Moving rehabilitation research forward: Developing consensus statements for rehabilitation and recovery research

Genetic polymorphisms and post-stroke upper limb motor improvement - A systematic review and meta-analysis

Background

Post-stroke upper limb (UL) motor improvement is associated with adaptive neuroplasticity and motor learning. Both intervention-related (including provision of intensive, variable, and task-specific practice) and individual-specific factors (including the presence of genetic polymorphisms) influence improvement. In individuals with stroke, most commonly, polymorphisms are found in Brain Derived Neurotrophic Factor (BDNF), Apolipoprotein (APOE) and Catechol-O-Methyltransferase (COMT). These involve a replacement of cystine by arginine (APOEε4) or valines by 1 or 2 methionines (BDNF:val66met, met66met; COMT:val158met; met158met). However, the implications of these polymorphisms on post-stroke UL motor improvement specifically have not yet been elucidated.

Objective

Examine the influence of genetic polymorphism on post-stroke UL motor improvement.

Design

Systematic Review and Meta-Analysis.

Methods

We conducted a systematic search of the literature published in English language. The modified Downs and Black checklist helped assess study quality. We compared change in UL motor impairment and activity scores between individuals with and without the polymorphisms. Meta-analyses helped assess change in motor impairment (Fugl Meyer Assessment) scores based upon a minimum of 2 studies/time point. Effect sizes (ES) were quantified based upon the Rehabilitation Treatment Specification System as follows: small (0.08-0.18), medium (0.19 -0.40) and large (≥0.41).

Results

We retrieved 10 (4 good and 6 fair quality) studies. Compared to those with BDNF val66met and met66met polymorphism, meta-analyses revealed lower motor impairment (large ES) in those without the polymorphism at intervention completion (0.5, 95% CI: 0.11-0.88) and at retention (0.58, 95% CI:0.06-1.11). The presence of CoMT val158met or met158met polymorphism had similar results, with lower impairment (large ES ≥1.5) and higher activity scores (large ES ranging from 0.5-0.76) in those without the polymorphism. Presence of APOEε4 form did not influence UL motor improvement.

Conclusion

Polymorphisms with the presence of 1 or 2 met alleles in BDNF and COMT negatively influence UL motor improvement.

Registration

https://osf.io/wk9cf/.

Understanding task "challenge" in stroke rehabilitation: an interdisciplinary concept analysis

PURPOSE

Rehabilitation plays a critical role in minimising disability after stroke, with the concept of "challenge" proposed to be essential to rehabilitation efficacy and outcomes. This review unpacks how challenge is conceptualised in stroke rehabilitation literature from the perspectives of physiotherapy, occupational therapy, speech-language therapy and people with stroke. A secondary purpose was to provide a definition of challenge that is applicable to stroke rehabilitation.

METHODS

Principle-based concept analysis was utilised to examine challenge within the stroke rehabilitation literature. Forty-two papers were included. Data analysis involved immersion, analytical questioning, coding and synthesis to elicit the conceptual components of challenge.

RESULTS

Challenge was understood as a multidimensional and dynamic concept with three facets: nominal, functional and perceived challenge. Functional and perceived challenge were integral to optimal challenge. Optimal challenge was central to enhancing the outcomes and experiences of people with stroke, in rehabilitation and everyday life.

CONCLUSIONS

Challenge is a key concept which, when carefully optimised to the person's ability and experience, may positively influence their learning, recovery and engagement after stroke. This review lays a conceptual foundation for better understanding, operationalisation and advancement of challenge, offering important implications for addressing the growing burden of stroke disability, through rehabilitation.

Stroke rehabilitation adaptive approaches: A theory-focused scoping review

BACKGROUND

Stroke rehabilitation consists of restorative and adaptive approaches. Multiple adaptive approaches exist.

AIMS/OBJECTIVES

The objective of this study was to develop a framework for categorising adaptive stroke rehabilitation interventions, based on underlying theory.

MATERIAL AND METHODS

We searched multiple databases to April 2020 to identify studies of interventions designed to improve participation in valued activities. We extracted the name of the intervention, underlying explicit or implicit theory, intervention elements, and anticipated outcomes. Using this information, we proposed distinct groups of interventions based on theoretical drivers.

RESULTS

Twenty-nine adaptive interventions were examined in at least one of 77 studies. Underlying theories included Cognitive Learning Theory, Self-determination Theory, Social Cognitive Theory, adult learning theories, and Psychological Stress and Coping Theory. Three overarching theoretical drivers were identified: learning, motivation, and coping.

CONCLUSIONS

At least 29 adaptive approaches exist, but each appear to be based on one of three underlying theoretical drivers. Consideration of effectiveness of these approaches by theoretical driver could help indicate underlying mechanisms and essential elements of effective adaptive approaches.

SIGNIFICANCE

Our framework is an important advance in understanding and evaluating adaptive approaches to stroke rehabilitation.

Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission

Stroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met.

In this Commission, we forecast the burden of stroke from 2020 to 2050. We project that stroke mortality will increase by 50%—from 6·6 million (95% uncertainty interval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million (8·0 million–11·6 million) in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million (133·9 million–156·9 million) in 2020, to 189·3 million (161·8 million–224·9 million) in 2050. These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation. We have also identified the barriers to, and facilitators for, the achievement of these four pillars. Disability-adjusted life-years (DALYs) The sum of the years of life lost as a result of premature mortality from a disease and the years lived with a disability associated with prevalent cases of the disease in a population. One DALY represents the loss of the equivalent of one year of full health

On the basis of our assessment, we have identified and prioritised several recommendations. For each of the four pillars (surveillance, prevention, acute care, and rehabilitation), we propose pragmatic solutions for the implementation of evidence-based interventions to reduce the global burden of stroke. The estimated direct (ie, treatment and rehabilitation) and indirect (considering productivity loss) costs of stroke globally are in excess of US$891 billion annually. The pragmatic solutions we put forwards for urgent implementation should help to mitigate these losses, reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases.

Reduction of the global burden of stroke, particularly in low-income and middle-income countries, by implementing primary and secondary stroke prevention strategies and evidence-based acute care and rehabilitation services is urgently required. Measures to facilitate this goal include: the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension; planning and delivery of acute stroke care services, including the establishment of stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally); the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other health-care providers working in stroke rehabilitation; and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders.

The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

Using volunteers to improve access to community rehabilitation in palliative care: the St Christopher's Living Well at Home Team

Background

UK hospices often provide outpatient rehabilitation services for people with advanced progressive illness. However, some people are unable to travel, leading to inequity in rehabilitation access.

Objectives

The Living Well at Home Team (LWAHT) at St Christopher's Hospice aimed to evaluate whether using volunteers to support rehabilitation in peoples' homes improved the reach of rehabilitation for people living in underserved localities and if it supported people to optimise their functional independence.

Methods

This service improvement project evaluated hospice rehabilitation uptake during the implementation of volunteer-supported community rehabilitation. Following assessment by an LWAHT therapist, eligible people were matched with a trained volunteer who supported four to eight rehabilitation sessions in the person's home. The evaluation assessed uptake of the rehabilitation sessions. Mobility, wellbeing, and goal attainment outcomes were assessed by the Life-Space Assessment (LSA), General Health Questionnaire (GHQ), and Goal Attainment Scale (GAS), respectively.

Results

In the first year, 183 patients were referred to the LWAHT; 123 were assessed and 96 received rehabilitation including 56 who were matched with a volunteer. Following volunteer support, patients reported significant improvements in mobility [LSA median 20 (IQR, 3.5-27.8)], general health [GHQ -2 (-5.25 to 0)], and achievement of goals [GAS T-score +8 (0-18.4)].

Conclusions

It was feasible to support community rehabilitation using hospice volunteers for people with advanced progressive illness. The LWAHT service also increased the uptake of hospice centre-based rehabilitation. Further work should test efficacy and identify patients requiring additional professional input.

Key message

This is the first known study reporting on the use of trained rehabilitation volunteers to extend the reach of hospice rehabilitation services. People with limited access to the hospice, because of geographical location or personal circumstances, valued and benefited from tailored rehabilitation supported by the volunteers in their own homes.

