Early mobilization and quality of life after stroke: Findings from AVERT

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.

A systematic review and meta-analysis of clinical efficacy of early and late rehabilitation interventions for ischemic stroke

INTRODUCTION

At present, stroke has become the first cause of death and disability among Chinese adults. With the coming of the aging population in China, the disease burden brought by stroke will be increasingly aggravated. And stroke is a leading cause of disability. There is a golden plastic period after stroke, during which timely and safe intervention and rehabilitation therapy can effectively improve the disability status. However, there is still controversy about the duration of interventional rehabilitation after stroke. This study conducted a meta-analysis on the influence of intervention in early and late ischemic stroke rehabilitation.

METHOD

Chinese language databases such as CNKI, Wanfang, and VIP, and English language databases such as Embase, PubMed, Web of Science, and The Cochrane Library were searched, and RCT related to early and late rehabilitation of ischemic stroke from the establishment of the database to October 2023 was collected. Review Manager 5.4.1 was used for relevant analysis. The main outcomes were Barthel Index or Modified Barthel Index, Fugl-Meyer Assessment scale, NIHSS, China Stroke Scale. Standardized Mean Difference (SMD) was used as an effective indicator of continuity variables, and the estimated interval was expressed by 95% confidence interval (CI).

RESULTS

A total of 1908 patients were included in 16 studies. The results showed that, compared with late rehabilitation, early rehabilitation improved clinical efficacy. Barthel Index or Modified Barthel Index score was [SMD = 1.40, 95%CI(1.16,1.63), p < 0.001]; the score of Fugl-Meyer Assessment Scale was [SMD = 1.18, 95%Cl (0.85, 1.52), P < 0.001]; the score of NIHSS was [SMD= -0.44, 95% CI(-0.65, -0.24), P < 0.001]; the result of China Stroke Scale score was [SMD= -0.37, 95%CI(-0.56, -0.18), P < 0.001].

CONCLUSION

In comparison with late rehabilitation, early rehabilitation can significantly improve self-care abilities, daily activities, and neurological functions of ischemic stroke patients.

TRIAL REGISTRATION

This meta-analysis has been registered with Prospero, and the registration number is CRD42022309911. The registration period is March 22, 2022.

Acquired brain injury (ABI) survivors' experience of occupation and activity during their inpatient stay: a scoping review

PURPOSE

This review aimed to characterise and map: (1) what type of evidence and what dominant study characteristics are available regarding acquired brain injury (ABI) survivors' experience of occupation and activity in hospital? (2) How are occupation and activity conceptualised in the literature? (3) How are ABI survivors experiencing occupation and activity while in hospital? (4) What factors create barriers or opportunities for engagement in occupations or activity in hospital? (5) Are there any knowledge gaps identified?

MATERIALS AND METHODS

A scoping review was conducted examining literature published between 2017 and 2022. Relevant studies were systematically retrieved from electronic databases.

RESULTS

Thirty-four publications were included. There were more quantitative studies (n = 18). Much of the research has been conducted outside of the UK. The populations studied were principally stroke (n = 22). The concept of activity rather than occupation predominates. Patients spend their time alone and inactive. Structural and contextual barriers for engaging in activity are identified. Qualitative study designs exclude ABI survivors with communication or cognitive impairment.

CONCLUSIONS

There is a paucity of research with ABI survivors in hospitals in the UK. Alternative methodological approaches such as ethnography would ensure those with communication or cognitive impairment are not excluded from research. Implications for rehabilitationRehabilitation professionals, especially occupational therapists, need to lead acquired brain injury (ABI) research in acute hospital settings in the UK.Conceptualisation of meaningful activity and occupation needs a clearer focus in ABI research.Qualitative studies frequently exclude participants with cognitive or communication impairments so methodologies that are more inclusive and representative of brain injury survivors are needed.

Utilization of Mirror Visual Feedback for Upper Limb Function in Poststroke Patients: A Systematic Review and Meta-Analysis

Mirror visual feedback (MVF), a noninvasive treatment method, is attracting attention as a possibility to promote the recovery of upper limb function in stroke patients. However, the cognitive effects of this therapy have received limited attention in the existing literature. To address this gap, we conducted a systematic review and meta-analysis to investigate the relationship between upper limb function and cognition in stroke patients and to evaluate the effect of MVF on improving upper limb function. A comprehensive search was performed on the Embase, MEDLINE, and PubMed databases to identify original articles and clinical studies published between 2013 and 2022. Qualitative analysis was performed using the Cochrane Risk of Bias tool, and in the quantitative analysis, a random-effects model was used as the effect model, and standard mean difference (SMD) was used as the effect measure. Eight studies that met the inclusion criteria were entered in the analysis. Data extraction included an assessment tool for upper extremity function. Results of the quantitative analysis demonstrate that MVF was effective in improving upper extremity function in stroke patients (SMD = 0.94, 95% CI 0.69 to 1.20). In conclusion, this systematic review and meta-analysis provides evidence supporting the effectiveness of MVF in improving upper limb function in stroke patients. However, further studies are needed to investigate the cognitive effects of MVF and elucidate the underlying mechanisms.

Effects of multicomponent exercise on quality of life, depression and anxiety among stroke survivors: A systematic review and meta-analysis

BACKGROUND

Current guidelines stress the importance of exercise, especially multicomponent exercise to older adults with chronic conditions.

AIM

To critically synthesise evidence that evaluates the effects of multicomponent exercise on quality of life, depression and anxiety after stroke.

DESIGN

Systematic review and meta-analysis followed the PRISMA 2020 statement.

