Perspectives on factors influencing quality of life in persons with long-term spinal cord injury: a qualitative study

STUDY DESIGN

Qualitative Cohort Study.

OBJECTIVES

Many people with long-term spinal cord injury (SCI) develop adaptation strategies to succeed. Understanding the factors that support their capacity to adapt and develop is important to enhance quality of life of others with SCI. This study aims to learn how these factors influence how people with SCI attain and maintain optimal quality of life as time since injury grows.

SETTING

IL, USA.

METHODS

A qualitative approach using one-on-one structured interviews with 16 individuals with long-term SCI was used to elicit perspectives of topics of importance. Analysis of these topics was done for the entire group, and for subgroups based on injury duration, i.e., 1-5 years, 5-15 years, and 15+ years post-injury. Deductive and inductive analyses of transcripts were performed.

RESULTS

Five important themes emerged: 1. Injury, Medical Care, and Rehabilitation; 2. Built Environment and Accessibility; 3. Relationships and Support Systems; 4. Intrapersonal Thoughts and Emotions; and 5. Handling Challenges and Adversity. Topics of importance evolved over time. Most important were: 1-5 years: injury and recovery process; 5-15 years: navigating the community and how to handle difficult situations; and 15+ years: self-reflection and understanding how to handle challenges positively.

CONCLUSIONS

Recognition of the factors (e.g. resilience, self-acceptance, built environment) that contribute to quality of life in people with SCI, and their prevalence over time, enables development of strategies to facilitate personal fulfillment and favorable adaptation at each stage.

TRIAL REGISTRATION

This trial was posted on clinicaltrials.gov under NCT04544761.

Noninvasive spinal stimulation improves walking in chronic stroke survivors: a proof-of-concept case series

BACKGROUND

After stroke, restoring safe, independent, and efficient walking is a top rehabilitation priority. However, in nearly 70% of stroke survivors asymmetrical walking patterns and reduced walking speed persist. This case series study aims to investigate the effectiveness of transcutaneous spinal cord stimulation (tSCS) in enhancing walking ability of persons with chronic stroke.

METHODS

Eight participants with hemiparesis after a single, chronic stroke were enrolled. Each participant was assigned to either the Stim group (N = 4, gait training + tSCS) or Control group (N = 4, gait training alone). Each participant in the Stim group was matched to a participant in the Control group based on age, time since stroke, and self-selected gait speed. For the Stim group, tSCS was delivered during gait training via electrodes placed on the skin between the spinous processes of C5-C6, T11-T12, and L1-L2. Both groups received 24 sessions of gait training over 8 weeks with a physical therapist providing verbal cueing for improved gait symmetry. Gait speed (measured from 10 m walk test), endurance (measured from 6 min walk test), spatiotemporal gait symmetries (step length and swing time), as well as the neurophysiological outcomes (muscle synergy, resting motor thresholds via spinal motor evoked responses) were collected without tSCS at baseline, completion, and 3 month follow-up.

RESULTS

All four Stim participants sustained spatiotemporal symmetry improvements at the 3 month follow-up (step length: 17.7%, swing time: 10.1%) compared to the Control group (step length: 1.1%, swing time 3.6%). Additionally, 3 of 4 Stim participants showed increased number of muscle synergies and/or lowered resting motor thresholds compared to the Control group.

CONCLUSIONS

This study provides promising preliminary evidence that using tSCS as a therapeutic catalyst to gait training may increase the efficacy of gait rehabilitation in individuals with chronic stroke. Trial registration NCT03714282 (clinicaltrials.gov), registration date: 2018-10-18.

Implementation of Home-Based Telerehabilitation of Patients With Stroke in the United States: Protocol for a Realist Review

BACKGROUND

Stroke is a common cause of mortality and morbidity. Insufficient and untimely rehabilitation has been associated with inadequate recovery. Telerehabilitation provides an opportunity for timely and accessible services for individuals with stroke, especially in remote areas. Telerehabilitation is defined as a health care team's use of a communication mode (eg, videoconferencing) to remotely provide rehabilitation services. Telerehabilitation is as effective as facility-based rehabilitation; however, it is infrequently used due to implementation barriers.

OBJECTIVE

The aim of the study is to explore the interaction between the implementation strategies, context, and outcomes of telerehabilitation of patients with stroke.

METHODS

This review will follow four steps: (1) defining the review scope, (2) literature search and quality appraisal, (3) data extraction and evidence synthesis, and (4) narrative development. PubMed via MEDLINE, the PEDro database, and CINAHL will be queried till June 2023 and supplemented with citation tracking and a gray literature search. The relevance and rigor of papers will be appraised using the TAPUPAS (Transparency, Accuracy, Purposivity, Utility, Propriety, Accessibility, and Specificity) and Weight of Evidence frameworks. The reviewers will extract and synthesize data iteratively and develop explanatory links between contexts, mechanisms, and outcomes. The results will be reported according to the Realist Synthesis publication standards set by Wong and colleagues in 2013.

