation of upper extremity following stroke. Overall, the review highlights a wide understanding and promise directed into introducing devices into a clinical setting. Analysis of all four categories; (1) Digital Technology, (2) Virtual Reality, (3) Robotics and (4) Leap Motion displayed varying qualities both-pro and negative across each device. Prevailing developments on use of these technologies highlights an evolutionary and revolutionary step into utilizing digital technologies for rehabilitation purposes due to the vast functional gains and engagement levels experienced by patients. The influx of more commercialised and accessible devices could alter stroke recovery further with initial recommendations for combination therapy utilizing conventional and digital resources.