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Liang HW, Wu CH, Lin C, Chang HC, Lin YH, Chen SY, Hsu WC. Rest-Activity Rhythm Differences in Acute Rehabilitation Between Poststroke Patients and Non-Brain Disease Controls: Comparative Study. J Med Internet Res 2024; 26:e49530. [PMID: 38963936 PMCID: PMC11258522 DOI: 10.2196/49530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 05/08/2024] [Accepted: 05/30/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Circadian rhythm disruptions are a common concern for poststroke patients undergoing rehabilitation and might negatively impact their functional outcomes. OBJECTIVE Our research aimed to uncover unique patterns and disruptions specific to poststroke rehabilitation patients and identify potential differences in specific rest-activity rhythm indicators when compared to inpatient controls with non-brain-related lesions, such as patients with spinal cord injuries. METHODS We obtained a 7-day recording with a wearable actigraphy device from 25 poststroke patients (n=9, 36% women; median age 56, IQR 46-71) and 25 age- and gender-matched inpatient control participants (n=15, 60% women; median age 57, IQR 46.5-68.5). To assess circadian rhythm, we used a nonparametric method to calculate key rest-activity rhythm indicators-relative amplitude, interdaily stability, and intradaily variability. Relative amplitude, quantifying rest-activity rhythm amplitude while considering daily variations and unbalanced amplitudes, was calculated as the ratio of the difference between the most active 10 continuous hours and the least active 5 continuous hours to the sum of these 10 and 5 continuous hours. We also examined the clinical correlations between rest-activity rhythm indicators and delirium screening tools, such as the 4 A's Test and the Barthel Index, which assess delirium and activities of daily living. RESULTS Patients who had a stroke had higher least active 5-hour values compared to the control group (median 4.29, IQR 2.88-6.49 vs median 1.84, IQR 0.67-4.34; P=.008). The most active 10-hour values showed no significant differences between the groups (stroke group: median 38.92, IQR 14.60-40.87; control group: median 31.18, IQR 18.02-46.84; P=.93). The stroke group presented a lower relative amplitude compared to the control group (median 0.74, IQR 0.57-0.85 vs median 0.88, IQR 0.71-0.96; P=.009). Further analysis revealed no significant differences in other rest-activity rhythm metrics between the two groups. Among the patients who had a stroke, a negative correlation was observed between the 4 A's Test scores and relative amplitude (ρ=-0.41; P=.045). Across all participants, positive correlations emerged between the Barthel Index scores and both interdaily stability (ρ=0.34; P=.02) and the most active 10-hour value (ρ=0.42; P=.002). CONCLUSIONS This study highlights the relevance of circadian rhythm disruptions in poststroke rehabilitation and provides insights into potential diagnostic and prognostic implications for rest-activity rhythm indicators as digital biomarkers.
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Affiliation(s)
- Huey-Wen Liang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Chueh-Hung Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chen Lin
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan City, Taiwan
| | - Hsiang-Chih Chang
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
| | - Yu-Hsuan Lin
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shao-Yu Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Chen Hsu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
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Frange C, Murray BJ, Coelho FMS. The Importance of Sleep for Successful Neurorehabilitation after Stroke. Sleep Sci 2023; 16:e335-e343. [PMID: 38196757 PMCID: PMC10773525 DOI: 10.1055/s-0043-1772805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/24/2022] [Indexed: 01/11/2024] Open
Abstract
Sleep has important clinical implications for neurorehabilitation after stroke. We aimed to systematically explore sleep (including naps) as an essential factor in the neurorehabilitation of patients after stroke. After titles and abstracts were screened, 49 full texts were reviewed, and 7 were included in this review. Data were extracted and assessed for quality and risk of bias. We looked at any neurorehabilitation setting, and compared sleep with no sleep and explored these factors in stroke patients versus healthy individuals. Rehabilitation is critical for many activities that may need to be learned or re-learned following stroke and for returning to everyday life. In this context, sleep is essential in neurorehabilitation and physical therapy practice as it supports neuroplasticity, memory, and learning. The available data suggest that sleep should be considered in the treatment plan for successfully targeted physiotherapy to optimize cognitive and motor learning. Physical therapists should advise about sleep hygiene and therapies to improve sleep, both quality and quantity.
