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Abstract
Stroke remains a major cause of disability. Intensive rehabilitation therapy can improve outcomes, but most patients receive limited doses. Telehealth methods can overcome obstacles to delivering intensive therapy and thereby address this unmet need. A specific example is reviewed in detail, focused on a telerehabilitation system that targets upper extremity motor deficits after stroke. Strengths of this system include provision of daily therapy associated with very high patient compliance, safety and feasibility in the inpatient or home setting, comparable efficacy to dose-matched therapy provided in-clinic, and a holistic approach that includes assessment, education, prevention, and activity-based therapy.
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Affiliation(s)
- Steven C Cramer
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA.
| | - Brittany M Young
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA
| | - Anne Schwarz
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA
| | - Tracy Y Chang
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA
| | - Michael Su
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA
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Caine S, Alaverdashvili M, Colbourne F, Muir GD, Paterson PG. A modified rehabilitation paradigm bilaterally increased rat extensor digitorum communis muscle size but did not improve forelimb function after stroke. PLoS One 2024; 19:e0302008. [PMID: 38603768 PMCID: PMC11008896 DOI: 10.1371/journal.pone.0302008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 03/26/2024] [Indexed: 04/13/2024] Open
Abstract
Malnutrition after stroke may lessen the beneficial effects of rehabilitation on motor recovery through influences on both brain and skeletal muscle. Enriched rehabilitation (ER), a combination of environmental enrichment and forelimb reaching practice, is used preclinically to study recovery of skilled reaching after stroke. However, the chronic food restriction typically used to motivate engagement in reaching practice is a barrier to using ER to investigate interactions between nutritional status and rehabilitation. Thus, our objectives were to determine if a modified ER program comprised of environmental enrichment and skilled reaching practice motivated by a short fast would enhance post-stroke forelimb motor recovery and preserve forelimb muscle size and metabolic fiber type, relative to a group exposed to stroke without ER. At one week after photothrombotic cortical stroke, male, Sprague-Dawley rats were assigned to modified ER or standard care for 2 weeks. Forelimb recovery was assessed in the Montoya staircase and cylinder task before stroke and on days 5-6, 22-23, and 33-34 after stroke. ER failed to improve forelimb function in either task (p > 0.05). Atrophy of extensor digitorum communis (EDC) and triceps brachii long head (TBL) muscles was not evident in the stroke-targeted forelimb on day 35, but the area occupied by hybrid fibers was increased in the EDC muscle (p = 0.038). ER bilaterally increased EDC (p = 0.046), but not TBL, muscle size; EDC muscle fiber type was unchanged by ER. While the modified ER did not promote forelimb motor recovery, it does appear to have utility for studying the role of skeletal muscle plasticity in post-stroke recovery.
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Affiliation(s)
- Sally Caine
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
| | | | - Frederick Colbourne
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
- Department of Psychology, University of Alberta, Edmonton, Canada
| | - Gillian D. Muir
- Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Phyllis G. Paterson
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
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Yu J, Joo IL, Bazzigaluppi P, Koletar MM, Cherin E, Stanisz AG, Graham JWC, Demore C, Stefanovic B. Micro-ultrasound based characterization of cerebrovasculature following focal ischemic stroke and upon short-term rehabilitation. J Cereb Blood Flow Metab 2024; 44:461-476. [PMID: 37974304 PMCID: PMC10981404 DOI: 10.1177/0271678x231215004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/21/2023] [Accepted: 10/27/2023] [Indexed: 11/19/2023]
Abstract
Notwithstanding recanalization treatments in the acute stage of stroke, many survivors suffer long-term impairments. Physical rehabilitation is the only widely available strategy for chronic-stage recovery, but its optimization is hindered by limited understanding of its effects on brain structure and function. Using micro-ultrasound, behavioral testing, and electrophysiology, we investigated the impact of skilled reaching rehabilitation on cerebral hemodynamics, motor function, and neuronal activity in a rat model of focal ischemic stroke. A 50 MHz micro-ultrasound transducer and intracortical electrophysiology were utilized to characterize neurovascular changes three weeks following focal ischemia elicited by endothelin-1 injection into the sensorimotor cortex. Sprague-Dawley rats were rehabilitated through tray reaching, and their fine skilled reaching was assessed via the Montoya staircase. Focal ischemia led to a sustained deficit in forelimb reaching; and increased tortuosity of the penetrating vessels in the perilesional cortex; with no lateralization of spontaneous neuronal activity. Rehabilitation improved skilled reaching; decreased cortical vascularity; was associated with elevated peri- vs. contralesional hypercapnia-induced flow homogenization and increased perilesional spontaneous cortical neuronal activity. Our study demonstrated neurovascular plasticity accompanying rehabilitation-elicited functional recovery in the subacute stage following stroke, and multiple micro-ultrasound-based markers of cerebrovascular structure and function modified in recovery from ischemia and upon rehabilitation.
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Affiliation(s)
- Johnson Yu
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Illsung L Joo
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Paolo Bazzigaluppi
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- MetaCell, Cagliari, Italy
| | - Margaret M Koletar
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Emmanuel Cherin
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Andrew G Stanisz
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - James WC Graham
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Christine Demore
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Bojana Stefanovic
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
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Noé E, Gómez A, Bernabeu M, Quemada I, Rodríguez R, Pérez T, López C, Laxe S, Colomer C, Ríos M, Juárez-Belaúnde A, González C, Pelayo R, Ferri J. Guidelines: basic principles of neurorehabilitation for patients with acquired brain injury. Recommendations of the Spanish Society of Neurorehabilitation. Neurologia 2024; 39:261-281. [PMID: 37116696 DOI: 10.1016/j.nrleng.2023.04.002] [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] [Received: 05/24/2021] [Accepted: 06/27/2021] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION We present the Spanish Society of Neurorehabilitation's guidelines for adult acquired brain injury (ABI) rehabilitation. These recommendations are based on a review of international clinical practice guidelines published between 2013 and 2020. DEVELOPMENT We establish recommendations based on the levels of evidence of the studies reviewed and expert consensus on population characteristics and the specific aspects of the intervention or procedure under research. CONCLUSIONS All patients with ABI should receive neurorehabilitation therapy once they present a minimal level of clinical stability. Neurorehabilitation should offer as much treatment as possible in terms of frequency, duration, and intensity (at least 45-60minutes of each specific form of therapy that is needed). Neurorehabilitation requires a coordinated, multidisciplinary team with the knowledge, experience, and skills needed to work in collaboration both with patients and with their families. Inpatient rehabilitation interventions are recommended for patients with more severe deficits and those in the acute phase, with outpatient treatment to be offered as soon as the patient's clinical situation allows it, as long as intensity criteria can be maintained. The duration of treatment should be based on treatment response and the possibilities for further improvement, according to the best available evidence. At discharge, patients should be offered health promotion, physical activity, support, and follow-up services to ensure that the benefits achieved are maintained, to detect possible complications, and to assess possible changes in functional status that may lead the patient to need other treatment programmes.
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Affiliation(s)
- E Noé
- NEURORHB Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Hospitales Vithas, Valencia, Spain.
| | - A Gómez
- Centro Estatal de Atención al Daño Cerebral-CEADAC, Madrid, Spain
| | | | - I Quemada
- Red Menni de Daño Cerebral, Bilbao, Spain
| | | | - T Pérez
- Clínica San Vicente, Madrid, Spain
| | - C López
- Centro Lescer, Madrid, Spain
| | - S Laxe
- Hospital Clínic, Barcelona, Spain
| | - C Colomer
- NEURORHB Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Hospitales Vithas, Valencia, Spain
| | - M Ríos
- Unidad de Daño Cerebral, Hospital Beata María Ana, Madrid, Spain
| | | | - C González
- Centro Estatal de Atención al Daño Cerebral-CEADAC, Madrid, Spain
| | - R Pelayo
- Institut Guttmann, Barcelona, Spain
| | - J Ferri
- NEURORHB Servicio de Neurorrehabilitación de Hospitales Vithas, Fundación Hospitales Vithas, Valencia, Spain
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Proietti T, Nuckols K, Grupper J, Schwerz de Lucena D, Inirio B, Porazinski K, Wagner D, Cole T, Glover C, Mendelowitz S, Herman M, Breen J, Lin D, Walsh C. Combining soft robotics and telerehabilitation for improving motor function after stroke. WEARABLE TECHNOLOGIES 2024; 5:e1. [PMID: 38510985 PMCID: PMC10952055 DOI: 10.1017/wtc.2023.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 11/07/2023] [Accepted: 12/02/2023] [Indexed: 03/22/2024]
Abstract
Telerehabilitation and robotics, either traditional rigid or soft, have been extensively studied and used to improve hand functionality after a stroke. However, a limited number of devices combined these two technologies to such a level of maturity that was possible to use them at the patients' home, unsupervised. Here we present a novel investigation that demonstrates the feasibility of a system that integrates a soft inflatable robotic glove, a cloud-connected software interface, and a telerehabilitation therapy. Ten chronic moderate-to-severe stroke survivors independently used the system at their home for 4 weeks, following a software-led therapy and being in touch with occupational therapists. Data from the therapy, including automatic assessments by the robot, were available to the occupational therapists in real-time, thanks to the cloud-connected capability of the system. The participants used the system intensively (about five times more movements per session than the standard care) for a total of more than 8 hr of therapy on average. We were able to observe improvements in standard clinical metrics (FMA +3.9 ± 4.0, p < .05, COPM-P + 2.5 ± 1.3, p < .05, COPM-S + 2.6 ± 1.9, p < .05, MAL-AOU +6.6 ± 6.5, p < .05) and range of motion (+88%) at the end of the intervention. Despite being small, these improvements sustained at follow-up, 2 weeks after the end of the therapy. These promising results pave the way toward further investigation for the deployment of combined soft robotic/telerehabilitive systems at-home for autonomous usage for stroke rehabilitation.
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Affiliation(s)
- Tommaso Proietti
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Kristin Nuckols
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Jesse Grupper
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Diogo Schwerz de Lucena
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Bianca Inirio
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | | | - Diana Wagner
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Tazzy Cole
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Christina Glover
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Sarah Mendelowitz
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Maxwell Herman
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Joan Breen
- Whittier Rehabilitation Hospital, Bradford, MA, USA
| | - David Lin
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- VA RR&D Center for Neurorestoration and Neurotechnology, Rehabilitation R&D Service, Department of VA Medical Center, Providence, RI, USA
| | - Conor Walsh
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
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Kuppuswamy A, Billinger S, Coupland KG, English C, Kutlubaev MA, Moseley L, Pittman QJ, Simpson DB, Sutherland BA, Wong C, Corbett D. Mechanisms of Post-Stroke Fatigue: A Follow-Up From the Third Stroke Recovery and Rehabilitation Roundtable. Neurorehabil Neural Repair 2024; 38:52-61. [PMID: 38156702 PMCID: PMC10798014 DOI: 10.1177/15459683231219266] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Post-stroke fatigue (PSF) is a significant and highly prevalent symptom, whose mechanisms are poorly understood. The third Stroke Recovery and Rehabilitation Roundtable paper on PSF focussed primarily on defining and measuring PSF while mechanisms were briefly discussed. This companion paper to the main paper is aimed at elaborating possible mechanisms of PSF. METHODS This paper reviews the available evidence that potentially explains the pathophysiology of PSF and draws parallels from fatigue literature in other conditions. We start by proposing a case for phenotyping PSF based on structural, functional, and behavioral characteristics of PSF. This is followed by discussion of a potentially significant role of early inflammation in the development of fatigue, specifically the impact of low-grade inflammation and its long-term systemic effects resulting in PSF. Of the many neurotransmitter systems in the brain, the dopaminergic systems have the most evidence for a role in PSF, along with a role in sensorimotor processing. Sensorimotor neural network dynamics are compromised as highlighted by evidence from both neurostimulation and neuromodulation studies. The double-edged sword effect of exercise on PSF provides further insight into how PSF might emerge and the importance of carefully titrating interventional paradigms. CONCLUSION The paper concludes by synthesizing the presented evidence into a unifying model of fatigue which distinguishes between factors that pre-dispose, precipitate, and perpetuate PSF. This framework will help guide new research into the biological mechanisms of PSF which is a necessary prerequisite for developing treatments to mitigate the debilitating effects of post-stroke fatigue.
