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Teasell R, Fleet JL, Harnett A. Post Stroke Exercise Training: Intensity, Dosage, and Timing of Therapy. Phys Med Rehabil Clin N Am 2024; 35:339-351. [PMID: 38514222 DOI: 10.1016/j.pmr.2023.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
More intense, earlier exercise in rehabilitation results in improved motor outcomes following stroke. Timing and intensity of therapy delivery vary from study to study. For more intensive therapies, there are practical challenges in implementation. However, there are also opportunities for high intensity treatment through innovative approaches and new technologies. Timing of rehabilitation is important. As time post stroke increases, the dosage of therapy required to improve motor recovery outcomes increases. Very early rehabilitation may improve motor outcomes but should be delayed for at least 24 hours post stroke.
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Affiliation(s)
- Robert Teasell
- Parkwood Institute Research, Parkwood Institute, D4-101A, 550 Wellington Road, London, Canada; St. Joseph's Health Care London, London, Canada; Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada.
| | - Jamie L Fleet
- Parkwood Institute Research, Parkwood Institute, D4-101A, 550 Wellington Road, London, Canada; St. Joseph's Health Care London, London, Canada; Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Amber Harnett
- Parkwood Institute Research, Parkwood Institute, B3-123, 550 Wellington Road, London, Ontario N6C 0A7, Canada
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Geng H, Li M, Tang J, Lv Q, Li R, Wang L. Early Rehabilitation Exercise after Stroke Improves Neurological Recovery through Enhancing Angiogenesis in Patients and Cerebral Ischemia Rat Model. Int J Mol Sci 2022; 23:ijms231810508. [PMID: 36142421 PMCID: PMC9499642 DOI: 10.3390/ijms231810508] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/03/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Among cerebrovascular diseases, ischemic stroke is a leading cause of mortality and disability. Thrombolytic therapy with tissue plasminogen activator is the first choice for clinical treatment, but its use is limited due to the high requirements of patient characteristics. Therefore, the choice of neurological rehabilitation strategies after stroke is an important prevention and treatment strategy to promote the recovery of neurological function in patients. This study shows that rehabilitation exercise 24 h after stroke can significantly improve the neurological function (6.47 ± 1.589 vs. 3.21 ± 1.069 and 0.76 ± 0.852), exercise ability (15.68 ± 5.95 vs. 162.32 ± 9.286 and 91.18 ± 7.377), daily living ability (23.37 ± 5.196 vs. 66.95 ± 4.707 and 6.55 ± 2.873), and quality of life (114.39 ± 7.772 vs. 168.61 ± 6.323 and 215.95 ± 10.977) of patients after 1 month and 3 months, and its ability to promote rehabilitation is better than that of rehabilitation exercise administered to patients 72 h after stroke (p < 0.001). Animal experiments show that treadmill exercise 24 h after middle cerebral artery occlusion and reperfusion can inhibit neuronal apoptosis, reduce the volume of cerebral infarction on the third (15.04 ± 1.07% vs. 30.67 ± 3.06%) and fifth (8.33 ± 1.53% vs. 30.67 ± 3.06%) days, and promote the recovery of neurological function on the third (7.22 ± 1.478 vs. 8.28 ± 1.018) and fifth (4.44 ± 0.784 vs. 6.00 ± 0.767) days. Mechanistic studies have shown that treadmill exercise increases the density of microvessels, regulates angiogenesis, and promotes the recovery of nerve function by upregulating the expression of vascular endothelial growth factor and laminin. This study shows that rehabilitation exercise 24 h after stroke is conducive to promoting the recovery of patients’ neurological function, and provides a scientific reference for the clinical rehabilitation of stroke patients.
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Affiliation(s)
- Huixia Geng
- Institute of Chronic Disease Risks Assessment, School of Nursing and Health Sciences, Henan University, Kaifeng 475004, China
| | - Min Li
- Institute of Chronic Disease Risks Assessment, School of Nursing and Health Sciences, Henan University, Kaifeng 475004, China
| | - Jing Tang
- The School of Life Sciences, Henan University, Kaifeng 475000, China
| | - Qing Lv
- Institute of Chronic Disease Risks Assessment, School of Nursing and Health Sciences, Henan University, Kaifeng 475004, China
| | - Ruiling Li
- Institute of Chronic Disease Risks Assessment, School of Nursing and Health Sciences, Henan University, Kaifeng 475004, China
- Correspondence: (R.L.); (L.W.); Tel.: +86-371-2388-7799 (R.L. & L.W.)
| | - Lai Wang
- Institute of Chronic Disease Risks Assessment, School of Nursing and Health Sciences, Henan University, Kaifeng 475004, China
- The School of Life Sciences, Henan University, Kaifeng 475000, China
- Correspondence: (R.L.); (L.W.); Tel.: +86-371-2388-7799 (R.L. & L.W.)
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Nishikawa Y, Hirata K, Ito Y, Ueda K, Kimura H. Effects of assigning physical therapists exclusively to the acute-phase stroke patient ward. J Phys Ther Sci 2022; 34:225-229. [PMID: 35291468 PMCID: PMC8918102 DOI: 10.1589/jpts.34.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/20/2021] [Indexed: 11/24/2022] Open
Abstract
[Purpose] In April 2014, an additional health insurance system aiming to maintain or
improve activities of daily living levels was newly established by the Japanese
government. The purpose of this study was to determine the influence of this new medical
system for rehabilitation on patient management (e.g., activities of daily living level
and length of hospital stay) in an acute-phase stroke patient ward. [Participants and
Methods] All patients were admitted to the stroke patient ward in our hospital and were
registered between January 2012 and December 2019. We assessed the differences in the time
to initiation of rehabilitation, length of hospitalization, implementation rate of
rehabilitation, and Barthel Index between the period before the start of the new medical
system (Prior period) and after this system was started (Post period). [Results]
Significant improvements were observed in the initiation of rehabilitation and the
difference in the Barthel Index scores after the start of the new medical system. Although
the length of hospitalization and implementation rate of rehabilitation did not differ
significantly, both indicators gradually improved after the start of the new system.
[Conclusion] Our results suggest that the new medical system for rehabilitation is
beneficial for patient management in the acute-phase stroke patient ward.
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Affiliation(s)
- Yuichi Nishikawa
- Faculty of Frontier Engineering, Institute of Science & Engineering, Kanazawa University: Kakuma-machi, Kanazawa, Ishikawa 920-1192, Japan
| | - Kazuhiko Hirata
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Japan
| | - Yoshihiro Ito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Japan
| | - Kazuyuki Ueda
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Japan
| | - Hiroaki Kimura
- Department of Rehabilitation Medicine, Hiroshima University Hospital, Japan
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Effects of exercise timing and intensity on neuroplasticity in a rat model of cerebral infarction. Brain Res Bull 2020; 160:50-55. [PMID: 32305405 DOI: 10.1016/j.brainresbull.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 12/11/2022]
Abstract
Exercise therapy plays key roles in functional improvements during neurorehabilitation. However, it may be difficult for some people to properly perform exercise because mobility and endurance might be restricted by neurological deficits due to stroke. Additionally, there is little evidence detailing the biological mechanisms underlying the most effective swimming exercise protocols for neuroplasticity after stroke. Thus, the present study investigated the effects of swimming exercise on neuroplasticity in a cerebral infarction rat model according to the timing and intensity of exercise. A total of 45 male Sprague-Dawley rats (300 ± 50 g, 10 weeks old) were subjected to photothrombotic cerebral infarction and randomly divided into five groups: non-exercise (group A, n = 9); early submaximal (group B, n = 9); early maximal (group C, n = 9); late submaximal (group D, n = 9); and late maximal (group E, n = 9). Swimming exercise was performed five times a week for 4 weeks, and cognition was evaluated with the Morris water maze (MWM) test. Assessments of superoxide dismutase (SOD) activity and malondialdehyde (MDA) levels and immunohistochemical analyses of brain-derived neurotrophic factor (BDNF) were conducted in the ipsilesional hippocampus region. After 4 weeks of exercise, the escape latency was shorter and velocity was greater in group B than in groups A, C, D, and E (p = 0.046, p < 0.001, respectively). Furthermore, SOD activity was higher and MDA levels were lower in group B than in groups A, C, D, and E (p = 0.004, p = 0.019). The immunohistochemistry results revealed that the greatest BDNF immunoreactivity was in group B. Taken together, these results indicate that early submaximal swimming exercise may be the most effective protocol for the recovery of neurological deficits in a rat model of cerebral infarction.