METHODS

A systematic search of PubMed, Embase, Web of Science, Cochrane Library, CINAHL and PsycINFO from inception to 12 June 2023 was performed. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2). Meta-analyses were conducted using Review Manager 5.4 and narrative syntheses were adopted whenever meta-analysis was inappropriate. The overall certainty of the evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Of 15,351 records identified, nine were eligible and data were available for seven randomised controlled trials, three of which were identified as having a high risk of bias, one as low risk, and five as having some concerns. Subgroup pooled analyses indicated that multicomponent exercise engaged in longer exercise sessions (>60 min) was effective in improving quality of life immediately post-intervention and through 3-6 months post-intervention. However, multicomponent exercise did not significantly affect depression and anxiety.

CONCLUSIONS

Multicomponent exercise with longer duration of exercise sessions has promising effects on both short- to medium-term quality of life among stroke survivors.

PATIENT OR PUBLIC CONTRIBUTION

This does not apply to our work as it is a review paper.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers could consider encouraging the patients to participate in multicomponent exercise sessions for more than 60 min. It is important to note that stroke survivors should be supervised by trained personnel at the beginning of the training.

REGISTRATION

The protocol was registered on PROSPERO.

Multidisciplinary Approach to Sedation and Early Mobility of Intubated Critically Ill Neurologic Patients Improves Mobility at Discharge

Background and Purpose

Over-sedation may confound neurologic assessment in critically ill neurologic patients and prolong duration of mechanical ventilation (MV). Decreased sedative use may facilitate early functional independence when combined with early mobility. The objective of this study was to evaluate the impact of a stepwise, multidisciplinary analgesia-first sedation pathway and early mobility protocol on medication use and mobility in the neuroscience intensive care unit (ICU).

Methods

We performed a single-center prospective cohort study with adult patients admitted to a neuroscience ICU between March and June 2016-2018 who required MV for greater than 48 hours. Patients were included from three separate phases of the study: Phase I - historical controls (2016); Phase II - analgesia-first pathway (2017); Phase III - early mobility protocol (2018). Primary outcomes included propofol requirements during MV, total rehabilitation therapy provided, and functional mobility during ICU admission.

Results

156 patients were included in the analysis. Decreasing propofol exposure was observed during Phase I, II, and III (median 2243.7 mg/day vs 2065.6 mg/day vs 1360.8 mg/day, respectively; P = .04 between Phase I and III). Early mobility was provided in 59.7%, 40%, and 81.6% of patients while admitted to the ICU in Phase I, II, and III, respectively (P < .01). An increased proportion of patients in Phase III were walking or ambulating at ICU discharge (26.7%; 8/30) compared to Phase I (7.9%, 3/38, P = .05).

Conclusions

An interdisciplinary approach with an analgesia-first sedation pathway with early mobility protocol was associated with less sedative use, increased rehabilitation therapy, and improved functional mobility status at ICU discharge.

Utilization of clinical and radiological parameters to predict cognitive prognosis in patients with mild-to-moderate traumatic brain injury

Background

Cognitive impairment is a common sequela following traumatic brain injury (TBI). This study aimed to identify risk factors for cognitive impairment after 3 and 12 months of TBI and to create nomograms to predict them.

Methods

A total of 305 mild-to-moderate TBI patients admitted to the First Affiliated Hospital with Nanjing Medical University from January 2018 to January 2022 were retrospectively recruited. Risk factors for cognitive impairment after 3 and 12 months of TBI were identified by univariable and multivariable logistic regression analyses. Based on these factors, we created two nomograms to predict cognitive impairment after 3 and 12 months of TBI, the discrimination and calibration of which were validated by plotting the receiver operating characteristic (ROC) curve and calibration curve, respectively.

Results

Cognitive impairment was detected in 125/305 and 52/305 mild-to-moderate TBI patients after 3 and 12 months of injury, respectively. Age, the Glasgow Coma Scale (GCS) score, >12 years of education, hyperlipidemia, temporal lobe contusion, traumatic subarachnoid hemorrhage (tSAH), very early rehabilitation (VER), and intensive care unit (ICU) admission were independent risk factors for cognitive impairment after 3 months of mild-to-moderate TBI. Meanwhile, age, GCS score, diabetes mellitus, tSAH, and surgical treatment were independent risk factors for cognitive impairment after 12 months of mild-to-moderate TBI. Two nomograms were created based on the risk factors identified using logistic regression analyses. The areas under the curve (AUCs) of the two nomograms to predict cognitive impairment after 3 and 12 months of mild-to-moderate TBI were 0.852 (95% CI [0.810, 0.895]) and 0.817 (95% CI [0.762, 0.873]), respectively.

Conclusion

Two nomograms are created to predict cognitive impairment after 3 and 12 months of TBI. Age, GCS score, >12 years of education, hyperlipidemia, temporal lobe contusion, tSAH, VER, and ICU admission are independent risk factors for cognitive impairment after 3 months of TBI; meanwhile, age, the GCS scores, diabetes mellitus, tSAH, and surgical treatment are independent risk factors of cognitive impairment after 12 months of TBI. Two nomograms, based on both groups of factors, respectively, show strong discriminative abilities.

Effect of the physical rehabilitation program based on self-care ability in patients with acute ischemic stroke: a quasi-experimental study

Introduction

It is the most practical goal of limb rehabilitation for stroke patients to make the upper limb, trunk, and lower limb joints link together as a whole and restore the ability to self-care. However, many previous studies focused on the single joint or single muscle group movement of stroke patients and did not integrate self-care ability training into the whole process of rehabilitation, which lacks accuracy, integrity, and systematization.