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Affiliation(s)
- Annapoorna Kuppuswamy
- Queen Square Institute of Neurology, University College London, London, UK
- Department of Biomedical Sciences, University of Leeds, Leeds, UK
| | - Sandra Billinger
- Department of Neurology, University of Kansas Medical Center, University of Kansas Alzheimer’s Disease Research Center, Fairway, KS, MO, USA
| | - Kirsten G. Coupland
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Australia Heart and Stroke Program, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Coralie English
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of Newcastle, Australia Heart and Stroke Program, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | | | - Lorimer Moseley
- IIMPACT in Health, University of South Australia, Adelaide, SA, Australia
| | - Quentin J. Pittman
- Department of Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Dawn B. Simpson
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of Newcastle, Australia Heart and Stroke Program, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Brad A. Sutherland
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, TS, Australia
| | - Connie Wong
- Centre for Inflammatory Diseases, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Dale Corbett
- Department of Cellular and Molecular Medicine, University of Ottawa Brain and Mind Institute, University of Ottawa, Ottawa, ON, Canada
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Okusanya D, Ezeugwa JC, Khan A, Buck B, Jickling GC, Ezeugwu VE. The whole day matters after stroke: Study protocol for a randomized controlled trial investigating the effect of a 'sit less, move more, sleep better' program early after stroke. PLoS One 2023; 18:e0290515. [PMID: 38060584 PMCID: PMC10703225 DOI: 10.1371/journal.pone.0290515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Movement-related behaviours, including prolonged sedentary behaviour, physical inactivity, and poor sleep, are associated with worse functional outcomes poststroke. Addressing these co-dependent behaviours early after stroke may help to optimize recovery and improve overall quality of life for individuals with stroke. OBJECTIVE This study aims to determine the feasibility and effect of a 'sit less, move more, sleep better' program early after stroke on functional mobility and global disability outcomes, while also exploring imaging and behavioural markers that may influence walking recovery. METHODS The study is an assessor-blinded, single-center, parallel-group, randomized controlled trial to be completed within 24 months from July 12, 2023 to June 30, 2025. We will enroll 50 patients with acute ischemic stroke within 7 days from symptom onset, aged 18 years or older, and with ongoing walking goals. Demographic and stroke characteristics, including stroke risk factors, neuroimaging, and acute stroke treatments, will be determined and documented. All participants will wear an accelerometer for one week at three different time-points (baseline, 6, and 12 weeks) to assess movement-related behaviours. Following randomization, participants in the intervention arm will receive a 'sit less, move more, sleep better' program for up to 1 hour/day, 5 days/week, for 6 weeks to enhance self-efficacy for change. Participants in the control arm will receive usual inpatient and early supported stroke discharge care. The feasibility outcomes will include reach (enrolled/eligible), retention (completed/enrolled), adverse events, and program adherence. Other outcomes at 6 and 12 weeks include the modified Rankin Scale, Timed-Up and Go, movement-related behaviours, walking endurance, gait speed, cognition, stroke severity and quality of life. Mixed-effects models will assess changes in outcomes over time. Compositional associations between movement-related behaviours and outcomes will consider covariates such as imaging markers. DISCUSSION Adopting a whole-day approach to poststroke rehabilitation will provide valuable insights into the relationship between optimizing movement-related behaviours early after stroke and their impact on functional outcomes. Through exploring person-specific behavioural and imaging markers, this study may inform precision rehabilitation strategies, and guide clinical decision making for more tailored interventions. TRIAL REGISTRATION Clinical Trial registration (ClinicalTrials.gov Identifier: NCT05753761, March 3, 2023).
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Affiliation(s)
- Deborah Okusanya
- Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| | - Joy C. Ezeugwa
- Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| | - Aiza Khan
- Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| | - Brian Buck
- Faculty of Medicine and Dentistry, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Glen C. Jickling
- Faculty of Medicine and Dentistry, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Victor E. Ezeugwu
- Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
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Rogalewski A, Schäbitz W. [Therapies for the Improvement of Stroke Recovery - Assessment of Clinical Trial Results]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2023; 91:516-522. [PMID: 38081165 DOI: 10.1055/a-2181-1026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Recovery processes after stroke include restoration or compensation of function initially lost or newly acquired after injury. Therapeutic interventions can either directly improve these processes and/or inhibit processes that impede regeneration. Numerous experimental studies suggested a great opportunity for such treatments, but the results from recent large clinical trials with neuromodulators such as dopamine and fluoxetine have been rather disappointing. The reasons for this are manifold and involve the extrapolation of results from animal models to humans. Given the differences between animals and humans in genetic and epigenetic background, brain size and anatomy, cerebral vascular anatomy, immune system, as well as clinical function, and behavior, direct extrapolation is unlikely to work. Backward blockades include the incompatible adaption of clinical trial objectives and outcomes in clinical trials with regard to previous preclinical findings. For example, the clinical recovery trial design widely varies and has been characterized by the selection of different clinical endpoints, the inclusion a wide spectrum of stroke subtypes and clinical syndromes, and different time windows for treatment initiation after onset of infarction. This review will discuss these aspects based on the results of the recent stroke recovery trials with the aim to contributing to the development of a therapy that improves the functional outcome of a chronic stroke patient.
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Affiliation(s)
- Andreas Rogalewski
- Klinik für Neurologie, Sankt Elisabeth-Hospital Gütersloh, Gütersloh, Germany
| | - Wolf Schäbitz
- Universitätsklinik für Neurologie, Evangelisches Klinikum Bethel, Universitätsklinikum OWL der Universität Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
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Gunduz ME, Bucak B, Keser Z. Advances in Stroke Neurorehabilitation. J Clin Med 2023; 12:6734. [PMID: 37959200 PMCID: PMC10650295 DOI: 10.3390/jcm12216734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Stroke is one of the leading causes of disability worldwide despite recent advances in hyperacute interventions to lessen the initial impact of stroke. Stroke recovery therapies are crucial in reducing the long-term disability burden after stroke. Stroke recovery treatment options have rapidly expanded within the last decade, and we are in the dawn of an exciting era of multimodal therapeutic approaches to improve post-stroke recovery. In this narrative review, we highlighted various promising advances in treatment and technologies targeting stroke rehabilitation, including activity-based therapies, non-invasive and minimally invasive brain stimulation techniques, robotics-assisted therapies, brain-computer interfaces, pharmacological treatments, and cognitive therapies. These new therapies are targeted to enhance neural plasticity as well as provide an adequate dose of rehabilitation and improve adherence and participation. Novel activity-based therapies and telerehabilitation are promising tools to improve accessibility and provide adequate dosing. Multidisciplinary treatment models are crucial for post-stroke neurorehabilitation, and further adjuvant treatments with brain stimulation techniques and pharmacological agents should be considered to maximize the recovery. Among many challenges in the field, the heterogeneity of patients included in the study and the mixed methodologies and results across small-scale studies are the cardinal ones. Biomarker-driven individualized approaches will move the field forward, and so will large-scale clinical trials with a well-targeted patient population.
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Affiliation(s)
- Muhammed Enes Gunduz
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Bilal Bucak
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA; (B.B.); (Z.K.)
| | - Zafer Keser
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA; (B.B.); (Z.K.)
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Broderick M, O'Shea R, Burridge J, Demain S, Johnson L, Bentley P. Examining Usability, Acceptability, and Adoption of a Self-Directed, Technology-Based Intervention for Upper Limb Rehabilitation After Stroke: Cohort Study. JMIR Rehabil Assist Technol 2023; 10:e45993. [PMID: 37603405 PMCID: PMC10477927 DOI: 10.2196/45993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/25/2023] [Accepted: 07/19/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND Upper limb (UL) recovery after stroke is strongly dependent upon rehabilitation dose. Rehabilitation technologies present pragmatic solutions to dose enhancement, complementing therapeutic activity within conventional rehabilitation, connecting clinicians with patients remotely, and empowering patients to drive their own recovery. To date, rehabilitation technologies have been poorly adopted. Understanding the barriers to adoption may shape strategies to enhance technology use and therefore increase rehabilitation dose, thus optimizing recovery potential. OBJECTIVE We examined the usability, acceptability, and adoption of a self-directed, exercise-gaming technology within a heterogeneous stroke survivor cohort and investigated how stroke survivor characteristics, technology usability, and attitudes toward technology influenced adoption. METHODS A feasibility study of a novel exercise-gaming technology for self-directed UL rehabilitation in early subacute stroke survivors (N=30) was conducted in an inpatient, acute hospital setting. Demographic and clinical characteristics were recorded; participants' performance in using the system (usability) was assessed using a 4-point performance rating scale (adapted from the Barthel index), and adherence with the system was electronically logged throughout the trial. The technology acceptance model was used to formulate a survey examining the acceptability of the system. Spearman rank correlations were used to examine associations between participant characteristics, user performance (usability), end-point technology acceptance, and intervention adherence (adoption). RESULTS The technology was usable for 87% (n=26) of participants, and the overall technology acceptance rating was 68% (95% CI 56%-79%). Participants trained with the device for a median of 26 (IQR 16-31) minutes daily over an enrollment period of 8 (IQR 5-14) days. Technology adoption positively correlated with user performance (usability) (ρ=0.55; 95% CI 0.23-0.75; P=.007) and acceptability as well as domains of perceived usefulness (ρ=0.42; 95% CI 0.09-0.68; P=.03) and perceived ease of use (ρ=0.46; 95% CI 0.10-0.74; P=.02). Technology acceptance decreased with increased global stroke severity (ρ=-0.56; 95% CI -0.79 to -0.22; P=.007). CONCLUSIONS This technology was usable and acceptable for the majority of the cohort, who achieved an intervention dose with technology-facilitated, self-directed UL training that exceeded conventional care norms. Technology usability and acceptability were determinants of adoption and appear to be mediated by stroke severity. The results demonstrate the importance of selecting technologies for stroke survivors on the basis of individual needs and abilities, as well as optimizing the accessibility of technologies for the target user group. Facilitating changes in stroke survivors' beliefs and attitudes toward rehabilitation technologies may enhance adoption. Further work is needed to understand how technology can be optimized to benefit those with more severe stroke.
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Affiliation(s)
- Michelle Broderick
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Robert O'Shea
- Department of Cancer Imaging, Kings College London, London, United Kingdom
| | - Jane Burridge
- School of Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Sara Demain
- School of Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Louise Johnson
- School of Life Sciences, University of Southampton, Southampton, United Kingdom
- University Hospitals Dorset NHS Foundation Trust, Bournemouth, United Kingdom
| | - Paul Bentley
- Department of Brain Sciences, Imperial College London, London, United Kingdom
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Moon JH, Kim J, Hwang Y, Jang S, Kim J. Novel evaluation of upper-limb motor performance after stroke based on normal reaching movement model. J Neuroeng Rehabil 2023; 20:66. [PMID: 37226265 DOI: 10.1186/s12984-023-01189-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 05/10/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Upper-limb rehabilitation robots provide repetitive reaching movement training to post-stroke patients. Beyond a pre-determined set of movements, a robot-aided training protocol requires optimization to account for the individuals' unique motor characteristics. Therefore, an objective evaluation method should consider the pre-stroke motor performance of the affected arm to compare one's performance relative to normalcy. However, no study has attempted to evaluate performance based on an individual's normal performance. Herein, we present a novel method for evaluating upper limb motor performance after a stroke based on a normal reaching movement model. METHODS To represent the normal reaching performance of individuals, we opted for three candidate models: (1) Fitts' law for the speed-accuracy relationship, (2) the Almanji model for the mouse-pointing task of cerebral palsy, and (3) our proposed model. We first obtained the kinematic data of healthy (n = 12) and post-stroke (n = 7) subjects with a robot to validate the model and evaluation method and conducted a pilot study with a group of post-stroke patients (n = 12) in a clinical setting. Using the models obtained from the reaching performance of the less-affected arm, we predicted the patients' normal reaching performance to set the standard for evaluating the affected arm. RESULTS We verified that the proposed normal reaching model identifies the reaching of all healthy (n = 12) and less-affected arm (n = 19; 16 of them showed an R2 > 0.7) but did not identify erroneous reaching of the affected arm. Furthermore, our evaluation method intuitively and visually demonstrated the unique motor characteristics of the affected arms. CONCLUSIONS The proposed method can be used to evaluate an individual's reaching characteristics based on an individuals normal reaching model. It has the potential to provide individualized training by prioritizing a set of reaching movements.
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Affiliation(s)
- James Hyungsup Moon
- School of Mechanical Engineering, Sungkyunkwan University, Suwon-Si, Gyeonggi-Do, 16419, Republic of Korea
| | - Jongbum Kim
- Department of Robotics and Mechatronics Engineering, Daegu Gyeongbuk Institute of Science and Technology (DGIST), Daegu, 42988, Republic of Korea
| | - Yeji Hwang
- School of Mechanical Engineering, Sungkyunkwan University, Suwon-Si, Gyeonggi-Do, 16419, Republic of Korea
| | - Sungho Jang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, 42415, Republic of Korea
| | - Jonghyun Kim
- School of Mechanical Engineering, Sungkyunkwan University, Suwon-Si, Gyeonggi-Do, 16419, Republic of Korea.
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12
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Pila O, Duret C, Koeppel T, Jamin P. Performance-Based Robotic Training in Individuals with Subacute Stroke: Differences between Responders and Non-Responders. SENSORS (BASEL, SWITZERLAND) 2023; 23:s23094304. [PMID: 37177508 PMCID: PMC10181678 DOI: 10.3390/s23094304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/17/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023]
Abstract
The high variability of upper limb motor recovery with robotic training (RT) in subacute stroke underscores the need to explore differences in responses to RT. We explored differences in baseline characteristics and the RT dose between responders (ΔFugl-Meyer Assessment (FMA) score ≥ 9 points; n = 20) and non-responders (n = 16) in people with subacute stroke (mean [SD] poststroke time at baseline, 54 (26) days, baseline FMA score, 23 (17) points) who underwent 16 RT sessions combined with conventional therapies. Baseline characteristics were compared between groups. During RT sessions, the actual practice time (%), number of movements performed, and total distance covered (cm) in assisted and unassisted modalities were compared between groups. At baseline, participant characteristics and FMA scores did not differ between groups. During the RT, non-responders increased practice time (+15%; p = 0.02), performed more movements (+285; p = 0.004), and covered more distance (+4037 cm; p < 10-3), with no difference between physical modalities. In contrast, responders decreased practice time (-21%; p = 0.01) and performed fewer movements (-338; p = 0.03) in the assisted modality while performing more movements (+328; p < 0.05) and covering a greater distance (+4779 cm; p = 0.01) in unassisted modalities. Despite a large amount of motor practice, motor outcomes did not improve in non-responders compared to responders: the difficulty level in RT may have been too low for them. Future studies should combine robot-based parameters to describe the treatment dose, especially in people with severe-to-moderate arm paresis, to optimize the RT and improve the recovery prognosis.
