Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue following Stroke Practice Guidelines, Update 2015

Structural brain networks correlating with poststroke cognition

Cognitive deficits are a common and debilitating consequence of stroke, yet our understanding of the structural neurobiological biomarkers predicting recovery of cognition after stroke remains limited. In this longitudinal observational study, we set out to investigate the effect of both focal lesions and structural connectivity on poststroke cognition. Sixty-two patients with stroke underwent advanced brain imaging and cognitive assessment, utilizing the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE), at 3-month and 12-month poststroke. We first evaluated the relationship between lesions and cognition at 3 months using voxel-based lesion-symptom mapping. Next, a novel correlational tractography approach, using multi-shell diffusion-weighted magnetic resonance imaging (MRI) data collected at both time points, was used to evaluate the relationship between the white matter connectome and cognition cross-sectionally at 3 months, and longitudinally (12 minus 3 months). Lesion-symptom mapping did not yield significant findings. In turn, correlational tractography analyses revealed positive associations between both MoCA and MMSE scores and bilateral cingulum and the corpus callosum, both cross-sectionally at the 3-month stage, and longitudinally. These results demonstrate that rather than focal neural structures, a consistent structural connectome underpins the performance of two frequently used cognitive screening tools, the MoCA and the MMSE, in people after stroke. This finding should encourage clinicians and researchers to not only suspect cognitive decline when lesions affect these tracts, but also to refine their investigation of novel approaches to differentially diagnosing pathology associated with cognitive decline, regardless of the aetiology.

Perceptions of Post-Stroke Fatigue among Health Care Practitioners: A Qualitative Interview Study

Background and Objectives: Post-Stroke Fatigue (PSF) is a complex, multidimensional, debilitating condition that affects almost half of all stroke survivors. This study explored the perceptions of physiatrists, physiotherapists, and occupational therapists about PSF and their experiences in managing patients with PSF in Saudi Arabia. Materials and Methods: Qualitative semi-structured interviews were conducted with participants from three different groups: eight physiotherapists (PTs), eight occupational therapists (OTs), and eight physiatrists (DRs). Using purposive sampling, participants with at least one year of experience in the field of PSF management were invited to take part. The data were analysed using inductive thematic analysis. Results: Twenty-four health care participants (eight PTs, eight OTs, eight DRs) were recruited. Five overarching themes encompassing various subthemes and sub-subthemes were generated: 'knowledge about post-stroke fatigue', 'diagnosing post-stroke fatigue', 'treatment approach', 'lack of awareness about post-stroke fatigue', and 'domains to improve'. The data indicated that participants used various strategies to manage PSF, including dietary changes, sleep hygiene, exercise, and energy conservation. Conclusions: Participants acknowledged that they lacked PSF-related management skills, despite possessing adequate knowledge about the management of stroke. Their openness to participating in activities that would improve their ability to diagnose and manage PSF was particularly striking.

Evaluating the feasibility and acceptability of the Mood Assessment Post-Stroke (MAPS) mood screening training

Mood problems are common after stroke, and screening is recommended. Training may support staff knowledge and implementation of screening, but the feasibility of training programmes in the Australian healthcare system has not been formally established. This study aimed to assess the feasibility of a mood screening training for a multidisciplinary team (MDT) of stroke clinicians working in a post-acute inpatient rehabilitation service.Twelve staff from a rehabilitation service at a major hospital in Sydney, Australia participated in a 3-h interactive training session. The feasibility of running the course, assessment of knowledge gained via a consolidation exercise and quiz and acceptability of the training were assessed via focus groups.The in-person modality of the training hindered recruitment and assessment of participants' knowledge, though the actual measures themselves appeared appropriate. Nine participants provided feedback in two focus groups. Thematic analysis identified positive reactions to the training. However, low self-efficacy persisted and organisational/socio-cultural barriers to implementation emerged. Following training, the medical officers of the MDT had successfully implemented routine screening.Overall, the training appeared acceptable and to foster knowledge in staff. However, limitations to recruitment and administering evaluations were identified. The development of flexible online training may improve future evaluations of screening training programmes/pathways.

A systematic review and evaluation of post-stroke depression clinical practice guidelines

OBJECTIVE

Post-stroke depression is a depressive mood disorder that follows a cerebrovascular accident and is a burden on stroke patients. Its management is included in clinical practice guidelines focused on stroke, and the recommended treatment is selective serotonin reuptake inhibitors in conjunction with psychotherapy. Clinical practice guidelines are recommendations used to standardize best medical practice, but there is no current evaluation of guidelines containing post stroke depression recommendations. Thus, the objective is to appraise the selected guidelines manner of development and quality.

MATERIALS AND METHODS

A systematic literature review across three databases and a manual google search was performed to collect guidelines that included recommendations on the management of post-stroke depression. 1236 guidelines were screened, and 27 were considered for inclusion. Considered guidelines were manually reviewed by the authors, and ultimately, 7 met inclusion criteria. The appraisal of guidelines for research and evaluation was used to evaluate these guidelines' recommendations around post-stroke depression.

RESULTS

Three guidelines met the threshold considered "High", with all of them having five or more quality domains eclipse the cutoff score of 70%. Across all guidelines, the highest scoring domains were "Scope and Purpose", "Clarity of Presentation", and "Editorial Independence" with scores of 76.98%, 73.81%, and 91.36% respectively. The lowest scoring domains were "Applicability", "Rigor of Development", and "Stakeholder Involvement" with respective scores of 58.73%, 54.02%, and 43.90%.

CONCLUSIONS

The domains "Applicability", "Rigor of Development," and "Stakeholder Involvement" were the lowest scoring domains. These specific domains represent areas in which future guidelines could be more developed.

A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization

BACKGROUND

There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines.

AIMS

To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced).

SUMMARY OF REVIEW

Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited.

CONCLUSION

The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.

A systematic review of auricular therapy for poststroke cognitive impairment and dementia: A protocol for systematic review and meta-analysis

BACKGROUND

Post-stroke cognitive impairment and dementia (PSCID) is the main source of morbidity and mortality after stroke worldwide. It is one consequence of ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. Cognitive impairment and dementia after the clinical stroke may contribute to the clinical expression of PSCID, which are prevalent clinical symptoms, especially in the elderly. Current problems in the field of PSCID are related to a lack of harmonization of the classification and definition, deficiency of well-defined diagnosis, deficiency of standardized and objective treatment plans, etc. Auricular therapy can effectively improve the symptoms of patients with PSCID. However, there has been no systematic review of auricular therapy for PSCID. This study aimed to evaluate the efficacy and safety of auricular therapy in patients with PSCID.

METHODS

Before December 2022, a systematic literature search was conducted using the following databases: PubMed, Embase, SinoMed (previously called the Chinese Biomedical Database), Web of Science, Chinese National Knowledge Infrastructure, and Wanfang Database. Review Manager software (version 5.3) will be used for statistical analysis; otherwise, descriptive analysis or subgroup analysis will be conducted. The quality of evidence for outcomes will be assessed with the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

This meta-analysis further confirmed the beneficial effects of auricular therapy in patients with PSCID.

CONCLUSION

This study investigated the efficacy and safety of auricular therapy in patients with PSCID, providing clinicians and patients with additional options for this disease.

Men Are at Higher Risk of Screening Positive for Vascular Cognitive Impairment Compared to Women after Stroke and Transient Ischemic Attack

While women have greater incidence of dementia, men have higher prevalence of vascular risk factors. This study examined sex differences in risk of screening positive for cognitive impairment after stroke. Ischemic stroke/TIA patients (N = 5969) participated in this prospective, multi-centered study, which screened for cognitive impairment using a validated brief screen. Men showed a higher risk of screening positive for cognitive impairment after adjusting for age, education, stroke severity, and vascular risk factors, suggesting that other factors may be contributing to increased risk among men (OR = 1.34, CI 95% [1.16, 1.55], p < 0.001). The effect of sex on cognitive impairment after stroke warrants further attention.

The Value of Bayesian Methods for Accurate and Efficient Neuropsychological Assessment

OBJECTIVE

Clinical neuropsychology has been slow in adopting novelties in psychometrics, statistics, and technology. Researchers have indicated that the stationary nature of clinical neuropsychology endangers its evidence-based character. In addition to a technological crisis, there may be a statistical crisis affecting clinical neuropsychology. That is, the frequentist null hypothesis significance testing framework remains the dominant approach in clinical practice, despite a recent surge in critique on this framework. While the Bayesian framework has been put forward as a viable alternative in psychology in general, the possibilities it offers to clinical neuropsychology have not received much attention.