The Effects of Stroke and Stroke Gait Rehabilitation on Behavioral and Neurophysiological Outcomes:: Challenges and Opportunities for Future Research

Stroke continues to be a leading cause of adult disability, contributing to immense healthcare costs. Even after discharge from rehabilitation, post-stroke individuals continue to have persistent gait impairments, which in turn adversely affect functional mobility and quality of life. Multiple factors, including biomechanics, energy cost, psychosocial variables, as well as the physiological function of corticospinal neural pathways influence stroke gait function and training-induced gait improvements. As a step toward addressing this challenge, the objective of the current perspective paper is to outline knowledge gaps pertinent to the measurement and retraining of stroke gait dysfunction. The paper also has recommendations for future research directions to address important knowledge gaps, especially related to the measurement and rehabilitation-induced modulation of biomechanical and neural processes underlying stroke gait dysfunction. We posit that there is a need for leveraging emerging technologies to develop innovative, comprehensive, methods to measure gait patterns quantitatively, to provide clinicians with objective measure of gait quality that can supplement conventional clinical outcomes of walking function. Additionally, we posit that there is a need for more research on how the stroke lesion affects multiple parts of the nervous system, and to understand the neuroplasticity correlates of gait training and gait recovery. Multi-modal clinical research studies that can combine clinical, biomechanical, neural, and computational modeling data provide promise for gaining new information about stroke gait dysfunction as well as the multitude of factors affecting recovery and treatment response in people with post-stroke hemiparesis.

Prediction of rehabilitation induced motor recovery after stroke using a multi-dimensional and multi-modal approach

Background

Stroke is a debilitating disease affecting millions of people worldwide. Despite the survival rate has significantly increased over the years, many stroke survivors are left with severe impairments impacting their quality of life. Rehabilitation programs have proved to be successful in improving the recovery process. However, a reliable model of sensorimotor recovery and a clear identification of predictive markers of rehabilitation-induced recovery are still needed. This article introduces the cross-modality protocols designed to investigate the rehabilitation treatment's effect in a group of stroke survivors.

Methods/design

A total of 75 stroke patients, admitted at the IRCCS San Camillo rehabilitation Hospital in Venice (Italy), will be included in this study. Here, we describe the rehabilitation programs, clinical, neuropsychological, and physiological/imaging [including electroencephalography (EEG), transcranial magnetic stimulation (TMS), and magnetic resonance imaging (MRI) techniques] protocols set up for this study. Blood collection for the characterization of predictive biological biomarkers will also be taken. Measures derived from data acquired will be used as candidate predictors of motor recovery.

Discussion/summary

The integration of cutting-edge physiological and imaging techniques, with clinical and cognitive assessment, dose of rehabilitation and biological variables will provide a unique opportunity to define a predictive model of recovery in stroke patients. Taken together, the data acquired in this project will help to define a model of rehabilitation induced sensorimotor recovery, with the final aim of developing personalized treatments promoting the greatest chance of recovery of the compromised functions.

Ayurvedic Treatment in the Rehabilitation of Ischemic Stroke Patients in India: A Randomized Controlled Trial Study Protocol

In patients with ischemic stroke, motor and sensory impairments are common and are associated with functional disability. Conventional physiotherapy (CP) is the primary modality of rehabilitation for post-stroke sensorimotor dysfunction. Ayurveda is a commonly practiced alternative system of medicine that offers unique rehabilitative measures for post-stroke recovery. We hypothesize that Ayurvedic rehabilitative treatment (ART) is superior to similar duration CP in improving the sensorimotor recovery of patients with ischemic stroke at 90 days after enrollment. AyuRvedic TrEatment in the Rehabilitation of Ischemic STrOke Patients in India: A Randomized controllEd trial (RESTORE) is an investigator-initiated, multicenter, prospective, randomized, controlled, parallel-arm, blinded outcome assessment trial being conducted under the Indian Stroke Clinical Trial (INSTRuCT) Network across the four comprehensive stroke centers in India. Consecutive hemodynamically stable adult patients with their first acute ischemic stroke between 1 and 3 months from stroke onset are being randomized (1:1) into two treatment groups to receive either 1 month of ART or 1 month of CP. The primary outcome measure is the Fugl Meyer Assessment-upper extremity for physical performance at 90 days. The secondary outcomes are the modified Rankin Scale, Barthel Index, Berg Balance, and SF-36 at 90 days. The safety outcomes include a composite of irreversible morbidity and mortality. A sample size of 140 (70 in each group) patients with ischemic stroke will allow us to detect a minimal clinical important difference of 9.4 (standard deviation) with superiority margin of 5, an attrition rate of 10%, alpha of 5%, and power of 80%. This randomized trial will systematically assess the efficacy and safety of traditional ART compared to CP. The trial has been registered in the Clinical Trial Registry India (CTRI/2018/04/013379).

Occupational therapists and physiotherapists experiences of using nature-based rehabilitation

BACKGROUND

Nature-based rehabilitation (NBR) is increasingly used within neurorehabilitation. The theoretical base is rooted in traditional neurorehabilitation professions, especially physiotherapy and occupational therapy, and relate to nature-based approaches.Objective: The objective was to explore the therapists' experiences of and rationale for applying NBR in neurorehabilitation when providing NBR to patients with acquired brain injury (ABI). Patients with ABI often experience severe consequences impacting their rehabilitation, activity, participation and quality of life.

METHODS

Qualitative focus group interviews with therapists were conducted at two Danish rehabilitation hospitals, Hammel Neurorehabilitation and Research Center (HNRC) (Hospital 1) and Vejlefjord Rehabilitation (VFR) (Hospital 2). These are highly specialized neurorehabilitation hospitals for patients in the acute-subacute and subacute-chronic phases. HNRC has several sensory gardens and VFR has a park and an inlet nearby. Content analysis was employed to analyze the interviews.

RESULTS

An occupational perspective of health was a frame to analyze and conceptualize the results. The analysis produced two main categories: What does nature offer - approach and rationale; Therapeutic rationale for conducting NBR.

CONCLUSION

The therapists applied known theories and methods; they perceived the natural environment as an extended room for training and activity, as a means for targeted rehabilitation and beneficial to the patients.

The effect of physical activity on health outcomes in people with moderate-to-severe traumatic brain injury: a rapid systematic review with meta-analysis

BACKGROUND

In 2020, the World Health Organization (WHO) released the first global physical activity and sedentary behaviour guidelines for children and adults living with disability. The evidence informing the guidelines though is not specific to people living with traumatic brain injury (TBI), but rather comes from other disabling conditions such as Parkinson's disease, and stroke. There remains a clear lack of direct evidence of the effects of physical activity for people living with TBI. The objective of this rapid review was to identify direct evidence of the effect of physical activity on health outcomes in people with moderate-to-severe TBI to inform adaptation of the WHO physical activity guidelines into clinical practice guidelines.

METHODS

We conducted a rapid systematic review with meta-analysis of randomised controlled trials, including people of any age with moderate-to-severe TBI, investigating physical activity interventions compared to either usual care, a physical activity intervention with different parameters, or a non-physical activity intervention. Four databases (CENTRAL, SPORTDiscus, PEDro, Ovid MEDLINE) were searched from inception to October 8, 2021. The primary outcomes were physical function, cognition, and quality of life.

RESULTS

Twenty-three studies were included incorporating 812 participants (36% females, majority working-age adults, time post-TBI in studies ranged from 56 days (median) to 16.6 years (mean)). A range of physical activity interventions were evaluated in rehabilitation (n = 12 studies), community (n = 8) and home (n = 3) settings. We pooled data from the end of the intervention for eight outcomes. Participation in a virtual reality physical activity intervention improved mobility, assessed by the Community Balance and Mobility Scale (range 0 to 96; higher score indicates better mobility) more than standard balance training (two studies, 80 participants, Mean Difference = 2.78, 95% CI 1.40 to 4.16; low certainty evidence). There was uncertainty of effect for the remaining outcomes, limited by small sample sizes, diverse comparators and a wide range of outcome measures.

CONCLUSION

This review consolidates the current evidence base for the prescription of physical activity for people with moderate-to-severe TBI. There remains a pressing need for further rigorous research in order to develop practice guidelines to support clinical decision-making when prescribing physical activity in this population.

Oscillatory beta/alpha band modulations: A potential biomarker of functional language and motor recovery in chronic stroke?

Stroke remains one of the leading causes of various disabilities, including debilitating motor and language impairments. Though various treatments exist, post-stroke impairments frequently become chronic, dramatically reducing daily life quality, and requiring specific rehabilitation. A critical goal of chronic stroke rehabilitation is to induce, usually through behavioral training, experience-dependent plasticity processes in order to promote functional recovery. However, the efficiency of such interventions is typically modest, and very little is known regarding the neural dynamics underpinning recovery processes and possible biomarkers of their efficiency. Some studies have emphasized specific alterations of excitatory–inhibitory balance within distributed neural networks as an important recovery correlate. Neural processes sensitive to these alterations, such as task-dependent oscillatory activity in beta as well as alpha bands, may be candidate biomarkers of chronic stroke functional recovery. In this review, we discuss the results of studies on motor and language recovery with a focus on oscillatory processes centered around the beta band and their modulations during functional recovery in chronic stroke. The discussion is based on a framework where task-dependent modulations of beta and alpha oscillatory activity, generated by the deep cortical excitatory–inhibitory microcircuits, serve as a neural mechanism of domain-general top-down control processes. We discuss the findings, their limitations, and possible directions for future research.