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Affiliation(s)
- Ophélie Pila
- Centre de Rééducation Fonctionnelle Les Trois Soleils, Médecine Physique et de Réadaptation, Unité de Neurorééducation, 77310 Boissise-Le-Roi, France
| | - Christophe Duret
- Centre de Rééducation Fonctionnelle Les Trois Soleils, Médecine Physique et de Réadaptation, Unité de Neurorééducation, 77310 Boissise-Le-Roi, France
| | - Typhaine Koeppel
- Centre de Rééducation Fonctionnelle Les Trois Soleils, Médecine Physique et de Réadaptation, Unité de Neurorééducation, 77310 Boissise-Le-Roi, France
| | - Pascal Jamin
- Institut Robert Merle d'Aubigné, Rééducation et Appareillage, 94460 Valenton, France
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13
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Morrow C, Woodbury M, Simpson AN, Almallouhi E, Simpson KN. Determining the Marginal Cost Differences of a Telehealth Versus an In-person Occupational Therapy Evaluation Session for Stroke Survivors Using Time-driven Activity-based Costing. Arch Phys Med Rehabil 2023; 104:547-553. [PMID: 36513124 PMCID: PMC10967225 DOI: 10.1016/j.apmr.2022.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 10/31/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To estimate the marginal cost differences and care delivery process of a telerehabilitation vs outpatient session. DESIGN This study used a time-driven activity-based costing approach including (1) observation of rehabilitation sessions and creation of manual time stamps, (2) structured and recorded interviews with 2 occupational therapists familiar with outpatient therapy and 2 therapists familiar with telerehabilitation, (3) collection of standard wages for providers, and (4) the creation of an iterative flowchart of both an outpatient and telerehabilitation session care delivery process. SETTING Telerehabilitation and outpatient therapy evaluation. PARTICIPANTS Three therapists familiar with care deliver for telerehabilitation or outpatient therapy (N=3). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Marginal cost difference between telerehabilitation and outpatient therapy evaluations. RESULTS Overall, telerehabilitation ($225.41) was more costly than outpatient therapy ($168.29) per session for a cost difference of $57.12. Primary time drivers of this finding were initial phone calls (0 minutes for OP therapists vs 35 minutes for TR) and post documentation (5 minutes for OP vs 30 minutes for TR) demands for telerehabilitation. CONCLUSIONS Telerehabilitation is an emerging platform with the potential to reduce costs, improve health care inequities, and facilitate better patient outcomes. Improvements in documentation practices, staffing, technology, and reimbursement structuring would allow for a more successful translation.
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Affiliation(s)
- Corey Morrow
- College of Health Professions, Medical University of South Carolina, Charleston, SC; Department of Occupational Therapy, Whitworth University, Spokane, WA.
| | - Michelle Woodbury
- College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - Annie N Simpson
- College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - Eyad Almallouhi
- College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Kit N Simpson
- College of Health Professions, Medical University of South Carolina, Charleston, SC
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14
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Kuo LC, Yang KC, Lin YC, Lin YC, Yeh CH, Su FC, Hsu HY. Internet of Things (IoT) Enables Robot-Assisted Therapy as a Home Program for Training Upper Limb Functions in Chronic Stroke: A Randomized Control Crossover Study. Arch Phys Med Rehabil 2023; 104:363-371. [PMID: 36122608 DOI: 10.1016/j.apmr.2022.08.976] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/18/2022] [Accepted: 08/31/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To compare the effects of using an Internet of things (IoT)-assisted tenodesis-induced-grip exoskeleton robot (TIGER) and task-specific motor training (TSMT) as home programs for the upper-limb (UL) functions of patients with chronic stroke to overturn conventional treatment modes for stroke rehabilitation. DESIGN A randomized 2-period crossover study. SETTING A university hospital. PARTICIPANTS Eighteen chronic stroke patients were recruited and randomized to receive either the IoT-assisted TIGER first or TSMT first at the beginning of the experiment (N=18). INTERVENTION In addition to the standard hospital-based therapy, participants were allocated to receive a 30-minute home-based, self-administered program of either IoT-assisted TIGER first or TSMT first twice daily for 4 weeks, with the order of both treatments reversed after a 12-week washout period. The exercise mode of the TIGER training included continuous passive motion and the functional mode of gripping pegs. The TSMT involved various movement components of the wrist and hand. MAIN OUTCOME MEASURES The outcome measures included the box and block test (BBT), the Fugl-Meyer assessment for upper extremity (FMA-UE), the motor activity log, the Semmes-Weinstein Monofilament test, the range of motion (ROM) of the wrist joint, and the modified Ashworth scale. RESULTS Significant treatment-by-time interaction effects emerged in the results for the BBT (F(1.31)=5.212 and P=.022), the FMA-UE (F(1.31)=6.807 and P=.042), and the ROM of the wrist extension (F(1.31)=8.618 and P=.009). The participants who trained at home with the IoT-assisted TIGER showed more improvement of their UL functions. CONCLUSIONS The IoT-assisted TIGER training has the potential for restoring the UL functions of stroke patients.
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Affiliation(s)
- Li-Chieh Kuo
- Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan; Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biomedical Engineering, College of Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Kang-Chin Yang
- Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Chen Lin
- Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational Therapy, Da-Yeh University, Changhua, Taiwan.
| | - Chien-Hsien Yeh
- Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Fong-Chin Su
- Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan; Department of Biomedical Engineering, College of Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Hsiu-Yun Hsu
- Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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15
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Swanson VA, Johnson C, Zondervan DK, Bayus N, McCoy P, Ng YFJ, Schindele, BS J, Reinkensmeyer DJ, Shaw S. Optimized Home Rehabilitation Technology Reduces Upper Extremity Impairment Compared to a Conventional Home Exercise Program: A Randomized, Controlled, Single-Blind Trial in Subacute Stroke. Neurorehabil Neural Repair 2023; 37:53-65. [PMID: 36636751 PMCID: PMC9896541 DOI: 10.1177/15459683221146995] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Upper extremity (UE) stroke rehabilitation requires patients to perform exercises at home, yet patients show limited benefit from paper-based home exercise programs. OBJECTIVE To compare the effectiveness of 2 home exercise programs for reducing UE impairment: a paper-based approach and a sensorized exercise system that incorporates recommended design features for home rehabilitation technology. METHODS In this single-blind, randomized controlled trial, 27 participants in the subacute phase of stroke were assigned to the sensorized exercise (n = 14) or conventional therapy group (n = 13), though 2 participants in the conventional therapy group were lost to follow-up. Participants were instructed to perform self-guided movement training at home for at least 3 hours/week for 3 consecutive weeks. The sensorized exercise group used FitMi, a computer game with 2 puck-like sensors that encourages movement intensity and auto-progresses users through 40 exercises. The conventional group used a paper book of exercises. The primary outcome measure was the change in Upper Extremity Fugl-Meyer (UEFM) score from baseline to follow-up. Secondary measures included the Modified Ashworth Scale for spasticity (MAS) and the Visual Analog Pain (VAP) scale. RESULTS Participants who used FitMi improved by an average of 8.0 ± 4.6 points on the UEFM scale compared to 3.0 ± 6.1 points for the conventional participants, a significant difference (t-test, P = .029). FitMi participants exhibited no significant changes in UE MAS or VAP scores. CONCLUSIONS A sensor-based exercise system incorporating a suite of recommended design features significantly and safely reduced UE impairment compared to a paper-based, home exercise program. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03503617.
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Affiliation(s)
- Veronica A. Swanson
- Department of Mechanical and Aerospace
Engineering, Henry Samueli School of Engineering, University of California, Irvine,
Irvine, CA, USA,Veronica A. Swanson, University of
California, Irvine, 3225 Engineering Gateway, Irvine, CA 92697-3975, USA.
| | - Christopher Johnson
- Department of Biomedical Engineering,
Henry Samueli School of Engineering, University of California, Irvine, Irvine, CA,
USA
| | | | - Nicole Bayus
- Rancho Research Institute, Rancho Los
Amigos National Rehabilitation Hospital, Downey, USA
| | - Phylicia McCoy
- Arthur J. Bond Department of Mechanical
Engineering, Alabama A&M University, Huntsville, AL, USA
| | - Yat Fung Joshua Ng
- School of Social Sciences, University
of California, Irvine, Irvine, CA, USA
| | - Jenna Schindele, BS
- Mathematics and Statistics, University
of California, Los Angeles, Los Angeles, CA, USA
| | - David J. Reinkensmeyer
- Department of Mechanical and Aerospace
Engineering, Henry Samueli School of Engineering, University of California, Irvine,
Irvine, CA, USA,Department of Anatomy and Neurobiology,
UC Irvine School of Medicine, University of California, Irvine, Irvine, CA,
USA
| | - Susan Shaw
- Department of Neurology, Rancho Los
Amigos National Rehabilitation Center, Downey, CA, USA
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16
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Lee Friesen C, Lawrence M, Ingram TGJ, Boe SG. Home-based portable fNIRS-derived cortical laterality correlates with impairment and function in chronic stroke. Front Hum Neurosci 2022; 16:1023246. [PMID: 36569472 PMCID: PMC9780676 DOI: 10.3389/fnhum.2022.1023246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction Improved understanding of the relationship between post-stroke rehabilitation interventions and functional motor outcomes could result in improvements in the efficacy of post-stroke physical rehabilitation. The laterality of motor cortex activity (M1-LAT) during paretic upper-extremity movement has been documented as a useful biomarker of post-stroke motor recovery. However, the expensive, labor intensive, and laboratory-based equipment required to take measurements of M1-LAT limit its potential clinical utility in improving post-stroke physical rehabilitation. The present study tested the ability of a mobile functional near-infrared spectroscopy (fNIRS) system (designed to enable independent measurement by stroke survivors) to measure cerebral hemodynamics at the motor cortex in the homes of chronic stroke survivors. Methods Eleven chronic stroke survivors, ranging widely in their level of upper-extremity motor deficit, used their stroke-affected upper-extremity to perform a simple unilateral movement protocol in their homes while a wireless prototype fNIRS headband took measurements at the motor cortex. Measures of participants' upper-extremity impairment and function were taken. Results Participants demonstrated either a typically lateralized response, with an increase in contralateral relative oxyhemoglobin (ΔHbO), or response showing a bilateral pattern of increase in ΔHbO during the motor task. During the simple unilateral task, M1-LAT correlated significantly with measures of both upper-extremity impairment and function, indicating that participants with more severe motor deficits had more a more atypical (i.e., bilateral) pattern of lateralization. Discussion These results indicate it is feasible to gain M1-LAT measures from stroke survivors in their homes using fNIRS. These findings represent a preliminary step toward the goals of using ergonomic functional neuroimaging to improve post-stroke rehabilitative care, via the capture of neural biomarkers of post-stroke motor recovery, and/or via use as part of an accessible rehabilitation brain-computer-interface.
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Affiliation(s)
- Christopher Lee Friesen
- Laboratory for Brain Recovery and Function, Dalhousie University, Halifax, NS, Canada
- Axem Neurotechnology, Halifax, NS, Canada
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada
| | - Michael Lawrence
- Laboratory for Brain Recovery and Function, Dalhousie University, Halifax, NS, Canada
- Axem Neurotechnology, Halifax, NS, Canada
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada
| | - Tony Gerald Joseph Ingram
- Laboratory for Brain Recovery and Function, Dalhousie University, Halifax, NS, Canada
- Axem Neurotechnology, Halifax, NS, Canada
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada
| | - Shaun Gregory Boe
- Laboratory for Brain Recovery and Function, Dalhousie University, Halifax, NS, Canada
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada
- School of Health and Human Performance, Dalhousie University, Halifax, NS, Canada
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
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17
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Vitrac C, Nallet-Khosrofian L, Iijima M, Rioult-Pedotti MS, Luft A. Endogenous dopamine transmission is crucial for motor skill recovery after stroke. IBRO Neurosci Rep 2022; 13:15-21. [PMID: 35707766 PMCID: PMC9189999 DOI: 10.1016/j.ibneur.2022.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Clément Vitrac
- Vascular Neurology and Rehabilitation, Department of Neurology, University of Zürich, Switzerland
- Correspondence to: Universitätspital Zürich, Vascular Neurology and Rehabilitation, Rämistrasse 100, 8091 Zürich, Switzerland.
| | | | - Maiko Iijima
- Vascular Neurology and Rehabilitation, Department of Neurology, University of Zürich, Switzerland
| | - Mengia-Seraina Rioult-Pedotti
- Vascular Neurology and Rehabilitation, Department of Neurology, University of Zürich, Switzerland
- Department of MCB, Brown University, Providence, RI, USA
| | - Andreas Luft
- Center for Neurology and Rehabilitation, Vitznau, Switzerland
- Department of Neurology, University Hospital Zürich, Zürich, Switzerland
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18
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PrimSeq: A deep learning-based pipeline to quantitate rehabilitation training. PLOS DIGITAL HEALTH 2022; 1. [PMID: 36420347 PMCID: PMC9681023 DOI: 10.1371/journal.pdig.0000044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Stroke rehabilitation seeks to accelerate motor recovery by training functional activities, but may have minimal impact because of insufficient training doses. In animals, training hundreds of functional motions in the first weeks after stroke can substantially boost upper extremity recovery. The optimal quantity of functional motions to boost recovery in humans is currently unknown, however, because no practical tools exist to measure them during rehabilitation training. Here, we present PrimSeq, a pipeline to classify and count functional motions trained in stroke rehabilitation. Our approach integrates wearable sensors to capture upper-body motion, a deep learning model to predict motion sequences, and an algorithm to tally motions. The trained model accurately decomposes rehabilitation activities into elemental functional motions, outperforming competitive machine learning methods. PrimSeq furthermore quantifies these motions at a fraction of the time and labor costs of human experts. We demonstrate the capabilities of PrimSeq in previously unseen stroke patients with a range of upper extremity motor impairment. We expect that our methodological advances will support the rigorous measurement required for quantitative dosing trials in stroke rehabilitation. Stroke commonly damages motor function in the upper extremity (UE), leading to long-term disability and loss of independence in a majority of individuals. Rehabilitation seeks to restore function by training daily activities, which deliver repeated UE functional motions. The optimal number of functional motions necessary to boost recovery is unknown. This gap stems from the lack of measurement tools to feasibly count functional motions. We thus developed the PrimSeq pipeline to enable the accurate and rapid counting of building-block functional motions, called primitives. PrimSeq uses wearable sensors to capture rich motion information from the upper body, and custom-built algorithms to detect and count functional primitives in this motion data. We showed that our deep learning algorithm precisely counts functional primitives performed by stroke patients and outperformed other benchmark algorithms. We also showed patients tolerated the wearable sensors and that the approach is 366 times faster at counting primitives than humans. PrimSeq thus provides a precise and practical means of quantifying functional primitives, which promises to advance stroke research and clinical care and to improve the outcomes of individuals with stroke.
