Gender differences in post-stroke functional outcome at discharge from an intensive rehabilitation hospital

Female Enrollment in Rehabilitation Trials: A Systematic Review of Reporting Sex and Female Participation in Randomized Controlled Trials of Poststroke Upper Extremity Rehabilitation Over 50 Years

OBJECTIVE

To systematically assess the reporting of sex and the percentage of female participants in randomized controlled trials (RCTs) examining interventions for the post-stroke rehabilitation of upper extremity (UE) motor disorders.

DATA SOURCES

CINAHL, Embase, PubMed, Scopus and Web of Science were searched from 1960 to April 1, 2021. Additional articles were identified using the Evidence-Based Review of Stroke Rehabilitation.

STUDY SELECTION

Studies were eligible for inclusion if they (1) were RCTs or crossovers published in English, (2) ≥50% of participants were diagnosed and affected by stroke, (3) included adults ≥18 years old, and (4) applied an intervention to the hemiparetic UE as the primary objective of the study.

DATA EXTRACTION

Two investigators independently screened the title and abstracts, and duplicates were removed. A full-text review was done for studies that met all inclusion criteria. Data were extracted using a custom data extraction template in Covidence and were transferred to online Excel (V16) for data management. Study characteristics and extracted variables were summarized using standard descriptive statistics. Data analyses were performed using SPSS (V29.0).

DATA SYNTHESIS

A total of 1276 RCTs met inclusion criteria, and of these, 5.2% did not report results on sex, accounting for 5.6% of participants. Women have been underrepresented in stroke RCTs, accounting for 38.8% of participants. Female participation was greater in the acute poststroke phase than in the chronic and subacute phases. Over almost 5 decades, there has been a small decrease in the proportion of female participants in these trials.

CONCLUSIONS

Evidence-based medicine for the treatment and prevention of stroke is guided by results from RCTs. Generalizability depends on sufficient representation in clinical trials. Stakeholders, such as funders and journal editors, play a key role in encouraging researchers to enroll enough of both sexes and to report the presence or absence of sex differences in RCTs.

A Cross-Sectional Study: Determining Factors of Functional Independence and Quality of Life of Patients One Month after Having Suffered a Stroke

(1) Background: loss of quality of life (QoL) and functional independence are two of the most common consequences of suffering a stroke. The main objective of this research is to study which factors are the greatest determinants of functional capacity and QoL a month after suffering a stroke so that they can be considered in early interventions. (2) Methods: a cross-sectional study was conducted which sample consisted of 81 people who had previously suffered a stroke. The study population was recruited at the time of discharge from the Neurology Service and Stroke Unit of the hospitals of Burgos and Córdoba, Spain, through a consecutive sampling. Data were collected one month after participants experienced a stroke, and the main study variables were quality of life, measured with the Stroke-Specific Quality of Life Measure (NEWSQOL), and functional independence, measured with the Functional Independence Measure-Functional Assessment Measure (FIM-FAM). (3) Results: the factors associated with a worse QoL and functional capacity one month after having suffered a stroke were living in a different dwelling than the usual flat or house (p < 0.05), a worse cognitive capacity (p < 0.001) and a worse functional capacity of the affected upper limb (p < 0.001). A higher age was related to a worse functional capacity one month after suffering a stroke (p = 0.048). (4) Conclusions: the type of dwelling, age, cognitive ability and functional capacity of the affected upper limb are determining aspects in functional independence and QoL during the first weeks after a stroke.

