Stroke Rehabilitation

Traditional Thai massage steps development in acute ischemic stroke patients

Stroke results in many survivors experiencing limb dysfunction and functional disability. Early rehabilitation has shown promise in improving recovery. Traditional Thai Massage (TTM) is noted for potential benefits in aiding stroke recovery. Chaophya Abhaibhubejhr Hospital in Thailand has integrated TTM in treating various diseases and has developed a specialized TTM protocol for acute stroke patients. We develop 23 unique Traditional Thai Massage Steps based on Chaophya Abhaibhubejhr Hospital Experience and assess the feasibility and safety of combining TTM steps with physical therapy (PT) in treating acute ischemic stroke compared to PT alone. 33 stroke patients were randomized into two groups: intervention (TTM + PT) and control (PT alone). The outcomes were improvements in daily living, quality of life, and acute stroke severity by using a modified Rankin Scale (mRS) score, Barthel index of activities of daily living (BI), National Institutes of Health Stroke Scale (NIHSS), and the Stroke Specific Quality Of Life scale (SS-QOL). Both groups significantly improved outcomes over the 20-day study. However, there were no significant differences between the two groups in these measures. Both groups also reported no adverse effects from the treatments.•The 23 unique Traditional Thai Massage Steps for acute ischemic stroke based on Chaophya Abhaibhubejhr Hospital Experience are developed.•TTM protocols for acute ischemic stroke are practical and approved by well-trained Traditional Thai Medicine Practitioners.•Although TTM protocols do not show additional benefits to conventional PT at day 20 after treatment, their combinations for patients with acute ischemic stroke appear safe and feasible.

Neurocritical Care for Patients With Ischemic Stroke

OBJECTIVE

Management of stroke due to large vessel occlusion (LVO) has undergone unprecedented change in the past decade. Effective treatment with thrombectomy has galvanized the field and led to advancements in all aspects of care. This article provides a comprehensive examination of neurologic intensive care unit (ICU) management of patients with stroke due to LVO. The role of the neurocritical care team in stroke systems of care and the importance of prompt diagnosis, initiation of treatment, and continued monitoring of patients with stroke due to LVO is highlighted.

LATEST DEVELOPMENTS

The management of complications commonly associated with stroke due to LVO, including malignant cerebral edema and respiratory failure, are addressed, stressing the importance of early identification and aggressive treatment in mitigating negative effects on patients' prognoses. In the realm of medical management, this article discusses various medical therapies, including antithrombotic therapy, blood pressure management, and glucose control, outlining evidence-based strategies for optimizing patient outcomes. It further emphasizes the importance of a multidisciplinary approach to provide a comprehensive care model. Lastly, the critical aspect of family communication and prognostication in the neurologic ICU is addressed.

ESSENTIAL POINTS

This article emphasizes the multidimensional aspects of neurocritical care in treating patients with stroke due to LVO.

Simultaneous high-definition transcranial direct current stimulation and robot-assisted gait training in stroke patients

This study investigates whether simultaneous high-definition transcranial direct current stimulation (HD-tDCS) enhances the effects of robot-assisted gait training in stroke patients. Twenty-four participants were randomly allocated to either the robot-assisted gait training with real HD-tDCS group (real HD-tDCS group) or robot-assisted gait training with sham HD-tDCS group (sham HD-tDCS group). Over four weeks, both groups completed 10 sessions. The 10 Meter Walk Test, Timed Up and Go, Functional Ambulation Category, Functional Reach Test, Berg Balance Scale, Dynamic Gait Index, Fugl-Meyer Assessment, and Korean version of the Modified Barthel Index were conducted before, immediately after, and one month after the intervention. The real HD-tDCS group showed significant improvements in the 10 Meter Walk Test, Timed Up and Go, Functional Reach Test, and Berg Balance Scale immediately and one month after the intervention, compared with before the intervention. Significant improvements in the Dynamic Gait Index and Fugl-Meyer Assessment were also observed immediately after the intervention. The sham HD-tDCS group showed no significant improvements in any of the tests. Application of HD-tDCS during robot-assisted gait training has a positive effect on gait and physical function in chronic stroke patients, ensuring long-term training effects. Our results suggest the effectiveness of HD-tDCS as a complementary tool to enhance robotic gait rehabilitation therapy in chronic stroke patients.

Predicting the functional outcome of intensive inpatient rehabilitation after stroke: results from the RIPS Study

BACKGROUND

The complexity of stroke sequelae, the heterogeneity of outcome measures and rehabilitation pathways, and the lack of extensively validated prediction models represent a challenge in predicting stroke rehabilitation outcomes.

AIM

To prospectively investigate a multidimensional set of variables collected at admission to inpatient post-stroke rehabilitation as potential predictors of the functional level at discharge.

DESIGN

Multicentric prospective observational study.

SETTING

Patients were enrolled in four Intensive Rehabilitation Units (IRUs).

POPULATION

Patients were consecutively recruited in the period December 2019-December 2020 with the following inclusion criteria: aged 18+, with ischemic/haemorrhagic stroke, and undergoing inpatient rehabilitation within 30 days from stroke.

METHODS

This is a multicentric prospective observational study. The rehabilitation pathway was reproducible and evidence-based. The functional outcome was disability in activities of daily living, measured by the modified Barthel Index (mBI) at discharge. Potential multidimensional predictors, assessed at admission, included demographics, event description, clinical assessment, functional and cognitive profile, and psycho-social domains. The variables statistically associated with the outcome in the univariate analysis were fed into a multivariable model using multiple linear regression.

RESULTS

A total of 220 patients were included (median [IQR] age: 80 [15], 112 women, 175 ischemic). Median mBI was 26 (43) at admission and 62.5 (52) at discharge. In the multivariable analysis younger age, along with better functioning, fewer comorbidities, higher cognitive abilities, reduced stroke severity, and higher motor functions at admission, remained independently associated with higher discharge mBI. The final model allowed a reliable prediction of discharge functional outcome (adjusted R2=77.2%).

CONCLUSIONS

The model presented in this study, based on easily collectable, reliable admission variables, could help clinicians and researchers to predict the discharge scores of the global functional outcome for persons enrolled in an evidence-based inpatient stroke rehabilitation program.

CLINICAL REHABILITATION IMPACT

A reliable outcome prediction derived from standardized assessment measures and validated treatment protocols could guide clinicians in the management of patients in the subacute phase of stroke and help improve the planning of the rehabilitation individualized project.

Assessment of functional fitness impacted by hospital rehabilitation in post-stroke patients who additionally contracted COVID-19

Background

The aim of the study was to assess the effects of rehabilitation in post-stroke patients, or post-stroke patients with simultaneous COVID-19 infection, in relation to: improved locomotion efficiency, improved balance, reduced risk of falling as well as the patients' more effective performance in everyday activities.

Methods

The study involved 60 patients in the early period (2-3 months) after a stroke. Group I consisted of 18 patients (30.0%) who, in addition to a stroke, also contracted COVID-19. Group II consisted of 42 patients (70%) post-stroke, with no SARS-CoV2 infection. The effects were assessed on the basis of: Tinetti test, Timed Up & Go test and Barthel scale.

Results

Both groups achieved a statistically significant improvement in their Barthel score after therapy (p < 0.001). The Tinetti test, assessing gait and balance, showed that participants in Group I improved their score by an average of 4.22 points. ±4.35, and in Group II, on average, by 3.48 points ± 3.45 points. In the Timed Up & Go test over a distance of 3 m, significant improvement was achieved in both groups, as well but the effect was higher in Group I (p < 0.001).

Conclusions

Hospital rehabilitation in the early period after stroke improved locomotion efficiency and balance, and reduced the risk of falls in post-stroke patients, both with and without COVID-19 infection.

Effects of anodal tDCS on resting state eeg power and motor function in acute stroke: a randomized controlled trial

BACKGROUND

Anodal transcranial direct current stimulation (tDCS) is a beneficial adjunctive tool in stroke rehabilitation. However, only a few studies have investigated its effects on acute stroke and recruited only individuals with mild motor deficits. This study investigated the effect of five consecutive sessions of anodal tDCS and conventional physical therapy on brain activity and motor outcomes in individuals with acute stroke, with low and high motor impairments.

