Rehabilitation for stroke: a review

From data to decisions: AI and functional connectivity for diagnosis, prognosis, and recovery prediction in stroke

Stroke is a severe medical condition which may lead to permanent disability conditions. The initial 8 weeks following a stroke are crucial for rehabilitation, as most recovery occurs during this period. Personalized approaches and predictive biomarkers are needed for tailored rehabilitation. In this context, EEG brain connectivity and Artificial Intelligence (AI) can play a crucial role in diagnosing and predicting stroke outcomes efficiently. In the present study, 127 patients with subacute ischemic lesions and 90 age- and gender-matched healthy controls were enrolled. EEG recordings were obtained from each participant within 15 days of stroke onset. Clinical evaluations were performed at baseline and at 40-days follow-up using the National Institutes of Health Stroke Scale (NIHSS). Functional connectivity analysis was conducted using Total Coherence (TotCoh) and Small Word (SW). Quadratic support vector machines (SVM) algorithms were implemented to classify healthy subjects compared to stroke patients (Healthy vs Stroke), determine the affected hemisphere (Left vs Right Hemisphere), and predict functional recovery (Functional Recovery Prediction). In the classification for Functional Recovery Prediction, an accuracy of 94.75%, sensitivity of 96.27% specificity of 92.33%, and AUC of 0.95 were achieved; for Healthy vs Stroke, an accuracy of 99.09%, sensitivity of 100%, specificity of 98.46%, and AUC of 0.99 were achieved. For Left vs Right Hemisphere classification, accuracy was 86.77%, sensitivity was 91.44%, specificity was 80.33%, and AUC was 0.87. These findings highlight the potential of utilizing functional connectivity measures based on EEG in combination with AI algorithms to improve patient outcomes by targeted rehabilitation interventions.

Vision-related quality of life after unilateral occipital stroke

BACKGROUND/OBJECTIVES

Stroke damage to the primary visual cortex induces large, homonymous visual field defects that impair daily living. Here, we asked if vision-related quality of life (VR-QoL) is impacted by time since stroke.

SUBJECTS/METHODS

We conducted a retrospective meta-analysis of 95 occipital stroke patients (female/male = 26/69, 27-78 years old, 0.5-373.5 months poststroke) in whom VR-QoL was estimated using the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ) and its 10-item neuro-ophthalmic supplement (Neuro10). Visual deficit severity was represented by the perimetric mean deviation (PMD) calculated from 24-2 Humphrey visual fields. Data were compared with published cohorts of visually intact controls. The relationship between VR-QoL and time poststroke was assessed across participants, adjusting for deficit severity and age with a multiple linear regression analysis.

RESULTS

Occipital stroke patients had significantly lower NEI-VFQ and Neuro10 composite scores than controls. All subscale scores describing specific aspects of visual ability and functioning were impaired except for ocular pain and general health, which did not differ significantly from controls. Surprisingly, visual deficit severity was not correlated with either composite score, both of which increased with time poststroke, even when adjusting for PMD and age.

CONCLUSIONS

VR-QoL appears to improve with time postoccipital stroke, irrespective of visual deficit size or patient age at insult. This may reflect the natural development of compensatory strategies and lifestyle adjustments. Thus, future studies examining the impact of rehabilitation on daily living in this patient population should consider the possibility that their VR-QoL may change gradually over time, even without therapeutic intervention.

AI in evaluating ambulation of stroke patients: severity classification with video and functional ambulation category scale

BACKGROUND

The evaluation of gait function and severity classification of stroke patients are important to determine the rehabilitation goal and the level of exercise. Physicians often qualitatively evaluate patients' walking ability through visual gait analysis using naked eye, video images, or standardized assessment tools. Gait evaluation through observation relies on the doctor's empirical judgment, potentially introducing subjective opinions. Therefore, conducting research to establish a basis for more objective judgment is crucial.

OBJECTIVE

To verify a deep learning model that classifies gait image data of stroke patients according to Functional Ambulation Category (FAC) scale.

METHODS

Gait vision data from 203 stroke patients and 182 healthy individuals recruited from six medical institutions were collected to train a deep learning model for classifying gait severity in stroke patients. The recorded videos were processed using OpenPose. The dataset was randomly split into 80% for training and 20% for testing.

RESULTS

The deep learning model attained a training accuracy of 0.981 and test accuracy of 0.903. Area Under the Curve(AUC) values of 0.93, 0.95, and 0.96 for discriminating among the mild, moderate, and severe stroke groups, respectively.

CONCLUSION

This confirms the potential of utilizing human posture estimation based on vision data not only to develop gait parameter models but also to develop models to classify severity according to the FAC criteria used by physicians. To develop an AI-based severity classification model, a large amount and variety of data is necessary and data collected in non-standardized real environments, not in laboratories, can also be used meaningfully.

Behavioral and neuroanatomical correlates of facial emotion processing in post-stroke depression

BACKGROUND

Emotion processing deficits are known to accompany depressive symptoms and are often seen in stroke patients. Little is known about the influence of post-stroke depressive (PSD) symptoms and specific brain lesions on altered emotion processing abilities and how these phenomena develop over time. This potential relationship may impact post-stroke rehabilitation of neurological and psychosocial function. To address this scientific gap, we investigated the relationship between PSD symptoms and emotion processing abilities in a longitudinal study design from the first days post-stroke into the early chronic phase.

METHODS

Twenty-six ischemic stroke patients performed an emotion processing task on videos with emotional faces ('happy,' 'sad,' 'anger,' 'fear,' and 'neutral') at different intensity levels (20%, 40%, 60%, 80%, 100%). Recognition accuracies and response times were measured, as well as scores of depressive symptoms (Montgomery-Åsberg Depression Rating Scale). Twenty-eight healthy participants matched in age and sex were included as a control group. Whole-brain support-vector regression lesion-symptom mapping (SVR-LSM) analyses were performed to investigate whether specific lesion locations were associated with the recognition accuracy of specific emotion categories.

RESULTS

Stroke patients performed worse in overall recognition accuracy compared to controls, specifically in the recognition of happy, sad, and fearful faces. Notably, more depressed stroke patients showed an increased processing towards specific negative emotions, as they responded significantly faster to angry faces and recognized sad faces of low intensities significantly more accurately. These effects obtained for the first days after stroke partly persisted to follow-up assessment several months later. SVR-LSM analyses revealed that inferior and middle frontal regions (IFG/MFG) and insula and putamen were associated with emotion-recognition deficits in stroke. Specifically, recognizing happy facial expressions was influenced by lesions affecting the anterior insula, putamen, IFG, MFG, orbitofrontal cortex, and rolandic operculum. Lesions in the posterior insula, rolandic operculum, and MFG were also related to reduced recognition accuracy of fearful facial expressions, whereas recognition deficits of sad faces were associated with frontal pole, IFG, and MFG damage.

CONCLUSION

PSD symptoms facilitate processing negative emotional stimuli, specifically angry and sad facial expressions. The recognition accuracy of different emotional categories was linked to brain lesions in emotion-related processing circuits, including insula, basal ganglia, IFG, and MFG. In summary, our study provides support for psychosocial and neural factors underlying emotional processing after stroke, contributing to the pathophysiology of PSD.

