Rehabilitation Outcomes: Ischemic versus Hemorrhagic Strokes

Combined robot-assisted therapy virtual reality for upper limb rehabilitation in stroke survivors: a systematic review of randomized controlled trials

BACKGROUND

Upper limb impairments are among the most common consequences following a stroke. Recently, robot-assisted therapy (RT) and virtual reality (VR) have been used to improve upper limb function in stroke survivors.

OBJECTIVES

This review aims to investigate the effects of combined RT and VR on upper limb function in stroke survivors and to provide recommendations for researchers and clinicians in the medical field.

METHODS

We searched PubMed, SCOPUS, REHABDATA, PEDro, EMBASE, and Web of Science from inception to March 28, 2024. Randomized controlled trials (RCTs) involving stroke survivors that compared combined RT and VR interventions with either passive (i.e., sham, rest) or active (i.e., traditional therapy, VR, RT) interventions and assessed outcomes related to upper limb function (e.g., strength, muscle tone, or overall function) were included. The Cochrane Collaboration tool was used to evaluate the methodological quality of the included studies.

RESULTS

Six studies were included in this review. In total, 201 patients with stroke (mean age 57.84 years) were involved in this review. Four studies were considered 'high quality', while two were considered as 'moderate quality' on the Cochrane Collaboration tool. The findings showed inconsistent results for the effects of combined RT and VR interventions on upper limb function poststroke.

CONCLUSION

In conclusion, there are potential effects of combined RT and VR interventions on improving upper limb function, but further research is needed to confirm these findings, understand the underlying mechanisms, and assess the consistency and generalizability of the results.

Combined noninvasive brain stimulation virtual reality for upper limb rehabilitation poststroke: A systematic review of randomized controlled trials

Upper limb impairments are common consequences of stroke. Noninvasive brain stimulation (NIBS) and virtual reality (VR) play crucial roles in improving upper limb function poststroke. This review aims to evaluate the effects of combined NIBS and VR interventions on upper limb function post-stroke and to provide recommendations for future studies in the rehabilitation field. PubMed, MEDLINE, PEDro, SCOPUS, REHABDATA, EMBASE, and Web of Science were searched from inception to November 2023. Randomized controlled trials (RCTs) encompassed patients with a confirmed stroke diagnosis, administrated combined NIBS and VR compared with passive (i.e., rest) or active (conventional therapy), and included at least one outcome assessing upper limb function (i.e., strength, spasticity, function) were selected. The quality of the included studies was assessed using the Cochrane Collaboration tool. Seven studies met the eligibility criteria. In total, 303 stroke survivors (Mean age: 61.74 years) were included in this review. According to the Cochrane Collaboration tool, five studies were classified as "high quality," while two were categorized as "moderate quality". There are mixed findings for the effects of combined NIBS and VR on upper limb function in stroke survivors. The evidence for the effects of combined transcranial direct current stimulation and VR on upper limb function post-stroke is promising. However, the evidence regarding the effects of combined repetitive transcranial magnetic stimulation and VR on upper limb function is limited. Further randomized controlled trials with long-term follow-up are strongly warranted.

Unraveling brain diseases: The promise of brain-on-a-chip models

Brain disorders, encompassing a wide spectrum of neurological and psychiatric conditions, present a formidable challenge in modern medicine. Despite decades of research, the intricate complexity of the human brain still eludes comprehensive understanding, impeding the development of effective treatments. Recent advancements in microfluidics and tissue engineering have led to the development of innovative platforms known as "Brain-on-a-Chip" (BoC) i.e., advanced in vitro systems that aim to replicate the microenvironment of the brain with the highest possible fidelity. This technology offers a promising test-bed for studying brain disorders at the cellular and network levels, providing insights into disease mechanisms, drug screening, and, in perspective, the development of personalized therapeutic strategies. In this review, we provide an overview of the BoC models developed over the years to model and understand the onset and progression of some of the most severe neurological disorders in terms of incidence and debilitation (stroke, Parkinson's, Alzheimer's, and epilepsy). We also report some of the cutting-edge therapeutic approaches whose effects were evaluated by means of these technologies. Finally, we discuss potential challenges, and future perspectives of the BoC models.

Isolation of a novel isoprenylated phenolic compound and neuroprotective evaluation of Dodonaea viscosa extract against cerebral ischaemia-reperfusion injury in rats

Dodonaea viscosa grows widely in Saudi Arabia, but studies evaluating its neuroprotective activity are lacking. Thus, this study aimed to isolate and identify the secondary metabolites and evaluate the neuroprotective effects of D. viscosa leaves. The isolation and identification of phytochemicals were performed using chromatographic and spectroscopic techniques. The neuroprotective potential of the extract was evaluated against focal cerebral ischaemia-reperfusion injury in rat model. Neurobehavioural deficits in the rats were evaluated, and their brains were harvested to measure infarct volume and oxidative biomarkers. Results revealed the presence of three compounds: a novel isoprenylated phenolic derivative that was elucidated as 4-hydroxy-3-(3'-methyl-2'-butenyl) phenyl 1-O-β-D-apiosyl-(1''' → 6'')- β-D-glucopyranoside (named Viscomarfadol) and two known compounds (isorhamnetin-3-O-rutinoside and epicatechin (4-8) catechin). Pre-treatment of the rats with the extract improved neurological outcomes. It significantly reduced neurological deficits and infarct volume; significantly reduced lipid peroxidation, as evidenced by decreased malondialdehyde levels; and significantly elevated antioxidant (superoxide dismutase, catalase, and glutathione) activities. These results indicate that D. viscosa is a promising source of bioactive compounds that can improve neurological status, decrease infarct volume, and enhance antioxidant activities in rats with cerebral ischaemic injury. Thus, D. viscosa could be developed into an adjuvant therapy for ischaemic stroke and other oxidative stress-related neurodegenerative disorders. Further investigations are warranted to explore other bioactive compounds in D. viscosa and evaluate their potential neuroprotective activities.