METHOD

In the current position paper, we discuss and reflect on the value of Bayesian methods for the advancement of evidence-based clinical neuropsychology.

RESULTS

We aim to familiarize clinical neuropsychologists and neuropsychological researchers to Bayesian methods of inference and provide a clear rationale for why these methods are valuable for clinical neuropsychology.

CONCLUSION

We argue that Bayesian methods allow for a more intuitive answer to our diagnostic questions and form a more solid foundation for sequential and adaptive diagnostic testing, representing uncertainty about patients' observed test scores and cognitive modeling of test results.

Can exercise training promote better sleep and reduced fatigue in people with chronic stroke? A systematic review

Poor sleep and chronic fatigue are common in people with chronic stroke (i.e. ≥ 6 months post-stroke). Exercise training is a viable, low-cost therapy for promoting sleep and reducing fatigue; however, the effects of exercise on sleep and fatigue in people with chronic stroke are unclear. Thus, we conducted a systematic review ascertaining the effects of exercise on sleep and fatigue in people with chronic stroke. We systematically searched EMBASE, MEDLINE, AgeLine, the Cochrane Database of Systematic Reviews, CINAHL, SPORTDiscus, SCOPUS, and reference lists of relevant reviews for articles that examined the effects of exercise on sleep or fatigue in chronic stroke. Search results were limited to adults ≥ 18 years, randomized controlled trials, non-randomized trials, and pre-post studies, which were published in English and examined the effects of exercise on sleep or fatigue in people with chronic stroke. We extracted study characteristics and information on the measurement of sleep and fatigue, and assessed study quality and risk of bias using the CONSORT criteria and Cochrane risk-of-bias tool, respectively. We found two studies that examined the effects of exercise on sleep, and two that examined the effects of exercise on fatigue. All studies reported positive effects of exercise training on sleep and fatigue; however, there were concerns of bias and study quality in all studies. There is preliminary evidence that exercise promotes sleep and reduces fatigue in people with chronic stroke; however, the extent to which exercise impacts these health parameters is unclear.

Occupational Therapy-Based Energy Management Education in People with Post-COVID-19 Condition-Related Fatigue: Results from a Focus Group Discussion

Persons with post-COVID-19 conditions have prolonged symptoms and longer-term consequences which can prevent them from returning to previous everyday functioning. Fatigue is the most frequent symptom reported in literature. Occupational therapists (OTs) are specialized in client-centered problem analysis, counseling, and education to recover occupational engagement and performance in everyday life. Since the beginning of the COVID-19 pandemic, OTs have been challenged to respond with services adequate to the needs of this patient group. Energy management education (EME) was initially developed for persons with multiple sclerosis-related fatigue and then made independent of diagnosis suitable to persons living with chronic disease-related fatigue. EME, a structured self-management education, is becoming a part of the new services. This study was aimed at exploring the initial experiences of OTs using the EME protocol and materials with persons with postacute COVID-19 and/or post-COVID-19 condition-related fatigue and gathering their recommendations for improvements and adaptions. One online focus group discussion took place in May 2021 with OTs experienced in using the EME protocol. The topics addressed were the institutional context of the OTs and their experiences during the treatment. A thematic analysis was performed. According to nine OTs working in different settings in Switzerland, the EME protocol is exploitable in both in- and outpatient settings and was judged appropriate by them, even if the EME materials can be improved. The main challenges for the OTs were the short period their patients had lived with fatigue; the discrepancy between self-concept, self-perception, and performance; and the insecurity, fear, and anxiety related to recovery. Further research is needed to include the perspective of EME participants and to measure quantitative outcomes such as fatigue impact, self-efficacy, occupational performance, and quality of life. Until the existing EME protocol is improved, it is applicable to persons with post-COVID-19 condition-related fatigue.

Clinician perspectives on implementing a team-based metacognitive strategy training approach to stroke rehabilitation

INTRODUCTION

The objective of this research study was to explore site and clinician specific experiences, successes and challenges in implementing a complex intervention (cognitive orientation to daily occupational performance approach) to enhance stroke team's ability to address cognitive impairments as part of comprehensive stroke rehabilitation.

METHODS

A focus group was held with clinicians from five study sites, all rehabilitation stroke hospitals in a large urban setting, to discuss implementation experiences. Participants were clinicians (site champions) from each of the five participating stroke program study sites and included four occupational therapists, three physiotherapists and one speech-language pathologist. Thematic analysis was used to identify themes that represented clinicians' perspectives.

RESULTS

Implementing this complex team-based intervention was influenced by three themes-organizational support, experiential evidence, and clinicians' perspectives. Continued implementation of the intervention following the withdrawal of study support was represented on a continuum that ranged from not using the approach at all to implementing it with all patients. Sites where managers encouraged and supported use of the intervention within teams (organization support), continued to use it after the study support period as did clinicians who were willing to try new interventions (clinicians' perspectives). Development of iterative conclusions through implementation or attempts to implement the intervention had both positive and negative effects on continued implementation (experiential evidence).

CONCLUSIONS

Strategies that reinforce development of positive experiential evidence and building organizational support for innovative practice were found to be useful adjuncts in facilitating implementation of complex interprofessional interventions.

Dual guidance structure for evaluation of patients with unclear diagnosis in centers for rare diseases (ZSE-DUO): study protocol for a controlled multi-center cohort study

Background

In individuals suffering from a rare disease the diagnostic process and the confirmation of a final diagnosis often extends over many years. Factors contributing to delayed diagnosis include health care professionals' limited knowledge of rare diseases and frequent (co-)occurrence of mental disorders that may complicate and delay the diagnostic process. The ZSE-DUO study aims to assess the benefits of a combination of a physician focusing on somatic aspects with a mental health expert working side by side as a tandem in the diagnostic process.

Study design

This multi-center, prospective controlled study has a two-phase cohort design.

Methods

Two cohorts of 682 patients each are sequentially recruited from 11 university-based German Centers for Rare Diseases (CRD): the standard care cohort (control, somatic expertise only) and the innovative care cohort (experimental, combined somatic and mental health expertise). Individuals aged 12 years and older presenting with symptoms and signs which are not explained by current diagnoses will be included. Data will be collected prior to the first visit to the CRD’s outpatient clinic (T0), at the first visit (T1) and 12 months thereafter (T2).

Outcomes

Primary outcome is the percentage of patients with one or more confirmed diagnoses covering the symptomatic spectrum presented. Sample size is calculated to detect a 10 percent increase from 30% in standard care to 40% in the innovative dual expert cohort. Secondary outcomes are (a) time to diagnosis/diagnoses explaining the symptomatology; (b) proportion of patients successfully referred from CRD to standard care; (c) costs of diagnosis including incremental cost effectiveness ratios; (d) predictive value of screening instruments administered at T0 to identify patients with mental disorders; (e) patients’ quality of life and evaluation of care; and f) physicians’ satisfaction with the innovative care approach.

Conclusions

This is the first multi-center study to investigate the effects of a mental health specialist working in tandem with a somatic expert physician in CRDs. If this innovative approach proves successful, it will be made available on a larger scale nationally and promoted internationally. In the best case, ZSE-DUO can significantly shorten the time to diagnosis for a suspected rare disease.

Trial registration ClinicalTrials.gov; Identifier: NCT03563677; First posted: June 20, 2018, https://clinicaltrials.gov/ct2/show/NCT03563677.