Effectiveness of Conventional Dysphagia Therapy (CDT), Neuromuscular Electrical Stimulation (NMES), and Transcranial Direct Current Stimulation (tDCS) in Acute Post-Stroke Dysphagia: A Comparative Evaluation

This study aims to compare the effectiveness of conventional dysphagia therapy (CDT), neuromuscular electrical stimulation (NMES), and transcranial direct current stimulation (tDCS) in the treatment of post-stroke dysphagia. A single-blind randomized controlled trial was conducted with 40 acute stroke patients - 18 females and 22 males with a mean age of 65.8 ± 11.9. The subjects were grouped into 4, with 10 individuals in each. The procedures administered to groups were as follows: the first group, sham tDCS and sham NMES; the second group, tDCS and sham NMES; the third group, NMES and sham tDCS; and the fourth group, all therapy procedures. CDT was applied to all groups either as a standalone procedure or combined with one or two of the instrumental techniques. Gugging Swallowing Screen (GUSS) and Videofluoroscopic Swallowing Study (VFSS) were employed to determine the severity of dysphagia and the effectiveness of treatment modalities. Additionally, the Penetration Aspiration Scale (PAS), Functional Oral Intake Scale (FOIS), and Dysphagia Severity Rating Scale (DSRS) were administered to interpret VFSS data. Pre- and post-treatment comparisons of all groups have revealed a statistically significant difference for all parameters except for the PAS scores at International Dysphagia Diet Standardization Initiative (IDDSI)-Level 4 consistencies. However, the differences between pre- and post-treatment scores of the fourth group across all parameters were significant - GUSS (p = 0.005), FOIS (p = 0.004), DSRS (p = 0.005), PAS IDDSI-4 (p = 0.027), PAS IDDSI-0 (p = 0.004). Inter-group comparisons, on the other hand, pointed out that the difference between pre- and post-treatment GUSS, FOIS, DSRS, and PAS scores at IDDSI Level-0 consistencies was statistically significant for all groups - GUSS (p = 0,009), FOIS (p = 0,004), DSRS (p = 0,002), PAS IDDSI-0 (p = 0,049). Closer examination of treatment groups indicated that the tDCS + CDT group, the NMES + CDT group, and the group that underwent the combination of three modalities made better progress than the one that was treated with only CDT. Though not statistically significant, the NMES + CDT group achieved better improvement than the tDCS + CDT group. This study has yielded that the group in which NMES, tDCS, and CDT were applied in combination has achieved better results than all the other groups. All treatment modalities applied to accelerate the general recovery process in acute stroke patients with dysphagia were found to be effective for the treatment of post-stroke swallowing disorders. The use of instrumental treatments such as NMES and tDCS enhanced the effectiveness of the treatment and provided more significant progress. Furthermore, combining treatment modalities such as NMES and tDCS was more effective when compared to using only conventional therapy. As a result, the most effective treatment outcomes were obtained by the group receiving CDT, NMES, and tDCS in combination. Therefore, the use of combined approaches has been recommended in appropriate patients; yet the provisional results should be tested in randomized trials with more participants.

Ipsilesional arm training in severe stroke to improve functional independence (IPSI): phase II protocol

BACKGROUND

We previously characterized hemisphere-specific motor control deficits in the ipsilesional, less-impaired arm of unilaterally lesioned stroke survivors. Our preliminary data indicate these deficits are substantial and functionally limiting in patients with severe paresis.

METHODS

We have designed an intervention ("IPSI") to remediate the hemisphere-specific deficits in the ipsilesional arm, using a virtual-reality platform, followed by manipulation training with a variety of real objects, designed to facilitate generalization and transfer to functional behaviors encountered in the natural environment. This is a 2-site (primary site - Penn State College of Medicine, secondary site - University of Southern California), two-group randomized intervention with an experimental group, which receives unilateral training of the ipsilesional arm throughout 3 one-hour sessions per week for 5 weeks, through our Virtual Reality and Manipulation Training (VRMT) protocol. Our control group receives a conventional intervention on the contralesional arm, 3 one-hour sessions per week for 5 weeks, guided by recently released practice guidelines for upper limb rehabilitation in adult stroke. The study aims to include a total of 120 stroke survivors (60 per group) whose stroke was in the territory of the middle cerebral artery (MCA) resulting in severe upper-extremity motor impairments. Outcome measures (Primary: Jebsen-Taylor Hand Function Test, Fugl-Meyer Assessment, Abilhand, Barthel Index) are assessed at five evaluation points: Baseline 1, Baseline 2, immediate post-intervention (primary endpoint), and 3-weeks (short-term retention) and 6-months post-intervention (long-term retention). We hypothesize that both groups will improve performance of the targeted arm, but that the ipsilesional arm remediation group will show greater improvements in functional independence.

DISCUSSION

The results of this study are expected to inform upper limb evaluation and treatment to consider ipsilesional arm function, as part of a comprehensive physical rehabilitation strategy that includes evaluation and remediation of both arms.

TRIAL REGISTRATION

This study is registered with ClinicalTrials.gov (Registration ID: NCT03634397 ; date of registration: 08/16/2018).

Validity and Reliability of Kinect v2 for Quantifying Upper Body Kinematics during Seated Reaching

Kinematic analysis of the upper limbs is a good way to assess and monitor recovery in individuals with stroke, but it remains little used in clinical routine due to its low feasibility. The aim of this study is to assess the validity and reliability of the Kinect v2 for the analysis of upper limb reaching kinematics. Twenty-six healthy participants performed seated hand-reaching tasks while holding a dumbbell to induce behaviour similar to that of stroke survivors. With the Kinect v2 and with the VICON, 3D upper limb and trunk motions were simultaneously recorded. The Kinect assesses trunk compensations, hand range of motion, movement time and mean velocity with a moderate to excellent reliability. In contrast, elbow and shoulder range of motion, time to peak velocity and path length ratio have a poor to moderate reliability. Finally, instantaneous hand and elbow tracking are not precise enough to reliably assess the number of velocity peaks and the peak hand velocity. Thanks to its ease of use and markerless properties, the Kinect can be used in clinical routine for semi-automated quantitative diagnostics guiding individualised rehabilitation of the upper limb. However, engineers and therapists must bear in mind the tracking limitations of the Kinect.

Endovascular thrombectomy for acute ischemic stroke

This review describes the evolution of endovascular treatment for acute ischemic stroke, current state of the art, and the challenges for the next decade. The rapid development of endovascular thrombectomy (EVT), from the first attempts into standard of care on a global scale, is one of the major achievements in modern medicine. It was possible thanks to the establishment of a scientific framework for patient selection, assessment of stroke severity and outcome, technical development by dedicated physicians and the MedTech industry, including noninvasive imaging for patient selection, and radiological outcome evaluation. A series of randomized controlled trials on EVT in addition to intravenous thrombolytics, with overwhelmingly positive results for anterior circulation stroke within 6 h of onset regardless of patient characteristics with a number needed to treat of less than 3 for any positive shift in outcome, paved the way for a rapid introduction of EVT into clinical practice. Within the "extended" time window of 6-24 h, the effect has been even greater for patients with salvageable brain tissue according to perfusion imaging with a number needed to treat below 2. Even so, EVT is only available for a small portion of stroke patients, and successfully recanalized EVT patients do not always achieve excellent functional outcome. The major challenges in the years to come include rapid prehospital detection of stroke symptoms, adequate clinical and radiological diagnosis of severe ischemic stroke cases, enabling effective recanalization by EVT in dedicated angiosuites, followed by personalized post-EVT stroke care.

Effect of Stretching of Spastic Elbow Under Intelligent Control in Chronic Stroke Survivors-A Pilot Study

Objective: To assess the short-term effects of strenuous dynamic stretching of the elbow joint using an intelligent stretching device in chronic spastic stroke survivors.

Methods: The intelligent stretching device was utilized to provide a single session of intensive stretching to the spastic elbow joint in the sagittal plane (i.e., elbow flexion and extension). The stretching was provided to the extreme range, safely, with control of the stretching velocity and torque to increase the joint range of motion (ROM) and reduce spasticity and joint stiffness. Eight chronic stroke survivors (age: 52.6 ± 8.2 years, post-stroke duration: 9.5 ± 3.6 years) completed a single 40-min stretching intervention session. Elbow passive and active ROM, strength, passive stiffness (quantifying the non-reflex component of spasticity), and instrumented tendon reflex test of the biceps tendon (quantifying the reflex component of the spasticity) were measured before and after stretching.