Repercussions of Caregiving on Caregivers of Stroke Survivors: A Cross-Sectional Study

BACKGROUND

Stroke is one of the most common causes of disability. Stroke survivors may have a wide variety of sensorimotor, cognitive, perceptual, and behavioral dysfunctions. The majority of long-term care for stroke survivors in residential settings is provided by informal caregivers, such as family members. This study was conducted to assess the burden of caregiving on caregivers of stroke survivors.

MATERIALS AND METHODS

This cross-sectional study was conducted by the Department of Physical Medicine and Rehabilitation in a tertiary care institute in Western India. Patients were evaluated for inclusion and exclusion criteria. Caregiver strain among caregivers was assessed using the Modified Caregiver Strain Index Questionnaire (MCSI). The Katz index was used to assess activities of daily living.

RESULTS

The inclusion and exclusion criteria were fulfilled by 125 primary caregivers of stroke patients. Among stroke survivors, the majority were male (57.6%), and caregivers were wives of stroke survivors (28.8%). There was a significant statistical difference in the median of the modified caregiver strain index when the stroke survivor was male (p=0.034), fully dependent (p<0.001), and had a hemorrhagic stroke (p<0.001). There was no significant statistical difference in the median of the MCSI based on the sex of caregivers (p=0.928). There was a positive correlation between the age of the patient and MCSI (r=0.373, p<0.001). No correlation was found between the MCSI and age of caregivers (r=-0.108, p=0.230) and duration of stroke (r=-0.089, p=0.321).

CONCLUSION

The findings in our study provide evidence that caregivers of stroke survivors experience significant levels of strain. It is desirable to recognize caregiver strain during the rehabilitation of stroke survivors and manage it appropriately.

Lesion-specific cortical activation following sensory stimulation in patients with subacute stroke

BACKGROUND

Sensory stimulation can play a fundamental role in the activation of the primary sensorimotor cortex (S1-M1), which can promote motor learning and M1 plasticity in stroke patients. However, studies have focused mainly on investigating the influence of brain lesion profiles on the activation patterns of S1-M1 during motor tasks instead of sensory tasks. Therefore, the objective of this study is to explore the lesion-specific activation patterns due to different brain lesion profiles and types during focal vibration (FV).

METHODS

In total 52 subacute stroke patients were recruited in this clinical experiment, including patients with basal ganglia hemorrhage/ischemia, brainstem ischemia, other subcortical ischemia, cortical ischemia, and mixed cortical-subcortical ischemia. Electroencephalograms (EEG) were recorded following a resting state lasting for 4 min and three sessions of FV. FV was applied over the muscle belly of the affected limb's biceps for 3 min each session. Beta motor-related EEG power desynchronization overlying S1-M1 was used to indicate the activation of S1-M1, while the laterality coefficient (LC) of the activation of S1-M1 was used to assess the interhemispheric asymmetry of brain activation.

RESULTS

(1) Regarding brain lesion profiles, FV could lead to the significant activation of bilateral S1-M1 in patients with basal ganglia ischemia and other subcortical ischemia. The activation of ipsilesional S1-M1 in patients with brainstem ischemia was higher than that in patients with cortical ischemia. No activation of S1-M1 was observed in patients with lesions involving cortical regions. (2) Regarding brain lesion types, FV could induce the activation of bilateral S1-M1 in patients with basal ganglia hemorrhage, which was significantly higher than that in patients with basal ganglia ischemia. Additionally, LC showed no significant correlation with the modified Barthel index (MBI) in all patients, but a positive correlation with MBI in patients with basal ganglia lesions.

CONCLUSIONS

These results reveal that sensory stimulation can induce lesion-specific activation patterns of S1-M1. This indicates FV could be applied in a personalized manner based on the lesion-specific activation of S1-M1 in stroke patients with different lesion profiles and types. Our study may contribute to a better understanding of the underlying mechanisms of cortical reorganization.

Feasibility and outcomes of supplemental gait training by robotic and conventional means in acute stroke rehabilitation

INTRODUCTION

Practicality of implementation and dosing of supplemental gait training in an acute stroke inpatient rehabilitation setting are not well studied but can have positive impact on outcomes.

OBJECTIVES

To determine the feasibility of early, intense supplemental gait training in inpatient stroke rehabilitation, compare functional outcomes and the specific mode of delivery.

DESIGN AND SETTING

Assessor blinded, randomized controlled trial in a tertiary Inpatient Rehabilitation Facility.

PARTICIPANTS

Thirty acute post-stroke patients with unilateral hemiparesis (≥ 18 years of age with a lower limb MAS ≤ 3).

INTERVENTION

Lokomat® or conventional gait training (CGT) in addition to standard mandated therapy time.

MAIN OUTCOME MEASURES

Number of therapy sessions; adverse events; functional independence measure (FIM motor); functional ambulation category (FAC); passive range of motion (PROM); modified Ashworth scale (MAS); 5 times sit-to-stand (5x-STS); 10-m walk test (10MWT); 2-min walk test (2MWT) were assessed before (pre) and after training (post).

RESULTS

The desired supplemental therapy was implemented during normal care delivery hours and the patients generally tolerated the sessions well. Both groups improved markedly on several measures; the CGT group obtained nearly 45% more supplemental sessions (12.8) than the Lokomat® group (8.9). Both groups showed greater FIM improvement scores (discharge - admission) than those from a reference group receiving no supplemental therapy. An overarching statistical comparison between methods was skewed towards a differential benefit (but not significant) in the Lokomat® group with medium effect sizes. By observation, the robotic group completed a greater number of steps, on average. These results provide some evidence for Lokomat® being a more efficient tool for gait retraining by providing a more optimal therapy "dose".

