What’s New in Stroke Rehabilitation

Physical functioning factors predicting a return home after stroke rehabilitation: A systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis sought to identify the physical functioning factors associated with home discharge after inpatient stroke rehabilitation.

DATA SOURCES

A search of PubMed, Embase, CINHAL, The Cochrane Library (Trials), Web of Science, and PEDro were conducted up until May 2023.

METHODS

Two independent reviewers selected studies for population (patients with stroke), predictive factors (physical functioning), outcome (discharge destination), setting (inpatient rehabilitation), and study designs (observational and experimental studies). Predictive factors were identified among assessments of the "body function" and "activity" components of the International Classification of Functioning. Methodological quality was assessed with the Newcastle-Ottawa Scale. The findings used quantitative and narrative syntheses. Meta-analyses were performed with the inverse variance method and the random-effects model using included studies with sufficient data.

RESULTS

Forty-five studies were included with 204,787 participants. Included studies assessed the association of independence in activities of daily living, walking, rolling, transferring, and balance on admission with a probability of returning home. Motor (odds ratio = 1.23, 95% confidence interval: 1.12-1.35, p < .001) and total (odds ratio = 1.34, 95% confidence interval: 1.14-1.57, p < .001) Functional Independence Measure scores on admission were significantly associated with home discharge in meta-analyses. Additionally, included studies showed that independence in motor activities, such as sitting, transferring, and walking, and scores above thresholds for the Functional Independence Measure and Berg Balance Scale on admission were associated with discharge destination.

CONCLUSION

This review showed that higher independence in activities of daily living on admission is associated with home discharge after inpatient stroke rehabilitation.

Automatic Generation of Personalised and Context-Dependent Textual Interventions During Neuro-rehabilitation

In this paper we present our system that synthesises personalised and context dependent texts during robot guided exercises for neuro-rehabilitation. This system is used to generate texts for the communication between a care robot and patients. We present requirements that a system in such a medical domain has to meet. Afterwards the results of a systematic literature review are presented. We present our solution based on the RosaeNLG system. It supports different language levels and referring expressions in a real-time text generation system, so that generated texts can be adapted to the reader in the best possible way. We evaluate our system with respect to the requirements. The contribution of the paper is twofold: We present a set of requirements for Natural Language Generation (NLG) in medical domains and we show how to extend RosaeNLG with an external dialogue memory to handle complex referring expressions in medical real time settings.

Muscle loading in exoskeletal orthotic use in an activity of daily living

Strokes are the leading cause of major adult disability with up to 85% of U.S. survivors experiencing hemiparesis. Physical characteristics of upper-extremity exoskeletal orthotics, used in stroke rehabilitation, were evaluated in terms of performance of activities of daily living (ADL), perceived exertion, and muscle load. Simulated orthotic weight distributions, with total extremity loads of 0.81 kg, 1.25 kg and 2.27 kg, were evaluated along with a 0 kg control condition. Response measures included average shoulder/elbow muscle surface electromyography (sEMG) signal amplitude, quality of task completion and total rest time during performance, and Borg CR-10 scale ratings. Device weight distribution, or imposed shoulder moment, was found to have a significant effect on biceps brachii and anterior deltoid activation levels, percent task completion, total rest time, and perceived exertion ratings. Results suggest that heavier upper-extremity orthotics could cause undesirable effects in terms of muscle loading, performance and exertion; such adverse effects could potentially lead to lack of use during patient's rehabilitation.