Results: After stretching, there was a significant increase in passive ROM of elbow flexion (p = 0.021, r = 0.59) and extension (p = 0.026, r = 0.59). Also, elbow active ROM and the spastic elbow flexors showed a trend of increase in their strength.

Conclusion: The intelligent stretching had a short-term positive influence on the passive movement ROM. Hence, intelligent stretching can potentially be used to repeatedly and regularly stretch spastic elbow joints, which subsequently helps to reduce upper limb impairments post-stroke.

Rehabilitation of visual perception in cortical blindness

Blindness is a common sequela after stroke affecting the primary visual cortex, presenting as a contralesional, homonymous, visual field cut. This can occur unilaterally or, less commonly, bilaterally. While it has been widely assumed that after a brief period of spontaneous improvement, vision loss becomes stable and permanent, accumulating data show that visual training can recover some of the vision loss, even long after the stroke. Here, we review the different approaches to rehabilitation employed in adult-onset cortical blindness (CB), focusing on visual restoration methods. Most of this work was conducted in chronic stroke patients, partially restoring visual discrimination and luminance detection. However, to achieve this, patients had to train for extended periods (usually many months), and the vision restored was not entirely normal. Several adjuvants to training such as noninvasive, transcranial brain stimulation, and pharmacology are starting to be investigated for their potential to increase the efficacy of training in CB patients. However, these approaches are still exploratory and require considerably more research before being adopted. Nonetheless, having established that the adult visual system retains the capacity for restorative plasticity, attention recently turned toward the subacute poststroke period. Drawing inspiration from sensorimotor stroke rehabilitation, visual training was recently attempted for the first time in subacute poststroke patients. It improved vision faster, over larger portions of the blind field, and for a larger number of visual discrimination abilities than identical training initiated more than 6 months poststroke (i.e., in the chronic period). In conclusion, evidence now suggests that visual neuroplasticity after occipital stroke can be reliably recruited by a range of visual training approaches. In addition, it appears that poststroke visual plasticity is dynamic, with a critical window of opportunity in the early postdamage period to attain more rapid, more extensive recovery of a larger set of visual perceptual abilities.

Rivermead assessment of somatosensory performance: Italian normative data

The Rivermead assessment of somatosensory performance (RASP) provides a quantitative assessment of somatosensory processing, suitable for brain-damaged patients suffering from stroke. It consists of seven subcomponents: Subtest 1 (sharp/dull discrimination), Subtest 2 (surface pressure touch), Subtest 3 (surface localization), Subtest 4 (sensory extinction), Subtest 5 (2-point discrimination), Subtest 6 (temperature discrimination), and Subtest 7 (proprioception). Overall, the RASP assesses 5 bilateral body regions: face (cheek), hand (palm and back), and foot (sole and back). This study aimed at providing normative data and cut-off scores for RASP subtests, for each body region, in a large Italian population sample. We present results from 300 healthy Italian individuals aged 19 to 98 years. Data represent a comprehensive set of norms that cover each subtest and each body region tested. Performance in Subtests 1, 5, and 6 decreased, for some body regions, with increasing age. Based on these results, norms were stratified for age (seven groups), with the pathological/non-pathological cut-off coinciding with the 5th percentile. Conversely, other results were not influenced by age; in such cases, a single error, in each body region, has to be considered indicative of pathological performance. This independent investigation of all subcomponents of the somatosensory system, for each body region, further confirms RASP's potential in clinical practice, for neurological assessment, as well as in research settings.

The Role of Surface Electromyography in Data Fusion with Inertial Sensors to Enhance Locomotion Recognition and Prediction

Locomotion recognition and prediction is essential for real-time human–machine interactive control. The integration of electromyography (EMG) with mechanical sensors could improve the performance of locomotion recognition. However, the potential of EMG in motion prediction is rarely discussed. This paper firstly investigated the effect of surface EMG on the prediction of locomotion while integrated with inertial data. We collected EMG signals of lower limb muscle groups and linear acceleration data of lower limb segments from ten healthy participants in seven locomotion activities. Classification models were built based on four machine learning methods—support vector machine (SVM), k-nearest neighbor (KNN), artificial neural network (ANN), and linear discriminant analysis (LDA)—where a major vote strategy and a content constraint rule were utilized for improving the online performance of the classification decision. We compared four classifiers and further investigated the effect of data fusion on the online locomotion classification. The results showed that the SVM model with a sliding window size of 80 ms achieved the best recognition performance. The fusion of EMG signals does not only improve the recognition accuracy of steady-state locomotion activity from 90% (using acceleration data only) to 98% (using data fusion) but also enables the prediction of the next steady locomotion (∼370 ms). The study demonstrates that the employment of EMG in locomotion recognition could enhance online prediction performance.

Rehabilitation of cortically induced visual field loss

PURPOSE OF REVIEW

Homonymous visual field defects are a common sequela of stroke, and are assumed to be permanent within a few weeks of the event. Because consensus about the efficacy of rehabilitation is lacking, visual therapy is rarely prescribed. Here, we review current rehabilitation options and strategies in the translational pipeline that could change these perspectives.

RECENT FINDINGS

The mainstays of available therapy for homonymous visual defects are compensation training and substitution, which allow patients to better use their spared vision. However, early clinical studies suggest that vision can partially recover following intensive training inside the blind field. Research into the relative efficacy of different restorative approaches continues, providing insights into neurophysiologic substrates of recovery and its limitations. This, in turn, has led to new work examining the possible benefits of earlier intervention, advanced training procedures, noninvasive brain stimulation, and pharmacological adjuvants, all of which remain to be vetted through properly powered, randomized, clinical trials.

SUMMARY

Research has uncovered substantial visual plasticity after occipital strokes, suggesting that rehabilitative strategies for this condition should be more aggressive. For maximal benefit, poststroke vision-restorative interventions should begin early, and in parallel with strategies that optimize everyday use of an expanding field of view.

Factors predicting rehabilitation outcomes after severe acquired brain injury in trauma, stroke and anoxia populations: A cohort study

Severe acquired brain injury has long-term physical and cognitive effects. Identifying patient variables predictive of recovery in different brain injury populations would generate improved prognostic information and help rehabilitation teams set appropriate therapeutic goals. This cohort study of 447 NHS neurorehabilitation inpatients aimed to identify functional and cognitive predictors of recovery following severe acquired brain injury caused by trauma, stroke and anoxia. Motor and cognitive impairment ratings were collected at admission and discharge using the Functional Independence Measure and Functional Assessment Measure (FIM+FAM), and injury-related and demographic data were collated from medical records. Predictors of physical, cognitive and overall recovery were identified via hierarchical regression analyses. Several key findings emerged. Firstly, on-admission motor skills predicted functional and overall outcomes across groups. Secondly, on-admission social interaction skills predicted cognitive discharge outcomes in stroke and trauma, and overall outcomes for stroke, but did not predict anoxia outcomes. Thirdly, age predicted all forms of recovery for stroke only. Further group-specific factors were also identified as predicting motor and cognitive recovery, indicating that factors key to the rehabilitation trajectory may differ between populations. These variables should be considered in rehabilitation goal planning, although further research is required to explore their contributions to recovery.

Magnitude, risk factors and outcomes of stroke at Debre Markos Referral Hospital, Northwest Ethiopia: a retrospective observational study

Background

Stroke is one of the leading causes of death and disability in developing countries. The burden of stroke has varied widely in different areas, and there is a paucity of information about stroke in the selected study area.