RESULTS

The literature search and screening will be completed in July 2023. Data extraction and analysis will be completed in August 2023, and findings will be synthesized and reported in October 2023.

CONCLUSIONS

This will be the first realist synthesis, uncovering the causal mechanisms to explain how, why, and to what extent implementation strategies impact telerehabilitation adoption and implementation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47009.

Overground walking with a constraint force on the non-paretic leg during swing improves weight shift toward the paretic side in people post-stroke

Background: Targeting enhancing the use of the paretic leg during locomotor practice might improve motor function of the paretic leg. Objective: The purpose of this study was to determine whether application of constraint force to the non-paretic leg in the posterior direction during overground walking would enhance the use of the paretic leg in people with chronic stroke. Methods: Fifteen individuals post-stroke participated in two experimental conditions, i.e., overground walking with a constraint force applied to the non-paretic leg, and overground walking only. Each participant was tested in the following procedures that consisted of overground walking with either constraint force or no constraint force, instrumented split-belt treadmill walking and pressure-sensitive gaitmat walking before and after the overground walking. Results: Overground walking practice with the constraint force resulted in greater enhancement in lateral weight shift toward the paretic side (P<0.01), muscle activity of the paretic hip abductors (P=0.04), and propulsion force of the paretic leg (P=0.05), compared with the results of no constraint condition. Overground walking practice with constraint force tended to induce greater increase in self-selected overground walking speed (P=0.06), compared with the effect of no constraint condition. The increase in propulsion force from the paretic leg was positively correlated with the increase in self-selected walking speed (r=0.6, P=0.03). Conclusion: Overground walking with the constraint force applied to the non-paretic leg during swing phase of gait may enhance use of the paretic leg, improve weight shifting toward the paretic side, propulsion of the paretic leg, and consequently increase walking speed.

Feasibility of PROMIS using computerized adaptive testing during inpatient rehabilitation

BACKGROUND

There has been an increased significance on patient-reported outcomes in clinical settings. We aimed to evaluate the feasibility of administering patient-reported outcome measures by computerized adaptive testing (CAT) using a tablet computer with rehabilitation inpatients, assess workload demands on staff, and estimate the extent to which rehabilitation inpatients have elevated T-scores on six Patient Reported Outcomes Measurement Information System® (PROMIS®) measures.

METHODS

Patients (N = 108) with stroke, spinal cord injury, traumatic brain injury, and other neurological disorders participated in this study. PROMIS computerized adaptive tests (CAT) were administered via a web-based platform. Summary scores were calculated for six measures: Pain Interference, Sleep Disruption, Anxiety, Depression, Illness Impact Positive, and Illness Impact Negative. We calculated the percent of patients with T-scores equivalent to 2 standard deviations or greater above the mean.

RESULTS

During the first phase, we collected data from 19 of 49 patients; of the remainder, 61% were not available or had cognitive or expressive language impairments. In the second phase of the study, 40 of 59 patients participated to complete the assessment. The mean PROMIS T-scores were in the low 50 s, indicating an average symptom level, but 19-31% of patients had elevated T-scores where the patients needed clinical action.

CONCLUSIONS

The study demonstrated that PROMIS assessment using a CAT administration during an inpatient rehabilitation setting is feasible with the presence of a research staff member to complete PROMIS assessment.

Enhanced phasic sensory afferents paired with controlled constraint force improve weight shift toward the paretic side in individuals post-stroke

PURPOSE

The goal of this study was to determine whether enhanced phasic sensory afferent input paired with the application of controlled constraint force during walking would improve weight shift toward the paretic side and enhance use of the paretic leg.

METHODS

Fourteen stroke survivors participated in two experimental conditions, sessions that consisted of 1 min treadmill walking without force and stimulation (baseline), 7 min walking with either "constraint force and sensory stimulation (constraint+stim)" or "constraint force only (constraint)" (adaptation), and then 2 min walking without force and stimulation (post-adaptation). Kinematics of the pelvis and legs, and muscle activity of the paretic leg were recorded.

RESULTS

Participants showed greater increases in hip abductor (p < 0.001) and adductor (p = 0.04) muscle activities, weight shift toward the paretic side (p = 0.002), and step length symmetry (p < 0.01) during the late post-adaptation period in the "constraint+stim" condition, compared with the effect of the "constraint" condition. In addition, changes in overground walking speed from baseline to 10 min post treadmill walking was significantly greater for the "constraint force and stimulation" condition than for the "constraint force only" condition (p = 0.04).

CONCLUSION

Enhanced targeted sensory afferent input during locomotor training may facilitate recruitment of targeted muscles of the paretic leg and facilitate use-dependent motor learning of locomotor tasks, which might retain longer and partially transfer from treadmill to overground walking, in stroke survivors.