Prevalence of dementia in ischaemic or mixed stroke populations: systematic review and meta-analysis

An understanding of the epidemiology of poststroke dementia (PSD) is necessary to inform research, practice and policy. With increasing primary studies, a contemporary review of PSD could allow for analyses of incidence and prevalence trends. Databases were searched using a prespecified search strategy. Eligible studies described an ischaemic or mixed stroke cohort with prospective clinical assessment for dementia. Pooled prevalence of dementia was calculated using random-effects models at any time after stroke (primary outcome) and at 1 year (range: 6-18 months), stratified for inclusion of prestroke dementia. Meta-regression explored the effect of year of study. Sensitivity analyses removed low-quality or outlier studies. Of 12 505 titles assessed, 44 studies were included in the quantitative analyses. At any time point after stroke, the prevalence of PSD was 16.5% (95% CI 10.4% to 25.1%) excluding prestroke dementia and 22.3% (95% CI 18.8% to 26.2%) including prestroke dementia. At 1 year, the prevalence of PSD was 18.4% (95% CI 7.4% to 38.7%) and 20.4% (95% CI 14.2% to 28.2%) with prestroke dementia included. In studies including prestroke dementia there was a negative association between dementia prevalence and year of study (slope coefficient=-0.05 (SD: 0.01), p<0.0001). Estimates were robust to sensitivity analyses. Dementia is common following stroke. At any point following stroke, more than one in five people will have dementia, although a proportion of this dementia predates the stroke. Declining prevalence of prestroke dementia may explain apparent reduction in PSD over time. Risk of dementia following stroke remains substantial and front-loaded, with high prevalence at 1 year post event.

The Clock Drawing Test as a predictor of cognitive decline in non-demented stroke patients

BACKGROUND

The early detection of patients at risk of post-stroke cognitive impairment (PSCI) may help planning subacute and long-term care. We aimed to determine the predictivity of two screening cognitive tests on the occurrence of mild cognitive impairment or dementia in acute stroke patients.

METHODS

A cognitive assessment within a few days of ischemic or hemorrhagic stroke was performed in patients consecutively admitted to a stroke unit over 14 months by means of the Clock Drawing Test (CDT) and the Montreal Cognitive Assessment-Basic (MoCA-B).

RESULTS

Out of 191 stroke survivors who were non-demented at baseline, 168 attended at least one follow-up visit. At follow-up (mean duration ± SD 12.8 ± 8.7 months), 28 (18.9%) incident cases of MCI and 27 (18%) cases of dementia were recorded. In comparison with patients who remained cognitively stable at follow-up, these patients were older, less educated, had more comorbidities, a higher score on the National Institutes of Health Stroke Scale (NIHSS) at admission, more severe cerebral atrophy, and lower MoCA-B and CDT scores at baseline. In multi-adjusted (for age, education, comorbidities score, NIHSS at admission and atrophy score) model, a pathological score on baseline CDT (< 6.55) was associated with a higher risk of PSCI at follow-up (HR 2.022; 95% CI 1.025-3.989, p < 0.05) with respect to non-pathological scores. A pathological baseline score on MoCA-B (< 24) did not predict increased risk of cognitive decline at follow-up nor increased predictivity of stand-alone CDT.

CONCLUSION

A bedside cognitive screening with the CDT helps identifying patients at higher risk of PSCI.

Effects of Combined Cognitive and Exercise Interventions on Poststroke Cognitive Function: A Systematic Review and Meta-Analysis

Objective

We investigated combined cognitive and exercise interventions in the literature and summarized their effectiveness in improving poststroke cognitive impairment (PSCI). Data Sources. Electronic databases and trial registries were searched from their inception until July 2020. Study Selection. Trials were collected with the following study inclusion criteria: (1) patients over 18 years of age who were diagnosed with PSCI; (2) combined cognitive-exercise interventions, regardless of the order of the two types of interventions or whether they were administered simultaneously; (3) any control group studied at the same time that was deemed acceptable, including no intervention/routine care, delayed intervention, sham intervention, and passive training; (4) the use of any validated cognitive neuropsychological test to evaluate cognitive function; and (5) clinically administered random trials with controls. Data Extraction. Five randomized controlled trials met the inclusion criteria. Two reviewers independently assessed the eligibility of the full texts and methodological quality of the included studies using the Cochrane risk of bias tool. Inconsistent results were resolved by additional discussion or decided by a third examiner, if necessary. Data Analysis. Meta-analysis demonstrated that the combined interventions had a significant effect on executive function and working memory [Stroop test (time), standardized mean difference (SMD) = 0.42, 95% confidence interval (CI): 0.80–0.04, p = 0.02; Trail Making Test, SMD = 0.49, 95% CI: 0.82–0.16, p = 0.004; Forward Digit Span Test, SMD = 0.91, 95% CI: 0.54–1.29, p ≤ 0.001]. While it was impossible to conduct a meta-analysis of global cognitive function and other cognitive domains, individual experiments demonstrated that the combined interventions played a significant role in global cognition, reasoning ability, logical thinking, and visual-spatial memory function.

Conclusions

Our analyses demonstrated that the combined interventions had a significant effect on the improvement of PSCI, particularly in terms of executive function. However, the moderate risk of bias in the included trials and the small number of relevant studies indicated a need for more uniform diagnostic and evaluation criteria, and larger trials would provide stronger evidence to better understand the effectiveness of the combined interventions. This trial is registered with trial registration number INPLASY202160090.

A Nationwide Multi-Center Questionnaire Survey on the Real-World State and Clinical Management of Poststroke Dementia in Japan

Background:

Poststroke dementia (PSD) is a serious problem for stroke survivors. However, there is still limited data on the real-world state and clinical management of PSD worldwide, and several countries already have a super-aged society.

Objective:

We conducted a nationwide questionnaire survey to examine the real-world state and management of PSD in Japan.

Methods:

A survey was conducted in the top 500 Japanese hospitals regarding the number of stroke patients treated between July 2018 and August 2019. Thirteen questions regarding PSD were mailed to doctors responsible for stroke management.

Results:

Responses were obtained from 251 hospitals (50.2%). The chief doctors responsible for stroke management answered the questionnaires. The median numbers of patients admitted annually with stroke in the departments of neurology and neurosurgery in the hospitals were 281.0 (interquartile range [IQR], 231.8–385.3) and 253.5 (IQR, 210.0–335.3), respectively, and most hospitals were acute care hospitals. Executive dysfunction was the most common cognitive dysfunction (10.9%), followed by amnesia (9.5%) and apathy (4.1%). Surprisingly, many stroke survivors lived alone at home (23.7%). Montreal Cognitive Assessment was significantly uncommon compared to Mini-Mental State Examination (p < 0.01). Furthermore, objective evaluation tests for behavioral and psychological symptoms of dementia were not often performed. Cognitive rehabilitation treatments were performed more often and earlier than drug treatments. The first drug of choice for PSD was predominantly donepezil (79.1%), followed by galantamine (6.1%), cilostazol (4.9%), memantine (2.5%), and rivastigmine (1.8%).

Conclusion:

Our study provides real-world evidence for the state of clinical practice related to PSD in Japan.

Reporting quality evaluation of the stroke clinical practice guidelines: a systematic review

OBJECTIVES

To analyze the effectiveness and quality of stroke clinical practice guidelines (CPGs) published in recent years in order to guide future guideline developers to develop better guidelines.

PARTICIPANTS

No patient involved METHOD: PubMed, China Biology Medicine (CBM), Wanfang, CNKI, and CPG-relevant websites were searched from January 2015 to December 2019 by two researchers independently. The RIGHT (Reporting Items for Practice Guidelines in Healthcare) checklist was used to assess the reporting quality in terms of domains and items. Then, a subgroup analysis of the results was performed.

PRIMARY AND SECONDARY OUTCOME MEASURES

RIGHT checklist reporting rate RESULTS: A total of 66 CPGs were included. Twice as many CPGs were published internationally as were published in China. More than half were updated. Most CPGs are published in journals, developed by societies or associations, and were evidence-based grading. The average reporting rate for all included CPGs was 47.6%. Basic information got the highest (71.7% ± 19.7%) reporting rate, while review and quality assurance got the lowest (22.0% ± 24.6%). Then, a cluster analysis between countries, publishing channels, and institutions was performed. There were no statistically significant differences in the reporting quality on the CPGs between publishing countries (China vs. international), publishing channels (journals vs. websites), and institutions (associations vs. non-associations).

CONCLUSIONS

Current stroke CPGs reports are of low quality. We recommend that guideline developers improve the quality of reporting of key information and improve the management of conflicts of interest. We recommend that guideline developers consider the RIGHT checklist as an important tool for guideline development.

TRIAL REGISTRATION

https://doi.org/10.17605/OSF.IO/PBWUX .

Quality of stroke guidelines in low- and middle-income countries: a systematic review

OBJECTIVE

To identify gaps in national stroke guidelines that could be bridged to enhance the quality of stroke care services in low- and middle-income countries.