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Mobilization for Persons With Acute Stroke: A Survey of Current Physical Therapy Clinical Practice. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2020. [DOI: 10.1097/jat.0000000000000116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Salcı Y, Balkan AF, Ceren AN, Karanfil E, Çetin B, Cengiz MS, Uca AU, Armutlu K. İnme Sonrası Erken Mobilizasyon Hakkında Profesyonel Görüşlerin İncelenmesi. DICLE MEDICAL JOURNAL 2019. [DOI: 10.5798/dicletip.540016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pournajaf S, Goffredo M, Agosti M, Massucci M, Ferro S, Franceschini M. Community ambulation of stroke survivors at 6 months follow-up: an observational study on sociodemographic and sub-acute clinical indicators. Eur J Phys Rehabil Med 2018; 55:433-441. [PMID: 30543267 DOI: 10.23736/s1973-9087.18.05489-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Despite the importance of walking recovery in real life contexts, only 7% of stroke survivors at discharge from neuro-rehabilitation units recover independent walking in the community. However, studies on outcome indicators of walking ability restoration following stroke rarely regard the community ambulation. AIM The aim of the study is to investigate how sociodemographic and sub-acute clinical characteristics of stroke survivors at admission and at discharge may predict a good participation in community walking activity 6 months post-stroke. DESIGN Retrospective observational study. SETTING Inpatient neuro-rehabilitation centers. POPULATION Three-hundred-ten stroke survivors. METHODS A secondary analysis were performed on collected sociodemographic and clinical data of subjects after first-ever stroke within 72 hours of admission to acute care facilities (T1), at discharge (T2), and subsequently after 6-months post-stroke (T3). The regression analysis between every independent variable at T1 and T2 and Walking Handicap Scale-WHS (negative: 1-3; positive: 4-6) assessed at T3 were performed to identify the most important early predictors. RESULTS At T1, being younger, having a good ability to walk, early mobilization out of bed, not having TACI, and being female are significant positive indicators while, clinical complications are significantly negative for a WHS:4-6 at T3. No correlation was found between WHS and gender, etiology, the side of lesion, the presence of aphasia, and the presence of risk factors. The combination of risk factors indicates a negative WHS at T3. CONCLUSIONS The presence of risk factors and clinical complications delay significantly the walking ability restoration and return to social life. Such status consistently with the patient's compliance must not postpone the rehabilitation relatively, rehabilitation must be facilitated with targeted programs taking care particularly of people with negative indicators for recovery of community ambulation 6 months post-stroke. CLINICAL REHABILITATION IMPACT Early indicators are considerable in order to predict a targeted prognosis and better provide a tailored rehabilitation program.
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Affiliation(s)
- Sanaz Pournajaf
- Department of Neurorehabilitation, San Raffaele Pisana Institute of Research and Care, Rome, Italy -
| | - Michela Goffredo
- Department of Neurorehabilitation, San Raffaele Pisana Institute of Research and Care, Rome, Italy
| | - Maurizio Agosti
- Department of Rehabilitation, Parma University Hospital, Parma, Italy
| | - Maurizio Massucci
- Unit of Rehabilitation, Passignano sul Trasimeno Hospital, Perugia, Italy
| | | | - Marco Franceschini
- Department of Neurorehabilitation, San Raffaele Pisana Institute of Research and Care, Rome, Italy.,San Raffaele University, Rome, Italy
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Langhorne P, Collier JM, Bate PJ, Thuy MNT, Bernhardt J. Very early versus delayed mobilisation after stroke. Cochrane Database Syst Rev 2018; 10:CD006187. [PMID: 30321906 PMCID: PMC6517132 DOI: 10.1002/14651858.cd006187.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Very early mobilisation (VEM) is performed in some stroke units and recommended in some acute stroke clinical guidelines. However, it is unclear whether very early mobilisation independently improves outcome after stroke. OBJECTIVES To determine whether very early mobilisation (started as soon as possible, and no later than 48 hours after onset of symptoms) in people with acute stroke improves recovery (primarily the proportion of independent survivors) compared with usual care. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched 31 July 2017). We also systematically searched 19 electronic databases including; CENTRAL; 2017, Issue 7 in the Cochrane Library (searched July 2017), MEDLINE Ovid (1950 to August 2017), Embase Ovid (1980 to August 2017), CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to August 2017) , PsycINFO Ovid (1806 to August 2017), AMED Ovid (Allied and Complementary Medicine Database), SPORTDiscus EBSCO (1830 to August 2017). We searched relevant ongoing trials and research registers (searched December 2016), the Chinese medical database, Wanfangdata (searched to November 2016), and reference lists, and contacted researchers in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) of people with acute stroke, comparing an intervention group that started out-of-bed mobilisation within 48 hours of stroke, and aimed to reduce time-to-first mobilisation, with or without an increase in the amount or frequency (or both) of mobilisation activities, with usual care, where time-to-first mobilisation was commenced later. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted data, assessed risk of bias, and applied the GRADE approach to assess the quality of the evidence. The primary outcome was death or poor outcome (dependency or institutionalisation) at the end of scheduled follow-up. Secondary outcomes included death, dependency, institutionalisation, activities of daily living (ADL), extended ADL, quality of life, walking ability, complications (e.g. deep vein thrombosis), patient mood, and length of hospital stay. We also analysed outcomes at three-month follow-up. MAIN RESULTS We included nine RCTs with 2958 participants; one trial provided most of the information (2104 participants). The median (range) delay to starting mobilisation after stroke onset was 18.5 (13.1 to 43) hours in the VEM group and 33.3 (22.5 to 71.5) hours in the usual care group. The median difference within trials was 12.7 (4 to 45.6) hours. Other differences in intervention varied between trials; in five trials, the VEM group were also reported to have received more time in therapy, or more mobilisation activity.Primary outcome data were available for 2542 of 2618 (97.1%) participants randomized and followed up for a median of three months. VEM probably led to similar or slightly more deaths and participants who had a poor outcome, compared with delayed mobilisation (51% versus 49%; odds ratio (OR) 1.08, 95% confidence interval (CI) 0.92 to 1.26; P = 0.36; 8 trials; moderate-quality evidence). Death occurred in 7% of participants who received delayed mobilisation, and 8.5% of participants who received VEM (OR 1.27, 95% CI 0.95 to 1.70; P = 0.11; 8 trials, 2570 participants; moderate-quality evidence), and the effects on experiencing any complication were unclear (OR 0.88; 95% CI 0.73 to 1.06; P = 0.18; 7 trials, 2778 participants; low-quality evidence). Analysis using outcomes collected only at three-month follow-up did not alter the conclusions.The mean ADL score (measured at end of follow-up, with the 20-point Barthel Index) was higher in those who received VEM compared with the usual care group (mean difference (MD) 1.94, 95% CI 0.75 to 3.13, P = 0.001; 8 trials, 9 comparisons, 2630/2904 participants (90.6%); low-quality evidence), but there was substantial heterogeneity (93%). Effect sizes were smaller for outcomes collected at three-month follow-up, rather than later.The mean length of stay was shorter in those who received VEM compared with the usual care group (MD -1.44, 95% CI -2.28 to -0.60, P = 0.0008; 8 trials, 2532/2618 participants (96.7%); low-quality evidence). Confidence in the answer was limited by the variable definitions of length of stay. The other secondary outcome analyses (institutionalisation, extended activities of daily living, quality of life, walking ability, patient mood) were limited by lack of data.Sensitivity analyses by trial quality: none of the outcome conclusions were altered if we restricted analyses to trials with the lowest risk of bias (based on method of randomization, allocation concealment, completeness of follow-up, and blinding of final assessment), or information about the amount of mobilisation.Sensitivity analysis by intervention characteristics: analyses restricted to trials where the mean VEM time-to-first mobilisation was less than 24 hours, showed an odds of death of 1.35 (95% CI 0.99 to 1.83; P = 0.06; I² = 25%; 5 trials). Analyses restricted to the trials that clearly reported a more prolonged out-of-bed activity showed a similar primary outcome (OR 1.14; 0.96 to 1.35; P = 0.13; I² = 28%; 5 trials), and odds of death (OR 1.27; 0.93 to 1.73; P = 0.13; I² = 0%; 4 trials) to the main analysis.Exploratory network meta-analysis (NMA): we were unable to analyze by the amount of therapy, but low-quality evidence indicated that time-to-first mobilisation at around 24 hours was associated with the lowest odds of death or poor outcome, compared with earlier or later mobilisation. AUTHORS' CONCLUSIONS VEM, which usually involved first mobilisation within 24 hours of stroke onset, did not increase the number of people who survived or made a good recovery after their stroke. VEM may have reduced the length of stay in hospital by about one day, but this was based on low-quality evidence. Based on the potential hazards reported in the single largest RCT, the sensitivity analysis of trials commencing mobilisation within 24 hours, and the NMA, there was concern that VEM commencing within 24 hours may carry an increased risk, at least in some people with stroke. Given the uncertainty around these effect estimates, more detailed research is still required.