Inducing self-selected human engagement in robotic locomotion training

Stroke leads to severe mobility impairments for millions of individuals each year. Functional outcomes can be improved through manual treadmill therapy, but high costs limit patient exposure and, thereby, outcomes. Robotic gait training could increase the viable duration and frequency of training sessions, but robotic approaches employed thus far have been less effective than manual therapy. These shortcomings may relate to subconscious energy-minimizing drives, which might cause patients to engage less actively in therapy when provided with corrective robotic assistance. We have devised a new method for gait rehabilitation that harnesses, rather than fights, least-effort tendencies. Therapeutic goals, such as increased use of the paretic limb, are made easier than the patient's nominal gait through selective assistance from a robotic platform. We performed a pilot test on a healthy subject (N = 1) in which altered self-selected stride length was induced using a tethered robotic ankle-foot orthosis. The subject first walked on a treadmill while wearing the orthosis with and without assistance at unaltered and voluntarily altered stride length. Voluntarily increasing stride length by 5% increased metabolic energy cost by 4%. Robotic assistance decreased energy cost at both unaltered and voluntarily increased stride lengths, by 6% and 8% respectively. We then performed a test in which the robotic system continually monitored stride length and provided more assistance if the subject's stride length approached a target increase. This adaptive assistance protocol caused the subject to slowly adjust their gait patterns towards the target, leading to a 4% increase in stride length. Metabolic energy consumption was simultaneously reduced by 5%. These results suggest that selective-assistance protocols based on targets relevant to rehabilitation might lead patients to self-select desirable gait patterns during robotic gait training sessions, possibly facilitating better adherence and outcomes.

Level and predictors of participation in patients with stroke undergoing inpatient rehabilitation

INTRODUCTION

The level of participation is an important factor influencing rehabilitation outcome. However, few studies have evaluated rehabilitation participation and its clinical predictors in patients with stroke. This study aimed to establish the level of participation in patients with stroke undergoing inpatient rehabilitation, and define the clinical predictors for participation.

METHODS

This was a prospective observational study of first-time patients with stroke admitted to a rehabilitation centre over a 12-month period. The primary outcome measure was the level of rehabilitation participation as measured on the Pittsburgh Rehabilitation Participation Scale (PRPS). PRPS measurements were made one week after admission and one week before planned discharge from inpatient rehabilitation. Other outcome measures evaluated were the National Institute of Health Stroke Scale, Functional Independence Measure (FIM), Elderly Cognitive Assessment Questionnaire (ECAQ), Centre for Epidemiologic Studies-Depression Scale, Fatigue Severity Scale (FSS), Lubben Social Network Scale-Revised, and Multidimensional Health Questionnaire.

RESULTS

A total of 122 patients with stroke were studied. The mean PRPS score on admission was relatively high at 4.30 ± 0.90, and this improved to 4.65 ± 0.79 before planned discharge (p < 0.001). On multivariate analysis, the mean PRPS score on admission was predicted by FIM, EACQ and FSS scores on admission, but not by variables such as age, gender, depression, social support, or health attitudes and beliefs.

CONCLUSION

Patients with lower levels of participation were more likely to be functionally dependent, cognitively impaired and have more fatigue. We suggest that in addition to cognition, fatigue should be routinely screened in patients with stroke undergoing rehabilitation.

Factors that Influence Functional Mobility Outcomes of Patients after Traumatic Brain Injury

Objective/Background

The consequences of traumatic brain injury (TBI) include physical, cognitive, psychological, behavioural, and emotional deficits. Prognostic factors such as age, mechanism of injury, and severity of injury assist in determining the outcome of the patient. It is believed that predictors of recovery assist both the patient as well as family members in determining the potential outcomes for the patient. The objective of this study was to identify factors that influence functional mobility outcome of patients after TBI.

Methods

This was a cross-sectional study. Participants were assessed predischarge. The Glasgow Coma Scale on admission was noted to establish the severity of the TBI. The Rivermead Mobility Index was used to establish the functional mobility outcome.

Results

The sample consisted of 60 participants of which 56 (93%) were males. The average age of the participants in the study was 28 ± 8.5 years. More than 50% of the participants were unable to walk outside and 37% were able to climb a flight of stairs without help at the time of discharge from the hospital. Younger age (p < .001), male gender (p = .001), Grade 12 education (p = .001), being self employed (p < .001), having bowel and bladder continence (p < .001), not smoking and drinking (p < .001), and having occupational therapy sessions (p = .002) had a positive impact on function after TBI.

Conclusion

Previous studies have identified a multitude of factors and this study has served to confirm factors that have a positive impact on physical function after TBI within this study group.