Research and application advances in rehabilitation assessment of stroke

Stroke has a high incidence and disability rate, and rehabilitation is an effective means to reduce the disability rate of patients. To systematize rehabilitation assessment, which is the foundation for rehabilitation therapy, we summarize the assessment methods commonly used in research and clinical applications, including the various types of stroke rehabilitation scales and their applicability, and related biomedical detection technologies, including surface electromyography (sEMG), motion analysis systems, transcranial magnetic stimulation (TMS), magnetic resonance imaging (MRI), and combinations of different techniques. We also introduce some assessment techniques that are still in the experimental phase, such as the prospective application of artificial intelligence (AI) with optical correlation tomography (OCT) in stroke rehabilitation. This review provides a useful bibliography for the assessment of not only the severity of stroke injury, but also the therapeutic effects of stroke rehabilitation, and establishes a solid base for the future development of stroke rehabilitation skills.

What Does It Take for Research to Be Rehabilitation Research?

Six recommendations to facilitate rehabilitation research and supplement existing research practices were identified. Rehabilitation practice requires research addressing different long-term multi-faceted needs and perspectives of end users, including service users, professionals, politicians, and administrators. Research in rehabilitation should therefore integrate different research traditions and methods. Rehabilitation research with a broad focus is sparse, and most of the research takes its starting point in the biomedical research tradition. Through a nominal group process, we developed recommendations to emphasize important issues in rehabilitation research.

Quantifying Quality of Reaching Movements Longitudinally Post-Stroke: A Systematic Review

Background

Disambiguation of behavioral restitution from compensation is important to better understand recovery of upper limb motor control post-stroke and subsequently design better interventions. Measuring quality of movement (QoM) during standardized performance assays and functional tasks using kinematic and kinetic metrics potentially allows for this disambiguation.

Objectives

To identify longitudinal studies that used kinematic and/or kinetic metrics to investigate post-stroke recovery of reaching and assess whether these studies distinguish behavioral restitution from compensation.

Methods

A systematic literature search was conducted using the databases PubMed, Embase, Scopus, and Wiley/Cochrane Library up to July 1st, 2020. Studies were identified if they performed longitudinal kinematic and/or kinetic measurements during reaching, starting within the first 6 months post-stroke.

Results

Thirty-two longitudinal studies were identified, which reported a total of forty-six different kinematic metrics. Although the majority investigated improvements in kinetics or kinematics to quantify recovery of QoM, none of these studies explicitly addressed the distinction between behavioral restitution and compensation. One study obtained kinematic metrics for both performance assays and a functional task.

Conclusions

Despite the growing number of kinematic and kinetic studies on post-stroke recovery, longitudinal studies that explicitly seek to delineate between behavioral restitution and compensation are still lacking in the literature. To rectify this situation, future studies should measure kinematics and/or kinetics during performance assays to isolate restitution and during a standardized functional task to determine the contributions of restitution and compensation.

Comparing two identically protocolized, multicentre, randomized controlled trials on caregiver-mediated exercises poststroke: Any differences across countries?

Background

The evidence for rehabilitation interventions poststroke lack sufficient robustness. However, variation in treatment effects across countries have been given little attention.

Objective

To compare two identically protocolized trials conducted in different western countries in order to identify factors that may have caused variation in secondary trial outcomes.

Methods

Comparative study based on individual patient data (N = 129) from two randomized controlled trials, conducted in hospitals and rehabilitation facilities in the Netherlands (N = 66) and Australia (N = 63). Patients with stroke and their caregivers were randomly allocated to an 8-week caregiver-mediated exercises intervention (N = 63; 31 Australian and 32 Dutch) or to a control group (N = 66; 32 Australian and 34 Dutch). Patient characteristics, compliance, usual care and process measures were compared across countries. We examined if study setting significantly moderated the trial outcomes: Hospital Anxiety and Depression Scale, Fatigue Severity Scale and General Self-Efficacy Scale, measured at 8- and 12 weeks follow-up. In addition, we explored if factors that were significantly different across countries caused variation in these trial outcomes.

Results

Most patients suffered an ischemic stroke, were in the subacute phase and participated with their partner. Dutch patients were younger (P = 0.005) and had a lower functional status (P = 0.001). Australian patients were recruited earlier poststroke (P<0.001), spent less time in exercise therapy (P<0.001) and had a shorter length of stay (P<0.001). The level of contamination was higher (P = 0.040) among Dutch controls. No effect modification was observed and trial outcomes did not change after controlling for cross-country differences.

Conclusions

The present study highlighted important clinical differences across countries whilst using an identical study protocol. The observed differences could result in a different potential for recovery and variation in treatment effects across trials. We argue that we can proceed faster to evaluating interventions within international pragmatic trials.

Effect of environmental enrichment on behavioral and morphological outcomes following neonatal hypoxia-ischemia in rodent models: A systematic review and meta-analysis

Neonatal hypoxia-ischemia (HI) is a major cause of mortality and morbidity in newborns and, despite recent advances in neonatal intensive care, there is no definitive treatment for this pathology. Once preclinical studies have shown that environmental enrichment (EE) seems to be a promising therapy for children with HI, the present study conducts a systematic review and meta-analysis of articles with EE in HI rodent models focusing on neurodevelopmental reflexes, motor and cognitive function as well as brain damage. The protocol was registered a priori at PROSPERO. The search was conducted in PubMed, Embase and PsycINFO databases, resulting in the inclusion of 22 articles. Interestingly, EE showed a beneficial impact on neurodevelopmental reflexes (SMD= -0.73, CI= [-0.98; -0.47], p< 0.001, I²= 0.0%), motor function (SMD= -0.55, CI= [-0.81; -0.28], p< 0.001, I²= 62.6%), cognitive function (SMD= -0.93, CI= [-1.14; -0.72], p< 0.001, I²= 27.8%) and brain damage (SMD= -0.80, CI= [-1.03; -0.58], p< 0.001, I²= 10.7%). The main factors that potentiate EE positive effects were enhanced study quality, earlier age at injury as well as earlier start and longer duration of EE exposure. Overall, EE was able to counteract the behavioral and histological damage induced by the lesion, being a promising therapeutic strategy for HI.

The ENIGMA Stroke Recovery Working Group: Big data neuroimaging to study brain-behavior relationships after stroke

The goal of the Enhancing Neuroimaging Genetics through Meta-Analysis (ENIGMA) Stroke Recovery working group is to understand brain and behavior relationships using well-powered meta- and mega-analytic approaches. ENIGMA Stroke Recovery has data from over 2,100 stroke patients collected across 39 research studies and 10 countries around the world, comprising the largest multisite retrospective stroke data collaboration to date. This article outlines the efforts taken by the ENIGMA Stroke Recovery working group to develop neuroinformatics protocols and methods to manage multisite stroke brain magnetic resonance imaging, behavioral and demographics data. Specifically, the processes for scalable data intake and preprocessing, multisite data harmonization, and large-scale stroke lesion analysis are described, and challenges unique to this type of big data collaboration in stroke research are discussed. Finally, future directions and limitations, as well as recommendations for improved data harmonization through prospective data collection and data management, are provided.

Long-term recovery of upper limb motor function and self-reported health: results from a multicenter observational study 1 year after discharge from rehabilitation

Background

Impaired motor functions after stroke are common and negatively affect patients' activities of daily living and quality of life. In particular, hand motor function is essential for daily activities, but often returns slowly and incompletely after stroke. However, few data are available on the long-term dynamics of motor recovery and self-reported health status after stroke. The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE) project aims to address this knowledge gap by studying the clinical course of recovery after inpatient rehabilitation.

Methods

In this prospective observational longitudinal multicenter study, patients were included towards the end of inpatient rehabilitation after ischemic or hemorrhagic stroke. Follow-up examination was performed at three, six, and twelve months after enrollment. Motor function was assessed by the Upper Extremity Fugl-Meyer Assessment (FMA), grip and pinch strength, and the nine-hole peg test. In addition, Patient-Reported Outcomes Measurement Information System 10-Question Short Form (PROMIS-10) was included. Linear mixed effect models were fitted to analyze change over time. To study determinants of hand motor function, patients with impaired hand function at baseline were grouped into improvers and non-improvers according to hand motor function after twelve months.