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Affiliation(s)
- Peter Langhorne
- ICAMS, University of GlasgowAcademic Section of Geriatric MedicineLevel 2, New Lister BuildingGlasgow Royal InfirmaryGlasgowUKG31 2ER
| | - Janice M Collier
- National Stroke Research InstituteVery Early Rehabilitation Stroke Research ProgramLevel 1, Neurosciences BuildingARMC Repat Campus, 300 Waterdale RoadHeidelberg HeightsVictoriaAustralia3081
| | | | - Matthew NT Thuy
- Austin HealthNational Stroke Research InstituteLevel 1, Neurosciences BuildingAustin Health, Repatriation Campus, 300 Waterdale RdHeidelberg HeightsVictoriaAustralia3081
| | - Julie Bernhardt
- Florey Institute of Neuroscience and Mental Health245 Burgundy StreetHeidelbergVictoriaAustralia3081
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Langhorne P, Wu O, Rodgers H, Ashburn A, Bernhardt J. A Very Early Rehabilitation Trial after stroke (AVERT): a Phase III, multicentre, randomised controlled trial. Health Technol Assess 2018; 21:1-120. [PMID: 28967376 DOI: 10.3310/hta21540] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Mobilising patients early after stroke [early mobilisation (EM)] is thought to contribute to the beneficial effects of stroke unit care but it is poorly defined and lacks direct evidence of benefit. OBJECTIVES We assessed the effectiveness of frequent higher dose very early mobilisation (VEM) after stroke. DESIGN We conducted a parallel-group, single-blind, prospective randomised controlled trial with blinded end-point assessment using a web-based computer-generated stratified randomisation. SETTING The trial took place in 56 acute stroke units in five countries. PARTICIPANTS We included adult patients with a first or recurrent stroke who met physiological inclusion criteria. INTERVENTIONS Patients received either usual stroke unit care (UC) or UC plus VEM commencing within 24 hours of stroke. MAIN OUTCOME MEASURES The primary outcome was good recovery [modified Rankin scale (mRS) score of 0-2] 3 months after stroke. Secondary outcomes at 3 months were the mRS, time to achieve walking 50 m, serious adverse events, quality of life (QoL) and costs at 12 months. Tertiary outcomes included a dose-response analysis. DATA SOURCES Patients, outcome assessors and investigators involved in the trial were blinded to treatment allocation. RESULTS We recruited 2104 (UK, n = 610; Australasia, n = 1494) patients: 1054 allocated to VEM and 1050 to UC. Intervention protocol targets were achieved. Compared with UC, VEM patients mobilised 4.8 hours [95% confidence interval (CI) 4.1 to 5.7 hours; p < 0.0001] earlier, with an additional three (95% CI 3.0 to 3.5; p < 0.0001) mobilisation sessions per day. Fewer patients in the VEM group (n = 480, 46%) had a favourable outcome than in the UC group (n = 525, 50%) (adjusted odds ratio 0.73, 95% CI 0.59 to 0.90; p = 0.004). Results were consistent between Australasian and UK settings. There were no statistically significant differences in secondary outcomes at 3 months and QoL at 12 months. Dose-response analysis found a consistent pattern of an improved odds of efficacy and safety outcomes in association with increased daily frequency of out-of-bed sessions but a reduced odds with an increased amount of mobilisation (minutes per day). LIMITATIONS UC clinicians started mobilisation earlier each year altering the context of the trial. Other potential confounding factors included staff patient interaction. CONCLUSIONS Patients in the VEM group were mobilised earlier and with a higher dose of therapy than those in the UC group, which was already early. This VEM protocol was associated with reduced odds of favourable outcome at 3 months cautioning against very early high-dose mobilisation. At 12 months, health-related QoL was similar regardless of group. Shorter, more frequent mobilisation early after stroke may be associated with a more favourable outcome. FUTURE WORK These results informed a new trial proposal [A Very Early Rehabilitation Trial - DOSE (AVERT-DOSE)] aiming to determine the optimal frequency and dose of EM. TRIAL REGISTRATION The trial is registered with the Australian New Zealand Clinical Trials Registry number ACTRN12606000185561, Current Controlled Trials ISRCTN98129255 and ISRCTN98129255. 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. 21, No. 54. See the NIHR Journals Library website for further project information. Funding was also received from the National Health and Medical Research Council Australia, Singapore Health, Chest Heart and Stroke Scotland, Northern Ireland Chest Heart and Stroke, and the Stroke Association. In addition, National Health and Medical Research Council fellowship funding was provided to Julie Bernhardt (1058635), who also received fellowship funding from the Australia Research Council (0991086) and the National Heart Foundation (G04M1571). The Florey Institute of Neuroscience and Mental Health, which hosted the trial, acknowledges the support received from the Victorian Government via the Operational Infrastructure Support Scheme.
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Affiliation(s)
- Peter Langhorne
- Academic Section of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Helen Rodgers
- Institute for Ageing and Health, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Ashburn
- Rehabilitation Research Unit, Southampton General Hospital, Southampton, UK
| | - Julie Bernhardt
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia.,University of Melbourne, Parkville, VIC, Australia
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Fuhs AK, LaGrone LN, Moscoso Porras MG, Rodríguez Castro MJ, Ecos Quispe RL, Mock CN. Assessment of Rehabilitation Infrastructure in Peru. Arch Phys Med Rehabil 2018; 99:1116-1123. [PMID: 29162468 PMCID: PMC5962371 DOI: 10.1016/j.apmr.2017.10.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 10/19/2017] [Accepted: 10/21/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess rehabilitation infrastructure in Peru in terms of the World Health Organization (WHO) health systems building blocks. DESIGN Anonymous quantitative survey; questions were based on the WHO's Guidelines for Essential Trauma Care and rehabilitation professionals' input. SETTING Large public hospitals and referral centers and an online survey platform. PARTICIPANTS Convenience sample of hospital personnel working in rehabilitation and neurology (N=239), recruited through existing contacts and professional societies. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Outcome measures were for 4 WHO domains: health workforce, health service delivery, essential medical products and technologies, and health information systems. RESULTS Regarding the domain of health workforce, 47% of physical therapists, 50% of occupational therapists, and 22% of physiatrists never see inpatients. Few reported rehabilitative nurses (15%) or prosthetist/orthotists (14%) at their hospitals. Even at the largest hospitals, most reported ≤3 occupational therapists (54%) and speech-language pathologists (70%). At hospitals without speech-language pathologists, physical therapists (49%) or nobody (34%) perform speech-language pathology roles. At hospitals without occupational therapists, physical therapists most commonly (59%) perform occupational therapy tasks. Alternate prosthetist/orthotist task performers are occupational therapists (26%), physical therapists (19%), and physicians (16%). Forty-four percent reported interdisciplinary collaboration. Regarding the domain of health services, the most frequent inpatient and outpatient rehabilitation barriers were referral delays (50%) and distance/transportation (39%), respectively. Regarding the domain of health information systems, 28% reported rehabilitation service data collection. Regarding the domain of essential medical products and technologies, electrophysical agents (88%), gyms (81%), and electromyography (76%) were most common; thickened liquids (19%), swallow studies (24%), and cognitive training tools (28%) were least frequent. CONCLUSIONS Rehabilitation emphasis is on outpatient services, and there are comparatively adequate numbers of physical therapists and physiatrists relative to rehabilitation personnel. Financial barriers seem low for accessing existing services. There appear to be shortages of inpatient rehabilitation, specialized services, and interdisciplinary collaboration. These may be addressed by redistributing personnel and investing in education and equipment for specialized services. Further examination of task sharing's role in Peru's rehabilitation services is necessary to evaluate its potential to address deficiencies.