Methods

A quasi-experimental study was conducted in a tertiary hospital. Eligible patients were recruited according to the inclusion criteria and exclusion criteria and then divided into an experimental group (n = 80) and a control group (n = 80) by the medical district. The control group received the routine physical rehabilitation intervention. The experimental group adopted the physical rehabilitation program based on self-care ability led by the nurses specializing in stroke rehabilitation to carry out the multi-joint coordinated exercise based on the control group. The training time and frequency were the same in both groups (45 min per session, one session per day for three consecutive months). The primary outcome was myodynamia. Secondary outcomes were the modified Barthel Index (MBI) and Stroke Specific Quality of Life Scale (SS-QOL). The primary and secondary outcomes were assessed before the intervention and at 1 and 3 months of intervention. In this study, the TREND checklist was followed for non-randomized controlled trials.

Results

A total of 160 participants completed the study. The physical rehabilitation program based on self-care ability was better than the routine rehabilitation program. With the prolongation of intervention time, all outcomes improved gradually in the experimental group (P < 0.05), and the myodynamia of lower limbs recovered faster than that of upper limbs. In the control group, the myodynamia of the affected limb was not significantly improved (P > 0.05), with only a small increase in MBI and SS-QOL scores (P < 0.05).

Conclusion

The physical rehabilitation program based on self-care ability after stroke was beneficial for acute ischemic stroke patients and improved the patient's myodynamia, quality of life, and self-care ability within the third month.

Early Mobilization for Critically Ill Patients

Advances in the field of critical care medicine have helped improve the survival rate of these ill patients. Several studies have demonstrated the potential benefits of early mobilization as an important component of critical care rehabilitation. However, there have been some inconsistent results. Moreover, the lack of standardized mobilization protocols and the associated safety concerns are a barrier to the implementation of early mobilization in critically ill patients. Therefore, determining the appropriate modalities of implementation of early mobilization is a key imperative to leverage its potential in these patients. In this paper, we review the contemporary literature to summarize the strategies for early mobilization of critically ill patients, assess the implementation and validity based on the International Classification of Functioning, Disability and Health, as well as discuss the safety aspects of early mobilization.

Functionality and quality of life in Brazilian patients 6 months post-stroke

Background

Surviving a stroke poses a social and economic impact that requires the care system to be reformulated and the patient to be addressed in a comprehensive approach.

Purpose

This study aims to investigate if there is a relationship between functional activities performed before the stroke, patients' clinical and hospitalization data, and functionality and quality of life measures in the first 6 months after the stroke.

Methods

This study used a prospective cohort of 92 patients. We investigated sociodemographic and clinical data, the modified Rankin Scale (mRS), and the Frenchay Activities Index (FAI) during hospitalization. The Barthel Index (BI) and EuroQol-5D (EQ-5D) were applied at the following time points: 30 days (T1), 90 days (T2), and 180 days (T3) following postictal state. Statistical analysis was conducted using Spearman's coefficient, Friedman's non-parametric test, and multiple linear regression models.

Results

No correlation was found between FAI, BI, and EQ-5D average scores. Severe patients, patients with comorbidities, and patients with extended hospital stays showed lower BI and EQ-5D scores □in the follow-up. BI and EQ-5D scores increased.

Conclusion

This research found no relationship between activities performed before the stroke and functionalities and quality of life after the stroke, but comorbidities and extended hospital stay were associated with worse outcomes.

A checklist-based survey for early mobilization of stroke unit patients in an Italian region

BACKGROUND

Although early mobilization (EM) is recommended by most guidelines in acute stroke patients, there is a paucity of tools to perform a standardized patient risk assessment prior to EM in stroke units (SUs).

OBJECTIVE

This survey aimed at assessing (1) the usefulness of an ad hoc checklist for a standardized approach to EM in SUs and (2) the relationship between EM achieved by this checklist and SU characteristics.

METHODS

This survey was carried out in 10 SUs in Piedmont, Italy. The EM checklist was based on 15 "items", including quantitative/qualitative, clinical and management features.

RESULTS

A total of 250 completed checklists were assessed. EM, defined as out-of-bed activity within 72 h of admission, was reached by 174 patients (69.6%), according to the checklist. There was a statistically significant association between the admission NIHSS score and EM. Hypotension at mobilization was observed in 29/250 patients (11.6%) and was significantly associated with EM. A total of 6 falls (2.4%) were reported. Nurses were most frequently involved in EM, either alone (40.8%) or with another professional.

CONCLUSION

A large percentage of acute stroke patients managed to achieve a safe EM in the SUs that adopted the novel checklist. These results suggest that this checklist may well be a user-friendly, reliable tool to assist SU professionals in deciding whether to mobilize or not, by means of a standardized approach.

Effectiveness of active occupational therapy in patients with acute stroke: A propensity score-weighted retrospective study

Background and purpose

The effects of therapy and patient characteristics on rehabilitation outcomes in patients with acute stroke are unclear. We investigated the effects of intensive occupational therapy (OT) on patients with acute stroke.

Methods

We performed a retrospective cohort study using the 2005-2016 Japan Rehabilitation Database, from which we identified patients with stroke (n = 10,270) who were admitted to acute care hospitals (n = 37). We defined active OT (AOT) and non-AOT as OT intervention times (total intervention time/length of hospital stay) longer or shorter than the daily physical therapy intervention time, respectively. The outcomes assessed were the Functional Independence Measure (FIM) and National Institutes of Health Stroke Scale (NIHSS) scores, duration of hospitalization, and rate of discharge. Propensity scores and inverse probability of treatment weighting analyses adjusted for patient characteristics were performed to investigate the effects of AOT on patient outcomes.

Results

We enrolled 3,501 patients (1,938 and 1,563 patients in the AOT and non-AOT groups, respectively) in the study. After inverse probability of treatment weighting, the AOT group had a shorter length of hospitalization (95% confidence interval: -3.7, -1.3, p < 0.001), and the FIM (95% confidence interval: 2.0, 5.7, p < 0.001) and NIHSS (95% confidence interval; 0.3, 1.1, p < 0.001) scores improved significantly. Subgroup analysis showed that lower NHISS scores for aphasia, gaze, and neglect and lower overall NIHSS and FIM scores on admission led to a greater increase in FIM scores in the AOT group.