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Affiliation(s)
- Cristina Frange
- Department of Neurology and Neurosurgery, Universidade Federal De São Paulo, São Paulo, São Paulo, Brazil
| | - Brian James Murray
- Department of Medicine, Division of Neurology, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Fernando Morgadinho Santos Coelho
- Department of Neurology and Neurosurgery, Universidade Federal De São Paulo, São Paulo, São Paulo, Brazil
- Department of Psychobiology, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
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Pellegrini M, Lannin NA, Mychasiuk R, Graco M, Kramer SF, Giummarra MJ. Measuring Sleep Quality in the Hospital Environment with Wearable and Non-Wearable Devices in Adults with Stroke Undergoing Inpatient Rehabilitation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3984. [PMID: 36900995 PMCID: PMC10001748 DOI: 10.3390/ijerph20053984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/02/2023] [Accepted: 02/19/2023] [Indexed: 06/18/2023]
Abstract
Sleep disturbances are common after stroke and may affect recovery and rehabilitation outcomes. Sleep monitoring in the hospital environment is not routine practice yet may offer insight into how the hospital environment influences post-stroke sleep quality while also enabling us to investigate the relationships between sleep quality and neuroplasticity, physical activity, fatigue levels, and recovery of functional independence while undergoing rehabilitation. Commonly used sleep monitoring devices can be expensive, which limits their use in clinical settings. Therefore, there is a need for low-cost methods to monitor sleep quality in hospital settings. This study compared a commonly used actigraphy sleep monitoring device with a low-cost commercial device. Eighteen adults with stroke wore the Philips Actiwatch to monitor sleep latency, sleep time, number of awakenings, time spent awake, and sleep efficiency. A sub-sample (n = 6) slept with the Withings Sleep Analyzer in situ, recording the same sleep parameters. Intraclass correlation coefficients and Bland-Altman plots indicated poor agreement between the devices. Usability issues and inconsistencies were reported between the objectively measured sleep parameters recorded by the Withings device compared with the Philips Actiwatch. While these findings suggest that low-cost devices are not suitable for use in a hospital environment, further investigations in larger cohorts of adults with stroke are needed to examine the utility and accuracy of off-the-shelf low-cost devices to monitor sleep quality in the hospital environment.
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Affiliation(s)
- Michael Pellegrini
- Department of Neuroscience, The Alfred Centre, Monash University, Melbourne, VIC 3004, Australia
| | - Natasha A. Lannin
- Department of Neuroscience, The Alfred Centre, Monash University, Melbourne, VIC 3004, Australia
- Alfred Health, Melbourne, VIC 3053, Australia
| | - Richelle Mychasiuk
- Department of Neuroscience, The Alfred Centre, Monash University, Melbourne, VIC 3004, Australia
| | - Marnie Graco
- Institute for Breathing and Sleep, Austin Health, Melbourne, VIC 3084, Australia
- Department of Physiotherapy, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Sharon Flora Kramer
- Department of Neuroscience, The Alfred Centre, Monash University, Melbourne, VIC 3004, Australia
- Institute for Health Transformation, Deakin University, Melbourne, VIC 3125, Australia
| | - Melita J. Giummarra
- Department of Neuroscience, The Alfred Centre, Monash University, Melbourne, VIC 3004, Australia
- Alfred Health, Melbourne, VIC 3053, Australia
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Prusynski RA, Kelly VE, Fogelberg DJ, Pradhan S. The association between sleep deficits and sedentary behavior in people with mild Parkinson disease. Disabil Rehabil 2022; 44:5585-5591. [PMID: 34218729 PMCID: PMC10659136 DOI: 10.1080/09638288.2021.1940320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 05/06/2021] [Accepted: 06/04/2021] [Indexed: 10/20/2022]
Abstract
Purpose: Sleep deficits are a common nonmotor symptom of Parkinson disease (PD). People with mild PD also achieve less physical activity (PA) than healthy older adults (HOA), but the relationship between sleep and PA in PD is unclear. This study examined associations between sleep and PA in participants with PD and HOA.Materials and Methods: Secondary analysis of a prospective observational study. Participants wore a commercially available activity monitor for two weeks. Wilcoxon Rank-Sum tests compared nighttime sleep, wakenings after sleep onset, number of wakenings, naps, step count, and PA intensity between PD and HOA groups. Age-adjusted regression models calculated associations between nighttime sleep and PA.Results: Per day, participants with PD slept 75 fewer minutes (p < 0.01), took 5,792 fewer steps (p < 0.001), achieved less PA at all intensities, and had 32% more sedentary time (p < 0.001) compared to HOA. Thirty minutes more sleep was associated with 26 fewer sedentary minutes for HOA (p = 0.01) and 25 fewer sedentary minutes for the PD group (p < 0.001).Conclusions: Sleep and PA are reduced in mild PD compared to HOA. Both groups demonstrated similar associations between reduced sleep and increased sedentary behavior. Results may encourage providers to screen for sleep deficits when promoting PA.IMPLICATIONS FOR REHABILITATIONThe use of a wrist-worn commercial activity and sleep monitor was well tolerated by both healthy older adults and people with mild Parkinson Disease in this study.People with mild Parkinson Disease slept less and were less active than a group of healthy older adults.Less sleep was associated with more sedentary behavior in both groups.The relationship between poor sleep and sedentary behavior in mild Parkinson Disease suggests that rehabilitation interventions may be optimized by targeting both physical activity and sleep deficits.