Repeated adaptation and de-adaptation to the pelvis resistance force facilitate retention of motor learning in stroke survivors

Locomotor adaptation to novel walking patterns induced by external perturbation has been tested to enhance motor learning for improving gait parameters in individuals post-stroke. However, little is known regarding whether repeated adaptation and de-adaptation to the externally perturbed walking pattern may facilitate or degrade the retention of locomotor learning. In this study, we examined whether the intermittent adaptation to novel walking patterns elicited by external perturbation induces greater retention of the adapted locomotion in stroke survivors, compared with effects of the continuous adaptation. Fifteen individuals post-stroke participated in two experimental conditions consisting of 1) treadmill walking with intermittent (i.e., interspersed 2 intervals of no perturbation) or continuous (no interval) adaptation to externally perturbed walking patterns and 2) overground walking before, immediately, and 10 min after treadmill walking. During the treadmill walking, we applied a laterally pulling force to the pelvis toward the non-paretic side during the stance phase of the paretic leg to disturb weight shifts toward the paretic side. Participants showed improved weight shift toward the paretic side and enhanced muscle activation of hip abductor/adductors immediately after the removal of the pelvis perturbation for both intermittent and continuous conditions (P<0.05), and showed longer retention of the improved weight shift and enhanced muscle activation for the intermittent condition, which transferred from treadmill to overground walking (P<0.05). In conclusion, repeated motor adaptation and de-adaptation to the pelvis resistance force during walking may promote the retention of error-based motor learning for improving weight shift toward the paretic side in individuals post-stroke.

Enhanced error facilitates motor learning in weight shift and increases use of the paretic leg during walking at chronic stage after stroke

The purpose of this study was to determine whether the application of lateral pelvis pulling force toward the non-paretic side during the stance phase of the paretic leg would enhance forced use of the paretic leg and increase weight shift toward the paretic side in stroke survivors. Eleven chronic stroke survivors participated in two experimental sessions, which consisted of (1) treadmill walking with the application of "pelvis resistance" or "pelvis assistance" and (2) overground walking. During the treadmill walking, the laterally pulling force was applied during the stance phase of the paretic leg toward the non-paretic side for the "pelvis resistance" condition or toward the paretic side for the "pelvis assistance" condition during the stance phase of the paretic leg. After force release, the "pelvis resistance" condition exhibited greater enhancement in muscle activation of hip ABD, ADD, and SOL and greater improvement in lateral weight shift toward the paretic side, compared with the effect of the "pelvis assistance" condition (P < 0.03). This improved lateral weight shift was associated with the enhanced muscle activation of hip ABD and ADD (R² = 0.67, P = 0.01). The pelvis resistance condition also improved overground walking speed and stance phase symmetry when measured 10 min after the treadmill walking (P = 0.004). In conclusion, applying pelvis resistance forces to increase error signals may facilitate motor learning of weight shift toward the paretic side and enhance use of the paretic leg in chronic stroke survivors. Results from this study may be utilized to develop an intervention approach to improve walking in stroke survivors.

Clinical Performance Measures for Stroke Rehabilitation: Performance Measures From the American Heart Association/American Stroke Association

The American Heart Association/American Stroke Association released the adult stroke rehabilitation and recovery guidelines in 2016. A working group of stroke rehabilitation experts reviewed these guidelines and identified a subset of recommendations that were deemed suitable for creating performance measures. These 13 performance measures are reported here and contain inclusion and exclusion criteria to allow calculation of rates of compliance in a variety of settings ranging from acute hospital care to postacute care and care in the home and outpatient setting.

Increased motor variability facilitates motor learning in weight shift toward the paretic side during walking in individuals post-stroke

The purpose of this study was to determine whether applying "varied" versus constant pelvis assistance force mediolaterally toward the paretic side of stroke survivors during walking would result in short-term improvement in weight shift toward the paretic side. Twelve individuals post-stroke (60.4 ± 6.2 years; gait speed: 0.53 ± 0.19 m/s) were tested under two conditions (varied vs. constant). Each condition was conducted in a single separate session, which consisted of (a) treadmill walking with no assistance force for 1 min (baseline), pelvis assistance toward the paretic side for 9 min (adaptation), and then no force for additional 1 min (post-adaptation), and (b) overground walking. In the "varied" condition, the magnitude of force was randomly changed across steps between 30% and 100% of the predetermined amount. In the abrupt condition, the magnitude of force was kept constant at 100% of the predetermined amount. Participants exhibited greater improvements in weight shift toward the paretic side (p < 0.01) and in muscle activity of plantar flexors and hip adductors of the paretic leg (p = 0.02) from baseline to late post-adaptation period for the varied condition than for the constant condition. Motor variability of the peak pelvis displacement at baseline was correlated with improvement in weight shift toward the paretic side after training for the varied (R²  = 0.64, p = 0.01) and the constant condition (R²  = 0.39, p = 0.03). These findings suggest that increased motor variability, induced by applying the varied pelvis assistance, may facilitate motor learning in weight shift and gait symmetry during walking in individuals post-stroke.