Objectives

To assess the burden, risk factors, and outcomes of stroke at Debre Markos Referral Hospital, Northwest Ethiopia

Patients and methods

A hospital-based retrospective observational study was conducted in the medical ward of Debre Markos Referral Hospital from March 2017 to April 2019. A pretested checklist was used to extract relevant data from the chart of stroke patients. All statistical analyses were performed in the SPSS version 20 software.

Results

From a total of 2100 admissions in the medical ward, 162 of them were stroke patients, giving the in-hospital magnitude of 7.7%. The in-hospital case fatality rate was 8.6%. Additionally, 27.2% of patients were improved and 39.5% of them were referred. There was a significant association between types of stroke and risk factors such as sex, comorbid hypertension, hyperlipidemia, and atrial fibrillation (P ≤ 0.05).

Conclusion

The in-hospital period prevalence of stroke was 7.7%. Ischemic stroke was the most common type of stroke. Hypertension and hyperlipidemia were the leading identified risk factors for stroke. The overall in-hospital mortality was lower than previous studies in sub-Saharan African countries. Therefore, effective strategies and guidelines for the prevention and control of stroke and its risk factors are needed.

Interventions for visual field defects in people with stroke

BACKGROUND

Visual field defects are estimated to affect 20% to 57% of people who have had a stroke. Visual field defects can affect functional ability in activities of daily living (commonly affecting mobility, reading and driving), quality of life, ability to participate in rehabilitation, and depression and anxiety following stroke. There are many interventions for visual field defects, which are proposed to work by restoring the visual field (restitution); compensating for the visual field defect by changing behaviour or activity (compensation); substituting for the visual field defect by using a device or extraneous modification (substitution); or ensuring appropriate diagnosis, referral and treatment prescription through standardised assessment or screening, or both.

OBJECTIVES

To determine the effects of interventions for people with visual field defects after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, the Cochrane Eyes and Vision Group Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, AMED, PsycINFO, and PDQT Databse, and clinical trials databases, including ClinicalTrials.gov and WHO Clinical Trials Registry, to May 2018. We also searched reference lists and trials registers, handsearched journals and conference proceedings, and contacted experts.

SELECTION CRITERIA

Randomised trials in adults after stroke, where the intervention was specifically targeted at improving the visual field defect or improving the ability of the participant to cope with the visual field loss. The primary outcome was functional ability in activities of daily living and secondary outcomes included functional ability in extended activities of daily living, reading ability, visual field measures, balance, falls, depression and anxiety, discharge destination or residence after stroke, quality of life and social isolation, visual scanning, adverse events, and death.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts, extracted data and appraised trials. We undertook an assessment of methodological quality for allocation concealment, blinding of outcome assessors, method of dealing with missing data, and other potential sources of bias. We assessed the quality of evidence for each outcome using the GRADE approach.

MAIN RESULTS

Twenty studies (732 randomised participants, with data for 547 participants with stroke) met the inclusion criteria for this review. However, only 10 of these studies compared the effect of an intervention with a placebo, control, or no treatment group, and eight had data which could be included in meta-analyses. Only two of these eight studies presented data relating to our primary outcome of functional abilities in activities of daily living. One study reported evidence relating to adverse events.Three studies (88 participants) compared a restitutive intervention with a control, but data were only available for one study (19 participants). There was very low-quality evidence that visual restitution therapy had no effect on visual field outcomes, and a statistically significant effect on quality of life, but limitations with these data mean that there is insufficient evidence to draw any conclusions about the effectiveness of restitutive interventions as compared to control.Four studies (193 participants) compared the effect of scanning (compensatory) training with a control or placebo intervention. There was low-quality evidence that scanning training was more beneficial than control or placebo on quality of life, measured using the Visual Function Questionnaire (VFQ-25) (two studies, 96 participants, mean difference (MD) 9.36, 95% confidence interval (CI) 3.10 to 15.62). However, there was low or very-low quality evidence of no effect on measures of visual field, extended activities of daily living, reading, and scanning ability. There was low-quality evidence of no significant increase in adverse events in people doing scanning training, as compared to no treatment.Three studies (166 participants) compared a substitutive intervention (a type of prism) with a control. There was low or very-low quality evidence that prisms did not have an effect on measures of activities of daily living, extended activities of daily living, reading, falls, or quality of life, and very low-quality evidence that they may have an effect on scanning ability (one study, 39 participants, MD 9.80, 95% CI 1.91 to 17.69). There was low-quality evidence of an increased odds of an adverse event (primarily headache) in people wearing prisms, as compared to no treatment.One study (39 participants) compared the effect of assessment by an orthoptist to standard care (no assessment) and found very low-quality evidence that there was no effect on measures of activities of daily living.Due to the quality and quantity of evidence, we remain uncertain about the benefits of assessment interventions.

AUTHORS' CONCLUSIONS

There is a lack of evidence relating to the effect of interventions on our primary outcome of functional ability in activities of daily living. There is limited low-quality evidence that compensatory scanning training may be more beneficial than placebo or control at improving quality of life, but not other outcomes. There is insufficient evidence to reach any generalised conclusions about the effect of restitutive interventions or substitutive interventions (prisms) as compared to placebo, control, or no treatment. There is low-quality evidence that prisms may cause minor adverse events.

Effect of afferent electrical stimulation with mirror therapy on motor function, balance, and gait in chronic stroke survivors: a randomized controlled trial

BACKGROUND

When solely mirror therapy is applied for a long period of time, spatial perception and attention to the damaged side may decrease, and the effect of mirror therapy may be limited. To overcome this limitation, it has recently been suggested that the combination of mirror therapy with mirror treatment is effective.

AIM

The aim of this study was to investigate the effects of afferent electrical stimulation with mirror therapy on motor function, balance, and gait in chronic stroke survivors.

DESIGN

A randomized controlled trial.

SETTING

Rehabilitation center.

POPULATION

Thirty stroke survivors were randomly assigned to two groups: the experimental group (N.=15) and the control group (N.=15).

METHODS

Participants of the experimental group received afferent electrical stimulation with mirror therapy, and participants of the control group received sham afferent electrical stimulation with sham mirror therapy for 60 minutes per day, 5 days per week, for 4 weeks. Motor function was measured using a handheld dynamometer and the Modified Ashworth Scale, balance was measured using the Berg Balance Scale, and gait was assessed using the GAITRite® (GAITRite, CIR System Inc., Franklin, NJ, USA) pressure-sensitive walkway at baseline and after 4 weeks.

RESULTS

The experimental group showed significant differences in muscle strength, Modified Ashworth Scale, and Berg Balance Scale results, and velocity, cadence, step length, stride length, and double support time of their gait (P<0.05) in the pre-post intervention comparison. Significant differences between the two groups in muscle strength, Berg Balance Scale, gait velocity, step length, and stride length (P<0.05) were found.

CONLCUSIONS

Mirror therapy with afferent electrical stimulation may effectively improve muscle strength and gait and balance abilities in hemiplegic stroke survivors.

CLINICAL REHABILITATION IMPACT

Afferent electrical stimulation combined with mirror therapy can be used as an effective intervention to improve lower limb motor function, balance, and gait in chronic stroke survivors in clinical settings.

The evidence for prolonged muscle stretching in ankle joint management in upper motor neuron lesions: considerations for rehabilitation - a systematic review

BACKGROUND

As clinicians, muscles stretching approaches are one of the most commonly used interventions in rehabilitation. However, there is a need for an in-depth evaluation of research on prolonged stretching in terms of the features of the stretching approaches, such as duration and frequency, as well as the compatible measures of a successful stretching approach.