Results

A total of 176 patients were included in the analysis. Improvement in all motor function scores and PROMIS-10 was shown up to 1 year after inpatient rehabilitation. FMA scores improved by an estimate of 5.0 (3.7–6.4) points per year. In addition, patient-reported outcome measures increased by 2.5 (1.4–3.6) and 2.4 (1.4–3.4) per year in the physical and mental domain of PROMIS-10. In the subgroup analysis non-improvers showed to be more often female (15% vs. 55%, p = 0.0155) and scored lower in the Montreal Cognitive Assessment (25 [23–27] vs. 22 [20.5–24], p = 0.0252).

Conclusions

Continuous improvement in motor function and self-reported health status is observed up to 1 year after inpatient stroke rehabilitation. Demographic and clinical parameters associated with these improvements need further investigation. These results may contribute to the further development of the post-inpatient phase of stroke rehabilitation.

Trial registration: The trial is registered at ClinicalTrials.gov (NCT04119479).

Motor learning in neurological rehabilitation

While most upper limb training interventions in neurological rehabilitation are based on established principles of motor learning and neural plasticity, recovery potential may be improved if the focus includes remediating an individual's specific motor impairment within the framework of a motor control theory. This paper reviews current theories of motor control and motor learning and describes how they can be incorporated into training programs to enhance sensorimotor recovery in patients with neurological lesions. An emphasis is placed on dynamical systems theory and the use of new technologies such as virtual, augmented and mixed reality applications for rehabilitation to facilitate learning.Implications for RehabilitationKinematic abundance allows the healthy nervous system to produce different combinations of joint rotations to perform a desired task.The structure of practice to improve the movement repertoire in rehabilitation should take into account the kinematic abundance of the system.Learning can be enhanced by varied practice with feedback about key movement elements.Virtual reality environments provide opportunities to manipulate the structure and schedule of practice and feedback.

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

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

Clinicians' perceptions of a potential wearable device for capturing upper limb activity post-stroke: a qualitative focus group study

Background

There is growing interest in the use of wearable devices that track upper limb activity after stroke to help determine and motivate the optimal dose of upper limb practice. The purpose of this study was to explore clinicians’ perceptions of a prospective wearable device that captures upper limb activity to assist in the design of devices for use in rehabilitation practice.

Methods

Four focus groups with 18 clinicians (occupational and physical therapists with stroke practice experience from a hospital or private practice setting) were conducted. Data were analyzed thematically.

Results

Our analysis revealed three themes: (1) “Quantity and quality is ideal” emphasized how an ideal device would capture both quantity and quality of movement; (2) “Most useful outside therapy sessions” described how therapists foresaw using the device outside of therapy sessions to monitor homework adherence, provide self-monitoring of use, motivate greater use and provide biofeedback on movement quality; (3) “User-friendly please” advocated for the creation of a device that was easy to use and customizable, which reflected the client-centered nature of their treatment.

Conclusions

Findings from this study suggest that clinicians support the development of wearable devices that capture upper limb activity outside of therapy for individuals with some reach to grasp ability. Devices that are easy to use and capture both quality and quantity may result in greater uptake in the clinical setting. Future studies examining acceptability of wearable devices for tracking upper limb activity from the perspective of individuals with stroke are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-021-00927-y.

Tractometry-Based Estimation of Corticospinal Tract Injury to Assess Initial Impairment and Predict Functional Outcomes in Ischemic Stroke Patients

BACKGROUND

Corticospinal tract (CST) injury has been shown to exert a major influence on functional recovery after ischemic stroke.

PURPOSE

To evaluate the prognostic value of CST injury estimated using a recent developed tractometry-based method.

STUDY TYPE

Prospective.

POPULATION

Forty-eight patients with CST damage induced by stroke lesion who underwent brain magnetic resonance imaging within 7 days from onset.

SEQUENCE

Diffusion-weighted imaging (b = 1000 seconds/mm² ) and diffusion kurtosis imaging (DKI) spin-echo echo-planar sequence with three b-values (0, 1250, and 2500 seconds/mm² ) at 3.0 T.

ASSESSMENT

A recently developed approach that combines tract segmentation and orientation mapping was used for CST-specific tractography and tractometry. CST injury was estimated using the proposed method with diffusion metrics extracted from DKI sequence and with the first principal component (PC1) of the metrics. We also calculated the weighted lesion load (wLL) for comparison. Clinical evaluation included the National Institutes of Health Stroke Score in the acute phase and the modified Rankin scale at 3 months post-stroke. The correlations between CST injury and initial motor impairment, as well as the prognostic values of CST injury for functional outcomes were evaluated.

STATISTICAL TESTS

Pearson correlation and logistic regression. Area under the receiver operating characteristic curve. P < 0.05 was considered statistically significant.

RESULTS

CST injury calculated with diffusion metrics except fractional anisotropy all showed significant correlations with initial motor impairment. PC1 achieved the largest correlation coefficient (R = 0.65) compared with wLL and other diffusion metrics. In addition to wLL, DKI_AK, AFD_total, and PC1 maximum all showed predictive values for functional outcomes.

DATA CONCLUSION

Structural injury to CST is important for the assessment of the extent of injury and the prediction of functional outcome. The method proposed in our study could provide an imaging indicator to quantify the CST injury after ischemic stroke.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 1.

Combined lesion-deficit and fMRI approaches in single-case studies: Unique contributions to cognitive neuroscience

Although lesion-deficit case studies are foundational in cognitive neuroscience, published papers presenting single lesion cases are declining. In this review, we argue that there is a valuable place for single-case lesion-deficit research, especially when combined with functional neuroimaging methods, such as functional magnetic resonance imaging (fMRI). To support this, we present a summary of notable findings from single-case combined lesion-deficit and fMRI studies published in recent years (2017-2020). These studies show the unique value that this combined approach brings to the understanding of complex functions, brain-level connectivity, and plasticity and recovery. We encourage researchers to consider combining lesion-deficit and functional imaging methods in the analysis of single cases, as this approach affords unique opportunities to address challenging unanswered questions about brain-behavior relationships.

Developmental and Interventional Plasticity of Motor Maps after Perinatal Stroke

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.

Delayed Exercise-induced Upregulation of Angiogenic Proteins and Recovery of Motor Function after Photothrombotic Stroke in Mice

Treatments promoting post-stroke functional recovery continue to be an unmet therapeutic problem with physical rehabilitation being the most reproduced intervention in preclinical and clinical studies. Unfortunately, physiotherapy is typically effective at high intensity and early after stroke - requirements that are hardly attainable by stroke survivors. The aim of this study was to directly evaluate and compare the dose-dependent effect of delayed physical rehabilitation (daily 5 h or overnight voluntary wheel running; initiated on post-stroke day 7 and continuing through day 21) on recovery of motor function in the mouse photothrombotic model of ischemic stroke and correlate it with angiogenic potential of the brain. Our observations indicate that overnight but not 5 h access to running wheels facilitates recovery of motor function in mice in grid-walking test. Western blotting and immunofluorescence microscopy experiments evaluating the expression of angiogenesis-associated proteins VEGFR2, doppel and PDGFRβ in the peri-infarct and corresponding contralateral motor cortices indicate substantial upregulation of these proteins (≥2-fold) in the infarct core and surrounding cerebral cortex in the overnight running mice on post-stroke day 21. These findings indicate that there is a dose-dependent relationship between the extent of voluntary exercise, motor recovery and expression of angiogenesis-associated proteins in this expert-recommended mouse ischemic stroke model. Notably, our observations also point out to enhanced angiogenesis and presence of pericytes within the infarct core region during the chronic phase of stroke, suggesting a potential contribution of this tissue area in the mechanisms governing post-stroke functional recovery.

Prospects for intelligent rehabilitation techniques to treat motor dysfunction

More than half of stroke patients live with different levels of motor dysfunction after receiving routine rehabilitation treatments. Therefore, new rehabilitation technologies are urgently needed as auxiliary treatments for motor rehabilitation. Based on routine rehabilitation treatments, a new intelligent rehabilitation platform has been developed for accurate evaluation of function and rehabilitation training. The emerging intelligent rehabilitation techniques can promote the development of motor function rehabilitation in terms of informatization, standardization, and intelligence. Traditional assessment methods are mostly subjective, depending on the experience and expertise of clinicians, and lack standardization and precision. It is therefore difficult to track functional changes during the rehabilitation process. Emerging intelligent rehabilitation techniques provide objective and accurate functional assessment for stroke patients that can promote improvement of clinical guidance for treatment. Artificial intelligence and neural networks play a critical role in intelligent rehabilitation. Multiple novel techniques, such as brain-computer interfaces, virtual reality, neural circuit-magnetic stimulation, and robot-assisted therapy, have been widely used in the clinic. This review summarizes the emerging intelligent rehabilitation techniques for the evaluation and treatment of motor dysfunction caused by nervous system diseases.