METHODS

Thirty participants were recruited and randomly allocated to either the anodal or sham tDCS group. Five consecutive sessions of tDCS (1.5 mA anodal or sham tDCS for 20 min) were administered, followed by conventional physical therapy. Electroencephalography (EEG), Fugl-Meyer Motor Assessment (FMA), and Wolf Motor Function Test (WMFT) were performed at pre-, post-intervention (day 5), and 1-month follow-up. Sub-analyses were performed on participants with low and high motor impairments. The relationship between EEG power and changes in motor functions was assessed.

RESULTS

Linear regression showed a significant positive correlation between beta bands and the FMA score in the anodal group. Elevated high frequency bands (alpha and beta) were observed at post-intervention and follow-up in all areas of both hemispheres in the anodal group, while only in the posterior area of the non-lesioned hemisphere in the sham group; however, such elevation induced by tDCS was not greater than sham. Lower limb function assessed by FMA was improved in the anodal group compared with the sham group at post-intervention and follow-up only in those with low motor impairment. For the upper limb outcomes, no difference between groups was found.

CONCLUSIONS

Five consecutive days of anodal tDCS and physical therapy in acute stroke did not result in a superior improvement of beta bands that commonly related to stroke recovery over sham, but improved lower extremity functions with a post-effect at 1-month follow-up in low motor impairment participants. The increase of beta bands in the lesioned brain in the anodal group was associated with improvement in lower limb function.

TRIAL REGISTRATION

NCT04578080, date of first registration 10/01/2020.

Cycling using functional electrical stimulation therapy to improve motor function and activity in post-stroke individuals in early subacute phase: a systematic review with meta-analysis

BACKGROUND

Stroke necessitates interventions to rehabilitate individuals with disabilities, and the application of functional electrical stimulation therapy (FEST) has demonstrated potential in this regard. This study aimed to analyze the efficacy and effectiveness of cycling using FEST to improve motor function and lower limb activity in post-stroke individuals.

METHODS

We performed a systematic review according to the recommendations of the PRISMA checklist, searching MEDLINE, Cochrane, EMBASE, LILACS, and PEDro databases by July 2022, without any date or language limitations. Studies were selected using the following terms: stroke, electrical stimulation therapy, cycling, and clinical trials. Randomized or quasi-randomized clinical trials that investigated the effectiveness of cycling using FEST combined with exercise programs and cycling using FEST alone for motor function and activity in subacute post-stroke individuals were included. The quality of included trials was assessed using the PEDro scores. Outcome data were extracted from eligible studies and combined in random-effects meta-analyses. The quality of evidence was determined according to the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

Five randomized clinical trials involving 187 participants were included. Moderate-quality evidence indicates that cycling using FEST combined with exercise programs promotes relevant benefits in trunk control (MD 9 points, 95% CI 0.36-17.64) and walking distance (MD 94.84 m, 95% CI 39.63-150.05, I = 0%), the other outcomes had similar benefits. Cycling using FEST alone compared to exercise programs promotes similar benefits in strength, balance, walking speed, walking distance, and activities of daily living.

CONCLUSION

This systematic review provides low- to moderate-quality evidence that cycling using FEST may be an effective strategy to consider in improving motor function and activity outcomes for post-stroke individuals in the early subacute phase.

REVIEW REGISTRATION

PROSPERO (CRD42022345282).

Exploring the efficacy of virtual reality-based rehabilitation in stroke: a narrative review of current evidence

BACKGROUND

Stroke rehabilitation presents a complex challenge, necessitating innovative approaches to optimise functional recovery. Virtual Reality-Based Rehabilitation (VRBR) has emerged as a promising intervention that capitalises on immersive technology to engage stroke survivors in their recovery journey. This review aims to examine the efficacy of VRBR in stroke rehabilitation, focusing on its advantages and challenges.

METHODS

A comprehensive search of relevant literature was conducted to gather evidence on the efficacy of VRBR in stroke survivors. Studies that investigated the impact of VRBR on patient engagement, functional recovery, and overall rehabilitation outcomes were included. The review also assessed the ability of VRBR to simulate real-life scenarios and facilitate essential daily activities for stroke survivors.

RESULTS

The review highlights that VRBR offers a unique immersive experience that enhances patient engagement and motivation during rehabilitation. The immersive nature of VRBR fosters a sense of presence, which can positively impact treatment adherence and outcomes. Moreover, VRBR's capacity to replicate real-world scenarios provides stroke survivors with opportunities to practice vital daily activities, promoting functional independence. In contrast, conventional rehabilitation methods lack the same level of engagement and real-world simulation.

CONCLUSION

VRBR holds promise as an efficacious intervention in stroke rehabilitation. Its immersive nature enhances patient engagement and motivation, potentially leading to better treatment adherence and outcomes. The ability of VRBR to simulate real-life scenarios offers a unique platform. However, challenges such as cost, equipment, patient suitability, data privacy, and acceptance must be addressed for successful integration into stroke rehabilitation practice.

Management of Upper-Limb Spasticity Using Modern Rehabilitation Techniques versus Botulinum Toxin Injections Following Stroke

Our purpose is to emphasize the role of botulinum toxin in spasticity therapy and functional recovery in patients following strokes. Our retrospective study compared two groups, namely ischemic and hemorrhagic stroke patients. The study group (BT group) comprised 80 patients who received focal botulinum toxin as therapy for an upper limb with spastic muscle three times every three months. The control group (ES group) comprised 80 patients who received only medical rehabilitation consisting of electrostimulation and radial shockwave therapy for the upper limb, which was applied three times every three months. Both groups received the same stretching program for spastic muscles as a home training program. We evaluated the evolution of the patients using muscle strength, Ashworth, Tardieu, Frenchay, and Barthel scales. The analysis indicated a statistically significant difference between the two groups for all scales, with better results for the BT group (p < 0.0001 for all scales). In our study, the age at disease onset was an important prediction factor for better recovery in both groups but not in all scales. Better recovery was obtained for younger patients (in the BT group, MRC scale: rho = -0.609, p-value < 0.0001; Tardieu scale: rho = -0.365, p-value = 0.001; in the ES group, MRC scale: rho = -0.445, p-value < 0.0001; Barthel scale: rho = -0.239, p-value = 0.033). Our results demonstrated the effectiveness of botulinum toxin therapy compared with the rehabilitation method, showing a reduction of the recovery time of the upper limb, as well as an improvement of functionality and a reduction of disability. Although all patients followed a specific kinetic program, important improvements were evident in the botulinum toxin group.

Nurse-led telerehabilitation intervention to improve stroke efficacy: Protocol for a pilot randomized feasibility trial

BACKGROUND

The prevalence of stroke continues to rise in low-middle income countries. The continual rise in stroke cases and increasing prevalence on post-acute needs represent a crucial call for increased accessibility and utilization of rehabilitation services.

AIM

The primary objective of the study is to test the feasibility of a nurse-led telerehabilitation intervention in improving self-efficacy among stroke survivors. The findings of the trial are intended for use in a future larger study.

METHODS

Participants would be recruited at the University of Ghana Hospital and randomized into an intervention group and a control group. Participants aged ≥ 18 years, diagnosed of stroke at most 12months prior the recruitment and requiring moderate level of assistance would be considered for eligibility. Participants in the intervention group will receive individualized and comprehensive nurse-led rehabilitation therapies in physical, emotional, cognitive and nursing education domains for 6 months, in addition to treatment as usual (TAU). The control group will only receive treatment as usual. Follow-up evaluations will occur immediately, 30 days and 90 days after the intervention.

DISCUSSION

Providing stroke rehabilitation services in low-resource settings presents a significant challenge due to limited infrastructure and a lack of trained healthcare professionals. The current study has the potential of contributing to the growing body of evidence on the impact of telerehabilitation services in mitigating these challenges in low-resource settings.

