Stroke Recovery and Rehabilitation Research: Issues, Opportunities, and the National Institutes of Health StrokeNet

Examination of acute spin exercise on GABA levels in aging and stroke: The EASE study protocol

BACKGROUND

Changes in regional levels of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) may indicate the potential for favorable responses to the treatment of stroke affecting the upper extremity. By selectively altering GABA levels during training, we may induce long-term potentiation and adjust excitatory/inhibitory balance (E/I balance). However, the impact of this alteration may be limited by neural damage or aging. Aerobic exercise has been shown to increase GABA levels in the sensorimotor cortex and improve motor learning by widening the dynamic range of E/I balance. The cross-sectional project, Effects of Acute Exercise on Functional Magnetic Resonance Spectroscopy Measures of GABA in Aging and Chronic Stroke (EASE), is designed to assess the functional relevance of changes in GABA concentration within the sensorimotor cortex before and after an acute aerobic exercise session.

METHODS/DESIGN

EASE will enroll 30 participants comprised of healthy younger adults (18-35 years; n = 10), older adults (60+ years; n = 10), and persons with chronic stroke (n = 10) affecting distal upper extremity function. We will use resting magnetic resonance spectroscopy to measure all participants' GABA levels at rest before and after aerobic exercise. In addition, we will employ functional magnetic resonance spectroscopy using motor skill acquisition and recall tasks in healthy adults. We hypothesize that acute aerobic exercise will increase resting sensorimotor GABA concentration and that higher GABA resting levels will predict better motor learning performance on measures taken both inside and outside the magnet. We also hypothesize that a higher dynamic range of GABA during task-based spectroscopy in healthy adults will predict better motor skill acquisition and recall.

DISCUSSION

The EASE project will evaluate the effect of acute exercise on GABA levels as a biomarker of upper extremity motor skill learning with two populations (aging adults and those with chronic stroke). We predict that acute exercise, higher sensorimotor GABA levels, and broader dynamic range will be related to better motor skill acquisition.

Trends in stroke-related journals: Examination of publication patterns using topic modeling

OBJECTIVES

This study aims to demonstrate the capacity of natural language processing and topic modeling to manage and interpret the vast quantities of scholarly publications in the landscape of stroke research. These tools can expedite the literature review process, reveal hidden themes, and track rising research areas.

MATERIALS AND METHODS

Our study involved reviewing and analyzing articles published in five prestigious stroke journals, namely Stroke, International Journal of Stroke, European Stroke Journal, Translational Stroke Research, and Journal of Stroke and Cerebrovascular Diseases. The team extracted document titles, abstracts, publication years, and citation counts from the Scopus database. BERTopic was chosen as the topic modeling technique. Using linear regression models, current stroke research trends were identified. Python 3.1 was used to analyze and visualize data.

RESULTS

Out of the 35,779 documents collected, 26,732 were classified into 30 categories and used for analysis. "Animal Models," "Rehabilitation," and "Reperfusion Therapy" were identified as the three most prevalent topics. Linear regression models identified "Emboli," "Medullary and Cerebellar Infarcts," and "Glucose Metabolism" as trending topics, whereas "Cerebral Venous Thrombosis," "Statins," and "Intracerebral Hemorrhage" demonstrated a weaker trend.

CONCLUSIONS

The methodology can assist researchers, funders, and publishers by documenting the evolution and specialization of topics. The findings illustrate the significance of animal models, the expansion of rehabilitation research, and the centrality of reperfusion therapy. Limitations include a five-journal cap and a reliance on high-quality metadata.

Sphenopalatine ganglion stimulation: a comprehensive evaluation across diseases in randomized controlled trials

Background

Current literature extensively covers the use of sphenopalatine ganglion stimulation (SPGs) in treating a broad spectrum of medical conditions, such as allergic rhinitis, cluster headaches, and strokes. Nevertheless, a discernible gap in the systematic organization and analysis of these studies is evident. This paper aims to bridge this gap by conducting a comprehensive review and analysis of existing literature on SPGs across various medical conditions.

Methods

This study meticulously constructed a comprehensive database through systematic computerized searches conducted on PubMed, Embase, CNKI, Wanfang, VIP, and CBM up to May 2022. The inclusion criteria encompassed randomized controlled trials (RCTs) published in either Chinese or English, focusing on the therapeutic applications of SPGs for various medical conditions. Both qualitative and quantitative outcome indicators were considered eligible for inclusion.

Results

This comprehensive study reviewed 36 publications, comprising 10 high-quality, 23 medium-quality, and three low-quality articles. The study investigated various diseases, including allergic rhinitis (AR), ischemic strokes (IS), cluster headache (CH), primary trigeminal neuralgia (PTN), pediatric chronic secretory otitis (PCSO), refractory facial paralysis (RFP), chronic tension-type headache (CTTH), as well as the analysis of low-frequency sphenopalatine ganglion stimulation (LF-SPGs) in chronic cluster headache (CCH) and the impact of SPGs on Normal nasal cavity function (NNCF). SPGs demonstrate efficacy in the treatment of AR. Regarding the improvement of rhinoconjunctivitis quality of life questionnaire (RQLQ) scores, SPGs are considered the optimal intervention according to the SUCRA ranking. Concerning the improvement in Total Nasal Symptom Score (TNSS), Conventional Acupuncture Combined with Tradiational Chinese Medicine (CA-TCM) holds a significant advantage in the SUCRA ranking and is deemed the best intervention. In terms of increasing Effective Rate (ER), SPGs outperformed both conventional acupuncture (CA) and Western Medicine (WM; P < 0.05). In the context of SPGs treatment for IS, the results indicate a significant improvement in the 3-month outcomes, as evaluated by the modified Rankin Scale (mRS) in the context of Cerebral Cortical Infarction (CCI; P < 0.05). In the treatment of CH with SPGs, the treatment has been shown to have a statistically significant effect on the relief and disappearance of headaches (P < 0.05). The impact of SPGs on NNCF reveals statistically significant improvements (P < 0.05) in nasal airway resistance (NAR), nasal cavity volume (NCV), exhaled nitric oxide (eNO), substance P (SP), vasoactive intestinal peptide (VIP) and neuropeptide Y (NPY). SPGs treatments for PCSO, RFP, and CTTH, when compared to control groups, yielded statistically significant results (P < 0.05).

Conclusion

SPGs demonstrate significant effectiveness in the treatment of AR, IS, and CH. Effective management of CCH may require addressing both autonomic dysregulation and deeper neural pathways. However, additional high-quality research is essential to clarify its effects on NNCF, PTN, PCSO, RFP, and CTTH.

Systematic Review Registration

PROSPERO, identifier CRD42021252073, https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=312429.

Post-Stroke Functional Changes: In-Depth Analysis of Clinical Tests and Motor-Cognitive Dual-Tasking Using Wearable Sensors

Clinical tests like Timed Up and Go (TUG) facilitate the assessment of post-stroke mobility, but they lack detailed measures. In this study, 21 stroke survivors and 20 control participants underwent TUG, sit-to-stand (STS), and the 10 Meter Walk Test (10MWT). Tests incorporated single tasks (STs) and motor-cognitive dual-task (DTs) involving reverse counting from 200 in decrements of 10. Eight wearable motion sensors were placed on feet, shanks, thighs, sacrum, and sternum to record kinematic data. These data were analyzed to investigate the effects of stroke and DT conditions on the extracted features across segmented portions of the tests. The findings showed that stroke survivors (SS) took 23% longer for total TUG (p < 0.001), with 31% longer turn time (p = 0.035). TUG time increased by 20% (p < 0.001) from STs to DTs. In DTs, turning time increased by 31% (p = 0.005). Specifically, SS showed 20% lower trunk angular velocity in sit-to-stand (p = 0.003), 21% longer 10-Meter Walk time (p = 0.010), and 18% slower gait speed (p = 0.012). As expected, turning was especially challenging and worsened with divided attention. The outcomes of our study demonstrate the benefits of instrumented clinical tests and DTs in effectively identifying motor deficits post-stroke across sitting, standing, walking, and turning activities, thereby indicating that quantitative motion analysis can optimize rehabilitation procedures.

Genome-Wide Association Studies of 3 Distinct Recovery Phenotypes in Mild Ischemic Stroke

BACKGROUND AND OBJECTIVES

Stroke genetic research has made substantial progress in the past decade. Its recovery application, however, remains behind, in part due to its reliance on the modified Rankin Scale (mRS) score as a measure of poststroke outcome. The mRS does not map well to biological processes because numerous psychosocial factors drive much of what the mRS captures. Second, the mRS contains multiple disparate biological events into a single measure further limiting its use for biological discovery. This led us to investigate the effect of distinct stroke recovery phenotypes on genetic variation associations with Genome-Wide Association Studies (GWASs) by repurposing the NIH Stroke Scale (NIHSS) and its subscores.