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Affiliation(s)
- Rachel A Prusynski
- Department of Rehabilitation Medicine, University of Washington, Washington, Seattle, WA, USA
| | - Valerie E Kelly
- Department of Rehabilitation Medicine, University of Washington, Washington, Seattle, WA, USA
| | - Donald J Fogelberg
- Department of Rehabilitation Medicine, University of Washington, Washington, Seattle, WA, USA
| | - Sujata Pradhan
- Department of Rehabilitation Medicine, University of Washington, Washington, Seattle, WA, USA
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Miano S, Fanfulla F, Nobili L, Heinzer R, Haba-Rubio J, Berger M, Cereda C, Schmidt M, Manconi M, Bassetti C. SAS CARE 1: Sleep architecture changes in a cohort of patients with Ischemic Stroke/TIA. Sleep Med 2022; 98:106-113. [DOI: 10.1016/j.sleep.2022.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/25/2022] [Accepted: 06/02/2022] [Indexed: 12/12/2022]
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Severin R, Sabbahi A, Arena R, Phillips SA. Precision Medicine and Physical Therapy: A Healthy Living Medicine Approach for the Next Century. Phys Ther 2022; 102:6413905. [PMID: 34718788 DOI: 10.1093/ptj/pzab253] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/27/2021] [Accepted: 10/20/2021] [Indexed: 11/14/2022]
Abstract
There is a reciprocal relationship between common health conditions encountered in physical therapist practice, disability, and healthy living factors, such as physical inactivity, blood pressure, sleep quality, diet, and obesity. This relationship is apparent across all practice settings. Physical therapists are well positioned in the health care system to mitigate chronic disease by routinely screening and addressing healthy living factors to improve overall health and lower the risk for chronic disease (healthy living medicine). However, there are several challenges to the successful implementation of this framework in physical therapist practice. This Perspective will elucidate this relationship between healthy living behaviors and physical therapist practice, review the current state of practice regarding screening and intervention of 5 key healthy living behaviors, and outline future steps the profession can take toward implementing precision medicine using a healthy living medicine approach.
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Affiliation(s)
- Richard Severin
- Department of Physical Therapy Program, University of Illinois-Chicago, Chicago, Illinois, USA.,Department of Physical Therapy, Robbins College of Health and Human Sciences, Baylor University, Waco, Texas, USA
| | - Ahmad Sabbahi
- Department of Physical Therapy Program, University of Illinois-Chicago, Chicago, Illinois, USA
| | - Ross Arena
- Department of Physical Therapy Program, University of Illinois-Chicago, Chicago, Illinois, USA
| | - Shane A Phillips
- Department of Physical Therapy Program, University of Illinois-Chicago, Chicago, Illinois, USA
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Williams-Cooke C, Watts E, Bonnett J, Alshehri M, Siengsukon C. Association Between Sleep Duration and Functional Disability in Inpatient Stroke Rehabilitation: A Pilot Observational Study. Arch Rehabil Res Clin Transl 2021; 3:100150. [PMID: 34589700 PMCID: PMC8463457 DOI: 10.1016/j.arrct.2021.100150] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective To describe the change in sleep duration during inpatient rehabilitation and to determine if sleep quality and sleep duration is associated with functional disability for individuals after stroke. It was hypothesized that participants who experienced optimal sleep during inpatient rehabilitation would have greater functional ability at discharge. Design Longitudinal observation study. Setting Inpatient rehabilitation unit at a large, urban hospital. Participants Thirty-seven individuals with acute stroke (N=37; mean age, 62.5±11.8y, male=20, female=17) were recruited from September 2018 to September 2019. Participants were invited to participate in the study by clinical personnel associated with their usual care as they were admitted to inpatient rehabilitation. Interventions Not applicable. Main Outcome Measures Participants were asked to wear an actigraph for the duration of their rehabilitation program to assess sleep. The first 3 nights of actigraphy data were averaged to obtain total sleep time (TST) and sleep efficiency (SE) at admission, and the last 3 nights were averaged for TST and SE at discharge. Functional disability (primary outcome was FIM) at admission and discharge was gathered from the participants’ medical records. One-way analysis of variance and chi-square analyses assessed for group differences, and regression modeling was used to determine if sleep was associated with functional ability at discharge. Results Sixteen participants (43%) were categorized as “good sleepers” and 21 (57%) were “poor sleepers” based on their TST at admission. Of the poor sleepers, 14 participants (66%) remained short duration sleepers (<7h at admission and discharge). Sleep outcomes did not significantly predict FIM score at discharge. Conclusions Most participants had less than optimal sleep duration during inpatient rehabilitation. Efforts may be warranted to optimize sleep during inpatient rehabilitation.