Delayed atomoxetine or fluoxetine treatment coupled with limited voluntary running promotes motor recovery in mice after ischemic stroke

Currently, there is an unmet need for treatments promoting post-stroke functional recovery. The aim of this study was to evaluate and compare the dose-dependent effect of delayed atomoxetine or fluoxetine therapy (starting on post-stroke day 5), coupled with limited physical exercise (2 hours daily voluntary wheel running; post-stroke days 9 to 42), on motor recovery of adult male mice after photothrombotic stroke. These drugs are selective norepinephrine or serotonin reuptake inhibitors indicated for disorders unrelated to stroke. The predetermined primary end-point for this study was motor function measured in two tasks of spontaneous motor behaviors in grid-walking and cylinder tests. Additionally, we quantified the running distance and speed throughout the study, the number of parvalbumin-positive neurons in the medial agranular cortex and infarct volumes. Both sensorimotor tests revealed that neither limited physical exercise nor a drug treatment alone significantly facilitated motor recovery in mice after stroke. However, combination of physical exercise with either of the drugs promoted restoration of motor function by day 42 post-stroke, with atomoxetine being a more potent drug. This was accompanied by a significant decrease in parvalbumin-positive inhibitory interneurons in the ipsilateral medial agranular cortex of mice with recovering motor function, while infarct volumes were comparable among experimental groups. If further validated in larger studies, our observations suggest that add-on atomoxetine or fluoxetine therapy coupled with limited, structured physical rehabilitation could offer therapeutic modality for stroke survivors who have difficulty to engage in early, high-intensity physiotherapy. Furthermore, in light of the recently completed Assessment oF FluoxetINe In sTroke recoverY (AFFINITY) and Efficacy oF Fluoxetine-a randomisEd Controlled Trial in Stroke (EFFECTS) trials, our observations call for newly designed studies where fluoxetine or atomoxetine pharmacotherapy is evaluated in combination with structured physical rehabilitation rather than alone. This study was approved by the Texas Tech University Health Sciences Center Institutional Animal Care and Use Committee (protocol # 16019).

The Indian Stroke Scale: Development and validation of a scale to measure participation in daily activities among patients with stroke in India

BACKGROUND

Prospects of a participation measure to be valid across cultures are debatable. Existing stroke outcome measures had been shown to have limited validity when used within Indian sociocultural contexts.

AIM

To develop and validate a patient-reported outcome measure of participation in daily activities appropriate for patients with stroke living in an Indian sociocultural context.

METHODS

The scale was developed in two phases: scale development and psychometric testing. Items were derived from a conceptual framework of participation in daily activities of patients who had experienced stroke within an Indian context. The final version of the scale consisted of 25 items. A total of 377 patients diagnosed with stroke were recruited from two tertiary care hospitals and five physiotherapy outpatient rehabilitation centers in India. Psychometric testing of the scale included investigation of internal consistency, unidimensionality, construct validity (known group and convergent validity), and test-retest reliability.

RESULTS

The scale items demonstrated good internal consistency (Cronbach's alpha = .94). Confirmatory factor analysis results showed acceptable goodness of fit. The scale has shown good construct validity and test-retest reliability (intraclass correlation coefficient = 0.80). The scale differentiated patients with low and high disability severity (mean difference = 34, 95% CI = 27 to 39) and moderately associated with physical and instrumental activities of daily living (r = 0.64, p < .001) and social participation domains of stroke impact scale (r = 0.44, p < .001) and Barthel index (r = 0.59, p < .001).

CONCLUSION

The Indian Stroke Scale has shown preliminary evidence of validity to support its use as a patient-reported outcome measure for evaluating poststroke participation in daily activities among patients with stroke in India.

Accuracy of the Upper Limb Prediction Algorithm PREP2 Applied 2 Weeks Poststroke: A Prospective Longitudinal Study

BACKGROUND

The Predict Recovery Potential algorithm (PREP2) was developed to predict upper limb (UL) function early after stroke. However, assessment in the acute phase is not always possible.

OBJECTIVE

To assess the prognostic accuracy of the PREP2 when applied in a subacute neurorehabilitation setting.

METHODS

This prospective longitudinal study included patients ≥18 years old with UL impairment following stroke. Patients were assessed in accordance with the PREP2 approach. However, 2 main components, the shoulder abduction finger extension (SAFE) score and motor-evoked potentials (MEPs) were obtained 2 weeks poststroke. UL function at 3 months was predicted in 1 of 4 categories and compared with the actual outcome at 3 months as assessed by the Action Research Arm Test. The prediction accuracy of the PREP2 was quantified using the correct classification rate (CCR).

RESULTS

Ninety-one patients were included. Overall CCR of the PREP2 was 60% (95% CI 50%-71%). Within the 4 categories, CCR ranged from the lowest value at 33% (95% CI 4%-85%) for the category Limited to the highest value at 78% (95% CI 43%-95%) for the category Poor. In the present study, the overall CCR was significantly lower (P < .001) than the 75% reported by the PREP2 developers.

CONCLUSIONS

The low overall CCR makes PREP2 obtained 2 weeks poststroke unsuited for clinical implementation. However, PREP2 may be used to predict either excellent UL function in already well-recovered patients or poor UL function in patients with persistent severe UL paresis.

Participation-focused interventions for stroke rehabilitation: a scoping review protocol

OBJECTIVE

The objectives of this scoping review are to i) identify adaptive stroke rehabilitation interventions using metacognitive or self-management approaches targeting participation as an outcome; ii) determine the explicit and implicit theories underlying these interventions; and iii) ascertain the elements in each intervention. This review will develop a catalogue of these interventions, improving the understanding of how these interventions work, thereby facilitating efficient development and testing of participation-focused interventions.

INTRODUCTION

Stroke rehabilitation interventions can be categorized as those aiming to correct impairment and those seeking participation improvement despite impairment. Impairment-focused interventions include a relatively small number of well-defined elements, generally based on motor learning or other types of learning theory. Participation-focused interventions span a large group of diverse interventions. The underlying theory is typically varied and often implicit, but many of these interventions are based on metacognitive or self-management approaches. An examination of the underlying theory and elements of participation-focused interventions would allow researchers to more effectively advance the science of these approaches.

INCLUSION CRITERIA

The review will include published papers describing rehabilitation interventions using metacognitive or self-management approaches to improve participation among adults who have experienced a stroke.

METHODS

The search will include JBI Evidence-Based Practice Database, MEDLINE, Embase, CINAHL, PsycINFO, OTSeeker, and PEDro databases. Studies will be selected according to a three-step process, including i) managing search results and removing duplicates, ii) title and abstract screening, and iii) full text screening. The extracted data will be presented in table form and narrative summary, aligning with the objectives and scope of this review.

Resting State Functional Connectivity Is Associated With Motor Pathway Integrity and Upper-Limb Behavior in Chronic Stroke

Background. Resting state functional connectivity (RSFC) is a developmental priority for stroke recovery. Objective. To determine whether (1) RSFC differs between stroke survivors based on integrity of descending motor pathways; (2) RSFC is associated with upper-limb behavior in chronic stroke; and (3) the relationship between interhemispheric RSFC and upper-limb behavior differs based on descending motor pathway integrity. Methods. A total of 36 people with stroke (aged 64.4 ± 11.1 years, time since stroke 4.0 ± 2.8 years) and 25 healthy adults (aged 67.3 ± 6.7 years) participated in this study. RSFC was estimated from electroencephalography (EEG) recordings. Integrity of descending motor pathways was ascertained using transcranial magnetic stimulation to determine motor-evoked potential (MEP) status and magnetic resonance imaging to determine lesion overlap and fractional anisotropy of the corticospinal tract (CST). For stroke participants, upper-limb motor behavior was assessed using the Fugl-Meyer test, Action Research Arm Test and grip strength. Results. β-Frequency interhemispheric sensorimotor RSFC was greater for MEP+ stroke participants compared with MEP- (P = .020). There was a significant positive correlation between β RSFC and upper-limb behavior (P = .004) that appeared to be primarily driven by the MEP+ group. A hierarchical regression identified that the addition of β RSFC to measures of CST integrity explained greater variance in upper-limb behavior (R² change = 0.13; P = .01). Conclusions. This study provides insight to understand the role of EEG-based measures of interhemispheric network activity in chronic stroke. Resting state interhemispheric connectivity was positively associated with upper-limb behavior for stroke survivors where residual integrity of descending motor pathways was maintained.