METHODS

In the Vitamin Intervention for Stroke Prevention cohort, we estimated changes in cognition, motor, and global impairments over 2 years using specific measures. We included genotyped participants with a total NIHSS score greater than zero at randomization and excluded those with recurrent stroke during the trial. A GWAS linear mixed-effects model predicted score changes, with participant as a random effect, and included initial score, age, sex, treatment group, and the first 5 ancestry principal components.

RESULTS

In total, 1,270 participants (64% male) were included with a median NIHSS score of 2 (interquartile range [IQR] 1-3) and median age 68 (IQR 59-75) years. At randomization, 20% had cognitive deficits (NIHSS Cog-4 score >0) and 70% had ≥1 motor deficits (impairment score >1). At 2 years, these percentages improved to 7.2% with cognitive deficits and 30% with motor deficits. GWAS identified novel suggestive gene-impairment associations (p < 5e-6) for cognition (CAMK2D, EVX2, LINC0143, PTPRM, SGMS1, and SMAD2), motor (ACBD6, KDM4B, MARK4, PTPRS, ROBO1, and ROBO2), and global (MSR1 and ROBO2) impairments.

DISCUSSION

Defining domain-specific stroke recovery phenotypes and using longitudinal clinical trial designs can help detect novel genes associated with chronic recovery. These data support the use of granular endpoints to identify genetic associations related to stroke recovery.

Feasibility and user-experience of a virtual environment for social connection and education after stroke: A pilot study

OBJECTIVES

To evaluate the feasibility and usability of stroke survivor participation in an 8-week virtual environment intervention that provides opportunities for social support exchanges, social network interactions, and recovery education.

MATERIALS AND METHODS

A single-group, pre- and post-test measure design was used. Descriptive statistics were used to examine enrollment and retention rates, proportion of questionnaires completed, and virtual environment process data (e.g., number of log-ins) and usability scores. Changes in pre- and post-intervention questionnaire (e.g., usability, social support, depression, anxiety, loneliness, and self-efficacy) scores were explored using Wilcoxon signed-rank tests and paired t-test.

RESULTS

Fifteen (65 %) of the eligible stroke survivors enrolled (60 % white, 27 % black), 12 (80 %) had an ischemic stroke, ages ranged from 33 to 74 years (mean 44 years), and mean months since stroke was 33 ± 23. Retention and questionnaire completion rates were both 93 % (n = 14). Survivors logged into the virtual environment a total of 122 times, logged an average of 49 min/log-in, and 12 (80 %) attended support groups and social activities. Median usability score indicated lower than average usability. Improvement trends in social support, loneliness, and depressive symptoms were found, but significant changes in mean questionnaire scores were not found.

CONCLUSIONS

Overall, the results suggest that using a virtual environment to foster social support exchanges, social network interactions, and recovery education after stroke is feasible. Similar to other chronic disease populations, stroke survivor adoption of a virtual environment likely requires ongoing technical assistance, repetition of instructions, and opportunities for practice to reinforce engagement.

TRIAL REGISTRATION

NCT05487144.

Financial Cost Analysis Associated with a Locomotor Exercise Randomized Controlled Trial in Chronic Stroke

Background

Post-stroke recovery trials pose distinct recruitment and retention challenges, and understanding the financial requirements of conducting randomized controlled trials is crucial to ensure sufficient resources for successful study execution. The purpose of this analysis was to quantify the costs at a single site with a large catchment area of the Moderate-Intensity Exercise Versus High-Intensity Interval Training to Recover Walking Post-Stroke, HIT Stroke Trial.

Methods

To determine cost, study expense reports were gathered and divided into four categories: oversight, recruitment, retention, and outcome assessments. Categories were then further divided into chronological order for initial contact and prescreening, consenting, initial screening, and baseline testing. The 12-week intervention was divided into 4-week blocks: intervention block 1, post 4-week outcome testing, intervention block 2, post 8-week outcome testing, intervention block 3, and post 12-week outcome testing.

Results

Total direct cost for site execution was $539,768 with cost per participant approximated as $35,984. Oversight costs accounted for 65.8% of the budget at $355,661. To achieve goals related to inclusive participant recruitment ($21,923) and retention ($28,009), our site costs totaled $49,932. Direct study-related costs included screening assessments ($5,905), baseline assessments ($15,028), intervention ($76,952), and outcome assessments ($36,288).

Conclusion

Clinical trials on walking rehabilitation and exercise, especially those involving multiple assessment visits, require intensive oversight. This cost analysis provides important and critical insight into the expenses required to successfully execute an exercise-based walking rehabilitation trial in the United States.

A systematic review on functional electrical stimulation based rehabilitation systems for upper limb post-stroke recovery

Background

Stroke is one of the most common neurological conditions that often leads to upper limb motor impairments, significantly affecting individuals' quality of life. Rehabilitation strategies are crucial in facilitating post-stroke recovery and improving functional independence. Functional Electrical Stimulation (FES) systems have emerged as promising upper limb rehabilitation tools, offering innovative neuromuscular reeducation approaches.

Objective

The main objective of this paper is to provide a comprehensive systematic review of the start-of-the-art functional electrical stimulation (FES) systems for upper limb neurorehabilitation in post-stroke therapy. More specifically, this paper aims to review different types of FES systems, their feasibility testing, or randomized control trials (RCT) studies.

Methods

The FES systems classification is based on the involvement of patient feedback within the FES control, which mainly includes "Open-Loop FES Systems" (manually controlled) and "Closed-Loop FES Systems" (brain-computer interface-BCI and electromyography-EMG controlled). Thus, valuable insights are presented into the technological advantages and effectiveness of Manual FES, EEG-FES, and EMG-FES systems.

Results and discussion

The review analyzed 25 studies and found that the use of FES-based rehabilitation systems resulted in favorable outcomes for the stroke recovery of upper limb functional movements, as measured by the FMA (Fugl-Meyer Assessment) (Manually controlled FES: mean difference = 5.6, 95% CI (3.77, 7.5), P < 0.001; BCI-controlled FES: mean difference = 5.37, 95% CI (4.2, 6.6), P < 0.001; EMG-controlled FES: mean difference = 14.14, 95% CI (11.72, 16.6), P < 0.001) and ARAT (Action Research Arm Test) (EMG-controlled FES: mean difference = 11.9, 95% CI (8.8, 14.9), P < 0.001) scores. Furthermore, the shortcomings, clinical considerations, comparison to non-FES systems, design improvements, and possible future implications are also discussed for improving stroke rehabilitation systems and advancing post-stroke recovery. Thus, summarizing the existing literature, this review paper can help researchers identify areas for further investigation. This can lead to formulating research questions and developing new studies aimed at improving FES systems and their outcomes in upper limb rehabilitation.

The Pre-Adaptation of a Stroke-Specific Self-Management Program Among Older Adults

Objectives: Managing multimorbidity as aging stroke patients is complex; standard self-management programs necessitate adaptations. We used visual analytics to examine complex relationships among aging stroke survivors' comorbidities. These findings informed pre-adaptation of a component of the Chronic Disease Self-Management Program. Methods: Secondary analysis of 2013-2014 Medicare claims with stroke as an index condition, hospital readmission within 90 days (n = 42,938), and 72 comorbidities. Visual analytics identified patient subgroups and co-occurring comorbidities. Guided by the framework for reporting adaptations and modifications to evidence-based interventions, an interdisciplinary team developed vignettes that highlighted multimorbidity to customize the self-management program. Results: There were five significant subgroups (z = 6.19, p < .001) of comorbidities such as obesity and cancer. We constructed 6 vignettes based on the 5 subgroups. Discussion: Aging stroke patients often face substantial disease-management hurdles. We used visual analytics to inform pre-adaptation of a self-management program to fit the needs of older adult stroke survivors.

Innovative Approaches and Therapies to Enhance Neuroplasticity and Promote Recovery in Patients With Neurological Disorders: A Narrative Review

Brain rehabilitation and recovery for people with neurological disorders, such as stroke, traumatic brain injury (TBI), and neurodegenerative diseases, depend mainly on neuroplasticity, the brain's capacity to restructure and adapt. This literature review aims to look into cutting-edge methods and treatments that support neuroplasticity and recovery in these groups. A thorough search of electronic databases revealed a wide range of research and papers investigating several neuroplasticity-targeting methods, such as cognitive training, physical activity, non-invasive brain stimulation, and pharmaceutical interventions. The results indicate that these therapies can control neuroplasticity and improve motor, mental, and sensory function. In addition, cutting-edge approaches, such as virtual reality (VR) and brain-computer interfaces (BCIs), promise to increase neuroplasticity and foster rehabilitation. However, many issues and restrictions still need to be resolved, including the demand for individualized treatments and the absence of defined standards. In conclusion, this review emphasizes the significance of neuroplasticity in brain rehabilitation. It identifies novel strategies and treatments that promise to enhance recovery in patients with neurological illnesses. Future studies should concentrate on improving these therapies and developing evidence-based standards to direct clinical practice and enhance outcomes for this vulnerable population.