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Affiliation(s)
- Cierra Williams-Cooke
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, KS
| | - Elise Watts
- Rehabilitation Department, St. Luke's Hospital, Kansas City, MO
| | | | - Mohammed Alshehri
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, KS
| | - Catherine Siengsukon
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, KS
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Gottlieb E, Khlif MS, Bird L, Werden E, Churchward T, Pase MP, Egorova N, Howard ME, Brodtmann A. Sleep architectural dysfunction and undiagnosed obstructive sleep apnea after chronic ischemic stroke. Sleep Med 2021; 83:45-53. [PMID: 33991892 DOI: 10.1016/j.sleep.2021.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/22/2021] [Accepted: 04/08/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE/BACKGROUND Sleep-wake dysfunction is bidirectionally associated with the incidence and evolution of acute stroke. It remains unclear whether sleep disturbances are transient post-stroke or are potentially enduring sequelae in chronic stroke. Here, we characterize sleep architectural dysfunction, sleep-respiratory parameters, and hemispheric sleep in ischemic stroke patients in the chronic recovery phase compared to healthy controls. PATIENTS/METHODS Radiologically confirmed ischemic stroke patients (n = 28) and matched control participants (n = 16) were tested with ambulatory polysomnography, bi-hemispheric sleep EEG, and demographic, stroke-severity, mood, and sleep-circadian questionnaires. RESULTS Twenty-eight stroke patients (22 men; mean age = 69.61 ± 7.4 years) were cross-sectionally evaluated 4.1 ± 0.9 years after mild-moderate ischemic stroke (baseline NIHSS: 3.0 ± 2.0). Fifty-seven percent of stroke patients (n = 16) exhibited undiagnosed moderate-to-severe obstructive sleep apnea (apnea-hypopnea index >15). Despite no difference in total sleep or wake after sleep onset, stroke patients had reduced slow-wave sleep time (66.25 min vs 99.26 min, p = 0.02), increased time in non-rapid-eye-movement (NREM) stages 1-2 (NREM-1: 48.43 vs 28.95, p = 0.03; NREM-2: 142.61 vs 115.87, p = 0.02), and a higher arousal index (21.46 vs 14.43, p = 0.03) when compared to controls. Controlling for sleep apnea severity did not attenuate the magnitude of sleep architectural differences between groups (NREM 1-3=ηp2 >0.07). We observed no differences in ipsilesionally versus contralesionally scored sleep architecture. CONCLUSIONS Fifty-seven percent of chronic stroke patients had undiagnosed moderate-severe obstructive sleep apnea and reduced slow-wave sleep with potentially compensatory increases in NREM 1-2 sleep relative to controls. Formal sleep studies are warranted after stroke, even in the absence of self-reported history of sleep-wake pathology.
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Affiliation(s)
- Elie Gottlieb
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; University of Melbourne, Melbourne, VIC, Australia.
| | - Mohamed S Khlif
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; University of Melbourne, Melbourne, VIC, Australia
| | - Laura Bird
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; University of Melbourne, Melbourne, VIC, Australia
| | - Emilio Werden
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; University of Melbourne, Melbourne, VIC, Australia
| | - Thomas Churchward
- Institute for Breathing and Sleep, Melbourne, VIC, Australia; Austin Health, Heidelberg, VIC, Australia
| | - Matthew P Pase
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, VIC, Australia; Harvard T.H. Chan School of Public Health, Harvard University, MA, USA
| | - Natalia Egorova
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; University of Melbourne, Melbourne, VIC, Australia; Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Mark E Howard
- University of Melbourne, Melbourne, VIC, Australia; Institute for Breathing and Sleep, Melbourne, VIC, Australia; Austin Health, Heidelberg, VIC, Australia
| | - Amy Brodtmann
- The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; University of Melbourne, Melbourne, VIC, Australia
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Fulk GD, Boyne P, Hauger M, Ghosh R, Romano S, Thomas J, Slutzky A, Klingman K. The Impact of Sleep Disorders on Functional Recovery and Participation Following Stroke: A Systematic Review and Meta-Analysis. Neurorehabil Neural Repair 2020; 34:1050-1061. [DOI: 10.1177/1545968320962501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Adequate sleep is vital for health and quality of life. People with stroke and a concomitant sleep disorder may have poorer outcomes than those without a sleep disorder. Objective To systematically evaluate the published literature to determine the impact of sleep disorders on physical, functional recovery at the activity and participation level after stroke. Methods A systematic review was conducted using PubMed, CINAHL, Scopus, and PsycINFO. Studies were selected that reported outcomes on physical, functional recovery at the activity and participation levels in participants with stroke and a diagnosed sleep disorder. A meta-analysis was performed on included studies that reported Barthel Index (BI) and modified Rankin Scale (mRS) scores. Results: A total of 33 studies were included in the systematic review with 9 of them in the meta-analysis. The mean mRS score was 0.51 points higher in participants with stroke and sleep disorders versus participants with stroke without sleep disorder [95% CI: 0.23-0.78]. The mean BI score was 10.2 points lower in participants with stroke and sleep disorders versus participants with stroke without sleep disorder [95% CI: −17.9 to −2.6]. Conclusions People with stroke and a sleep disorder have greater functional limitations and disability than those without a sleep disorder. Rehabilitation professionals should screen their patients with stroke for potential sleep disorders and further research is needed to develop sleep and rehabilitation interventions that can be delivered in combination. PROSPERO registration number: CRD42019125562.
