Enhancing physical activity and brain reorganization after stroke

An machine learning model to predict quality of life subtypes of disabled stroke survivors

OBJECTIVE

Stroke causes serious physical disability with impaired quality of life (QoL) and heavy burden on health. The goal of this study is to explore the impaired QoL typologies and their predicting factors in physically disabled stroke survivors with machine learning approach.

METHODS

Non-negative matrix factorization (NMF) was applied to clustering 308 physically disabled stroke survivors in rural China based on their responses on the short form 36 (SF-36) assessment of quality of life. Principal component analysis (PCA) was conducted to differentiate the subtypes, and the Boruta algorithm was used to identify the variables relevant to the categorization of two subtypes. A gradient boosting machine(GBM) and local interpretable model-agnostic explanation (LIME) algorithms were used to apply to interpret the variables that drove subtype predictions.

RESULTS

Two distinct subtypes emerged, characterized by short form 36 (SF-36) domains. The feature difference between worsen QoL subtype and better QoL subtype was as follows: role-emotion (RE), body pain (BP) and general health (GH), but not physical function (PF); the most relevant predictors of worsen QoL subtypes were help from others, followed by opportunities for community activity and rehabilitation needs, rather than disability severity or duration since stroke.

INTERPRETATION

The results suggest that the rehabilitation programs should be tailored toward their QoL clustering feature; body pain and emotional-behavioral problems are more crucial than motor deficit; stroke survivors with worsen QoL subtype are most in need of social support, return to community, and rehabilitation.

Effects of dry needling and exercise therapy on post-stroke spasticity and motor function- protocol of randomized clinical trial

BACKGROUND

Spasticity is one of the most common problems after the first stroke. Dry needling (DN) has been presented as a new therapeutic approach used by physiotherapists for the management of post-stroke spasticity. This study aimed to determine whether the addition of exercise therapy to the DN results in better outcomes in wrist flexors spasticity, motor neuron excitability, motor function and range of motion (ROM) in patients with chronic stroke.

METHODS

We will use a single-blind randomized controlled trial (RCT) in accordance with the CONSORT guidelines. A total of 24 patients with stroke will be included from the University Rehabilitation Clinics. The outcome measures will include Modified Modified Ashworth Scale, H_max/M_max ratio, H-reflex latency, Action Research Arm Test, Fugl-Meyer Assessment, and wrist extension active and passive range of motion. Patients in the DN and exercise therapy group will undergo 4 sessions of deep DN in flexor carpi radialis and flexor carpi ulnaris muscles on the affected upper limb and exercise therapy. Participants in the DN group will only receive DN for target muscles. Clinical and neurophysiological tests will be performed at baseline, after four therapy sessions, and at three weeks' follow-up.

DISCUSSION

This study will provide evidence for additional effects of exercise therapy to DN in comparison to DN alone on wrist flexors spasticity, motor neuron excitability, upper-limb motor function, and ROM in patients with chronic stroke.

Virtual Reality and Physiotherapy in Post-Stroke Functional Re-Education of the Lower Extremity: A Controlled Clinical Trial on a New Approach

Numerous Virtual Reality (VR) systems address post-stroke functional recovery of the lower extremity (LE), most of them with low early applicability due to the gait autonomy they require. The aim of the present study was to evaluate the feasibility of a specific VR treatment and its clinical effect on LE functionality, gait, balance, and trunk control post-stroke. A controlled, prospective, clinical trial was carried out with 20 stroke patients, who were divided into two groups: the first group (VR + CP; n = 10) received combined therapy of 1 h VR and 1 h of conventional physiotherapy (CP) and the second group (CP; n = 10) received 2 h of CP (5 days/week, for 3 weeks). The following pre-post-intervention measuring scales were used: Functional Ambulatory Scale (FAC), Functional Independence Measure (FIM), Fugl-Meyer Assessment (FM), Berg Balance Scale (BBS), and Trunk Control Test (TCT). Only VR + CP showed a significant improvement in FAC. In FIM, CP presented a tendency to significance, whereas VR + CP showed significance. Both groups improved significantly in FM (especially in amplitude/pain in VR + CP and in sensitivity in CP) and in BBS. In TCT, there was a non-significant improvement in both groups. The results indicate that the intervention with VR is a feasible treatment in the post-stroke functional re-education of the LE, with the potential to be an optimal complement of CP.

Classification of Congenital Zika Syndrome: Muscle Tone, Motor Type, Body Segments Affected, and Gross Motor Function

Aim: To identify abnormalities in muscle tone and motor function associated with congenital Zika syndrome (CZS).Method: A cross-sectional observational study involving 96 children (55 males) with CZS at a mean (SD) age 35.2 ± 2.9 months. Children's muscle tone was investigated using the pull to sit, scarf sign, shoulder suspension and ventral suspension tests and the modified Ashworth scale (MAS). Motor impairment was determined using the Gross Motor Function Classification System (GMFCS) and body segments most affected with motor impairment.Results: 58 (60,5%) children tested positive for ≥1 maneuver used to evaluate muscle tone, while 38 (39.5%) tested negative in all the tests. MAS score was >0 for at least one of the appendicular muscles in 91 children (94.8%). In 88 children (91.7%), all four limbs were affected.Conclusion: Findings suggestive of axial hypotonia and appendicular hypertonia associated with severe motor impairment were prevalent in children with CZS.