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19
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Frisoli A, Barsotti M, Sotgiu E, Lamola G, Procopio C, Chisari C. A randomized clinical control study on the efficacy of three-dimensional upper limb robotic exoskeleton training in chronic stroke. J Neuroeng Rehabil 2022; 19:14. [PMID: 35120546 PMCID: PMC8817500 DOI: 10.1186/s12984-022-00991-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 01/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Although robotics assisted rehabilitation has proven to be effective in stroke rehabilitation, a limited functional improvements in Activities of Daily Life has been also observed after the administration of robotic training. To this aim in this study we compare the efficacy in terms of both clinical and functional outcomes of a robotic training performed with a multi-joint functional exoskeleton in goal-oriented exercises compared to a conventional physical therapy program, equally matched in terms of intensity and time. As a secondary goal of the study, it was assessed the capability of kinesiologic measurements—extracted by the exoskeleton robotic system—of predicting the rehabilitation outcomes using a set of robotic biomarkers collected at the baseline.
Methods A parallel-group randomized clinical trial was conducted within a group of 26 chronic post-stroke patients. Patients were randomly assigned to two groups receiving robotic or manual therapy. The primary outcome was the change in score on the upper extremity section of the Fugl-Meyer Assessment (FMA) scale. As secondary outcome a specifically designed bimanual functional scale, Bimanual Activity Test (BAT), was used for upper limb functional evaluation. Two robotic performance indices were extracted with the purpose of monitoring the recovery process and investigating the interrelationship between pre-treatment robotic biomarkers and post-treatment clinical improvement in the robotic group. Results A significant clinical and functional improvements in both groups (p < 0.01) was reported. More in detail a significantly higher improvement of the robotic group was observed in the proximal portion of the FMA (p < 0.05) and in the reduction of time needed for accomplishing the tasks of the BAT (p < 0.01). The multilinear-regression analysis pointed out a significant correlation between robotic biomarkers at the baseline and change in FMA score (R2 = 0.91, p < 0.05), suggesting their potential ability of predicting clinical outcomes. Conclusion Exoskeleton-based robotic upper limb treatment might lead to better functional outcomes, if compared to manual physical therapy. The extracted robotic performance could represent predictive indices of the recovery of the upper limb. These results are promising for their potential exploitation in implementing personalized robotic therapy. Clinical Trial Registration clinicaltrials.gov, NCT03319992 Unique Protocol ID: RH-UL-LEXOS-10. Registered 20.10.2017, https://clinicaltrials.gov/ct2/show/NCT03319992
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Affiliation(s)
- Antonio Frisoli
- Institute of Mechanical Intelligence, Scuola Superiore Sant'Anna of Pisa, PERCRO Lab, Via Alamanni, 13b, San Giuliano Terme, Ghezzano, 56010, Pisa, Italy.
| | - Michele Barsotti
- Institute of Mechanical Intelligence, Scuola Superiore Sant'Anna of Pisa, PERCRO Lab, Via Alamanni, 13b, San Giuliano Terme, Ghezzano, 56010, Pisa, Italy
| | - Edoardo Sotgiu
- INL-International Iberian Nanotechnology Laboratory, Braga, Portugal
| | | | - Caterina Procopio
- Institute of Mechanical Intelligence, Scuola Superiore Sant'Anna of Pisa, PERCRO Lab, Via Alamanni, 13b, San Giuliano Terme, Ghezzano, 56010, Pisa, Italy
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20
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Metzler MJ, O'Grady K, Fay L, Herrero M, Dunbar M, Fehlings D, Andersen J, Kirton A. Feasibility of High Repetition Upper Extremity Rehabilitation for Children with Unilateral Cerebral Palsy. Phys Occup Ther Pediatr 2022; 42:242-258. [PMID: 34872435 DOI: 10.1080/01942638.2021.2010857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIMS In pediatric upper extremity rehabilitation, feasible repetition rates are unknown. Our objectives were to examine repetition rates during rehabilitation and their impact on outcomes. METHODS Children with unilateral cerebral palsy due to perinatal stroke (n = 55, median 10 y 7 mo, 30 males) received Constraint-Induced Movement Therapy (CIMT) followed by Bimanual Therapy, each for 5 days. Repetitions were documented during one-on-one therapy (1.5 h/day). Outcomes included the Assisting Hand Assessment (AHA), Jebsen Taylor Test of Hand Function (JTTHF), and Box and Block Test (BBT). Means and standard deviations for motor outcomes and frequencies for repetition rates were calculated. Factors associated with repetition rates and outcome change were explored using standard linear regression. RESULTS Repetitions/hour averaged 365 ± 165 during CIMT and 285 ± 103 during Bimanual Therapy. Higher repetition rates were associated with higher baseline function by older age, a main effect of younger age, and improving motor skill (p < .05). Higher repetition rates corresponded with improvement of the AHA and BBT (p < .05, standardized ß = 0.392, 0.358). CONCLUSIONS Results suggest high repetition therapy is feasible in school-aged children with perinatal stroke, albeit with high individual variability. Multiple associations between repetition rates and baseline function and change point to the clinical importance of this measurable and potentially modifiable factor.
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Affiliation(s)
- Megan J Metzler
- Department of Clinical Neurosciences, Alberta Children's Hospital, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | | | - Linda Fay
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Mia Herrero
- Department of Clinical Neurosciences, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Mary Dunbar
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Calgary Pediatric Stroke Program, University of Calgary, Calgary, Alberta, Canada
| | - Darcy Fehlings
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - John Andersen
- Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Adam Kirton
- Department of Clinical Neurosciences, Alberta Children's Hospital, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada.,Calgary Pediatric Stroke Program, University of Calgary, Calgary, Alberta, Canada.,Department of Pediatrics, Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Calgary, Alberta, Canada
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21
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Garro F, Chiappalone M, Buccelli S, De Michieli L, Semprini M. Neuromechanical Biomarkers for Robotic Neurorehabilitation. Front Neurorobot 2021; 15:742163. [PMID: 34776920 PMCID: PMC8579108 DOI: 10.3389/fnbot.2021.742163] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/22/2021] [Indexed: 02/06/2023] Open
Abstract
One of the current challenges for translational rehabilitation research is to develop the strategies to deliver accurate evaluation, prediction, patient selection, and decision-making in the clinical practice. In this regard, the robot-assisted interventions have gained popularity as they can provide the objective and quantifiable assessment of the motor performance by taking the kinematics parameters into the account. Neurophysiological parameters have also been proposed for this purpose due to the novel advances in the non-invasive signal processing techniques. In addition, other parameters linked to the motor learning and brain plasticity occurring during the rehabilitation have been explored, looking for a more holistic rehabilitation approach. However, the majority of the research done in this area is still exploratory. These parameters have shown the capability to become the “biomarkers” that are defined as the quantifiable indicators of the physiological/pathological processes and the responses to the therapeutical interventions. In this view, they could be finally used for enhancing the robot-assisted treatments. While the research on the biomarkers has been growing in the last years, there is a current need for a better comprehension and quantification of the neuromechanical processes involved in the rehabilitation. In particular, there is a lack of operationalization of the potential neuromechanical biomarkers into the clinical algorithms. In this scenario, a new framework called the “Rehabilomics” has been proposed to account for the rehabilitation research that exploits the biomarkers in its design. This study provides an overview of the state-of-the-art of the biomarkers related to the robotic neurorehabilitation, focusing on the translational studies, and underlying the need to create the comprehensive approaches that have the potential to take the research on the biomarkers into the clinical practice. We then summarize some promising biomarkers that are being under investigation in the current literature and provide some examples of their current and/or potential applications in the neurorehabilitation. Finally, we outline the main challenges and future directions in the field, briefly discussing their potential evolution and prospective.
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Affiliation(s)
- Florencia Garro
- Rehab Technologies, Istituto Italiano di Tecnologia, Genoa, Italy.,Department of Informatics, Bioengineering, Robotics and Systems Engineering, University of Genoa, Genoa, Italy
| | - Michela Chiappalone
- Rehab Technologies, Istituto Italiano di Tecnologia, Genoa, Italy.,Department of Informatics, Bioengineering, Robotics and Systems Engineering, University of Genoa, Genoa, Italy
| | - Stefano Buccelli
- Rehab Technologies, Istituto Italiano di Tecnologia, Genoa, Italy
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22
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Gharaei N, Ismail W, Grosan C, Hendradi R. Optimizing the setting of medical interactive rehabilitation assistant platform to improve the performance of the patients: A case study. Artif Intell Med 2021; 120:102151. [PMID: 34629147 DOI: 10.1016/j.artmed.2021.102151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 07/19/2021] [Accepted: 08/16/2021] [Indexed: 11/24/2022]
Abstract
Tele-rehabilitation is an alternative to the conventional rehabilitation service that helps patients in remote areas to access a service that is practical in terms of logistics and cost, in a controlled environment. It includes the usage of mobile phones or other wireless devices that are applied to rehabilitation exercises. Such applications or software include exercises in the form of virtual games, treatment monitoring based on the rehabilitation progress and data analysis. However, nowadays, physiotherapists use a default profiling setting for patients carrying out rehabilitation, due to lack of information. Medical Interactive Rehabilitation Assistant (MIRA) is a computer-based (virtual reality) rehabilitation platform. The profile setting includes: a level of difficulty, percentage of tolerance and maximum range. To the best of our knowledge, there is a lack of optimization in the parameter values setting of MIRA exergames that could enhance patients' performance. Generally, non-optimal profile setting leads to reduced effectiveness. Therefore, this study aims to develop a method that optimizes the profile setting of each patient according to the estimated (desired) optimal results. The proposed method is developed using unsupervised and supervised machine learning techniques. We use Self-Organizing Map (SOM) to cluster patient records into several distinct clusters. K-fold cross validation is applied to construct the prediction models. Classification And Regression Tree (CART) is utilized to predict the patient's optimal input setting for playing the MIRA games. The combination of these techniques seems to improve the efficiency of the standard (default) way in predicting the optimal settings for exergames. To evaluate the proposed method, we conduct an experiment with data collected from a rehabilitation center. We use three metrics to quantify the quality of the results: R-squared (R2), Mean Absolute Error (MAE) and Root Mean Square Error (RMSE). The results of experimental analysis demonstrate that the proposed method is effective in predicting the adequate parameter setting in MIRA platform. The method has potential to be implemented as an intelligent system for MIRA prediction in healthcare. Moreover, the method could be extended to similar platforms for which data is available to train our method on.
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Affiliation(s)
- Niayesh Gharaei
- Faculty of Science and Technology, Universiti Sains Islam Malaysia, Nilai, Negeri Sembilan, Malaysia.
| | - Waidah Ismail
- Faculty of Science and Technology, Universiti Sains Islam Malaysia, Nilai, Negeri Sembilan, Malaysia; Information System Study Program, Faculty Science and Technology, Universitas Airlangga, Indonesia Kampus C, Surabaya, Indonesia.
| | - Crina Grosan
- Department of Computer Science, Brunel University London, United Kingdom.
| | - Rimuljo Hendradi
- Information System Study Program, Faculty Science and Technology, Universitas Airlangga, Indonesia Kampus C, Surabaya, Indonesia.
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23
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Wolf VL, Ergul A. Progress and challenges in preclinical stroke recovery research. Brain Circ 2021; 7:230-240. [PMID: 35071838 PMCID: PMC8757504 DOI: 10.4103/bc.bc_33_21] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/16/2021] [Accepted: 10/22/2021] [Indexed: 01/29/2023] Open
Abstract
Significant innovations in the management of acute ischemic stroke have led to an increased incidence in the long-term complications of stroke. Therefore, there is an urgent need for improvements in and refinement of rehabilitation interventions that can lead to functional and neuropsychological recovery. The goal of this review is to summarize the current progress and challenges involved with preclinical stroke recovery research. Moving forward, stroke recovery research should be placing an increased emphasis on the incorporation of comorbid diseases and biological variables in preclinical models in order to overcome translational roadblocks to establishing successful clinical rehabilitation interventions.
