Treatments for Poststroke Motor Deficits and Mood Disorders: A Systematic Review for the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Guidelines for Stroke Rehabilitation

Feasibility, safety, and efficacy of task-oriented mirrored robotic training on upper-limb functions and activities of daily living in subacute poststroke patients: a pilot study

BACKGROUND

Robotic training with high repetitions facilitates upper-limb movements but provides fewer benefits for activities of daily living. Integrating activities of daily living training tasks and mirror therapy into a robot may enhance the functional gains of robotic training.

AIM

The aim of this study was to investigate the feasibility, safety, and efficacy of the task-oriented mirrored upper-limb robotic training on the upper-limb functions and activities of daily living of subacute poststroke patients.

DESIGN

This study is a single-blinded, active-controlled pilot study.

SETTING

The study was carried out at rehabilitation outpatient clinic and ward.

POPULATION

A total of 32 subacute poststroke patients were enrolled in the study.

METHODS

The enrolled patients were allocated into two groups in a ratio of 1:1. The experimental group received 4 weeks of task-oriented mirrored upper-limb robotic training, consisting of five sessions of 30-minute duration, along with 30 minutes of conventional training. The control group only received 60 minutes of conventional training. The outcome measures were the Fugl-Meyer Assessment Scale for Upper Extremity, Modified Barthel Index, Stroke Self-Efficacy Scale, System Usability Scale, and Quebec User Evaluation with Assistive Technology.

RESULTS

All patients completed the full training sessions without significant adverse events related to robotic training. The task-oriented mirrored upper-limb robotic training led to increased Fugl-Meyer Assessment Scale for Upper Extremity (difference: 10.38 points, P<0.001) and Modified Barthel Index (difference: 18.38 points, P<0.001) scores, both of which exceeded the minimal clinically important difference. Intergroup analysis showed significantly higher improvements in the Fugl-Meyer Assessment Scale for Upper Extremity total scores, shoulder, wrist, and hand scores; and Modified Barthel Index scores in the experimental group than in conventional training (all P<0.05). Both groups showed significant improvements in Stroke Self-Efficacy Scale scores after the intervention (both P<0.001), but without a statistically significant intergroup difference (P>0.05). Participants in the experimental group scored an average usability perception score of 74.74 (good) and an average satisfaction score of four or more out of five.

CONCLUSIONS

In general, task-oriented mirrored upper-limb robotic training appears feasible and safe for subacute poststroke rehabilitation, facilitating the recovery of upper-limb functions and activities of daily living.

CLINICAL REHABILITATION IMPACT

Task-oriented mirrored upper-limb robotic training shows promise for future clinical rehabilitation and clinical trials involving subacute poststroke patients.

Machine learning algorithms assisted identification of post-stroke depression associated biological features

Objectives

Post-stroke depression (PSD) is a common and serious psychiatric complication which hinders functional recovery and social participation of stroke patients. Stroke is characterized by dynamic changes in metabolism and hemodynamics, however, there is still a lack of metabolism-associated effective and reliable diagnostic markers and therapeutic targets for PSD. Our study was dedicated to the discovery of metabolism related diagnostic and therapeutic biomarkers for PSD.

Methods

Expression profiles of GSE140275, GSE122709, and GSE180470 were obtained from GEO database. Differentially expressed genes (DEGs) were detected in GSE140275 and GSE122709. Functional enrichment analysis was performed for DEGs in GSE140275. Weighted gene co-expression network analysis (WGCNA) was constructed in GSE122709 to identify key module genes. Moreover, correlation analysis was performed to obtain metabolism related genes. Interaction analysis of key module genes, metabolism related genes, and DEGs in GSE122709 was performed to obtain candidate hub genes. Two machine learning algorithms, least absolute shrinkage and selection operator (LASSO) and random forest, were used to identify signature genes. Expression of signature genes was validated in GSE140275, GSE122709, and GSE180470. Gene set enrichment analysis (GSEA) was applied on signature genes. Based on signature genes, a nomogram model was constructed in our PSD cohort (27 PSD patients vs. 54 controls). ROC curves were performed for the estimation of its diagnostic value. Finally, correlation analysis between expression of signature genes and several clinical traits was performed.