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Affiliation(s)
| | | | | | | | | | | | - Amy Slutzky
- Upstate Medical University, Syracuse, NY, USA
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10
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Fulk G, Duncan P, Klingman KJ. Sleep problems worsen health-related quality of life and participation during the first 12 months of stroke rehabilitation. Clin Rehabil 2020; 34:1400-1408. [PMID: 32602376 PMCID: PMC11145505 DOI: 10.1177/0269215520935940] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Evaluate the impact of self-reported sleep problems on post-stroke recovery. DESIGN Cross-sectional secondary analysis of longitudinal data from the Locomotor Experience Applied Post-Stroke (LEAPS) rehabilitation and recovery study (phase-III single-blind randomized controlled clinical trial). Group medians were compared for three sleep problem groups across three time points. SETTING Outpatient and in-home physical therapy. SUBJECTS Adults during the first year following stroke (n = 408, 380, 360 at 2, 6, 12 months, respectively). INTERVENTIONS The original study compared effects of locomotor training with body weight support in the year post-stroke. This analysis evaluated function in three sleep/functional-impact groups: no sleep problems, sleep problems with no-to-minimal-impact and sleep problems with moderate-to-quite-a-bit of impact. MAIN MEASURES Participants' responses regarding if they had "a sleep problem, such as insomnia" and, if so, what the impact was on their function. Stroke Impact Scale subscales for strength, hand function, mobility, ADLs, memory, communication, emotion, participation, and percent recovery. RESULTS About 25% of people with stroke reported sleep difficulty, 10% perceived sleep problems negatively impact function. Groups self-reporting worse sleep performed worse in all functional subscales (except self-perceived percent recovery) during the first year post-stroke. CONCLUSION Self-reported poor sleep adversely effects post-stroke functional recovery.
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Affiliation(s)
- George Fulk
- SUNY Upstate Medical University, Syracuse, NY, USA
| | - Pamela Duncan
- Wake Forest University Health Sciences, Wake Forest, NC, USA
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11
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Sridhar N, Shoeb A, Stephens P, Kharbouch A, Shimol DB, Burkart J, Ghoreyshi A, Myers L. Deep learning for automated sleep staging using instantaneous heart rate. NPJ Digit Med 2020; 3:106. [PMID: 32885052 PMCID: PMC7441407 DOI: 10.1038/s41746-020-0291-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/19/2020] [Indexed: 12/16/2022] Open
Abstract
Clinical sleep evaluations currently require multimodal data collection and manual review by human experts, making them expensive and unsuitable for longer term studies. Sleep staging using cardiac rhythm is an active area of research because it can be measured much more easily using a wide variety of both medical and consumer-grade devices. In this study, we applied deep learning methods to create an algorithm for automated sleep stage scoring using the instantaneous heart rate (IHR) time series extracted from the electrocardiogram (ECG). We trained and validated an algorithm on over 10,000 nights of data from the Sleep Heart Health Study (SHHS) and Multi-Ethnic Study of Atherosclerosis (MESA). The algorithm has an overall performance of 0.77 accuracy and 0.66 kappa against the reference stages on a held-out portion of the SHHS dataset for classifying every 30 s of sleep into four classes: wake, light sleep, deep sleep, and rapid eye movement (REM). Moreover, we demonstrate that the algorithm generalizes well to an independent dataset of 993 subjects labeled by American Academy of Sleep Medicine (AASM) licensed clinical staff at Massachusetts General Hospital that was not used for training or validation. Finally, we demonstrate that the stages predicted by our algorithm can reproduce previous clinical studies correlating sleep stages with comorbidities such as sleep apnea and hypertension as well as demographics such as age and gender.
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Affiliation(s)
| | - Ali Shoeb
- Verily Life Sciences, Mountain View, CA USA
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12
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The influence of sleep quality and circadian preferences on upper extremity rehabilitation in stroke patients after constraint-induced movement therapy. Int J Rehabil Res 2020; 43:20-27. [DOI: 10.1097/mrr.0000000000000379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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13
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Neuroplasticity in Brain Injury: Maximizing Recovery. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00242-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Lau HL, Rundek T, Ramos AR. Sleep and Stroke: New Updates on Epidemiology, Pathophysiology, Assessment, and Treatment. CURRENT SLEEP MEDICINE REPORTS 2019; 5:71-82. [PMID: 31850157 PMCID: PMC6916645 DOI: 10.1007/s40675-019-00142-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review aims to discuss the most recent data on sleep disorders and stroke, highlighting relevant findings for the practicing neurologist or health providers who encounter patients with sleep disorders and stroke. RECENT FINDINGS Sleep apnea and abnormal sleep duration have the strongest association with stroke risk. Possible mechanisms include non-dipping of blood pressure during sleep, hypoxemia or reoxygenation leading to sympathetic activation, hypertension, atrial fibrillation and impaired cerebral hemodynamics. Treatment studies suggest that continuous positive airway pressure (CPAP) for sleep apnea could improve primary prevention of stroke, but data is equivocal for secondary prevention. However, CPAP could improve functional outcomes after stroke. SUMMARY Sleep disorders present an opportunity to improve stroke risk and functional outcomes. However, new strategies are needed to determine the patients at high-risk who would most likely benefit from targeted care. Novel methods for phenotyping sleep disorders could provide personalized stroke care to improve clinical outcomes and public health strategies.