Gradual adaptation to pelvis perturbation during walking reinforces motor learning of weight shift toward the paretic side in individuals post-stroke

The purpose of this study was to determine whether the gradual versus abrupt adaptation to lateral pelvis assistance force improves weight shift toward the paretic side and enhance forced use of the paretic leg during walking. Sixteen individuals who had sustained a hemispheric stroke participated in two experimental sessions, which consisted of (1) treadmill walking with the application of lateral pelvis assistance force (gradual vs. abrupt condition) and (2) overground walking. In the "gradual" condition, during treadmill walking, the assistance force was gradually increased from 0 to 100% of the predetermined force step by step. In the abrupt condition, the force was applied at 100% of the predetermined force throughout treadmill walking. Participants exhibited significant improvements in hip abductor and adductor, ankle dorsiflexor, and knee extensor muscle activities, weight shift toward the paretic side, and overground walking speed in the gradual condition (P < 0.05), but showed no significant changes in the abrupt condition (P > 0.20). Changes in weight shift toward the paretic side were statistically different between conditions (P < 0.001), although changes in muscle activities were not (P > 0.11). In the gradual condition, the error amplitude was proportional to the improvement in weight shift during the late post-adaptation (R² = 0.32, P = 0.03), but not in the abrupt condition (R² = 0.001, P = 0.93). In conclusion, the "gradual adaptation" inducing "small errors" during constraint-induced walking may improve weight shift and enhance forced use of the paretic leg in individuals post-stroke. Applying gradual pelvis assistance force during walking may be used as an intervention strategy to improve walking in individuals post-stroke.

Intense Arm Rehabilitation Therapy Improves the Modified Rankin Scale Score: Association Between Gains in Impairment and Function

OBJECTIVE

To evaluate the effect of intensive rehabilitation on the modified Rankin Scale (mRS), a measure of activities limitation commonly used in acute stroke studies, and to define the specific changes in body structure/function (motor impairment) most related to mRS gains.

METHODS

Patients were enrolled >90 days poststroke. Each was evaluated before and 30 days after a 6-week course of daily rehabilitation targeting the arm. Activity gains, measured using the mRS, were examined and compared to body structure/function gains, measured using the Fugl-Meyer (FM) motor scale. Additional analyses examined whether activity gains were more strongly related to specific body structure/function gains.

RESULTS

At baseline (160 ± 48 days poststroke), patients (n = 77) had median mRS score of 3 (interquartile range, 2-3), decreasing to 2 [2-3] 30 days posttherapy (p < 0.0001). Similarly, the proportion of patients with mRS score ≤2 increased from 46.8% at baseline to 66.2% at 30 days posttherapy (p = 0.015). These findings were accounted for by the mRS score decreasing in 24 (31.2%) patients. Patients with a treatment-related mRS score improvement, compared to those without, had similar overall motor gains (change in total FM score, p = 0.63). In exploratory analysis, improvement in several specific motor impairments, such as finger flexion and wrist circumduction, was significantly associated with higher likelihood of mRS decrease.

CONCLUSIONS

Intensive arm motor therapy is associated with improved mRS in a substantial fraction (31.2%) of patients. Exploratory analysis suggests specific motor impairments that might underlie this finding and may be optimal targets for rehabilitation therapies that aim to reduce activities limitations.

CLINICAL TRIAL

Clinicaltrials.gov identifier: NCT02360488.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for patients >90 days poststroke with persistent arm motor deficits, intensive arm motor therapy improved mRS in a substantial fraction (31.2%) of patients.

The Value of Rehabilitation Interventions --Integrating Evidence, Clinical Expertise, Critical Assessment, and , Patient Needs: A Conference Report

In order to understand issues related to value, outcomes, and cost-effectiveness of rehabilitation interventions, and to explore how scientific evidence, clinical expertise, and patient needs can be integrated, the Rehabilitation Research and Training Center on Developing Optimal Strategies in Exercise and Survival Skills to Increase Health and Function held a State of the Science (SOS) Symposium on "The Value of Rehabilitation Interventions" at Shirley Ryan AbilityLab in Chicago in 2017. In this conference, the perspectives of 35 invited experts, including people with disabilities, professionals, and consumers, explored the topic of "value" of rehabilitation interventions and discussed their perspectives on the means to integrate best scientific evidence with clinical expertise and patient preferences. This Symposium also resulted in the production of several multifaceted manuscripts providing perspectives on the topic of value and how to use evidence to best determine and demonstrate it. These papers comprise this Supplement. The present paper introduces the key concepts of value, evidence, and knowledge translation, in an effort to provide a context for the papers of the Supplement.