CONCLUSIONS

With careful planning, supplemental therapy was possible with minimal intrusion to schedules and was well tolerated. Participants showed meaningful functional improvement with relatively little supplemental therapy over a relatively short time in study.

Ischemic and hemorrhagic strokes in young adults: Comparison of functional outcomes and return to work after stroke

BACKGROUND

Functional recovery and return to work (RTW) after stroke are important rehabilitation goals that have significant impact on quality of life. Comparisons of functional outcomes and RTW between ischemic stroke (IS) and hemorrhagic stroke (HS), especially among young adults with stroke, have either been limited or yielded inconsistent results. We aimed to assess functional outcomes and ability to RTW in young adults with IS and HS, specifically primary spontaneous intracranial hemorrhage (SICH).

METHODS

Young adults with IS or SICH aged 18-50-years-old were included. Outcome measures were modified Rankins score (mRS) on discharge and 3-months and RTW at 3-months after stroke. Good functional outcome was defined as an mRS of 0-2.

RESULTS

We included 459 patients (71.5% male) with a mean age of 43.3 ± 5.7 years, comprising 49.2% IS and 50.8% SICH. Patients with SICH were more likely to have unfavourable shifts in ordinal mRS on discharge (OR 7.52, CI 5.18-10.87, p < 0.001) and at 3-months (OR 6.41, CI 4.17-9.80, p < 0.001). Patients with IS more likely achieved good functional outcomes (80.2% vs. 51.8%, p < 0.001) and were able to RTW at 3-months (54.4% vs. 36.3%, p = 0.004). Among all stroke patients with good functional outcomes, one-third did not RTW at 3-months. Patients with longer length of hospitalisation and higher National Institutes of Health Stroke Scale (NIHSS) score on admission, especially in the domain categories of level of consciousness, vision, motor function, language and neglect, were less likely to RTW at 3-months.

CONCLUSION

Patients with IS were more likely to RTW when compared to SICH patients. Many young stroke patients did not RTW despite good functional outcomes. Further research should therefore address differences in prognosis and identify predictors that influence ability to RTW after stroke in the young adult population.

Cerebrovascular Disease Mortality Trends in Brazil: An In-Depth Joinpoint Analysis

Background Cerebrovascular disease is the second leading cause of death and the third leading cause of disability following heart disease. In 2019, there were over 101 million people living with a stroke and 12.2 million incidents of stroke globally. For the past three decades, stroke has remained the leading cause of death in Brazil, causing over 100,000 fatalities annually, along with numerous functional impairments among those who survive. The Brazilian healthcare system has witnessed notable advancements in the last decade, including the establishment of additional hospitals and a rise in the count of healthcare professionals specializing in cardiovascular and neurological surgery. However, there exists a gap in the research landscape for continuous comprehensive studies aimed at exploring the evolving mortality rates related to cerebrovascular diseases, of which the last one included data up to 2019. This study aimed to address this gap by meticulously analyzing the trends in cerebrovascular disease mortality in Brazil from 2000 to 2021, for the variables age, sex, state of residence, and geographic region. Methods This is a descriptive, ecological, and time series study. Nationwide data for annual cerebrovascular mortality from Brazil were used for the period 2000-2021. Age-adjusted mortality rates (AAMRs) by direct standardization, encompassing people above 20 years of age, were calculated and expressed per 100,000 persons. Mortality trends were assessed using joinpoint regression analysis by calculating the annual percentage change (APC) and its corresponding 95% confidence interval (CI) across categories of age, sex, and state and region of residence. Results The mortality rates decreased for the sex categories over the analyzed years. The AAMR for the categories decreased as follows: males and females (95 deaths/100,000 to 52 deaths/100,000 inhabitants), males (108 deaths/100,000 to 63 deaths/100,000 inhabitants), and females (83 deaths/100,000 to 44 deaths/100,000 inhabitants). The most substantial reduction in AAMR for males occurred in the 30-39-year age group (APC: -4.10), while the smallest decline was observed in the 20-29-year age group (APC: -1.44). All five macro-regions demonstrated statistically significant and downward AAPC values in mortality rates. The south and midwest regions decreased at a stable rate, as denoted by the same APC and AAPC values (-4.05 and -3.11, respectively). The north and northeast regions exhibited an increase in AAMR, followed by a decrease (APC: 0.68 to -1.42 and 2.63 to -2.35, respectively). Conclusions Our comprehensive analysis revealed a downward trend in cerebrovascular disease mortality rates across diverse demographic groups and macro-regions. Females experienced a more substantial reduction compared to males. Despite higher mortality rates among individuals aged 50 and above, all age groups displayed a marked decrease. The continuous decline can be attributed to policy interventions aimed at enhancing healthcare delivery, increased awareness, and healthier diets and lifestyles. With regard to the macro-regions, the regions in the southern zone demonstrated a more significant decrease as compared to the northern part. In Brazil, a more significant decline in cerebrovascular disease mortality rates could be achieved through increased focus on prevention measures and efforts toward mitigating disparities and inequalities between macro-regions.