Effect of the Frequency of Rehabilitation Treatments on the Long-Term Mortality of Stroke Survivors with Mild-to-Moderate Disabilities under the Korean National Health Insurance Service System

Given the increase in stroke-related social costs, studies on survival and functional prognosis after stroke are urgently needed. Therefore, we investigated the relationship between the frequency of rehabilitation treatments in the acute and subacute phases of stroke and the long-term mortality of stroke survivors with mild-to-moderate disabilities. We performed a retrospective cohort study using data from the Korean National Health Insurance Service database. Our final cohort included 733 patients with national disability registration grades 4-6. The number of special rehabilitation treatment claim codes was used as a proxy for the frequency of rehabilitation treatments. Furthermore, we categorized the rehabilitation frequencies within 24 months of stroke onset as 1-50, 51-200, 201-400, and >400. The dependent variable was all-cause mortality, and it was evaluated from 24 to 84 months after stroke onset. Severe disability was associated with a lower long-term mortality rate in the chronic phase (p < 0.001). In the Cox regression analysis, severe disability, older age, male sex, and chronic kidney disease were independent risk factors for long-term mortality in patients with stroke and mild-to-moderate disabilities. However, the frequency of acute/subacute rehabilitation treatments did not significantly improve long-term mortality. Our results suggest that the association between rehabilitation frequency and lower long-term mortality for patients with mild-to-moderate stroke was inconclusive. Therefore, further study is needed to determine a better-customized rehabilitation treatment system for these patients.

Assessment of Passive Upper Limb Stiffness and Its Function in Post-Stroke Individuals Wearing an Inertial Sensor during the Pendulum Test

This article proposes the evaluation of the passive movement of the affected elbow during the pendulum test in people with stroke and its correlation with the main clinical scales (Modified Ashworth Scale, Motor Activity Log, and Fulg Meyer). An inertial sensor was attached to the forearm of seven subjects, who then passively flexed and extended the elbow. Joint angles and variables that indicate viscoelastic properties, stiffness (K), damping (B), E1 amp, F1 amp, and relaxation indices were collected. The results show that the FM scale is significantly correlated with the natural frequency (p = 0.024). The MAL amount-of-use score correlates with the natural frequency (p = 0.024). The variables E1 amp, F1 amp, RI, and ERI are not correlated with the clinical scales, but they correlate with each other; the variable E1 amp correlates with F1 amp (p = 0.024) and RI (p = 0.024), while F1 amp correlates with ERI (p = 0.024). There was also a correlation between the natural frequency and K (r = 0.96, p = 0.003). Non-linear results were found for the properties of the elbow joint during the pendulum test, which may be due to the presence of neural and non-neural factors. These results may serve as a reference for future studies if alternative scales do not provide an accurate reflection.

Chronic Phase Survival Rate in Stroke Patients With Severe Functional Limitations According to the Frequency of Rehabilitation Treatment

OBJECTIVE

To investigate the chronic phase survival rate according to the frequency of rehabilitation treatment in the acute and subacute phases in stroke patients with severe functional limitations.

DESIGN

A retrospective longitudinal cohort study.

SETTING

Population-based study using the Korean National Health Insurance Database from 2007 to 2018.

PARTICIPANTS

We enrolled 593 patients who experienced stroke in 2009 with national disability registration (NDR) grade of 3 or less (N=593).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The frequencies of rehabilitation treatment within 24 months after stroke were categorized into none, 1-50, 51-200, 201-400, and >400 treatments based on requests made to the Health Insurance Review and Assessment Service. As a dependent variable, we assessed all-cause mortality from 24 to 120 months after stroke.

RESULTS

The study enrolled 283 patients in NDR grade 1 (the most severe), 158 in grade 2, and 152 in grade 3. Groups with more severe functional limitations showed a lower chronic phase survival rate (P<.001). The groups with higher frequencies of rehabilitation treatment in the acute and subacute phases showed a higher chronic phase survival rate (P<.001). In the Cox regression analysis, a higher degree of functional limitation, lower frequency of rehabilitation treatment, older age, male sex, and chronic kidney disease were independent risk factors for chronic phase mortality in stroke patients with severe functional limitations.

CONCLUSIONS

A high frequency of rehabilitation treatment in the acute and subacute phases was associated with the long-term survival of stroke patients with severe functional limitations.

Motor sequela of adult and pediatric stroke: Imminent losses and ultimate gains

Stroke is the leading cause of neurological disability in the United States and worldwide. Remarkable advances have been made over the past 20 years in acute vascular treatments to reduce infarct size and improve neurological outcome. Substantially less progress has been made in the understanding and clinical approaches to neurological recovery after stroke. This chapter reviews the epidemiology, bedside examination, localization approaches, and classification of stroke, with an emphasis on motor stroke presentations and management, and promising research approaches to enhancing motor aspects of stroke recovery.

The critical role of the endolysosomal system in cerebral ischemia

Cerebral ischemia is a serious disease that triggers sequential pathological mechanisms, leading to significant morbidity and mortality. Although most studies to date have typically focused on the lysosome, a single organelle, current evidence supports that the function of lysosomes cannot be separated from that of the endolysosomal system as a whole. The associated membrane fusion functions of this system play a crucial role in the biodegradation of cerebral ischemia-related products. Here, we review the regulation of and the changes that occur in the endolysosomal system after cerebral ischemia, focusing on the latest research progress on membrane fusion function. Numerous proteins, including N-ethylmaleimide-sensitive factor and lysosomal potassium channel transmembrane protein 175, regulate the function of this system. However, these proteins are abnormally expressed after cerebral ischemic injury, which disrupts the normal fusion function of membranes within the endolysosomal system and that between autophagosomes and lysosomes. This results in impaired "maturation" of the endolysosomal system and the collapse of energy metabolism balance and protein homeostasis maintained by the autophagy-lysosomal pathway. Autophagy is the final step in the endolysosomal pathway and contributes to maintaining the dynamic balance of the system. The process of autophagosome-lysosome fusion is a necessary part of autophagy and plays a crucial role in maintaining energy homeostasis and clearing aging proteins. We believe that, in cerebral ischemic injury, the endolysosomal system should be considered as a whole rather than focusing on the lysosome. Understanding how this dynamic system is regulated will provide new ideas for the treatment of cerebral ischemia.

Barriers to Enrollment in Post-Stroke Brain Stimulation in a Racially and Ethnically Diverse Population

BACKGROUND AND PURPOSE

Brain stimulation is an adjuvant strategy to promote rehabilitation after stroke. Here, we evaluated the influence of inclusion/exclusion criteria on enrollment in a transcranial direct current stimulation (tDCS) trial in the context of a racially/ethnically diverse acute stroke service at University of Texas Southwestern (UTSW).

METHODS

3124 (59.7 ± 14.5 years) racially/ethnically diverse (38.4% non-Hispanic white, (W), Hispanic (H) 22%, African American (AA) 33.5%, Asian (A) 2.3%) patients were screened in the acute stroke service at UTSW. Demographics, stroke characteristics, and reasons for exclusion were recorded prospectively.

RESULTS

2327 (74.5%) patients had a verified stroke. Only 44 of them (1.9%) were eligible. Causes for exclusion included in order of importance: (1) magnitude of upper extremity (UE) motor impairment, (2) prior strokes (s), (3) hemorrhagic stroke, (4) psychiatric condition or inability to follow instructions, and (5) old age, of these (2) and (4) were more common in AA patients but not in other minorities. 31 of the 44 eligible individuals were enrolled (W 1.68%, H 1.37%, AA .77%, A 3.774%). 90.5% of verified stroke patients did not exhibit contraindications for stimulation.

CONCLUSIONS

3 main conclusions emerged: (a) The main limitations for inclusion in brain stimulation trials of motor recovery were magnitude of UE motor impairments and stroke lesion characteristics, (b) most stroke patients could be stimulated with tDCS without safety concerns and (c) carefully tailored inclusion criteria could increase diversity in enrollment.Clinical Trial Registration-URL: http://clinicaltrials.gov. Unique identifier: NCT01007136.

A Large-Scale Prospective Study on Functional Ability and Mortality Following Stroke Based on HRS Data Set: Implications for Rehabilitation

According to the WHO, 15 million people worldwide suffer a stroke annually. Of these, 5 million die and another 5 million are left permanently disabled. Patients endure the impacts of strokes during their rehabilitation and afterward, placing economical and emotional burdens on family and community. Using data from the Health and Retirement Study (HRS) of the USA, the research performed a large-scale prospective analysis to examine how demographics, socioeconomic factors, cognition, emotion, and physical activity predict functional impairment and mortality. Multiple regression was employed to identify statistically significant variables that predict longitudinal Activities of Daily Life (ADLs). The least absolute shrinkage and selection operator (LASSO) logistic regression, a supervised machine learning approach, was deliberately chosen to obtain the subset of predictors that provide the best possible classification for the dependent variable. The LASSO regression produced a model with a fair mean Area Under the Curve (AUC) of 0.75 in predicting the risk of the patient's mortality. My findings also uncovered the important roles of BMI, mobility, muscle strength, memory, mental status, and socioeconomic status play in the long-term ADLs and survival of patients with stroke.