TRIAL REGISTRATION

PACTR202210685104862, Pan African Clinical Trial Registry.

Stroke Rehabilitation and Motor Recovery

OBJECTIVE

Up to 50% of the nearly 800,000 patients who experience a new or recurrent stroke each year in the United States fail to achieve full independence afterward. More effective approaches to enhance motor recovery following stroke are needed. This article reviews the rehabilitative principles and strategies that can be used to maximize post-stroke recovery.

LATEST DEVELOPMENTS

Evidence dictates that mobilization should not begin prior to 24 hours following stroke, but detailed guidelines beyond this are lacking. Specific classes of potentially detrimental medications should be avoided in the early days poststroke. Patients with stroke who are unable to return home should be referred for evaluation to an inpatient rehabilitation facility. Research suggests that a substantial increase in both the dose and intensity of upper and lower extremity exercise is beneficial. A clinical trial supports vagus nerve stimulation as an adjunct to occupational therapy for motor recovery in the upper extremity. The data remain somewhat mixed as to whether robotics, transcranial magnetic stimulation, functional electrical stimulation, and transcranial direct current stimulation are better than dose-matched traditional exercise. No current drug therapy has been proven to augment exercise poststroke to enhance motor recovery.

ESSENTIAL POINTS

Neurologists will collaborate with rehabilitation professionals for several months following a patient's stroke. Many questions still remain about the ideal exercise regimen to maximize motor recovery in patients poststroke. The next several years will likely bring a host of new research studies exploring the latest strategies to enhance motor recovery using poststroke exercise.

Predictive Factors and Interventional Modalities of Post-stroke Motor Recovery: An Overview

Stroke is the most common cause of motor impairment worldwide. Therefore, many factors are being investigated for their predictive and facilitatory effects on recovery of motor function after stroke. Motor recovery can be predicted through several factors, such as clinical assessment, clinical biomarkers, and gene-based variations. As for interventions, many methods are under experimental investigation that aim to improve motor recovery, including different types of pharmacological interventions, non-invasive stimulation, and rehabilitation training by inducing cortical reorganization, neuroplasticity, angiogenesis, changing the levels of neurotransmitters in the brain, and altering the inflammatory and apoptotic processes occurring after stroke. Studies have shown that clinical biomarkers combined with clinical assessment and gene-based variations are reliable factors for predicting motor recovery after stroke. Moreover, different types of interventions such as pharmacological agents (selective serotonin reuptake inhibitors {SSRI}, noradrenaline reuptake inhibitors {NARIs}, levodopa, and amphetamine), non-invasive stimulation, and rehabilitation training have shown significant results in improving functional and motor recovery.

Knowledge, attitude, and practice regarding stroke potential complications among stroke survivors' family members in Shiraz, Iran

Objectives

This study aimed to evaluate stroke survivors' family members' knowledge, attitude, and practice about these sequelae.

Patients and methods

In this cross-sectional survey, 105 family members (57 males, 48 females; mean age: 48.3±9.7 years; range 18 to 60 years) of stroke survivors were examined via a self-structured questionnaire between September 2019 and January 2020. Patients' medical characteristics, as well as participants' sociodemographic and opinions regarding studying variables, were surveyed.

Results

The participants were mostly married and had relatively high scores in knowledge, attitude, and practice questionnaires. We found a significant correlation between participants' knowledge and practice. Moreover, data analysis revealed significantly higher knowledge scores in the employed participants and higher practice scores in the urban population. Furthermore, the relationship of patients with their family members can affect their attitude toward stroke complications.

Conclusion

This study has revealed that caregivers in rural areas with lower education levels are less knowledgeable about potential stroke complications, and subsequently, the patients are more vulnerable to those sequelae. Stakeholders should consider these groups their priorities in education and empowerment processes for stroke survivors' caregivers.

Effects of trunk stabilization exercises using laser pointer visual feedback in patients with chronic stroke: A randomized controlled study

BACKGROUND

Many previous studies have cited the importance of trunk stabilization exercises in patients with stroke. However, the evidence for optimal trunk stabilization exercises for patients with stroke is still lacking.

OBJECTIVE

To investigate the effects of laser pointer visual feedback in trunk stabilization exercises that are important for improving trunk dysfunction in patients with stroke.

METHODS

In total, 30 patients with chronic stroke were randomly assigned to experimental and control groups. The experimental group underwent a traditional stroke rehabilitation program and trunk stabilization exercises using laser pointer visual feedback. The control group underwent a traditional stroke rehabilitation program and trunk stabilization exercises without visual feedback. Pre- and postintervention results after 6 weeks were evaluated using the Berg Balance Scale, static and dynamic plantar pressure, 10-m walk test, and the Korean version of the Fall Efficacy Scale. The results were analyzed using a general linear repeated measurement model.

RESULTS

Both groups showed significant improvements in BBS scores, static plantar pressure, dynamic plantar pressure, 10 MWT, and K-FES scores after 6 weeks of intervention (P< 0.05). Compared to the control group, significant improvements were observed in the experimental group in the Berg Balance Scale scores, dynamic paretic posterior plantar pressure, 10-m walk test, and Korean version of the Fall Efficacy Scale scores (P< 0.025).

CONCLUSION

Our results demonstrated the effectiveness of visual feedback during trunk stabilization exercises for resolving trunk dysfunction in patients with stroke. Trunk stabilization exercises using laser pointer visual feedback have been found to be more effective in balance, walking, and fall efficacy in patients with stroke.

The Impact of Depression on the Functional Outcome of the Elderly Stroke Victim from a Gender Perspective: A Systematic Review

(1) Background: The aim of this systematic review focused on analyzing the impact of depression on the functional outcome of the elderly stroke victim and how this disorder affects both the female and the male population. (2) Methods: We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review was registered in PROSPERO (ID 346284). The systematic search for clinical trials was performed in the databases Pubmed, Otseeker, Scopus, Web of Science, Psycinfo, Medline Complete, ScienceDirect, SciELO, and Dialnet. Articles were selected according to the inclusion and exclusion criteria, including those dealing with post-stroke depression in adults whose psychological status had changed. Studies that only assessed the psychological state of caregivers were excluded. (3) Results: In total, 609 articles were identified, of which 11 randomized controlled trials were finally included in the review. The results indicate that post-stroke depression influences the recovery of functionality and quality of life. In addition, the need to detect the mood of the adult population after the stroke and to provide individualized treatment according to the characteristics of the person is highlighted. (4) Conclusions: This systematic review shows how early detection of post-stroke depressive symptoms can improve the degree of disability and quality of life of the person, especially in women.

Predictors of functional outcomes in adults with brain tumor undergoing rehabilitation treatment: a systematic review

INTRODUCTION

The number of diagnosed brain tumors (BT) has increased in recent years. The results of treatment of patients with surgery, chemotherapy and radiotherapy are also improving and their survival rate has increased significantly. Symptoms of the disease and side effects of oncological treatment may reduce the functional performance of patients. It is so important to conduct rehabilitation in this group of patients. The aim of this systematic review is to identify predictors of effective rehabilitation in aspects of physical functioning of BT patients. The study was registered with health and social care, welfare, public health, education, crime, justice and international development departments, where there is a health-related interest outcome PROSPERO. We have received registration number is: CRD42021269398.

EVIDENCE ACQUISITION

To find relevant publications, the algorithm of keywords ("brain tumor") AND (rehabilitation OR "physical activity" OR exercise OR "physical therapy") was used. The search was conducted in PubMed, Web of Science, PEDro, ClinicalTrials.gov and Cochrane Library. Information was extracted using the PICO format (i.e., participants, intervention, comparison, outcomes).

EVIDENCE SYNTHESIS

the initial search identified a total of 1122 results, and 21 articles met the criteria and were selected for analysis.

CONCLUSIONS

The results present that rehabilitation is an important and safe cancer encouraging therapy, brings functional benefits. The type of rehabilitation program, especially in BT patients, depends on many factors such as time and type of oncological treatment, general conditions which is strongly related to the general functioning of the patient. It still is a need for clinical research into the safety and effectiveness of rehabilitation interventions already during radio or chemotherapy in this group of cancer patients.