Conclusions

AOT improved the limitations in performing activities of daily living (ADL) and physical function in patients with acute stroke and reduced the length of hospitalization. Additionally, subgroup analysis suggested that the increase in FIM score was greater in patients with severe limitations in performing ADLs and worse cognitive impairment, such as neglect, on admission.

Early Rehabilitation Exercise after Stroke Improves Neurological Recovery through Enhancing Angiogenesis in Patients and Cerebral Ischemia Rat Model

Among cerebrovascular diseases, ischemic stroke is a leading cause of mortality and disability. Thrombolytic therapy with tissue plasminogen activator is the first choice for clinical treatment, but its use is limited due to the high requirements of patient characteristics. Therefore, the choice of neurological rehabilitation strategies after stroke is an important prevention and treatment strategy to promote the recovery of neurological function in patients. This study shows that rehabilitation exercise 24 h after stroke can significantly improve the neurological function (6.47 ± 1.589 vs. 3.21 ± 1.069 and 0.76 ± 0.852), exercise ability (15.68 ± 5.95 vs. 162.32 ± 9.286 and 91.18 ± 7.377), daily living ability (23.37 ± 5.196 vs. 66.95 ± 4.707 and 6.55 ± 2.873), and quality of life (114.39 ± 7.772 vs. 168.61 ± 6.323 and 215.95 ± 10.977) of patients after 1 month and 3 months, and its ability to promote rehabilitation is better than that of rehabilitation exercise administered to patients 72 h after stroke (p < 0.001). Animal experiments show that treadmill exercise 24 h after middle cerebral artery occlusion and reperfusion can inhibit neuronal apoptosis, reduce the volume of cerebral infarction on the third (15.04 ± 1.07% vs. 30.67 ± 3.06%) and fifth (8.33 ± 1.53% vs. 30.67 ± 3.06%) days, and promote the recovery of neurological function on the third (7.22 ± 1.478 vs. 8.28 ± 1.018) and fifth (4.44 ± 0.784 vs. 6.00 ± 0.767) days. Mechanistic studies have shown that treadmill exercise increases the density of microvessels, regulates angiogenesis, and promotes the recovery of nerve function by upregulating the expression of vascular endothelial growth factor and laminin. This study shows that rehabilitation exercise 24 h after stroke is conducive to promoting the recovery of patients’ neurological function, and provides a scientific reference for the clinical rehabilitation of stroke patients.

Occupational therapy for cognitive impairment in stroke patients

BACKGROUND

Cognitive impairment is a frequent consequence of stroke and can impact on a person's ability to perform everyday activities. Occupational therapists use a range of interventions when working with people who have cognitive impairment poststroke. This is an update of a Cochrane Review published in 2010.

OBJECTIVES

To assess the impact of occupational therapy on activities of daily living (ADL), both basic and instrumental, global cognitive function, and specific cognitive abilities in people who have cognitive impairment following a stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, four other databases (all last searched September 2020), trial registries, and reference lists.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that evaluated an intervention for adults with clinically defined stroke and confirmed cognitive impairment. The intervention needed either to be provided by an occupational therapist or considered within the scope of occupational therapy practice as defined in the review. We excluded studies focusing on apraxia or perceptual impairments or virtual reality interventions as these are covered by other Cochrane Reviews. The primary outcome was basic activities of daily living (BADL) such as dressing, feeding, and bathing. Secondary outcomes were instrumental ADL (IADL) (e.g. shopping and meal preparation), community integration and participation, global cognitive function and specific cognitive abilities (including attention, memory, executive function, or a combination of these), and subdomains of these abilities. We included both observed and self-reported outcome measures.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies that met the inclusion criteria, extracted data, and assessed the certainty of the evidence. A third review author moderated disagreements if consensus was not reached. We contacted trial authors for additional information and data, where available. We assessed the certainty of key outcomes using GRADE.  MAIN RESULTS: We included 24 trials from 11 countries involving 1142 (analysed) participants (two weeks to eight years since stroke onset). This update includes 23 new trials in addition to the one study included in the previous version. Most were parallel randomised controlled trials except for one cross-over trial and one with a two-by-two factorial design. Most studies had sample sizes under 50 participants. Twenty studies involved a remediation approach to cognitive rehabilitation, particularly using computer-based interventions. The other four involved a compensatory and adaptive approach. The length of interventions ranged from 10 days to 18 weeks, with a mean total length of 19 hours. Control groups mostly received usual rehabilitation or occupational therapy care, with a few receiving an attention control that was comparable to usual care; two had no intervention (i.e. a waiting list). Apart from high risk of performance bias for all but one of the studies, the risk of bias for other aspects was mostly low or unclear.  For the primary outcome of BADL, meta-analysis found a small effect on completion of the intervention with a mean difference (MD) of 2.26 on the Functional Independence Measure (FIM) (95% confidence interval (CI) 0.17 to 4.22; P = 0.03, I2 = 0%; 6 studies, 336 participants; low-certainty evidence). Therefore, on average, BADL improved by 2.26 points on the FIM that ranges from 18 (total assist) to 126 (complete independence). On follow-up, there was insufficient evidence of an effect at three months (MD 10.00, 95% CI -0.54 to 20.55; P = 0.06, I2 = 53%; 2 studies, 73 participants; low-certainty evidence), but evidence of an effect at six months (MD 11.38, 95% CI 1.62 to 21.14, I2 = 12%; 2 studies, 73 participants; low-certainty evidence). These differences are below 22 points which is the established minimal clinically important difference (MCID) for the FIM for people with stroke. For IADL, the evidence is very uncertain about an effect (standardised mean difference (SMD) 0.94, 95% CI 0.41 to 1.47; P = 0.0005, I2 = 98%; 2 studies, 88 participants). For community integration, we found insufficient evidence of an effect (SMD 0.09, 95% CI -0.35 to 0.54; P = 0.68, I2 = 0%; 2 studies, 78 participants). There was an improvement of clinical importance in global cognitive functional performance after the intervention (SMD 0.35, 95% CI 0.16 to 0.54; P = 0.0004, I2 = 0%; 9 studies, 432 participants; low-certainty evidence), equating to 1.63 points on the Montreal Cognitive Assessment (MoCA) (95% CI 0.75 to 2.52), which exceeds the anchor-based MCID of the MoCA for stroke rehabilitation patients of 1.22. We found some effect for attention overall (SMD -0.31, 95% CI -0.47 to -0.15; P = 0.0002, I2 = 20%; 13 studies, 620 participants; low-certainty evidence), equating to a difference of 17.31 seconds (95% CI 8.38 to 26.24), and for executive functional performance overall (SMD 0.49, 95% CI 0.31 to 0.66; P < 0.00001, I2 = 74%; 11 studies, 550 participants; very low-certainty evidence), equating to 1.41 points on the Frontal Assessment Battery (range: 0-18). Of the cognitive subdomains, we found evidence of effect of possible clinical importance, immediately after intervention, for sustained visual attention (moderate certainty) equating to 15.63 seconds, for working memory (low certainty) equating to 59.9 seconds, and thinking flexibly (low certainty), compared to control.