Co-creating Digital Stories With UK-Based Stroke Survivors With the Aim of Synthesizing Collective Lessons From Individual Experiences of Interacting With Healthcare Professionals

Background

Stroke survivor narratives can provide valuable insight into experiences of healthcare and beyond. There is need to further understand collective lessons from stroke survivor narratives, yet prior studies utilizing digital storytelling tend to not synthesize lessons from individual experiences. This study aims to develop a novel method to co-create digital stories with stroke survivors that will aim to synthesize and portray important collective lessons from individual stroke survivors' experiences of interacting with healthcare professionals.

Methods

This study follows-up a qualitative study conducted with 30 stroke survivors exploring factors that help or hinder survivors to positively reconfigure their identity post-stroke. Five co-creation workshops were conducted with a subset of UK-based stroke survivors from this previous study. Participants were invited to join through: online workshops, an online bulletin board, and as an advisor. A four-stage workshop framework was developed through the integration of UK Design Council's Double Diamond method, digital storytelling strategies and the Behavior Change Wheel (BCW) framework for developing behavioral change interventions.

Findings

Six online workshop participants (three male, three female; aged 33–63; time since stroke 2–16 years) co-created digital stories that share six collective lessons aimed at increasing empathy and encouraging behavior change in healthcare professionals (HCPs) working with stroke survivors. Online bulletin board participants (n = 1) and advisors (n = 5) supported the co-creation process. Collective lessons identified were: (1) Stroke has a variety of symptoms that must all be considered; (2) Stroke can affect anyone of any age and not just the elderly; (3) Assumptions should not be made about a survivor's lifestyle or habits; (4) It is important to acknowledge the person behind the stroke and ensure that they are communicated with and listened to; (5) Stroke survivors can often feel unprepared for the reality of life after stroke; (6) Adapting to life after stroke is a long-term process requiring long-term support.

Conclusion

Stroke survivor stories highlighted preconceptions, attitudes and behaviors embedded within healthcare that negatively impacted their experiences and recovery. The novel methodology employed in this study enabled these stories to be synthesized into collective lessons to bring about improvements in these behaviors in future.

The effects of socioeconomic and geographic factors on chronic phase long-term survival after stroke in South Korea

The stroke incidence has increased rapidly in South Korea, calling for a national-wide system for long-term stroke management. We investigated the effects of socioeconomic status (SES) and geographic factors on chronic phase survival after stroke. We retrospectively enrolled 6994 patients who experienced a stroke event in 2009 from the Korean National Health Insurance database. We followed them up from 24 to 120 months after stroke onset. The endpoint was all-cause mortality. We defined SES using a medical-aid group and four groups divided by health insurance premium quartiles. Geographic factors were defined using Model 1 (capital, metropolitan, city, and county) and Model 2 (with or without university hospitals). The higher the insurance premium, the higher the survival rate tended to be (P < 0.001). The patient survival rate was highest in the capital city and lowest at the county level (P < 0.001). Regions with a university hospital(s) showed a higher survival rate (P = 0.006). Cox regression revealed that the medical-aid group was identified as an independent risk factor for chronic phase mortality. Further, NHIP level had a more significant effect than geographic factors on chronic stroke mortality. From these results, long-term nationwide efforts to reduce inter-regional as well as SES discrepancies affecting stroke management are needed.

Tongqiao Huoxue Decoction for the treatment of acute ischemic stroke: A Systematic Review and meta-analysis

ETHNOPHARMACOLOGICAL RELEVANCE

The aim of this study was to evaluate the efficacy and safety of Tongqiao Huoxue Decoction (TQHXT) in the treatment of acute ischemic stroke (AIS); Study Design: A total of 17 randomized controlled trials, involving 1489 AIS patients, were included for data analyses.

MATERIALS AND METHODS

All randomized controlled trials (RCTs) of TQHXT in the treatment of acute ischemic stroke before September 2020 were retrieved from seven electronic databases, including PubMed, Web of Science, Central, CNKI, CBM, Wanfang, and VIP. Data were analyzed by RevMan 5.3 software, and quality was evaluated by GRADEpro; Results: Results showed that, while TQHXT demonstrated undeniable positive effects in clinical effective rate, neurological deficit scores, activities of daily living (ADL) scores, and hemorheology (including HCT; fibrinogen; plasma viscosity and platelet adherence rate), adverse events (AE) require further study; and Conclusions: This study provides evidence that TQHXT is an effective treatment for acute ischemic stroke. However, due to the limited quality of the included studies, the above conclusion needs to be further verified by stricter randomized controlled, double-blind, large-sample, high-quality trials.

Kinematic Analysis of 360° Turning in Stroke Survivors Using Wearable Motion Sensors

Background: A stroke often bequeaths surviving patients with impaired neuromusculoskeletal systems subjecting them to increased risk of injury (e.g., due to falls) even during activities of daily living. The risk of injuries to such individuals can be related to alterations in their movement. Using inertial sensors to record the digital biomarkers during turning could reveal the relevant turning alterations. Objectives: In this study, movement alterations in stroke survivors (SS) were studied and compared to healthy individuals (HI) in the entire turning task due to its requirement of synergistic application of multiple bodily systems. Methods: The motion of 28 participants (14 SS, 14 HI) during turning was captured using a set of four Inertial Measurement Units, placed on their sternum, sacrum, and both shanks. The motion signals were segmented using the temporal and spatial segmentation of the data from the leading and trailing shanks. Several kinematic parameters, including the range of motion and angular velocity of the four body segments, turning time, the number of cycles involved in the turning task, and portion of the stance phase while turning, were extracted for each participant. Results: The results of temporal processing of the data and comparison between the SS and HI showed that SS had more cycles involved in turning, turn duration, stance phase, range of motion in flexion–extension, and lateral bending for sternum and sacrum (p-value < 0.035). However, HI exhibited larger angular velocity in flexion–extension for all four segments. The results of the spatial processing, in agreement with the prior method, showed no difference between the range of motion in flexion–extension of both shanks (p-value > 0.08). However, it revealed that the angular velocity of the shanks of leading and trailing legs in the direction of turn was more extensive in the HI (p-value < 0.01). Conclusions: The changes in upper/lower body segments of SS could be adequately identified and quantified by IMU sensors. The identified kinematic changes in SS, such as the lower flexion–extension angular velocity of the four body segments and larger lateral bending range of motion in sternum and sacrum compared to HI in turning, could be due to the lack of proper core stability and effect of turning on vestibular system of the participants. This research could facilitate the development of a targeted and efficient rehabilitation program focusing on the affected aspects of turning movement for the stroke community.

Central Recruitment: A process for engaging and recruiting individuals with spinal cord injury/disease in research at Toronto Rehabilitation Institute

CONTEXT

Insufficient recruitment is a barrier to research and limits statistical power. We describe an initiative aimed to streamline recruitment and consent processes for inpatients with spinal cord injury or disease (SCI/D) via implementation of a Central Recruitment (CR) process. The CR process adhered to ethical standards, reduced participant burden, and maximized research participation.

METHODS

In this CR process, the inpatient's nurse affirmed suitability for research approach based on fluency, cognition and health stability. A patient research liaison (PRL) was the sole contact for information regarding the research process, and introduced ongoing studies, screened for eligibility, and completed the consent process(es).

RESULTS

Over five and a half years, 1,561 inpatients with SCI/D were screened for eligibility upon admission, of whom 80% (1256/1561) were deemed suitable for the PRL approach. Of those suitable for the CR process, 80% (1001/1256) agreed to discuss current research opportunities, 46% (235/516) consented to participate in one or more studies, and 86% (856/1001) agreed to future research contact.

CONCLUSION

This process adhered to ethical procedures and reduced the burden of having multiple researchers approach each individual inpatient regarding research participation, with high consent rates for low-risk studies. Future evaluation of the process scalability is underway.

HIF‑1α in cerebral ischemia (Review)

Cerebral ischemic injury may lead to a series of serious brain diseases, death or different degrees of disability. Hypoxia-inducible factor-1α (HIF-1α) is an oxygen-sensitive transcription factor, which mediates the adaptive metabolic response to hypoxia and serves a key role in cerebral ischemia. HIF-1α is the main molecule that responds to hypoxia. HIF-1α serves an important role in the development of cerebral ischemia by participating in numerous processes, including metabolism, proliferation and angiogenesis. The present review focuses on the endogenous protective mechanism of cerebral ischemia and elaborates on the role of HIF-1α in cerebral ischemia. In addition, it focuses on cerebral ischemia interventions that act on the HIF-1α target, including biological factors, non-coding RNA, hypoxic-ischemic preconditioning and drugs, and expands upon the measures to strengthen the endogenous compensatory response to support HIF-1α as a therapeutic target, thus providing novel suggestions for the treatment of cerebral ischemia.