Non-paretic leg movements can facilitate cortical drive to the paretic leg in individuals post stroke with severe motor impairment: Implications for motor priming

Cross-education, a phenomenon where unilateral strength (or skill) training enhances strength (or skill) in the contralateral untrained limb, has been well studied in able-bodied individuals. Cross-education effect accompanies bilateral changes of corticomotor activity in the motor cortex (M1). Recent reports demonstrated greater cross-education effect in stroke survivors compared to healthy individuals, however, corticomotor responses to cross-education in stroke remains unclear. This study aimed to determine the effects of non-paretic leg movements on corticomotor excitability (CME) and reaction time of the paretic leg in severely impaired stroke survivors. Seventeen post stroke individuals with severe leg motor impairment (Fugl-Meyer lower extremity score less than 21 and absence of motor evoked potential in the paretic leg) performed three 20-min motor trainings using their non-paretic ankle: skill (targeted dynamic movements), strength (isometric resistance) and sham (sub-threshold electrical nerve stimulation). During training, verbal instructions were given to the participants to limit their movement to the non-paretic leg and this was confirmed with visual observation of the paretic leg. Transcranial magnetic stimulation measured CME of the contralateral pathways from the non-lesioned M1 to the non-paretic tibialis anterior (TA) muscle, ipsilateral pathways to the paretic TA and transcallosal inhibition (TCI) from the non-lesioned to lesioned M1. Paretic ankle reaction time was measured using a reaction time paradigm. All outcomes were measured before, immediately post, 30-min post and 60-min post priming. CME of the non-paretic TA increased after skill (.08 ± .10 mV) and strength (.06 ± .05 mV) training (p < .01). Ipsilateral CME of the paretic TA (.02 ± .01 mV) and TCI (.01 ± .01 s, ipsilateral silent period; more inhibition to the lesioned M1) increased after skill (p < .05) but not strength training. Reaction time of the paretic ankle improved after skill and strength training (-.11 ± .2 and -.13 ± .20 s, respectively; p < .05) and was sustained at 60 min. No changes were observed during the sham condition. Our findings may inform future studies for using non-paretic leg movements as a priming modality, especially for those who are contraindicated to other priming paradigms (e.g., brain stimulation) or unable to perform paretic leg movements. Conclusion: Non-paretic leg movements can be used as a priming modality, especially for those who are contraindicated to other priming paradigms (e.g., brain stimulation) or unable to perform paretic leg movements.

Trends and Treatment Approaches for Complications in Neuroscience Experiments with Monkey Species

Our goal in this manuscript is to advance the assessment and treatment of monkey species in neuroscience research. We hope to begin a discussion and establish baseline data on how complications are identified and treated. We surveyed the neuroscience research community working with monkeys and compiled responses to questions about investigator demographics, assessment of animal wellbeing, treatment choices, and approaches to mitigate risks associated with CNS procedures and promote monkey health and wellbeing. The majority of the respondents had worked with nonhuman primates (NHP) for over 15 y. Identification of procedure-related complications and efficacy of treatment generally rely on common behavioral indices. Treatments for localized inflammatory responses are generally successful, whereas the treatment success for meningitis or meningoencephalitis, abscesses, and hemorrhagic stroke are less successful. Behavioral signs of pain are treated successfully with NSAIDs and opioids. Our future plans are to collate treatment protocols and develop best practices that can be shared across the neuroscience community to improve treatment success rates and animal welfare and therefore science. Human protocols can be used to develop best practices, assess outcomes, and promote further refinements in treatment practices for monkeys to enhance research outcomes.

Effect of Core Exercises on Motor Function Recovery in Stroke Survivors with Very Severe Motor Impairment

Paresis of the upper and lower limbs is a typical issue in stroke survivors. This study aims to determine whether core exercises help stroke survivors with very severe motor impairment recover their motor function. This study employed a within-subjects design. Eleven hemiparetic stroke patients with very severe motor impairment (FMA score < 35) and ages ranging from 24 to 52 years old were enrolled in this study. All participants engaged in supervised core exercise training twice a week for 12 weeks. The main outcome measures were Fugl-Meyer Assessment Lower Extremity (FMA-LE) and Fugl-Meyer Assessment Upper Extremity (FMA-UE), which were measured before training and at intervals of four weeks during training. Repeated measures ANOVA was used to analyze the effect of core exercises on motor function performance and lower extremity motor function and upper extremity motor function recovery. There were significant differences in the mean scores for motor function performance, lower extremity motor function, and upper extremity motor function throughout the four time points. A post-hoc pairwise comparison using the Bonferroni correction revealed that mean scores significantly increased and were statistically different between the initial assessment and follow-up assessments four, eight, and twelve weeks later. This study suggests that 12 weeks of core exercise training is effective for improving motor function recovery in patients with very severe motor impairment.

Cognitive Profile in Patients Admitted to Intensive Rehabilitation after Stroke Is Associated with the Recovery of Dysphagia: Preliminary Results from the RIPS (Intensive Post-Stroke Rehabilitation) Study

Dysphagia represents one of the most frequent symptoms in the post-acute stroke population. Swallowing impairment and cognitive deficits can often co-occur. This study aims to investigate the relationship between cognitive impairment and the recovery of dysphagia in patients attending specific rehabilitation. Patients admitted to intensive rehabilitation units were administered the Functional Oral Intake Scale (FOIS) and Montreal Cognitive Screening Test (MoCA); when screening positive for dysphagia, they entered a rehabilitation program. Their FOIS score at discharge was the primary outcome measure. In the multivariate analysis, younger age (B = - 0.077, p = 0.017), higher MoCA (B = 0.191, p = 0.002), and higher FOIS (B = 1.251, p = 0.032) at admission were associated with higher FOIS at discharge. When executive function (EF) replaced the MoCA total score in the model, younger age (B = - 0.134, p = 0.001), higher admission EF (B = 1.451, p < 0.001), and FOIS (B = 1.348, p = 0.035) were associated with higher FOIS at discharge. Our results confirm the hypothesis that a better cognitive profile upon admission is associated with a higher probability of dysphagia recovery at discharge. EF seems to have a crucial role in dysphagia recovery. These results highlight the importance of considering the cognitive profile when assessing and treating dysphagia after stroke and of using screening tests that include executive functions.