METHODS

We systematically searched medical databases and websites of medical societies and contacted international organizations. Country-specific guidelines on care and control of stroke in any language published from 2010 to 2020 were eligible for inclusion. We reviewed each included guideline for coverage of four key components of stroke services (surveillance, prevention, acute care and rehabilitation). We also assessed compliance with the eight Institute of Medicine standards for clinical practice guidelines, the ease of implementation of guidelines and plans for dissemination to target audiences.

FINDINGS

We reviewed 108 eligible guidelines from 47 countries, including four low-income, 24 middle-income and 19 high-income countries. Globally, fewer of the guidelines covered primary stroke prevention compared with other components of care, with none recommending surveillance. Guidelines on stroke in low- and middle-income countries fell short of the required standards for guideline development; breadth of target audience; coverage of the four components of stroke services; and adaptation to socioeconomic context. Fewer low- and middle-income country guidelines demonstrated transparency than those from high-income countries. Less than a quarter of guidelines encompassed detailed implementation plans and socioeconomic considerations.

CONCLUSION

Guidelines on stroke in low- and middle-income countries need to be developed in conjunction with a wider category of health-care providers and stakeholders, with a full spectrum of translatable, context-appropriate interventions.

Obstacle Avoidance and Dual-Tasking During Reaching While Standing in Patients With Mild Chronic Stroke

Background. Poststroke individuals use their paretic arms less often than expected in daily life situations, even when motor recovery is scored highly in clinical tests. Real-world environments are often unpredictable and require the ability to multitask and make decisions about rapid and accurate arm movement adjustments. Objective. To identify whether and to what extent cognitive-motor deficits in well-recovered individuals with stroke affect the ability to rapidly adapt reaching movements in changing cognitive and environmental conditions. Methods. Thirteen individuals with mild stroke and 11 healthy controls performed an obstacle avoidance task in a virtual environment while standing. Subjects reached for a virtual juice bottle with their hemiparetic arm as quickly as possible under single- and dual-task conditions. In the single-task condition, a sliding glass door partially obstructed the reaching path of the paretic arm. A successful trial was counted when the subject touched the bottle without the hand colliding with the door. In the dual-task condition, subjects repeated the same task while performing an auditory-verbal working memory task. Results. Individuals with stroke had significantly lower success rates than controls in avoiding the moving door in single-task (stroke: 51.8 ± 21.2%, control: 70.6 ± 12.7%; P = .018) and dual-task conditions (stroke: 40.0 ± 27.6%, control: 65.3 ± 20.0%; P = .015). Endpoint speed was lower in stroke subjects for successful trials in both conditions. Obstacle avoidance deficits were exacerbated by increased cognitive demands in both groups. Individuals reporting greater confidence using their hemiparetic arm had higher success rates. Conclusion. Clinically well-recovered individuals with stroke may have persistent deficits performing a complex reaching task.

Post-stroke fatigue: A factor associated with inability to return to work in patients <60 years-A 1-year follow-up

This study investigated the association between post-stroke fatigue and inability to return to work/drive in young patients aged <60 years with first stroke who were employed prior to infarct while controlling for stroke severity, age, extent of disability, cognitive function, and depression. The Fatigue Severity Scale (FSS) was used to evaluate post-stroke fatigue in this 1-year prospective cohort study. Follow-ups were completed at 3, 6, and 12 months post rehabilitation discharge. A total of 112 patients were recruited, 7 were excluded, due to loss to follow-up (n = 6) and being palliative (n = 1), resulting in 105 participants (71% male, average age 49 ±10.63 years). Stroke patients receiving both inpatient and outpatient rehabilitation were consecutively recruited. Persistent fatigue remained associated with inability to return to work when controlling for other factors at 3 months (adjusted OR = 18, 95% CI: 2.9, 110.3, p = 0.002), 6 months (adjusted OR = 29.81, 95% CI: 1.7, 532.8, p = 0.021), and 12 months (adjusted OR = 31.6, 95% CI: 1.8, 545.0, p = 0.018). No association was found between persistent fatigue and return to driving. Fatigue at admission was associated with inability to return to work at 3 months but not return to drive. Persistent fatigue was found to be associated with inability to resume work but not driving. It may be beneficial to routinely screen post-stroke fatigue in rehabilitation and educate stroke survivors and employers on the impacts of post-stroke fatigue on return to work.

Primary Care of Adult Patients After Stroke: A Scientific Statement From the American Heart Association/American Stroke Association

Primary care teams provide the majority of poststroke care. When optimally configured, these teams provide patient-centered care to prevent recurrent stroke, maximize function, prevent late complications, and optimize quality of life. Patient-centered primary care after stroke begins with establishing the foundation for poststroke management while engaging caregivers and family members in support of the patient. Screening for complications (eg, depression, cognitive impairment, and fall risk) and unmet needs is both a short-term and long-term component of poststroke care. Patients with ongoing functional impairments may benefit from referral to appropriate services. Ongoing care consists of managing risk factors such as high blood pressure, atrial fibrillation, diabetes, carotid stenosis, and dyslipidemia. Recommendations to reduce risk of recurrent stroke also include lifestyle modifications such as healthy diet and exercise. At the system level, primary care practices can use quality improvement strategies and available resources to enhance the delivery of evidence-based care and optimize outcomes.

Impairment in Health-Related Quality of Life among Community-Dwelling Stroke Survivors

INTRODUCTION

Health utility instruments are increasingly being used to measure impairment in health-related quality of life (HRQoL) after stroke. Population-based studies of HRQoL after stroke and assessment of differences by age and functional domain are needed.

METHODS

We used the Canadian Community Health Survey linked with administrative databases to determine HRQoL using the Health Utilities Index Mark 3 (HUI3) among those with prior hospitalization or emergency department visit for stroke and compared to controls without stroke. We used multivariable linear regression to determine the difference in HUI3 between those with stroke and controls for the global index and individual attributes, with assessment for modification by age (<60, 60-74, and 75+ years) and sex, and we combined estimates across survey years using random effects meta-analysis.

RESULTS

Our cohort contained 1240 stroke survivors and 123,765 controls and was weighted to be representative of the Canadian household population. Mean health utility was 0.63 (95% confidence interval [CI] 0.58, 0.68) for those with stroke and 0.83 (95% CI 0.82, 0.84) for controls. There was significant modification by age, but not sex, with the greatest adjusted reduction in HUI3 among stroke respondents aged 60-74 years. Individual HUI3 attributes with the largest reductions in utility among stroke survivors compared to controls were mobility, cognition, emotion, and pain.

CONCLUSIONS

In this population-based study, the reduction in HUI3 among stroke survivors compared to controls was greatest among respondents aged 60-74, and in attributes of mobility, cognition, emotion, and pain. These results highlight the persistent impairment of HRQoL in the chronic phase of stroke and potential targets for community support.

The Cognitive-Communication Checklist for Acquired Brain Injury: A Means of Identifying, Recording, and Tracking Communication Impairments

Purpose The communication service needs of individuals with acquired brain injuries (ABIs) are frequently overlooked, leading to delays, denials, or premature discharge from communication interventions. This is particularly true for those with subtle cognitive-communication deficits, which may not be apparent until sufficiently challenged at work, in school, or in the community. The purpose of this study was to evaluate a referral tool that could promote understanding of the broad range of communication impairments that occur following ABI and lead to improved identification and referral. Method This study evaluated the Cognitive-Communication Checklist for Acquired Brain Injury (CCCABI) through a survey. The CCCABI is a referral tool that summarizes 45 communication difficulties in 10 areas of cognitive-communication functioning. One hundred sixteen speech-language pathologists, 34 multidisciplinary referral sources, and 41 individuals with lived experience of brain injury were surveyed to evaluate the utility of this referral tool. Results The need for such a referral tool was endorsed by 96% of speech-language pathology respondents, 91% of multidisciplinary respondents, and 100% of respondents with lived experience of brain injury. Responses supported the CCCABI as a clear, comprehensive, and accessible tool for education and identification of the communication impairments that can occur after ABI. Conclusion The CCCABI is a means of increasing understanding of communication service needs following ABI in a manner that is accessible to individuals, families, program designers, funding sources, administrators, and multidisciplinary referral sources.