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Affiliation(s)
- H Lee Lau
- Departments of Neurology, Miller School of Medicine University of Miami, Miami, Florida, USA
| | - Tanja Rundek
- Departments of Neurology, Miller School of Medicine University of Miami, Miami, Florida, USA
| | - Alberto R Ramos
- Departments of Neurology, Miller School of Medicine University of Miami, Miami, Florida, USA
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Gottlieb E, Landau E, Baxter H, Werden E, Howard ME, Brodtmann A. The bidirectional impact of sleep and circadian rhythm dysfunction in human ischaemic stroke: A systematic review. Sleep Med Rev 2019; 45:54-69. [DOI: 10.1016/j.smrv.2019.03.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 01/11/2023]
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Backhaus W, Braass H, Gerloff C, Hummel FC. Can Daytime Napping Assist the Process of Skills Acquisition After Stroke? Front Neurol 2018; 9:1002. [PMID: 30524365 PMCID: PMC6262055 DOI: 10.3389/fneur.2018.01002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 11/06/2018] [Indexed: 01/14/2023] Open
Abstract
Acquisition and reacquisition of skills is a main pillar of functional recovery after stroke. Nighttime sleep has a positive influence on motor learning in healthy individuals, whereas the effect of daytime sleep on neuro-rehabilitative training and relearning of the trained skills is often neglected. The aim of this study was to investigate the relationship between daytime sleep (napping) and the ability to learn a new visuomotor task in chronic stroke patients. The main hypothesis was that sleep enhances motor memory consolidation after training resulting in better motor performance after a period of daytime sleep. Thirty stroke survivors completed the study. They were randomized to one of three different conditions (i) wakeful resting, (ii) short nap (10-20 min), or (iii) long nap (50-80 min). All individuals trained the task with the contralesional, stroke-impaired hand, behavioral evaluation was performed after the break time (wake, nap), and 24 h later. Patients demonstrated a significant task-related behavioral improvement throughout the training. In contrast to the main hypothesis, there was no evidence for sleep-dependent motor consolidation early after the initial, diurnal break, or after an additional full night of sleep. In a secondary analysis, the performance changes of stroke survivors were compared with those of a group of healthy older adults who performed the identical task within the same experimental setup with their non-dominant hand. Performance levels were comparable between both cohorts at all time points. Stroke-related difficulties in motor control did not impact on the degree of performance improvement through training and daytime sleep did not impact on the behavioral gains in the two groups. In summary, the current study indicates that one-time daytime sleep after motor training does not influence behavioral gains.
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Affiliation(s)
- Winifried Backhaus
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Defitech Chair of Clinical Neuroengineering, Brain Mind Institute and Center for Neuroprosthetics, Swiss Federal Institute of Technology (EPFL), Geneva, Switzerland
- Defitech Chair of Clinical Neuroengineering, Brain Mind Institute and Center for Neuroprosthetics, Swiss Federal Institute of Technology Valais (EPFL Valais), Clinique Romande de Réadaptation, Sion, Switzerland
| | - Hanna Braass
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friedhelm C. Hummel
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Defitech Chair of Clinical Neuroengineering, Brain Mind Institute and Center for Neuroprosthetics, Swiss Federal Institute of Technology (EPFL), Geneva, Switzerland
- Defitech Chair of Clinical Neuroengineering, Brain Mind Institute and Center for Neuroprosthetics, Swiss Federal Institute of Technology Valais (EPFL Valais), Clinique Romande de Réadaptation, Sion, Switzerland
- Clinical Neuroscience, Medical School University of Geneva, Geneva, Switzerland
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Pace M, Camilo MR, Seiler A, Duss SB, Mathis J, Manconi M, Bassetti CL. Rapid eye movements sleep as a predictor of functional outcome after stroke: a translational study. Sleep 2018; 41:5056018. [DOI: 10.1093/sleep/zsy138] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Indexed: 12/18/2022] Open
Affiliation(s)
- Marta Pace
- Center for Experimental Neurology (ZEN), Department of Neurology, University Hospital (Inselspital), Bern, Switzerland
- Department of Neuroscience and Brain Technologies, Istituto Italiano di Tecnologia (IIT), Genova, Italy
| | - Millene R Camilo
- Department of Neurology, University Hospital-Inselspital, Bern, Switzerland
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Andrea Seiler
- Department of Neurology, University Hospital-Inselspital, Bern, Switzerland
| | - Simone B Duss
- Department of Neurology, University Hospital-Inselspital, Bern, Switzerland
| | - Johannes Mathis
- Department of Neurology, University Hospital-Inselspital, Bern, Switzerland
| | - Mauro Manconi
- Department of Neurology, University Hospital-Inselspital, Bern, Switzerland
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital (EOC) of Lugano, Lugano, Switzerland
| | - Claudio L Bassetti
- Center for Experimental Neurology (ZEN), Department of Neurology, University Hospital (Inselspital), Bern, Switzerland
- Department of Neurology, University Hospital-Inselspital, Bern, Switzerland
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18
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Sterr A, Kuhn M, Nissen C, Ettine D, Funk S, Feige B, Umarova R, Urbach H, Weiller C, Riemann D. Post-stroke insomnia in community-dwelling patients with chronic motor stroke: Physiological evidence and implications for stroke care. Sci Rep 2018; 8:8409. [PMID: 29849087 PMCID: PMC5976765 DOI: 10.1038/s41598-018-26630-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 04/16/2018] [Indexed: 01/30/2023] Open
Abstract
Questionnaire studies suggest that stroke patients experience sustained problems with sleep and daytime sleepiness, but physiological sleep studies focussing specifically on the chronic phase of stroke are lacking. Here we report for the first time physiological data of sleep and daytime sleepiness obtained through the two gold-standard methods, nocturnal polysomnography and the Multiple Sleep Latency Test. Data from community-dwelling patients with chronic right-hemispheric stroke (>12 months) were compared to sex- and age-matched controls. Behavioural and physiological measures suggested that stroke patients had poorer sleep with longer sleep latencies and lower sleep efficiency. Patients further spent more time awake during the night, and showed greater high-frequency power during nonREM sleep than controls. At the same time the Multiple Sleep Latency Test revealed greater wake efficiency in patients than controls. Importantly these findings were not due to group differences in sleep disordered breathing or periodic limb movements. Post-stroke insomnia is presently not adequately addressed within the care pathway for stroke. A holistic approach to rehabilitation and care provision, that includes targeted sleep interventions, is likely to enhance long-term outcome and quality of live in those living with chronic deficits after stroke.