OBJECTIVE

This review is an effort to synthesize findings from studies on "prolonged" stretching approaches in patients with UMNs including stroke, spinal cord injuries, and traumatic brain injuries. We investigated the compatible features of successful stretching regimens in terms of reducing spasticity, improving the Active Range of Motion (AROM), Passive Range of Motion (PROM), and gait training of spastic patient with upper motor neuron lesions.

METHODS

Studies evaluating the effectiveness of "prolonged" stretching on spastic ankle planterflexor muscles and its complications were critically reviewed, and the level of evidence was analyzed.

RESULTS

There is a sufficient level of evidence to support the use of stretching as and effective techniques in rehabilitation. However, more research is yet to be done to objectively examine the ideal parameters of a successful stretching approach using functional assessments, such as walking, speed, walking capacity, and balance.

CONCLUSION

The review adds stronger understanding with regard to stretching considerations in rehabilitation following UMNs. The ideal approach, as well as the functional implications on motor performance are yet to be further studied.

A pilot randomized controlled trial comparing effectiveness of prism glasses, visual search training and standard care in hemianopia

OBJECTIVE

Pilot trial to compare prism therapy and visual search training, for homonymous hemianopia, to standard care (information only).

METHODS

Prospective, multicentre, parallel, single-blind, three-arm RCT across fifteen UK acute stroke units.

PARTICIPANTS

Stroke survivors with homonymous hemianopia.

INTERVENTIONS

Arm a (Fresnel prisms) for minimum 2 hours, 5 days per week over 6 weeks. Arm b (visual search training) for minimum 30 minutes, 5 days per week over 6 weeks. Arm c (standard care-information only).

INCLUSION CRITERIA

Adult stroke survivors (>18 years), stable hemianopia, visual acuity better than 0.5 logMAR, refractive error within ±5 dioptres, ability to read/understand English and provide consent.

OUTCOMES

Primary outcomes were change in visual field area from baseline to 26 weeks and calculation of sample size for a definitive trial. Secondary measures included Rivermead Mobility Index, Visual Function Questionnaire 25/10, Nottingham Extended Activities of Daily Living, Euro Qual, Short Form-12 questionnaires and Radner reading ability. Measures were post-randomization at baseline and 6, 12 and 26 weeks.

RANDOMIZATION

Randomization block lists stratified by site and partial/complete hemianopia.

BLINDING

Allocations disclosed to patients. Primary outcome assessor blind to treatment allocation.

RESULTS

Eighty-seven patients were recruited: 27-Fresnel prisms, 30-visual search training and 30-standard care; 69% male; mean age 69 years (SD 12). At 26 weeks, full results for 24, 24 and 22 patients, respectively, were compared to baseline. Sample size calculation for a definitive trial determined as 269 participants per arm for a 200 degree² visual field area change at 90% power. Non-significant relative change in area of visual field was 5%, 8% and 3.5%, respectively, for the three groups. Visual Function Questionnaire responses improved significantly from baseline to 26 weeks with visual search training (60 [SD 19] to 68.4 [SD 20]) compared to Fresnel prisms (68.5 [SD 16.4] to 68.2 [18.4]: 7% difference) and standard care (63.7 [SD 19.4] to 59.8 [SD 22.7]: 10% difference), P=.05. Related adverse events were common with Fresnel prisms (69.2%; typically headaches).

CONCLUSIONS

No significant change occurred for area of visual field area across arms over follow-up. Visual search training had significant improvement in vision-related quality of life. Prism therapy produced adverse events in 69%. Visual search training results warrant further investigation.

HIF-1α triggers long-lasting glutamate excitotoxicity via system xc- in cerebral ischaemia-reperfusion

Hypoxia-inducible factor 1α (HIF-1α) controls many genes involved in physiological and pathological processes. However, its roles in glutamatergic transmission and excitotoxicity are unclear. Here, we proposed that HIF-1α might contribute to glutamate-mediated excitotoxicity during cerebral ischaemia-reperfusion (CIR) and investigated its molecular mechanism. We showed that an HIF-1α conditional knockout mouse displayed an inhibition in CIR-induced elevation of extracellular glutamate and N-methyl-d-aspartate receptor (NMDAR) activation. By gene screening for glutamate transporters in cortical cells, we found that HIF-1α mainly regulates the cystine-glutamate transporter (system x_c^- ) subunit xCT by directly binding to its promoter; xCT and its function are up-regulated in the ischaemic brains of rodents and humans, and the effects lasted for several days. Genetic deletion of xCT in cortical cells of mice inhibits either oxygen glucose deprivation/reoxygenation (OGDR) or CIR-mediated glutamate excitotoxicity in vitro and in vivo. Pharmaceutical inhibition of system x_c^- by a clinically approved anti-cancer drug, sorafenib, improves infarct volume and functional outcome in rodents with CIR and its therapeutic window is at least 3 days. Taken together, these findings reveal that HIF-1α plays a role in CIR-induced glutamate excitotoxicity via the long-lasting activation of system x_c^- -dependent glutamate outflow and suggest that system x_c^- is a promising therapeutic target with an extended therapeutic window in stroke. Copyright © 2016 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

The Community Dependency Index: A Standardised Assessment of Need and Occupational Therapy

Key elements of the Government's community care policy are the assessment of disabled people's needs and the measurement of the outcome of any services provided. This article describes the development of a standardised assessment which could be used by community occupational therapists both to assess the level of need and to measure outcome in relation to occupational therapy.

Commentary on ‘A Critical Evaluation of the Barthel Index’

The Barthel Index is the most extensively researched scale and is considered superior to and more robust than any other ADL scale. The Barthel scores can gauge the need for care and help to report therapeutically meaningful and valid information of patient outcomes. Rehabilitation workers can feel confident in advocating the use of the Bl, as modified by Shah et al in 1989, as the preferred measure of ADL.

Documentation for Measuring Stroke Rehabilitation Outcomes

Stroke is the third commonest cause of hospital admission in Australia. Approximately 71% of patients with an acute stroke are likely to be admitted to public and private hospitals. With no advanced clinical information system in place in Australia, it is difficult to determine who is likely to benefit, what type of inpatient care is efficient and effective in providing maximum potential to the stroke patients. This paper highlights some of the problems encountered with the current medical records, in conducting a prospective, multi-institutional, population based stroke rehabilitation outcome study in Brisbane. The paper also discusses how these deficiencies affect health professionals such as occupational therapists, and how one can work with the medical record administrators of today as key resource people in health information management. To illustrate this, a pro forma rectifying some of the current deficiencies in the medical records is provided as a guide. (AMRJ, 1991, 21(3), 88–95).

A randomized controlled trial on rehabilitation through caregiver-delivered nurse-organized service programs for disabled stroke patients in rural china (the RECOVER trial): design and rationale

RATIONALE

Stroke is the leading cause of death and disability in rural China. For stroke patients residing in resource-limited rural areas, secondary prevention and rehabilitation are largely unavailable, and where present, are far below evidence-based standards.

AIM

This study aims to develop and implement a simplified stroke rehabilitation program that utilizes nurses and family caregivers for service delivery, and evaluate its feasibility and effectiveness in rural China.

METHODS AND DESIGN

This 2-year randomized controlled trial is being conducted in 2-3 county hospitals located in northwest, northeast, and southwest China. Eligible and consenting stroke inpatients (200 in total) have been recruited and randomized into either a control or intervention group. Nurses in the county hospital are trained by rehabilitation specialists and in turn train the family caregivers in the intervention group. They also provide telephone follow-up care three times post discharge. The recruitment, baseline, intervention, follow-up care, and evaluation are guided by the RECOVER mobile phone app specifically designed for this study.

STUDY OUTCOME

The primary outcome is patients' Barthel Index (activities of daily living: mobility, self-care, and toileting) at 6 months. Process and economic evaluation will also be conducted.