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Affiliation(s)
- Victoria Lea Wolf
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | - Adviye Ergul
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
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24
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Noé E, Gómez A, Bernabeu M, Quemada I, Rodríguez R, Pérez T, López C, Laxe S, Colomer C, Ríos M, Juárez-Belaúnde A, González C, Pelayo R, Ferri J. Guía: Principios básicos de la neurorrehabilitación del paciente con daño cerebral adquirido. Recomendaciones de la Sociedad Española de Neurorrehabilitación. Neurologia 2021. [DOI: 10.1016/j.nrl.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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25
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Rogalewski A, Schäbitz WR. Stroke recovery enhancing therapies: lessons from recent clinical trials. Neural Regen Res 2021; 17:717-720. [PMID: 34472456 PMCID: PMC8530130 DOI: 10.4103/1673-5374.314287] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Poststroke recovery processes include restoration or compensation of function, respectively functions initially lost or new functions acquired after an injury. Therapeutic interventions can enhance these processes and/or reduce processes impeding regeneration. Numerous experimental studies suggest great opportunities for such treatments, but the results from recent large clinical trials using neuromodulators such as dopamine and fluoxetine are disappointing. The reasons for this are manifold affecting forward translation of results from animals models into the human situation. This “translational road block” is defined by differences between animals and humans with regard to the genetic and epigenetic background, size and anatomy of the brain, cerebral vascular anatomy, immune system, as well as clinical function and behavior. Backward blockade includes the incompatible adaption of targets and outcomes in clinical trials with regard to prior preclinical findings. For example, the design of clinical recovery trials varies widely and was characterized by the selection of different clinical endpoints, the inclusion a broad spectrum of stroke subtypes and clinical syndromes as well as different time windows for treatment initiation after infarct onset. This review will discuss these aspects based on the results of the recent stroke recovery trials with the goal to contribute to the currently biggest unmet need in stroke research - the development of a recovery enhancing therapy that improves the functional outcome of a chronic stroke patient.
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Affiliation(s)
- Andreas Rogalewski
- Department of Neurology, Bethel - EVKB, University of Bielefeld, Bielefeld, Germany
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26
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Zhang SY, Jeffers MS, Lagace DC, Kirton A, Silasi G. Developmental and Interventional Plasticity of Motor Maps after Perinatal Stroke. J Neurosci 2021; 41:6157-6172. [PMID: 34083257 PMCID: PMC8276736 DOI: 10.1523/jneurosci.3185-20.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/14/2021] [Accepted: 05/20/2021] [Indexed: 02/07/2023] Open
Abstract
Within the perinatal stroke field, there is a need to establish preclinical models where putative biomarkers for motor function can be examined. In a mouse model of perinatal stroke, we evaluated motor map size and movement latency following optogenetic cortical stimulation against three factors of post-stroke biomarker utility: (1) correlation to chronic impairment on a behavioral test battery; (2) amenability to change using a skilled motor training paradigm; and (3) ability to distinguish individuals with potential to respond well to training. Thy1-ChR2-YFP mice received a photothrombotic stroke at postnatal day 7 and were evaluated on a battery of motor tests between days 59 and 70. Following a cranial window implant, mice underwent longitudinal optogenetic motor mapping both before and after 3 weeks of skilled forelimb training. Map size and movement latency of both hemispheres were positively correlated with impaired spontaneous forelimb use, whereas only ipsilesional hemisphere map size was correlated with performance in skilled reaching. Map size and movement latency did not show groupwise changes with training; however, mice with the smallest pretraining map sizes and worst impairments demonstrated the greatest expansion of map size in response to skilled forelimb training. Overall, motor map size showed utility as a potential biomarker for impairment and training-induced modulation in specific individuals. Future assessment of the predictive capacity of post-stroke motor representations for behavioral outcome in animal models opens the possibility of dissecting how plasticity mechanisms contribute to recovery following perinatal stroke.SIGNIFICANCE STATEMENT We investigated the utility of two cortical motor representation measures (motor map size and movement onset latency) as potential biomarkers for post-stroke motor recovery in a mouse model of perinatal stroke. Both motor map size and movement latency were associated with functional recovery after perinatal stroke, with map size showing an additional association between training responsiveness and severity of impairment. Overall, both motor map size and movement onset latency show potential as neurophysiological correlates of recovery. As such, future studies of perinatal stroke rehabilitation and neuromodulation should include these measures to help explain neurophysiological changes that might be occurring in response to treatment.
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Affiliation(s)
- Sarah Y Zhang
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5
| | - Matthew S Jeffers
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5
| | - Diane C Lagace
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5
- Ottawa Hospital Research Institute, Neuroscience Program, Ottawa, Ontario, Canada K1H 8L6
- Brain and Mind Research Institute, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5
| | - Adam Kirton
- Alberta Children's Hospital, Calgary Pediatric Stroke Program, Calgary, Alberta, Canada K1H 8M5
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada T2N 1N4
- Hotchkiss Brain Institute, Calgary, Alberta, Canada T2N 4N1
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada T2N 4N1
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada T2N 4N1
| | - Gergely Silasi
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5
- Brain and Mind Research Institute, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5
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27
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Ostrowska PM, Śliwiński M, Studnicki R, Hansdorfer-Korzon R. Telerehabilitation of Post-Stroke Patients as a Therapeutic Solution in the Era of the Covid-19 Pandemic. Healthcare (Basel) 2021; 9:654. [PMID: 34072939 PMCID: PMC8229171 DOI: 10.3390/healthcare9060654] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 01/11/2023] Open
Abstract
(1) Background: Due to the pandemic caused by the SARS-CoV-2 virus, rehabilitation centres have become less available for neurological patients. This is the result of efforts to physically distance society, to try to slow the spread of the pathogen. Health care facilities were mainly restricted to urgent cases, while most physiotherapy treatments, mainly for patients with chronic conditions, were suspended. Some countries have seen a reduction in acute stroke hospital admissions of from 50% to 80%. One solution to the above problem is the use of telerehabilitation in the home environment as an alternative to inpatient rehabilitation. (2) Aim of the study: The purpose of this review is to analyse the benefits and limitations of teletherapy in relation to the functional condition of post-stroke patients. (3) Methods: Selected publications from 2019 to 2021 on the telerehabilitation of stroke patients were reviewed. The review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. (4) Results: Studies have proven that teletherapy significantly improves the functional condition of post-stroke patients, resulting in improved quality of life and faster return to independence (while maintaining maximum possible precautions related to the SARS-CoV-2 virus pandemic). (5) Conclusions: Analysis of the study results showed comparable effectiveness of rehabilitation in the tele system to inpatient therapy. However, it should be emphasised that patients undergoing telerehabilitation must meet strict conditions to be eligible for this type of treatment program. However, the strength of the evidence itself supporting the effectiveness of this method ranks low due to the limited number of randomised control trials (RCT), small number of participants, and heterogeneous trials.
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Affiliation(s)
- Paulina Magdalena Ostrowska
- Department of Physiotherapy, Medical University of Gdańsk, 7 Dębinki Street, 80-211 Gdańsk, Poland; (M.Ś.); (R.S.); (R.H.-K.)
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28
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DeBoer SR, Hubbard R, Mersha M, Pinilla Monsalve G, Winter S, Zeiler SR. Enhanced Spontaneous Motor Recovery After Stroke in Mice Treated With Cerebrolysin. Neurorehabil Neural Repair 2021; 35:525-533. [PMID: 33955296 DOI: 10.1177/15459683211000734] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Motor recovery after stroke in humans and in rodent models is time sensitive. Recovery in patients is a result of biological spontaneous recovery via endogenous repair mechanisms and is likely improved by enhancing the synaptic plasticity required for endogenous repair. Cerebrolysin is a polypeptide preparation known to enhance neuroplasticity and may improve recovery in patients. In mice, we tested the hypothesis that Cerebrolysin can act poststroke to enhance both spontaneous and training-associated motor recovery. METHODS Mice were trained to perform a skilled prehension task. We then induced a photothrombotic stroke in the caudal forelimb area, after which we retrained animals on the prehension task in the presence or absence of Cerebrolysin after a 2-day or 8-day delay. Mice received daily intraperitoneal Cerebrolysin or saline injections starting poststroke day 1 or poststroke day 7. RESULTS Prior studies showed that poststroke recovery of prehension can occur if animals receive rehabilitative training during an early sensitive period but is incomplete if rehabilitative training is delayed. In contrast, we show complete recovery of prehension, despite a delay in rehabilitative training, when mice receive daily Cerebrolysin administration starting on poststroke day 1 or on poststroke day 8. When Cerebrolysin is given on poststroke day 1, recovery occurred even in the absence of training. Stroke volumes were similar across groups. CONCLUSIONS Poststroke Cerebrolysin administration leads to recovery of motor function independent of rehabilitative training without a protective effect on stroke volume. This is one of the first demonstrations of training-independent motor recovery in rodent stroke models.
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Affiliation(s)
| | | | | | | | - Stefan Winter
- Ever Neuro Pharma GmbH, Unterach, Oberösterreich, Austria
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29
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McDonald MW, Jeffers MS, Issa L, Carter A, Ripley A, Kuhl LM, Morse C, Comin CH, Jasmin BJ, Lacoste B, Corbett D. An Exercise Mimetic Approach to Reduce Poststroke Deconditioning and Enhance Stroke Recovery. Neurorehabil Neural Repair 2021; 35:471-485. [PMID: 33825581 PMCID: PMC8135250 DOI: 10.1177/15459683211005019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Evidence supports early rehabilitation after stroke to limit disability. However, stroke survivors are typically sedentary and experience significant cardiovascular and muscular deconditioning. Despite growing consensus that preclinical and clinical stroke recovery research should be aligned, there have been few attempts to incorporate cardiovascular and skeletal muscle deconditioning into animal models of stroke. Here, we demonstrate in rats that a hindlimb sensorimotor cortex stroke results in both cardiovascular and skeletal muscle deconditioning and impairments in gait akin to those observed in humans. To reduce poststroke behavioral, cardiovascular, and skeletal muscle perturbations, we then used a combinatorial intervention consisting of aerobic and resistance exercise in conjunction with administration of resveratrol (RESV), a drug with exercise mimetic properties. A combination of aerobic and resistance exercise mitigated decreases in cardiovascular fitness and attenuated skeletal muscle abnormalities. RESV, beginning 24 hours poststroke, reduced acute hindlimb impairments, improved recovery in hindlimb function, increased vascular density in the perilesional cortex, and attenuated skeletal muscle fiber changes. Early RESV treatment and aerobic and resistance exercise independently provided poststroke benefits, at a time when individuals are rapidly becoming deconditioned as a result of inactivity. Although no additive effects were observed in these experiments, this approach represents a promising strategy to reduce poststroke behavioral impairments and minimize deconditioning. As such, this treatment regime has potential for enabling patients to engage in more intensive rehabilitation at an earlier time following stroke when mechanisms of neuroplasticity are most prevalent.
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Affiliation(s)
- Matthew W McDonald
- University of Ottawa, ON, Canada.,Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada
| | - Matthew S Jeffers
- University of Ottawa, ON, Canada.,Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada
| | | | - Anthony Carter
- Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, ON, Canada
| | | | | | | | | | | | - Baptiste Lacoste
- University of Ottawa, ON, Canada.,Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, ON, Canada.,University of Ottawa Brain and Mind Research Institute, ON, Canada
| | - Dale Corbett
- University of Ottawa, ON, Canada.,Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada.,University of Ottawa Brain and Mind Research Institute, ON, Canada
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30
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Proietti T, O'Neill C, Hohimer CJ, Nuckols K, Clarke ME, Zhou YM, Lin DJ, Walsh CJ. Sensing and Control of a Multi-Joint Soft Wearable Robot for Upper-Limb Assistance and Rehabilitation. IEEE Robot Autom Lett 2021. [DOI: 10.1109/lra.2021.3061061] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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31
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Sommer CJ, Schäbitz WR. Principles and requirements for stroke recovery science. J Cereb Blood Flow Metab 2021; 41:471-485. [PMID: 33175596 PMCID: PMC7907998 DOI: 10.1177/0271678x20970048] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 10/03/2020] [Accepted: 10/05/2020] [Indexed: 12/11/2022]
Abstract
The disappointing results in bench-to-bedside translation of neuroprotective strategies caused a certain shift in stroke research towards enhancing the endogenous recovery potential of the brain. One reason for this focus on recovery is the much wider time window for therapeutic interventions which is open for at least several months. Since recently two large clinical studies using d-amphetamine or fluoxetine, respectively, to enhance post-stroke neurological outcome failed again it is a good time for a critical reflection on principles and requirements for stroke recovery science. In principal, stroke recovery science deals with all events from the molecular up to the functional and behavioral level occurring after brain ischemia eventually ending up with any measurable improvement of various clinical parameters. A detailed knowledge of the spontaneously occurring post-ischemic regeneration processes is the indispensable prerequisite for any therapeutic approaches aiming to modify these responses to enhance post-stroke recovery. This review will briefly illuminate the molecular mechanisms of post-ischemic regeneration and the principle possibilities to foster post-stroke recovery. In this context, recent translational approaches are analyzed. Finally, the principal and specific requirements and pitfalls in stroke recovery research as well as potential explanations for translational failures will be discussed.