Neuroimaging biomarkers of cognitive recovery after ischemic stroke

Post-stroke cognitive impairment affects more than one-third of patients after an ischemic stroke (IS). Identifying markers of potential cognitive recovery after ischemic stroke can guide patients' selection for treatments, enrollment in clinical trials, and cognitive rehabilitation methods to restore cognitive abilities in post-stroke patients. Despite the burden of post-stroke cognitive impairment, biomarkers of cognitive recovery are an understudied area of research. This narrative review summarizes and critically reviews the current literature on the use and utility of neuroimaging as a predictive biomarker of cognitive recovery after IS. Most studies included in this review utilized structural Magnetic Resonance Imaging (MRI) to predict cognitive recovery after IS; these studies highlighted baseline markers of cerebral small vessel disease and cortical atrophy as predictors of cognitive recovery. Functional Magnetic Resonance Imaging (fMRI) using resting-state functional connectivity and Diffusion Imaging are potential biomarkers of cognitive recovery after IS, although more precise predictive tools are needed. Comparison of these studies is limited by heterogeneity in cognitive assessments. For all modalities, current findings need replication in larger samples. Although no neuroimaging tool is ready for use as a biomarker at this stage, these studies suggest a clinically meaningful role for neuroimaging in predicting post-stroke cognitive recovery.

African Americans and Women Have Lower Functional Gains During Acute Inpatient Rehabilitation After Hemorrhagic Stroke

OBJECTIVE

Intracerebral hemorrhage can lead to significant long-term disability. While research in stroke rehabilitation has focused primarily on ischemic strokes, identifying factors that impact recovery in patients with intracerebral hemorrhage is necessary. Our purpose is to identify factors, including racial and sex disparities, associated with functional outcomes in intracerebral hemorrhage patients after inpatient rehabilitation.

DESIGN

This was a retrospective analysis of consecutive patients with intracerebral hemorrhage admitted to an inpatient rehabilitation facility at an academic tertiary facility in the Southeastern United States from 2016 to 2019. Clinical characteristics, demographics, admission, and discharge Functional Independence Measure scores were collected.

RESULTS

We evaluated 59 patients (54.4 ± 14.1 yrs, 39% females, 48.2% African American) with a median intracerebral hemorrhage volume of 13.4 (4.2-33.0) and a mean (SD) Functional Independence Measure efficiency of 1.8 ± 1.3. In multiple regression, being female was negatively associated with Functional Independence Measure efficiency (β = -1.13, P = 0.0037) when adjusting for race and intracerebral hemorrhage score. The Functional Independence Measure efficiency was lower in African Americans (β = -0.97, P = 0.0119) when adjusting for sex and intracerebral hemorrhage volume.

CONCLUSIONS

The results of our study indicate that Functional Independence Measure efficiency was worse for African Americans and female patients with intracerebral hemorrhage. Future research should consider these racial and sex disparities and focus on providing targeted rehabilitation therapy.

Repeated Measures of Modified Rankin Scale Scores to Assess Functional Recovery From Stroke: AFFINITY Study Findings

Background

Function after acute stroke using the modified Rankin Scale (mRS) is usually assessed at a point in time. The analytical implications of serial mRS measurements to evaluate functional recovery over time is not completely understood. We compare repeated‐measures and single‐measure analyses of the mRS from a randomized clinical trial.

Methods and Results

Serial mRS data from AFFINITY (Assessment of Fluoxetine in Stroke Recovery), a double‐blind placebo randomized clinical trial of fluoxetine following stroke (n=1280) were analyzed to identify demographic and clinical associations with functional recovery (reduction in mRS) over 12 months. Associations were identified using single‐measure (day 365) and repeated‐measures (days 28, 90, 180, and 365) partial proportional odds logistic regression. Ninety‐five percent of participants experienced a reduction in mRS after 12 months. Functional recovery was associated with age at stroke <70 years; no prestroke history of diabetes, coronary heart disease, or ischemic stroke; prestroke history of depression, a relationship partner, living with others, independence, or paid employment; no fluoxetine intervention; ischemic stroke (compared with hemorrhagic); stroke treatment in Vietnam (compared with Australia or New Zealand); longer time since current stroke; and lower baseline National Institutes of Health Stroke Scale & Patient Health Questionnaire‐9 scores. Direction of associations was largely concordant between single‐measure and repeated‐measures models. Association strength and variance was generally smaller in the repeated‐measures model compared with the single‐measure model.

Conclusions

Repeated‐measures may improve trial precision in identifying trial associations and effects. Further repeated‐measures stroke analyses are required to prove methodological value.

Registration

URL: http://www.anzctr.org.au; Unique identifier: ACTRN12611000774921.

Magnitude and Predictors of In-Hospital Stroke Mortality in Ethiopia: A Systematic Review and Meta-Analysis

Introduction

Stroke is the second leading cause of mortality worldwide, accounting for approximately 5.5 million deaths each year. Due to demographic and health changes, the epidemiology of stroke is shifting from industrialized to low- and middle-income nations. Ethiopia is a developing country with a population that reflects this shift. Therefore, this systematic review and meta-analysis are aimed at evaluating the extent of in-hospital mortality of both ischemic and hemorrhagic stroke in Ethiopia and determining relevant factors associated with the mortality.

Methods

Observational studies published as of July 15, 2020, that reported the magnitude, predictors, and causes of in-hospital mortality of stroke were systematically and comprehensively retrieved using the PRISMA 2020 criteria from databases such as PubMed/MEDLINE, Science Direct, and Google Scholar. The review papers were chosen based on the study methodology (facility-based observational), the study area (Ethiopia), the study population (adult patients with stroke), the outcome (in-hospital mortality), and the fact that they were published in English.