Vascular Risk Factors in Ischemic Stroke Survivors: A Retrospective Study in Catalonia, Spain

Background: The distribution of vascular risk factors (VRFs) and stroke management vary by geographic area. Our aim was to examine the percentage of the VRFs according to age and sex in ischemic stroke survivors in a geographical area on the Mediterranean coast of Southern Catalonia, Spain. Methods: This was a multicenter, observational, retrospective, community-based study of a cohort, the data of which we obtained from digital clinical records of the Catalan Institute of Health. The study included all patients with a confirmed diagnosis of ischemic stroke who were treated between 1 January 2011 and 31 December 2020. Patients met the following inclusion criteria: residing in the study area, age ≥ 18 years, and presenting ≥1 modifiable vascular risk factor. The exclusion criteria were as follows: death patients (non-survivors) and patients without modifiable VRFs. We collected the demographic, clinical, and VRF variables of the total of 2054 cases included, and we analyzed the data according to age groups, sex, and number of VRFs. Results: Most of the patients included were in the 55−80 age group (n = 1139; 55.45%). Of the patients, 56.48% (n = 1160) presented ≤ 2 modifiable VRFs, and the age group <55 years old (67.01%) presented more VRFs. Hypertension and (>80 years old (38.82%)) and dyslipidemia (<55 years (28.33%)) were the most prevalent VRFs. In the age group 55−80 (69.59% men), the prevalence of VRFs was higher ((3−4 VRF (42.76%) and >4 VRF (5.35%)). Conclusions: These results suggest the presence of many VRFs in people diagnosed with ischemic stroke—although with a lower percentage compared to other studies—and the need for specific individualized interventions for the control of modifiable RFs related to primary and secondary prevention of stroke.

Sexual dimorphism in immune cell responses following stroke

Recent bodies of work in regard to stroke have revealed significant sex differences in terms of risk and outcome. While differences in sex hormones have been the focus of earlier research, the reasons for these differences are much more complex and require further identification. This review covers differences in sex related immune responses with a focus on differences in immune cell composition and function. While females are more susceptible to immune related diseases, they seem to have better outcomes from stroke at the experimental level with reduced pro-inflammatory responses. However, at the clinical level, the picture is much more complex with worse neurological outcomes from stroke. While the use of exogenous sex steroids can replicate some of these findings, it is apparent that many other factors are involved in the modulation of immune responses. As a result, more research is needed to better understand these differences and identify appropriate interventions and risk modification.

Gender Influences Virtual Reality-Based Recovery of Cognitive Functions in Patients with Traumatic Brain Injury: A Secondary Analysis of a Randomized Clinical Trial

The rehabilitation of cognitive deficits in individuals with traumatic brain injury is essential for promoting patients’ recovery and autonomy. Virtual reality (VR) training is a powerful tool for reaching this target, although the effectiveness of this intervention could be interfered with by several factors. In this study, we evaluated if demographical and clinical variables could be related to the recovery of cognitive function in TBI patients after a well-validated VR training. One hundred patients with TBI were enrolled in this study and equally randomized into the Traditional Cognitive Rehabilitation Group (TCRG: n = 50) or Virtual Reality Training Group (VRTG: n = 50). The VRTG underwent a VRT with BTs-N, whereas the TCRG received standard cognitive treatment. All the patients were evaluated by a complete neuropsychological battery before (T0) and after the end of the training (T1). We found that the VR-related improvement in mood, as well as cognitive flexibility, and selective attention were influenced by gender. Indeed, females who underwent VR training were those showing better cognitive recovery. This study highlights the importance of evaluating gender effects in planning cognitive rehabilitation programs. The inclusion of different repetitions and modalities of VR training should be considered for TBI male patients.

Beneficial Effects of Robot-Assisted Gait Training on Functional Recovery in Women after Stroke: A Cohort Study