Sleep Disorders in Stroke: An Update on Management

Stroke is a leading cause of disability and mortality all over the world. Due to an aging population, the incidence of stroke is rising significantly, which has led to devastating consequences for patients. In addition to traditional risk factors such as age, hypertension, hyperlipidemia, diabetes and atrial fibrillation, sleep disorders, as independent modifiable risk factors for stroke, have been highlighted increasingly. In this review, we provide an overview of common types of current sleep disturbances in cerebrovascular diseases, including insomnia, hypersomnia, breathing-related sleep disorders, and parasomnias. Moreover, evidence-based clinical therapeutic strategies and pitfalls of specific sleep disorders after stroke are discussed. We also review the neurobiological mechanisms of these treatments as well as their effects on stroke. Since depression after stroke is so prevalent and closely related to sleep disorders, treatments of post-stroke depression are also briefly mentioned in this review article.

Eye Movement Technique to Improve Executive Function in Patients With Stroke: A Randomized Controlled Trial

Objective: To investigate the efficacy of eye movement technique for the treatment of executive dysfunction of patients with stroke.

Methods: This was a prospective, single-blinded, randomized, controlled, single-center clinical trial conducted from June 2018 to December 2019 in patients with stroke. The patients were randomized 1:1 to the routine (conventional management) and eye-move group (routine management plus eye movement technique: 5-min goal management training, 5-min computer-aided working memory, and 10 min of inhibitory control training and set conversion training). The intervention lasted 6 weeks, followed by a 4-week follow-up. The primary endpoint was the Behavioral Assessment of the Dysexecutive Syndrome (BADS) score. The secondary endpoints mainly included the Montreal Cognitive Assessment (MoCA), Wisconsin Card Sorting Test (WCST), and modified Barthel Index (MBI) scores.

Results: Sixty-four patients were enrolled (32/group). After the 6-week intervention, the BADS and WCST scores of the eye-move group were significantly improved than those of the routine group (all P < 0.05), but the effects were attenuated in certain subscores after follow-up (all P > 0.05). The MoCA and MBI scores of the eye-move group were significantly higher, and the reaction time was significantly lower than those of the routine group at 4 weeks after the intervention (all P < 0.05). After follow-up, the MBI scores of the eye-move group were still higher than that of the routine group (P < 0.001), but there were no differences for MoCA scores and reaction time (both P > 0.05).

Conclusion: The eye movement technique could improve the executive function of patients with stroke. These results have to be confirmed.

This was a prospective, single-blinded, randomized, controlled, single-center clinical trial (ChiCTR2000036393).

Clinical Trial Registration: [www.chictr.org.cn], identifier [ChiCTR2000036393].

Predictors and short-term outcomes of post-stroke fatigue in initial phase of transition from hospital to home: A prospective observational study

AIM

To analyse the interactions of associated factors with post stroke fatigue (PSF) after discharge home and determine the predictors of PSF and their impact on stroke survivors.

DESIGN

A prospective observational study.

METHODS

A total of 94 patients with acute stroke were recruited between May 2019 -July 2020. The main outcomes were fatigue, depression, insomnia, sarcopenia, and health-related quality of life (HRQOL) and were assessed at admission and 1 month after discharge. Fatigue was measured using the Fatigue Assessment Scale. Depression and Insomnia were assessed using the Hospital Anxiety and Depression Scale-Depression and Insomnia Severity Index, respectively. Sarcopenia was measured using the SARC-F questionnaire, and HRQOL was assessed using the Short Form-8.

RESULTS

Acute phase PSF was an independent predictor of PSF after discharge home. Moreover the path analysis revealed that this effect is mediated through both the direct effect of acute-phase PSF on PSF after discharge home and through the indirect effect of interaction with pre-stroke SARC-F, acute phase depression, and acute phase insomnia, which remains a separate predictor of acute-phase PSF. In total, 17% of the survivors had persistent PSF. Persistent PSF was significantly associated with depression, insomnia, sarcopenia, and a lower quality of life scores.

CONCLUSIONS

Post-stroke fatigue may occur in the acute phase and persists after discharge, it will not only affect later depression, insomnia, and quality of life, but also sarcopenia.

IMPACT

Acute phase PSF was found to be an independent predictor of PSF after discharge home. In addition, the interaction with pre-stroke SARC-F, acute phase depression and insomnia had an indirect connection with PSF after discharge home, which remains a separate predictor of acute-phase PSF. Thus, early assessment and management of mental status, sleep problems, and sarcopenia during hospitalization might be an important step in post-stroke rehabilitation and home transition.

Association of Therapy Time and Cognitive Recovery in Stroke Patients in Post-Acute Rehabilitation

OBJECTIVES

Cognitive impairment is highly prevalent after stroke, with 77% of people having impairment in at least 2 cognitive domains. The purpose of this study is to describe the association between therapy minutes per length of stay (LOS) day and cognitive recovery in patients receiving rehabilitation services in inpatient post-acute care facilities following a stroke.

DESIGN

Secondary analyses of data collected in inpatient rehabilitation and skilled nursing facilities from 2005 to 2010 for an observational cohort study.

SETTING AND PARTICIPANTS

Participants were adults aged ≥65 years with Medicare insurance and primary diagnosis of stroke (N = 100). Participants who met criteria for dementia (n = 5) were excluded from analyses. We calculated therapy minutes per LOS day for occupational therapy, physical therapy, speech-language pathology, and all therapies combined; therapy times were dichotomized into high or low minutes per LOS day (MLD). We used an ordinary least squares regression model for cognitive outcome at discharge to control for cognitive status at admission, therapy intensity by discipline, and LOS.

RESULTS

At baseline, participants were classified as having severe (n = 11), moderate (n = 39), or mild (n = 45) cognitive impairment. Impairment groups were not significantly different on any demographic variables. The adjusted regression model showed that high occupational therapy MLD (>50 minutes per LOS day) (P = .028) was significantly associated with cognitive measure at discharge compared with low occupational therapy MLD when controlling for cognitive impairment group at baseline (P < .001). Neither high physical therapy MLD nor speech-language pathology MLD was significantly associated with cognitive outcome relative to their respective low TMLD groups.

CONCLUSIONS AND IMPLICATIONS

Our results show that higher-intensity occupational therapy services were associated with better cognitive outcome at discharge from inpatient rehabilitation after stroke. Findings also suggest that volume of therapy alone does not necessarily produce optimal outcomes. Both amount and type of therapy should be tailored to meet the needs of individual patients.

Development and Internal Validation of a Nomogram to Predict Post-Stroke Fatigue After Discharge

OBJECTIVES

We aimed to develop and validate a nomogram for the individualized prediction of the risk of post-stroke fatigue (PSF) after discharge.

MATERIALS AND METHODS

Fatigue was measured using the Fatigue Assessment Scale. Multivariable logistic regression analysis was applied to build a prediction model incorporating the feature selected in the least absolute shrinkage and selection operator regression model. Discrimination, calibration, and clinical usefulness of the predictive model were assessed using the C-index, calibration plot, and decision curve analysis. Internal validation was conducted using bootstrapping validation. Finally, a web application was developed to facilitate the use of the nomogram.

RESULTS

We developed a nomogram based on 95 stroke patients. The predictors included in the nomogram were sex, pre-stroke sarcopenia, acute phase fatigue, dysphagia, and depression. The model displayed good discrimination, with a C-index of 0.801 (95% confidence interval: 0.700-0.902) and good calibration. A high C-index value of 0.762 could still be reached in the interval validation. Decision curve analysis showed that the risk of PSF after discharge was clinically useful when the intervention was decided at the PSF risk possibility threshold of 10% to 90%.

CONCLUSION

This nomogram could be conveniently used to provide an individual, visual, and precise prediction of the risk probability of PSF after being discharged home. Thus, as an aid in decision-making, physicians and other healthcare professionals can use this predictive method to provide early intervention or a discharge plan for stroke patients during the hospitalization period.

Development of a Care Bundle for Stroke Survivors with Psychological Symptoms: Evidence Summary and Delphi Study

Background

Psychological symptoms such as depression and anxiety are quite common among stroke survivors and have great negative impacts on patients.

Objective

To develop a care bundle through reviewing and integrating care strategies for psychological symptoms after stroke and then improve the bundle by Delphi study.