Results

Functional enrichment analysis indicated that DEGs in GSE140275 enriched in metabolism pathway. A total of 8,188 metabolism associated genes were identified by correlation analysis. WGCNA analysis was constructed to obtain 3,471 key module genes. A total of 557 candidate hub genes were identified by interaction analysis. Furthermore, two signature genes (SDHD and FERMT3) were selected using LASSO and random forest analysis. GSEA analysis found that two signature genes had major roles in depression. Subsequently, PSD cohort was collected for constructing a PSD diagnosis. Nomogram model showed good reliability and validity. AUC values of receiver operating characteristic (ROC) curve of SDHD and FERMT3 were 0.896 and 0.964. ROC curves showed that two signature genes played a significant role in diagnosis of PSD. Correlation analysis found that SDHD (r = 0.653, P &lt; 0.001) and FERM3 (r = 0.728, P &lt; 0.001) were positively related to the Hamilton Depression Rating Scale 17-item (HAMD) score.

Conclusion

A total of 557 metabolism associated candidate hub genes were obtained by interaction with DEGs in GSE122709, key modules genes, and metabolism related genes. Based on machine learning algorithms, two signature genes (SDHD and FERMT3) were identified, they were proved to be valuable therapeutic and diagnostic biomarkers for PSD. Early diagnosis and prevention of PSD were made possible by our findings.

Noninvasive Brain Stimulation for Neurorehabilitation in Post-Stroke Patients

Characterized by high morbidity, mortality, and disability, stroke usually causes symptoms of cerebral hypoxia due to a sudden blockage or rupture of brain vessels, and it seriously threatens human life and health. Rehabilitation is the essential treatment for post-stroke patients suffering from functional impairments, through which hemiparesis, aphasia, dysphagia, unilateral neglect, depression, and cognitive dysfunction can be restored to various degrees. Noninvasive brain stimulation (NIBS) is a popular neuromodulatory technology of rehabilitation focusing on the local cerebral cortex, which can improve clinical functions by regulating the excitability of corresponding neurons. Increasing evidence has been obtained from the clinical application of NIBS, especially repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS). However, without a standardized protocol, existing studies on NIBS show a wide variation in terms of stimulation site, frequency, intensity, dosage, and other parameters. Its application for neurorehabilitation in post-stroke patients is still limited. With advances in neuronavigation technologies, functional near-infrared spectroscopy, and functional MRI, specific brain regions can be precisely located for stimulation. On the basis of our further understanding on neural circuits, neuromodulation in post-stroke rehabilitation has also evolved from single-target stimulation to co-stimulation of two or more targets, even circuits and the network. The present study aims to review the findings of current research, discuss future directions of NIBS application, and finally promote the use of NIBS in post-stroke rehabilitation.

A novel strategy for designing the magic shotguns for distantly related target pairs

Due to its promising capacity in improving drug efficacy, polypharmacology has emerged to be a new theme in the drug discovery of complex disease. In the process of novel multi-target drugs (MTDs) discovery, in silico strategies come to be quite essential for the advantage of high throughput and low cost. However, current researchers mostly aim at typical closely related target pairs. Because of the intricate pathogenesis networks of complex diseases, many distantly related targets are found to play crucial role in synergistic treatment. Therefore, an innovational method to develop drugs which could simultaneously target distantly related target pairs is of utmost importance. At the same time, reducing the false discovery rate in the design of MTDs remains to be the daunting technological difficulty. In this research, effective small molecule clustering in the positive dataset, together with a putative negative dataset generation strategy, was adopted in the process of model constructions. Through comprehensive assessment on 10 target pairs with hierarchical similarity-levels, the proposed strategy turned out to reduce the false discovery rate successfully. Constructed model types with much smaller numbers of inhibitor molecules gained considerable yields and showed better false-hit controllability than before. To further evaluate the generalization ability, an in-depth assessment of high-throughput virtual screening on ChEMBL database was conducted. As a result, this novel strategy could hierarchically improve the enrichment factors for each target pair (especially for those distantly related/unrelated target pairs), corresponding to target pair similarity-levels.