Self-Rehabilitation for Post-Stroke Motor Function and Activity-A Systematic Review and Meta-Analysis

Background. Due to an increasing stroke incidence, a lack of resources to implement effective rehabilitation and a significant proportion of patients with remaining impairments after treatment, there is a rise in demand for effective and prolonged rehabilitation. Development of self-rehabilitation programs provides an opportunity to meet these increasing demands.Objective. The primary aim of this meta-analysis was to determine the effect of self-rehabilitation on motor outcomes, in comparison to conventional rehabilitation, among patients with stroke. The secondary aim was to assess the influence of trial location (continent), technology, time since stroke (acute/subacute vs chronic), dose (total training duration > vs ≤ 15 hours), and intervention design (self-rehabilitation in addition/substitution to conventional therapy) on effect of self-rehabilitation.Methods. Studies were selected if participants were adults with stroke; the intervention consisted of a self-rehabilitation program defined as a tailored program where for most of the time, the patient performed rehabilitation exercises independently; the control group received conventional therapy; outcomes included motor function and activity; and the study was a randomized controlled trial with a PEDro score ≥5.Results. Thirty-five trials were selected (2225 participants) and included in quantitative synthesis regarding motor outcomes. Trials had a median PEDro Score of 7 [6-8]. Self-rehabilitation programs were shown to be as effective as conventional therapy. Trial location, use of technology, stroke stage, and intervention design did not appear to have a significant influence on outcomes.Conclusion. This meta-analysis showed low to moderate evidence that self-rehabilitation and conventional therapy efficacy was equally valuable for post-stroke motor function and activity.

Timing and Dose of Upper Limb Motor Intervention After Stroke: A Systematic Review

This systematic review aimed to investigate timing, dose, and efficacy of upper limb intervention during the first 6 months poststroke. Three online databases were searched up to July 2020. Titles/abstracts/full-text were reviewed independently by 2 authors. Randomized and nonrandomized studies that enrolled people within the first 6 months poststroke, aimed to improve upper limb recovery, and completed preintervention and postintervention assessments were included. Risk of bias was assessed using Cochrane reporting tools. Studies were examined by timing (recovery epoch), dose, and intervention type. Two hundred and sixty-one studies were included, representing 228 (n=9704 participants) unique data sets. The number of studies completed increased from one (n=37 participants) between 1980 and 1984 to 91 (n=4417 participants) between 2015 and 2019. Timing of intervention start has not changed (median 38 days, interquartile range [IQR], 22-66) and study sample size remains small (median n=30, IQR 20-48). Most studies were rated high risk of bias (62%). Study participants were enrolled at different recovery epochs: 1 hyperacute (<24 hours), 13 acute (1-7 days), 176 early subacute (8-90 days), 34 late subacute (91-180 days), and 4 were unable to be classified to an epoch. For both the intervention and control groups, the median dose was 45 (IQR, 600-1430) min/session, 1 (IQR, 1-1) session/d, 5 (IQR, 5-5) d/wk for 4 (IQR, 3-5) weeks. The most common interventions tested were electromechanical (n=55 studies), electrical stimulation (n=38 studies), and constraint-induced movement (n=28 studies) therapies. Despite a large and growing body of research, intervention dose and sample size of included studies were often too small to detect clinically important effects. Furthermore, interventions remain focused on subacute stroke recovery with little change in recent decades. A united research agenda that establishes a clear biological understanding of timing, dose, and intervention type is needed to progress stroke recovery research. Prospective Register of Systematic Reviews ID: CRD42018019367/CRD42018111629.

Why Are Stroke Rehabilitation Trial Recruitment Rates in Single Digits?

Background: Recruitment of patients in early subacute rehabilitation trials (<30 days post-stroke) presents unique challenges compared to conventional stroke trials recruiting individuals >6 months post-stroke. Preclinical studies suggest treatments be initiated sooner after stroke, thus requiring stroke rehabilitation trials be conducted within days post-stroke. How do specific inclusion and exclusion criteria affect trial recruitment rates for early stroke rehabilitation trials?

Objectives: Provide estimates of trial recruitment based on screening and enrollment data from a phase II early stroke rehabilitation trial.

Methods: CPASS, a phase II intervention trial screened ischemic stroke patients in acute care (18-months, N = 395) and inpatient rehabilitation (22-months, N = 673). Patients were stratified by upper extremity (UE) impairment into mild (NIHSS motor arm = 0, 1); moderate (NIHSS = 2, 3); severe (NIHSS = 4) and numbers of patients disqualified due to CPASS exclusion criteria determined. We also examined if a motor-specific evaluation (Action Research Arm Test, ARAT) increases the pool of eligible patients disqualified by the NIHSS motor arm item.

Results: CPASS recruitment in acute care (5.3%) and inpatient rehabilitation (5%) was comparable to prior trials. In acute care, a short stay (7–17-days), prior stroke (13.5% in moderately; 13.2% in severely impaired) disqualified the majority. In inpatient rehabilitation, the majority (40.8%) were excluded for “too mild” impairment. The next majority were disqualified for reaching inpatient rehabilitation “too late” to participate in an early stroke trial (15% in moderately; 24% in severely impaired). Mean ARAT in the “too mild” showed significant impairment and potential to benefit from participation in select UE rehabilitation trials.

Conclusions: Screening of ischemic stroke patients while they are still in acute care is crucial to successful recruitment for early stroke rehabilitation trials. A significant proportion of eligible patients are lost to “short length of stay” in acute care, and arrive to inpatient rehabilitation “too late” for an early rehabilitation trial. Additional screening of mildly impaired patients using a motor function specific scale will benefit the trial recruitment and generalizability.

Trial Registration Number:http://www.clinicaltrials.gov Identifier: NCT02235974.

Patients' physical activity in stroke units in Latvia and Sweden

OBJECTIVE

A prospective, observational study to describe levels of physical activity in patients with stroke in a comprehensive stroke unit in Sweden and Latvia, comparing data between countries.

METHODS

The study was performed at stroke units in one hospital in Sweden (data were acquired over a 2-month period in 2017) and two hospitals in Latvia (data were acquired over a 3-month period between 2016 and 2017). Patients with stroke were observed for 1 min every 10 min. The level of physical activity, location, and the people present were noted at each time-point.

RESULTS

A total of 27 patients were observed in Latvia and 25 patients in Sweden. Patients from both countries were in bed half of the time and spent the majority of the day in their bedroom and alone. Patients in Sweden had higher physical activity levels, spent more time outside their bedroom and spent more time with rehabilitation specialists and visitors.

CONCLUSION

Patients are inactive and alone for a majority of the time during hospitalization at a comprehensive stroke unit in both countries. There are differences in environment in the stroke unit between countries.

Lost in Translation: Simple Steps in Experimental Design of Neurorehabilitation-Based Research Interventions to Promote Motor Recovery Post-Stroke

Stroke continues to be a leading cause of disability. Basic neurorehabilitation research is necessary to inform the neuropathophysiology of impaired motor control, and to develop targeted interventions with potential to remediate disability post-stroke. Despite knowledge gained from basic research studies, the effectiveness of research-based interventions for reducing motor impairment has been no greater than standard of practice interventions. In this perspective, we offer suggestions for overcoming translational barriers integral to experimental design, to augment traditional protocols, and re-route the rehabilitation trajectory toward recovery and away from compensation. First, we suggest that researchers consider modifying task practice schedules to focus on key aspects of movement quality, while minimizing the appearance of compensatory behaviors. Second, we suggest that researchers supplement primary outcome measures with secondary measures that capture emerging maladaptive compensations at other segments or joints. Third, we offer suggestions about how to maximize participant engagement, self-direction, and motivation, by embedding the task into a meaningful context, a strategy more likely to enable goal-action coupling, associated with improved neuro-motor control and learning. Finally, we remind the reader that motor impairment post-stroke is a multidimensional problem that involves central and peripheral sensorimotor systems, likely influenced by chronicity of stroke. Thus, stroke chronicity should be given special consideration for both participant recruitment and subsequent data analyses. We hope that future research endeavors will consider these suggestions in the design of the next generation of intervention studies in neurorehabilitation, to improve translation of research advances to improved participation and quality of life for stroke survivors.

Does Cathodal vs. Sham Transcranial Direct Current Stimulation Over Contralesional Motor Cortex Enhance Upper Limb Motor Recovery Post-stroke? A Systematic Review and Meta-analysis

Background: During recovery from stroke, the contralesional motor cortex (M1) may undergo maladaptive changes that contribute to impaired interhemispheric inhibition (IHI). Transcranial direct current stimulation (tDCS) with the cathode over contralesional M1 may inhibit this maladaptive plasticity, normalize IHI, and enhance motor recovery.