Transcranial-Direct-Current-Stimulation Accelerates Motor Recovery After Cortical Infarction in Mice: The Interplay of Structural Cellular Responses and Functional Recovery

BACKGROUND

Transcranial direct current stimulation (tDCS) promotes recovery after stroke in humans. The underlying mechanisms, however, remain to be elucidated. Animal models suggest tDCS effects on neuroinflammation, stem cell proliferation, neurogenesis, and neural plasticity.

OBJECTIVE

In a longitudinal study, we employed tDCS in the subacute and chronic phase after experimental focal cerebral ischemia in mice to explore the relationship between functional recovery and cellular processes.

METHODS

Mice received photothrombosis in the right motor cortex, verified by Magnetic Resonance Imaging. A composite neuroscore quantified subsequent functional deficits. Mice received tDCS daily: either 5 sessions from day 5 to 9, or 10 sessions with days 12 to 16 in addition. TDCS with anodal or cathodal polarity was compared to sham stimulation. Further imaging to assess proliferation and neuroinflammation was performed by immunohistochemistry at different time points and Positron Emission Tomography at the end of the observation time of 3 weeks.

RESULTS

Cathodal tDCS at 198 kC/m² (220 A/m²) between days 5 and 9 accelerated functional recovery, increased neurogenesis, decreased microglial activation, and mitigated CD16/32-expression associated with M1-phenotype. Anodal tDCS exerted similar effects on neurogenesis and microglial polarization but not on recovery of function or microglial activation. TDCS on days 12 to 16 after stroke did not induce any further effects, suggesting that the therapeutic time window was closed by then.

CONCLUSION

Overall, data suggest that non-invasive neuromodulation by tDCS impacts neurogenesis and microglial activation as critical cellular processes influencing functional recovery during the early phase of regeneration from focal cerebral ischemia.

Toward an Adapted Neurofeedback for Post-stroke Motor Rehabilitation: State of the Art and Perspectives

Stroke is a severe health issue, and motor recovery after stroke remains an important challenge in the rehabilitation field. Neurofeedback (NFB), as part of a brain–computer interface, is a technique for modulating brain activity using on-line feedback that has proved to be useful in motor rehabilitation for the chronic stroke population in addition to traditional therapies. Nevertheless, its use and applications in the field still leave unresolved questions. The brain pathophysiological mechanisms after stroke remain partly unknown, and the possibilities for intervention on these mechanisms to promote cerebral plasticity are limited in clinical practice. In NFB motor rehabilitation, the aim is to adapt the therapy to the patient’s clinical context using brain imaging, considering the time after stroke, the localization of brain lesions, and their clinical impact, while taking into account currently used biomarkers and technical limitations. These modern techniques also allow a better understanding of the physiopathology and neuroplasticity of the brain after stroke. We conducted a narrative literature review of studies using NFB for post-stroke motor rehabilitation. The main goal was to decompose all the elements that can be modified in NFB therapies, which can lead to their adaptation according to the patient’s context and according to the current technological limits. Adaptation and individualization of care could derive from this analysis to better meet the patients’ needs. We focused on and highlighted the various clinical and technological components considering the most recent experiments. The second goal was to propose general recommendations and enhance the limits and perspectives to improve our general knowledge in the field and allow clinical applications. We highlighted the multidisciplinary approach of this work by combining engineering abilities and medical experience. Engineering development is essential for the available technological tools and aims to increase neuroscience knowledge in the NFB topic. This technological development was born out of the real clinical need to provide complementary therapeutic solutions to a public health problem, considering the actual clinical context of the post-stroke patient and the practical limits resulting from it.

Quantitative Assessment of Hand Function in Healthy Subjects and Post-Stroke Patients with the Action Research Arm Test

The Action Research Arm Test (ARAT) can provide subjective results due to the difficulty assessing abnormal patterns in stroke patients. The aim of this study was to identify joint impairments and compensatory grasping strategies in stroke patients with left (LH) and right (RH) hemiparesis. An experimental study was carried out with 12 patients six months after a stroke (three women and nine men, mean age: 65.2 ± 9.3 years), and 25 healthy subjects (14 women and 11 men, mean age: 40.2 ± 18.1 years. The subjects were evaluated during the performance of the ARAT using a data glove. Stroke patients with LH and RH showed significantly lower flexion angles in the MCP joints of the Index and Middle fingers than the Control group. However, RH patients showed larger flexion angles in the proximal interphalangeal (PIP) joints of the Index, Middle, Ring, and Little fingers. In contrast, LH patients showed larger flexion angles in the PIP joints of the Middle and Little fingers. Therefore, the results showed that RH and LH patients used compensatory strategies involving increased flexion at the PIP joints for decreased flexion in the MCP joints. The integration of a data glove during the performance of the ARAT allows the detection of finger joint impairments in stroke patients that are not visible from ARAT scores. Therefore, the results presented are of clinical relevance.

Accidente cerebrovascular isquémico de la arteria cerebral media

La segunda causa de muerte a nivel mundial corresponde a los ataques cerebrovasculares (ACV), de los cuales más de dos terceras partes son de origen isquémico. Causan discapacidad a largo plazo por lo que conocer la anatomía de la circulación cerebral y las posibles manifestaciones clínicas del ACV isquémico permite sospechar, diagnosticar y brindar un manejo oportuno y apropiado, reduciendo el impacto en la salud y la calidad de vida del paciente y sus cuidadores. Objetivo: relacionar los últimos hallazgos en la anatomía arterial cerebral, los mecanismos fisiopatológicos y las manifestaciones clínicas del ACV isquémico de la arteria cerebral media (ACM). Materiales y métodos: revisión de la literatura mediante la búsqueda con términos MeSH en la base de datos Medline, incluyendo estudios, ensayos y metaanálisis publicados entre 2000 y 2020 en inglés y español, además de otras referencias para complementar la información. Resultados: se seleccionaron 59 publicaciones, priorizando la de los últimos 5 años y las más relevantes del rango temporal consultado. Conclusiones: son escasos los estudios sobre la presentación clínica de los ACV, lo que sumado a la variabilidad interindividual de la irrigación cerebral, dificulta la determinación clínica de la localización de la lesión dentro del lecho vascular. La reperfusión del área de penumbra isquémica como objetivo terapéutico se justifica por los mecanismos fisiopatológicos de la enfermedad.

Reward System Dysfunction and the Motoric-Cognitive Risk Syndrome in Older Persons

During aging, many physiological systems spontaneously change independent of the presence of chronic diseases. The reward system is not an exception and its dysfunction generally includes a reduction in dopamine and glutamate activities and the loss of neurons of the ventral tegmental area (VTA). These impairments are even more pronounced in older persons who have neurodegenerative diseases and/or are affected by cognitive and motoric frailty. All these changes may result in the occurrence of cognitive and motoric frailty and accelerated progression of neurodegenerative diseases, such as Alzheimer’s and Parkinson’s diseases. In particular, the loss of neurons in VTA may determine an acceleration of depressive symptoms and cognitive and motor frailty trajectory, producing an increased risk of disability and mortality. Thus, we hypothesize the existence of a loop between reward system dysfunction, depression, and neurodegenerative diseases in older persons. Longitudinal studies are needed to evaluate the determinant role of the reward system in the onset of motoric-cognitive risk syndrome.