Methods

A structured search of the literature was performed to identify studies evaluating interventions for stroke patients with psychological symptoms such as depression and anxiety. Two trained researchers screened papers through the titles, abstracts, and full-texts independently. All studies complying with the eligibility criteria were appraised using quality assessment tools. Related interventions with evaluated evidence levels formed the preliminary bundle. Afterward, the Delphi study was carried out to improve the bundle, and the experts were contacted by e-mail. Ten clinical experts specialized in stroke and psychological rehabilitation were recruited. The reliability of experts was represented by the effective response rate and authority coefficient (Cr). The consensus was deemed to be reached when the mean score for item importance is all equal or above 3.50 and the coefficient of variation (CV) is all equal or below 0.20. The Kendall coefficient W test was adopted to evaluate the consensus on agreement among the experts as well. Data analysis was performed using SPSS V.22.0.

Results

Through a systematic evidence summary and two-round Delphi study, the items that were given high scores and got consensus by experts were chosen for the bundle. The iDAME bundle consisted of five interventions eventually: maintaining Interaction, tailored Diet, Acupressure, mindfulness Meditation, and physical Exercise.

Conclusion

The development of an evidence-based and consensus-based iDAME bundle which integrated western and traditional Chinese medicine intervention was described. Evidence summary made the bundle become scientific, while the Delphi study made it more maneuverable. Based on these results, the bundle would be potentially implemented in stroke patients for their psychological symptoms.

Improving the Social Relevance of Experimental Stroke Models: Social Isolation, Social Defeat Stress and Stroke Outcome in Animals and Humans

The outcome of ischemic stroke varies across socioeconomic strata, even among countries with universal health care. Emerging evidence suggests that psychosocial aspects of low socioeconomic status such as social isolation and social defeat stress interact with, and contribute to, stroke pathophysiology. However, experimental investigations of stroke rarely account for such socioeconomic influences. Social isolation in stroke survivors is associated with increased infarction volume, increased risk of post-stroke depression, and worse long-term functional outcome. Social defeat is thought to contribute significantly to chronic stress in low socioeconomic status groups and is associated with poor health outcomes. Chronic stress is also associated with worse post-stroke functional outcome and greater disability even after accounting for stroke severity, vascular risk factors, and access to acute stroke care. Experimental stroke studies which incorporate social isolation or social defeat stress have shown that both tissue and functional stroke outcome is affected by the increased expression of TNF-α and IL-6, increased glucocorticoid production, and suppression of the protooncogene bcl-2. This review explores the consequences of social isolation and social defeat stress on stroke, preclinical stroke models that have been used to investigate these factors, and possible molecular mechanisms underlying the influence of socioeconomic disparities on stroke outcome.

Non-Pharmacological Interventions for Post-Stroke Fatigue: Systematic Review and Network Meta-Analysis

Post-stroke fatigue (PSF) is one of the most serious sequelae, which often interferes with the rehabilitation process and impairs the functional recovery of patients. Due to insufficient evidence, it is unclear which specific pharmacological interventions should be recommended. Therefore, in this paper, we compare the effectiveness of non-pharmacological interventions in PSF. A systematic review and network meta-analysis of randomized controlled trials were performed using EMBASE, MEDLINE, CINAHL, Cochrane library, ClinicalTrials.gov, CNKI, and CQVIP, from inception to January 2018, in the English and Chinese languages. RCTs involving different non-pharmacological interventions for PSF with an outcome of fatigue measured using the Fatigue Severity Scale were included. Multiple intervention comparisons based on a Bayesian network are used to compare the relative effects of all included interventions. Ten RCTs with eight PSF non-pharmacological interventions were identified, comprising 777 participants. For effectiveness, most interventions did not significantly differ from one another. The cumulative probabilities of the best non-pharmacological intervention for fatigue reduction included Community Health Management (CHM), followed by Traditional Chinese Medicine (TCM) and Cognitive Behavioral Therapy (CBT). Network meta-analysis based on data from the selected RCTs indicated that the eight PSF non-pharmacological interventions shared equivalent efficacy, but CHM, TCM, and CBT showed potentially better efficacy. In the future, fatigue needs to be recognized and more accurate assessment methods for PSF are required for diagnosis and to develop more effective clinical interventions.

Comparing face-to-face and videoconference completion of the Montreal Cognitive Assessment (MoCA) in community-based survivors of stroke

Introduction

Videoconferencing may help address barriers associated with poor access to post-stroke cognitive screening. However, the equivalence of videoconference and face-to-face administrations of appropriate cognitive screening tools needs to be established. We compared face-to-face and videoconference administrations of the Montreal Cognitive Assessment (MoCA) in community-based survivors of stroke. We also evaluated whether participant characteristics (e.g. age) influenced equivalence.

Methods

We used a randomised crossover design (two-week interval). Participants were recruited through community advertising and use of a stroke-specific database. Both sessions were conducted by the same researcher in the same location. Videoconference sessions were conducted using Zoom. A repeated-measures t-test, intraclass correlation coefficient (ICC), Bland–Altman plot and multivariate regression modelling were used to establish equivalence.

Results

Forty-eight participants (26 men, Mage = 64.6 years, standard deviation ( SD) = 10.1; Mtime since stroke = 5.2 years, SD = 4.0) completed the MoCA face-to-face and via videoconference on average 15.8 ( SD = 9.7) days apart. Participants did not perform systematically better in a particular condition, and no participant variable predicted difference in MoCA performance. However, the ICC was low (0.615), and the Bland–Altman plot indicated wide limits of agreement, indicating variability between sessions.

Discussion

Our findings provide preliminary evidence to support the use of videoconference to administer the MoCA following stroke. However, further research into the test–retest reliability of scores derived from the MoCA is needed in this population. Administering the MoCA via videoconference holds potential to ensure that all stroke survivors undergo cognitive screening, in line with recommended clinical practice.

The Dutch version of the Oxford Cognitive Screen (OCS-NL): normative data and their association with age and socio-economic status

The Oxford Cognitive Screen (OCS) is a screening tool designed for stroke patients, assessing attention, executive functions, language, praxis, numeric cognition and memory. Here we present norms for the two parallel versions of the Dutch OCS (OCS-NL, acquired in 246 participants for version A and a subset of 179 participants for version B. We evaluated the association of age and socio-economic status (i.e. education, income, occupation) with OCS-NL performance There were no systematic performance differences between income groups, nor between manual and non-manual workers. There were small differences between education groups. The association of education and performance did not vary across subtests. The association of age and performance varied across subtests, with the strongest associations for the naming, praxis, verbal memory and executive task. Thus, OCS-NL norms do not need to be stratified on income and occupation and age-specific norms are recommended for some subtests.

Synergistic Benefits of Combined Aerobic and Cognitive Training on Fluid Intelligence and the Role of IGF-1 in Chronic Stroke

BACKGROUND

Paired exercise and cognitive training have the potential to enhance cognition by "priming" the brain and upregulating neurotrophins.

METHODS

Two-site randomized controlled trial. Fifty-two patients >6 months poststroke with concerns about cognitive impairment trained 50 to 70 minutes, 3× week for 10 weeks with 12-week follow-up. Participants were randomized to 1 of 2 physical interventions: Aerobic (>60% VO_2peak using <10% body weight-supported treadmill) or Activity (range of movement and functional tasks). Exercise was paired with 1 of 2 cognitive interventions (computerized dual working memory training [COG] or control computer games [Games]). The primary outcome for the 4 groups (Aerobic + COG, Aerobic + Games, Activity + COG, and Activity + Games) was fluid intelligence measured using Raven's Progressive Matrices Test administered at baseline, posttraining, and 3-month follow-up. Serum neurotrophins collected at one site (N = 30) included brain-derived neurotrophic factor (BDNF) at rest (BDNF_resting) and after a graded exercise test (BDNF_response) and insulin-like growth factor-1 at the same timepoints (IGF-1_rest, IGF-1_response).

RESULTS

At follow-up, fluid intelligence scores significantly improved compared to baseline in the Aerobic + COG and Activity + COG groups; however, only the Aerobic + COG group was significantly different (+47.8%) from control (Activity + Games -8.5%). Greater IGF-1_response at baseline predicted 40% of the variance in cognitive improvement. There was no effect of the interventions on BDNF_resting or BDNF_response; nor was BDNF predictive of the outcome.