Backward locomotor treadmill training combined with transcutaneous spinal direct current stimulation in stroke: a randomized pilot feasibility and safety study

Walking impairment impacts nearly 66% of stroke survivors and is a rising cause of morbidity worldwide. Despite conventional post-stroke rehabilitative care, the majority of stroke survivors experience continued limitations in their walking speed, temporospatial dynamics and walking capacity. Hence, novel and comprehensive approaches are needed to improve the trajectory of walking recovery in stroke survivors. Herein, we test the safety, feasibility and preliminary efficacy of two approaches for post-stroke walking recovery: backward locomotor treadmill training and transcutaneous spinal direct current stimulation. In this double-blinded study, 30 chronic stroke survivors (>6 months post-stroke) with mild-severe residual walking impairment underwent six 30-min sessions (three sessions/week) of backward locomotor treadmill training, with concurrent anodal (N = 19) or sham transcutaneous spinal direct current stimulation (N = 11) over the thoracolumbar spine, in a 2:1 stratified randomized fashion. The primary outcomes were: per cent participant completion, safety and tolerability of these two approaches. In addition, we collected data on training-related changes in overground walking speed, cadence, stride length (baseline, daily, 24-h post-intervention, 2 weeks post-intervention) and walking capacity (baseline, 24-h post-intervention, 2 weeks post-intervention), as secondary exploratory aims testing the preliminary efficacy of these interventions. Eighty-seven per cent (N = 26) of randomized participants completed the study protocol. The majority of the study attrition involved participants with severe baseline walking impairment. There were no serious adverse events in either the backward locomotor treadmill training or transcutaneous spinal direct current stimulation approaches. Also, both groups experienced a clinically meaningful improvement in walking speed immediately post-intervention that persisted at the 2-week follow-up. However, in contrast to our working hypothesis, anodal-transcutaneous spinal direct current stimulation did not enhance the degree of improvement in walking speed and capacity, relative to backward locomotor treadmill training + sham, in our sample. Backward locomotor treadmill training and transcutaneous spinal direct current stimulation are safe and feasible approaches for walking recovery in chronic stroke survivors. Definitive efficacy studies are needed to validate our findings on backward locomotor treadmill training-related changes in walking performance. The results raise interesting questions about mechanisms of locomotor learning in stroke, and well-powered transcutaneous spinal direct current stimulation dosing studies are needed to understand better its potential role as a neuromodulatory adjunct for walking rehabilitation.

Protocol for a multicenter observational prospective study of functional recovery from stroke beyond inpatient rehabilitation - The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE)

Introduction

Stroke and its long-term consequences pose major challenges for the lives of those affected and healthcare systems. Neurological rehabilitation therefore primarily attempts to improve function in order to increase independence in activities of daily living, and to enable social participation. There is only scarce data on dynamics of functional recovery after patients discharge from inpatient neurological rehabilitation. Even less is known about the patient's perspective on long-term recovery from stroke. The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE) aims to address this knowledge gap by providing new insights into the dynamics and extent of functional recovery from stroke beyond inpatient rehabilitation treatment.

Methods

We provide the protocol for an observational, longitudinal, multicenter study conducted in an Universitary Stroke Center in cooperation with five Neurological Rehabilitation Centers in Northern Germany. Patients who suffered from ischemic or hemorrhagic stroke will be enrolled by the end of inpatient rehabilitation and followed up to 1 year. In addition, a group of chronic stroke patients and a group of craniocerebral trauma patients will be enrolled as a comparison group. Data on stroke characteristics, vascular risk factors, co-morbidities, social support, and demographics will be recorded. Comprehensive clinical evaluation will be performed at baseline, three, six, and twelve months after enrollment. The assessments and scores used reflect the three components of the International Classification of Functioning, Disability and Health (ICF), some of them are tests regularly used in rehabilitation settings. Tests of motor function, cognition, and mood are included, as are tests of self-reported health-related quality of life. Primary outcome measure is a hand motor score, built by the sum of the hand items of the Fugl-Meyer Assessment as an objective measurement of hand function at 12 months after enrollment. Predictors of the primary outcome will be analyzed using linear regression analysis.

Perspective

The results of IMPROVE will inform about the long-term dynamics of functional stroke recovery after patients' discharge from inpatient rehabilitation and will provide insights into the association of clinical and demographic factors with recovery of function.

Trial registration

The protocol is registered at ClinicalTrials.gov (NCT04119479).

Advanced Neurotechnologies for the Restoration of Motor Function

Stroke is one of the leading causes of long-term disability. Advanced technological solutions ("neurotechnologies") exploiting robotic systems and electrodes that stimulate the nervous system can increase the efficacy of stroke rehabilitation. Recent studies on these approaches have shown promising results. However, a paradigm shift in the development of new approaches must be made to significantly improve the clinical outcomes of neurotechnologies compared with those of traditional therapies. An "evolutionary" change can occur only by understanding in great detail the basic mechanisms of natural stroke recovery and technology-assisted neurorehabilitation. In this review, we first describe the results achieved by existing neurotechnologies and highlight their current limitations. In parallel, we summarize the data available on the mechanisms of recovery from electrophysiological, behavioral, and anatomical studies in humans and rodent models. Finally, we propose new approaches for the effective use of neurotechnologies in stroke survivors, as well as in people with other neurological disorders.

Moving exercise research in multiple sclerosis forward (the MoXFo initiative): Developing consensus statements for research

Exercise as a subset of physical activity is a cornerstone in the management of multiple sclerosis (MS) based on its pleotropic effects. There is an exponential increase in the quantity of research on exercise in MS, yet a number of barriers associated with study content and quality hamper rapid progress in the field. To address these barriers and accelerate discovery, a new international partnership of MS-related experts in exercise has emerged with the goal of advancing the research agenda. As a first step, the expert panel met in May 2018 and identified the most urgent areas for moving the field forward, and discussed the framework for such a process. This led to identification of five themes, namely "Definitions and terminology," "Study methodology," "Reporting and outcomes," "Adherence to exercise," and "Mechanisms of action." Based on the identified themes, five expert groups have been formed, that will further (a) outline the challenges per theme and (b) provide recommendations for moving forward. We aim to involve and collaborate with people with MS/MS organizations (e.g. Multiple Sclerosis International Federation (MSIF) and European Multiple Sclerosis Platform (EMSP)) in all of these five themes. The generation of this thematic framework with multi-expert perspectives can bolster the quality and scope of exercise studies in MS that may ultimately improve the daily lives of people with MS.

Predicting Upper Limb Motor Impairment Recovery after Stroke: A Mixture Model

OBJECTIVE

Spontaneous recovery is an important determinant of upper extremity recovery after stroke and has been described by the 70% proportional recovery rule for the Fugl-Meyer motor upper extremity (FM-UE) scale. However, this rule is criticized for overestimating the predictability of FM-UE recovery. Our objectives were to develop a longitudinal mixture model of FM-UE recovery, identify FM-UE recovery subgroups, and internally validate the model predictions.

METHODS

We developed an exponential recovery function with the following parameters: subgroup assignment probability, proportional recovery coefficient r k , time constant in weeks τ k , and distribution of the initial FM-UE scores. We fitted the model to FM-UE measurements of 412 first-ever ischemic stroke patients and cross-validated endpoint predictions and FM-UE recovery cluster assignment.

RESULTS

The model distinguished 5 subgroups with different recovery parameters ( r1 = 0.09, τ1 = 5.3, r2 = 0.46, τ2 = 10.1, r3 = 0.86, τ3 = 9.8, r4 = 0.89, τ4 = 2.7, r5 = 0.93, τ5 = 1.2). Endpoint FM-UE was predicted with a median absolute error of 4.8 (interquartile range [IQR] = 1.3-12.8) at 1 week poststroke and 4.2 (IQR = 1.3-9.8) at 2 weeks. Overall accuracy of assignment to the poor (subgroup 1), moderate (subgroups 2 and 3), and good (subgroups 4 and 5) FM-UE recovery clusters was 0.79 (95% equal-tailed interval [ETI] = 0.78-0.80) at 1 week poststroke and 0.81 (95% ETI = 0.80-0.82) at 2 weeks.

INTERPRETATION

FM-UE recovery reflects different subgroups, each with its own recovery profile. Cross-validation indicates that FM-UE endpoints and FM-UE recovery clusters can be well predicted. Results will contribute to the understanding of upper limb recovery patterns in the first 6 months after stroke. ANN NEUROL 2020;87:383-393 Ann Neurol 2020;87:383-393.