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Affiliation(s)
- Clemens J Sommer
- Institute of Neuropathology, University Medical Center of the
Johannes Gutenberg-University Mainz, Mainz, Germany
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Hayward KS, Churilov L, Dalton EJ, Brodtmann A, Campbell BCV, Copland D, Dancause N, Godecke E, Hoffmann TC, Lannin NA, McDonald MW, Corbett D, Bernhardt J. Advancing Stroke Recovery Through Improved Articulation of Nonpharmacological Intervention Dose. Stroke 2021; 52:761-769. [PMID: 33430635 DOI: 10.1161/strokeaha.120.032496] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Dose articulation is a universal issue of intervention development and testing. In stroke recovery, dose of a nonpharmaceutical intervention appears to influence outcome but is often poorly reported. The challenges of articulating dose in nonpharmacological stroke recovery research include: (1) the absence of specific internationally agreed dose reporting guidelines; (2) inadequate conceptualization of dose, which is multidimensional; and (3) unclear and inconsistent terminology that incorporates the multiple dose dimensions. To address these challenges, we need a well-conceptualized and consistent approach to dose articulation that can be applied across stroke recovery domains to stimulate critical thinking about dose during intervention development, as well as promote reporting of planned intervention dose versus actually delivered dose. We followed the Design Research Paradigm to develop a framework that guides how to articulate dose, conceptualizes the multidimensional nature and systemic linkages between dose dimensions, and provides reference terminology for the field. Our framework recognizes that dose is multidimensional and comprised of a duration of days that contain individual sessions and episodes that can be active (time on task) or inactive (time off task), and each individual episode can be made up of information about length, intensity, and difficulty. Clinical utility of this framework was demonstrated via hypothetical application to preclinical and clinical domains of stroke recovery. The suitability of the framework to address dose articulation challenges was confirmed with an international expert advisory group. This novel framework provides a pathway for better articulation of nonpharmacological dose that will enable transparent and accurate description, implementation, monitoring, and reporting, in stroke recovery research.
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Affiliation(s)
- Kathryn S Hayward
- Melbourne School of Health Sciences, Florey Institute of Neuroscience and Mental Health and NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery (K.S.H.), University of Melbourne, Heidelberg, Australia
| | - Leonid Churilov
- Melbourne Medical School (L.C.), University of Melbourne, Parkville, Australia
| | - Emily J Dalton
- Melbourne School of Health Sciences (E.J.D.), University of Melbourne, Heidelberg, Australia
| | - Amy Brodtmann
- Florey Institute of Neuroscience and Mental Health (A.B.), University of Melbourne, Heidelberg, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital (B.C.V.C.), University of Melbourne, Parkville, Australia
| | - David Copland
- School of Health and Rehabilitation Sciences, Queensland Aphasia Research Centre and UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia (D. Copland).,NHMRC Centre of Research Excellence in Aphasia Recovery and Rehabilitation, Melbourne, Victoria, Australia (D. Copland, E.G.)
| | - Numa Dancause
- Département de Neurosciences, Université de Montréal, Canada (N.D.)
| | - Erin Godecke
- NHMRC Centre of Research Excellence in Aphasia Recovery and Rehabilitation, Melbourne, Victoria, Australia (D. Copland, E.G.).,School of Medical and Health Sciences, Edith Cowan University, and Speech Pathology Department, Sir Charles Gairdner Hospital, Perth, Australia (E.G.)
| | - Tammy C Hoffmann
- Institute for Evidence-Based Healthcare, Bond University, Robina, Australia (T.C.H.)
| | - Natasha A Lannin
- Department of Neurosciences, Central Clinical School, Alfred Health, Monash University, Melbourne, Australia (N.A.L.)
| | - Matthew W McDonald
- Cellular and Molecular Medicine and Canadian Partnership for Stroke Recovery, University of Ottawa, Canada (M.W.M., D. Corbett)
| | - Dale Corbett
- Cellular and Molecular Medicine and Canadian Partnership for Stroke Recovery, University of Ottawa, Canada (M.W.M., D. Corbett)
| | - Julie Bernhardt
- Florey Institute of Neuroscience and Mental Health and NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery (J.B.), University of Melbourne, Heidelberg, Australia
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Dalton EJ, Churilov L, Lannin NA, Corbett D, Campbell BCV, Hayward KS. Early-phase dose articulation trials are underutilized for post-stroke motor recovery: A systematic scoping review. Ann Phys Rehabil Med 2021; 65:101487. [PMID: 33429089 DOI: 10.1016/j.rehab.2021.101487] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND To enable development of effective interventions, there is a need to complete systematic early-phase dose articulation research. This scoping review aimed to synthesize dose articulation research of behavioral motor interventions for stroke recovery. METHODS MEDLINE and EMBASE were systematically searched for dose articulation studies. Preclinical experiments and adult clinical trials were classified based on the discovery pipeline and analyzed to determine which dose dimensions were articulated (time, scheduling or intensity) and how they were investigated (unidimensional vs multidimensional approach). Reporting of dose, safety and efficacy outcomes were summarized. The intervention description, risk of bias, and quality was appraised. RESULTS We included 41 studies: 3 of preclinical dose preparation (93 rodents), 2 Phase I dose ranging (21 participants), 9 Phase IIA dose screening (198 participants), and 27 Phase IIB dose finding (1879 participants). All studies adopted a unidimensional approach. Time was the most frequent dimension investigated (53%), followed by intensity (29%), and scheduling (18%). Overall, 95% studies reported an efficacy outcome; however, only 65% reported dose and 45% reported safety. Across studies, 61% were at high risk of bias, and the average percentage reporting of intervention description and quality was 61% and 67%, respectively. CONCLUSION This review highlights a need to undertake more high-quality, early-phase studies that systematically articulate intervention doses from a multidimensional perspective in the field of behavioral motor stroke recovery. To address this gap, we need to invest in adapting early phase trial designs, especially Phase I, to support multidimensional dose articulation.
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Affiliation(s)
- Emily J Dalton
- Melbourne School of Health Sciences, University of Melbourne, Heidelberg, Australia
| | - Leonid Churilov
- Melbourne Medical School, University of Melbourne, Parkville, Australia
| | - Natasha A Lannin
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia; Alfred Health, Melbourne, Australia
| | - Dale Corbett
- Cellular & Molecular Medicine and Canadian Partnership for Stroke Recovery, University of Ottawa, Canada
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Kathryn S Hayward
- Melbourne School of Health Sciences and Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, 3084 Heidelberg, Australia.
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Hansen GM, Brunner I, Pallesen H. Patients' and Health Professionals' Experiences of Group Training to Increase Intensity of Training after Acquired Brain Injury: A Focus Group Study. Rehabil Res Pract 2021; 2021:8838038. [PMID: 33505728 PMCID: PMC7808818 DOI: 10.1155/2021/8838038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/21/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Increased intensity of training in the subacute phase after acquired brain injury facilitates plasticity and enhances better function. Group training can be a motivating factor and an effective means of increasing intensity. Reports on patients' and health care professionals' experiences on increasing the amount of active practice through group training during in-patient rehabilitation after acquired brain injury have been limited. METHODS Two focus groups, patients and health care professionals, participated each in two interviews, before and after implementation of the Activity block, i.e., 2-hour daily intensive group training. The data from the interviews were analyzed from a phenomenological perspective. RESULTS Three categories emerged from the data analyzes (i) training intensity, (ii) motivation and meaningfulness, and (iii) expectations and concerns. Both groups experienced that the training after implementation of the Activity block had become more intense and that motivation was increased induced by the group setting. Also, both groups found self-management enhanced. Some challenges were also reported. Patients expressed concerns to finding a balance between rest and activity, while the health professionals mentioned practical challenges, i.e., planning the content of the day and finding their role in the Activity block. CONCLUSION Activity block benefitted a heterogeneous group of patients with acquired brain injury and was perceived as an overall positive experience by patients and health personnel. Matching the training to the individuals' need for support, finding a balance between rest and activity and using tasks that support patients' motivation, appeared important.
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Affiliation(s)
- Gunhild Mo Hansen
- Hammel Neurorehabilitation Centre and University Clinic, Aarhus University, Aarhus, Denmark
| | - Iris Brunner
- Hammel Neurorehabilitation Centre and University Clinic, Aarhus University, Aarhus, Denmark
| | - Hanne Pallesen
- Hammel Neurorehabilitation Centre and University Clinic, Aarhus University, Aarhus, Denmark
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Abstract
PURPOSE OF REVIEW This article describes restorative therapies to improve patient outcomes after stroke. These therapies contrast with acute stroke treatments such as recombinant tissue plasminogen activator (rtPA) and thrombectomy that target clots, aim to salvage threatened brain tissue to limit injury, and have a time window measured in hours. Restorative therapies target the brain, aim to promote plasticity within surviving brain tissue, and have a time window measured in days to weeks or longer. RECENT FINDINGS A number of drugs are under study. Preclinical studies are providing attractive therapeutic candidates for translation, such as the C-C chemokine receptor 5 inhibitor maraviroc. Some drug studies have used a pragmatic approach, which is premature for the nascent field of neural repair. Substantial data support the utility of activity-dependent therapies, including constraint-induced movement therapy, with recent studies supporting the need for very high doses to generate the best functional gains. While stem cell therapies are at an early stage, mounting preclinical evidence supports the efficacy of mesenchymal stem cells; some initial human studies are supportive. Several types of brain stimulation have been examined, and in some cases initial studies are promising. SUMMARY Improved insights into stroke recovery and its treatment have the potential to reduce disability in a large segment of stroke survivors.
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Lohse KR, Hawe RL, Dukelow SP, Scott SH. Statistical Considerations for Drawing Conclusions About Recovery. Neurorehabil Neural Repair 2020; 35:10-22. [PMID: 33317423 DOI: 10.1177/1545968320975437] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Numerous studies have found associations when change scores are regressed onto initial impairments in people with stroke (slopes ≈ 0.7). However, there are important statistical considerations that limit the conclusions we can draw about recovery from these studies. OBJECTIVE To provide an accessible checklist of conceptual and analytical issues on longitudinal measures of stroke recovery. Proportional recovery is an illustrative example, but these considerations apply broadly to studies of change over time. METHODS Using a pooled data set of n = 373 Fugl-Meyer Assessment upper extremity scores, we ran simulations to illustrate 3 considerations: (1) how change scores can be problematic in this context; (2) how "nil" and nonzero null-hypothesis significance tests can be used; and (3) how scale boundaries can create the illusion of proportionality, whereas other analytical procedures (eg, post hoc classifications) can augment this problem. RESULTS Our simulations highlight several limitations of common methods for analyzing recovery. We find that uniform recovery leads to similar group-level statistics (regression slopes) and individual-level classifications (into fitters and nonfitters) that have been claimed as evidence for the proportional recovery rule. New analyses, however, also speak to the complexities in variance about the regression slope. CONCLUSIONS Our results highlight that one cannot identify whether proportional recovery is true or not based on commonly used methods. We illustrate how these techniques, measurement tools, and post hoc classifications (eg, nonfitters) can create spurious results. Going forward, the field needs to carefully consider the influence of these factors on how we measure, analyze, and conceptualize recovery.
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Kjeldsen SS, Brodal L, Brunner I. Activity and rest in patients with severe acquired brain injury: an observational study. Disabil Rehabil 2020; 44:2744-2751. [PMID: 33161752 DOI: 10.1080/09638288.2020.1844317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To examine activity levels, types of activities and their distribution across the day in patients with severe acquired brain injury including disorders of consciousness admitted to subacute neurorehabilitation. METHODS In this observational cross-sectional study, a modified behavioural mapping tool was used to document activity of patients admitted to a specialized rehabilitation ward for three consecutive days from 8.00 am to 8.00 pm. Observers walked a fixed route and returned to each patient every 10 min. RESULTS Complete data was obtained in 1722/1728 observations on eight patients. Patients were registered as being in any activity in 55.6% and resting or sleeping in 30.3% of all observations. Patients were alone for 50.4% and were lying or sitting for 98.5% of the time. The major part (45%) of rehabilitation activities occurred during the morning before noon. The odds of being engaged in a rehabilitation activity were significantly different from afternoon and evening p = 0.02. Patients with higher function were more active. CONCLUSION Patients with severe ABI were involved in some kind of activity for more than half the day and resting approximately 1/3 of the day. Health personnel and visitors were present in most activities.Implications for rehabilitationRehabilitation of patients with severe acquired brain injury (ABI) comprises a high level of a broad range of activities and interactions.In order to truly offer round the clock rehabilitation, rehabilitation hospitals need to focus on delivering rehabilitation activities evenly across the waking hours.The long periods of daytime sleep and rest in patients with severe ABI should be further examined as there might be a potential to intensify rehabilitation.
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Affiliation(s)
- Simon S Kjeldsen
- Hammel Neurocenter and University Research Clinic, Aarhus University, Aarhus, Denmark
| | - Liv Brodal
- Department of Physiotherapy, Faculty of Health Science, VIA University College, Aarhus, Denmark
| | - Iris Brunner
- Hammel Neurocenter and University Research Clinic, Aarhus University, Aarhus, Denmark
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Wu J, Dodakian L, See J, Burke Quinlan E, Meng L, Abraham J, Wong EC, Le V, McKenzie A, Cramer SC. Gains Across WHO Dimensions of Function After Robot-Based Therapy in Stroke Subjects. Neurorehabil Neural Repair 2020; 34:1150-1158. [PMID: 33084499 DOI: 10.1177/1545968320956648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Studies examining the effects of therapeutic interventions after stroke often focus on changes in loss of body function/structure (impairment). However, improvements in activities limitations and participation restriction are often higher patient priorities, and the relationship that these measures have with loss of body function/structure is unclear. OBJECTIVE This study measured gains across WHO International Classification of Function (ICF) dimensions and examined their interrelationships. METHODS Subjects were recruited 11 to 26 weeks after hemiparetic stroke. Over a 3-week period, subjects received 12 sessions of intensive robot-based therapy targeting the distal arm. Each subject was assessed at baseline and at 1 month after end of therapy. RESULTS At baseline, subjects (n = 40) were 134.7 ± 32.4 (mean ± SD) days poststroke and had moderate-severe arm motor deficits (arm motor Fugl-Meyer score of 35.6 ± 14.4) that were stable. Subjects averaged 2579 thumb movements and 1298 wrist movements per treatment session. After robot therapy, there was significant improvement in measures of body function/structure (Fugl-Meyer score) and activity limitations (Action Research Arm Test, Barthel Index, and Stroke Impact Scale-Hand), but not participation restriction (Stroke Specific Quality of Life Scale). Furthermore, while the degree of improvement in loss of body function/structure was correlated with improvement in activity limitations, neither improvement in loss of body function/structure nor improvement in activity limitations was correlated with change in participation restriction. CONCLUSIONS After a 3-week course of robotic therapy, there was improvement in body function/structure and activity limitations but no reduction in participation restriction.