Music-based intervention drives paretic limb acceleration into intentional movement frequencies in chronic stroke rehabilitation

This study presented a novel kinematic assessment of paretic limb function "online" during the actual therapeutic exercisers rooted within the acceleration domain. Twenty-eight patients at chronic stroke stages participated in an auditory-motor intervention mapping reaching movements of the paretic arm unto surfaces of large digital musical instruments and sound tablets that provided rhythmic entrainment cues and augmented auditory feedback. Patients also wore a tri-axial accelerometer on the paretic limb during the nine-session intervention. The resulting acceleration profiles were extracted and quantified within the frequency domain. Measures of peak power and peak width were leveraged to estimate volitional control and temporal consistency of paretic limb movements, respectively. Clinical assessments included the Wolf Motor Function Test and Fugl-Meyer - Upper Extremity subtest. The results showed that peak power increased significantly from Session 1 to Session 9 within oscillatory frequency ranges associated with intentional movement execution (i.e., 4.5 Hz). Decreases in peak width over time provided additional evidence for improved paretic arm control from a temporal perspective. In addition, Peak width values obtained in Session 1 was significantly correlated with pre-test Fugl-Meyer - Upper Extremity scores. These results highlighted improvements in paretic limb acceleration as an underlying mechanism in stroke motor recovery and shed further light on the utility of accelerometry-based measures of paretic limb control in stroke rehabilitation. The data reported here was obtained from a larger clinical trial: https://clinicaltrials.gov/ct2/show/NCT03246217 ClinicalTrials.gov Identifier: NCT03246217.

Do patients with and survivors of COVID-19 benefit from telerehabilitation? A meta-analysis of randomized controlled trials

Background

Coronavirus disease 2019 (COVID-19) significantly impacts physical, psychological, and social functioning and reduces quality of life, which may persist for at least 6 months. Given the fact that COVID-19 is a highly infectious disease and therefore healthcare facilities may be sources of contagion, new methods avoiding face-to-face contact between healthcare workers and patients are urgently needed. Telerehabilitation is the provision of rehabilitation services to patients at a distance via information and communication technologies. However, high-quality evidence of the efficacy of telerehabilitation for COVID-19 is still lacking. This meta-analysis aimed to investigate the efficacy of telerehabilitation for patients with and survivors of COVID-19.

Methods

We searched the Cochrane Library, EMBASE, Medline (via PubMed), PEDro, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform from January 1st, 2020 to April 30th, 2022 for randomized controlled trials published in English, which aimed to evaluate the efficacy of telerehabilitation vs. face-to-face rehabilitation, usual care, or no treatment for COVID-19. Methodological quality and overall evidence quality of the included studies were assessed. The statistical reliability of the data was quantified using the trial sequential analysis.

Results

Seven randomized controlled trials with eight comparisons were included and all of them were used for meta-analysis. The meta-analyses of absolute values showed the superiority of telerehabilitation over no treatment or usual care for dyspnea (Borg scale: mean difference = -1.88, -2.37 to -1.39; Multidimensional dyspnea-12: mean difference = -3.70, -5.93 to -1.48), limb muscle strength (mean difference = 3.29; 2.12 to 4.47), ambulation capacity (standardized mean difference = 0.88; 0.62 to 1.14), and depression (mean difference = -5.68; -8.62 to -2.74). Significant improvement in these variables persisted in the meta-analyses of change scores. No significant difference was found in anxiety and quality of life. No severe adverse events were reported in any of the included studies.

Conclusions

Moderate- to very low-quality evidence demonstrates that telerehabilitation may be an effective and safe solution for patients with and survivors of COVID-19 in dyspnea, lower limb muscle strength, ambulation capacity, and depression. Further well-designed studies are required to evaluate the long-term effects, cost-effectiveness, and satisfaction in larger samples.