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Affiliation(s)
| | | | - Miguel G Moscoso Porras
- School of Physical Therapy, Peruvian University of Applied Sciences, Lima, Peru; Association for the Development of Student Research in Health Sciences, San Marcos Major National University, Lima, Peru
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Li Z, Zhang X, Wang K, Wen J. Effects of Early Mobilization after Acute Stroke: A Meta-Analysis of Randomized Control Trials. J Stroke Cerebrovasc Dis 2018; 27:1326-1337. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.12.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/02/2017] [Accepted: 12/17/2017] [Indexed: 02/01/2023] Open
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Di Carlo A, Lamassa M, Franceschini M, Bovis F, Cecconi L, Pournajaf S, Paravati S, Biggeri A, Inzitari D, Ferro S. Impact of acute-phase complications and interventions on 6-month survival after stroke. A prospective observational study. PLoS One 2018; 13:e0194786. [PMID: 29570742 PMCID: PMC5865737 DOI: 10.1371/journal.pone.0194786] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 03/10/2018] [Indexed: 11/25/2022] Open
Abstract
The outcome of stroke patients is complex and multidimensional. We evaluated the impact of acute-phase variables, including clinical state, complications, resource use and interventions, on 6-month survival after first-ever stroke, taking into account baseline conditions exerting a possible effect on outcome. As part of a National Research Program, we performed a prospective observational study of acute stroke patients in four Italian Regions. Consecutive patients admitted for a period of 3 months to the emergency rooms of participating hospitals were included. A total of 1030 patients were enrolled (median age 76.0 years, 52.1% males). At 6 months, 816 (79.2%) were alive, and 164 (15.9%) deceased. Survival status at the 6-month follow-up was missing for 50 (4.9%). Neurological state in the acute phase was significantly worse in patients deceased at 6 months, who showed also higher frequency of acute-phase complications. Cox regression analysis adjusted for demographics, pre-stroke function, baseline diseases and risk factors, indicated as significant predictors of 6-month death altered consciousness (HR, 1.70; 95% CI, 1.14–2.53), total anterior circulation infarct (HR, 2.13; 95% CI, 1.44–3.15), hyperthermia (HR, 1.70; 95% CI, 1.18–2.45), pneumonia (HR, 1.76; 95% CI, 1.18–2.61), heart failure (HR, 2.87; 95% CI, 1.34–6.13) and nasogastric feeding (HR, 2.35; 95% CI, 1.53–3.60), while antiplatelet therapy during acute phase (HR, 0.56; 95% CI, 0.39–0.79), and early mobilisation (HR, 0.55; 95% CI, 0.36–0.84) significantly increased 6-month survival. In a prospective observational study, stroke severity and some acute-phase complications, potentially modifiable, significantly increased the risk of 6-month death, independently of baseline variables. Early mobilisation positively affected survival, highlighting the role of early rehabilitation after stroke.
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Affiliation(s)
- Antonio Di Carlo
- Institute of Neuroscience, Italian National Research Council, Florence, Italy
- * E-mail:
| | - Maria Lamassa
- Department of NEUROFARBA, Neuroscience Section, University of Florence, Florence, Italy
| | - Marco Franceschini
- IRCCS San Raffaele Pisana, Rome, Italy
- San Raffaele University, Rome, Italy
| | - Francesca Bovis
- Department of NEUROFARBA, Neuroscience Section, University of Florence, Florence, Italy
- Biostatistics Unit, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | | | | | | | | | - Domenico Inzitari
- Institute of Neuroscience, Italian National Research Council, Florence, Italy
- Department of NEUROFARBA, Neuroscience Section, University of Florence, Florence, Italy
| | - Salvatore Ferro
- Department of Hospital Services, Emilia-Romagna Region Health Authority, Bologna, Italy
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13
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Xu T, Yu X, Ou S, Liu X, Yuan J, Chen Y. Efficacy and Safety of Very Early Mobilization in Patients with Acute Stroke: A Systematic Review and Meta-analysis. Sci Rep 2017; 7:6550. [PMID: 28747763 PMCID: PMC5529532 DOI: 10.1038/s41598-017-06871-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 06/20/2017] [Indexed: 01/20/2023] Open
Abstract
Whether very early mobilization (VEM) improves outcomes in stroke patients and reduces immobilization-related complications (IRCs) is currently unknown. The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of VEM in acute stroke patients following admission. Medline, Embase, and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) that examined the efficacy or safety of VEM in patients with acute stroke. VEM was defined as out of bed activity commencing within 24 or 48 hours after the onset of stroke. A total of 9 RCTs with 2,803 participants were included. Upon analysis, VEM was not associated with favorable functional outcomes (modified Ranking Scale: 0–2) at 3 months [relative risk (RR): 0.96; 95% confidence interval (CI): 0.86–1.06]; VEM did not reduce the risk of IRCs during follow up. With respect to safety outcomes, VEM was not associated with a higher risk of death (RR: 1.04; 95% CI: 0.52–2.09) and did not increase the risk of neurological deterioration or incidence of falls with injury. In conclusion, pooled data from RCTs concluded that VEM is not associated with beneficial effects when carried out in patients 24 or 48 hours after the onset of a stroke.
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Affiliation(s)
- Tao Xu
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Xinyuan Yu
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Shu Ou
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Xi Liu
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Jinxian Yuan
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Yangmei Chen
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China.
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Effects of task-specific rehabilitation training on tau modification in rat with photothrombotic cortical ischemic damage. Neurochem Int 2017; 108:309-317. [PMID: 28499951 DOI: 10.1016/j.neuint.2017.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/02/2017] [Accepted: 05/08/2017] [Indexed: 01/05/2023]
Abstract
Although stroke elicits progressive cognitive decline and is a leading cause of dementia, molecular interplay between stroke and Alzheimer's disease (AD) pathology has not been fully elucidated. Furthermore, studies on the effects of post-stroke rehabilitation on AD pathology are limited. We evaluated the acute effect of stroke on tau modification, and the molecular effects of task-specific training (TST) on tau modification using a model of photochemically-induced thrombosis (PIT)-induced cortical infarction. Following PIT in the dominant side of sensorimotor cortex, the rehabilitation group received 4-weeks of TST rehabilitation once daily by single pellet reaching training, whereas the sedentary control group did not received any type of training. Cortical expression levels of proteins related to tau modification were evaluated on post-stroke day 1 (PSD1) and 28; functional tests were also evaluated performed every week. The expression levels of acetyl-tau, phosphorylated-tau (p-tau), cyclooxygenase-2 and Akt-mTORC1-p70S6K pathway in infarcted cortices on PSD1 were significantly greater, whereas the expression levels of p-AMPK were significantly lower than in the paired contralateral sides. TST rehabilitation for 4 weeks greatly improved functional motor performance but not memory, which concurred with the down-regulations of ipsilateral p-AMPK, cyclooxygenase-2, Akt-mTORC1-p70S6K pathway, and p-tau in rehabilitation group. PIT-induced cortical infarction was found to induce cortical tau modification through the Akt-mTORC1-p70S6K activation, and to suppress the expression of AMPK-related proteins. TST rehabilitation greatly improved motor function, but not memory, and suppressed p-tau expression and neuroinflammation. Nevertheless, the role of TST-mediated regulation of tau hyperphosphorylation required further clarification.