Effects of the brain-damaged side after stroke on the learning of a balance task in a non-immersive virtual reality environment

Background: Post-stroke survivors with right hemisphere injury have more impairments in postural control and balance. However, the impact of the hemisphere injured on the process of balance reacquisition has not been fully explored. We hypothesized that stroke survivors could learn balance tasks (H1), but right hemisphere damaged patients would show poor motor learning if compared to left hemisphere damaged patients (H2)Objective: To investigate whether the brain-damaged side after stroke affects the learning of a balance task. Methods: Three groups were recruited: twenty stroke survivors (ten left and ten right hemisphere damage) and twenty healthy volunteers. The participants practiced a balance task for thirty minutes, four consecutive days. The task was the Table Tilt game (Nintendo^TM Company), which induces balance demands with a progression of complexity. Motor performance was assessed at baseline, post-practice and after one week (retention test). Accuracy, errors, and complexity of the task achieved during the trial were assessedResults: Participants in all groups improved their performance (p < .001) and maintained it at the retention test. The control group showed better performance if compared to the right and left hemisphere damaged stroke survivors (p < .05). There was no difference between individuals with right and left hemisphere damaged, but the right hemisphere damaged patients demonstrated more errors at higher levels of complexityConclusion: Stroke survivors can learn balance tasks (H1), and the right hemisphere damaged patients demonstrate more errors than those with left hemisphere injury in higher complexity conditions (H2).

Does grip strength predict lower limb global strength in subjects with stroke?

Abstract Introduction: Grip strength is an important clinical measure and has been used for several purposes in different populations, including those to predict the global strength of lower limbs (LL) and upper limbs. However, little is known about the association between grip strength and lower limb (LL) global strength in subjects with stroke. Objective: To investigate the relationship between grip strength and LL global strength in stroke with subjects at both subacute and chronic phases. Method: Measures of grip strength (handgrip dynamometer) and LL global strength (hand-held dynamometer) were obtained in 20 subjects in the subacute phase of the stroke and 18 in the chronic phase. Pearson correlation coefficient was used to investigate the correlation between grip strength and LL global strength (α = 0.05). Results: Subjects in the subacute phase showed a moderate statistically significant correlation between paretic grip strength and global strength of the non-paretic LL (r = 0.50; p < 0.05), but no correlation with the paretic LL was found (p = 0.25). The non-paretic grip strength showed no statistically significant correlation with global strength of the paretic LL (p = 0.93) and of the non-paretic LL (p = 0.64). In chronic subjects, no statistically significant correlation (0.50 ≤ p ≤ 0.97) was observed. Conclusion: Grip strength does not seem to be an adequate indicator to predict LL global strength of subjects with stroke. This conclusion is different from that obtained for other populations.

Timing of Repetitive Transcranial Magnetic Stimulation Onset for Upper Limb Function After Stroke: A Systematic Review and Meta-Analysis

Background: Repetitive transcranial magnetic stimulation (rTMS) is a promising intervention to promote upper limb recovery after stroke. We aimed to identify differences in the efficacy of rTMS treatment on upper limb function depending on the onset time post-stroke.

Methods: We searched PubMed, Embase, and the Cochrane Library to identify relevant RCTs from their inception to February 2018. RCTs on the effects of rTMS on upper limb function in adult patients with stroke were included. Study quality and risk of bias were assessed independently by two authors. Meta-analyses were performed for outcomes on individual upper limb outcome measures (function or activity) and for function and activity measures jointly, categorized by timing of treatment initiation. Timing of treatment initiation post-stroke was categorized as follows: acute to early subacute (<1 month), early subacute (1–3 months), late subacute (3–6 months), and chronic (>6 months).

Results: We included 38 studies involving 1,074 stroke patients. Subgroup analysis demonstrated benefit of rTMS applied within the first month post-stroke [MD = 9.31; 95% confidence interval (6.27–12.34); P < 0.0001], but not in the early subacute phase (1–3 months post-stroke) [MD = 1.14; 95% confidence interval (−5.32 to 7.59), P = 0.73) or chronic phase (>6 months post-stroke) [MD = 1.79; 95% confidence interval (−2.00 to 5.59]; P = 0.35), when assessed with a function test [Fugl-Meyer Arm test (FMA)]. There were no studies within the late subacute phase (3–6 months post-stroke) that used the FMA. Tests at the level of function revealed improved upper limb function after rTMS [SMD = 0.43; 95% confidence interval (0.02–0.75); P = 0.0001], but tests at the level of activity did not, independent of rTMS onset post-stroke [SMD = 0.17; 95% confidence interval (−0.09 to 0.44); P = 0.19]. Heterogeneities in the results of the individual studies included in the main analyses were large, as suggested by funnel plot asymmetry.

Conclusions: Based on the FMA, rTMS seems more beneficial only when started in the first month post-stroke. Tests at the level of function are likely more sensitive to detect beneficial rTMS effects on upper limb function than tests at the level of activity. However, heterogeneities in treatment designs and outcomes are high. Future rTMS trials should include the FMA and work toward a core set of outcome measures.

Elucidating the Structural and Functional Correlates of Upper-Limb Poststroke Motor Impairment

Background and Purpose—

Many studies have attempted to bring to light the neural correlates of poststroke motor impairment, but few have used multimodal approach to explain it. The aim of this study was to elucidate neural structural and functional correlates of upper limb motor impairment by combining electrophysiological, anatomic, and functional neuroimaging data.

Methods—

Forty ischemic stroke patients (median [min–max] age: 63 [33–82] years, time poststroke: 3.5 [1.1–58] months) with unilateral upper limb weakness were included. The upper limb motor impairment was defined by a motor composite score. Simple linear analysis followed by multiple linear regression analysis were performed to identify which variables (corticospinal excitability, laterality indices within the primary motor cortex or corticospinal [CST], and corpus callosum tracts integrity) were the best explaining factors of upper limb motor impairment.

Results—

There was a significant correlation between the resting motor threshold ratio and CST damage ( r = −0.50 [95% CI, −0.70 to −0.22]; P <0.001) as well as the motor-evoked potentials amplitude ( r = −0.73 [95% CI, −0.85 to −0.54]; P <0.001). Only the resting motor threshold ratio was retained by the multiple regression model and explained half of the variance (49%; P <0.001) of the upper limb motor impairment after stroke.

Conclusions—

The implementation of quantitative neurophysiological measurements such as the resting motor threshold as a surrogate marker of impairment could be considered in neurorehabilitation trials.

Dose Articulation in Preclinical and Clinical Stroke Recovery: Refining a Discovery Research Pipeline and Presenting a Scoping Review Protocol

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.

Effects of a Robot-Assisted Arm Training Plus Hand Functional Electrical Stimulation on Recovery After Stroke: A Randomized Clinical Trial

OBJECTIVE

To compare the effects of unilateral, proximal arm robot-assisted therapy combined with hand functional electrical stimulation with intensive conventional therapy for restoring arm function in survivors of subacute stroke.

DESIGN

This was a single-blinded, randomized controlled trial.

SETTING

Inpatient rehabilitation university hospital.

PARTICIPANTS

Patients (N=40) diagnosed as having ischemic stroke (time since stroke <8wk) and upper limb impairment were enrolled.

INTERVENTIONS

Participants randomized to the experimental group received 30 sessions (5 sessions/wk) of robot-assisted arm therapy and hand functional electrical stimulation (RAT+FES). Participants randomized to the control group received a time-matched intensive conventional therapy.

MAIN OUTCOME MEASURES

The primary outcome was arm motor recovery measured with the Fugl-Meyer Motor Assessment. Secondary outcomes included motor function, arm spasticity, and activities of daily living. Measurements were performed at baseline, after 3 weeks, at the end of treatment, and at 6-month follow-up. Presence of motor evoked potentials (MEPs) was also measured at baseline.

RESULTS

Both groups significantly improved all outcome measures except for spasticity without differences between groups. Patients with moderate impairment and presence of MEPs who underwent early rehabilitation (<30d post stroke) demonstrated the greatest clinical improvements.

CONCLUSIONS

RAT+FES was no more effective than intensive conventional arm training. However, at the same level of arm impairment and corticospinal tract integrity, it induced a higher level of arm recovery.

Virtual Reality and Noninvasive Brain Stimulation in Stroke: How Effective Is Their Combination for Upper Limb Motor Improvement?-A Meta-Analysis

BACKGROUND

Efforts to augment post-stroke upper limb (UL) motor improvement include the use of newer interventions such as noninvasive brain stimulation (NIBS) and task practice in virtual reality environments (VEs). Despite increasing interest in using a combination of these 2 interventions, the effectiveness of this combination to enhance UL motor improvement outcomes has not been examined.

OBJECTIVE

To evaluate the effectiveness of a combination of NIBS and task practice in a VE to augment post-stroke UL motor improvement.

METHODS

We conducted a systematic search of the published literature using standard methodology. The Down and Black checklist and the Physiotherapy Evidence Database Research Organization Scale were used to assess study quality. We compared changes in UL impairment and activity levels between active stimulation and sham or other interventions using standardized mean differences and derived a summary effect size.

RESULTS

We retrieved 5 studies that examined the role of a combination of NIBS and task practice in a VE to optimize UL motor improvement. These 5 studies included 3 randomized controlled trials, 1 cross-sectional study, and 1 crossover study. There was level 1a evidence that the combination was beneficial in subacute stroke. There was level 1b evidence that provision of real stimulation was not superior to sham stimulation in chronic stroke. Effect sizes favoring the combination were moderate for improvements in UL impairment and small for activity levels.