Stepwise Regression and Latent Profile Analyses of Locomotor Outcomes Poststroke

BACKGROUND AND PURPOSE

Previous data suggest patient demographics and clinical presentation are primary predictors of motor recovery poststroke, with minimal contributions of physical interventions. Other studies indicate consistent associations between the amount and intensity of stepping practice with locomotor outcomes. The goal of this study was to determine the relative contributions of these combined variables to locomotor outcomes poststroke across a range of patient demographics and baseline function.

METHODS

Data were pooled from 3 separate trials evaluating the efficacy of high-intensity training, low-intensity training, and conventional interventions. Demographics, clinical characteristics, and training activities from 144 participants >1-month poststroke were included in stepwise regression analyses to determine their relative contributions to locomotor outcomes. Subsequent latent profile analyses evaluated differences in classes of participants based on their responses to interventions.

RESULTS

Stepwise regressions indicate primary contributions of stepping activity on locomotor outcomes, with additional influences of age, duration poststroke, and baseline function. Latent profile analyses revealed 2 main classes of outcomes, with the largest gains in those who received high-intensity training and achieved the greatest amounts of stepping practice. Regression and latent profile analyses of only high-intensity training participants indicated age, baseline function, and training activities were primary determinants of locomotor gains. Participants with the smallest gains were older (≈60 years), presented with slower gait speeds (<0.40 m/s), and performed 600 to 1000 less steps/session.

CONCLUSIONS

Regression and cluster analyses reveal primary contributions of training interventions on mobility outcomes in patients >1-month poststroke. Age, duration poststroke, and baseline impairments were secondary predictors. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02507466 and NCT01789853.

Targeted Pelvic Constraint Force Induces Enhanced Use of the Paretic Leg During Walking in Persons Post-Stroke

The purpose of this study was to determine whether activation of muscles in the paretic leg, particularly contributing to propulsion, and gait symmetry can be improved by applying a targeted resistance force to the pelvis in the backward direction during stance phase while walking in individuals post-stroke. Thirteen individuals post-stroke participated in two experimental sessions, which consisted of treadmill walking, with either targeted or constant resistances, together with overground walking. For the targeted condition, a resistance force was applied to the pelvis during the stance phase of the paretic leg. For the constant condition, the resistance force was applied throughout the whole gait cycle. Participants showed greater increase in medial hamstring muscle activity in the paretic leg and improved step length symmetry after the removal of targeted resistance force, compared to effects of a constant resistance force (P < 0.03). In addition, treadmill walking with the targeted resistance induced more symmetrical step length during overground walking 10 min after the treadmill walking, compared to the result of the constant resistance force (P = 0.01). Applying a targeted resistance force to the pelvis during the stance phase of the paretic leg may induce an enhanced use of the paretic leg and an improvement in gait symmetry in individuals post-stroke. These results provide evidence showing that applying a targeted resistance to the pelvis may induce a forced use of the paretic leg during walking.

Survivors of Chronic Stroke Experience Continued Impairment of Dexterity But Not Strength in the Nonparetic Upper Limb

OBJECTIVE

To investigate the performance of the less affected upper limb in people with stroke compared with normative values. To examine less affected upper limb function in those whose prestroke dominant limb became paretic and those whose prestroke nondominant limb became paretic.

DESIGN

Cohort study of survivors of chronic stroke (7.2±6.7y post incident).

SETTING

The study was performed at a freestanding academic rehabilitation hospital.

PARTICIPANTS

Survivors of chronic stroke (N=40) with severe hand impairment (Chedoke-McMaster Stroke Assessment rating of 2-3 on Stage of Hand) participated in the study. In 20 participants the prestroke dominant hand (DH) was tested (nondominant hand [NH] affected by stroke), and in 20 participants the prestroke NH was tested (DH affected by stroke).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Jebsen-Taylor Hand Function Test. Data from survivors of stroke were compared with normative age- and sex-matched data from neurologically intact individuals.

RESULTS

When combined, DH and NH groups performed significantly worse on fine motor tasks with their nonparetic hand relative to normative data (P<.007 for all measures). Even the participants who continued to use their prestroke DH as their primary hand after the stroke demonstrated reduced fine motor skills compared with normative data. In contrast, grip strength was not significantly affected in either group of survivors of stroke (P>.140).

CONCLUSIONS

Survivors of stroke with severe impairment of the paretic limb continue to present significant upper extremity impairment in their nominally nonparetic limb even years after stroke. This phenomenon was observed regardless of whether the DH or NH hand was primarily affected. Because this group of survivors of stroke is especially dependent on the nonparetic limb for performing functional tasks, our results suggest that the nonparetic upper limb should be targeted for rehabilitation.