Quantitative Evaluation System of Upper Limb Motor Function of Stroke Patients Based on Desktop Rehabilitation Robot

Rehabilitation training and movement evaluation after stroke have become a research hotspot as stroke has become a very common and harmful disease. However, traditional rehabilitation training and evaluation are mainly conducted under the guidance of rehabilitation doctors. The evaluation process is time-consuming and the evaluation results are greatly influenced by doctors. In this study, a desktop upper limb rehabilitation robot was designed and a quantitative evaluation system of upper limb motor function for stroke patients was proposed. The kinematics and dynamics data of stroke patients during active training were collected by sensors. Combined with the scores of patients' upper limb motor function by rehabilitation doctors using the Wolf Motor Function Test (WMFT) scale, three different quantitative evaluation models of upper limb motor function based on Back Propagation Neural Network (BPNN), K-Nearest Neighbors (KNN), and Support Vector Regression (SVR) algorithms were established. To verify the effectiveness of the quantitative evaluation system, 10 healthy subjects and 21 stroke patients were recruited for experiments. The experimental results show that the BPNN model has the best evaluation performance among the three quantitative evaluation models. The scoring accuracy of the BPNN model reached up to 87.1%. Moreover, there was a significant correlation between the models' scores and the doctors' scores. The proposed system can help doctors to quantitatively evaluate the upper limb motor function of stroke patients and accurately master the rehabilitation progress of patients.

COVID-19 and Physical Activity Behaviour in People with Neurological Diseases: A Systematic Review

The COVID-19 pandemic has led to a radical lifestyle change, which may unintendedly change physical activity levels. We aimed to perform a systematic review to investigate the physical activity changes in people with neurological diseases, and to examine the relationship between physical activity and disease symptoms, and psychosocial factors. The review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A systematic search of the literature across five databases (PubMed, CINAHL, Web of Science, SCOPUS, and Cochrane Library) was carried out using the keywords relating to COVID-19, physical activity, sedentary behaviour, exercise, and the name of the neurological diseases. The systematic search was updated on 4 February 2021 with the same keywords. Fourteen studies (n = 7662 persons with neurological diseases, n = 1663 healthy controls) were eligible for this review. The study populations were Parkinson disease (n = 7), dementia (n = 1), multiple sclerosis (n = 1), spinal cord injury (n = 1), hereditary spastic paraplegia (n = 1), neuromuscular diseases (n = 1), Charcot-Marie-Tooth neuropathy (n = 1), and epilepsy (n = 1). Thirteen studies reported a decreased physical activity level, one study reported a high interruption rate of physiotherapy/rehabilitation. Furthermore, the physical activity reduction was associated with worse disease symptoms, depression, perceived health, and mental and physical components of quality of life. The COVID-19 pandemic has a negative impact on the physical activity levels of people with neurological diseases, and this change was related to the worsening of disease symptoms and psychosocial factors. Registration number A protocol of the review was registered with the PROSPERO database (CRD42020207676).

Supplementary Information

The online version contains supplementary material available at 10.1007/s10882-022-09836-x.

Comparing Neuroplasticity Changes Between High and Low Frequency Gait Training in Subacute Stroke: Protocol for a Randomized, Single-Blinded, Controlled Study

Background

Walking recovery post stroke can be slow and incomplete. Determining effective stroke rehabilitation frequency requires the assessment of neuroplasticity changes. Neurobiological signals from electroencephalogram (EEG) can measure neuroplasticity through incremental changes of these signals after rehabilitation. However, changes seen with a different frequency of rehabilitation require further investigation. It is hypothesized that the association between the incremental changes from EEG signals and the improved functional outcome measure scores are greater in higher rehabilitation frequency, implying enhanced neuroplasticity changes.

Objective

The purpose of this study is to identify the changes in the neurobiological signals from EEG, to associate these with functional outcome measures scores, and to compare their associations in different therapy frequency for gait rehabilitation among subacute stroke individuals.

Methods

A randomized, single-blinded, controlled study among patients with subacute stroke will be conducted with two groups: an intervention group (IG) and a control group (CG). Each participant in the IG and CG will receive therapy sessions three times a week (high frequency) and once a week (low frequency), respectively, for a total of 12 consecutive weeks. Each session will last for an hour with strengthening, balance, and gait training. The main variables to be assessed are the 6-Minute Walk Test (6MWT), Motor Assessment Scale (MAS), Berg Balance Scale (BBS), Modified Barthel Index (MBI), and quantitative EEG indices in the form of delta to alpha ratio (DAR) and delta-plus-theta to alpha-plus-beta ratio (DTABR). These will be measured at preintervention (R0) and postintervention (R1). Key analyses are to determine the changes in the 6MWT, MAS, BBS, MBI, DAR, and DTABR at R0 and R1 for the CG and IG. The changes in the DAR and DTABR will be analyzed for association with the changes in the 6MWT, MAS, BBS, and MBI to measure neuroplasticity changes for both the CG and IG.

Results

We have recruited 18 participants so far. We expect to publish our results in early 2023.

Conclusions

These associations are expected to be positive in both groups, with a higher correlation in the IG compared to the CG, reflecting enhanced neuroplasticity changes and objective evaluation on the dose-response relationship.

International Registered Report Identifier (IRRID)

DERR1-10.2196/27935

Ipsilesional Motor Cortex Activation with High-force Unimanual Handgrip Contractions of the Less-affected Limb in Participants with Stroke

Stroke is a leading cause of severe disability that often presents with unilateral motor impairment. Conventional rehabilitation approaches focus on motor practice of the affected limb and aim to suppress brain activity in the contralesional hemisphere. Conversely, exercise of the less-affected limb promotes contralesional brain activity which is typically viewed as contraindicated in stroke recovery due to the interhemispheric inhibitory influence onto the ipsilesional hemisphere. Yet, high-force unimanual handgrip contractions are known to increase ipsilateral brain activation in control participants, and it remains to be determined if high-force contractions with the less-affected limb would promote ipsilateral brain activation in participants with stroke (i.e., the ipsilesional hemisphere). Therefore, this study aimed to determine how parametric increases in handgrip force during repeated contractions with the less-affected limb impacts brain activity bilaterally in participants with stroke and in a cohort of neurologically intact controls. Participants performed repeated submaximal contractions at 25%, 50%, and 75% of their maximum voluntary contraction during separate functional magnetic resonance imaging brain scans. Brain activation during the tasks was quantified as the present change from resting levels. In this study, higher force contractions were found to increase brain activation in the ipsilesional (stroke)/ipsilateral (controls) hemisphere in both groups (p = .002), but no between group differences were observed. These data suggest that high-force exercise with the less-affected limb may promote ipsilesional cortical plasticity to promote motor recovery of the affected-limb in participants with stroke.

Application Value of Rehabilitation Nursing in Patients with Stroke Based on the Theory of Interactive Standard: A Randomized Controlled Study

Objective

To explore the application value of rehabilitation nursing based on the theory of interactive standards in stroke patients.

Methods

A total of 120 stroke patients who were treated in our hospital from December 2018 to September 2020 were selected as the research objects, and the patients were divided into a control group (60 cases) and an observation group (60 cases) according to the random number table method. The control group used routine nursing care, and the observation group used interactive rehabilitation care based on the control group. The Barthel Index, National Institute of Health Stroke Scale (NIHSS) score, Specific Quality Of Life Scale (SS-QOL) score, rehabilitation standard rate, nursing satisfaction, improvement time of limb function, and compliance with rehabilitation exercise were compared between the two groups of patients.

Results

After intervention, the Barthel Index of the two groups increased, and the Barthel Index of the observation group was comparatively higher (P < 0.05); the NIHSS scores of the two groups of patients reduced, and the NIHSS scores of the observation group were significantly lower than those of the control group (P < 0.05); the SS-QOL scores of the two groups of patients improved, and the increase in SS-QOL scores in the observation group was found to be significantly higher than those in the control group (P < 0.05); the compliance rate was found to be in favor of the observation group (83.33 (50/60) vs 63.33 (38/60)) (χ² = 6.136, P˂0.05); the total satisfaction of nursing care of patients in the observation group was superior to the control group (96.67% vs 78.33%) (χ² = 9.219, P˂0.05); the limb function improvement time of the observation group was significantly shorter (P < 0.05); the observation group had significantly higher rehabilitation exercise compliance scores (P < 0.05).

Conclusion

The rehabilitation nursing based on the interactive standard theory can promote the stroke patients to complete the rehabilitation goals, improve the neurological and limb functions, and enhance the patients' daily living ability, quality of life, and nursing satisfaction, which is worthy of clinical promotion and application.