Dose-response relationship of robot-assisted stroke motor rehabilitation: the impact of initial motor status

BACKGROUND AND PURPOSE

The increasing availability of robot-assisted therapy (RT), which provides quantifiable, reproducible, interactive, and intensive practice, holds promise for stroke rehabilitation, but data on its dose-response relation are scanty. This study used 2 different intensities of RT to examine the treatment effects of RT and the effect on outcomes of the severity of initial motor deficits.

METHODS

Fifty-four patients with stroke were randomized to a 4-week intervention of higher-intensity RT, lower-intensity RT, or control treatment. The primary outcome, the Fugl-Meyer Assessment, was administered at baseline, midterm, and posttreatment. Secondary outcomes included the Medical Research Council scale, the Motor Activity Log, and the physical domains of the Stroke Impact Scale.

RESULTS

The higher-intensity RT group showed significantly greater improvements on the Fugl-Meyer Assessment than the lower-intensity RT and control treatment groups at midterm (P=0.003 and P=0.02) and at posttreatment (P=0.04 and P=0.02). Within-group gains on the secondary outcomes were significant, but the differences among the 3 groups did not reach significance. Recovery rates of the higher-intensity RT group were higher than those of the lower-intensity RT group, particularly on the Fugl-Meyer Assessment. Scatterplots with curve fitting showed that patients with moderate motor deficits gained more improvements than those with severe or mild deficits after the higher-intensity RT.

CONCLUSIONS

This study demonstrated the higher treatment intensity provided by RT was associated with better motor outcome for patients with stroke, which may shape further stroke rehabilitation. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00917605.

Effect of duration, participation rate, and supervision during community rehabilitation on functional outcomes in the first poststroke year in Singapore

OBJECTIVE

To examine the effect of duration, participation rate, and supervision during community rehabilitation on functional outcome during the first poststroke year.

DESIGN

Prospective longitudinal study with interviews at admission, discharge, 1 month, 6 months, and 1 year after discharge.

SETTING

Two subacute inpatient rehabilitation units and the community after discharge in Singapore.

PARTICIPANTS

Subacute nonaphasic stroke patients (N=215).

INTERVENTION

Participation rate in supervised therapy (at an outpatient rehabilitation center) and unsupervised therapy (at home) as defined as proportion of time performing therapy as prescribed by the subacute hospital's multidisciplinary rehabilitation team at discharge.

MAIN OUTCOME MEASURE

Performance of activities of daily living as measured by Barthel Index (BI) score at 1 year and improvement in BI scores between adjacent timepoints.

RESULTS

At 1 month after discharge, 33.3% were performing supervised therapy more than 25% of the recommended time, and 66.3% of subjects were performing unsupervised therapy more than 75% of the recommended time. On a mixed-model analysis, the independent predictors of lower BI scores were older age, hypertension, greater cognitive impairment, greater depressive symptoms, and greater neurologic impairment. Adjusting for these independent factors, performance of supervised therapy at 1 (β=8.8; 95% confidence interval [CI], 0.5-17.0; P=.039) and 6 (β=20.1; 95% CI, 11.0-29.2; P<.001) months postdischarge, but not unsupervised therapy, predicted better BI score at 1 year. Those who performed supervised therapy more than 25% of the recommended time achieved their maximal functional recovery faster than those who performed supervised therapy 25% or less of the recommended time (1 mo vs 6 mo).

CONCLUSIONS

Supervised stroke rehabilitation in the community at 1 and 6 months was associated with better functional status at 1 year than unsupervised therapy, and a higher participation rate in supervised therapy was associated with greater and faster functional recovery.

Plasticity of Cortical Maps

Sensory and motor representations embedded in topographic cortical maps are use-dependent, dynamically maintained, and self-organizing functional mosaics that constitute idiosyncratic entities involved in perceptual and motor learning abilities. Studies of cortical map plasticity have substantiated the view that local reorganization of sensory and motor areas has great significance in recovery of function following brain damage or spinal cord injury. In addition, the transfer of function to distributed cortical areas and subcortical structures represents an adaptive strategy for functional compensation. There is a growing consensus that subject-environment interactions, by continuously refining the canvas of synaptic connectivity and reshaping the anatomical and functional architecture of neural circuits, promote adaptive behavior throughout life. Taking advantage of use-dependent neural plasticity, early initiated rehabilitative procedures improve the potential for recovery.