Dance-based exergaming for upper extremity rehabilitation and reducing fall-risk in community-dwelling individuals with chronic stroke. A preliminary study

Background: Post-stroke, individuals demonstrate persistent upper extremity (UE) motor impairments that impact functional movements and change-in-support strategies essential for recovery from postural instability. OBJECTIVES: This study primarily aims to quantify the effect of dance-based exergaming (DBExG) intervention on improving paretic UE movement control. The secondary aim is to assess if these improvements in UE movement control if observed, could partially account for improved fall-risk.Methods: Thirteen adults with chronic stroke received DBExG training using the commercially available Kinect dance gaming "Just Dance 3". Surface electromyography of shoulder muscle activity during the stand-reaching task and UE shoulder kinematics for a dance trial were recorded. Changes in balance control were determined using the Activities-specific Balance Confidence scale [ABC] and Timed-Up-and-Go test [TUG].Results: Post-training, participants demonstrated improvements in shoulder muscle activity in the form of performance (reaction time, burst duration, and movement time) and production outcomes (peak acceleration) (p < .05). There was also a post-training increase in shoulder joint excursion (Ex) and peak joint angles (∠) during dance trials (p < .05). Participants exhibited positive post-intervention correlations between ABC and shoulder joint Ex [R² of 0.43 (p < .05)] and between TUG and peak joint ∠ [R² of 0.51 (p < .05)]. CONCLUSION: Findings demonstrated the beneficial effect of DBExG for improving UE movement and the training-induced gains were also positively correlated with improvements in fall-risk measures in people with chronic stroke. Thus, DBEx training could be used as a meaningful clinical application for this population group.

Effect of high-intensity exercise on cardiorespiratory fitness in stroke survivors: A systematic review and meta-analysis

BACKGROUND

Knowledge of the optimal protocol and safety of particularly high-intensity exercise applied to individuals with stroke is lacking.

OBJECTIVE

This systematic review and meta-analysis aimed to investigate the effect of high-intensity exercise on cardiorespiratory fitness in stroke survivors.

METHODS

We performed a systematic electronic search for articles in MedLine via PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, CINAHL, and SPORTSDiscus up to April 1, 2019. Peak oxygen consumption (VO₂peak), 6-min walk test (6MWT), fastest 10-m walk test (10MWT), and adverse events were assessed. The standardized mean difference (SMD), weighted mean difference (WMD), and odds ratios (ORs) were used to compute the effect size, and subgroup analysis was conducted to test the consistency of results as well as sensitivity analysis to assess the robustness of the results. The quality of evidence was assessed with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

We included 17 studies (PEDro score≥4) in the meta-analysis. Post-intervention, high-intensity exercise had a significant effect on peak oxygen uptake (VO₂peak; SMD=0.56, P<0.01, I²=8%; WMD=2.53mL/kg/min; high quality of evidence) and 6MWT (SMD=0.26, P<0.01, I²=40%; WMD=17.08m; moderate quality of evidence) but not fastest 10MWT (SMD=0.33, P=0.27, I²=77%; WMD=0.05m/s; low quality of evidence). Subgroup analysis showed better effects of higher-intensity treadmill training (≥70% heart rate reserve/VO₂peak) for a longer duration (≥12 weeks) on VO₂peak and 6MWT in sub-acute or chronic stroke survivors. The high-intensity exercise and control groups did not differ in adverse events including falls [odds ratio (OR) 1.40, P=0.35, I²=11%; low quality of evidence], pain (OR 3.34, P=0.09, I²=0%; moderate quality of evidence), or skin injuries (OR 1.08, P=0.90, I²=0%; low quality of evidence).

CONCLUSIONS

Our meta-analysis suggests that high-intensity exercise is beneficial for cardiorespiratory fitness in stroke survivors and might be safe as a novel intervention in cardiopulmonary rehabilitation after stroke.