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Imura T, Nagasawa Y, Fukuyama H, Imada N, Oki S, Araki O. Effect of early and intensive rehabilitation in acute stroke patients: retrospective pre-/post-comparison in Japanese hospital. Disabil Rehabil 2017; 40:1452-1455. [DOI: 10.1080/09638288.2017.1300337] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Takeshi Imura
- Department of Rehabilitation, Araki Neurosurgical Hospital, Japan, Hiroshima
| | - Yuki Nagasawa
- Department of Rehabilitation, Araki Neurosurgical Hospital, Japan, Hiroshima
| | - Hiroki Fukuyama
- Department of Rehabilitation, Araki Neurosurgical Hospital, Japan, Hiroshima
| | - Naoki Imada
- Department of Rehabilitation, Araki Neurosurgical Hospital, Japan, Hiroshima
| | - Shuichi Oki
- Department of Neurosurgery, Araki Neurosurgical Hospital, Hiroshima, Japan
| | - Osamu Araki
- Department of Neurosurgery, Araki Neurosurgical Hospital, Hiroshima, Japan
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Kim DY, Kim YH, Lee J, Chang WH, Kim MW, Pyun SB, Yoo WK, Ohn SH, Park KD, Oh BM, Lim SH, Jung KJ, Ryu BJ, Im S, Jee SJ, Seo HG, Rah UW, Park JH, Sohn MK, Chun MH, Shin HS, Lee SJ, Lee YS, Park SW, Park YG, Paik NJ, Lee SG, Lee JK, Koh SE, Kim DK, Park GY, Shin YI, Ko MH, Kim YW, Yoo SD, Kim EJ, Oh MK, Chang JH, Jung SH, Kim TW, Kim WS, Kim DH, Park TH, Lee KS, Hwang BY, Song YJ. Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016. BRAIN & NEUROREHABILITATION 2017. [DOI: 10.12786/bn.2017.10.e11] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Deog Young Kim
- Department of Rehabilitation Medicine, Yonsei University College of Medicine, Korea
| | - Yun-Hee Kim
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea
| | - Jongmin Lee
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea
| | - Min-Wook Kim
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Sung-Bom Pyun
- Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Korea
| | - Woo-Kyoung Yoo
- Department of Physical Medicine and Rehabilitation, Hallym University College of Medicine, Korea
| | - Suk Hoon Ohn
- Department of Physical Medicine and Rehabilitation, Hallym University College of Medicine, Korea
| | - Ki Deok Park
- Department of Rehabilitation Medicine, Gachon University College of Medicine, Korea
| | - Byung-Mo Oh
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Seong Hoon Lim
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Kang Jae Jung
- Department of Physical Medicine and Rehabilitation, Eulji University Hospital & Eulji University School of Medicine, Korea
| | - Byung-Ju Ryu
- Department of Physical Medicine and Rehabilitation, Sahmyook Medical Center, Korea
| | - Sun Im
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Sung Ju Jee
- Department of Rehabilitation Medicine, Chungnam National University College of Medicine, Korea
| | - Han Gil Seo
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Ueon Woo Rah
- Department of Physical Medicine and Rehabilitation, Ajou University School of Medicine, Korea
| | - Joo Hyun Park
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Min Kyun Sohn
- Department of Rehabilitation Medicine, Chungnam National University College of Medicine, Korea
| | - Min Ho Chun
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Hee Suk Shin
- Department of Rehabilitation Medicine and Institute of Health Sciences, Gyeongsang National University College of Medicine, Korea
| | - Seong Jae Lee
- Department of Rehabilitation Medicine, College of Medicine Dankook University, Korea
| | - Yang-Soo Lee
- Department of Rehabilitation Medicine, Kyungpook National University School of Medicine, Korea
| | - Si-Woon Park
- Department of Rehabilitation Medicine, Catholic Kwandong University International St Mary's Hospital, Korea
| | - Yoon Ghil Park
- Department of Rehabilitation Medicine, Yonsei University College of Medicine, Korea
| | - Nam Jong Paik
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Sam-Gyu Lee
- Department of Physical and Rehabilitation Medicine, Chonnam National University Medical School, Korea
| | - Ju Kang Lee
- Department of Rehabilitation Medicine, Gachon University College of Medicine, Korea
| | - Seong-Eun Koh
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Korea
| | - Don-Kyu Kim
- Department of Physical Medicine and Rehabilitation, College of Medicine, Chung-Ang University, Korea
| | - Geun-Young Park
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
| | - Yong Il Shin
- Department of Rehabilitation Medicine, Pusan National University Hospital, Korea
| | - Myoung-Hwan Ko
- Department of Physical Medicine and Rehabilitation, Chonbuk National University Medical School, Korea
| | - Yong Wook Kim
- Department of Rehabilitation Medicine, Yonsei University College of Medicine, Korea
| | - Seung Don Yoo
- Department of Physical Medicine and Rehabilitation, Kyung Hee University College of Medicine, Korea
| | - Eun Joo Kim
- Department of Physical Medicine and Rehabilitation, National Rehabilitation Hospital, Korea
| | - Min-Kyun Oh
- Department of Rehabilitation Medicine and Institute of Health Sciences, Gyeongsang National University College of Medicine, Korea
| | - Jae Hyeok Chang
- Department of Rehabilitation Medicine, Pusan National University Hospital, Korea
| | - Se Hee Jung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Tae-Woo Kim
- TBI rehabilitation center, National Traffic Injury Rehabilitation Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Won-Seok Kim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Korea
| | - Dae Hyun Kim
- Department of Physical Medicine and Rehabilitation, Veterans Health Service Medical Center, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Korea
| | - Kwan-Sung Lee
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Byong-Yong Hwang
- Department of Physical Therapy, Yong-In University College of Health & Welfare, Korea
| | - Young Jin Song
- Department of Rehabilitation Medicine, Asan Medical Center, Korea
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17
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Sisante JFV, Abraham MG, Phadnis MA, Billinger SA, Mittal MK. Ambulatory Status Protects against Venous Thromboembolism in Acute Mild Ischemic Stroke Patients. J Stroke Cerebrovasc Dis 2016; 25:2496-501. [PMID: 27423367 DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 05/18/2016] [Accepted: 06/17/2016] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Ischemic stroke patients are at high risk (up to 18%) for venous thromboembolism. We conducted a retrospective cross-sectional study to understand the predictors of acute postmild ischemic stroke patient's ambulatory status and its relationship with venous thromboembolism, hospital length of stay, and in-hospital mortality. METHODS We identified 522 patients between February 2006 and May 2014 and collected data about patient demographics, admission NIHSS (National Institutes of Health Stroke Scale), venous thromboembolism prophylaxis, ambulatory status, diagnosis of venous thromboembolism, and hospital outcomes (length of stay, mortality). Chi-square test, t-test and Wilcoxon rank-sum test, and binary logistic regression were used for statistical analysis as appropriate. RESULTS A total of 61 (11.7%), 48 (9.2%), and 23 (4.4%) mild ischemic stroke patients developed venous thromboembolism, deep venous thrombosis, and pulmonary embolism, respectively. During hospitalization, 281 (53.8%) patients were ambulatory. Independent predictors of in-hospital ambulation were being married (OR 1.64, 95% CI 1.10-2.49), being nonreligious (OR 2.19, 95% CI 1.34-3.62), admission NIHSS (per unit decrease in NIHSS; OR 1.62, 95% CI 1.39-1.91), and nonuse of mechanical venous thromboembolism prophylaxis (OR 1.62, 95% CI 1.02-2.61). After adjusting for confounders, ambulatory patients had lower rates of venous thromboembolism (OR .47, 95% CI .25-.89), deep venous thrombosis (OR .36, 95% CI .17-.73), prolonged length of hospital stay (OR .24, 95% CI .16-.37), and mortality (OR .43, 95% CI .21-.84). CONCLUSIONS Our findings suggest that for hospitalized acute mild ischemic stroke patients, ambulatory status is an independent predictor of venous thromboembolism (specifically deep venous thrombosis), hospital length of stay, and in-hospital mortality.
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Affiliation(s)
- Jason-Flor V Sisante
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, Kansas
| | - Michael G Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas; Department of Radiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Milind A Phadnis
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, Kansas
| | - Sandra A Billinger
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, Kansas
| | - Manoj K Mittal
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas.
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Bernhardt J, Churilov L, Ellery F, Collier J, Chamberlain J, Langhorne P, Lindley RI, Moodie M, Dewey H, Thrift AG, Donnan G. Prespecified dose-response analysis for A Very Early Rehabilitation Trial (AVERT). Neurology 2016; 86:2138-45. [PMID: 26888985 PMCID: PMC4898313 DOI: 10.1212/wnl.0000000000002459] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 01/12/2016] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Our prespecified dose-response analyses of A Very Early Rehabilitation Trial (AVERT) aim to provide practical guidance for clinicians on the timing, frequency, and amount of mobilization following acute stroke. METHODS Eligible patients were aged ≥18 years, had confirmed first (or recurrent) stroke, and were admitted to a stroke unit within 24 hours of stroke onset. Patients were randomized to receive very early and frequent mobilization, commencing within 24 hours, or usual care. We used regression analyses and Classification and Regression Trees (CART) to investigate the effect of timing and dose of mobilization on efficacy and safety outcomes, irrespective of assigned treatment group. RESULTS A total of 2,104 patients were enrolled, of whom 2,083 (99.0%) were followed up at 3 months. We found a consistent pattern of improved odds of favorable outcome in efficacy and safety outcomes with increased daily frequency of out-of-bed sessions (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.09 to 1.18, p < 0.001), keeping time to first mobilization and mobilization amount constant. Increased amount (minutes per day) of mobilization reduced the odds of a good outcome (OR 0.94, 95% CI 0.91 to 0.97, p < 0.001). Session frequency was the most important variable in the CART analysis, after prognostic variables age and baseline stroke severity. CONCLUSION These data suggest that shorter, more frequent mobilization early after acute stroke is associated with greater odds of favorable outcome at 3 months when controlling for age and stroke severity. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that shorter, more frequent early mobilization improves the chance of regaining independence after stroke.