Objective: The objective of this systematic review and meta-analysis was to evaluate available evidence to determine whether cathodal tDCS on contralesional M1 enhances motor re-learning or recovery post-stroke more than sham tDCS.

Methods: We searched OVID Medline, Embase, and the Cochrane Central Register of Controlled Trials for participants with stroke (>1 week post-onset) with motor impairment and who received cathodal or sham tDCS to contralesional M1 for one or more sessions. The outcomes included a change in any clinically validated assessment of physical function, activity, or participation, or a change in a movement performance variable (e.g., time, accuracy). A meta-analysis was performed by pooling five randomized controlled trials (RCTs) and comparing the change in Fugl–Meyer upper extremity scores between cathodal and sham tDCS groups.

Results: Eleven studies met the inclusion criteria. Qualitatively, four out of five cross-over design studies and three out of six RCTs reported a significant effect of cathodal vs. sham tDCS. In the quantitative synthesis, cathodal tDCS (n = 65) did not significantly reduce motor impairment compared to sham tDCS (n = 67; standardized mean difference = 0.33, z = 1.79, p = 0.07) with a little observed heterogeneity (I² = 5%).

Conclusions: The effects of cathodal tDCS to contralesional M1 on motor recovery are small and consistent. There may be sub-populations that may respond to this approach; however, further research with larger cohorts is required.

Virtual Reality for Motor and Cognitive Rehabilitation From Clinic to Home: A Pilot Feasibility and Efficacy Study for Persons With Chronic Stroke

Aims: Continuity of care is an important issue in healthcare for persons after stroke. The present multi-center pilot study investigates the feasibility and efficiency of an innovative approach, the Human Empowerment Aging and Disability (HEAD), for digital-health motor and cognitive rehabilitation. The approach is explored within an in-clinic context (ClinicHEAD) and in continuity of care (HomeHEAD) for persons after chronic stroke. Methods: Thirty-four outpatients with chronic stroke (mean age 55 years, SD 13.7) participated. The HEAD VR protocol was administered in two consecutive phases: Phase I in clinic (ClinicHEAD) consisting of 4 weeks of 12 supervised HEAD rehabilitation sessions (45-min), including motor, cognitive and dual task for all participants; Phase II at home (HomeHEAD) consisted of 60 sessions of the same VR activities, 5 times/week for 3 months. All participants in the ClinicHEAD were allocated (ratio 1:2) to continue with tele-monitored home rehabilitation (HH, N = 11) or to follow usual care (UC, N = 23). Blind evaluation was carried out at baseline, after ClinicHEAD, after 3 months of HomeHEAD and at 3 months Follow-up. Primary outcomes were functional mobility [2-min Walking Test (2MWT)] and cognition [Montreal Cognitive Assessment (MoCA)]. Feasibility and acceptance were assessed with adherence to treatment and the System Usability Satisfaction. Within group analyses were done with dependent samples t-tests, and between groups HomeHEAD comparisons were carried out on change scores with independent samples t-test (p = 0.05, two tailed). Results: The HEAD protocol was feasible with good adherence both in the ClinicHEAD phase (92%) and HomeHEAD (89%) phase, along with good perceived system satisfaction. ClinicHEAD resulted in a significant increase in functional mobility (2MWT, p = 0.02) and cognition (MoCA, p = 0.003) and most secondary outcome variables. At 3 months follow up of HomeHEAD the HH_group showed a further significantly greater maintenance of functional mobility with respect to UC_group (p = 0.04). Conclusion: The HEAD VR protocol was feasible in clinical and at home tele-rehabilitation for persons in the chronic phase after stroke. In clinic the approach was effective in augmenting motor and cognitive abilities and at home it was effective in longterm maintenance of functional mobility, indicating its usefulness in continuity of care. Clinical Trial Registration: ClinicalTrials.gov, NCT03025126.

Comparing a Novel Neuroanimation Experience to Conventional Therapy for High-Dose Intensive Upper-Limb Training in Subacute Stroke: The SMARTS2 Randomized Trial

BACKGROUND

Evidence from animal studies suggests that greater reductions in poststroke motor impairment can be attained with significantly higher doses and intensities of therapy focused on movement quality. These studies also indicate a dose-timing interaction, with more pronounced effects if high-intensity therapy is delivered in the acute/subacute, rather than chronic, poststroke period.

OBJECTIVE

To compare 2 approaches of delivering high-intensity, high-dose upper-limb therapy in patients with subacute stroke: a novel exploratory neuroanimation therapy (NAT) and modified conventional occupational therapy (COT).

METHODS

A total of 24 patients were randomized to NAT or COT and underwent 30 sessions of 60 minutes time-on-task in addition to standard care. The primary outcome was the Fugl-Meyer Upper Extremity motor score (FM-UE). Secondary outcomes included Action Research Arm Test (ARAT), grip strength, Stroke Impact Scale hand domain, and upper-limb kinematics. Outcomes were assessed at baseline, and days 3, 90, and 180 posttraining. Both groups were compared to a matched historical cohort (HC), which received only 30 minutes of upper-limb therapy per day.

RESULTS

There were no significant between-group differences in FM-UE change or any of the secondary outcomes at any timepoint. Both high-dose groups showed greater recovery on the ARAT (7.3 ± 2.9 points; P = .011) but not the FM-UE (1.4 ± 2.6 points; P = .564) when compared with the HC.

CONCLUSIONS

Neuroanimation may offer a new, enjoyable, efficient, and scalable way to deliver high-dose and intensive upper-limb therapy.

An analysis of the CatWalk XT and a composite score to assess neurofunctional deficits after photothrombosis in mice

The purpose of this study was to evaluate CatWalk's capability for assessing the functional outcome after photothrombotic stroke affecting the motor cortex of mice. Mice were tested up to 21 days after photothrombosis or sham surgery using CatWalk, and a composite score assessing functional deficits (neuroscore). The neuroscore demonstrated deficits of the contralateral forelimb for more than two weeks after stroke. There were no asymmetric or coordinative dysfunctions of limbs detected by CatWalk. However, CatWalk data revealed impairment of locomotion speed and its depending parameters for one-week after stroke in strong correlation to the neuroscore. Data suggest that the composite neuroscore allows to more sensitively and precisely specify and quantify photothrombosis-induced hemisyndromes than CatWalk.

Principles of Neural Repair and Their Application to Stroke Recovery Trials

Neural repair is the underlying therapeutic strategy for many treatments currently under investigation to improve recovery after stroke. Repair-based therapies are distinct from acute stroke strategies: instead of salvaging threatened brain tissue, the goal is to improve behavioral outcomes on the basis of experience-dependent brain plasticity. Furthermore, timing, concomitant behavioral experiences, modality specific outcome measures, and careful patient selection are fundamental concepts for stroke recovery trials that can be deduced from principles of neural repair. Here we discuss core principles of neural repair and their implications for stroke recovery trials, highlighting related issues from key studies in humans. Research suggests a future in which neural repair therapies are personalized based on measures of brain structure and function, genetics, and lifestyle factors.

Intense Arm Rehabilitation Therapy Improves the Modified Rankin Scale Score: Association Between Gains in Impairment and Function

OBJECTIVE

To evaluate the effect of intensive rehabilitation on the modified Rankin Scale (mRS), a measure of activities limitation commonly used in acute stroke studies, and to define the specific changes in body structure/function (motor impairment) most related to mRS gains.

METHODS

Patients were enrolled >90 days poststroke. Each was evaluated before and 30 days after a 6-week course of daily rehabilitation targeting the arm. Activity gains, measured using the mRS, were examined and compared to body structure/function gains, measured using the Fugl-Meyer (FM) motor scale. Additional analyses examined whether activity gains were more strongly related to specific body structure/function gains.

RESULTS

At baseline (160 ± 48 days poststroke), patients (n = 77) had median mRS score of 3 (interquartile range, 2-3), decreasing to 2 [2-3] 30 days posttherapy (p < 0.0001). Similarly, the proportion of patients with mRS score ≤2 increased from 46.8% at baseline to 66.2% at 30 days posttherapy (p = 0.015). These findings were accounted for by the mRS score decreasing in 24 (31.2%) patients. Patients with a treatment-related mRS score improvement, compared to those without, had similar overall motor gains (change in total FM score, p = 0.63). In exploratory analysis, improvement in several specific motor impairments, such as finger flexion and wrist circumduction, was significantly associated with higher likelihood of mRS decrease.

CONCLUSIONS

Intensive arm motor therapy is associated with improved mRS in a substantial fraction (31.2%) of patients. Exploratory analysis suggests specific motor impairments that might underlie this finding and may be optimal targets for rehabilitation therapies that aim to reduce activities limitations.

CLINICAL TRIAL

Clinicaltrials.gov identifier: NCT02360488.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for patients >90 days poststroke with persistent arm motor deficits, intensive arm motor therapy improved mRS in a substantial fraction (31.2%) of patients.