Result

A total of 3709 patients with stroke were included in this systematic review and meta-analysis, which included 19 publications. In-hospital mortality was 14.03 percent on average in the studies, with reports ranging from 6.04 percent to 37.37 percent. Patients with hemorrhagic type stroke, admission Glasgow Coma Scale less than or equal to 12, impaired mental status, National Institutes of Health Stroke Scale stroke level greater than 13, prolonged hospital stay, any incontinence, pneumonia, and/or swallowing trouble had an increased risk of death after stroke.

Conclusion

The magnitude of in-hospital mortality of patients with stroke in Ethiopia is high. The assessment of the level of consciousness is vital for clinical management and as an indicator of prognosis. Patients with unfavorable prognostic signs, such as entry Glasgow Coma Scale, National Institutes of Health Stroke Scale stroke level > 13, hemorrhagic stroke, pneumonia, incontinence, and dysphagia, should be given priority.

Are There Differences in Long-Term Functioning and Recovery Between Hemorrhagic and Ischemic Stroke Patients Receiving Rehabilitation?

OBJECTIVE

Previous research suggested better recovery in functioning of patients with hemorrhagic as compared to ischemic stroke. Now that more effective acute treatment for ischemic stroke, i.e. thrombolysis and thrombectomy, has become available, this observational cohort study aimed to examine if current rehabilitation outcomes differ between patients with hemorrhagic and ischemic stroke.

MATERIALS AND METHODS

The Barthel Index, 4 domains of the Stroke Impact Scale (SIS) and the EuroQol 5Dimensions were completed in all consecutive patients who received stroke rehabilitation at start of rehabilitation and during follow-up (for Barthel Index at discharge, SIS and EuroQol 5D after three and six months). Outcomes and recovery (i.e. change of scores between baseline and last follow-up) were compared between patients with hemorrhagic stroke and ischemic stroke (total and categorized by initial hospital treatment) using the Kruskall Wallis test. In addition, recovery was compared between ischemic and hemorrhagic stroke in multiple regression analyses with bootstrapping.

RESULTS

Baseline functioning did not differ between 117 patients with a hemorrhagic stroke, 118 ischemic stroke patient treated with reperfusion therapy, and 125 ischemic stroke patients without reperfusion therapy. There were no differences in functioning at follow-up nor in recovery concerning the Barthel Index, SIS domains 'mobility', 'communication', 'memory and thinking' and 'mood and emotions', and EuroQoL 5D between the three categories.

CONCLUSIONS

In a rehabilitation population the recovery and functioning at three or six months did not differ between ischemic stroke patients and hemorrhagic stroke patients, regardless of the hospital treatment they had received.

The addition of mirror therapy improved upper limb motor recovery and level of independence after stroke: a randomized controlled trial

Abstract Introduction In stroke survivors, the prevalence of upper motor disability remains high. There has not been much report on the success of post-stroke mirror therapy, especially in developing countries. Objective The focus of this research is to see how mirror therapy, in addition to standard rehabilitation for hand paresis, affects upper limb motor recovery and level of independence in self-care after stroke at an Indonesian teaching hospital. Method This was a randomized controlled trial with no assessor blinding. The study included 18 subacute stroke patients who did not have cognitive or visual impairment. The mirror group received a 20-minute mirror therapy session in addition to conventional rehabilitation, while the control group received only the standard program for 5 weeks (2 times per week). The Brunnstrom score and self-care level of independence elements of the Functional Independence Measure (FIM) were used as outcome measures. Results Baseline comparisons of lesion type and Brunnstrom score showed significant between-group differences. The ANACOVA test showed the difference had no effect on the FIM change in scores (P > 0.05). One patient (mirror group) was dropped out from the study. After 5 weeks (n=17), the mirror group showed improvement in both the Brunnstrom and FIM scores (P < 0.05) compared to the control group. Conclusions Mirror treatment improves upper limb motor recovery and level of independence in self-care after stroke when combined with standard hand paresis rehabilitation 2 times a week for 5 weeks.

The Effect of Implanted Functional Electrical Stimulation on Gait Performance in Stroke Survivors: A Systematic Review

The emerging literature suggests that implantable functional electrical stimulation may improve gait performance in stroke survivors. However, there is no review providing the possible therapeutic effects of implanted functional electrical stimulation on gait performance in stroke survivors. We performed a web-based, systematic paper search using PubMed, the Cochrane Library, and EMBASE. We limited the search results to human subjects and papers published in peer-reviewed journals in English. We did not restrict demographic or clinical characteristics. We included 10 papers in the current systematic review. Across all included studies, we found preliminary evidence of the potential therapeutic effects of functional electrical stimulation on walking endurance, walking speed, ankle mobility, and push-off force in stroke survivors. However, due to the heterogeneity between the included studies, small sample size, and lack of randomized controlled trials, more studies are critically needed to confirm whether implanted functional electrical stimulation can improve gait performance in stroke survivors.

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

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

Comparison of Ischemic and Hemorrhagic Stroke in the Medical Ward of Dessie Referral Hospital, Northeast Ethiopia: A Retrospective Study

Background

Distinguishing the category of stroke plays a vital role in planning patient care. Simple clinical findings help distinguish the type of stroke. However, there is a need for diagnostic imaging. In Ethiopia, stroke is the most common neurological condition in patients admitted to hospitals. Yet, there are limited data on comparisons of stroke subtypes. Thus, this study was designed to determine the prevalence of stroke and to compare ischemic and hemorrhagic strokes.

Methods

A retrospective cross-sectional study design was employed. Medical records containing complete information and confirmed diagnosis using imaging techniques were included. The data were entered into SPSS version 24.0 for analysis. Results with a P value of <0.05 were considered statistically significant.