Background and Objectives: Robot-assisted gait training (RAGT) could be a rehabilitation option for patients after experiencing a stroke. This study aims to determine the sex-related response to robot-assisted gait training in a cohort of subacute stroke patients considering mixed results previously reported. Materials and Methods: In this study, 236 participants (145 males, 91 females) were admitted to a rehabilitation facility after experiencing a stroke and performed RAGT within a multidisciplinary rehabilitation program. Functional Independence Measure (FIM) and Functional Ambulatory Category (FAC) were assessed at admission and discharge to determine sex-related outcomes. Results: At the baseline, no significant difference among sexes was observed. At the end of rehabilitation, both males and females exhibited significant improvements in FIM (71% of males and 80% of females reaching the MCID cut-off value) and FAC (∆score: men 1.9 ± 1.0; women 2.1 ± 1.1). A more remarkable improvement was observed in women of the whole population during the study, but statistical significance was not reached. When analysing the FAC variations with respect to the total number of RAGT sessions, a more significant improvement was observed in women than men (p = 0.025). Conclusion: In conclusion, among subacute stroke patients, benefits were observed following RAGT during a multidisciplinary rehabilitation program in both sexes. A greater significant recovery for women with an ischemic stroke or concerning the number of sessions attended was also highlighted. The use of gait robotics for female patients may favour a selective functional recovery after stroke.

Previous Disability and Benefit of Acute Phase Therapy in Functional Prognosis of Selected Patients with Ischemic Stroke

OBJECTIVES

Patients' previous disability (PD) is a key factor when considering acute stroke therapy. PD's exact impact on functional prognosis of patients with acute ischemic stroke remains not entirely clarified. We aimed to analyze PD's influence on functional outcome three months after ischemic stroke.

MATERIALS AND METHODS

Retrospective analysis of prospectively collected data concerning patients with acute ischemic stroke admitted to Stroke Unit of a tertiary center who underwent acute phase therapy between 2017 and 2019. Modified Rankin Scale (mRS) was used to define PD (with previous mRS≥3). Patients with PD were selected for treatment based on similar baseline characteristics to patients without PD. Patients were classified into two groups according to previous mRS: mRS<3 and mRS≥3. We defined bad outcome at three months after stroke as mRS≥3 for patients with previous mRS<3, and as a higher score than baseline mRS for patients with previous mRS≥3.

RESULTS

We identified 1169 eligible patients - 1016 patients with previous mRS<3 and 153 patients with previous mRS≥3. Most baseline characteristics did not differ significantly between them. For patients ≤75 years old, PD was associated with worse outcome (odds ratio estimate [OR] 4.50, p < 0.001). For patients >75 years old, PD was protective against worse outcome (OR 0.42, p < 0.001). In patients with previous mRS≥3 and >75 years old, there was a higher proportion of women (p = 0.005).

CONCLUSIONS

PD might not be a relevant factor when considering acute stroke therapy in selected patients >75 years old, especially women. Further studies are needed to clarify these findings.

The Route of Motor Recovery in Stroke Patients Driven by Exoskeleton-Robot-Assisted Therapy: A Path-Analysis

Background: Exoskeleton-robot-assisted therapy is known to positively affect the recovery of arm functions in stroke patients. However, there is a lack of evidence regarding which variables might favor a better outcome and how this can be modulated by other factors. Methods: In this within-subject study, we evaluated the efficacy of a robot-assisted rehabilitation system in the recovery of upper limb functions. We performed a path analysis using a structural equation modeling approach in a large sample of 102 stroke patients (age 63.6 ± 13.1 years; 61% men) in the post-acute phase. They underwent 7 weeks of bilateral arm training assisted by an exoskeleton robot combined with a conventional treatment (consisting of simple physical activity together with occupational therapy). The upper extremity section of the Fugl–Meyer (FM-UE) scale at admission was used as a predictor of outcome, whereas age, gender, side of the lesion, days from the event, pain scale, duration of treatment, and number of sessions as mediators. Results: FM-UE at admission was a direct predictor of outcome, as measured by the motricity index of the contralateral upper limb and trunk control test, without any other mediating factors. Age, gender, days from the event, side of lesion, and pain scales were independently associated with outcomes. Conclusions: To the best of our knowledge, this is the first study assessing the relationship between clinical variables and outcomes induced by robot-assisted rehabilitation with a path-analysis model. We define a new route for motor recovery of stroke patients driven by exoskeleton-robot-assisted therapy, highlighting the role of FM-UE at admission as a useful predictor of outcome, although other variables need to be considered in the time-course of disease.