AUTHORS' CONCLUSIONS

The effectiveness of occupational therapy for cognitive impairment poststroke remains unclear. Occupational therapy may result in little to no clinical difference in BADL immediately after intervention and at three and six months' follow-up. Occupational therapy may slightly improve global cognitive performance of a clinically important difference immediately after intervention, likely improves sustained visual attention slightly, and may slightly increase working memory and flexible thinking after intervention. There is evidence of low or very low certainty or insufficient evidence for effect on other cognitive domains, IADL, and community integration and participation.  Given the low certainty of much of the evidence in our review, more research is needed to support or refute the effectiveness of occupational therapy for cognitive impairment after stroke. Future trials need improved methodology to address issues including risk of bias and to better report the outcome measures and interventions used.

Updated evidence of Dengzhan Shengmai capsule against ischemic stroke: A systematic review and meta-analysis

ETHNOPHARMACOLOGICAL RELEVANCE

Ischemic stroke is the most common type of stroke, with high mortality, disability and recurrence rate, which brings a heavy burden to individuals, families and the medical system. Therefore, the intervention and treatment of ischemic stroke are of great significance. Chinese herbal medicine is widely used in treating stroke, for example, Dengzhan shengmai (DZSM) capsule. The current systematic review aims to comprehensively evaluate the efficacy and safety of the DZSM capsule in treating ischemic stroke.

MATERIALS AND METHODS

Eligible randomized controlled trials (RCTs) were included to evaluate the efficacy and safety of Chinese herbal medicine DZSM capsule in treating ischemic stroke. Eight electronic databases were searched up to January 27, 2021. The risk ratio (RR), standardized mean difference (SMD), or weighted mean difference (WMD) with 95% confidence interval (CI) were used to assess DZSM capsule treatment outcomes.

RESULTS

A total of 28 RCTs involving 6683 participants were included in the systematic review and meta-analysis. Compared with conventional therapy group, DZSM capsule plus conventional therapy improved Barthel Index scores (WMD: 8.97, 95%CI: 5.88-12.05) and reduced modified Rankin Scale (WMD: -0.75, 95%CI: -1.02∼ -0.48), reduced neurological functional deficit scores (WMD: -2.81, 95%CI: -4.17∼ -1.44), recurrence rate (RR: 0.57, 95%CI: 0.44-0.73) and mortality (RR: 0.54, 95%CI: 0.31-0.95), improved clinical effect (RR: 1.18, 95%CI: 1.12-1.24) and quality of life (WMD: 21.67, 95%CI: 6.74-36.61), exhibited a beneficial effect on hemorheology such as elevated levels of APTT (SMD: 1.17, 95%CI: 0.87-1.47) and INR (SMD: 1.12, 95%CI: 0.82-1.42), and on lipid metabolism such as levels of TC (SMD: -0.62, 95%CI: -1.04 ∼ -0.20), TG (SMD: -0.72, 95%CI: -1.18∼ -0.26), LDL (SMD: -1.14, 95%CI: -1.57∼ -0.71) and HDL (SMD: 0.93, 95%CI: 0.36-1.50). No trials reported severe adverse events.

CONCLUSION

DZSM capsule appears to be safe and effective in clinical applications for ischemic stroke. Based on conventional therapy, adding the DZSM capsule could reduce the mortality, recurrence rate, and neurological functional deficit scores, improve clinical effect and quality of life. In addition, compared with conventional therapy, the addition of the DZSM capsule played a beneficial role in hemorheology and lipid metabolism, which may attribute to the potential mechanism.

Medical Rehabilitation Need, Case Complexity, and Related Issues among Patients in an Acute Stroke Rehabilitation Setting

This narrative review introduces case complexity and medical rehabilitation needs in a stroke rehabilitation setting, and proposes methods to more efficiently enhance functional recovery in the acute stage after stroke onset. Therapists may measure a construct of individual need complexity around and beyond the basic and common needs for medical necessity, and thereby screen acute patients who could benefit more from additional rehabilitation inputs. This review also describes the clinical significance of medical rehabilitation needs and challenges for efficient stroke rehabilitation. Overall, we propose that challenging research trials should be conducted to compare the effectiveness of the arrangement of rehabilitation service allocation based on needs assessment after stroke with the usual care pathway.