Use of Pelvic Corrective Force With Visual Feedback Improves Paretic Leg Muscle Activities and Gait Performance After Stroke

The purpose of this study was to examine the effects of combined pelvic corrective force and visual feedback during treadmill walking on paretic leg muscle activity and gait characteristics in individuals with post-stroke hemiparesis. Fifteen chronic stroke participants completed visual feedback only and combined pelvic corrective force and visual feedback conditions during treadmill walking. Each condition included: 1-minute baseline, 7-minute training with visual feedback only or additional pelvic corrective force, 1-minute post training, 1-minute standing break, and another 5-minute training. EMGs from the paretic leg muscles and step length were measured. Overground walking was evaluated before treadmill walking, immediately and 10 minutes after treadmill walking. Greater increases in integrated EMG of all muscles, except vastus medialis and tibialis anterior, were observed with the application of additional pelvic corrective force compared to visual feedback only during treadmill walking. Overground walking speed significantly increased after treadmill training with combined pelvic correction force and visual feedback, but was not significant for the visual feedback only condition. Voluntary weight shifting with additional pelvic corrective force enhanced paretic leg muscle activities and improved gait characteristics during walking. Individuals with post-stroke hemiparesis could adapt feedforward control and generalize the adaptation to overground walking.

Efficacy of Home-Based Telerehabilitation vs In-Clinic Therapy for Adults After Stroke: A Randomized Clinical Trial

Importance

Many patients receive suboptimal rehabilitation therapy doses after stroke owing to limited access to therapists and difficulty with transportation, and their knowledge about stroke is often limited. Telehealth can potentially address these issues.

Objectives

To determine whether treatment targeting arm movement delivered via a home-based telerehabilitation (TR) system has comparable efficacy with dose-matched, intensity-matched therapy delivered in a traditional in-clinic (IC) setting, and to examine whether this system has comparable efficacy for providing stroke education.

Design, Setting, and Participants

In this randomized, assessor-blinded, noninferiority trial across 11 US sites, 124 patients who had experienced stroke 4 to 36 weeks prior and had arm motor deficits (Fugl-Meyer [FM] score, 22-56 of 66) were enrolled between September 18, 2015, and December 28, 2017, to receive telerehabilitation therapy in the home (TR group) or therapy at an outpatient rehabilitation therapy clinic (IC group). Primary efficacy analysis used the intent-to-treat population.

Interventions

Participants received 36 sessions (70 minutes each) of arm motor therapy plus stroke education, with therapy intensity, duration, and frequency matched across groups.

Main Outcomes and Measures

Change in FM score from baseline to 4 weeks after end of therapy and change in stroke knowledge from baseline to end of therapy.

Results

A total of 124 participants (34 women and 90 men) had a mean (SD) age of 61 (14) years, a mean (SD) baseline FM score of 43 (8) points, and were enrolled a mean (SD) of 18.7 (8.9) weeks after experiencing a stroke. Among those treated, patients in the IC group were adherent to 33.6 of the 36 therapy sessions (93.3%) and patients in the TR group were adherent to 35.4 of the 36 assigned therapy sessions (98.3%). Patients in the IC group had a mean (SD) FM score change of 8.36 (7.04) points from baseline to 30 days after therapy (P < .001), while those in the TR group had a mean (SD) change of 7.86 (6.68) points (P < .001). The covariate-adjusted mean FM score change was 0.06 (95% CI, -2.14 to 2.26) points higher in the TR group (P = .96). The noninferiority margin was 2.47 and fell outside the 95% CI, indicating that TR is not inferior to IC therapy. Motor gains remained significant when patients enrolled early (<90 days) or late (≥90 days) after stroke were examined separately.

Conclusions and Relevance

Activity-based training produced substantial gains in arm motor function regardless of whether it was provided via home-based telerehabilitation or traditional in-clinic rehabilitation. The findings of this study suggest that telerehabilitation has the potential to substantially increase access to rehabilitation therapy on a large scale.

Trial Registration

ClinicalTrials.gov identifier: NCT02360488.

Contributions of Stepping Intensity and Variability to Mobility in Individuals Poststroke

Background and Purpose- The amount of task-specific stepping practice provided during rehabilitation poststroke can influence locomotor recovery and reflects one aspect of exercise dose that can affect the efficacy of specific interventions. Emerging data suggest that markedly increasing the intensity and variability of stepping practice may also be critical, although such strategies are discouraged during traditional rehabilitation. The goal of this study was to determine the individual and combined contributions of intensity and variability of stepping practice to improving walking speed and distance in individuals poststroke. Methods- This phase 2, randomized, blinded assessor clinical trial was performed between May 2015 and November 2018. Individuals between 18 and 85 years old with hemiparesis poststroke of >6 months duration were recruited. Of the 152 individuals screened, 97 were randomly assigned to 1 of 3 training groups, with 90 completing >10 sessions. Interventions consisted of either high-intensity stepping (70%-80% heart rate reserve) of variable, difficult stepping tasks (high variable), high-intensity stepping performing only forward walking (high forward), and low-intensity stepping in variable contexts at 30% to 40% heart rate reserve (low variable). Participants received up to 30 sessions over 2 months, with testing at baseline, post-training, and a 3-month follow-up. Primary outcomes included walking speeds and timed distance, with secondary measures of dynamic balance, transfers, spatiotemporal kinematics, and metabolic measures. Results- All walking gains were significantly greater following either high-intensity group versus low-variable training (all P<0.001) with significant correlations with stepping amount and rate (r=0.48-60; P<0.01). Additional gains in spatiotemporal symmetry were observed with high-intensity training, and balance confidence increased only following high-variable training in individuals with severe impairments. Conclusions- High-intensity stepping training resulted in greater improvements in walking ability and gait symmetry than low-intensity training in individuals with chronic stroke, with potential greater improvements in balance confidence. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT02507466.