Optimizing Recruitment Strategies and Physician Engagement for Stroke Recovery Research

BACKGROUND AND PURPOSE

A major challenge for stroke rehabilitation and recovery research is the recruitment and retention of participants. Our prior challenges and successes have influenced our team to rethink our approach and the potential for large-scale stroke recruitment.

SUMMARY OF KEY POINTS

In this special interest article, we highlight how the adoption and implementation of recruitment strategies such as physician engagement and a streamlined "customer service" approach helped us improve our enrollment and maximize efficiency. Another positive outcome of enrollment was increased representation of those who identify as underrepresented minority or live in rural areas.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Rethinking our recruitment processes and infrastructure allowed for greater interprofessional interactions, minimal burden for our stroke physician team members, and maximized enrollment into our stroke studies.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A324).

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

OBJECTIVES

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

DESIGN

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

SETTING AND PARTICIPANTS

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

RESULTS

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

CONCLUSIONS AND IMPLICATIONS

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

Health-Related Quality of Life in Stroke Survivors in Relation to the Type of Inpatient Rehabilitation in Serbia: A Prospective Cohort Study

Background and objectives: Health-related quality of life after stroke is an important public health issue. The objective of the study was to investigate the relationship between the perceived health-related quality of life in stroke survivors in relation to the type of inpatient rehabilitation. Materials and Methods: Using a random selection method out of a total of 688 patients, every fourth survivor who had a stroke in the period from 1 January 2017 to 31 December 2019 was selected from the admission protocol of the Clinic for Rehabilitation and Physical Medicine of the Clinical Centre Niš, Serbia. A total of 160 first-ever stroke survivors were included (80 underwent additional inpatient rehabilitation and 80 underwent only inpatient rehabilitation in a tertiary health institution) in a twelve-month prospective study. The EuroQuol-5 Dimension (EQ5D) questionnaire and Stroke Impact Scale were used for the assessment. Multivariate linear regression analysis was done. Results: Multivariate linear regression analysis showed that additional inpatient rehabilitation from six up to eight weeks after discharge was significantly associated with better self-reported health condition by 3.9 times (from 1.9 to 8.2), significantly decreased the ranks of EQ5D by 1.78 times (from 1.02 to 3.11), and showed a higher health-related quality of life. We determined a significant increase of strength, emotions, mobility, and participation role in survivors who underwent additional inpatient rehabilitation compared with those who did not. Conclusions: There was a significant difference in health-related quality of life perceived by stroke survivors who underwent additional hospital rehabilitation in relation to those who underwent only inpatient rehabilitation.

Exploratory study of how Cognitive Multisensory Rehabilitation restores parietal operculum connectivity and improves upper limb movements in chronic stroke

Cognitive Multisensory Rehabilitation (CMR) is a promising therapy for upper limb recovery in stroke, but the brain mechanisms are unknown. We previously demonstrated that the parietal operculum (parts OP1/OP4) is activated with CMR exercises. In this exploratory study, we assessed the baseline difference between OP1/OP4 functional connectivity (FC) at rest in stroke versus healthy adults to then explore whether CMR affects OP1/OP4 connectivity and sensorimotor recovery after stroke. We recruited 8 adults with chronic stroke and left hemiplegia/paresis and 22 healthy adults. Resting-state FC with the OP1/OP4 region-of-interest in the affected hemisphere was analysed before and after 6 weeks of CMR. We evaluated sensorimotor function and activities of daily life pre- and post-CMR, and at 1-year post-CMR. At baseline, we found decreased FC between the right OP1/OP4 and 34 areas distributed across all lobes in stroke versus healthy adults. After CMR, only four areas had decreased FC compared to healthy adults. Compared to baseline (pre-CMR), participants improved on motor function (MESUPES arm p = 0.02; MESUPES hand p = 0.03; MESUPES total score p = 0.006); on stereognosis (p = 0.03); and on the Frenchay Activities Index (p = 0.03) at post-CMR and at 1-year follow-up. These results suggest enhanced sensorimotor recovery post-stroke after CMR. Our results justify larger-scale studies.

Robot-assisted training compared with an enhanced upper limb therapy programme and with usual care for upper limb functional limitation after stroke: the RATULS three-group RCT

BACKGROUND

Loss of arm function is common after stroke. Robot-assisted training may improve arm outcomes.

OBJECTIVE

The objectives were to determine the clinical effectiveness and cost-effectiveness of robot-assisted training, compared with an enhanced upper limb therapy programme and with usual care.

DESIGN

This was a pragmatic, observer-blind, multicentre randomised controlled trial with embedded health economic and process evaluations.

SETTING

The trial was set in four NHS trial centres.

PARTICIPANTS

Patients with moderate or severe upper limb functional limitation, between 1 week and 5 years following first stroke, were recruited.

INTERVENTIONS

Robot-assisted training using the Massachusetts Institute of Technology-Manus robotic gym system (InMotion commercial version, Interactive Motion Technologies, Inc., Watertown, MA, USA), an enhanced upper limb therapy programme comprising repetitive functional task practice, and usual care.

MAIN OUTCOME MEASURES

The primary outcome was upper limb functional recovery 'success' (assessed using the Action Research Arm Test) at 3 months. Secondary outcomes at 3 and 6 months were the Action Research Arm Test results, upper limb impairment (measured using the Fugl-Meyer Assessment), activities of daily living (measured using the Barthel Activities of Daily Living Index), quality of life (measured using the Stroke Impact Scale), resource use costs and quality-adjusted life-years.

RESULTS

A total of 770 participants were randomised (robot-assisted training, n = 257; enhanced upper limb therapy, n = 259; usual care, n = 254). Upper limb functional recovery 'success' was achieved in the robot-assisted training [103/232 (44%)], enhanced upper limb therapy [118/234 (50%)] and usual care groups [85/203 (42%)]. These differences were not statistically significant; the adjusted odds ratios were as follows: robot-assisted training versus usual care, 1.2 (98.33% confidence interval 0.7 to 2.0); enhanced upper limb therapy versus usual care, 1.5 (98.33% confidence interval 0.9 to 2.5); and robot-assisted training versus enhanced upper limb therapy, 0.8 (98.33% confidence interval 0.5 to 1.3). The robot-assisted training group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale) than the usual care group at 3 and 6 months. The enhanced upper limb therapy group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale), better mobility (as measured by the Stroke Impact Scale mobility domain) and better performance in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the usual care group, at 3 months. The robot-assisted training group performed less well in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the enhanced upper limb therapy group at 3 months. No other differences were clinically important and statistically significant. Participants found the robot-assisted training and the enhanced upper limb therapy group programmes acceptable. Neither intervention, as provided in this trial, was cost-effective at current National Institute for Health and Care Excellence willingness-to-pay thresholds for a quality-adjusted life-year.

CONCLUSIONS

Robot-assisted training did not improve upper limb function compared with usual care. Although robot-assisted training improved upper limb impairment, this did not translate into improvements in other outcomes. Enhanced upper limb therapy resulted in potentially important improvements on upper limb impairment, in performance of activities of daily living, and in mobility. Neither intervention was cost-effective.

FUTURE WORK

Further research is needed to find ways to translate the improvements in upper limb impairment seen with robot-assisted training into improvements in upper limb function and activities of daily living. Innovations to make rehabilitation programmes more cost-effective are required.

LIMITATIONS

Pragmatic inclusion criteria led to the recruitment of some participants with little prospect of recovery. The attrition rate was higher in the usual care group than in the robot-assisted training or enhanced upper limb therapy groups, and differential attrition is a potential source of bias. Obtaining accurate information about the usual care that participants were receiving was a challenge.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN69371850.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 54. See the NIHR Journals Library website for further project information.

Depressive symptoms after stroke are associated with worse recovery

OBJECTIVE

More studies are needed on how depressive symptoms in stroke patients can impact outcomes. We evaluated the relationship between depression symptom severity and motor outcomes in a cohort of patients with motor impairment from ischemic stroke.

METHOD

We enrolled consecutive ischemic stroke patients without a clinical diagnosis of depression who presented to a single-center urban academic referral hospital. The Patient Health Questionnaire-9 (PHQ-9) scale was used to measure depression symptom severity at three months. Three assessments of motor function were collected at stroke onset and three months: Fugl-Meyer upper extremity (FM-UE), Motricity Index, and Action Research Arm Test (ARAT). We assessed the association between three-month severity on PHQ-9 scores with the outcome measures using univariable and multivariable linear regression models.

RESULTS

Fifty-seven patients (mean age 67.8 ± 17.0 years; 50.9% male; 59.6% Caucasian) were included in the final analysis. Mean (standard deviation) outcome scores at three months were PHQ-9: 6.39 (5), Motricity Index: 86.93 (30.04), FM-UE: 52.67 (17.83), and ARAT: 43.77 (20.03). After adjusting for age, initial National Institute of Health Stroke Scale, and if patient discharged after hospitalization on a selective serotonin reuptake inhibitor, sex, and baseline motor outcome, we found that for every point increase in PHQ-9, the Motricity Index decreased by 0.82 points (p = 0.02) and the FM-UE decreased by 0.77 points (p = 0.049).