Intermittent theta-burst stimulation with physical exercise improves poststroke motor function: A systemic review and meta-analysis

Background

Intermittent theta-burst stimulation (iTBS) is an optimized rTMS modality that could modulate the excitability of neural structures. Several studies have been conducted to investigate the efficacy of iTBS in improving the motor function of stroke patients. However, the specific role of iTBS in motor function recovery after stroke is unclear. Hence, in our study, we performed a meta-analysis to investigate the efficacy of iTBS for the motor function improvement of stroke patients.

Methods

MEDLINE, Embase, and Cochrane Library were searched until May 2022 for randomized controlled trials (RCTs).

Results

Thirteen RCTs with 334 patients were finally included in our study. The primary endpoints were the Fugl-Meyer assessment scale (FMA) and Motor Assessment Scale (MAS) change from baseline. We found that iTBS led to a significant reduction in FMA score (P = 0.002) but not in MAS score (P = 0.24) compared with the sham group. Moreover, standard 600-pulse stimulation showed a better effect on motor function improvement than the sham group (P = 0.004), however, 1200-pulse iTBS showed no effect on motor function improvement after stroke (P = 0.23). The effect of iTBS for improving motor function only exists in chronic stroke patients (P = 0.02) but not in subacute patients (P = 0.27).

Conclusion

This study supports that iTBS has good efficacy for improving motor function in stroke patients. Therefore, standard 600-pulse stimulation iTBS therapy is proper management and treatment for chronic stroke.

Depression, Anxiety, and Suicide After Stroke: A Narrative Review of the Best Available Evidence

Depression and anxiety each affect around 1 in 3 people during the first year after a stroke. Suicide causes the death of about 3 to 4/1000 stroke survivors during the first 5 years. This narrative review describes the best available evidence for the epidemiology of depression, anxiety, and suicide; their prevention; and the treatment of anxiety and depression. We conclude with directions for future research.

Calorie restriction conferred improvement effect on long-term rehabilitation of ischemic stroke via gut microbiota

Calorie restriction can modulate the gut microbiota and protect against many diseases including ischemic stroke. However, the role of calorie-restriction-induced microbiota alteration remained unknown in ischemic stroke rehabilitation. Here we conducted 30% reduction of caloric intake on mice for four weeks, to evaluate its role on ischemic stroke rehabilitation. Significantly, this calorie restriction led to better long-term rehabilitation in comparison of normal control. Notably, the transplantation of gut microbiome from calorie-restriction-treated mice to post-stroke mice was eligible to obtain better long-term rehabilitation of stroke mice. Bifidobacterium identified by 16 S ribosomal RNA sequencing were enriched in those of calorie-restriction mice. Then we administrated Bifidobacterium to stroke mice and found Bifidobacterium treatment could successfully improve the long-term rehabilitation of cerebral ischemia mice. Furthermore, the metabolomics analysis revealed a panel of upshifting metabolites, suggesting that calorie restriction greatly altered the gut microbiota composition and its metabolism. Hence, we discovered the novel effect of CR on long-term rehabilitation of ischemic stroke and the underlying role of gut microbiota, which might provide novel thoughts for the clinical post-stroke rehabilitation.

Does the Initiation of Fluoxetine Postacute Stroke Result in Improved Functional Recovery?: A Critically Appraised Topic

BACKGROUND

Stroke is a leading cause of disability worldwide. Selective serotonin reuptake inhibitors are often prescribed following stroke due to high rates of depression. Interest in selective serotonin reuptake inhibitor use for poststroke motor and functional recovery was generated after the publication of the Fluoxetine for motor recovery after acute ischemic stroke (FLAME) trial in 2011, which showed improved motor recovery in ischemic stroke patients with moderate to severe motor deficits. The objective of this study was to critically assess current evidence regarding the use of fluoxetine compared with placebo for poststroke functional recovery.

METHODS

The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario and question, literature search, critical appraisal, results, evidence summary, commentary, and clinical bottom line conclusions. Participants included consultant and resident neurologists, medical librarian, clinical epidemiologists, and content experts in the field of cerebrovascular neurology and physical medicine and rehabilitation.