Orthopaedic surgery for patients with central nervous system lesions: Concepts and techniques

Since ancient times, the aim of orthopedic surgery has been to correct limb and joint deformities, including those resulting from central nervous system lesions. Recent developments in the treatment of spasticity have led to changes in concepts and management strategies. The increase in life expectancy has increased the functional needs of patients. Orthopedic surgery, along with treatments for spasticity, improves the functional capacity of patients with neuro-orthopaedic disorders, improving their autonomy. In this paper, we describe key moments in the history of orthopedic surgery regarding the treatment of patients with central nervous system lesions, from poliomyelitis to stroke-related hemiplegia, from the limbs to the spine, and from contractures to heterotopic ossification. A synthesis of the current surgical techniques is then provided, and the importance of multidisciplinary evaluation and management is highlighted, along with indications for medical, rehabilitation and surgical treatments and their combinations. We explain why it is essential to consider patients' expectations and to set achievable goals, particularly before surgery, which is by nature irreversible. More recently, specialized surgical teams have begun to favor the use of soft-tissue techniques over bony and joint procedures, except for spinal disorders. We highlight that orthopedic surgery is no longer the end-point of treatment. For example, lengthening a contractured muscle improves the balance around a joint, improving mobility and stability but may be only part of the problem. Further medical treatment and rehabilitation, or additional surgery, are often necessary to continue to improve the function of the limb. Despite the recognized effectiveness of orthopedic surgery for neuro-orthopedic disorders, few studies have formally evaluated them. Hence, there is a need for research to provide evidence to support orthopedic surgery for treating neuro-orthopedic disorders.

A qualitative exploration of post-acute stroke participants' experiences of a multimodal intervention incorporating horseback riding

Background

Multimodal rehabilitation interventions delivered in late phase of stroke recovery involve physical (motor and sensory), social, and cognitively challenging activities. Horseback riding can be incorporated within such interventions, leading to meaningful long-term improvements when applied to individuals with moderate levels of disability. There is a lack of research illuminating stroke survivors’ experiences and perceptions of horseback riding in the context of multimodal interventions.

Aim

To explore stroke survivors’ experiences of participation in a multimodal group-based intervention that included horseback riding.

Methods

An explorative interview study was conducted with individual face-to-face interviews performed on a single occasion, utilising a semi-structured interview guide. Eighteen participants were purposively selected from a larger trial (mean age 62, 12 men, 6 women) within four weeks after treatment completion. The interview duration was between 17 and 50 minutes. The data was analysed using a qualitative content analysis method.

Findings

Four broad themes were identified from the analysis. These themes were: transformative experiences; human–horse interaction; togetherness and belonging; and the all-in-one solution. Interacting with the horse and peers had a profound emotional impact on the participants. The participants also reported having learned new skills, increased self-efficacy and self-esteem, and improvements in balance and gait, all of which could be transferred to everyday life. The horse itself played a central role, but other components, such as the other group members, the instructors, and the challenging tasks on the horseback, were also important.

Conclusion

A multimodal rehabilitation intervention that includes horseback riding may provide stroke survivors in a late phase of recovery with rich pleasurable experiences that may have life-changing and profound impacts on their emotional and physical state.

Sleep Duration and Physical Activity Profiles Associated With Self-Reported Stroke in the United States: Application of Bayesian Belief Network Modeling Techniques

Introduction: Physical activity (PA) and sleep are associated with cerebrovascular disease and events like stroke. Though the interrelationships between PA, sleep, and other stroke risk factors have been studied, we are unclear about the associations of different types, frequency and duration of PA, sleep behavioral patterns (short, average and long sleep durations), within the context of stroke-related clinical, behavioral, and socio-demographic risk factors. The current study utilized Bayesian Belief Network analysis (BBN), a type of machine learning analysis, to develop profiles of physical activity (duration, intensity, and frequency) and sleep duration associated with or no history of stroke, given the influence of multiple stroke predictors and correlates. Such a model allowed us to develop a predictive classification model of stroke which can be used in post-stroke risk stratification and developing targeted stroke rehabilitation care based on an individual's profile. Method: Analysis was based on the 2004-2013 National Health Interview Survey (n = 288,888). Bayesian BBN was used to model the omnidirectional relationships of sleep duration and physical activity to history of stroke. Demographic, behavioral, health/medical, and psychosocial factors were considered as well as sleep duration [defined as short < 7 h. and long ≥ 9 h, referenced to healthy sleep (7-8 h)], and intensity (moderate and vigorous) and frequency (times/week) of physical activity. Results: Of the sample, 48.1% were ≤ 45 years; 55.7% female; 77.4% were White; 15.9%, Black/African American; and 45.3% reported an annual income < $35 K. Overall, the model had a precision index of 95.84%. We found that adults who reported 31-60 min of vigorous physical activity six times for the week and average sleep duration (7-8 h) had the lowest stroke prevalence. Of the 36 sleep (short, average, and long sleep) and physical activity profiles we tested, 30 profiles had a self-reported stroke prevalence lower than the US national average of approximately 3.07%. Women, compared to men with the same sleep and physical activity profile, appeared to have higher self-reported stroke prevalence. We also report age differences across three groups 18-45, 46-65, and 66+. Conclusion: Our findings indicate that several profiles of sleep duration and physical activity are associated with low prevalence of self-reported stroke and that there may be sex differences. Overall, our findings indicate that more than 10 min of moderate or vigorous physical activity, about 5-6 times per week and 7-8 h of sleep is associated with lower self-reported stroke prevalence. Results from the current study could lead to more tailored and personalized behavioral secondary stroke prevention strategies.