CONCLUSIONS

Aerobic exercise combined with cognitive training improved fluid intelligence by almost 50% in patients >6 months poststroke. Participants with more robust improvements in cognition were able to upregulate higher levels of serum IGF-1 suggesting that this neurotrophin may be involved in behaviorally induced plasticity.

Screening for Post-Stroke Depression and Cognitive Impairment at Baseline Predicts Long-Term Patient-Centered Outcomes After Stroke

BACKGROUND

Independence and reintegration into community roles are important patient-centered outcomes after stroke. Depression and cognitive impairment are common post-stroke conditions that may impair long-term function even years after a stroke. However, screening for these post-stroke comorbidities remains infrequent in stroke prevention clinics and the utility of this screening for predicting long-term higher-level function has not been evaluated.

AIMS

To evaluate the ability of a validated brief Depression, Obstructive sleep apnea, and Cognitive impairment screen (DOC screen) to predict long-term (2-3 years after stroke) community participation and independence in instrumental activities of daily living post stroke.

METHODS

One hundred twenty-four patients (mean age, 66.3 [standard deviation = 15.7], 52.4% male) completed baseline depression and cognitive impairment screening at first stroke clinic visit, and telephone interviews 2 to 3 years post stroke to assess community independence (Frenchay Activities Index [FAI]) and participation (Reintegration to Normal Living Index [RNLI]). A subset of these patients also consented to complete detailed neuropsychological testing at baseline. Univariate and multivariate linear (FAI) and logistic (RNLI) regression analyses were used to determine the individual relationship between baseline data (predictors) and follow-up scores.

RESULTS

Older age (β = -0.17, P = .001), greater stroke severity (β = 1.84, P = .015), more depressive (β = -2.41, P = .023), and cognitive (β = -2.15, P = .046) symptoms independently predicted poor instrumental activity ( R² = .27; P < .001). Measures of executive dysfunction were the strongest correlates of poor instrumental activity. Higher depression risk was the only significant predictor of participation on the RNLI in regression modeling (odds ratio = 0.46, P = .028).

CONCLUSIONS

Baseline DOC screening in stroke prevention clinics shows that symptoms of depression and cognitive impairment are independent predictors of impaired higher-level functioning and community reintegration 2 to 3 years after stroke. Novel rehabilitation and psychological interventions targeting people with these conditions are needed to improve long-term patient-centered outcomes.

Lithium Carbonate in a Poststroke Population: Exploratory Analyses of Neuroanatomical and Cognitive Outcomes

PURPOSE/BACKGROUND

Loss of gray matter after stroke has been associated with cognitive impairment. This pilot study aimed to investigate the therapeutic potential of lithium, a putative neurotrophic agent, in the stroke recovery process within a year of stroke occurrence.

METHODS

Twelve stroke patients (mean ± SD age, 71.1 ± 11.9 years) were recruited to the study, and eligible participants were prescribed open-label lithium for 60 days. Magnetic resonance imaging was used to assess global gray matter at baseline and end of treatment; global cognition was assessed using the standardized Mini-Mental State Examination and Montreal Cognitive Assessment, and verbal memory was evaluated using the Hopkins Verbal Learning Test-Revised.

FINDINGS/RESULTS

There was no difference in global gray matter volume between baseline and follow-up (t = 1.977, P = 0.074). There was a significant interaction between higher lithium dose and increased global gray matter volume (F = 14.25, P = 0.004) and a correlation between higher lithium dose and improved verbal memory (r = 0.576, P = 0.05).

IMPLICATIONS/CONCLUSIONS

Lithium pharmacotherapy may be associated with gray matter volume change and verbal memory improvement in stroke patients, providing a rationale for future trials assessing therapeutic potential of lithium in a poststroke population.

Traditional Chinese medicine for post-stroke depression: A systematic review and network meta-analysis (Protocol)

BACKGROUND

Post-stroke depression (PSD) is common in stroke survivors, with significantly negative effects and serious impairments in terms of personal and social functioning. While both pharmacological and traditional Chinese medicine (TCM) interventions have been administered for PSD, there is still uncertainty about the balance between these and what treatment strategy should be preferred in clinical practice. Therefore, we aim to compare and rank, describing the protocol of a systematic review and network meta-analysis (NMA), the commonly used TCM interventions for PSD.

METHODS AND ANALYSIS

We will search CENTRAL (the Cochrane Central Register of Controlled Trials), CINAHL, Embase, PubMed, CBM and PsycINFO, the US National Institutes of Health and the World Health Organisation International Trials Registry Platform search portal from inception to November 2018. There will be no restrictions on language, publication year or publication type. Only randomized clinical trials (RCTs) accessing any TCM treatments against active comparator or other controls for PSD will be included. The primary outcomes will be efficacy (the total number of participants, declining more than 50% on the total score between baseline) and acceptability of treatment (dropout rate due to any cause). A Bayesian NMA will be performed to compare all relative outcome of different TCM interventions. we will conduct the network meta-regression meta-analyses of data on the sex ratio, the types of stroke and the treatment duration of TCM interventions. Potential explanations in extra subgroup analyses according to the results of heterogeneity and inconsistency will be explored, and sensitivity analyses will be conducted to assess the robustness of the findings.

TRIALS REGISTRATION NUMBER

PROSPERO CRD42018082400.

CONCLUSION

Our study will generate evidence for TCM in the treatment of PSD and help to reduce the uncertainty about the effectiveness of PSD management, which will encourage further suggestions for TCM clinical practice or guideline.

Depressed TSH level as a predictor of poststroke fatigue in patients with acute ischemic stroke

Objective

To investigate whether thyroid function profiles can predict poststroke fatigue (PSF) in patients with acute ischemic stroke.

Methods

Patients with stroke were consecutively recruited within 3 days of onset in Jinling Hospital. Serum levels of thyroid hormones, thyroid antibodies, hematologic indexes, and biochemical indexes were measured on admission. Fatigue was scored using the Fatigue Severity Scale. Associations were analyzed with multivariate regression and restricted cubic splines.

Results

Of the 704 patients with stroke, 292 (41.5%) were diagnosed with fatigue in the acute stage and 224 (35.3%) 6 months after the index stroke. The serum levels of thyroid-stimulating hormone (TSH) were inversely associated with the risk of PSF in both the acute phase and at follow-up evaluations after adjusting for potential confounders (odds ratio 0.30, 95% confidence interval 0.24–0.37 in the acute phase, and odds ratio 0.70, 95% confidence interval 0.58–0.84 at follow-up). The subgroup analysis indicated that in the acute phase of ischemic stroke, TSH was associated with severity of PSF in the groups with euthyroidism (β = −0.70, p < 0.001), subclinical hypothyroidism (β = −0.44, p < 0.001), and low-T3 syndrome (β = −0.34, p = 0.008). Higher TSH was associated with better Fatigue Severity Scale scores in patients with low-T3 syndrome 6 months after the index stroke (β = −0.35, p = 0.01). Furthermore, in the group with low-T3 syndrome, FT3 serum level could also indicate a higher risk of PSF (β = −2.54, p < 0.001 in the acute phase, and β = −2.67, p < 0.001 at follow-up).

Conclusion

Thyroid function profiles may predict fatigue after acute ischemic stroke, suggesting that neuroendocrine responses could have a role in PSF.

Screening Adherence for Depression Post Stroke: Evaluation of Outpatients, a London Experience (SAD PEOPLE)

BACKGROUND

Post stroke depression (PSD) is common, and the transition home following discharge may be especially challenging for stroke survivors.

OBJECTIVES

This study aimed to determine how well specific Canadian Best Practice Recommendations for PSD screening were adopted within a stroke rehabilitation outpatient clinic before and after the utilization of a standardized clinical form.

METHODS

Practices were evaluated through retrospective chart review before and after the implementation of the standardized form which cued physicians to administer the Patient Health Questionnaire 9 (PHQ-9) at the first outpatient visit. Participants included those aged ≥18 years with a primary diagnosis of stroke.

RESULTS

One hundred thirty-five subjects' charts were reviewed. Form implementation was associated with increased rates of PSD screening (93.8% versus 0%) and charting regarding mood (55.4% versus 15.7%).

CONCLUSION

This study highlights the frequency of depressive symptoms in an outpatient cohort and demonstrates how screening rates can be improved by using a standardized form. Routine PHQ-9 completion at the first outpatient visit was associated with more physician-patient discussion and documentation regarding mood.