Overview of Acute Ischemic Stroke Evaluation and Management

Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.

Image Features of Magnetic Resonance Angiography under Deep Learning in Exploring the Effect of Comprehensive Rehabilitation Nursing on the Neurological Function Recovery of Patients with Acute Stroke

This study was to explore the effects of imaging characteristics of magnetic resonance angiography (MRA) based on deep learning on the comprehensive rehabilitation nursing on the neurological recovery of patients with acute stroke. In this study, 84 patients with acute stroke who were treated in hospital were selected as the research objects, and they were rolled into a control group (routine care) and an experimental group (comprehensive rehabilitation care). The dense dilated block-convolution neural network (DD-CNN) algorithm under deep learning for cerebrovascular was adopted to assess the effect of comprehensive rehabilitation care on the neurological recovery of patients with acute stroke. The results showed that the Berg scale scores, Fugl-Meyer scores, and Functional Independence Measure (FIM) scores of the experimental group of patients after 6 weeks and 12 weeks of comprehensive rehabilitation nursing were greatly different from those before treatment, showing statistical differences (P < 0.05). Compared with conventional magnetic resonance imaging (MRI) images, MRA images based on CNN algorithm, Dense Net algorithm, and DD-CNN algorithm can more clearly show the patient's cerebral artery occlusion. The average dice similarity coefficient (DSC) values of CNN algorithm, Dense Net algorithm, and DD-CNN algorithm were determined to be 84.3%, 95.7%, and 97.8%, respectively; the average sensitivity (Sen) values of the three algorithms were 76.1%, 95.4%, and 96.8%, respectively; and the average accuracy (Acc) values were 87.9%, 96.3%, and 97.9%, respectively. Thus, there were statistically obvious differences among the three algorithms in terms of average values of DSC, Sen, and Acc (P < 0.05). The MRA images processed by the DD-CNN algorithm showed that the degree of neurological recovery of the experimental group was observably greater than that of the control group, and the difference was statistically obvious (P < 0.05). In short, the image features of MRA based on the deep learning DD-CNN algorithm showed good application value in studying the effect of comprehensive rehabilitation nursing on the neurological recovery of patients with acute stroke, and it was worthy of promotion.

Exploring Stroke Rehabilitation in Malaysia: Are Robots Better than Humans for Stroke Recuperation?

Ranked as the second leading cause of death and the primary factor to adult disability worldwide, stroke has become a global epidemic problem and burden. As a developing country, Malaysia still faces challenges in providing ideal rehabilitation services to individuals with physical disabilities including stroke survivors. Conventional post-stroke care is often delivered in a team-based approach and involves several disciplines, such as physical therapy, occupational therapy, speech and language therapy, depending on the nature and severity of the deficits. Robots are potential tools for stroke rehabilitation as they can enhance existing conventional therapy by delivering a precise and consistent therapy of highly repetitive movements. In addition, robot-assisted physiotherapy could facilitate the effectiveness of unsupervised rehabilitation and thus, may reduce the cost and duration of therapist-assisted rehabilitation. Research on robot-assisted physiotherapy for stroke in Malaysia is slowly coming into the limelight in the past two decades. This review explores the effectiveness of robot-assisted physiotherapy particularly in improving motor functions of stroke survivors in Malaysia.

Clinical Evaluation of Different Treatment Strategies for Motor Recovery in Poststroke Rehabilitation during the First 90 Days

Background: Motor recovery after stroke is based on neuronal plasticity and the structural reorganization of the brain. Questions are debated about the proper moment to start rehabilitation in the acute period of stroke, the significance of rehabilitation interventions during the so-called “plastic window”, and the advantages of modern and traditional programs. The aims of this study were to evaluate the role of different rehabilitation strategies and their combinations for motor recovery and the impact on functional disability by way of neurological and functional outcomes 3 months after ischemic stroke. Methods: We used three rehabilitation approaches: early rehabilitation from the first day of stroke (Phase I), traditional exercise programs (Phase II), and an author’s new method of biofeedback rehabilitation using motion sensors and augmented reality (AR) rehabilitation (Phase III). Clinical and functional outcomes were measured on the 90th day after stroke. We developed algorithms for quantifying the quality of movements during the execution of tasks in the motor domains of the AR rehabilitation program. Results: Phase I of rehabilitation led to an improvement in functional independence, and the recovery of motor functions of the extremities with an absence of mortality and clinical deterioration. AR rehabilitation led to significant improvement both with respect to clinical and functional scores on scales and to variables reflecting the quality of movements. Patients who were actively treated during Phases II and III achieved the same final level of motor recovery and functional outcomes as that of participants who had only received AR rehabilitation during Phase III. Patients who underwent outpatient observation after Phase I showed a deficit of spontaneous motor recovery on the 90th day after stroke. Conclusions: Early rehabilitation was successful but was not enough; rehabilitation programs should be carried out throughout the entire “sensitive period” of poststroke plasticity. The newly developed AR biofeedback motion training is effective and safe as a separate rehabilitation method in the early recovery period of moderately severe, hemiparalytic, and ischemic stroke. These two rehabilitation approaches must be applied together or after each other, not instead of each other, as shown in clinical practice.

Psychometric properties of a patient-reported outcome set in acute stroke patients

OBJECTIVES

Impairments after stroke may affect multiple domains of health-related quality of life (HRQoL). Patient-reported outcome measures (PROMs) have proven valuable in measuring patients' well-being. We examine the psychometric properties of a standard set of PROMs assessing global health, anxiety, and depression, and functioning in a German health care setting.

METHOD

We included inpatients at the Department of Neurology at the University Medical Center Hamburg-Eppendorf, diagnosed with stroke. Following the stroke-specific standard set of the International Consortium for Health Outcome Measurement, we collected demographic and clinical information at baseline, and PROMs for global health (PROMIS-10), three items for self-reported functioning, anxiety, and depression (PHQ-4) at 90 days follow-up. We calculated confirmatory factor analyses to test factorial validity and correlation analyses to test construct validity. We further conducted item and reliability analyses.

RESULTS

In a sample of 487 patients (mean age, SD: 71.1, 12.6; 47% female) with mild and moderate symptoms, model fit for the PROMIS-10 was acceptable for the two-factor and single-factor models. Factor loadings ranged from 0.52 to 0.94. The postulated single-factor model for functioning was saturated with zero degrees of freedom. Factor loadings ranged from 0.90 to 0.96. For the PHQ-4, the two-factor model showed excellent model fit. Factor loadings ranged from 0.78 to 0.87. Internal consistency was acceptable to good. Construct validity was generally confirmed.

CONCLUSIONS

The PROMIS-10 is a valid and reliable instrument to measure HRQoL among German stroke patients. While the PHQ-4 was confirmed as a screening measure for mental disorders, further research is needed on items assessing self-reported functioning. Results are limited to patients showing minimal functional deficits.

From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke

Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond.

Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT.

Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability.

Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.

Effect of vitamin D supplementation on lower extremity motor function and ambulation in stroke patients

Background/aim

The aim of this study was to investigate the effect of vitamin D supplementation on ambulation and mobility in hospitalized patients undergoing stroke rehabilitation.

Materials and methods

This study was conducted retrospectively between September 2020 and October 2020 at Gazi University Faculty of Medicine Physical Medicine and Rehabilitation Department. Seventy-six patients who received inpatient stroke rehabilitation treatment between May 2018 and February 2020 were included in the study. The patients were divided into two groups as those who did and did not take vitamin D supplements. Lower extremity motor function and ambulation status were compared using Brunnstrom recovery stage (lower extremity) and functional ambulation classification (FAC) scores before and after rehabilitation.