Arterial Stiffness in Subacute Stroke: Changing Pattern and Relationship with Functional Recovery

BACKGROUND

To examine changing patterns in arterial stiffness and functional outcome in patients with subacute stroke, and to determine which parameter shows a strong correlation with the reversal of arterial stiffness, during a 3-month period of comprehensive rehabilitation therapy.

METHODS

This descriptive, observational cohort study enrolled 60 patients (43 male and 17 female; average age, 62.7 years), and all received conventional rehabilitation therapy, during a 3-month period. Brachial-ankle pulse wave velocity (baPWV) was measured as an index of arterial stiffness. Functional assessments included the 6-minute walk test (6MWT), Fugl-Meyer Assessment of hemiparetic upper and lower limbs, the functional ambulatory category, the Berg balance scale, the Korean Mini-Mental Status Examination, and the Korean-Modified Barthel Index. All measurements were conducted at baseline and 1 and 3 months after stroke onset.

RESULTS

Rehabilitation therapy resulted in a statistically significant improvement in baPWV since 3 months post stroke. Another functional outcome measure showed statistically significant improvements since 1 month after rehabilitation. Multivariable linear regression analysis revealed that a change in baPWV was significantly correlated with changes in the 6MWT.

CONCLUSIONS

Three months of comprehensive rehabilitation therapy led to statistically significant improvements in arterial stiffness and functional outcomes during the subacute phase of stroke. Thus, the comprehensive rehabilitation focused on improving gait endurance would be warranted in subacute stroke patients.

A Personalized Self-Management Rehabilitation System for Stroke Survivors: A Quantitative Gait Analysis Using a Smart Insole

BACKGROUND

In the United Kingdom, stroke is the single largest cause of adult disability and results in a cost to the economy of £8.9 billion per annum. Service needs are currently not being met; therefore, initiatives that focus on patient-centered care that promote long-term self-management for chronic conditions should be at the forefront of service redesign. The use of innovative technologies and the ability to apply these effectively to promote behavior change are paramount in meeting the current challenges.

OBJECTIVE

Our objective was to gain a deeper insight into the impact of innovative technologies in support of home-based, self-managed rehabilitation for stroke survivors. An intervention of daily walks can assist with improving lower limb motor function, and this can be measured by using technology. This paper focuses on assessing the usage of self-management technologies on poststroke survivors while undergoing rehabilitation at home.

METHODS

A realist evaluation of a personalized self-management rehabilitation system was undertaken in the homes of stroke survivors (N=5) over a period of approximately two months. Context, mechanisms, and outcomes were developed and explored using theories relating to motor recovery. Participants were encouraged to self-manage their daily walking activity; this was achieved through goal setting and motivational feedback. Gait data were collected and analyzed to produce metrics such as speed, heel strikes, and symmetry. This was achieved using a "smart insole" to facilitate measurement of walking activities in a free-living, nonrestrictive environment.

RESULTS

Initial findings indicated that 4 out of 5 participants performed better during the second half of the evaluation. Performance increase was evident through improved heel strikes on participants' affected limb. Additionally, increase in performance in relation to speed was also evident for all 5 participants. A common strategy emerged across all but one participant as symmetry performance was sacrificed in favor of improved heel strikes. This paper evaluates compliance and intensity of use.

CONCLUSION

Our findings suggested that 4 out of the 5 participants improved their ability to heel strike on their affected limb. All participants showed improvements in their speed of gait measured in steps per minute with an average increase of 9.8% during the rehabilitation program. Performance in relation to symmetry showed an 8.5% average decline across participants, although 1 participant improved by 4%. Context, mechanism, and outcomes indicated that dual motor learning and compensatory strategies were deployed by the participants.

Assessing Walking Strategies Using Insole Pressure Sensors for Stroke Survivors

Insole pressure sensors capture the different forces exercised over the different parts of the sole when performing tasks standing up such as walking. Using data analysis and machine learning techniques, common patterns and strategies from different users to achieve different tasks can be automatically extracted. In this paper, we present the results obtained for the automatic detection of different strategies used by stroke survivors when walking as integrated into an Information Communication Technology (ICT) enhanced Personalised Self-Management Rehabilitation System (PSMrS) for stroke rehabilitation. Fourteen stroke survivors and 10 healthy controls have participated in the experiment by walking six times a distance from chair to chair of approximately 10 m long. The Rivermead Mobility Index was used to assess the functional ability of each individual in the stroke survivor group. Several walking strategies are studied based on data gathered from insole pressure sensors and patterns found in stroke survivor patients are compared with average patterns found in healthy control users. A mechanism to automatically estimate a mobility index based on the similarity of the pressure patterns to a stereotyped stride is also used. Both data gathered from stroke survivors and healthy controls are used to evaluate the proposed mechanisms. The output of trained algorithms is applied to the PSMrS system to provide feedback on gait quality enabling stroke survivors to self-manage their rehabilitation.

Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery

Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients' mobility, their limitation in daily life activities, their participation in society and their odds of returning to professional activities. All of these factors contribute to a low overall quality of life. Rehabilitation training is the most effective way to reduce motor impairments in stroke patients. This multiple systematic review focuses both on standard treatment methods and on innovating rehabilitation techniques used to promote upper extremity motor function in stroke patients. A total number of 5712 publications on stroke rehabilitation was systematically reviewed for relevance and quality with regards to upper extremity motor outcome. This procedure yielded 270 publications corresponding to the inclusion criteria of the systematic review. Recent technology-based interventions in stroke rehabilitation including non-invasive brain stimulation, robot-assisted training, and virtual reality immersion are addressed. Finally, a decisional tree based on evidence from the literature and characteristics of stroke patients is proposed. At present, the stroke rehabilitation field faces the challenge to tailor evidence-based treatment strategies to the needs of the individual stroke patient. Interventions can be combined in order to achieve the maximal motor function recovery for each patient. Though the efficacy of some interventions may be under debate, motor skill learning, and some new technological approaches give promising outcome prognosis in stroke motor rehabilitation.

Physical activity in chronic home-living and sub-acute hospitalized stroke patients using objective and self-reported measures

BACKGROUND

Despite confirmed reduced physical activity (PA) after stroke in various stages of recovery, the type of activities stroke patients executed and the time spent at different activity levels have not been sufficiently verified with stroke-validated assessment tools.

DESIGN

Observational study.

OBJECTIVE

To determine PA of sub-acute stroke patients hospitalized in a rehabilitation centre (HOS) compared to chronic home-living stroke patients (HOM) using objective and self-reported measures during 2 weekdays and 1 weekend day.

METHODS

Fifteen HOS and 15 HOM patients wore a Sense Wear Pro 2 accelerometer (METs*minutes/24 h) and a knee-worn pedometer Yamax Digi Walker SW 200 (steps) and filled in a coded activity diary (kcal/24 h; METs*minutes/24 h) during three consecutive days.

RESULTS

In HOM significantly more steps (stepstotal HOM = 18722.6 ± 10063.6; stepstotal HOS = 7097.8 ± 5850.5) and higher energy expenditure (EE) levels (EEtotal HOM = 7759.34 ± 2243.04; EEtotal HOS = 5860.15 ± 1412.78) were measured. In this group less moderate activity (≥3-6 ≤ METs) was performed on a weekday (pday1 = 0.006; pday2 = 0.027) and in total (p = 0.037). Few therapy hours (physical, occupational and speech therapy, and psychological support) were provided in HOM compared to HOS (p < 0.001). Vigorous activities were only seen in HOM. In both groups few patients executed sport activities.

CONCLUSIONS

In HOM significantly more steps were performed and higher EE values were measured. However, participation in moderate activities and time spent on therapy were less in HOM. Evaluating PA with quantitative measures is feasible in both chronic home-living and sub-acute hospitalized patients with stroke.

A Personalized Self-Management Rehabilitation System with an Intelligent Shoe for Stroke Survivors: A Realist Evaluation

BACKGROUND

In the United Kingdom, stroke is the most significant cause of adult disability. Stroke survivors are frequently left with physical and psychological changes that can profoundly affect their functional ability, independence, and social participation. Research suggests that long-term, intense, task- and context-specific rehabilitation that is goal-oriented and environmentally enriched improves function, independence, and quality of life after a stroke. It is recommended that rehabilitation should continue until maximum recovery has been achieved. However, the increasing demand on services and financial constraints means that needs cannot be met through traditional face-to-face delivery of rehabilitation. Using a participatory design methodology, we developed an information communication technology-enhanced Personalized Self-Managed rehabilitation System (PSMrS) for stroke survivors with integrated insole sensor technology within an "intelligent shoe.". The intervention model was based around a rehabilitation paradigm underpinned by theories of motor relearning and neuroplastic adaptation, motivational feedback, self-efficacy, and knowledge transfer.

OBJECTIVE

To understand the conditions under which this technology-based rehabilitation solution would most likely have an impact on the motor behavior of the user, what would work for whom, in what context, and how. We were interested in what aspects of the system would work best to facilitate the motor behavior change associated with self-managed rehabilitation and which user characteristics and circumstances of use could promote improved functional outcomes.

METHODS

We used a Realist Evaluation (RE) framework to evaluate the final prototype PSMrS with the assumption that the intervention consists of a series of configurations that include the Context of use, the underlying Mechanisms of change and the potential Outcomes or impacts (CMOs). We developed the CMOs from literature reviews and engagement with clinicians, users, and caregivers during a series of focus groups and home visits. These CMOs were then tested in five in-depth case studies with stroke survivors and their caregivers.

RESULTS

While two new propositions emerged, the second importantly related to the self-management aspects of the system. The study revealed that the system should also encourage independent use and the setting of personalized goals or activities.