Clock Drawing Test in acute stroke and its relationship with long-term functional and cognitive outcomes

Objective: The Clock Drawing Test (CDT) is commonly used as a screening tool for the assessment of dementia. The association between the CDT in acute stroke and long-term functional and cognitive outcomes in this population is unknown. The present prospective study is the first to examine if CDT scores in the acute stage after stroke are related to long-term outcomes and to compare the predictive ability of two scoring systems in a large sample of stroke patients. Method: A total of 340 patients admitted to an acute stroke unit were included in the present study. Separate stepwise multiple linear regression analyses were performed with eight independent variables (demographic/pre-stroke variables - age, sex, premorbid functioning; stroke-related variables - stroke severity, localization; cognitive variables - Orientation Test, CDT [2 scoring systems]), and four dependent variables administered one year post-stroke (Barthel Index, modified Rankin Scale, Reintegration to Normal Living index, Global Deterioration Scale). Results: Although both CDT scoring methods were related to all long-term outcome measures, the more comprehensive scoring system was the only baseline variable that significantly explained the variance in outcome measures in all four multiple regression models. Conclusion: Performance on the CDT in acute stroke is related to long-term outcomes including patients' degree of independence in performing activities of daily living, the degree to which they achieved reintegration into daily occupations, and the degree of cognitive decline observed one-year post-stroke. Future studies are needed to clarify the nature of the relationship between different CDT scoring systems and post-stroke outcomes.

The Feasibility and Longitudinal Effects of a Home-Based Sedentary Behavior Change Intervention After Stroke

OBJECTIVE

To evaluate the feasibility and preliminary effects of a sedentary behavior change intervention on sedentary behavior, physical activity, function, and quality of life following inpatient stroke rehabilitation.

DESIGN

Single-group, longitudinal, intervention study with 1-week baseline, 8-week intervention, and 8-week follow-up.

SETTING

Community.

PARTICIPANTS

Individuals (N=34) with subacute stroke recruited within 1 month following discharge home from inpatient stroke rehabilitation.

INTERVENTION

STand Up Frequently From Stroke (STUFFS) intervention that involved interrupting and replacing sedentary time with upright activities (standing and walking) at home and in the community. A motivational wrist-worn activity monitor was used throughout the intervention.

MAIN OUTCOME MEASURES

Primary outcomes were reach (enrolled/eligible), retention (completed/enrolled), satisfaction, and compliance with the intervention. Secondary outcomes were sedentary behavior, physical activity, lower extremity impairment, self-efficacy, cognitive status, mobility, and quality of life outcomes.

RESULTS

Forty-four participants were eligible to participate. Of the eligible, 34 (77.3%; time since stroke onset: 3.5±1.1 months) were enrolled at baseline and 32 (94.1%) of the enrolled had complete data at follow-up. Satisfaction with the program was 89%. Sedentary time decreased by 54.2±13.7 minutes per day (P<.01) at postintervention and 26.8±14.0 minutes per day (P=.07) at follow-up, relative to baseline. There were significant improvements in walking speed, cognition, impairment, and self-reported quality of life over time (P<.05). Self-efficacy was high across all time points. The number of steps and time spent stepping were not statistically different across both time periods.

CONCLUSIONS

The program was feasible to deliver in the home environment with good retention and satisfaction. Further research is required to test the effectiveness of the STUFFS program compared with usual care.

Reported use of technology in stroke rehabilitation by physical and occupational therapists

PURPOSE

With the patient care experience being a healthcare priority, it is concerning that patients with stroke reported boredom and a desire for greater fostering of autonomy, when evaluating their rehabilitation experience. Technology has the potential to reduce these shortcomings by engaging patients through entertainment and objective feedback. Providing objective feedback has resulted in improved outcomes and may assist the patient in learning how to self-manage rehabilitation. Our goal was to examine the extent to which physical and occupational therapists use technology in clinical stroke rehabilitation home exercise programs.

MATERIALS AND METHODS

Surveys were sent via mail, email and online postings to over 500 therapists, 107 responded.

RESULTS

Conventional equipment such as stopwatches are more frequently used compared to newer technology like Wii and Kinect games. Still, less than 25% of therapists' report using a stopwatch five or more times per week. Notably, feedback to patients is based upon objective data less than 50% of the time by most therapists. At the end of clinical rehabilitation, patients typically receive a written home exercise program and non-technological equipment, like theraband and/or theraputty to continue rehabilitation efforts independently.

CONCLUSIONS

The use of technology is not pervasive in the continuum of stroke rehabilitation. Implications for Rehabilitation The patient care experience is a priority in healthcare, so when patients report feeling bored and desiring greater fostering of autonomy in stroke rehabilitation, it is troubling. Research examining the use of technology has shown positive results for improving motor performance and engaging patients through entertainment and use of objective feedback. Physical and occupational therapists do not widely use technology in stroke rehabilitation. Therapists should consider using technology in stroke rehabilitation to better meet the needs of the patient.

Comparative efficacy and acceptability of antidepressant treatment in poststroke depression: a multiple-treatments meta-analysis

OBJECTIVE

The aim of this study is to create a rank order of the comparative efficacy and acceptability (risk of all-cause discontinuation) of antidepressant treatment in poststroke depression (PSD) by integrating direct and indirect evidence.

DESIGN

Multiple-treatments meta-analysis of randomised controlled trials.

PARTICIPANTS

Patients with depression following stroke.

INTERVENTIONS

10 antidepressants and placebo in the acute treatment of PSD.

OUTCOME MEASURES

The primary outcomes were the overall efficacy, defined as the mean change of the total depression score. The secondary outcome was the acceptability, defined as risk of all-cause discontinuation. These estimates as standardised mean differences or ORs with 95% CIs.

RESULTS

We identified 12 suitable trials, with data from 707 participants. All drugs were significantly more effective than placebo apart from sertraline, nefiracetam and fluoxetine. Most of the comparisons for acceptability revealed no significant differences except that paroxetine had significantly lower all-cause discontinuation than doxepin, citalopram and fluoxetine. Standardised mean differences compared with placebo for efficacy varied from -6.54 for the best drug (reboxetine) to 0.51 for the worst drug (nefiracetam). ORs compared with placebo for acceptability ranged from 0.09 for the best drug (paroxetine) to 3.42 for the worst drug (citalopram). For the efficacy rank, reboxetine, paroxetine, doxepin and duloxetine were among the most efficacious treatments, the cumulative probabilities of which were 100%, 85.7%, 83.2%, 62.4%, respectively. With respect to the acceptability rank, paroxetine, placebo, sertraline and nortriptyline were among the most acceptable treatments, the cumulative probabilities of which were 92.4%, 63.5%, 57.3%, 56.3%.

CONCLUSION

After weighing the efficacy and acceptability, we conclude that paroxetine might be the best choice when starting acute treatment for PSD, and fluoxetine might be the worst choice.

TRIAL REGISTRATION NUMBER

This systematic review has been registered in the Prospective Register of Systematic Review Protocols (PROSPERO) public database (CRD42017054741; http://www.crd.york.ac.uk/PROSPERO).

Cognitive behavioural therapy for post-stroke fatigue and sleep disturbance: a pilot randomised controlled trial with blind assessment

The objective of this study was to evaluate the effectiveness of individual cognitive behavioural therapy (CBT) for post-stroke fatigue and sleep disturbance compared to treatment as usual (TAU). In a parallel two-group pilot randomised controlled trial of 15 participants, nine were allocated to eight weekly sessions of adapted CBT and six continued usual care rehabilitation. The primary outcome was the Fatigue Severity Scale (FSS-7) at two and four months from baseline. Secondary outcomes included measures of sleep, mood and quality of life. Outcomes were assessed by a rater who was blind to group membership. At the four-month endpoint, the CBT group demonstrated significantly reduced fatigue relative to TAU (FSS-7 mean difference: 1.92, 95% CI: 0.24 to 3.60). Significant group differences also emerged for sleep quality and depression, favouring the CBT group. Insomnia and physical quality of life improved immediately post-therapy but were no longer superior to TAU at follow-up. Overall, CBT is a promising treatment for improving post-stroke fatigue, sleep quality and depression. Gains were maintained for two months after therapy cessation and represented large treatment effects. These findings highlight the feasibility of the intervention and warrant extension to a phase III clinical trial.