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Affiliation(s)
- Julie Bernhardt
- From The Florey Institute of Neuroscience and Mental Health (J.B., L.C., F.E., J. Collier, J. Chamberlain, H.D., G.D.), La Trobe University (J.B.), Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; George Institute for Global Health and Westmead Hospital Clinical School (R.I.L.), University of Sydney; Deakin Health Economics (M.M.), Faculty of Health, Deakin University, Burwood; and Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences (H.D.), and Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Clayton, Australia.
| | - Leonid Churilov
- From The Florey Institute of Neuroscience and Mental Health (J.B., L.C., F.E., J. Collier, J. Chamberlain, H.D., G.D.), La Trobe University (J.B.), Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; George Institute for Global Health and Westmead Hospital Clinical School (R.I.L.), University of Sydney; Deakin Health Economics (M.M.), Faculty of Health, Deakin University, Burwood; and Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences (H.D.), and Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Clayton, Australia
| | - Fiona Ellery
- From The Florey Institute of Neuroscience and Mental Health (J.B., L.C., F.E., J. Collier, J. Chamberlain, H.D., G.D.), La Trobe University (J.B.), Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; George Institute for Global Health and Westmead Hospital Clinical School (R.I.L.), University of Sydney; Deakin Health Economics (M.M.), Faculty of Health, Deakin University, Burwood; and Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences (H.D.), and Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Clayton, Australia
| | - Janice Collier
- From The Florey Institute of Neuroscience and Mental Health (J.B., L.C., F.E., J. Collier, J. Chamberlain, H.D., G.D.), La Trobe University (J.B.), Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; George Institute for Global Health and Westmead Hospital Clinical School (R.I.L.), University of Sydney; Deakin Health Economics (M.M.), Faculty of Health, Deakin University, Burwood; and Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences (H.D.), and Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Clayton, Australia
| | - Jan Chamberlain
- From The Florey Institute of Neuroscience and Mental Health (J.B., L.C., F.E., J. Collier, J. Chamberlain, H.D., G.D.), La Trobe University (J.B.), Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; George Institute for Global Health and Westmead Hospital Clinical School (R.I.L.), University of Sydney; Deakin Health Economics (M.M.), Faculty of Health, Deakin University, Burwood; and Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences (H.D.), and Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Clayton, Australia
| | - Peter Langhorne
- From The Florey Institute of Neuroscience and Mental Health (J.B., L.C., F.E., J. Collier, J. Chamberlain, H.D., G.D.), La Trobe University (J.B.), Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; George Institute for Global Health and Westmead Hospital Clinical School (R.I.L.), University of Sydney; Deakin Health Economics (M.M.), Faculty of Health, Deakin University, Burwood; and Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences (H.D.), and Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Clayton, Australia
| | - Richard I Lindley
- From The Florey Institute of Neuroscience and Mental Health (J.B., L.C., F.E., J. Collier, J. Chamberlain, H.D., G.D.), La Trobe University (J.B.), Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; George Institute for Global Health and Westmead Hospital Clinical School (R.I.L.), University of Sydney; Deakin Health Economics (M.M.), Faculty of Health, Deakin University, Burwood; and Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences (H.D.), and Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Clayton, Australia
| | - Marj Moodie
- From The Florey Institute of Neuroscience and Mental Health (J.B., L.C., F.E., J. Collier, J. Chamberlain, H.D., G.D.), La Trobe University (J.B.), Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; George Institute for Global Health and Westmead Hospital Clinical School (R.I.L.), University of Sydney; Deakin Health Economics (M.M.), Faculty of Health, Deakin University, Burwood; and Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences (H.D.), and Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Clayton, Australia
| | - Helen Dewey
- From The Florey Institute of Neuroscience and Mental Health (J.B., L.C., F.E., J. Collier, J. Chamberlain, H.D., G.D.), La Trobe University (J.B.), Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; George Institute for Global Health and Westmead Hospital Clinical School (R.I.L.), University of Sydney; Deakin Health Economics (M.M.), Faculty of Health, Deakin University, Burwood; and Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences (H.D.), and Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Clayton, Australia
| | - Amanda G Thrift
- From The Florey Institute of Neuroscience and Mental Health (J.B., L.C., F.E., J. Collier, J. Chamberlain, H.D., G.D.), La Trobe University (J.B.), Melbourne, Australia; Institute of Cardiovascular and Medical Sciences (P.L.), University of Glasgow, UK; George Institute for Global Health and Westmead Hospital Clinical School (R.I.L.), University of Sydney; Deakin Health Economics (M.M.), Faculty of Health, Deakin University, Burwood; and Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences (H.D.), and Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health (A.G.T.), Monash University, Clayton, Australia
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Saunders DH, Sanderson M, Hayes S, Kilrane M, Greig CA, Brazzelli M, Mead GE. Physical fitness training for stroke patients. Cochrane Database Syst Rev 2016; 3:CD003316. [PMID: 27010219 PMCID: PMC6464717 DOI: 10.1002/14651858.cd003316.pub6] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability. OBJECTIVES To determine whether fitness training after stroke reduces death, dependence, and disability and to assess the effects of training with regard to adverse events, risk factors, physical fitness, mobility, physical function, quality of life, mood, and cognitive function. Interventions to improve cognitive function have attracted increased attention after being identified as the highest rated research priority for life after stroke. Therefore we have added this class of outcomes to this updated review. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 1: searched February 2015), MEDLINE (1966 to February 2015), EMBASE (1980 to February 2015), CINAHL (1982 to February 2015), SPORTDiscus (1949 to February 2015), and five additional databases (February 2015). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field. SELECTION CRITERIA Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses. Diverse outcome measures limited the intended analyses. MAIN RESULTS We included 58 trials, involving 2797 participants, which comprised cardiorespiratory interventions (28 trials, 1408 participants), resistance interventions (13 trials, 432 participants), and mixed training interventions (17 trials, 957 participants). Thirteen deaths occurred before the end of the intervention and a further nine before the end of follow-up. No dependence data were reported. Diverse outcome measures restricted pooling of data. Global indices of disability show moderate improvement after cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) 0.19 to 0.84; P value = 0.002) and by a small amount after mixed training (SMD 0.26, 95% CI 0.04 to 0.49; P value = 0.02); benefits at follow-up (i.e. after training had stopped) were unclear. There were too few data to assess the effects of resistance training.Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 6.71 metres per minute, 95% CI 2.73 to 10.69), preferred gait speed (MD 4.28 metres per minute, 95% CI 1.71 to 6.84), and walking capacity (MD 30.29 metres in six minutes, 95% CI 16.19 to 44.39) at the end of the intervention. Mixed training, involving walking, increased preferred walking speed (MD 4.54 metres per minute, 95% CI 0.95 to 8.14), and walking capacity (MD 41.60 metres per six minutes, 95% CI 25.25 to 57.95). Balance scores improved slightly after mixed training (SMD 0.27, 95% CI 0.07 to 0.47). Some mobility benefits also persisted at the end of follow-up. The variability, quality of the included trials, and lack of data prevents conclusions about other outcomes and limits generalisability of the observed results. AUTHORS' CONCLUSIONS Cardiorespiratory training and, to a lesser extent, mixed training reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve the speed and tolerance of walking; some improvement in balance could also occur. There is insufficient evidence to support the use of resistance training. The effects of training on death and dependence after stroke are still unclear but these outcomes are rarely observed in physical fitness training trials. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription and identify long-term benefits.
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Affiliation(s)
- David H Saunders
- Institute for Sport, Physical Education and Health Sciences (SPEHS), University of EdinburghMoray House School of EducationSt Leonards LandHolyrood RoadEdinburghUKEH8 2AZ
| | - Mark Sanderson
- University of the West of ScotlandInstitute of Clinical Exercise and Health ScienceRoom A071A, Almada BuildingHamiltonUKML3 0JB
| | - Sara Hayes
- University of LimerickDepartment of Clinical TherapiesLimerickIreland
| | - Maeve Kilrane
- Royal Infirmary of EdinburghDepartment of Stroke MedicineWard 201 ‐ Stroke UnitLittle FranceEdinburghUKEH16 4SA
| | - Carolyn A Greig
- University of BirminghamSchool of Sport, Exercise and Rehabilitation Sciences, MRC‐ARUK Centre for Musculoskeletal Ageing ResearchEdgbastonBirminghamUKB15 2TT
| | - Miriam Brazzelli
- University of AberdeenHealth Services Research UnitHealth Sciences BuildingForesterhillAberdeenUKAB25 2ZD
| | - Gillian E Mead
- University of EdinburghCentre for Clinical Brain SciencesRoom S1642, Royal InfirmaryLittle France CrescentEdinburghUKEH16 4SA
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Willems M, Schröder C, van der Weijden T, Post MW, Visser-Meily AM. Encouraging post-stroke patients to be active seems possible: results of an intervention study with knowledge brokers. Disabil Rehabil 2016; 38:1748-55. [DOI: 10.3109/09638288.2015.1107644] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
In acute stroke, the major factor for recovery is the early use of thrombolysis aimed at arterial recanalization and reperfusion of ischemic brain tissue. Subsequently, neurorehabilitative training critically improves clinical recovery due to augmention of postlesional plasticity. Neuroimaging and electrophysiology studies have revealed that the location and volume of the stroke lesion, the affection of nerve fiber tracts, as well as functional and structural changes in the perilesional tissue and in large-scale bihemispheric networks are relevant biomarkers of post-stroke recovery. However, associated disorders, such as mood disorders, epilepsy, and neurodegenerative diseases, may induce secondary cerebral changes or aggravate the functional deficits and, thereby, compromise the potential for recovery.