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Affiliation(s)
- Jennifer Wu
- University of California, Irvine, Orange, CA, USA
| | | | - Jill See
- University of California, Irvine, Orange, CA, USA
| | - Erin Burke Quinlan
- University of California, Irvine, Orange, CA, USA.,Institute of Psychiatry, Psychology, & Neuroscience and King's College London, London, England, UK
| | - Lisa Meng
- University of California, Irvine, Orange, CA, USA
| | - Jeby Abraham
- University of California, Irvine, Orange, CA, USA.,Tripler Army Medical Center, Honolulu, HI, USA
| | - Ellen C Wong
- University of California, Los Angeles, and California Rehabilitation Institute, Los Angeles, CA, USA
| | - Vu Le
- University of California, Irvine, Orange, CA, USA
| | | | - Steven C Cramer
- University of California, Irvine, Orange, CA, USA.,University of California, Los Angeles, and California Rehabilitation Institute, Los Angeles, CA, USA
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Thakkar HK, Liao WW, Wu CY, Hsieh YW, Lee TH. Predicting clinically significant motor function improvement after contemporary task-oriented interventions using machine learning approaches. J Neuroeng Rehabil 2020; 17:131. [PMID: 32993692 PMCID: PMC7523081 DOI: 10.1186/s12984-020-00758-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 09/10/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Accurate prediction of motor recovery after stroke is critical for treatment decisions and planning. Machine learning has been proposed to be a promising technique for outcome prediction because of its high accuracy and ability to process large volumes of data. It has been used to predict acute stroke recovery; however, whether machine learning would be effective for predicting rehabilitation outcomes in chronic stroke patients for common contemporary task-oriented interventions remains largely unexplored. This study aimed to determine the accuracy and performance of machine learning to predict clinically significant motor function improvements after contemporary task-oriented intervention in chronic stroke patients and identify important predictors for building machine learning prediction models. METHODS This study was a secondary analysis of data using two common machine learning approaches, which were the k-nearest neighbor (KNN) and artificial neural network (ANN). Chronic stroke patients (N = 239) that received 30 h of task-oriented training including the constraint-induced movement therapy, bilateral arm training, robot-assisted therapy and mirror therapy were included. The Fugl-Meyer assessment scale (FMA) was the main outcome. Potential predictors include age, gender, side of lesion, time since stroke, baseline functional status, motor function and quality of life. We divided the data set into a training set and a test set and used the cross-validation procedure to construct machine learning models based on the training set. After the models were built, we used the test data set to evaluate the accuracy and prediction performance of the models. RESULTS Three important predictors were identified, which were time since stroke, baseline functional independence measure (FIM) and baseline FMA scores. Models for predicting motor function improvements were accurate. The prediction accuracy of the KNN model was 85.42% and area under the receiver operating characteristic curve (AUC-ROC) was 0.89. The prediction accuracy of the ANN model was 81.25% and the AUC-ROC was 0.77. CONCLUSIONS Incorporating machine learning into clinical outcome prediction using three key predictors including time since stroke, baseline functional and motor ability may help clinicians/therapists to identify patients that are most likely to benefit from contemporary task-oriented interventions. The KNN and ANN models may be potentially useful for predicting clinically significant motor recovery in chronic stroke.
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Affiliation(s)
- Hiren Kumar Thakkar
- Department of Computer Science Engineering and School of Engineering and Applied Sciences, Bennett University, Plot Nos 8-11, TechZone II, Greater Noida, 201310 Uttar Pradesh India
| | - Wan-wen Liao
- Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Taoyuan, Taiwan
| | - Ching-yi Wu
- Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Taoyuan, Taiwan
- Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan
- Department of Physical Medicine and Rehabilitation, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Wei Hsieh
- Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Taoyuan, Taiwan
- Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan
- Department of Physical Medicine and Rehabilitation, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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40
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Poststroke Impairment and Recovery Are Predicted by Task-Specific Regionalization of Injury. J Neurosci 2020; 40:6082-6097. [PMID: 32605940 DOI: 10.1523/jneurosci.0057-20.2020] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 06/18/2020] [Accepted: 06/24/2020] [Indexed: 01/01/2023] Open
Abstract
Lesion size and location affect the magnitude of impairment and recovery following stroke, but the precise relationship between these variables and functional outcome is unknown. Herein, we systematically varied the size of strokes in motor cortex and surrounding regions to assess effects on impairment and recovery of function. Female Sprague Dawley rats (N = 64) were evaluated for skilled reaching, spontaneous limb use, and limb placement over a 7 week period after stroke. Exploration and reaching were also tested in a free ranging, more naturalistic, environment. MRI voxel-based analysis of injury volume and its likelihood of including the caudal forelimb area (CFA), rostral forelimb area (RFA), hindlimb (HL) cortex (based on intracranial microstimulation), or their bordering regions were related to both impairment and recovery. Severity of impairment on each task was best predicted by injury in unique regions: impaired reaching, by damage in voxels encompassing CFA/RFA; hindlimb placement, by damage in HL; and spontaneous forelimb use, by damage in CFA. An entirely different set of voxels predicted recovery of function: damage lateral to RFA reduced recovery of reaching, damage medial to HL reduced recovery of hindlimb placing, and damage lateral to CFA reduced recovery of spontaneous limb use. Precise lesion location is an important, but heretofore relatively neglected, prognostic factor in both preclinical and clinical stroke studies, especially those using region-specific therapies, such as transcranial magnetic stimulation.SIGNIFICANCE STATEMENT By estimating lesion location relative to cortical motor representations, we established the relationship between individualized lesion location, and functional impairment and recovery in reaching/grasping, spontaneous limb use, and hindlimb placement during walking. We confirmed that stroke results in impairments to specific motor domains linked to the damaged cortical subregion and that damage encroaching on adjacent regions reduces the ability to recover from initial lesion-induced impairments. Each motor domain encompasses unique brain regions that are most associated with recovery and likely represent targets where beneficial reorganization is taking place. Future clinical trials should use individualized therapies (e.g., transcranial magnetic stimulation, intracerebral stem/progenitor cells) that consider precise lesion location and the specific functional impairments of each subject since these variables can markedly affect therapeutic efficacy.
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41
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Sanders Q, Chan V, Augsburger R, Cramer SC, Reinkensmeyer DJ, Do AH. Feasibility of Wearable Sensing for In-Home Finger Rehabilitation Early After Stroke. IEEE Trans Neural Syst Rehabil Eng 2020; 28:1363-1372. [PMID: 32305930 DOI: 10.1109/tnsre.2020.2988177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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42
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Advances and challenges in stroke rehabilitation. Lancet Neurol 2020; 19:348-360. [PMID: 32004440 DOI: 10.1016/s1474-4422(19)30415-6] [Citation(s) in RCA: 321] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/20/2019] [Accepted: 10/21/2019] [Indexed: 01/21/2023]
Abstract
Stroke remains a leading cause of adult disability and the demand for stroke rehabilitation services is growing. Substantial advances are yet to be made in stroke rehabilitation practice to meet this demand and improve patient outcomes relative to current care. Several large intervention trials targeting motor recovery report that participants' motor performance improved, but to a similar extent for both the intervention and control groups in most trials. These neutral results might reflect an absence of additional benefit from the tested interventions or the many challenges of designing and doing large stroke rehabilitation trials. Strategies for improving trial quality include new approaches to the selection of patients, control interventions, and endpoint measures. Although stroke rehabilitation research strives for better trials, interventions, and outcomes, rehabilitation practices continue to help patients regain independence after stroke.
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43
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Abstract
Novel therapeutic intervention that aims to enhance the endogenous recovery potential of the brain during the subacute phase of stroke has produced promising results. The paradigm shift in treatment approaches presents new challenges to preclinical and clinical researchers alike, especially in the functional endpoints domain. Shortcomings of the "neuroprotection" era of stroke research are yet to be fully addressed. Proportional recovery observed in clinics, and potentially in animal models, requires a thorough reevaluation of the methods used to assess recovery. To this end, this review aims to give a detailed evaluation of functional outcome measures used in clinics and preclinical studies. Impairments observed in clinics and animal models will be discussed from a functional testing perspective. Approaches needed to bridge the gap between clinical and preclinical research, along with potential means to measure the moving target recovery, will be discussed. Concepts such as true recovery of function and compensation and methods that are suitable for distinguishing the two are examined. Often-neglected outcomes of stroke, such as emotional disturbances, are discussed to draw attention to the need for further research in this area.
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Affiliation(s)
- Mustafa Balkaya
- Burke Neurological Research Institute, White Plains, NY, USA
| | - Sunghee Cho
- Burke Neurological Research Institute, White Plains, NY, USA.,Feil Family Brain and Mind Research Institute, Weill Cornell Medicine at Burke Neurological Research Institute, White Plains, NY, USA
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44
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Dalton E, Churilov L, Lannin NA, Corbett D, Hayward KS. Dose Articulation in Preclinical and Clinical Stroke Recovery: Refining a Discovery Research Pipeline and Presenting a Scoping Review Protocol. Front Neurol 2019; 10:1148. [PMID: 31781018 PMCID: PMC6851169 DOI: 10.3389/fneur.2019.01148] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/14/2019] [Indexed: 02/03/2023] Open
Abstract
Introduction: Despite an increase in the quality of clinical trials in stroke recovery, interventions have failed to markedly impact the trajectory of recovery after stroke. Failure may be due to the lack of consideration for the complexity of dose and its articulation within research trials. Prior to commencing the scoping review, we identified two research gaps to be addressed. Firstly, transparent application of a multidimensional definition of dose to clinical trial phases and secondly, the development of a quality tool to critique the articulation of dose across the pipeline. Building on this, we present the protocol for a scoping review that aims to synthesis what is known about dose articulation in stroke recovery in preclinical and clinical populations, and characterize research designs and statistical approaches used in dose articulation trials, and the associated advantages and disadvantages. Methods: The scoping review will apply Arksey and O'Malley's methodological framework. Two systematic searches that target preclinical and clinical literature will be run in Medline and Embase, which will be complimented by consultation with field experts and hand searching of included trials and relevant reviews. Search results will be imported into Covidence for transparent management. One reviewer will screen all abstracts and titles. Two reviewers will screen full text and a third reviewer included to resolve discrepancies. A standardized data charting form will be used to extract information and appraise the intervention description, risk of bias, and quality of both preclinical and clinical studies. Results will be summarized in tabular and narrative format to inform the development of recommendations for future research. Ethics approval is not required as data used will be secondary and de-identified. Conclusion: Development of a new quality tool to appraise the quality of both preclinical and clinical dose studies may serve to strengthen collaborative efforts between the fields. The findings from this review will advance the use of a discovery pipeline in stroke recovery research to ultimately inform clinical practice.
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Affiliation(s)
- Emily Dalton
- Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Parkville, VIC, Australia
| | - Leonid Churilov
- Melbourne Medical School, University of Melbourne, Parkville, VIC, Australia.,NHMRC CRE in Stroke Rehabilitation and Brain Recovery, University of Melbourne, Heidelberg, VIC, Australia
| | - Natasha A Lannin
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Department of Occupational Therapy, Alfred Health, Prahran, VIC, Australia
| | - Dale Corbett
- Cellular and Molecular Medicine and Canadian Partnership for Stroke Recovery, University of Ottawa, Ottawa, ON, Canada
| | - Kathryn S Hayward
- Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Parkville, VIC, Australia.,NHMRC CRE in Stroke Rehabilitation and Brain Recovery, University of Melbourne, Heidelberg, VIC, Australia.,AVERT Early Rehabilitation Research Group, Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
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45
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Bernhardt J, Hayward KS, Dancause N, Lannin NA, Ward NS, Nudo RJ, Farrin A, Churilov L, Boyd LA, Jones TA, Carmichael ST, Corbett D, Cramer SC. A Stroke Recovery Trial Development Framework: Consensus-Based Core Recommendations from the Second Stroke Recovery and Rehabilitation Roundtable. Neurorehabil Neural Repair 2019; 33:959-969. [PMID: 31674274 DOI: 10.1177/1545968319888642] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A major goal of the Stroke Recovery and Rehabilitation Roundtable (SRRR) is to accelerate development of effective treatments to enhance stroke recovery beyond that expected to occur spontaneously or with current approaches. In this paper, we describe key issues for the next generation of stroke recovery treatment trials and present the Stroke Recovery and Rehabilitation Roundtable Trials Development Framework (SRRR-TDF). An exemplar (an upper limb recovery trial) is presented to demonstrate the utility of this framework to guide the GO, NO-GO decision-making process in trial development.