CONCLUSIONS

Information communication technology that purports to support the self-management of stroke rehabilitation should give significant consideration to the need for motivational feedback that provides quantitative, reliable, accurate, context-specific, and culturally sensitive information about the achievement of personalized goal-based activities.

Upper Limb Immobilisation: A Neural Plasticity Model with Relevance to Poststroke Motor Rehabilitation

Advances in our understanding of the neural plasticity that occurs after hemiparetic stroke have contributed to the formulation of theories of poststroke motor recovery. These theories, in turn, have underpinned contemporary motor rehabilitation strategies for treating motor deficits after stroke, such as upper limb hemiparesis. However, a relative drawback has been that, in general, these strategies are most compatible with the recovery profiles of relatively high-functioning stroke survivors and therefore do not easily translate into benefit to those individuals sustaining low-functioning upper limb hemiparesis, who otherwise have poorer residual function. For these individuals, alternative motor rehabilitation strategies are currently needed. In this paper, we will review upper limb immobilisation studies that have been conducted with healthy adult humans and animals. Then, we will discuss how the findings from these studies could inspire the creation of a neural plasticity model that is likely to be of particular relevance to the context of motor rehabilitation after stroke. For instance, as will be elaborated, such model could contribute to the development of alternative motor rehabilitation strategies for treating poststroke upper limb hemiparesis. The implications of the findings from those immobilisation studies for contemporary motor rehabilitation strategies will also be discussed and perspectives for future research in this arena will be provided as well.

Classifying physical activity research following stroke using the behavioral epidemiologic framework

BACKGROUND

Stroke is a significant public health issue in the USA and a need emerges to better understand how to reduce an individual's co-morbidity risk. Physical activity is one approach to improving the health of individuals and comprehensive literature supports increased activity as a means to reduce risk of morbidity and mortality. One approach to examining whether research in a field is addressing a public health issue is through application of the behavioral epidemiological framework.

OBJECTIVE

To classify physical activity research for individuals following stroke into distinct phases so that efforts can be made to systematically address gaps and disseminate evidence-based practice.

METHODS

Specific key words were identified and then searched through EBSCO host, PubMed, and Google Scholar. Physical activity and stroke literature from 2000-2014 was categorized into one of five discrete phases. Research in Phase 1 identified associations between activity and health; Phase 2 established valid measures of activity; Phase 3 examined determinants of behavior; Phase 4 evaluated activity interventions; and Phase 5 disseminated evidence-based practice.

RESULTS

A comprehensive review of literature identified 202 articles with 70% categorized in Phase 1 (n = 141), 11% in Phase 2 (n = 23), 10% in Phase 3 (n = 20), 8% in Phase 4 (n = 15), and 1% in Phase 5 (n = 3).

CONCLUSION

Findings suggest that physical activity research for individuals following stroke is in the early stages of development with less than 10% of research evaluating or disseminating interventions.

Blood pressure and heart rate adjustment following acute Frenkel's ambulatory exercise in chronic hemiparetics stroke survivors: a comparative study

BACKGROUND

Frenkel's ambulatory activity has been routinely employed by physiotherapists for rehabilitation of gait coordination, however, its immediate influence on blood pressure and heart rate has not been investigated.

OBJECTIVE

To investigate the acute effect of Frenkel's ambulatory activity on blood pressure and heart rate of chronic hemiparetic stroke survivors.

METHOD

Using a comparative study design, 60 chronic hemiparetic stroke survivors of varying onset of stroke, ≤6, >6-11 and ≥12 months were subjected to a 2-minute Frenkel's ambulatory activity on marked footsteps (from standard adult described footsteps). Participants were assessed for both blood pressure and heart rate before and after the Frenkel's ambulatory activity.

RESULTS

Blood pressure and heart rate significantly increased (p<0.05) following Frenkel's ambulatory activity in all the 3 categories of stroke onset above baseline. However, there was no significant difference (p>0.05) across the onsets in both blood pressure and heart rate responses.

CONCLUSION

The outcome of this study indicated that Frenkel's ambulatory activity has the propensity to increase blood pressure and heart rate of hemiparetic stroke survivors irrespective of the onset of stroke. We recommend a pre, within and post-activity monitoring of stroke survivors while subjecting them to Frenkel's ambulatory activity.

Stroke patients' utilisation of extrinsic feedback from computer-based technology in the home: a multiple case study realistic evaluation

Background

Evidence indicates that post − stroke rehabilitation improves function, independence and quality of life. A key aspect of rehabilitation is the provision of appropriate information and feedback to the learner.

Advances in information and communications technology (ICT) have allowed for the development of various systems to complement stroke rehabilitation that could be used in the home setting. These systems may increase the provision of rehabilitation a stroke survivor receives and carries out, as well as providing a learning platform that facilitates long-term self-managed rehabilitation and behaviour change. This paper describes the application of an innovative evaluative methodology to explore the utilisation of feedback for post-stroke upper-limb rehabilitation in the home.