DISCUSSION

The results of our study will generate initial high-quality evidence to improve stroke care in resource-scarce settings. If proven effective, this innovative care delivery model has the potential to improve the health and function of stroke patients, relieve caregiver burden, guide policy-making, and advance translational research in the field of stroke care.

Changes of Achilles tendon properties via 12-week PNF based robotic rehabilitation of ankle joints with spasticity and/or contracture

Ankle joint with spasticity and/or contracture can severely affect mobility and independence of stroke survivors. Due to that, the Achilles tendon(AT) is affected. In this paper, we aim to study changes of AT properties via proprioceptive neuromuscular facilitation (PNF) treatment. A robotic ankle-foot rehabilitation system has been proposed, which consists of a robotic ankle-foot platform and a graphic user interface. In this pilot study, two post-stroke patients participated and carried out a 12-week PNF treatment with the robotic system. The treatment is evaluated quantitatively in AT properties. The evaluation shows that after the PNF treatment, the average decrease of AT length is 4.1 mm (6.5%) and the recovery ratio is 30.4%, while the thickness has no change. The results indicate that the PNF based robotic rehabilitation for ankle joints with spasticity and/or contracture is effective to improve the ankle spasticity/contracture.

The impact of somatosensory function on activity performance and length of hospital stay in geriatric patients with stroke

Objective: To investigate in geriatric patients with stroke the relationship between somatosensory function, activity performance and the length of stay (LOS) in either hospital or nursing home.

Design: Survey.

Setting: Stroke unit and geriatric rehabilitation unit.

Subjects: One hundred and fifteen consecutive patients with acute stroke ≥65 years old.

Main outcome measures: Clinically assessed somatosensory function, activity of daily living according to the Barthel Index (BI) (0–100 points), mobility according to the Rivermead Mobility Index (RMI) (0–15 points) and LOS.

Results: Ten days after stroke onset, the patients with normal ( n = 46), impaired ( n = 31) and nonassessable ( n = 38) somatosensory function scored 85, 40 and 0 points respectively on the BI, and 8.5, 2 and 0 points respectively on the RMI. Forty-one of 46 patients (89%) with normal somatosensory function were discharged home within three months, compared with 10 of 31 patients (32%) with impaired somatosensory function and three of 38 patients (8%) who were nonassessable. These between-group differences were statistically significant ( p < 0.001). Multiple regression, to adjust for the impact of age, social situation and bladder function on outcome still proved a statistically significant ( p < 0.001) predictive value of normal somatosensory function.

Conclusions: Normal somatosensory function is related to high activity levels and short LOS more often than somatosensory impairment is related to activity limitations and long LOS.

Impact of factors indicating a poor prognosis on stroke rehabilitation effectiveness

This study examines the impact of factors indicating a poor prognosis on rehabilitation effectiveness of 124 first stroke patients admitted to a comprehensive rehabilitation unit in Kitakyushu, Japan. A multiple regression model, employing a forced entry of variables guided by prior studies on these factors, found four significant factors. Lack of motivation, urinary incontinence, each 10 years of age, and each day's delay from stroke onset to the commencement of rehabilitation reduced the rehabilitation effectiveness by 20%, 15%, 4%, and 0.1% respectively. The values of beta-coefficients showed that onset-rehabilitation delay and lack of motivation were relatively important in our model. These findings are consistent with clinical impressions and provide useful information for planning stroke rehabilitation programmes.

Current practice and clinical relevance of somatosensory assessment after stroke

Objective: To examine the perceived clinical relevance, current practice and knowledge of somatosensory testing in three professional groups involved in the management and rehabilitation of stroke.

Design: Structured postal questionnaire sent to therapists and doctors. Subjects: One hundred and eighty occupational therapists from the National Association of Neurological Occupational Therapists (NANOT), 180 physiotherapists from the Association of Chartered Physiotherapists with an Interest in Neurology (ACPIN) and 360 doctors from the Association of British Neurologists (ABN) and the British Geriatrics Society (BSG).

Setting: Hospitals and rehabilitation centres in the UK.

Results: Replies were obtained from 84 occupational therapists (47%), 98 physiotherapists (55%) and 78 doctors (22%). Sixty-four occupational therapists (77%), 82 physiotherapists (84%) and 66 doctors (87%) indicated that they routinely performed somatosensory assessment as part of their clinical assessment. The two most commonly used measures were proprioception and light touch. Seventy-eight occupational therapists (93%), 88 physiotherapists (90%) and 67 doctors (91%) regarded sensory assessment as clinically significant in determining prognosis after stroke.

Conclusions: Despite published reservations concerning its usefulness and reliability, most therapists and doctors routinely assess somatosensory loss after stroke. All three professions agreed that somatosensory testing presented useful information for prognosis. Furthermore, all professional groups believe somatosensory assessment to be clinically relevant.

Development of a Chinese version of the Modified Barthel Index — validity and reliability

Objective: To establish the structural validity of the Chinese version of the Modified Barthel Index and to estimate its inter-rater reliability for use with patients who have had a stroke.

Design: Prospective study.

Setting: A regional general hospital and a day hospital in Hong Kong.

Subjects: One hundred and sixteen older people who had had a stroke (mean age 76.0; SD 7.6) were involved in the establishment of evidence of the structural validity and item quality. Another 15 older people with stroke (mean age 78.0; SD 7.1) participated in estimating the reliability of the instrument.

Methods and results: The Modified Barthel Index was translated into Chinese. Factor analyses revealed a two-factor structure that explained 75.7% of the total variance. Factor 1 was found to consist of eight items relating to patients' functional performance. Factor 2 consisted of the two items that focused on patients' `physiological needs'. The test—retest reliability of the Chinese version at the item level was comparable with that of the original version, with kappa statistics ranging from 0.63 to 1.00 (P < 0.001).

Conclusion: The Chinese version of the Modified Barthel Index (MBI-C) seems to be valid and reliable for use with older people with stroke. Changes were made to the item content and the rating criteria that were specific to Chinese culture. The structural validity and the reliability of the Chinese version were shown to be robust across the original and Chinese groups.

Relearning to See in Cortical Blindness

The incidence of cortically induced blindness is increasing as our population ages. The major cause of cortically induced blindness is stroke affecting the primary visual cortex. While the impact of this form of vision loss is devastating to quality of life, the development of principled, effective rehabilitation strategies for this condition lags far behind those used to treat motor stroke victims. Here we summarize recent developments in the still emerging field of visual restitution therapy, and compare the relative effectiveness of different approaches. We also draw insights into the properties of recovered vision, its limitations and likely neural substrates. We hope that these insights will guide future research and bring us closer to the goal of providing much-needed rehabilitation solutions for this patient population.

The role of P300 event-related potentials in the cognitive recovery after the stroke

The aim of this study was to elucidate the effects of an ischemic stroke on the amplitude and latency of the P300 wave and evaluate their changes over a prospective 1-year follow-up period. We recorded the P300 wave using an auditory oddball paradigm in 60 consecutive brain infarct patients at baseline (i.e., within 4 weeks after the stroke), after 3 months, after 12 months and in 30 healthy control subjects. The P300 latencies in stroke patients were significantly longer and the P300 amplitudes were significantly smaller than those of the control group. The latency of P300 showed a highly significant average improvement 12 months after the stroke compared to the baseline. There was no significant change observed for the P300 amplitude during the same period. The P3 latency is initially more increased in the patients with hemispheric brain infarction but shows a better recovery compared to the patients with brainstem infarction. Also, the results of the P300 latency of patients with the left-sided lesions was significantly longer compared to the patients with right-sided lesions on the beginning of the study but not 3 and 12 months after the stroke. The results of our study show the importance of P300 event-related potentials in the detection and follow-up of cognitive changes after ischemic stroke.

