Update on Stroke Rehabilitation in Motor Impairment

Current Trends in Gait Rehabilitation for Stroke Survivors: A Scoping Review of Randomized Controlled Trials

BACKGROUND

Stroke stands as a significant global health concern, constituting a leading cause of disability worldwide. Rehabilitation interventions are crucial in aiding the recovery of stroke patients, contributing to an overall enhancement in their quality of life. This scoping review seeks to identify current trends in gait rehabilitation for stroke survivors.

METHODS

The review followed the methodological framework suggested by Arksey and O'Malley. Electronic databases, such as CINAHL Complete, MEDLINE Complete, and Nursing & Allied Health Collection, were systematically searched in November 2023. Inclusion criteria comprised papers published in either English or Portuguese from 2013 to 2023.

RESULTS

From the initial search, a total of 837 papers were identified; twenty-one papers were incorporated into this review. Thirteen distinct categories of gait rehabilitation interventions were identified, encompassing diverse approaches. These categories comprise conventional rehabilitation exercises, traditional gait training with integrated technology, and gait training supported by modern technologies.

CONCLUSIONS

Although traditional rehabilitation exercises have historically proven effective in aiding stroke survivors, a recent trend has emerged, emphasizing the development and integration of innovative therapeutic approaches that harness modern technologies.

Neurobiomechanical mechanism of Tai Chi to improve upper limb coordination function in post-stroke patients: a study protocol for a randomized controlled trial

BACKGROUND

Upper limb dysfunction seriously affects the ability of stroke patients to perform activities of daily living. As a popular exercise therapy, Tai Chi may become an alternative intervention. However, the neurophysiological mechanism by which Tai Chi improves upper limb dysfunction in stroke patients is still unclear, which limits its further promotion and application. Therefore, conducting a strict randomized clinical trial is necessary to observe how Tai Chi affects upper limb dysfunction in stroke patients and to explore its neurophysiological mechanism.

METHODS/DESIGN

This report describes a randomized, parallel-controlled trial with distributive concealment and evaluator blinding. A total of 84 eligible participants will be randomly assigned to the Tai Chi group or the control group in a 1:1 ratio. The participants in the Tai Chi group will receive 4 weeks of Tai Chi training: five 60-min sessions a week for a total of 20 sessions. The participants in the control group will not receive Tai Chi training. Both groups will receive medical treatment and routine rehabilitation training. The primary outcome measure is the mean change in the Fugl-Meyer Assessment Upper Extremity (FMA-UE) scale score between baseline and 4 weeks; the secondary outcomes are the mean changes in kinematic characteristics and the Wolf Motor Function Test (WMFT) and Stroke Impact Scale (SIS) scores. In addition, the corticomuscular coupling level and near-infrared brain functional imaging will be monitored to explore the mechanism by which Tai Chi improves upper limb function of stroke patients.

DISCUSSION

This randomized controlled trial will examine the effectiveness of Tai Chi in stroke patients with upper limb dysfunction and explore the neurophysiological mechanism. Positive results will verify that Tai Chi can improve upper limb function of stroke patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registration Center, ChiCTR2200061376 (retrospectively registered). Registered June 22, 2022. http://www.chictr.org.cn/listbycreater.aspx . Manuscript Version: 3.0 Manuscript Date: October 10, 2023.

Remote Ischemic Conditioning for Motor Recovery after Acute Ischemic Stroke

BACKGROUND

Remote ischemic conditioning (RIC) has shown an impressive neuroprotective effect on acute ischemic stroke (AIS) in animal experiments. But whether chronic RIC improves long-term functional outcomes remains unclear.

MATERIALS AND METHODS

We performed a non-randomized controlled trial. Eligible patients (aged 18 -80 y) with hemiplegia caused by AIS were allocated to the RIC group and the control group. All participants received normal protocol rehabilitation therapy. Patients in the RIC group underwent RIC twice daily for 90 days. The outcome included the 90-day Fugl-Meyer Assessment (FMA) scores and modified Rankin's scale (mRS) scores, as well as changes in angiogenesis-related factors in serum from baseline to 90 days.

RESULTS

Twenty-seven patients were included in the analysis (13 in the RIC group and 14 in the control group). There was no significant difference in 90-day total FMA scores between the two groups. Lower limb FMA scores at day 90 were significantly higher in the RIC group (32.8±8.7 vs. 24.8±5.4, adjusted P =0.042). The proportion of favorable outcome (mRS<2) was higher in the RIC group than that in the control group, but no significant difference was detected (8 [61.5%] vs. 7 [50%], P =0.705). A significant increase has been found in the level of epidermal growth factor (EGF) in serum (9.4 [1.1 to 25.7] vs. -8.7 [-15.1 to 4.7], P =0.036) after chronic RIC procedure.

CONCLUSION

This study investigated the role that RIC plays in AIS recovery, especially in motor function. RIC may have beneficial effects on lower limbs recovery by enhancing the EGF level. The effect of RIC on motor recovery should be further validated in future studies.