RESULTS

A randomized, placebo-controlled clinical trial was selected for critical appraisal. This trial compared the functional outcomes of subjects poststroke receiving fluoxetine versus placebo. There was no significant difference in functional outcome measured by the Modified Rankin Scale between the 2 groups. Prespecified secondary analysis showed significantly decreased rates of depression in the fluoxetine group, but significantly increased rates of bone fracture.

CONCLUSION

Among patients with stroke, early initiation of fluoxetine did not result in improved functional recovery. Lower rates of depression were observed in the fluoxetine-treated group; however these patients experienced higher rates of bone fracture.

Potential Factors for Psychological Symptoms at Three Months in Patients with Young Ischemic Stroke

Objective

Psychological status plays a vital role in the recovery in young ischemic stroke patients. However, few reports on the psychological symptoms in Chinese young ischemic stroke patients have been published. In the present study, we aimed to outline the psychological status of young ischemic stroke patients and its risk factors at three months after their stroke.

Methods

364 patients with young ischemic stroke and 384 age-matched healthy controls were consecutively recruited from our study hospitals of the mainland of China between June 2018 and November 2020. Social demographic and clinical data were collected from all enrolled participants in the acute stage of their stroke, and their psychological variables were assessed via the Symptom Checklist 90 Revised (SCL-90-R) at three-month timepoint after their stroke. Multivariable logistic regression analyses were run to identify the independent factors for psychological variables in patients.

Results

Compared with healthy controls, patients with young ischemic stroke had significantly higher total score of SCL-90-R and all subscale total scores (p < 0.01 or 0.05). 22.3% (81/364 cases) in young ischemic stroke patients had psychological abnormalities. Compared with young ischemic stroke patients without psychological symptoms (n = 283), patients with psychological symptoms (n = 81) had higher rate of married status (p = 0.03), rate of hypertension (p = 0.01), infarct size (p = 0.01), and the family dysfunction (p < 0.01). Multivariate logistic regression analyses revealed that the family dysfunction (odds ratio [OR], 2.50, 95% confidence interval [CI]: 1.71 to 3.54, p < 0.01), having hypertension (OR, 3.27, 95% CI: 1.92 to 4.27, p = 0.02), and ≥20mm³ infarct size (OR, 2.39, 95% CI: 1.53 to 3.45, p < 0.01) were independent factors for having psychological abnormalities in patients with young ischemic stroke at three months after their stroke. Single (OR, 1.23, 95% CI: 1.03 to 1.54, p = 0.01), poor family function (OR, 1.21, 95% CI: 1.05 to 1.45, p = 0.03), and ≥20mm³ infarct size (OR, 1.74, 95% CI: 1.14 to 3.13, p = 0.02) were independent factors for having depression in patents with psychological symptoms. The family dysfunction (OR, 2.32, 95% CI: 1.51 to 2.80, p < 0.01) and hypertension (OR, 2.41, 95% CI: 1.54 to 3.46, p = 0.03) were independent factors for emerging somatization and anxiety in patients with psychological symptoms, respectively.

Conclusions

At three months after their stroke, young ischemic stroke patients had psychological problems and risk factors for developing them.

Medical Care of Adults With Down Syndrome: A Clinical Guideline

IMPORTANCE

Down syndrome is the most common chromosomal condition, and average life expectancy has increased substantially, from 25 years in 1983 to 60 years in 2020. Despite the unique clinical comorbidities among adults with Down syndrome, there are no clinical guidelines for the care of these patients.

OBJECTIVE

To develop an evidence-based clinical practice guideline for adults with Down syndrome.