Long-term disability after lacunar stroke: secondary prevention of small subcortical strokes

OBJECTIVES

To determine whether vascular and demographic factors predict worsening disability up to 8 years after lacunar stroke.

METHODS

SPS3 (Secondary Prevention of Small Subcortical Strokes) was a clinical trial in lacunar stroke patients with annual assessment of disability using the Older Americans Resources and Survey instrumental activities of daily living (IADL) scale (range 0-14). Generalized estimating equations modeled the likelihood of disability (IADL <14) over time, adjusting for demographics, medical risk factors, cognition, mood, stroke location, and geographic region in univariate and multivariable models. IADL assessments after recurrent stroke were censored. We stratified by study region and age quartile.

RESULTS

Among 2,820 participants, mean age was 63.4 years (SD 10.8), 63% were male, 36% had diabetes, 90% hypertension, and 10% prior stroke. Mean follow-up was 3.7 years. In multivariable models, female sex, education, diabetes, nonregular alcohol use, prior stroke, Cognitive Abilities Screening Instrument score, depression, mild cognitive impairment, and stroke location were associated with disability. The youngest age quartile had decreased odds of disability over time (odds ratio 0.90 per year, 95% confidence interval 0.85-0.95), whereas the oldest age quartile had increased odds (2.20, 95% confidence interval 1.75-2.75). Americans and Latin Americans had >2-fold greater odds of disability per year compared with Spaniards (p < 0.0001).

CONCLUSIONS

In lacunar stroke patients, older age was associated with worsening long-term disability, even without recurrence. Worse long-term function was associated with diabetes, cognitive status, and prior stroke, and regional differences may be attributable to variations in health care delivery or scale interpretation.

Recovery Time of Independent Poststroke Life Habits: Part II

The purposes of this study were to determine the time of the recovery of poststroke life habits and to identify prognostic indicators associated with recovery time among stroke patients in a rehabilitation program. A sample of 421 stroke patients who were admitted to a rehabilitation center was recruited from medical records available from January 1987 to December 1992. The relation between the achievement of independent life habits including bed mobility, transfers and ambulation, bathing activities, dressing activities, eating activities, home activities, sphincter control, and sleep with the potential covariates associated with recovery time was assessed through the analysis of survival data using the Cox maximum-likelihood proportional hazard models. The poststroke life habits obtained generated mean recovery times ranging from 5.51 to 57.60 days from admission to rehabilitation. The survival analysis revealed that the recovery time of the selected poststroke abilities was significantly influenced (p <.05) by one or several indicators; these included physical ability and neuropsychological and life habit characteristics. With this precious information, stroke rehabilitation specialists may be able to reduce the length of time required to recover independent poststroke life habits by treating the specific neuropsychological, physical, and life habit characteristics identified in this study. A faster poststroke recovery would reduce the socioeconomic impact generated by stroke disability and would also ensure a better quality of life to the stroke survivor.

Plasticity and Reorganization of the Brain Post Stroke

Reorganization of the cortex post stroke is dependent not only on the lesion site but also on remote brain areas that have structural connections with the area damaged by the stroke. Motor recovery is largely dependent on the intact cortex adjacent to the infarct, which points out the importance of preserving the penumbral areas. There appears to be a priority setting with contralateral and ipsilateral motor pathways, with ipsilateral (unaffected hemisphere) pathways only becoming prominent after more severe strokes where functional contralateral (affected hemisphere) pathways are unable to recover. Ipsilateral or unaffected hemisphere motor pathway activation is therefore associated with a worse prognosis.

The Effects of Exercise Intensity on p-NR2B Expression in Cerebral Ischemic Rats

Background:

The current study explored the effects of treadmill exercise intensity on functional recovery and hippocampal phospho-NR2B (p-NR2B) expression in cerebral ischemic rats, induced by permanent middle cerebral artery occlusion (MCAO) surgery.

Method:

Adult male Sprague-Dawley rats were randomly divided into four groups, including sham, no exercise (NE), low intensity training (LIT, v = 15 m/min), and moderate intensity training groups (MIT, v = 20 m/min). At different time points, the hippocampal expressions of p-NR2B and total NR2B were examined. In addition, neurological deficit score (NDS), body weight, and 2,3,5-triphenyltetrazolium chloride (TTC) staining were used to evaluate brain infarct volume as assessments of post-stroke functional recovery. In order to investigate the effect of exercise on survival, the mortality rate was also recorded.

Results:

The results showed that treadmill exercise significantly decreased hippocampal expression of p-NR2B but didn't change the total NR2B, compared to the NE group on the 3rd, 7th, and 14th days following MCAO surgery. The effect on changes in p-NR2B levels, body weight, and brain infarct volume were more significant in the LIT compared to the MIT group.

Discussion and Conclusion:

The current findings demonstrate that physical exercise can produce neuroprotective effects, in part by down-regulating p-NR2B expression. Furthermore, the appropriate intensity of physical exercise is critical for post-stroke rehabilitation.

A randomised controlled trial to compare the clinical and cost-effectiveness of prism glasses, visual search training and standard care in patients with hemianopia following stroke: a protocol

INTRODUCTION

Homonymous hemianopia is a common and disabling visual problem after stroke. Currently, prism glasses and visual scanning training are proposed to improve it. The aim of this trial is to determine the effectiveness of these interventions compared to standard care.

METHODS AND ANALYSIS

The trial will be a multicentre three arm individually randomised controlled trial with independent assessment at 6 week, 12 week and 26 week post-randomisation. Recruitment will occur in hospital, outpatient and primary care settings in UK hospital trusts. A total of 105 patients with homonymous hemianopia and without ocular motility impairment, visual inattention or pre-existent visual field impairment will be randomised to one of three balanced groups. Randomisation lists will be stratified by site and hemianopia level (partial or complete) and created using simple block randomisation by an independent statistician. Allocations will be disclosed to patients by the treating clinician, maintaining blinding for outcome assessment. The primary outcome will be change in visual field assessment from baseline to 26 weeks. Secondary measures will include the Rivermead Mobility Index, Visual Function Questionnaire 25/10, Nottingham Extended Activities of Daily Living, Euro Qual-5D and Short Form-12 questionnaires. Analysis will be by intention to treat.

ETHICS AND DISSEMINATION

This study has been developed and supported by the UK Stroke Research Network Clinical Studies Group working with service users. Multicentre ethical approval was obtained through the North West 6 Research ethics committee (Reference 10/H1003/119). The trial is funded by the UK Stroke Association. Trial Registration: Current Controlled Trials ISRCTN05956042. Dissemination will consider usual scholarly options of conference presentation and journal publication in addition to patient and public dissemination with lay summaries and articles.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN05956042.

Design considerations for a theory-driven exergame-based rehabilitation program to improve walking of persons with stroke

Virtual rehabilitation approaches for promoting motor recovery has attracted considerable attention in recent years. It appears to be a useful tool to provide beneficial and motivational rehabilitation conditions. Following a stroke, hemiparesis is one of the most disabling impairments and, therefore, many affected people often show substantial deficits in walking abilities. Hence, one of the major goals of stroke rehabilitation is to improve patients' gait characteristics and hence to regain their highest possible level of walking ability. Because previous studies indicate a relationship between walking and balance ability, this article proposes a stroke rehabilitation program that targets balance impairments to improve walking in stroke survivors. Most currently, available stroke rehabilitation programs lack a theory-driven, feasible template consistent with widely accepted motor learning principles and theories in rehabilitation. To address this hiatus, we explore the potential of a set of virtual reality games specifically developed for stroke rehabilitation and ordered according to an established two-dimensional motor skill classification taxonomy. We argue that the ensuing "exergame"-based rehabilitation program warrants individually tailored balance progression in a learning environment that allows variable practice and hence optimizes the recovery of walking ability.