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Affiliation(s)
- Julie Bernhardt
- Stroke Theme and NHRMC CRE in Stroke Rehabilitation and Brain Recovery, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Kathryn S Hayward
- Stroke Theme and NHRMC CRE in Stroke Rehabilitation and Brain Recovery, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Numa Dancause
- Departement de Neurosciences, Université de Montréal, Montréal, Québec, Canada
| | - Natasha A Lannin
- Department of Clinical Neuroscience, Central Clinical School, Monash University; Alfred Health, Melbourne, Australia
| | - Nick S Ward
- Department of Clinical and Motor Neuroscience, UCL Queen Square Institute of Neurology, London, UK
| | - Randolph J Nudo
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Amanda Farrin
- Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, UK
| | - Leonid Churilov
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Lara A Boyd
- Department of Physical Therapy & Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Theresa A Jones
- Psychology Department and Institute for Neuroscience, University of Texas at Austin, Austin, TX, USA
| | - S Thomas Carmichael
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Dale Corbett
- Cellular & Molecular Medicine and Canadian Partnership for Stroke Recovery, University of Ottawa, Ottawa, Canada
| | - Steven C Cramer
- Department of Neurology, David Geffen School of Medicine at UCLA; California Rehabilitation Institute, Los Angeles, CA, USA
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46
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Bernhardt J, Hayward KS, Dancause N, Lannin NA, Ward NS, Nudo RJ, Farrin A, Churilov L, Boyd LA, Jones TA, Carmichael ST, Corbett D, Cramer SC. A stroke recovery trial development framework: Consensus-based core recommendations from the Second Stroke Recovery and Rehabilitation Roundtable. Int J Stroke 2019; 14:792-802. [DOI: 10.1177/1747493019879657] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A major goal of the Stroke Recovery and Rehabilitation Roundtable (SRRR) is to accelerate development of effective treatments to enhance stroke recovery beyond that expected to occur spontaneously or with current approaches. In this paper, we describe key issues for the next generation of stroke recovery treatment trials and present the Stroke Recovery and Rehabilitation Roundtable Trials Development Framework (SRRR-TDF). An exemplar (an upper limb recovery trial) is presented to demonstrate the utility of this framework to guide the GO, NO-GO decision-making process in trial development.
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Affiliation(s)
- Julie Bernhardt
- Stroke Theme and NHRMC CRE in Stroke Rehabilitation and Brain Recovery, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Kathryn S Hayward
- Stroke Theme and NHRMC CRE in Stroke Rehabilitation and Brain Recovery, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Numa Dancause
- Département de Neurosciences, Université de Montréal, Montréal, Québec, Canada
| | - Natasha A Lannin
- Department of Clinical Neuroscience, Central Clinical School, Monash University; Alfred Health, Melbourne, Australia
| | - Nick S Ward
- Department of Clinical and Motor Neuroscience, UCL Queen Square Institute of Neurology, London, UK
| | - Randolph J Nudo
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Amanda Farrin
- Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, UK
| | - Leonid Churilov
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Lara A Boyd
- Department of Physical Therapy & Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Theresa A Jones
- Psychology Department and Institute for Neuroscience, University of Texas at Austin, Austin, TX, USA
| | - S Thomas Carmichael
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Dale Corbett
- Cellular & Molecular Medicine and Canadian Partnership for Stroke Recovery, University of Ottawa, Ottawa, Canada
| | - Steven C Cramer
- Department of Neurology, David Geffen School of Medicine at UCLA; California Rehabilitation Institute, Los Angeles, CA, USA
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47
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Cramer SC, Dodakian L, Le V, See J, Augsburger R, McKenzie A, Zhou RJ, Chiu NL, Heckhausen J, Cassidy JM, Scacchi W, Smith MT, Barrett AM, Knutson J, Edwards D, Putrino D, Agrawal K, Ngo K, Roth EJ, Tirschwell DL, Woodbury ML, Zafonte R, Zhao W, Spilker J, Wolf SL, Broderick JP, Janis S. Efficacy of Home-Based Telerehabilitation vs In-Clinic Therapy for Adults After Stroke: A Randomized Clinical Trial. JAMA Neurol 2019; 76:1079-1087. [PMID: 31233135 DOI: 10.1001/jamaneurol.2019.1604] [Citation(s) in RCA: 182] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance Many patients receive suboptimal rehabilitation therapy doses after stroke owing to limited access to therapists and difficulty with transportation, and their knowledge about stroke is often limited. Telehealth can potentially address these issues. Objectives To determine whether treatment targeting arm movement delivered via a home-based telerehabilitation (TR) system has comparable efficacy with dose-matched, intensity-matched therapy delivered in a traditional in-clinic (IC) setting, and to examine whether this system has comparable efficacy for providing stroke education. Design, Setting, and Participants In this randomized, assessor-blinded, noninferiority trial across 11 US sites, 124 patients who had experienced stroke 4 to 36 weeks prior and had arm motor deficits (Fugl-Meyer [FM] score, 22-56 of 66) were enrolled between September 18, 2015, and December 28, 2017, to receive telerehabilitation therapy in the home (TR group) or therapy at an outpatient rehabilitation therapy clinic (IC group). Primary efficacy analysis used the intent-to-treat population. Interventions Participants received 36 sessions (70 minutes each) of arm motor therapy plus stroke education, with therapy intensity, duration, and frequency matched across groups. Main Outcomes and Measures Change in FM score from baseline to 4 weeks after end of therapy and change in stroke knowledge from baseline to end of therapy. Results A total of 124 participants (34 women and 90 men) had a mean (SD) age of 61 (14) years, a mean (SD) baseline FM score of 43 (8) points, and were enrolled a mean (SD) of 18.7 (8.9) weeks after experiencing a stroke. Among those treated, patients in the IC group were adherent to 33.6 of the 36 therapy sessions (93.3%) and patients in the TR group were adherent to 35.4 of the 36 assigned therapy sessions (98.3%). Patients in the IC group had a mean (SD) FM score change of 8.36 (7.04) points from baseline to 30 days after therapy (P < .001), while those in the TR group had a mean (SD) change of 7.86 (6.68) points (P < .001). The covariate-adjusted mean FM score change was 0.06 (95% CI, -2.14 to 2.26) points higher in the TR group (P = .96). The noninferiority margin was 2.47 and fell outside the 95% CI, indicating that TR is not inferior to IC therapy. Motor gains remained significant when patients enrolled early (<90 days) or late (≥90 days) after stroke were examined separately. Conclusions and Relevance Activity-based training produced substantial gains in arm motor function regardless of whether it was provided via home-based telerehabilitation or traditional in-clinic rehabilitation. The findings of this study suggest that telerehabilitation has the potential to substantially increase access to rehabilitation therapy on a large scale. Trial Registration ClinicalTrials.gov identifier: NCT02360488.
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Affiliation(s)
| | - Lucy Dodakian
- Department of Neurology, University of California, Irvine
| | - Vu Le
- Department of Neurology, University of California, Irvine
| | - Jill See
- Department of Neurology, University of California, Irvine
| | - Renee Augsburger
- Department of Neurology, University of California, Irvine.,Sue & Bill Gross Stem Cell Research Center, University of California, Irvine
| | - Alison McKenzie
- Department of Neurology, University of California, Irvine.,Sue & Bill Gross Stem Cell Research Center, University of California, Irvine.,Department of Physical Therapy, Chapman University, Irvine, California
| | - Robert J Zhou
- Department of Neurology, University of California, Irvine.,Sue & Bill Gross Stem Cell Research Center, University of California, Irvine
| | - Nina L Chiu
- Department of Neurology, University of California, Irvine.,Sue & Bill Gross Stem Cell Research Center, University of California, Irvine
| | - Jutta Heckhausen
- Department of Psychological Science, University of California, Irvine
| | - Jessica M Cassidy
- Department of Neurology, University of California, Irvine.,Sue & Bill Gross Stem Cell Research Center, University of California, Irvine
| | - Walt Scacchi
- Institute for Software Research, University of California, Irvine
| | | | - A M Barrett
- Department of Stroke Rehabilitation Research, Kessler Foundation, West Orange, New Jersey.,Department of Stroke Rehabilitation, Kessler Institute for Rehabilitation, West Orange, New Jersey
| | - Jayme Knutson
- Department of Physical Medicine and Rehabilitation, MetroHealth System, Case Western Reserve University, Cleveland, Ohio
| | - Dylan Edwards
- Brain Stimulation and Robotics Laboratory, Burke Neurological Institute, White Plains, New York
| | - David Putrino
- Department of Telemedicine and Virtual Rehabilitation, Burke Medical Research Institute, White Plains, New York
| | - Kunal Agrawal
- Department of Clinical Neurosciences, University of California, San Diego, La Jolla
| | - Kenneth Ngo
- Brooks Rehabilitation Clinical Research Center, Brooks Rehabilitation, Jacksonville, Florida
| | - Elliot J Roth
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois
| | | | - Michelle L Woodbury
- Department of Health Science and Research, Medical University of South Carolina, Charleston
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts.,Massachusetts General Hospital, Boston.,Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Wenle Zhao
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Judith Spilker
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | - Steven L Wolf
- Division of Physical Therapy Education, Department of Rehabilitation Medicine, Emory University, Atlanta, Georgia.,Atlanta Veterans Affairs Health Care System, Center for Visual and Neurocognitive Rehabilitation, Decatur, Georgia
| | | | - Scott Janis
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
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Schambra HM, Parnandi A, Pandit NG, Uddin J, Wirtanen A, Nilsen DM. A Taxonomy of Functional Upper Extremity Motion. Front Neurol 2019; 10:857. [PMID: 31481922 PMCID: PMC6710387 DOI: 10.3389/fneur.2019.00857] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/24/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Functional upper extremity (UE) motion enables humans to execute activities of daily living (ADLs). There currently exists no universal language to systematically characterize this type of motion or its fundamental building blocks, called functional primitives. Without a standardized classification approach, pooling mechanistic knowledge and unpacking rehabilitation content will remain challenging. Methods: We created a taxonomy to characterize functional UE motions occurring during ADLs, classifying them by motion presence, temporal cyclicity, upper body effector, and contact type. We identified five functional primitives by their phenotype and purpose: reach, reposition, transport, stabilize, and idle. The taxonomy was assessed for its validity and interrater reliability in right-paretic chronic stroke patients performing a selection of ADL tasks. We applied the taxonomy to identify the primitive content and motion characteristics of these tasks, and to evaluate the influence of impairment level on these outcomes. Results: The taxonomy could account for all motions in the sampled activities. Interrater reliability was high for primitive identification (Cohen's kappa = 0.95–0.99). Using the taxonomy, the ADL tasks were found to be composed primarily of transport and stabilize primitives mainly executed with discrete, proximal motions. Compared to mildly impaired patients, moderately impaired patients used more repeated reaches and axial-proximal UE motion to execute the tasks. Conclusions: The proposed taxonomy yields objective, quantitative data on human functional UE motion. This new method could facilitate the decomposition and quantification of UE rehabilitation, the characterization of functional abnormality after stroke, and the mechanistic examination of shared behavior in motor studies.
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Affiliation(s)
- Heidi M Schambra
- Mobilis Lab, Department of Neurology, New York University School of Medicine, New York, NY, United States.,Department of Rehabilitation Medicine, New York University School of Medicine, New York, NY, United States
| | - Avinash Parnandi
- Mobilis Lab, Department of Neurology, New York University School of Medicine, New York, NY, United States
| | - Natasha G Pandit
- Mobilis Lab, Department of Neurology, New York University School of Medicine, New York, NY, United States
| | - Jasim Uddin
- Department of Neurology, Columbia University, New York, NY, United States
| | - Audre Wirtanen
- Mobilis Lab, Department of Neurology, New York University School of Medicine, New York, NY, United States
| | - Dawn M Nilsen
- Department of Rehabilitation and Regenerative Medicine, Columbia University, New York, NY, United States
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49
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Abstract
People with hemiparesis after stroke appear to recover 70% to 80% of the difference between their baseline and the maximum upper extremity Fugl-Meyer (UEFM) score, a phenomenon called proportional recovery (PR). Two recent commentaries explained that PR should be expected because of mathematical coupling between the baseline and change score. Here we ask, If mathematical coupling encourages PR, why do a fraction of stroke patients (the "nonfitters") not exhibit PR? At the neuroanatomical level of analysis, this question was answered by Byblow et al-nonfitters lack corticospinal tract (CST) integrity at baseline-but here we address the mathematical and behavioral causes. We first derive a new interpretation of the slope of PR: It is the average probability of scoring across remaining scale items at follow-up. PR therefore breaks when enough test items are discretely more difficult for a patient at follow-up, flattening the slope of recovery. For the UEFM, we show that nonfitters are most unlikely to recover the ability to score on the test items related to wrist/hand dexterity, shoulder flexion without bending the elbow, and finger-to-nose movement, supporting the finding that nonfitters lack CST integrity. However, we also show that a subset of nonfitters respond better to robotic movement training in the chronic phase of stroke. These persons are just able to move the arm out of the flexion synergy and pick up small blocks, both markers of CST integrity. Nonfitters therefore raise interesting questions about CST function and the basis for response to intensive movement training.
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50
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Schuch CP, Balbinot G, Jeffers MS, McDonald MW, Dykes A, Kuhl LM, Corbett D. An RFID-based activity tracking system to monitor individual rodent behavior in environmental enrichment: Implications for post-stroke cognitive recovery. J Neurosci Methods 2019; 324:108306. [DOI: 10.1016/j.jneumeth.2019.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/13/2019] [Accepted: 05/28/2019] [Indexed: 12/21/2022]
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