EVIDENCE REVIEW

The Global Down Syndrome Foundation Medical Care Guidelines for Adults with Down Syndrome Workgroup (n = 13) developed 10 Population/Intervention/ Comparison/Outcome (PICO) questions for adults with Down syndrome addressing multiple clinical areas including mental health (2 questions), dementia, screening or treatment of diabetes, cardiovascular disease, obesity, osteoporosis, atlantoaxial instability, thyroid disease, and celiac disease. These questions guided the literature search in MEDLINE, EMBASE, PubMed, PsychINFO, Cochrane Library, and the TRIP Database, searched from January 1, 2000, to February 26, 2018, with an updated search through August 6, 2020. Using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology and the Evidence-to-Decision framework, in January 2019, the 13-member Workgroup and 16 additional clinical and scientific experts, nurses, patient representatives, and a methodologist developed clinical recommendations. A statement of good practice was made when there was a high level of certainty that the recommendation would do more good than harm, but there was little direct evidence.

FINDINGS

From 11 295 literature citations associated with 10 PICO questions, 20 relevant studies were identified. An updated search identified 2 additional studies, for a total of 22 included studies (3 systematic reviews, 19 primary studies), which were reviewed and synthesized. Based on this analysis, 14 recommendations and 4 statements of good practice were developed. Overall, the evidence base was limited. Only 1 strong recommendation was formulated: screening for Alzheimer-type dementia starting at age 40 years. Four recommendations (managing risk factors for cardiovascular disease and stroke prevention, screening for obesity, and evaluation for secondary causes of osteoporosis) agreed with existing guidance for individuals without Down syndrome. Two recommendations for diabetes screening recommend earlier initiation of screening and at shorter intervals given the high prevalence and earlier onset in adults with Down syndrome.

CONCLUSIONS AND RELEVANCE

These evidence-based clinical guidelines provide recommendations to support primary care of adults with Down syndrome. The lack of high-quality evidence limits the strength of the recommendations and highlights the need for additional research.

The Usefulness and Clinical Characteristics of Antidepressant Use for Stroke Patients with Rehabilitation Program: An Exploratory Analysis

Objective

There has been a lack of data regarding the usefulness and clinical characteristic between patients-treated with and without antidepressants (Pw/Pwo ADs).

Methods

One hundred and eighty inpatients were recruited and observed for a 6-month. The depressive, cognitive, daily activity, and motor symptoms were evaluated at baseline and tracked at month 6, with the use of rating scales including Beck Depression Inventory (BDI), Mini Mental State Examination (MMSE), Global Deterioration Scale (GDS), modified Rankin Scale (MRS), modified Barthel Index (MBI), and Berg Balance Scale (BBS).

Results

Among 178 patients, 84 (47.2%) were treated with ADs. PwAD had numerically or significantly higher depressive cognitive, and motor symptoms along with daily activity impairment (8.3 point higher in BDI score, p < 0.001; 3.6 point lower in MMSE, p = 0.003; 0.8 point higher in GDS score, p = nonsignificant; 8.2 point lower in BBS score, p = 0.053, and 0.4 point higher in MBI score, p = nonsignificant) than PwoAD. Psychiatric consultation was also significantly higher in PwAD than in PwoAD (p < 0.001). The numbers need to treat for good clinical outcomes between PwAD and PwoAD were 5.8, 6.0, and 7.5, respectively, by MRS, MBI, and BBS scores.

Conclusion

Our findings suggest the potential utility of AD treatment and different clinical parameters between patients-treated with and without ADs. Adequately-powered and well-controlled further studies are mandatory to confirm and fully elaborate such association.

Neuropsychiatric issues after stroke: Clinical significance and therapeutic implications

A spectrum of neuropsychiatric disorders is a common complication from stroke. Neuropsychiatric disorders after stroke have negative effects on functional recovery, increasing the rate of mortality and disability of stroke survivors. Given the vital significance of maintaining physical and mental health in stroke patients, neuropsychiatric issues after stroke have raised concerns by clinicians and researchers. This mini-review focuses on the most common non-cognitive functional neuropsychiatric disorders seen after stroke, including depressive disorders, anxiety disorders, post-traumatic stress disorder, psychosis, and psychotic disorders. For each condition, the clinical performance, epidemiology, identification of the therapeutic implication, and strategies are reviewed and discussed; the main opinions and perspectives presented here are based on the latest controlled studies, meta-analysis, or updated systematic reviews. In the absence of data from controlled studies, consensus recommendations were provided accordingly.