Reabilitação robótica em pacientes com AVC: protocolo de ensaio clínico randomizado

RESUMO O objetivo deste estudo foi propor um protocolo de ensaio clínico randomizado para avaliar o efeito da reabilitação robótica sobre a funcionalidade de pacientes com acidente vascular cerebral (AVC) subagudo. Trata-se de um protocolo de um ensaio clínico randomizado que será desenvolvido no hospital e centro de reabilitação do Pavilhão Pereira Filho da Irmandade da Santa Casa de Misericórdia de Porto Alegre (ISCMPA). Quarenta pacientes com AVC, de ambos os sexos, com idades entre 18 e 85 anos e que apresentem hemiparesia ou fraqueza muscular (Medical Research Council - MRC <48 pontos) serão divididos aleatoriamente em grupo controle ou grupo de intervenção. O grupo de intervenção será aquele que realizará reabilitação robótica utilizando equipamento Erigo®, além da fisioterapia convencional, e o grupo controle receberá fisioterapia convencional por meio de exercícios com movimentos semelhantes aos realizados no robô. As intervenções ocorrerão todos os dias na fase hospitalar e, após a alta, três vezes por semana, totalizando aproximadamente 18 sessões. A funcionalidade será considerada o desfecho primário do estudo e será avaliada por meio da escala de Fugl-Meyer. Consideramos como desfechos secundários a força muscular (MRC e teste de repetição máxima), espasticidade (escala de Ashworth modificada), arquitetura do músculo quadríceps e ecogenicidade (ultrassom), mobilidade (teste timed up and go), grau de incapacidade e dependência (escala de Rankin e de medida de independência funcional), qualidade de vida (questionário EQ-5D), repercussões cardiorrespiratórias (monitoramento de sinais vitais), tempo de internação (em dias) e mortalidade (número de óbitos). Os grupos serão avaliados antes das intervenções, após a décima sessão e ao final de seis semanas de tratamento ou 18 sessões.

Associations between suicidal ideation and health-related quality of life among community-dwelling stroke survivors: 2013-2017 Korea National Health and Nutrition Examination Survey

PURPOSE

The study aimed to identify differences between individuals with stroke and the general population regarding socioeconomic, mental health, and Health-related quality of life (HRQOL) factors, and associations among Suicidal ideation (SI), HRQOL, and mental health.

METHODS

Data of individuals with stroke (n = 592) and without stroke (n = 23,562) aged 20 or older from the 2013-2017 Korea National Health and Nutrition Examination Survey were analyzed. Chi-square tests examined differences in socioeconomic status, mental health, and HRQOL (EQ-5D) between groups. Independent associations between each EQ-5D dimension and SI were analyzed through multivariable logistic regression.

RESULTS

Individuals with stroke were more likely to have problems on all EQ-5D dimensions. Significant univariate associations were identified between four EQ-5D dimensions and SI among individuals with stroke. Pain/discomfort (odds ratio [OR] = 1.32; 95% confidence interval [CI], 1.01-1.75, p = 0.048) and anxiety/depression (OR = 4.66; 95% CI, 3.69-5.89, p < .0001) of the EQ-5D were associated with SI when adjusting for all socioeconomic variables; anxiety/depression (OR = 2.80; 95% CI, 2.18-3.60, p < .0001) was the only risk factor for SI after controlling for socioeconomic and mental health variables.

CONCLUSION

Individuals with stroke showed higher rates for problems on the EQ-5D, SI, and depression compared to the general population. They also demonstrated significant associations between SI and each EQ-5D dimension except physical activity, especially pain/discomfort and depression/anxiety. The study's findings can be referred to when predicting suicide risk in individuals with stroke by analyzing their EQ-5D scores.

Very early mobilization in the stroke unit: Functionality, quality of life and disability at 90 days and 1 year post-stroke

BACKGROUND

The evidence of early mobilization after stroke is conflicting, and the recovery period is an important concern.

OBJECTIVE

To analyse the functionality, quality of life and disability at 90 days and 1 year post-stroke of patients who received a Very Early Mobilization Protocol (VEMP).

METHODS

Prospective cohort study in a tertiary stroke unit. Consecutive patients aged≥18 years and without prior significant disability, who presented motor deficit after acute stroke, were included. A symmetry test was performed to compare the changes in the main variables: Barthel Index (BI), Functional Ambulation Category (FAC), modified Rankin Scale (mRS) and EuroQol five-dimensions three-level (EQ-5D-3L) between 90 days and 1 year post-stroke.

RESULTS

A total of 123 patients were recruited. The BI reflected an improvement at 1 year in transfer to chair/bed in 25.8%(p <  0.01) of patients and in toilet use in 25.8%(p = 0.02). The FAC showed an improvement at 1 year in 44.4%(p <  0.01) of patients and the mRS in 19.1%(p = 0.01). The usual activities dimension of the EQ-5D-3L showed a clinically relevant improvement after 1 year in 15.9%(p = 0.23) of patients.

CONCLUSIONS

A significant percentage of patients show improvements in some functional areas and in disability between 90 days and 1 year post-stroke.

Effectiveness of Rehabilitation Nursing versus Usual Therapist-Led Treatment in Patients with Acute Ischemic Stroke: A Randomized Non-Inferiority Trial

Purpose

To determine the effectiveness of rehabilitation nursing program interventions in patients with acute ischemic stroke.

Patients and Methods

An assessment-blinded randomized controlled trial was conducted at a tertiary referral hospital in China. Eligible patients were stratified according to their weighted corticospinal tract lesion load and then randomly assigned to an experimental group (n = 121) or a control group (n = 103). The experimental group received rehabilitation nursing from well-trained, qualified nurses (30 minutes per session, two sessions per day for seven consecutive days). The control group received therapist-led rehabilitation with the same timing and frequency. Comparative analysis of the primary outcomes was performed to determine non-inferiority with a predetermined non-inferiority margin. The primary outcomes were the Motor Assessment Scale, Fugl-Meyer Assessment, and the Action Research Arm Test assessed at baseline and after seven days of treatment. The secondary outcomes were the modified Barthel Index, the National Institutes of Health Stroke Scale, and the modified Rankin Scale, evaluated before and after the intervention and at 4 and 12 weeks of follow-up.