CONCLUSION

Depressive symptoms are common in the stroke population. Depressive symptoms after stroke are associated with multiple types of motor impairments. We need better understanding of the biologic and psychologic aspects of depression involved in stroke recovery.

Virtual reality interventions to enhance upper limb motor improvement after a stroke: commonly used types of platform and outcomes

Introduction: Virtual Reality (VR) based platforms are useful in enhancing post-stroke sub-optimal upper limb (UL) motor improvement. A variety of options are available from expensive highly customizable platforms to low cost turnkey solutions. Clinical outcomes primarily help assess the effects of VR-based platforms. These outcomes mainly quantify how much improvement has occurred. Very few outcomes characterize the type (i.e. how) of recovery. We categorized the types of VR-based platforms and outcome measures commonly used for post-stroke UL motor improvement.Methods: We reviewed the published literature in English from 2000-2019. Different types of VR-based platforms were grouped into those available commercially and those developed by the various research groups. We initially classified outcomes from the retrieved studies under the appropriate International Classification of Functioning categories. Then, we divided the outcomes as those quantifying the type or extent of improvement.Results: We found a total of 125 studies. Majority of the studies used commercially available platforms. A total of 42 different outcome measures were used. Seventeen different outcomes were used to assess body structure and functions as well as in activity limitations. Eight outcomes assessed the effects of contextual factors and participation restrictions. The Fugl Meyer Assessment, Wolf Motor Function Test and Stroke Impact Scale were most often used across the three categories. Of the 125 studies, 52 used outcomes characterizing the type of recovery. Although a smaller proportion, 24 studies included movement patterns outcomes.Conclusion: A standardized set of outcomes can promote better comparisons between studies using different VR-based platforms for post-stroke UL motor improvement.Implications for RehabilitationA wide variety of commercially available systems are present from expensive customizable systems to low-cost turnkey systems.The Fugl-Meyer Assessment and Wolf Motor Function Test along with the Stroke Impact Scale-Social Participation subscale were used most often across all studies as assessments of body structure and function, activity limitations and participation restriction.It is essential to include movement pattern outcomes addressing whether recovery of compensation occurs with the use of VR-based platforms.

CKLF1/CCR5 axis is involved in neutrophils migration of rats with transient cerebral ischemia

BACKGROUND

Chemokine-like factor 1 (CKLF1) is a chemokine increased significantly in ischemic brain poststroke. It shows chemotaxis effects on various immune cells, but the mechanisms of CKLF1 migrating neutrophils are poorly understood. Recent studies have provided evidence that CC chemokine receptor 5 (CCR5), a receptor of CKLF1, is involved in ischemic stroke.

PURPOSES

To investigate the effects of HIF-1α guided AAV in ischemic brain, investigating the outcome of stroke, and examining the involvement of CKLF1/CCR5 axis in recruitment of neutrophils.

RESULTS

HIF-1α guided AAV knocked down CKLF1 in ischemic area and alleviated brain damage of rats. CKLF1 migrated neutrophils through CCR5, worsening inflammatory responses. Akt/GSK-3β pathway may involve in CKLF1/CCR5 axis guided neutrophils chemotaxis.

CONCLUSIONS

CKLF1/CCR5 axis is involved in neutrophils migration of rats with transient cerebral ischemia. CKLF1/CCR5 axis may be a useful target for stroke therapy.

Predictors of Neurological and Functional Recovery in Patients with Moderate to Severe Ischemic Stroke: The EPICA Study

BACKGROUND

Improving our knowledge about the impact of restorative therapies employed in the rehabilitation of a stroke patient may help guide practitioners in prescribing treatment regimen that may lead to better post-stroke recovery and quality of life.

AIMS

To evaluate the neurological and functional recovery for 3 months after an acute ischemic stroke occurred within previous 3 months. To determine predictors of recovery.

DESIGN

Prospective observational registry. Population. Patients having suffered acute moderate to severe ischemic stroke of moderate to severe intensity within the previous 3 months with National Institutes of Health Stroke Scale (NIHSS) score from 10 to 20, 24 hours after arrival at emergency room (ER).

METHODS

All prespecified variables (sociodemographic and clinical data, lifestyle recommendations, rehabilitation prescription, and neurological assessments) were assessed at three visits, i.e., baseline (D0), one month (M1), and three months (M3).

RESULTS

Out of 143 recruited patients, 131 could be analysed at study entry within 3 months after stroke onset with a mean acute NIHSS score of 14.05, decreased to 10.8 at study baseline. Study sample was aged 64.9 ± 13.8 years, with 49.2% of women. Neurorehabilitation treatment was applied to 9 of 10 patients from the acute phase and for three months with different intensities depending on the centre. A large proportion of patients recovered from severe dependency on activities of daily living (ADL) at D0 to a mild or moderate disability requiring some help at M3: mean NIHSS = 10.8 to 5.7; median modified Rankin Scale (mRS) = 4 to 3; Barthel index (BI) = 40 to 70; all p values < 0.001. Multivariate analyses integrating other regression variables showed a trend in favour of rehabilitation and revascularization therapies on recovery although did not reach statistical significance and that the positive predictors of recovery improvement were baseline BI score, time to treatment, and dietary supplement MLC901 (NurAiD™II). A larger percentage of patients with more severe stroke (NIHSS > 14) who received MLC901 showed above median improvements on mRS compared to control group at M1 (71.4% vs. 29.4%; p = 0.032) and M3 (85.7% vs. 50%; p = 0.058). Older subjects and women tend to have less improvement by M3.

CONCLUSIONS

Our study in patients with moderate to severe stroke shows overall recovery on neurological and functional assessments during the 3 months of study observation. Apart from demonstrating traditional "non-modifiable" predictors of outcome after stroke, like age, sex, and stroke severity, we also detected association between the use of dietary supplement MLC901 and recovery.

Mechanisms of action of acute and subacute sphenopalatine ganglion stimulation for ischemic stroke

BACKGROUND

Sphenopalatine ganglion stimulation (SPG-Stim) for ischemic stroke, starting 8-24 h after onset and continuing through five days in a pooled analysis of two recent, randomized, sham-controlled trials, improved outcome of acute ischemic stroke patients with confirmed cortical involvement. As a neuromodulatory therapy, SPG-Stim differs substantially from existing pharmacologic (lytic and antiplatelets) and device (endovascular thrombectomy) acute ischemic stroke treatments.

AIM

Focused review of SPG anatomy, physiology, and neurovascular and neurobiologic mechanisms of action mediating benefit of SPG-Stim in acute ischemic stroke.

SUMMARY OF REVIEW

Located posterior to the maxillary sinus, the SPG is the main source of parasympathetic innervation to the anterior circulation. Preclinical and human studies delineate four distinct mechanisms of action by which the SPG-Stim may confer benefit in acute ischemic stroke: (1) collateral vasodilation and enhanced cerebral blood flow, mediated by release of neurotransmitters with vasodilatory effects, nitric oxide, and acetylcholine, (2) stimulation frequency- and intensity-dependent stabilization of the blood-brain barrier, reducing edema (3) direct acute neuroprotection from activation of the central cholinergic system with resulting anti-inflammatory, anti-apoptotic, and anti-excitatory effects; and (4) neuroplasticity enhancement from enhanced central cholinergic and adrenergic neuromodulation of cortical networks and nitrous oxide release stimulating neurogenesis.

CONCLUSION

The benefit of SPG-Stim in acute ischemic stroke is likely conferred not only by potent collateral augmentation, but also blood-barrier stabilization, direct neuroprotection, and neuroplasticity enhancement. Further studies clarifying the relative contribution of these mechanisms and the stimulation protocols that maximize each may help optimize SPG-Stim as a therapy for acute ischemic stroke.

Feasibility of Wearable Sensing for In-Home Finger Rehabilitation Early After Stroke

Wearable grip sensing shows potential for hand rehabilitation, but few studies have studied feasibility early after stroke. Here, we studied a wearable grip sensor integrated with a musical computer game (MusicGlove). Among the stroke patients admitted to a hospital without limiting complications, 13% had adequate hand function for system use. Eleven subjects used MusicGlove at home over three weeks with a goal of nine hours of use. On average they achieved 4.1 ± 3.2 (SD) hours of use and completed 8627 ± 7500 grips, an amount comparable to users in the chronic phase of stroke measured in a previous study. The rank-order usage data were well fit by distributions that arise in machine failure theory. Users operated the game at high success levels, achieving note-hitting success >75% for 84% of the 1061 songs played. They changed game parameters infrequently (31% of songs), but in a way that logically modulated challenge, consistent with the Challenge Point Hypothesis from motor learning. Thus, a therapy based on wearable grip sensing was feasible for home rehabilitation, but only for a fraction of subacute stroke subjects. Subjects made usage decisions consistent with theoretical models of machine failure and motor learning.