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Affiliation(s)
- Rüdiger J Seitz
- Department of Neurology, Centre of Neurology and Neuropsychiatry, LVR-Klinikum Düsseldorf, Heinrich-Heine-University Düsseldorf , Düsseldorf , Germany ; Biomedical Research Centre, Heinrich-Heine-University Düsseldorf , Düsseldorf , Germany ; Florey Institute of Neuroscience and Mental Health, University of Melbourne , Parkville, VIC , Australia
| | - Geoffrey A Donnan
- Florey Institute of Neuroscience and Mental Health, University of Melbourne , Parkville, VIC , Australia
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Chippala P, Sharma R. Effect of very early mobilisation on functional status in patients with acute stroke: a single-blind, randomized controlled trail. Clin Rehabil 2015. [DOI: 10.1177/0269215515596054] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To evaluate the effect of very early mobilisation on functional status following acute stroke. Design: Single blind, randomized controlled trial. Setting: University hospital. Subjects: Eighty-six patients with acute stroke (42 men and 38 women) aged 30-80 years were randomized to an Intervention group and a Standard care group. Interventions: All participants received 45 minutes standard care once a day for seven days. In addition, the intervention group ( n=43) performed very early mobilisation consisting of early and frequent out of bed activities which started within 24 hours of stroke onset for 5 to 30 minutes at least twice a day, for seven days. Outcome measures: Functional status was measured with Barthel ADL Index on admission, discharge and three months follow up. Results: Intervention group showed a significant improvement in Barthel Index change scores (discharge - admission) (median=35, IQR=30-38.75 versus median=17.50, IQR=10-30) than the standard care group. Intervention group showed a significant improvement in Barthel Index change scores (three month follow up - admission) (median=42.50, IQR=35-55) versus (median=30, IQR=20-35) than the standard care group. The Intervention group reported statistically significant improvement in functional status at discharge ( P<0.001) and at three months follow up ( P<0.001) compared with the Standard care group. Conclusions: The results indicate that very early mobilisation in addition to the standard care may be effective in improving the functional status following acute stroke.
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Affiliation(s)
| | - Raghava Sharma
- Department of Medicine, K S Hegde Medical Academy, Nitte University, Deralakatte, Mangalore, India
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Tyson SF, Burton L, McGovern A. The effect of a structured programme to increase patient activity during inpatient stroke rehabilitation: a Phase I cohort study. Clin Rehabil 2015; 30:191-8. [PMID: 25758942 DOI: 10.1177/0269215515575335] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 02/07/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To develop an intervention and undertake a proof-of-concept evaluation of its feasibility, acceptability, and impact on recorded patient activity levels during inpatient stroke rehabilitation. DESIGN A longitudinal cohort design. SETTING Three inpatient stroke rehabilitation services. SUBJECTS Stroke survivors receiving inpatient rehabilitation. INTERVENTION A programme designed to increase patient activity, including individualised patient timetables, independent practice, therapeutic group work, and structured social activities was developed and implemented without additional resource. MAIN MEASURES Patients' recorded activity levels were compared for two weeks before and after implementation of the programme. Data regarding the estimated time spent in different types of activity were extracted from patient treatment records, patients' and therapists' diaries, or timetables (if used) to measure patient activity levels RESULTS At baseline, recorded activity levels were low; patients undertook a mean of 61 minutes (SD = 39) of activity per day. After implementation of the programme, recorded activity levels significantly increased to a mean of 123 minutes (SD = 88) per day (p = 0.0001). The time spent in all types of recorded activity increased (p = 0.0001-0.002), except psychology where the increase did not reach significance (p = 0.670). CONCLUSIONS A structured programme can significantly increase recorded patient activity levels during inpatient stroke rehabilitation without additional resource.
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Affiliation(s)
- S F Tyson
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK
| | - L Burton
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK Greater Manchester Strategic Clinical Network, Stockport, UK
| | - A McGovern
- Greater Manchester Strategic Clinical Network, Stockport, UK
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Hayward KS, Brauer SG. Dose of arm activity training during acute and subacute rehabilitation post stroke: a systematic review of the literature. Clin Rehabil 2015; 29:1234-43. [PMID: 25568073 DOI: 10.1177/0269215514565395] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 12/01/2014] [Indexed: 11/16/2022]
Abstract
AIM To determine the dose of activity-related arm training undertaken by stroke survivors during acute and subacute rehabilitation. METHODS A systematic review of PubMed, CINAHL and EMBASE up to December 2014 was completed. Studies were eligible if they defined the dose (time or repetitions) of activity-related arm training using observational methods for a cohort of adult stroke survivors receiving acute or subacute rehabilitation. All studies were quality appraised using an evidence-based learning critical appraisal checklist. Data was analysed by method of documented dose per session (minutes, repetitions), environment (acute or subacute rehabilitation) and therapy discipline (physiotherapy, occupational therapy). RESULTS Ten studies were included: two observed stroke survivors during acute rehabilitation and eight during subacute rehabilitation. During acute rehabilitation, one study reported 4.1 minutes per session during physiotherapy and 11.2 minutes during occupational therapy, while another study reported 5.7 minutes per session during physiotherapy only. During inpatient rehabilitation, activity-related arm training was on average undertaken for 4 minutes per session (range 0.9 to 7.9, n = 4 studies) during physiotherapy and 17 minutes per session (range 9.3 to 28.9, n = 3 studies) during occupational therapy. Repetitions per session were reported by two studies only during subacute rehabilitation. One study reported 23 repetitions per session during physiotherapy and occupational therapy, while another reported 32 repetitions per session across both disciplines. CONCLUSION The dose of activity-related arm training during acute and subacute rehabilitation after stroke is limited.
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Affiliation(s)
- Kathryn S Hayward
- Division of Physiotherapy, The University of Queensland, Brisbane, Australia
| | - Sandra G Brauer
- Division of Physiotherapy, The University of Queensland, Brisbane, Australia
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Dodakian L, Campbell Stewart J, Cramer SC. Motor imagery during movement activates the brain more than movement alone after stroke: a pilot study. J Rehabil Med 2014; 46:843-8. [PMID: 25182189 DOI: 10.2340/16501977-1844] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To examine the neural correlates of motor imagery performed in conjunction with movement of the paretic arm after stroke. DESIGN Cross-sectional, cohort study. SUBJECTS Seven individuals in the chronic phase of stroke recovery (median (range): age: 58 years (37-73); time post-stroke: 9 months (4-42); upper extremity Fugl-Meyer motor score: 48 (36-64)). METHODS Participants actively moved the paretic/right arm under two conditions while undergoing functional magnetic resonance imaging. In the motor condition, pronation/supination movements were made in response to a visual cue. In the motor + imagery condition, the same movements were performed in response to a visual cue but the participants were instructed to imagine opening and closing a doorknob during performance of the movement. RESULTS For the motor condition, the anticipated motor network was activated and included left sensorimotor cortex and right cerebellum. For performance of the same movements during the motor + imagery condition, additional brain regions were significantly engaged including the left inferior parietal lobule and right dorsolateral prefrontal cortex. CONCLUSIONS The addition of motor imagery to movement may provide a practical, accessible way to modulate activity in both the planning and execution components of the motor network after stroke.
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Affiliation(s)
- Lucy Dodakian
- Departments of Neurology and Anatomy and Neurobiology, University of California, Irvine, USA
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Aries A, Hunter SM. Optimising rehabilitation potential after stroke: a 24-hour interdisciplinary approach. ACTA ACUST UNITED AC 2014. [DOI: 10.12968/bjnn.2014.10.6.268] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Alison Aries
- Lecturer, School of Health and Rehabilitation and Institute for Science and Technology in Medicine (ISTM)
| | - Susan M Hunter
- Senior Lecturer, School of Health and Rehabilitation and Institute for Science and Technology in Medicine (ISTM), Keele University
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Karic T, Sorteberg A, Haug Nordenmark T, Becker F, Roe C. Early rehabilitation in patients with acute aneurysmal subarachnoid hemorrhage. Disabil Rehabil 2014; 37:1446-54. [DOI: 10.3109/09638288.2014.966162] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Dorsch AK, Thomas S, Xu X, Kaiser W, Dobkin BH. SIRRACT: An International Randomized Clinical Trial of Activity Feedback During Inpatient Stroke Rehabilitation Enabled by Wireless Sensing. Neurorehabil Neural Repair 2014; 29:407-15. [PMID: 25261154 DOI: 10.1177/1545968314550369] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Walking-related disability is the most frequent reason for inpatient stroke rehabilitation. Task-related practice is a critical component for improving patient outcomes. OBJECTIVE To test the feasibility of providing quantitative feedback about daily walking performance and motivating greater skills practice via remote sensing. METHODS In this phase III randomized, single blind clinical trial, patients participated in conventional therapies while wearing wireless sensors (triaxial accelerometers) at both ankles. Activity-recognition algorithms calculated the speed, distance, and duration of walking bouts. Three times a week, therapists provided either feedback about performance on a 10-meter walk (speed only) or walking speed feedback plus a review of walking activity recorded by the sensors (augmented). Primary outcomes at discharge included total daily walking time, derived from the sensors, and a timed 15-meter walk. RESULTS Sixteen rehabilitation centers in 11 countries enrolled 135 participants over 15 months. Sensors recorded more than 1800 days of therapy, 37 000 individual walking bouts, and 2.5 million steps. No significant differences were found between the 2 feedback groups in daily walking time (15.1 ± 13.1 vs 16.6 ± 14.3 minutes, P = .54) or 15-meter walking speed (0.93 ± 0.47 vs 0.91 ± 0.53 m/s, P = .96). Remarkably, 30% of participants decreased their total daily walking time over their rehabilitation stay. CONCLUSIONS In this first trial of remote monitoring of inpatient stroke rehabilitation, augmented feedback beyond speed alone did not increase the time spent practicing or improve walking outcomes. Remarkably modest time was spent walking. Wireless sensing, however, allowed clinicians to audit skills practice and provided ground truth regarding changes in clinically important, mobility-related activities.