Results

Two hundred participants completed the trial. In both groups, all outcomes improved significantly after seven days and at follow-ups. The rehabilitation nursing program was non-inferior to therapist-led treatment with lower 95% confidence limits beyond the margins for primary outcomes (P < 0.001).

Conclusion

Both treatments had comparable effects; however, no definite conclusion could be drawn. Adequately powered studies are required.

Effect of early intensive rehabilitation on the clinical outcomes of patients with acute stroke

AIM

Intensive rehabilitation effectively improves physical functions in patients with acute stroke, but the frequency of intervention and its cost-effectiveness are poorly studied. This study aimed to examine the effect of early high-frequency rehabilitation intervention on inpatient outcomes and medical expenses of patients with stroke.

METHODS

The study retrospectively included 1759 patients with acute stroke admitted to the Kobe City Medical Center General Hospital between 2013 and 2016. Patients with a transient ischemic attack, subarachnoid hemorrhage, and those who underwent urgent surgery were excluded. Patients were divided into two groups according to the frequency of rehabilitation intervention: the high-frequency intervention group (>2 times/day, n = 1105) and normal-frequency intervention group (<2 times/day, n = 654). A modified Rankin scale score ≤2 at discharge, immobility-related complications and medical expenses were compared between the groups.

RESULTS

The high-frequency intervention group had a significantly shorter time to first rehabilitation (median [interquartile range], 19.0 h [13.1-38.4] vs. 24.7 h [16.1-49.4], P < 0.001) and time to first mobilization (23.3 h [8.7-47.2] vs. 22.8 h [5.7-62.3], P = 0.65) than the normal-frequency intervention group. Despite higher disease severity, the high-frequency intervention group exhibited favorable outcomes at discharge (modified Rankin scale, ≤2; adjusted odds ratio, 1.89; 95% confidence interval, 1.25-2.85; P = 0.002). No significant differences were observed between the two groups concerning the rate of immobility-related complications and total medical expenses during hospitalization.

CONCLUSIONS

High-frequency intervention was associated with improved outcomes and decreased medical expenses in patients with stroke. Our results may contribute to reducing medical expenses by increasing the efficiency of care delivery. Geriatr Gerontol Int 2021; 21: 623-628.

Time Window for Ischemic Stroke First Mobilization Effectiveness: Protocol for an Investigator-Initiated Prospective Multicenter Randomized 3-Arm Clinical Trial

OBJECTIVE

The purpose of this study is to investigate the optimal time window for initiating mobilizing after acute ischemic stroke.

METHODS

The TIME Trial is a pragmatic, investigator-initiated, multi-center, randomized, 3-arm parallel group, clinical trial. This trial will be conducted in 57 general hospitals in mainland China affiliated with the China Stroke Databank Center and will enroll 6033 eligible patients with acute ischemic stroke. Participants will be randomly allocated to either (1) the very early mobilization group in which mobilization is initiated within 24 hours from stroke onset, (2) the early mobilization group in which mobilization begins between 24 and 72 hours poststroke, or (3) the late mobilization group in which mobilization is started after 72 hours poststroke. The mobilization protocol is otherwise standardized and identical for each comparison group. Mobilization is titrated by baseline mobility level and progress of patients throughout the intervention period. The primary outcome is death or disability assessed with the modified Rankin scale at 3 months poststroke. Secondary outcomes include impairment score of the National Institutes of Health Stroke Scale, dependence in activities of daily living as measured using the modified Barthel Index, cognitive ability assessed with the Mini-Mental State Examination, incidence of adverse events, hospital length of stay, and total medical costs.

IMPACT

The TIME Trial is designed to answer the question "when is the best time to start mobilization after stroke?" The effect of timing is isolated from the effect of type and dose of mobilization by otherwise applying a standard mobilization protocol across groups. The TIME Trial may, therefore, contribute to increasing the knowledge base regarding the optimal time window for initiating mobilization after acute ischemic stroke.

Health related quality of life and satisfaction with care of stroke patients in Budapest: A substudy of the EuroHOPE project

BACKGROUND

Disadvantaged socioeconomic status is associated with higher stroke incidence and mortality, and higher readmission rate. We aimed to assess the effect of socioeconomic factors on case fatality, health related quality of life (HRQoL), and satisfaction with care of stroke survivors in the framework of the European Health Care Outcomes, Performance and Efficiency (EuroHOPE) study in Hungary, one of the leading countries regarding stroke mortality.

METHODS

We evaluated 200 consecutive patients admitted for first-ever ischemic stroke in a single center and performed a follow-up at 3 months after stroke. We recorded pre- and post-stroke socioeconomic factors, and assessed case fatality, HRQoL and patient satisfaction with the care received. Stroke severity at onset was scored by the National Institutes of Health Stroke scale (NIHSS), disability at discharge from acute care was evaluated by the modified Rankin Score (mRS). To evaluate HRQoL and patient satisfaction with care we used the EQ-5D-5L, 15D and EORTC IN PATSAT 32 questionnaires.