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Affiliation(s)
- A Sterr
- School of Psychology, University of Surrey, Guildford, UK.
| | - M Kuhn
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - C Nissen
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- University Hospital of Psychiatry and Psychotherapy, Bern, Switzerland
- Sleep Wake Epilepsy Center, Neuroscience Center, Bern, Switzerland
| | - D Ettine
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - S Funk
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - B Feige
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - R Umarova
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - H Urbach
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - C Weiller
- Department of Neurology, Medical Center, University of Freiburg, Freiburg, Germany
| | - D Riemann
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Schaefer SY, Duff K. Within-session and one-week practice effects on a motor task in amnestic mild cognitive impairment. J Clin Exp Neuropsychol 2017; 39:473-484. [PMID: 27690745 PMCID: PMC5453647 DOI: 10.1080/13803395.2016.1236905] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Practice effects on neuropsychological tests, which are improvements in test scores due to repeated exposure to testing materials, are robust in healthy elders, but muted in older adults with cognitive disorders. Conversely, few studies have investigated practice effects on motor tasks involving procedural memory, particularly across test-retest periods exceeding 24 hours. The current study examined one-week practice effects on a novel upper extremity motor task in 54 older adults with amnestic mild cognitive impairment. Results indicate that these individuals with primary memory deficits did improve on this motor task within a brief training session as well as across one week. These practice effects were unrelated to demographic characteristics or global cognition. One-week practice effects were, however, negatively related to delayed memory function, with larger practice effects being associated with poorer delayed memory and potentially better visuospatial ability. The presence of longer term practice effects on a procedural motor task not only has implications for how longitudinal assessments with similar measures involving implicit memory might be interpreted, but may also inform future rehabilitative strategies for patients with more severe declarative memory deficits.
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Affiliation(s)
- Sydney Y. Schaefer
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ
- Center on Aging, University of Utah, Salt Lake City, UT, USA
| | - Kevin Duff
- Center on Aging, University of Utah, Salt Lake City, UT, USA
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- Center for Alzheimer’s Care, Imaging and Research, University of Utah, Salt Lake City, UT, USA
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20
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Executive Function Is Associated With Off-Line Motor Learning in People With Chronic Stroke. J Neurol Phys Ther 2017; 41:101-106. [DOI: 10.1097/npt.0000000000000170] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Pace M, Adamantidis A, Facchin L, Bassetti C. Role of REM Sleep, Melanin Concentrating Hormone and Orexin/Hypocretin Systems in the Sleep Deprivation Pre-Ischemia. PLoS One 2017; 12:e0168430. [PMID: 28061506 PMCID: PMC5218733 DOI: 10.1371/journal.pone.0168430] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 12/01/2016] [Indexed: 12/19/2022] Open
Abstract
STUDY OBJECTIVES Sleep reduction after stroke is linked to poor recovery in patients. Conversely, a neuroprotective effect is observed in animals subjected to acute sleep deprivation (SD) before ischemia. This neuroprotection is associated with an increase of the sleep, melanin concentrating hormone (MCH) and orexin/hypocretin (OX) systems. This study aims to 1) assess the relationship between sleep and recovery; 2) test the association between MCH and OX systems with the pathological mechanisms of stroke. METHODS Sprague-Dawley rats were assigned to four experimental groups: (i) SD_IS: SD performed before ischemia; (ii) IS: ischemia; (iii) SD_Sham: SD performed before sham surgery; (iv) Sham: sham surgery. EEG and EMG were recorded. The time-course of the MCH and OX gene expression was measured at 4, 12, 24 hours and 3, 4, 7 days following ischemic surgery by qRT-PCR. RESULTS A reduction of infarct volume was observed in the SD_IS group, which correlated with an increase of REM sleep observed during the acute phase of stroke. Conversely, the IS group showed a reduction of REM sleep. Furthermore, ischemia induces an increase of MCH and OX systems during the acute phase of stroke, although, both systems were still increased for a long period of time only in the SD_IS group. CONCLUSIONS Our data indicates that REM sleep may be involved in the neuroprotective effect of SD pre-ischemia, and that both MCH and OX systems were increased during the acute phase of stroke. Future studies should assess the role of REM sleep as a prognostic marker, and test MCH and OXA agonists as new treatment options in the acute phase of stroke.