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Affiliation(s)
| | - Seth Thomas
- University of California, Los Angeles, CA, USA
| | - Xiaoyu Xu
- University of California, Los Angeles, CA, USA
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29
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Abstract
The aim of this article is to elevate the standard of ward-based routine care by informing readers about the prevention and management of muscular contractures post-cerebrovascular accident (CVA). Musculoskeletal complications can develop at any time during the acute or latter stages of stroke care and rehabilitation; therefore, it is imperative that all nurses understand the importance of correct limb placement and some of the detrimental complications that can occur. By placing more onus on therapeutic positioning and earlier mobilisation, nurses, working alongside allied health professionals, can significantly improve morbidity-related outcomes.
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Affiliation(s)
- Diana De
- Senior Lecturer, Adult Nursing, University of South Wales
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30
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Abstract
PURPOSE OF REVIEW Rehabilitation for sensorimotor impairments aims to improve daily activities, walking, exercise, and motor skills. Monitoring of practice and measuring outcomes, however, is usually restricted to laboratory-based procedures and self-reports. Mobile health devices may reverse these confounders of daily care and research trials. RECENT FINDINGS Wearable, wireless motion sensor data, analyzed by activity pattern-recognition algorithms, can describe the type, quantity, and quality of mobility-related activities in the community. Data transmission from the sensors to a cell phone and the Internet enable continuous monitoring. Remote access to laboratory quality data about walking speed, duration and distance, gait asymmetry and smoothness of movements, as well as cycling, exercise, and skills practice, opens new opportunities to engage patients in progressive, personalized therapies with feedback about the performance. Clinical trial designs will be able to include remote verification of the integrity of complex physical interventions and compliance with practice, as well as capture repeated, ecologically sound, ratio scale outcome measures. SUMMARY Given the progressively falling cost of miniaturized wearable gyroscopes, accelerometers, and other physiologic sensors, as well as inexpensive data transmission, sensing systems may become as ubiquitous as cell phones for healthcare. Neurorehabilitation can develop these mobile health platforms for daily care and clinical trials to improve exercise and fitness, skills learning, and physical functioning.
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Lynch E, Hillier S, Cadilhac D. When Should Physical Rehabilitation Commence after Stroke: A Systematic Review. Int J Stroke 2014; 9:468-78. [DOI: 10.1111/ijs.12262] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 12/16/2013] [Indexed: 12/01/2022]
Abstract
Background Knowing when to commence physical rehabilitation after stroke is important to ensure optimal benefit for stroke survivors and efficient health care. The aims of this review were to: determine the effects on mortality, function and complications when physical rehabilitation commences ‘early’ (within seven days of stroke); and describe the effects of early transfer to rehabilitation wards/hospitals when sustained rehabilitation is unavailable in acute stroke units. Review summary From 3751 potential articles we included 5 randomized controlled trials and 38 cohort studies. Meta-analysis was performed with 3 randomized controlled trials involving 159 people to investigate the effects of commencing physical rehabilitation within 24 h of stroke compared to 48 h. Commencing physical rehabilitation within 24 h trended towards greater mortality (Mantel-Haenszel odds ratio 2·58; 95% confidence interval 0·98 to 6·79, P = 0·06), with no differences in complications or health outcomes. The cohort studies provided evidence of benefits when physical rehabilitation was commenced on the day of admission ( n = 1), within 3 days of stroke ( n = 3), or ‘sooner rather than later’ (3 of 4 studies). The effect of earlier transfer to rehabilitation was reported in 32 cohort studies. In 23/26 (88%) cohort studies that accounted for age and stroke severity, results favored earlier transfer for improving post-stroke function, with no consensus on timeframes. Conclusion In summary, the benefits of commencing physical rehabilitation within 24 h of stroke remain unclear from the current literature. Commencing physical rehabilitation or transferring to rehabilitation services ‘early’ may provide better functional outcomes.
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Affiliation(s)
- Elizabeth Lynch
- International Centre for Allied Health Evidence, School of Health Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - Susan Hillier
- International Centre for Allied Health Evidence, School of Health Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - Dominique Cadilhac
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic., Australia
- Stroke and Ageing Research Centre, Department of Medicine, Monash University, Clayton, Vic., Australia
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Physical activity early after stroke and its association to functional outcome 3 months later. J Stroke Cerebrovasc Dis 2014; 23:e305-12. [PMID: 24529353 DOI: 10.1016/j.jstrokecerebrovasdis.2013.12.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 11/29/2013] [Accepted: 12/09/2013] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Early rehabilitation that includes early mobilization and increased amount of motor activity is hypothesized to be one of the most important factors contributing to the beneficial effect of comprehensive stroke unit treatment, whereas too much bed rest is hypothesized to be harmful. The purpose of the present study was to assess the association between early activity/bed rest and functional outcome 3 months later. METHODS This was a prospective cohort study including patients with the diagnosis of stroke admitted to Trondheim University Hospital, Norway. Patients were eligible if they were less than 14 days poststroke and did not receive palliative care. Motor activity/bed rest was recorded in the acute phase using a standard method of observation, and the outcome was assessed by the modified Rankin Scale (mRS) score 3 months later. A proportional odds model was used to analyze the association between motor activity/bed rest and outcome. All analyses were adjusted for age, gender, stroke severity, time from stroke to observation, and prestroke function. RESULTS A total of 106 patients (mean age 79.0 years, 56.6% men) were included. The odds ratio for a higher mRS score (poor outcome) was 1.04 (95% confidence interval [CI] 1.02-1.07, P = .001) as time in bed increased and .97 (95% CI .93-1.02, P = .283) as time in motor activity increased. CONCLUSIONS This study confirms that time in bed in the early phase is associated with poor functional outcome 3 months later, indicating that too much bed rest should be avoided in the early phase after stroke.
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Affiliation(s)
- Michael Brainin
- Department of Clinical Neurosciences, Danube University Krems, Karl Dorrekstrasse 30, 3500 Krems, Austria.
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Dobkin BH, Duncan PW. Should body weight-supported treadmill training and robotic-assistive steppers for locomotor training trot back to the starting gate? Neurorehabil Neural Repair 2012; 26:308-17. [PMID: 22412172 DOI: 10.1177/1545968312439687] [Citation(s) in RCA: 143] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Body weight-supported treadmill training (BWSTT) and robotic-assisted step training (RAST) have not, so far, led to better outcomes than a comparable dose of progressive over-ground training (OGT) for disabled persons with stroke, spinal cord injury, multiple sclerosis, Parkinson's disease, or cerebral palsy. The conceptual bases for these promising rehabilitation interventions had once seemed quite plausible, but the results of well-designed, randomized clinical trials have been disappointing. The authors reassess the underpinning concepts for BWSTT and RAST, which were derived from mammalian studies of treadmill-induced hind-limb stepping associated with central pattern generation after low thoracic spinal cord transection, as well as human studies of the triple crown icons of task-oriented locomotor training, massed practice, and activity-induced neuroplasticity. The authors retrospectively consider where theory and practice may have fallen short in the pilot studies that aimed to produce thoroughbred interventions. Based on these shortcomings, the authors move forward with recommendations for the future development of workhorse interventions for walking. In the absence of evidence for physical therapists to employ these strategies, however, BWSTT and RAST should not be provided routinely to disabled, vulnerable persons in place of OGT outside of a scientifically conducted efficacy trial.
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Affiliation(s)
- Bruce H Dobkin
- Geffen UCLA School of Medicine, Los Angeles, CA 90095, USA.
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