Results

From a total of 312 stroke patients, 204 (65.4%) patients were admitted due to ischemic stroke. More females, 59 (18.9%), were admitted for hemorrhagic stroke than males. In both ischemic, 175 (56.1%) and hemorrhagic, 91 (29.2%) stroke cases, most of the patients were 45 years and above. Middle cerebral artery territory was the most common site of arterial territory infarctions in ischemic stroke, 158 (50.7%). Middle cerebral artery territory also was the most common site of hematoma in hemorrhagic stroke, 91 (29.2%). Infarctions in more than one lobe of the cerebrum (16.4%) and intracerebral hemorrhage in multiple areas of the cerebrum (7.4%) were observed in ischemic as well as hemorrhagic stroke cases. Most of the ischemic, 124 (39.8%), and hemorrhagic, 39 (12.5%), stroke patients presented loss of sensation and weakness of body parts. Hypertension was observed in 124 (39.8%) ischemic and 73 (23.4%) hemorrhagic stroke patients. The mortality rate of ischemic stroke, 47 (15.3%), was two times higher than hemorrhagic stroke, 20 (6.5%). Hypertension was the most common predictor of death in both ischemic and hemorrhagic stroke cases.

Conclusions

Ischemic stroke is a common type of stroke in the medical ward of the study hospital. More females were affected by hemorrhagic stroke than males. Middle cerebral artery territory was the most affected area of the brain in both ischemic and hemorrhagic strokes. Most ischemic and hemorrhagic stroke patients were admitted due to loss of sensation and weakness of body parts. Hypertension was the most common risk factor of stroke as well as a predictor of stroke-related deaths. Identification of the stroke subtypes may be important in the management of stroke. Thus, health professionals, government officials, community leaders, and the population at large could be involved in creating awareness about antecedent risk factors and clinical presentations of stroke subtypes.

The effects of kinesthetic and visual motor imagery on interjoint coordination in the hemiplegic index finger: an experimental study using the index of temporal coordination

Abstract Upper limb hemiparesis is a common impairment following stroke and can affect interjoint coordination. Motor imagery training is one treatment strategy. However, motor imagery can use visual or kinesthetic modalities and there has been a lack of research comparing the effectiveness of these modalities when treating the upper limb. The aim of this study was to compare visual and kinesthetic motor imagery in improving interjoint coordination in the hemiparetic index finger. Fifteen stroke survivors with upper limb hemiparesis were allocated to groups using kinesthetic or visual motor imagery, or a control group using guided relaxation. Reaching and grasping movements of the upper limb were captured using optoelectronic motion capture. Interjoint coordination of the hemiparetic index finger was analysed using the index of temporal coordination. No significant differences were found for interjoint coordination following treatment in either condition. Future work should focus on comparing kinesthetic and visual motor imagery in the rehabilitation of more proximal upper limb joints.

Neurovascular Inflammaging in Health and Disease

Aging is characterized by a chronic low-grade sterile inflammation dubbed as inflammaging, which in part originates from accumulating cellular debris. These, acting as danger signals with many intrinsic factors such as cytokines, are sensed by a network of pattern recognition receptors and other cognate receptors, leading to the activation of inflammasomes. Due to the inflammasome activity-dependent increase in the levels of pro-inflammatory interleukins (IL-1β, IL-18), inflammation is initiated, resulting in tissue injury in various organs, the brain and the spinal cord included. Similarly, in age-related diseases of the central nervous system (CNS), inflammasome activation is a prominent moment, in which cells of the neurovascular unit occupy a significant position. In this review, we discuss the inflammatory changes in normal aging and summarize the current knowledge on the role of inflammasomes and contributing mechanisms in common CNS diseases, namely Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis and stroke, all of which occur more frequently with aging.

Functional Recovery Patterns of Hemorrhagic and Ischemic Stroke Patients Under Post-Acute Care Rehabilitation Program

BACKGROUND

Tailored rehabilitation programs for stroke patients cannot be made without knowledge of their recovery potential. The aim of this study is to characterize the functional recovery patterns of ischemic stroke (IS) and intracerebral hemorrhage (ICH) patients under post-acute care stroke rehabilitation.

METHODS

This retrospective study analyzed the data of patients enrolled in the Post-Acute Care-Cerebrovascular Disease (PAC-CVD) rehabilitation program, which provides an individualized 1- to 3-hour intensive physical, occupational, and speech and language therapy for post-acute stroke patients in Taoyuan Chang Gung Memorial hospital in Taiwan. Our primary endpoint measure was Barthel Index (BI), and secondary endpoint measures included other 12 functional measures.

RESULTS

A total of 489 patients were included for analysis. Patients with stroke history had less BI improvement than those who suffered their first-ever stroke. In first-ever stroke patients who had completed 6 to 12 weeks of PAC-CVD program, subcortical ICH patients had greater BI, quality of life, sensation, and balance improvements, and had greater late-phase recovery than their IS counterparts. In IS patients, those with age >75 had less BI improvement; those with National Institute of Health Stroke Scale (NIHSS) score 1-5 had greater Motor Activity Log quality of use (MAL-quality) improvement than those with NIHSS score >5; those with Mini-Mental State Examination (MMSE) score ≥24 had greater BI and instrumental activities of daily living (IADL) improvement. Using the general linear model, previous stroke (ß: -6.148, p=0.01) and subcortical ICH (ß: 5.04, p=0.03) were factors associated with BI improvement.

CONCLUSION

Subcortical ICH patients have greater functional improvement and greater late-phase recovery than their IS counterparts following PAC rehabilitation. More studies are needed to validate our findings and unravel the underlying mechanisms of stroke recovery to optimize the treatment strategy following a stroke.