Position as Well as Velocity Dependence of Spasticity-Four-Dimensional Characterizations of Catch Angle

We investigated the muscle alterations related to spasticity in stroke quantitatively using a portable manual spasticity evaluator.

Methods: Quantitative neuro-mechanical evaluations under controlled passive elbow stretches in stroke survivors and healthy controls were performed in a research laboratory of a rehabilitation hospital. Twelve stroke survivors and nine healthy controls participated in the study. Spasticity and catch angle were evaluated at 90°/s and 270°/s with the velocities controlled through real-time audiovisual feedback. The elbow range of motion (ROM), stiffness, and energy loss were determined at a slow velocity of 30°/s. Four-dimensional measures including joint position, torque, velocity and torque change rate were analyzed jointly to determine the catch angle.

Results: The catch angle was dependent on the stretch velocity and occurred significantly later with increasing velocity (p < 0.001), indicating position dependence of spasticity. The higher resistance felt by the examiner at the higher velocity was also due to more extreme joint position (joint angle) since the spastic joint was moved significantly further to a stiffer elbow position with the higher velocity. Stroke survivors showed smaller ROM (p < 0.001), higher stiffness (p < 0.001), and larger energy loss (p = 0.005). Compared to the controls, stroke survivors showed increased reflex excitability with higher reflex-mediated torque (p < 0.001) and at higher velocities (p = 0.02).

Conclusion: Velocity dependence of spasticity is partially due to joint angle position dependence with the joint moved further (to a stiffer position where higher resistance was felt) at a higher velocity. The “4-dimensional characterization” including the joint angle, velocity, torque, and torque change rate provides a systematic tool to characterize catch angle and spasticity quantitatively.

Walking and balance outcomes for stroke survivors: a randomized clinical trial comparing body-weight-supported treadmill training with versus without challenging mobility skills

Background

Treadmill training, with or without body-weight support (BWSTT), typically involves high step count, faster walking speed, and higher heart-rate intensity than overground walking training. The addition of challenging mobility skill practice may offer increased opportunities to improve walking and balance skills. Here we compare walking and balance outcomes of chronic stroke survivors performing BWSTT with BWSTT including challenging mobility skills.

Methods

Single-blind randomized clinical trial comparing two BWSTT interventions performed in a rehabilitation research laboratory facility over 6 weeks. Participants were 18+ years of age with chronic (≥5 months) poststroke hemiparesis due to a cortical or subcortical ischemic or hemorrhagic stroke and walking speeds < 1.1 m/s at baseline. A hands-free group (HF; n = 15) performed BWSTT without assistance from handrails or assistive devices, and a hands-free plus challenge group (HF + C; n = 14) performed the same protocol while additionally practicing challenging mobility skills. The primary outcome was change in comfortable walking speed (CWS), with secondary outcomes of fast walk speed (FWS), six-minute walk distance, Berg Balance Scale (BBS) scores, and Activities Specific Balance Confidence (ABC) scores.

Results

Significant pre-post improvement of CWS (Z = − 4.2, p ≤ 0.0001) from a median of 0.35 m/s (range 0.10 to 1.09) to a median of 0.54 m/s (range 0.1 to 1.17), but no difference observed between groups (U = 96.0, p = 0.69). Pre-post improvements across all participants resulted in reclassified baseline ambulation status from sixteen to ten household ambulators, three to seven limited community ambulators, and ten to twelve community ambulators. Secondary outcomes showed similar pre-post improvements with no between-group differences.

Conclusions

The addition of challenging mobility skills to a hands-free BWSTT protocol did not lead to greater improvements in CWS following 6 weeks of training. One reason for lack of group differences may be that both groups were adequately challenged by walking in an active, self-driven treadmill environment without use of handrails or assistive devices.

Trial registration

NCT02787759 Falls-based Training for Walking Post-Stroke (FBT); retrospectively registered June 1st, 2016.

Forced Use of the Paretic Leg Induced by a Constraint Force Applied to the Nonparetic Leg in Individuals Poststroke During Walking

BACKGROUND

Individuals with stroke usually show reduced muscle activities of the paretic leg and asymmetrical gait pattern during walking.

OBJECTIVE

To determine whether applying a resistance force to the nonparetic leg would enhance the muscle activities of the paretic leg and improve the symmetry of spatiotemporal gait parameters in individuals with poststroke hemiparesis.