The development of an upper limb stroke rehabilitation robot: identification of clinical practices and design requirements through a survey of therapists

PURPOSE. Timely and adequate rehabilitation after a stroke is crucial to maximising recovery. A way of increasing treatment access could be through robots, which would aid therapists in providing post-stroke rehabilitation. This research sought to discover the needs and preferences of therapists with respect to a robot that focuses on upper limb rehabilitation. Understanding requirements for devices could help to increase integration into clinical practice. METHODS. An international online survey was distributed through professional organisations and e-mail list services to therapists. The survey contained 85 items covering topics such as therapist background and treatment approach, rehabilitation aims and robotic rehabilitation device attributes. RESULTS. Data were analysed for 233 respondents, most of whom were physiotherapists and occupational therapists from Australia, Canada and USA. Top attributes included: facilitating a variety of arm movements, being usable while seated, giving biofeedback to clients, having virtual activities specific to daily living, being useful in-home and having resistance adjustable to client needs. In addition, the device should cost under 6000 USD. CONCLUSIONS. Findings from this survey provide guidance for technology developers regarding therapists' specifications for a robotic device for upper limb rehabilitation. In addition, findings offer a better understanding of how acceptance of such devices may be facilitated.

Rehabilitation and indigenous peoples: the Māori experience

Indigenous peoples often have the worst health status in comparison to non-indigenous people in their own nations; urgent action to address the health inequities for indigenous people is required. The role of rehabilitation in addressing health and disability inequities is particularly important due to the health need of indigenous peoples; the unequal distribution of health determinants; and disparities in access to, quality of care through and outcomes following rehabilitation. This article will present a perspective for Māori, the indigenous peoples of New Zealand, on a framework for improving rehabilitation services for Māori and ultimately their health and wellbeing.

Place Integration through Daily Activities 1 Year after Stroke

Actions link meaning to particular places over time. This study examined how familiar places, in turn, inspired or influenced actions in the rehabilitation process for individuals who had experienced stroke. The aim of this study was to describe the meanings of actions in different places during 1 year of rehabilitation after stroke. The interview data were longitudinal and collected on four occasions during the first year after stroke (e.g., at 1, 3, 6, and 12 months). Seven categories emerged from the data analysis using a constant comparative method: (1) workplace in mind, (2) experiences at home enabling reflection, (3) rehabilitation setting creates uncertainty, (4) retrieving inspiration from familiar places, (5) matching the complexity of tasks across places, (6) understanding the reality by confrontation, and (7) on the way to place integration. From these themes, a core or overarching theme emerged: the desire for place integration inspires engagement in rehabilitation. The central finding in this study revealed a strong relationship between the desire to be reintegrated into familiar places, such as work and home, and motivation to engage in rehabilitation. Further, this desire for place integration was a constant driving force over the year that motivated the participants to find activities on their own that matched the task demands at their workplaces.

Impact of intensity of practice after stroke: Issues for consideration

PURPOSE

The present debate paper addresses four relevant issues related to the impact of intensity of practice after stroke. First, the best way to define intensity of practice is discussed. Second, the paper describes the evidence that exists for a dose-response relationship in stroke rehabilitation. Third, the relevance of an appropriate patient selection for a meaningful intensive practice is explored. Finally, the paper raises the question of what it is that patients actually learn when they improve their functional skills. Search strategy. For this purpose articles from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE and PiCarta and references presented in relevant publications were examined.

DISCUSSION AND CONCLUSION

Although, there is strong evidence that early augmented exercise therapy time (expressed as time dedicated to practice) may enhance functional recovery, there is a discrepancy between the evidence for the benefits of intensive practice, on the one hand, and, the implementation of intensive rehabilitation treatment programmes in the current healthcare system on the other. Further emphasis should be given on a better understanding of the time-dependency of prognostic factors that determine the effectiveness of intensive practice in patients with stroke. In addition, a better understanding is needed of the neurophysiological and biomechanical mechanisms that underlie compensation-related learning of functional tasks after stroke.