Iron Pathophysiology in Stroke

Ischemic and hemorrhagic stroke are the common types of stroke that lead to brain injury neurological deficits and mortality. All forms of stroke remain a serious health issue, and there is little successful development of drugs for treating stroke. Incomplete understanding of stroke pathophysiology is considered the main barrier that limits this research progress. Besides mitochondria and free radical-producing enzymes, labile iron is an important contributor to oxidative stress. Although iron regulation and metabolism in cerebral stroke are not fully understood, much progress has been achieved in recent years. For example, hepcidin has recently been recognized as the principal regulator of systemic iron homeostasis and a bridge between inflammation and iron regulation. This review discusses recent research progress in iron pathophysiology following cerebral stroke, focusing molecular regulation of iron metabolism and potential treatment targets.

Long-Term Survival and Function After Stroke: A Longitudinal Observational Study From the Swedish Stroke Register

Background and Purpose- Longitudinal long-term prognostic data after stroke based on large cohorts are sparse. We report recent survival and functional outcome data on ischemic stroke (IS) and intracerebral hemorrhage (ICH) for up to 5 years poststroke from the Swedish Stroke Register (Riksstroke). Methods- Beyond Riksstroke's regular follow-up surveys at 3 and 12 months, additional surveys were conducted in 2016 on 2 one-year cohorts with stroke 3 and 5 years earlier. Functional dependency was defined as modified Rankin Scale ≥3. Mortality data of the original cohorts were obtained from the Swedish Causes of Death Register. Multiple imputation was used to estimate functional status in nonresponders. Results- The study included 22 929 patients, 87.5% with IS and 12.5% with ICH. Loss to follow-up in the 4 surveys was 12.8% to 21.2%. Thirty-day mortality was higher for ICH than for IS (30.7% versus 11.1%; P<0.01), whereas for 30-day survivors, 5-year mortality did not differ significantly (P=0.858). Functional outcome was less favorable for ICH at all follow-up points. At 5 years, poor outcome (death or dependency) was 79% in ICH and 70.6% in IS (including imputed data; P<0.01). Favorable outcome was less common with increasing age and in patients with prestroke functional dependency. Conclusions- Despite advances in stroke care, long-term prognosis remains a cause for concern. At 5 years after stroke over 2 in 3 patients with IS, and over 3 in 4 patients with ICH, were dead or dependent. We present robust long-term prognostic data to serve as a reference for further development of healthcare and research in stroke.

Neurochemical changes underpinning the development of adjunct therapies in recovery after stroke: A role for GABA?

Stroke is a leading cause of long-term disability, with around three-quarters of stroke survivors experiencing motor problems. Intensive physiotherapy is currently the most effective treatment for post-stroke motor deficits, but much recent research has been targeted at increasing the effects of the intervention by pairing it with a wide variety of adjunct therapies, all of which aim to increase cortical plasticity, and thereby hope to maximize functional outcome. Here, we review the literature describing neurochemical changes underlying plasticity induction following stroke. We discuss methods of assessing neurochemicals in humans, and how these measurements change post-stroke. Motor learning in healthy individuals has been suggested as a model for stroke plasticity, and we discuss the support for this model, and what evidence it provides for neurochemical changes. One converging hypothesis from animal, healthy and stroke studies is the importance of the regulation of the inhibitory neurotransmitter GABA for the induction of cortical plasticity. We discuss the evidence supporting this hypothesis, before finally summarizing the literature surrounding the use of adjunct therapies such as non-invasive brain stimulation and SSRIs in post-stroke motor recovery, both of which have been show to influence the GABAergic system.

Hemorrhagic versus ischemic stroke: Who can best benefit from blended conventional physiotherapy with robotic-assisted gait therapy?

BACKGROUND

Contrary to common belief of clinicians that hemorrhagic stroke survivors have better functional prognoses than ischemic, recent studies show that ischemic survivors could experience similar or even better functional improvements. However, the influence of stroke subtype on gait and posture outcomes following an intervention blending conventional physiotherapy with robotic-assisted gait therapy is missing.

OBJECTIVE

This study compared gait and posture outcome measures between ambulatory hemorrhagic patients and ischemic patients, who received a similar 4 weeks' intervention blending a conventional bottom-up physiotherapy approach and an exoskeleton top-down robotic-assisted gait training (RAGT) approach with Lokomat.

METHODS

Forty adult hemiparetic stroke inpatient subjects were recruited: 20 hemorrhagic and 20 ischemic, matched by age, gender, side of hemisphere lesion, stroke severity, and locomotor impairments. Functional Ambulation Category, Postural Assessment Scale for Stroke, Tinetti Performance Oriented Mobility Assessment, 6 Minutes Walk Test, Timed Up and Go and 10-Meter Walk Test were performed before and after a 4-week long intervention. Functional gains were calculated for all tests.

RESULTS

Hemorrhagic and ischemic subjects showed significant improvements in Functional Ambulation Category (P<0.001 and P = 0.008, respectively), Postural Assessment Scale for Stroke (P<0.001 and P = 0.003), 6 Minutes Walk Test (P = 0.003 and P = 0.015) and 10-Meter Walk Test (P = 0.001 and P = 0.024). Ischemic patients also showed significant improvements in Timed Up and Go. Significantly greater mean Functional Ambulation Category and Tinetti Performance Oriented Mobility Assessment gains were observed for hemorrhagic compared to ischemic, with large (dz = 0.81) and medium (dz = 0.66) effect sizes, respectively.

CONCLUSION

Overall, both groups exhibited quasi similar functional improvements and benefits from the same type, length and frequency of blended conventional physiotherapy and RAGT protocol. The use of intensive treatment plans blending top-down physiotherapy and bottom-up robotic approaches is promising for post-stroke rehabilitation.