Comparison of functional electrical stimulation associated with kinesiotherapy and kinesiotherapy alone in patients with hemiparesis during the subacute phase of ischemic cerebrovascular accident

OBJECTIVE

To compare the functional electrical stimulation associated with functional kinesiotherapy alone in patients after ischemic cerebrovascular accident.

METHODS

The study included 20 patients who were divided into two groups: Group I (GI): functional electrical stimulation plus functional kinesiotherapy and Group II (GII): functional kinesiotherapy. We evaluated active and passive range of motion, in knee flexion and extension muscle strength, activities of daily living and quality of life. The evaluations were conducted in the pretreatment period, after 10 sessions and after 20 physical therapy sessions.

RESULTS

There was a significant improvement in all variables studied for both groups. However, significant improvements for the sub-items functional capacity and social aspects were seen only in the patients treated with associated functional electrical stimulation and kinesiotherapy.

CONCLUSION

Although both groups of patients improved with the treatment, the association of functional electrical stimulation and kinesiotherapy showed superiority in two quality of life items, in the sub-items functional capacity and social aspects.

Trajectory of functional decline before and after ischemic stroke: the Northern Manhattan Study

BACKGROUND AND PURPOSE

Previous research in our cohort showed a delayed decline in functional status after first ischemic stroke. We compared the long-term trajectory of functional status before and after ischemic stroke.

METHODS

The Northern Manhattan Study contains a prospective, population-based study of stroke-free individuals age ≥40 years, followed for a median of 11 years. The Barthel index (BI), a commonly used measure of activities of daily living, was assessed annually. Generalized estimating equations were used to assess functional decline over time before stroke and beginning 6 months after stroke. Follow-up was censored at the time of recurrent stroke.

RESULTS

Among 3298 participants, 210 participants had an ischemic stroke during follow-up and had poststroke BI assessed. Mean age (±SD) was 77±9 years, 38% were men, 52% were Hispanic, 37% had diabetes, and 31% had coronary artery disease. There was no difference in rate of functional decline over time before and after stroke (P=0.51), with a decline of 0.96 BI points per year before stroke (P<0.0001) and 1.24 BI points after stroke (P=0.001). However, when stratified by insurance status, among those with Medicaid or no insurance, in a fully adjusted model, there was a difference in slope before and after stroke (P=0.04), with a decline of 0.58 BI points per year before stroke (P=0.02) and 1.94 BI points after stroke (P=0.001).

CONCLUSIONS

In this large, prospective, population-based study with long-term follow-up, there was a significantly steeper decline in functional status after ischemic stroke compared with before stroke among those with Medicaid or no insurance, after adjusting for confounders.

Influence of sensory loss on the perception of verticality in stroke patients

PURPOSE

The aim of this study was to investigate the relationship between somatosensory loss and perception of verticality in stroke patients suffering single-hemisphere lesions.

METHOD

Somatosensory loss was measured using the Rivermead Assessment for Somatosensory Performance (RASP). Perception of verticality was assessed with the Subjective Visual Vertical (SVV) and the Subjective Postural Vertical (SPV) tests. Absolute Values of SVV and SPV were used to analyze the amount of deviation in relation to somatosensory loss.

RESULTS

Thirty-two patients were included in the study (mean age = 45.91 SD = 31.88 years). Analysis showed that somatosensory loss was related to results of the SVV (r = -0.552, p = 0.001, Pearson Rank) and the SPV (r = -0.661, p < 0.001, Spearman Ï). Furthermore, results showed that both joint-related (SVV: r = -0.411, p = 0.019, Pearson Rank; SPV: r = -0.597, p = 0.001, Spearman Ï) and skin-related (SVV: r = -0.595, p < 0.001, Pearson Rank; SPV: r = -0.663, p < 0.001, Spearman Ï) somatosensory information is related to verticality perception.

CONCLUSIONS

This study provides evidence that perception of verticality is related to somatosensory loss, which means that somatosensory loss will lead to a larger amount of deviation of SVV and SPV in relation to the gravitational vector. Furthermore, it is interesting to note that both SVV and SPV are influenced by somatosensory loss.

IMPLICATIONS FOR REHABILITATION

• Somatosensory information is related to both visual and postural aspects of verticality perception. • Both joint- and cutaneous-related modalities of sensory information are related to perception of verticality. • Sensory training could be important in the recovery of verticality perception.

Interventions for visual field defects in patients with stroke

BACKGROUND

Visual field defects are estimated to affect 20% to 57% of people who have had a stroke. Visual field defects can affect functional ability in activities of daily living (commonly affecting mobility, reading and driving), quality of life, ability to participate in rehabilitation, and depression, anxiety and social isolation following stroke. There are many interventions for visual field defects, which are proposed to work by restoring the visual field (restitution); compensating for the visual field defect by changing behaviour or activity (compensation); substituting for the visual field defect by using a device or extraneous modification (substitution); or ensuring appropriate diagnosis, referral and treatment prescription through standardised assessment or screening, or both.

OBJECTIVES

To determine the effects of interventions for people with visual field defects after stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (February 2011), the Cochrane Eyes and Vision Group Trials Register (December 2009) and nine electronic bibliographic databases including CENTRAL (The Cochrane Library 2009, Issue 4), MEDLINE (1950 to December 2009), EMBASE (1980 to December 2009), CINAHL (1982 to December 2009), AMED (1985 to December 2009), and PsycINFO (1967 to December 2009). We also searched reference lists and trials registers, handsearched journals and conference proceedings and contacted experts.

SELECTION CRITERIA

Randomised trials in adults after stroke, where the intervention was specifically targeted at improving the visual field defect or improving the ability of the participant to cope with the visual field loss. The primary outcome was functional ability in activities of daily living and secondary outcomes included functional ability in extended activities of daily living, reading ability, visual field measures, balance, falls, depression and anxiety, discharge destination or residence after stroke, quality of life and social isolation, visual scanning, adverse events and death.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts, extracted data and appraised trials. We undertook an assessment of methodological quality for allocation concealment, blinding of outcome assessors, method of dealing with missing data, and other potential sources of bias.

MAIN RESULTS

Thirteen studies (344 randomised participants, 285 of whom were participants with stroke) met the inclusion criteria for this review. However, only six of these studies compared the effect of an intervention with a placebo, control or no treatment group and were included in comparisons within this review. Four studies compared the effect of scanning (compensatory) training with a control or placebo intervention. Meta-analysis demonstrated that scanning training is more effective than control or placebo at improving reading ability (three studies, 129 participants; mean difference (MD) 3.24, 95% confidence interval (CI) 0.84 to 5.59) and visual scanning (three studies, 129 participants; MD 18.84, 95% CI 12.01 to 25.66) but that scanning may not improve visual field outcomes (two studies, 110 participants; MD -0.70, 95% CI -2.28 to 0.88). There were insufficient data to enable generalised conclusions to be made about the effectiveness of scanning training relative to control or placebo for the primary outcome of activities of daily living (one study, 33 participants). Only one study (19 participants) compared the effect of a restitutive intervention with a control or placebo intervention and only one study (39 participants) compared the effect of a substitutive intervention with a control or placebo intervention.

AUTHORS' CONCLUSIONS

There is limited evidence which supports the use of compensatory scanning training for patients with visual field defects (and possibly co-existing visual neglect) to improve scanning and reading outcomes. There is insufficient evidence to reach a conclusion about the impact of compensatory scanning training on functional activities of daily living. There is insufficient evidence to reach generalised conclusions about the benefits of visual restitution training (VRT) (restitutive intervention) or prisms (substitutive intervention) for patients with visual field defects after stroke.