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Affiliation(s)
- Marta Pace
- Center for Experimental Neurology (ZEN), Department of Neurology, Bern University Hospital, Bern, Switzerland
- Department of Neuroscience and Brain Technologies, Italian Institute of Technology (IIT), Genova, Italy
- * E-mail:
| | - Antoine Adamantidis
- Center for Experimental Neurology (ZEN), Department of Neurology, Bern University Hospital, Bern, Switzerland
| | - Laura Facchin
- Center for Experimental Neurology (ZEN), Department of Neurology, Bern University Hospital, Bern, Switzerland
| | - Claudio Bassetti
- Center for Experimental Neurology (ZEN), Department of Neurology, Bern University Hospital, Bern, Switzerland
- Sleep-Wake-Epilepsy-Center, Department of Neurology, Bern University Hospital, Bern, Switzerland
- Division of Cognitive and Restorative Neurology, Department of Neurology, Bern University Hospital, Bern, Switzerland
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22
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Duss SB, Seiler A, Schmidt MH, Pace M, Adamantidis A, Müri RM, Bassetti CL. The role of sleep in recovery following ischemic stroke: A review of human and animal data. Neurobiol Sleep Circadian Rhythms 2017; 2:94-105. [PMID: 31236498 PMCID: PMC6575180 DOI: 10.1016/j.nbscr.2016.11.003] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 11/04/2016] [Accepted: 11/07/2016] [Indexed: 01/02/2023] Open
Abstract
Despite advancements in understanding the pathophysiology of stroke and the state of the art in acute management of afflicted patients as well as in subsequent neurorehabilitation training, stroke remains the most common neurological cause of long-term disability in adulthood. To enhance stroke patients' independence and well-being it is necessary, therefore, to consider and develop new therapeutic strategies and approaches. We postulate that sleep might play a pivotal role in neurorehabilitation following stroke. Over the last two decades compelling evidence for a major function of sleep in neuroplasticity and neural network reorganization underlying learning and memory has evolved. Training and learning of new motor skills and knowledge can modulate the characteristics of subsequent sleep, which additionally can improve memory performance. While healthy sleep appears to support neuroplasticity resulting in improved learning and memory, disturbed sleep following stroke in animals and humans can impair stroke outcome. In addition, sleep disorders such as sleep disordered breathing, insomnia, and restless legs syndrome are frequent in stroke patients and associated with worse recovery outcomes. Studies investigating the evolution of post-stroke sleep changes suggest that these changes might also reflect neural network reorganization underlying functional recovery. Experimental and clinical studies provide evidence that pharmacological sleep promotion in rodents and treatment of sleep disorders in humans improves functional outcome following stroke. Taken together, there is accumulating evidence that sleep represents a "plasticity state" in the process of recovery following ischemic stroke. However, to test the key role of sleep and sleep disorders for stroke recovery and to better understand the underlying molecular mechanisms, experimental research and large-scale prospective studies in humans are necessary. The effects of hospital conditions, such as adjusting light conditions according to the patients' sleep-wake rhythms, or sleep promoting drugs and non-invasive brain stimulation to promote neuronal plasticity and recovery following stroke requires further investigation.
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Affiliation(s)
- Simone B. Duss
- Sleep-Wake-Epilepsy-Center, Department of Neurology, Bern University Hospital, Bern, Switzerland
| | - Andrea Seiler
- Sleep-Wake-Epilepsy-Center, Department of Neurology, Bern University Hospital, Bern, Switzerland
| | - Markus H. Schmidt
- Sleep-Wake-Epilepsy-Center, Department of Neurology, Bern University Hospital, Bern, Switzerland
- Center for Experimental Neurology (ZEN), Department of Neurology, Bern University Hospital, Bern, Switzerland
| | - Marta Pace
- Center for Experimental Neurology (ZEN), Department of Neurology, Bern University Hospital, Bern, Switzerland
| | - Antoine Adamantidis
- Center for Experimental Neurology (ZEN), Department of Neurology, Bern University Hospital, Bern, Switzerland
| | - René M. Müri
- Division of Cognitive and Restorative Neurology, Department of Neurology, Bern University Hospital, Bern, Switzerland
| | - Claudio L. Bassetti
- Sleep-Wake-Epilepsy-Center, Department of Neurology, Bern University Hospital, Bern, Switzerland
- Center for Experimental Neurology (ZEN), Department of Neurology, Bern University Hospital, Bern, Switzerland
- Division of Cognitive and Restorative Neurology, Department of Neurology, Bern University Hospital, Bern, Switzerland
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