Results

Thirty-nine patients received vitamin D treatment during the rehabilitation process and 37 patients did not. The two groups were similar in terms of age, sex, time since stroke, stroke type, comorbid diseases, nutritional status, rehabilitation duration, and FAC and Brunnstrom scores before rehabilitation (p > 0.05). At the end of rehabilitation, the changes in FAC and Brunnstrom scores were higher in patients receiving vitamin D supplementation (p = 0.005 and p = 0.018). The change in FAC and Brunnstrom scores in patients who were undergoing rehabilitation for the first time and/or in the first 3 months after stroke was higher in the group receiving vitamin D supplementation compared with the group not receiving vitamin D (p < 0.05). In patients who were not within the first 3 months after stroke, vitamin D treatment did not affect FAC and Brunnstrom scores.

Conclusion

Vitamin D supplementation may increase the success of rehabilitation therapy in patients during the first 3 months poststroke.

Angiogenin in the Neurogenic Subventricular Zone After Stroke

Ischemic stroke is a leading cause of death and disability worldwide with effective acute thrombolytic treatments. However, brain repair mechanisms related to spontaneous or rehabilitation-induced recovery are still under investigation, and little is known about the molecules involved. The present study examines the potential role of angiogenin (ANG), a known regulator of cell function and metabolism linked to neurological disorders, focusing in the neurogenic subventricular zone (SVZ). Angiogenin expression was examined in the mouse SVZ and in SVZ-derived neural stem cells (NSCs), which were exposed to exogenous ANG treatment during neurosphere formation as well as in other neuron-like cells (SH-SY5Y). Additionally, male C57Bl/6 mice underwent a distal permanent occlusion of the middle cerebral artery to study endogenous and exercise-induced expression of SVZ-ANG and neuroblast migration. Our results show that SVZ areas are rich in ANG, primarily expressed in DCX+ neuroblasts but not in nestin+NSCs. In vitro, treatment with ANG increased the number of SVZ-derived NSCs forming neurospheres but could not modify SH-SY5Y neurite differentiation. Finally, physical exercise rapidly increased the amount of endogenous ANG in the ipsilateral SVZ niche after ischemia, where DCX-migrating cells increased as part of the post-stroke neurogenesis process. Our findings position for the first time ANG in the SVZ during post-stroke recovery, which could be linked to neurogenesis.

Stroke survivors' experiences with rebuilding life in the community and exercising at home: A qualitative study

Aim

This study aimed to explore how stroke survivors deal with stroke‐related impairments when rebuilding their lives in the community and their experiences of exercising at home.

Design

An explorative and descriptive qualitative study.

Methods

A purposive sample of ten stroke survivors residing at home was recruited to explore experiences of rebuilding their lives in the community and exercising at home. One focus group interview was conducted followed by semi‐structured interviews. Data were analysed using thematic analysis.

Results

Three main themes were identified: “Framing exercise within the context of everyday life” describes how stroke survivors integrate exercise in everyday activities with varying success and the social importance of exercising; “Managing the challenges of physical impairment” describes the taxing undertakings in daily living, loss of concentration and identity; “Long‐term challenges of everyday life” describes how the stroke survivors manage depression and live with a sense of uncertainty.

Exploring patient perspectives of barriers and facilitators to participating in hospital-based stroke rehabilitation

BACKGROUND

Patient participation is recognized as an important element of rehabilitation. However, few studies have used a qualitative lens to specifically examine factors influencing patient participation in stroke rehabilitation.

AIM

The purpose of this study was to investigate patient perspectives of barriers and facilitators to participating in hospital-based stroke rehabilitation.

METHODS

Semi-structured interviews were conducted with 11 patients, with confirmed diagnoses of stroke, recruited from three separate rehabilitation settings. Analysis of the interviews was guided by a process of interpretive description to identify key barriers and facilitators to participation in stroke rehabilitation.

RESULTS

Four main themes and corresponding sub-themes were constructed concerning participation in rehabilitation: (i) Environmental Factors, (ii) Components of Therapy, (iii) Physical and Emotional Well-Being, and (iv) Personal Motivators. An exploratory model of personalized rehabilitation emerged, integrating the themes emerging from the data.

DISCUSSION

Personalized rehabilitation can be considered in comparison to person-centred care principles. The barriers and enablers experienced by patients in this study contribute to the existing knowledge of the patient experience of stroke rehabilitation and may be used to inform clinical practices and future research.Implications for RehabilitationThe surrounding environments can facilitate participation in rehabilitation using strategies to reduce noise and disruption and also by encouraging social interactions among patients.Increasing the frequency and consistency of communication with patients about rehabilitation goals and progress could enhance participation.Designing interventions to include activities that are meaningful and focused on the resumption of valued life roles is key to participation.Therapy intensity, time spent sedentary, and the emotional impact of stroke are aspects of rehabilitation patient's feel are neglected.

Early tracheostomy in stroke patients: A meta-analysis and comparison with late tracheostomy

Tracheostomy (TQT) timing and its benefits is a current discussion in medical society. We aimed to compare the outcomes of early (ET) versus late tracheostomy (LT) in stroke patients with systematic review and meta-analysis, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Five hundred and nineteen studies were retrieved, whereas three were selected for the systematic review and meta-analysis. There were 5636 patients in the ET group (3151 male, 2470 female, 15 not reported - NR) and 7637 patients in the LT group (4098 male, 3542 female, and 33 NR). ET was significantly associated with fewer days in the hospital (weighted mean difference: -7.73 [95 % CI -8.59-6.86], p < 0.001) and reduced cases of ventilator-associated pneumonia (VAP) (risk difference: 0.71 [95 % CI 0.62-0.81], p < 0.001). There were no between-group statistical differences in intensive care unit stay duration, mechanical ventilation duration, or mortality. The findings from this meta-analysis cannot state that ET in severe stroke patients contributes to better outcomes when compared with LT. Scandalized assessments and randomized trials are encourage for better assessment.

Does overground robotic gait training improve non-motor outcomes in patients with chronic stroke? Findings from a pilot study

Stroke is the leading cause of disability among the elderly in the industrialized world. No more than 40% of stroke survivors walk independently, and only after receiving appropriate rehabilitation treatment; many stroke patients have also non-motor symptoms. The aim of this pilot study is to evaluate the effects of Ekso-training on non-motor outcomes, including gastrointestinal function and psychological well-being, in post stroke patients. We enrolled 30 post-stroke subjects, which were randomized into two groups in order of recruitment: 15 patients were trained with the overground exoskeleton Ekso-GT (experimental group, EG), whereas 15 patients were submitted to a standard gait training (control group, CG). Both the groups underwent the same amount of physiotherapy. At the end of the training, only in the EG we observed a significant improvement in constipation, mood, and coping strategies, with regard to social support, as well as in the perception of quality of life (as per SF-12). According to these preliminary data, overground robotic gait training can be considered a valuable tool in improving non-motor symptoms, including constipation and behavioral disorders in patients with chronic stroke.

Late functional improvement and 5-year poststroke outcomes: a population-based cohort study

BACKGROUND

Late functional improvement between 3 and 12 months poststroke occurs in about one in four patients with ischaemic stroke, more commonly in lacunar strokes. It is unknown whether this late improvement is associated with better long-term clinical or health economic outcomes.

METHODS

In a prospective, population-based cohort of 1-year ischaemic stroke survivors (Oxford Vascular Study; 2002-2014), we examined changes in functional status (modified Rankin Scale (mRS), Rivermead Mobility Index (RMI), Barthel Index (BI)) from 3 to 12 months poststroke. We used Cox regressions adjusted for age, sex, 3-month disability and stroke subtype (lacunar vs non-lacunar) to examine the association of late improvement (by ≥1 mRS grades, ≥1 RMI points and/or ≥2 BI points between 3 and 12 months) with 5-year mortality and institutionalisation. We used similarly adjusted generalised linear models to examine association with 5-year healthcare/social-care costs.

RESULTS

Among 1288 one-year survivors, 1135 (88.1%) had 3-month mRS >0, of whom 319 (28.1%) demonstrated late functional improvement between 3 and 12 months poststroke. Late improvers had lower 5-year mortality (aHR per mRS=0.68, 95% CI 0.51 to 0.91, p=0.009), institutionalisation (aHR 0.48, 0.33 to 0.72, p<0.001) and healthcare/social care costs (margin US$17 524, -24 763 to -10 284, p<0.001). These associations remained on excluding patients with recurrent strokes during follow-up (eg, 5-year mortality/institutionalisation: aHR 0.59, 0.44 to 0.79, p<0.001) and on examining late improvement per RMI and/or BI (eg, 5-year mortality/institutionalisation with RMI/BI: aHR 0.73, 0.58 to 0.92, p=0.008).