CONCLUSIONS

Preliminary evidence supports the effectiveness of this combination in subacute stroke. Emergent questions need to be addressed to derive maximum benefit of this combination to augment post-stroke UL motor improvement.

LEVEL OF EVIDENCE

I.

Plasticity and recovery of function

The frontal lobe plays a crucial role in human motor behavior. It is one of the last areas of the brain to mature, especially the prefrontal regions. After a brief historical perspective on the perceived dichotomy between the view of the brain as a static organ and that of a plastic, constantly changing structure, we discuss the stability/plasticity dilemma including examples of documented cortical reorganization taking place at multiple spatial and temporal scales. We pose that while plasticity is needed for motor learning, stability of the system is necessary for storage and maintenance of memorized skills. We discuss how this plasticity/stability dilemma is resolved along the life span and after a brain injury. We then examine the main challenges that clinicians have to overcome to promote recovery of function in patients with brain lesions, including attempts to use neurostimulation techniques as adjuvant to training-based customary neurorehabilitation.

Methods for an Investigation of Neurophysiological and Kinematic Predictors of Response to Upper Extremity Repetitive Task Practice in Chronic Stroke

Objective

To demonstrate the feasibility of algorithmic prediction using a model of baseline arm movement, genetic factors, demographic characteristics, and multimodal assessment of the structure and function of motor pathways. To identify prognostic factors and the biological substrate for reductions in arm impairment in response to repetitive task practice.

Design

This prospective single-group interventional study seeks to predict response to a repetitive task practice program using an intent-to-treat paradigm. Response is measured as a change of ≥5 points on the Upper Extremity Fugl-Meyer from baseline to final evaluation (at the end of training).

Setting

General community.

Participants

Anticipated enrollment of community-dwelling adults with chronic stroke (N = 96; onset≥6mo) and moderate to severe residual hemiparesis of the upper limb as defined by a score of 10-45 points on the Upper Extremity Fugl-Meyer.

Intervention

The intervention is a form of repetitive task practice using a combination of robot-assisted therapy coupled with functional arm use in real-world tasks administered over 12 weeks.

Main Outcome Measures

Upper Extremity Fugl-Meyer Assessment (primary outcome), Wolf Motor Function Test, Action Research Arm Test, Stroke Impact Scale, questionnaires on pain and expectancy, magnetic resonance imaging, transcranial magnetic stimulation, arm kinematics, accelerometry, and a saliva sample for genetic testing.

Results

Methods for this trial are outlined, and an illustration of interindividual variability is provided by example of 2 participants who present similarly at baseline but achieve markedly different outcomes.

Conclusion

This article presents the design, methodology, and rationale of an ongoing study to develop a predictive model of response to a standardized therapy for stroke survivors with chronic hemiparesis. Applying concepts from precision medicine to neurorehabilitation is practicable and needed to establish realistic rehabilitation goals and to effectively allocate resources.

The effect of cerebellar transcranial direct current stimulation to improve standing balance performance early post-stroke, study protocol of a randomized controlled trial

RATIONALE

Restoration of adequate standing balance after stroke is of major importance for functional recovery. POstural feedback ThErapy combined with Non-invasive TranscranIAL direct current stimulation (tDCS) in patients with stroke (POTENTIAL) aims to establish if cerebellar tDCS has added value in improving standing balance performance early post-stroke.

METHODS

Forty-six patients with a first-ever ischemic stroke will be enrolled in this double-blind controlled trial within five weeks post-stroke. All patients will receive 15 sessions of virtual reality-based postural feedback training (VR-PFT) in addition to usual care. VR-PFT will be given five days per week for 1 h, starting within five weeks post-stroke. During VR-PFT, 23 patients will receive 25 min of cerebellar anodal tDCS (cb_tDCS), and 23 patients will receive sham stimulation.

STUDY OUTCOME

Clinical, posturographic, and neurophysiological measurements will be performed at baseline, directly post-intervention, two weeks post-intervention and at 15 weeks post-stroke. The primary outcome measure will be the Berg Balance Scale (BBS) for which a clinical meaningful difference of six points needs to be established between the intervention and control group at 15 weeks post-stroke.

DISCUSSION

POTENTIAL will be the first proof-of-concept randomized controlled trial to assess the effects of VR-PFT combined with cerebellar tDCS in terms of standing balance performance in patients early post-stroke. Due to the combined clinical, posturographical and neurophysiological measurements, this trial may give more insights in underlying post-stroke recovery processes and whether these can be influenced by tDCS.

The functional role of beta-oscillations in the supplementary motor area during reaching and grasping after stroke: A question of structural damage to the corticospinal tract

Hand motor function is often severely affected in stroke patients. Non-satisfying recovery limits reintegration into normal daily life. Understanding stroke-related network changes and identifying common principles that might underlie recovered motor function is a prerequisite for the development of interventional therapies to support recovery. Here, we combine the evaluation of functional activity (multichannel electroencephalography) and structural integrity (diffusion tensor imaging) in order to explain the degree of residual motor function in chronic stroke patients. By recording neural activity during a reaching and grasping task that mimics activities of daily living, the study focuses on deficit-related neural activation patterns. The study showed that the functional role of movement-related beta desynchronization in the supplementary motor area (SMA) for residual hand motor function in stroke patients depends on the microstructural integrity of the corticospinal tract (CST). In particular, in patients with damaged CST, stronger task-related activity in the SMA was associated with worse residual motor function. Neither CST damage nor functional brain activity alone sufficiently explained residual hand motor function. The findings suggest a central role of the SMA in the motor network during reaching and grasping in stroke patients, the degree of functional relevance of the SMA is depending on CST integrity.

Setting the scene for the Second Stroke Recovery and Rehabilitation Roundtable

The Stroke Recovery and Rehabilitation Roundtable (SRRR) meetings bring together an international group of preclinical and clinical researchers along with statisticians, methodologists, funders and consumers, working to accelerate the development of effective treatments for stroke recovery and to support best-evidence uptake in rehabilitation practice. The first meeting (2016) focused on four recommendation areas: translation of preclinical evidence into human discovery trials; recovery biomarkers to provide knowledge of therapeutic targets and prognosis in human stroke; intervention development, monitoring, and reporting standards; and standardized measurement in motor recovery trials. The impact of SRRR is growing, with uptake of recommendations emerging, and funders exploring ways to incorporate research targets and recommendations. At our second meeting (SRRR2, 2018), we worked on new priority areas: (1) cognitive impairment, (2) standardizing metrics for measuring quality of movement, (3) improving development of recovery trials, and (4) moving evidence-based treatments into practice. To accelerate progress towards breakthrough treatments, formation of an International Stroke Recovery and Rehabilitation Alliance is our next step, where working groups will take recommendations and build partnerships needed to achieve our goals.

Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme

OBJECTIVE

Persistent difficulty in using the upper limb remains a major contributor to physical disability post-stroke. There is a nihilistic view about what clinically relevant changes are possible after the early post-stroke phase. The Queen Square Upper Limb Neurorehabilitation programme delivers high-quality, high-dose, high-intensity upper limb neurorehabilitation during a 3-week (90 hours) programme. Here, we report clinical changes made by the chronic stroke patients treated on the programme, factors that might predict responsiveness to therapy and the relationship between changes in impairment and activity.

METHODS

Upper limb impairment and activity were assessed on admission, discharge, 6 weeks and 6 months after treatment, with modified upper limb Fugl-Meyer (FM-UL, max-54), Action Research Arm Test (ARAT, max-57) and Chedoke Arm and Hand Activity Inventory (CAHAI, max-91). Patient-reported outcome measures were recorded with the Arm Activity Measure (ArmA) parts A (0-32) and B (0-52), where lower scores are better.

RESULTS

224 patients (median time post-stroke 18 months) completed the 6-month programme. Median scores on admission were as follows: FM-UL = 26 (IQR 16-37), ARAT=18 (IQR 7-33), CAHAI=40 (28-55), ArmA-A=8 (IQR 4.5-12) and ArmA-B=38 (IQR 24-46). The median scores 6 months after the programme were as follows: FM-UL=37 (IQR 24-48), ARAT=27 (IQR 12-45), CAHAI=52 (IQR 35-77), ArmA-A=3 (IQR 1-6.5) and ArmA-B=19 (IQR 8.5-32). We found no predictors of treatment response beyond admission scores.

CONCLUSION

With intensive upper limb rehabilitation, chronic stroke patients can change by clinically important differences in measures of impairment and activity. Crucially, clinical gains continued during the 6-month follow-up period.