Swallowing and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented evidence

PURPOSE

This review presents the state of swallowing rehabilitation science as it relates to evidence for neural plastic changes in the brain. The case is made for essential collaboration between clinical and basic scientists to expand the positive influences of dysphagia rehabilitation in synergy with growth in technology and knowledge. The intent is to stimulate thought and propose potential research directions.

METHOD

A working group of experts in swallowing and dysphagia reviews 10 principles of neural plasticity and integrates these advancing neural plastic concepts with swallowing and clinical dysphagia literature for translation into treatment paradigms. In this context, dysphagia refers to disordered swallowing associated with central and peripheral sensorimotor deficits associated with stroke, neurodegenerative disease, tumors of the head and neck, infection, or trauma.

RESULTS AND CONCLUSIONS

The optimal treatment parameters emerging from increased understanding of neural plastic principles and concepts will contribute to evidence-based practice. Integrating these principles will improve dysphagia rehabilitation directions, strategies, and outcomes. A strategic plan is discussed, including several experimental paradigms for the translation of these principles and concepts of neural plasticity into the clinical science of rehabilitation for oropharyngeal swallowing disorders, ultimately providing the evidence to substantiate their translation into clinical practice.

Translating principles of neural plasticity into research on speech motor control recovery and rehabilitation

PURPOSE

To review the principles of neural plasticity and make recommendations for research on the neural bases for rehabilitation of neurogenic speech disorders.

METHOD

A working group in speech motor control and disorders developed this report, which examines the potential relevance of basic research on the brain mechanisms involved in neural plasticity and discusses possible similarities and differences for application to speech motor control disorders. The possible involvement of neural plasticity in changes in speech production in normalcy, development, aging, and neurological diseases and disorders was considered. This report focuses on the appropriate use of functional and structural neuroimaging and the design of feasibility studies aimed at understanding how brain mechanisms are altered by environmental manipulations such as training and stimulation and how these changes might enhance the future development of rehabilitative methods for persons with speech motor control disorders.

CONCLUSIONS

Increased collaboration with neuroscientists working in clinical research centers addressing human communication disorders might foster research in this area. It is hoped that this article will encourage future research on speech motor control disorders to address the principles of neural plasticity and their application for rehabilitation.

Socially assistive robotics for post-stroke rehabilitation

Background

Although there is a great deal of success in rehabilitative robotics applied to patient recovery post stroke, most of the research to date has dealt with providing physical assistance. However, new rehabilitation studies support the theory that not all therapy need be hands-on. We describe a new area, called socially assistive robotics, that focuses on non-contact patient/user assistance. We demonstrate the approach with an implemented and tested post-stroke recovery robot and discuss its potential for effectiveness.

Results

We describe a pilot study involving an autonomous assistive mobile robot that aids stroke patient rehabilitation by providing monitoring, encouragement, and reminders. The robot navigates autonomously, monitors the patient's arm activity, and helps the patient remember to follow a rehabilitation program. We also show preliminary results from a follow-up study that focused on the role of robot physical embodiment in a rehabilitation context.

Conclusion

We outline and discuss future experimental designs and factors toward the development of effective socially assistive post-stroke rehabilitation robots.

Future prospects of ERD/ERS in the context of brain-computer interface (BCI) developments

ERD/ERS patterns characterize the dynamics of brain oscillations time-locked but not phase-locked to an externally or internally triggered event. Recent studies have shown that ERD/ERS phenomena in narrow frequency bands are remarkably stable over time and across different testing situations. The high reproducibility of ERD/ERS promotes the usefulness of this biometric measure in assessing individual characteristics. In addition to the spatio-temporal patterns of (de)synchronization processes the most reactive frequency components are especially highly subject-specific and, therefore, open up new possibilities for user authentication and person identification. In contrast, ERD/ERS research will continue to be useful in clinical brain-computer interface (BCI) implementation. Promising novel applications of an ERD/ERS based BCI may contribute to enhanced functional recovery and rehabilitation in patients suffering from chronic stroke. According to current therapeutic strategies, feedback-regulated motor imagery could be used to enhance antagonistic ERD/ERS patterns and therewith, support activation of the stroke affected and inhibition of the non-affected, contralesional hemisphere.