Current Trends in Balance Rehabilitation for Stroke Survivors: A Scoping Review of Experimental Studies

Balance impairment is a common consequence of a stroke, which can significantly hinder individuals' participation in daily activities, social interactions, and leisure pursuits and their ability to return to work. Rehabilitation is vital for minimizing post-stroke sequelae and facilitating the recovery of patients. This review aims to identify current trends in balance rehabilitation of stroke survivors. This Scoping review followed Arksey and O'Malley's methodological framework. The literature search was conducted in electronic databases, including CINAHL Complete, MEDLINE Complete, and Nursing & Allied Health Collection. The search was performed in March 2023, and the inclusion criteria were articles published in English or Portuguese between 2013 and 2023. A total of 446 articles were identified. After selecting and analyzing the reports, fourteen publications were included in this review. Seven distinct categories of balance rehabilitation interventions were identified, covering various approaches. These categories included conventional rehabilitation exercises, gym-based interventions, vibration therapy, rhythmic auditory stimulation training, boxing therapy, dual-task training, and technology-based rehabilitation interventions. Each of these methods presents unique benefits and can significantly impact the recovery of balance in stroke survivors, enhancing their overall well-being and functional capacity.

Accessibility for Rehabilitation Therapy According to Socioeconomic Status in Patients With Stroke: A Population-Based Retrospective Cohort Study

This study aimed to investigate accessibility for rehabilitation therapy according to socioeconomic status (SES) after stroke using nationwide population-based cohort data. We selected patients with a diagnosis with stroke (International Classification of Diseases, 10th Revision code: I60-64) and SES including residential area, income level, and insurance type were also assessed. Receiving continuous rehabilitation therapy was defined as accumulation of "Rehabilitative developmental therapy for disorder of central nervous system (claim code: MM105)" more than 41 times. Logistic regression analyses were performed to investigate the association between SES and rehabilitation therapy using odds ratios (ORs) and 95% confidence intervals (CIs). A total of 18,842 patients with stroke were enrolled. Rural area (OR, 0.745; 95% CI, 0.664-0.836) and medical aid (OR, 0.605; 95% CI, 0.494-0.741) were associated with lower rate of receiving rehabilitation therapy. As for income level, when lowest income group was used as a reference group, low-middle group showed an increased rate of receiving rehabilitation therapy (OR, 1.206; 95% CI, 1.020-1.426). Although rehabilitation therapy after stroke is covered with national health insurance program in Korea, there still existed disparities of accessibility for rehabilitation therapy according to SES. Our results would suggest helpful information for health policy in patients with stroke.

Progress in the clinical application of constraint-induced therapy following stroke since 2014

Stroke is a group of cerebrovascular diseases with high prevalence and mortality rate. Stroke can induce many impairments, including motor and cognitive dysfunction, aphasia/dysarthria, dysphagia, and mood disorders, which may reduce the quality of life among the patients. Constraint-induced therapy has been proven to be an effective treatment method for stroke rehabilitation. It has been widely used in the recovery of limb motor dysfunction, aphasia, and other impairment like unilateral neglect after stroke. In recent years, constraint-induced therapy can also combine with telehealth and home rehabilitation. In addition, constraint-induced therapy produces significant neuroplastic changes in the central nervous system. Functional magnetic resonance imaging, diffusion tensor imaging, and other imaging/electrophysiology methods have been used to clarify the mechanism and neuroplasticity. However, constraint-induced therapy has some limitations. It can only be used under certain conditions, and the treatment time and effectiveness are controversial. Further research is needed to clarify the mechanism and effectiveness of CI therapy.

MRI-Based Personalized Transcranial Direct Current Stimulation to Enhance the Upper Limb Function in Patients with Stroke: Study Protocol for a Double-Blind Randomized Controlled Trial

Transcranial direct current stimulation (tDCS) has been shown to have the potential to improve the motor recovery of the affected upper limbs in patients with stroke, and recently, several optimized tDCS methods have been proposed to magnify its effectiveness. This study aims to determine the effectiveness of personalized tDCS using brain MRI-based electrical field simulation and optimization, to enhance motor recovery of the upper limbs in the patients. This trial is a double-blind, randomized controlled trial in the subacute to chronic rehabilitation phase. Forty-two adult stroke patients with unilateral upper limb involvement will be randomly allocated to three groups: (1) personalized tDCS with MRI-based electrical field simulation and optimized stimulation, (2) conventional tDCS with bihemispheric stimulation of the primary motor cortex, and (3) sham tDCS. All three groups will undergo 10 intervention sessions with 30 min of 2-mA intensity stimulation, during a regular upper limb rehabilitation program over two weeks. The primary outcome measure for the motor recovery of the upper limb impairment is the Fugl-Meyer assessment for the upper extremity score at the end of the intervention, and the secondary measures include changes in the motor evoked potentials, the frequency power and coherence of the electroencephalography, performance in activities of daily living, and adverse events with a 1-month follow-up assessment. The primary outcome will be analyzed on the intention-to-treat principle. There is a paucity of studies regarding the effectiveness of personalized and optimized tDCS that considers individual brain lesions and electrical field characteristics in the real world. No feasibility or pivotal studies have been performed in stroke patients using brain MRI, to determine a lesion-specific tDCS simulation and optimization that considers obstacles in the segmentation and analysis of the affected brain tissue, such as ischemic and hemorrhagic lesions. This trial will contribute to addressing the effectiveness and safety of personalized tDCS, using brain MRI-based electrical field simulation and optimization, to enhance the motor recovery of the upper limbs in patients with stroke.