Methods

Using the principles of realistic evaluation, this study aimed to test and refine intervention theories by exploring the complex interactions of contexts, mechanisms and outcomes that arise from technology deployment in the home. Methods included focus groups followed by multi-method case studies (n = 5) before, during and after the use of computer-based equipment. Data were analysed in relation to the context-mechanism-outcome hypotheses case by case. This was followed by a synthesis of the findings to answer the question, ‘what works for whom and in what circumstances and respects?’

Results

Data analysis reveals that to achieve desired outcomes through the use of ICT, key elements of computer feedback, such as accuracy, measurability, rewarding feedback, adaptability, and knowledge of results feedback, are required to trigger the theory-driven mechanisms underpinning the intervention. In addition, the pre-existing context and the personal and environmental contexts, such as previous experience of service delivery, personal goals, trust in the technology, and social circumstances may also enable or constrain the underpinning theory-driven mechanisms.

Conclusions

Findings suggest that the theory-driven mechanisms underpinning the utilisation of feedback from computer-based technology for home-based upper-limb post-stroke rehabilitation are dependent on key elements of computer feedback and the personal and environmental context. The identification of these elements may therefore inform the development of technology; therapy education and the subsequent adoption of technology and a self-management paradigm; long-term self-managed rehabilitation; and importantly, improvements in the physical and psychosocial aspects of recovery.

Voluntary forced use of the impaired limb following stroke facilitates functional recovery in the rat

Constraint induced movement therapy (CIMT), which forces use of the impaired arm following stroke, improves functional recovery. The mechanisms underlying recovery are not well understood, necessitating further investigation into how rehabilitation may affect neuroplasticity using animal models. Animal motivation and stress make modelling CIMT in animals challenging. We have shown that following focal ischemia, voluntary forced use therapy using pet activity balls could engage the impaired forelimb and result in a modest acceleration in recovery. In this study, we investigated the effects of a more intensive appetitively motivated regimen that included task specific reaching exercises. Adult male Sprague Dawley rats were subjected to focal unilateral stroke using intracerebral injections of endothelin-1 or sham surgery. Three days later, stroke animals were assigned to daily rehabilitation or control therapy. Rehabilitation consisted of 30 min of generalized movement sessions in activity balls, followed by 30 min of voluntary task-specific movement using reaching boxes. Rats were tested weekly to measure forelimb deficit and recovery. After 30 days, animals were euthanized and tissue was examined for infarct volume, brain derived neurotrophic factor expression, and the presence of new neurons using doublecortin immunohistochemistry. Rehabilitation resulted in a significant acceleration of forelimb recovery in several tests, and a significant increase in the number of doublecortin-expressing cells. Furthermore, while the proportion of cells expressing BDNF in the peri-infarct region did not change, there was a shift in the cellular origin of expressed BDNF, resulting in significantly more non-neuronal, non-astrocytic BDNF, presumed to be of microglial origin.

Characteristics of exercise training interventions to improve cardiorespiratory fitness after stroke: a systematic review with meta-analysis

BACKGROUND

Cardiorespiratory fitness is low after stroke. Improving fitness has the potential to improve function and reduce secondary cardiovascular events.

OBJECTIVE

. This review with meta-analysis aims to identify characteristics and determine the effectiveness of interventions to improve cardiorespiratory fitness after stroke.

METHODS

A systematic search and review with meta-analysis was undertaken. Key inclusion criteria were the following: peer-reviewed articles published in English, adult stroke survivors, an intervention with the potential to improve cardiorespiratory fitness, and peak oxygen consumption (VO2peak) assessed preintervention and postintervention via a progressive aerobic exercise test.

RESULTS

From 3209 citations identified, 28 studies were included, reporting results for 920 participants. Studies typically included chronic, ambulant participants with mild to moderate deficits; used an aerobic or mixed (with an aerobic component) intervention; and prescribed 3 sessions per week for 30 to 60 minutes per session at a given intensity. Baseline VO2peak values were low (8-23 mL/kg/min). Meta-analysis of the 12 randomized controlled trials demonstrated overall improvements in VO2peak of 2.27 (95% confidence interval = 1.58, 2.95) mL/kg/min postintervention. A similar 10% to 15% improvement occurred with both aerobic and mixed interventions and in shorter (≤ 3 months) and longer (>3 months) length programs. Only 1 study calculated total dose received and only 1 included long-term follow-up.

CONCLUSIONS

The results demonstrate that interventions with an aerobic component can improve cardiorespiratory fitness poststroke. Further investigation is required to determine effectiveness in those with greater impairment and comorbidities, optimal timing and dose of intervention, whether improvements can be maintained in the longer term, and whether improved fitness results in better function and reduced risk of subsequent cardiovascular events.