RESULTS

At 3 months after stroke the odds of death was significantly increased by stroke severity (NIHSS, OR = 1.209, 95%CI: 1.125-1.299, p<0.001) and age (OR = 1.045, 95%CI: 1.003-1.089, p = 0.038). In a multiple linear regression model, independent predictors of HRQoL were age, disability at discharge, satisfaction with care, type of social dwelling after stroke, length of acute hospital stay and rehospitalization. Satisfaction with care was influenced negatively by stroke severity (Coef. = -1.111, 95%C.I.: -2.159- -0.062, p = 0.040), and positively by having had thrombolysis (Coef. = 25.635, 95%C.I.: 5.212-46.058, p = 0.016) and better HRQoL (Coef. = 22.858, 95%C.I.: 6.007-39.708, p = 0.009).

CONCLUSION

In addition to age, disability, and satisfaction with care, length of hospital stay and type of social dwelling after stroke also predicted HRQoL. Long-term outcome after stroke could be improved by reducing time spent in hospital, i.e. by developing home care rehabilitation facilities thus reducing the need for readmission to inpatient care.

Aerobic exercise attenuates neurodegeneration and promotes functional recovery - Why it matters for neurorehabilitation & neural repair

Aerobic exercise facilitates optimal neurological function and exerts beneficial effects in neurologic injuries. Both animal and clinical studies have shown that aerobic exercise reduces brain lesion volume and improves multiple aspects of cognition and motor function after stroke. Studies using animal models have proposed a wide range of potential molecular mechanisms that underlie the neurological benefits of aerobic exercise. Furthermore, additional exercise parameters, including time of initiation, exercise dosage (exercise duration and intensity), and treatment modality are also critical for clinical application, as identifying the optimal combination of parameters will afford patients with maximal functional gains. To clarify these issues, the current review summarizes the known neurological benefits of aerobic exercise under both physiological and pathological conditions and then considers the molecular mechanisms underlying these benefits in the contexts of stroke-like focal cerebral ischemia and cardiac arrest-induced global cerebral ischemia. In addition, we explore the key roles of exercise parameters on the extent of aerobic exercise-induced neurological benefits to elucidate the optimal combination for aerobic exercise intervention. Finally, the current challenges for aerobic exercise implementation after stroke are discussed.

Early head-up mobilisation versus standard care for patients with severe acquired brain injury: A systematic review with meta-analysis and Trial Sequential Analysis

BACKGROUND

There is increasing focus on earlier rehabilitation in patients with traumatic or hypoxic brain injury or stroke. This systematic review evaluates the benefits and harms of early head-up mobilisation versus standard care in patients with severe acquired brain injury.

METHODS

We searched Medline, CENTRAL, EMBASE, four other databases and 13 selected clinical trial registries until April 2020. Eligible randomised clinical trials compared early head-up mobilisation versus standard care in patients with severe acquired brain injury and were analysed conducting random- and fixed-effects meta-analyses and Trial Sequential Analysis (TSA). Certainty of evidence was assessed by GRADE.

MAIN RESULTS

We identified four randomised clinical trials (total n = 385 patients) with severe acquired brain injury (stroke 86% and traumatic brain injury 13%). Two trials were at low risk and two at high risk of bias. We found no evidence of a difference between early mobilisation vs. standard care on mortality or poor functional outcome at end of the intervention (relative risk (RR) 1.19, 95% CI 0.93 to 1.53; I2 0%; very low certainty) or at maximal follow-up (RR 1.03, 95% CI 0.89 to 1.21; I2 0%; very low certainty). We found evidence against an effect on quality of life at maximal follow-up. The proportion of patients with at least one serious adverse event did not differ at end of intervention or at maximal follow-up. For most comparisons, TSA suggested that further trials are needed.

CONCLUSIONS

We found no evidence of a difference between early mobilisation versus standard care for patients with severe acquired brain injury. Early mobilisation appeared not to exert a major impact on quality of life. This systematic review highlights the insufficient evidence in patients with severe brain injury, and no firm conclusions can be drawn from these data.

TRIAL REGISTRATION

Protocol uploaded to PROSPERO: April 2018 (revised October 2018, CRD42018088790).

Exploring post acute rehabilitation service use and outcomes for working age stroke survivors (≤65 years) in Australia, UK and South East Asia: data from the international AVERT trial

OBJECTIVES

Information about younger people of working age (≤65 years), their post stroke outcomes and rehabilitation pathways can highlight areas for further research and service change. This paper describes: (1) baseline demographics; (2) post acute rehabilitation pathways; and (3) 12-month outcomes; disability, mobility, depression, quality of life, informal care and return to work of working age people across three geographic regions (Australasia (AUS), South East (SE) Asia and UK).

DESIGN

This post hoc descriptive exploration of data from the large international very early rehabilitation trial (A Very Early Rehabilitation Trial (AVERT)) examined the four common post acute rehabilitation pathways (inpatient rehabilitation, home with community rehabilitation, inpatient rehabilitation then community rehabilitation and home with no rehabilitation) experienced by participants in the 3 months post stroke and describes their 12-month outcomes.

SETTING

Hospital stroke units in AUS, UK and SE Asia.

PARTICIPANTS

Patients who had an acute stroke recruited within 24 hours who were ≤65 years.

RESULTS

668 participants were ≤65 years; 99% lived independently, and 88% no disability (modified Rankin Score (mRS)=0) prior to stroke. We had complete data for 12-month outcomes for n=631 (94%). The proportion receiving inpatient rehabilitation was higher in AUS than other regions (AUS 52%; UK 25%; SE Asia 23%), whereas the UK had higher community rehabilitation (UK 65%; AUS 61%; SE Asia 39%). At 12 months, 70% had no or little disability (mRS 0-2), 44% were depressed, 28% rated quality of life as poor or worse than death. For those working prior to stroke (n=228), only 57% had returned to work. A noteworthy number of working age survivors received no rehabilitation services within 3 months post stroke.

CONCLUSIONS

There was considerable variation in rehabilitation pathways and post acute service use across the three regions. At 12 months, there were high rates of depression, poor quality of life and low rates of return to work.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12606000185561).