CONCLUSION

Late functional improvement poststroke is associated with lower 5-year mortality, institutionalisation rates and healthcare/social care costs. These findings should motivate patients and clinicians to maximise late recovery in routine practice, and to consider extending access to proven rehabilitative therapies during the first year poststroke.

A Practical EEG-Based Human-Machine Interface to Online Control an Upper-Limb Assist Robot

Background and Objective: Electroencephalography (EEG) can be used to control machines with human intention, especially for paralyzed people in rehabilitation exercises or daily activities. Some effort was put into this but still not enough for online use. To improve the practicality, this study aims to propose an efficient control method based on P300, a special EEG component. Moreover, we have developed an upper-limb assist robot system with the method for verification and hope to really help paralyzed people.

Methods: We chose P300, which is highly available and easily accepted to obtain the user's intention. Preprocessing and spatial enhancement were firstly implemented on raw EEG data. Then, three approaches– linear discriminant analysis, support vector machine, and multilayer perceptron –were compared in detail to accomplish an efficient P300 detector, whose output was employed as a command to control the assist robot.

Results: The method we proposed achieved an accuracy of 94.43% in the offline test with the data from eight participants. It showed sufficient reliability and robustness with an accuracy of 80.83% and an information transfer rate of 15.42 in the online test. Furthermore, the extended test showed remarkable generalizability of this method that can be used in more complex application scenarios.

Conclusion: From the results, we can see that the proposed method has great potential for helping paralyzed people easily control an assist robot to do numbers of things.

Adherence to a Rehabilitation Regimen in Stroke Patients: A Concept Analysis

BACKGROUND

Adherence to rehabilitation regimens is a major issue in the treatment of stroke. Despite the agreement on the importance of adherence, there is still no clear definition of this concept in rehabilitation. The aim of this study was the concept analysis of the concept of adherence to rehabilitation regimens in stroke patients.

MATERIALS AND METHODS

This qualitative concept analysis was performed using Walker and Avant's method. English and Persian articles were searched using keywords such as "adherence", "compliance", "rehabilitation", "stroke", and other related keywords among articles published from 1997 to 2018 in PubMed, Scopus, Web of Science, Google Scholar, Iranmedex, Magiran, and Scientific Information Database (SID). Related textbooks were also searched and all articles containing definitions, attributes, antecedents, and consequences of the concept were included in the study.

RESULTS

The attributes of the concept included complex, multidimensional, and dynamic behavior in the treatment process, personal experience, and adaptive behavior in patients, changeable, situational, voluntary, and collaborative behavior, and active communication between the patient and the healthcare provider. Common antecedents of the concept of adherence to the rehabilitation regimen were classified into patient-related and environmental-related categories and the consequences were classified into the three categories of patient-related, healthcare professional-related, and healthcare system-related.

CONCLUSIONS

This concept analysis can be useful in eliminating any ambiguity of the concept of adherence to rehabilitation regimens. It helps clarify the vague concepts used in nursing rehabilitation instead of adherence. The results of this study can be helpful for researchers for further studies in this context.

[Possibilities of neurotrophic therapy in early recovery after stroke]

The high prevalence and disability of patients with ischemic stroke make the further development of the rehabilitation system relevant. The implementation of neuroplasticity mechanisms is largely provided by neurotrophic factors. One of the most well-known neurotrophic drugs is cerebrolysin, the efficacy of which in patients with stroke has been confirmed in many clinical studies. A recent meta-analysis included 9 randomized, double-blind, placebo-controlled clinical studies of using cerebrolysin in 1879 patients with hemispheric ischemic stroke, where it was administered at a dose of 30-50 ml for at least 1 week (10-21 days) and therapy was started during 72 hours after stroke. Cerebrolysin has been shown to give patients a 60% chance of better outcomes after a stroke, improves early recovery and increases the likelihood of better recovery.

Organisational and Economic Activities for Provision of Medical Rehabilitation Services on an Outpatient Basis to Patients That Have Suffered an Acute Cerebrovascular Accident

The aim of this study was to develop legal, organizational and economic activities for providing medical rehabilitation on an outpatient basis to patients that have suffered an acute cerebrovascular accident (CVA). The study included patients who had suffered a CVA and were undergoing medical rehabilitation on an outpatient basis (400 individuals participated in a retrospective study and 400 individuals took part in a sociological survey) and medical rehabilitation specialists providing care on an outpatient basis to patients who had suffered a CVA (n = 50). All included patients received medical rehabilitation in accordance with the Guidelines of the Ministry of Health of the Russian Federation (No: 70). It should be noted that patients who suffered a CVA occupy a central place in the system of medical rehabilitation performed on an outpatient basis. Medical rehabilitation is important for their medical and social characteristics, motivation, environment, adherence to treatment and a healthy lifestyle. In accordance with the above mentioned, the following activities should be planned and implemented: a) work with doctors, b) work with patients; c) work with patients’ relatives; d) organizational aspects, and e) economic aspects. When organizing medical rehabilitation on an outpatient basis, it should be considered as a system of interaction between all participants in the rehabilitation process, in the center of which the patient is located. The main organizational activity for conducting medical rehabilitation in an outpatient setting is the implementation of a comprehensive interaction of all participants in the rehabilitation process.

Brain Functional Reserve in the Context of Neuroplasticity after Stroke

Stroke is the second cause of death and more importantly first cause of disability in people over 40 years of age. Current therapeutic management of ischemic stroke does not provide fully satisfactory outcomes. Stroke management has significantly changed since the time when there were opened modern stroke units with early motor and speech rehabilitation in hospitals. In recent decades, researchers searched for biomarkers of ischemic stroke and neuroplasticity in order to determine effective diagnostics, prognostic assessment, and therapy. Complex background of events following ischemic episode hinders successful design of effective therapeutic strategies. So far, studies have proven that regeneration after stroke and recovery of lost functions may be assigned to neuronal plasticity understood as ability of brain to reorganize and rebuild as an effect of changed environmental conditions. As many neuronal processes influencing neuroplasticity depend on expression of particular genes and genetic diversity possibly influencing its effectiveness, knowledge on their mechanisms is necessary to understand this process. Epigenetic mechanisms occurring after stroke was briefly discussed in this paper including several mechanisms such as synaptic plasticity; neuro-, glio-, and angiogenesis processes; and growth of axon.

Effect of Caregiver Driven Robot-Assisted In-Ward Training in Subacute Stroke Patients: A Case Series

Objective

To evaluate the effect of caregiver driven robot-assisted in-ward training in subacute stroke patients.

Methods

A retrospective evaluation was performed for patients treated with caregiver driven robot-assisted in-ward training to retain gait function from June 2014 and December 2016. All patients received more than 2 weeks of caregiver driven robot-assisted in-ward training after undergoing conventional programs. The robot was used as a sitting device, a standing frame, or a high-walker depending on functional status of the patient. Patients were evaluated before and after robot training. Patient records were assessed by Korean version of Modified Barthel Index (K-MBI), Functional Independence Measure (FIM), and Functional Ambulation Category (FAC).

Results

Initially, patients used the robot as a sitting device (n=6), a standing frame (n=7), or a partial body-weight support high-walker (n=2). As patient functions were improved, usage level of the robot was changed to the next level. At the end of the treatment, the robot was used as a sitting device (n=1), a standing frame (n=6), or high-walker (n=8). Scores of K-MBI (Δ17.47±10.72) and FIM (Δ19.80±12.34) were improved in all patients.

Conclusion

Patients' usage level of the robot and functional scores were improved. Therefore, performing additional caregiver driven robot-assisted in-ward training is feasible and beneficial for subacute stroke patients.