The immediate and long-term effects of a walking-skill program compared to usual physiotherapy care in patients who have undergone total knee arthroplasty (TKA): a randomized controlled trial

PURPOSE

To examine the immediate and long-term effects of a walking-skill program compared with usual physiotherapy on physical function, pain and perceived self-efficacy in patients after total knee arthroplasty (TKA).

METHOD

A single blind randomized controlled trial design was applied. Fifty-seven patients with primary TKA, mean age of 69 years (SD ± 9), were randomly assigned to a walking-skill program emphasizing weight-bearing exercises or usual physiotherapy. Outcomes were assessed before the interventions started at 6 weeks postoperatively (T1), directly after the interventions at 12-14 weeks (T2) and 9 months after the interventions (T3). Walking was the primary outcome, assessed by the 6 min walk test (6MWT). The secondary outcomes were timed stair climbing, timed stands, Figure-of-eight test, Index of muscle function, active knee range of motion, Knee Injury and Osteoarthritis Outcome Score and self-efficacy score.

RESULTS

From T1 to T2, a better 6MWT score was found in favor of the walking-skill program of 39 m (2-76), p = 0.04. The difference between the groups in 6MWT persisted at T3, 44 m (8-80), p = 0.02. No differences in other outcome measures were found.

CONCLUSION

The walking-skill program had better effect on walking than usual physiotherapy. Weight bearing was tolerated. Implications for Rehabilitation Weight-bearing exercises are tolerated by the patients in the early stage after TKA. Physiotherapy that focuses on learning different ways of walking through practice may be a plausible way to train patients after TKA.

A novel approach to induction and rehabilitation of deficits in forelimb function in a rat model of ischemic stroke

AIM

Constraint-induced movement therapy (CIMT), which forces use of the impaired arm following unilateral stroke, promotes functional recovery in the clinic but animal models of CIMT have yielded mixed results. The aim of this study is to develop a refined endothelin-1 (ET-1) model of focal ischemic injury in rats that resulted in reproducible, well-defined lesions and reliable upper extremity impairments, and to determine if an appetitively motivated form of rehabilitation (voluntary forced use movement therapy; FUMT) would accelerate post-ischemic motor recovery.

METHODS

Male Sprague Dawley rats (3 months old) were given multiple intracerebral microinjections of ET-1 into the sensorimotor cortex and dorsolateral striatum. Sham-operated rats received the same surgical procedure up to but not including the drill holes on the skull. Functional deficits were assessed using two tests of forelimb placing, a forelimb postural reflex test, a forelimb asymmetry test, and a horizontal ladder test. In a separate experiment ET-1 stroke rats were subjected to daily rehabilitation with FUMT or with a control therapy beginning on post-surgery d 5. Performance and post-mortem analysis of lesion volume and regional BDNF expression were measured.

RESULTS

Following microinjections of ET-1 animals exhibited significant deficits in contralateral forelimb function on a variety of tests compared with the sham group. These deficits persisted for up to 20 d with no mortality and were associated with consistent lesion volumes. FUMT therapy resulted in a modest but significantly accelerated recovery in the forelimb function as compared with the control therapy, but did not affect lesion size or BDNF expression in the ipsilesional hemisphere.

CONCLUSION

We conclude that refined ET-1 microinjection protocols and forcing use of the impaired forelimb in an appetitively motivated paradigm may prove useful in developing strategies to study post-ischemic rehabilitation and neuroplasticity.

Physical, cognitive and social activity levels of stroke patients undergoing rehabilitation within a mixed rehabilitation unit

OBJECTIVE

To determine physical, cognitive and social activity levels of stroke patients undergoing rehabilitation, and whether these changed over time.

DESIGN

Observational study using behavioural mapping techniques to record patient activity over 12 hours on one weekday and one weekend day at baseline (week 1) and again two weeks later (week 2).

SETTING

A 20-bed mixed rehabilitation unit.

SUBJECTS

Fourteen stroke patients.

INTERVENTIONS

None.

MAIN MEASURES

Percentage of day spent in any activity or physical, cognitive and social activities. Level of independence using the Functional Independence Measure (FIM) and mood using the Patient Health Questionniare-9 (PHQ-9).

RESULTS

The stroke patients performed any activity for 49%, social activity for 32%, physical activity for 23% and cognitive activity for 4% of the day. Two weeks later, physical activity levels had increased by 4% (95% confidence interval (CI) 1 to 8), but levels of any activity or social and cognitive activities had not changed significantly. There was a significant: (i) positive correlation between change in physical activity and change in FIM score (r = 0.80), and (ii) negative correlation between change in social activity and change in PHQ-9 score (r = -0.72). The majority of activity was performed by the bedside (37%), and most physical (47%) and cognitive (54%) activities performed when alone. Patients undertook 5% (95% CI 2 to 9) less physical activity on the weekends compared with the weekdays.

CONCLUSIONS

Levels of physical, cognitive and social activity of stroke patients were low and remained so even though level of independence and mood improved. These findings suggest the need to explore strategies to stimulate activity within rehabilitation environments.