METHODS

Fifteen individuals with chronic poststroke hemiparesis participated in this study. A controlled resistance force was applied to the nonparetic leg using a customized cable-driven robotic system while subjects walked on a treadmill. Subjects completed 2 test sections with the resistance force applied at different phases of gait (ie, early and late swing phases) and different magnitudes (10%, 20%, and 30% of maximum voluntary contraction [MVC] of nonparetic leg hip flexors). Electromyographic (EMG) activity of the muscles of the paretic leg and spatiotemporal gait parameters were collected.

RESULTS

Significant increases in integrated EMG of medial gastrocnemius, medial hamstrings, vastus medialis, and tibialis anterior of the paretic leg were observed when the resistance was applied during the early swing phase of the nonparetic leg, compared with baseline. Additionally, resistance with 30% of MVC induced the greatest level of muscle activity than that with 10% or 20% of MVC. The symmetry index of gait parameters also improved with resistance applied during the early swing phase.

CONCLUSION

Applying a controlled resistance force to the nonparetic leg during early swing phase may induce forced use on the paretic leg and improve the spatiotemporal symmetry of gait in individuals with poststroke hemiparesis.

Quantification of a single score (1+) in the Modified Ashworth Scale (MAS), a clinical assessment of spasticity

The Modified Ashworth Scale (MAS) is an assessment that is often used by clinicians to grade spasticity in the affected limbs of stroke survivors. The MAS is a function of the angle at which the clinician perceives a resistance to stretch and/or a `catch' during a passive joint rotation. The qualitative nature of the assessment in combination with the low resolution of the scale could result in varied grouping of spastic patients, even for a single score. The objective of this pilot study was to develop a method for the quantification of the MAS, which could provide greater resolution and could eventually guide better informed therapeutic interventions. The MAS assessment at the elbow joint for four stroke survivors with the same clinical MAS score of 1+ was performed by a clinician and quantified using signals from surface electromyography (EMG) and an electrogoniometer. The subjects were tested on both the affected and contralateral upper limbs. The findings from this study show a varied set of signal outputs across four stroke survivors, all graded at 1+. The quantification provides insight as to the mechanisms underlying the passive resistance.

Timing, Intensity, and Duration of Rehabilitation for Hip Fracture and Stroke: Report of a Workshop at the National Center for Medical Rehabilitation Research

This article summarizes the proceedings of an NIH workshop on timing, intensity, and duration of rehabilitation for acute stroke and hip fracture. Participants concentrated on methodological issues facing investigators and suggested priorities for future research in this area.

Rehabilitation Medicine Summit: Building Research Capacity Executive Summary

The general objective of the “Rehabilitation Medicine Summit: Building Research Capacity” was to advance and promote research in medical rehabilitation by making recommendations to expand research capacity. The five elements of research capacity that guided the discussions were: (1) researchers; (2) research culture, environment, and infrastructure; (3) funding; (4) partnerships; and (5) metrics. The 100 participants included representatives of professional organizations, consumer groups, academic departments, researchers, governmental funding agencies, and the private sector. The small group discussions and plenary sessions generated an array of problems, possible solutions, and recommended actions. A post-Summit, multi-organizational initiative is called to pursue the agendas outlined in this report.

Abstract TP156: Robot-Guided Ankle and Knee Therapeutic Training Improves Motor Functions in Stroke

Introduction: Stroke survivors develop substantial disability such as weakness, spasticity, increased stiffness, and reduced range of motion in lower limbs, contributing to reduced quality of life. It is important to stretch impaired ankle and knee to increase range of motion and reduce spasticity, and to conduct active movement training to improve balance and locomotion.

Hypothesis: We addressed the hypotheses that robot-aided ankle and knee training will reduce motor impairments and improve balance and gait functions, and the improvements will maintain to the 6-weeks follow-up.

Methods: Seven male stroke survivors participated in the robot-guided ankle and knee rehabilitation training using a pair of ankle and knee rehabilitation robots over 18 training sessions (3 sessions/week for 6 weeks). Three evaluations were done before and after training, and 6 weeks follow-up. Each session involved passive stretching under intelligent control and active movement training under real-time, audiovisual and haptic feedback. About equal time was spent on the ankle and knee training.

Results: We found significant improvement in 6-Minute Walk Test (6MWT: 294.8 m pre-training to 386.4 m post training; p<0.01), Berg Balance Scale (BBS, 45 pre to 52 post; p<0.05), ankle active range of motion (AROM) (-11.7° pre to 1.7° post; p<0.05, a negative value means not being able to reach 0° dorsiflexion), passive ROM in dorsiflexion (12.7° pre to 23.3° post; p<0.01), and dorsiflexion muscle strength (-0.3 Nm pre to 5.7 Nm post; p<0.05, negative means lower than the passive torque at 0° ankle dorsiflexion). The knee had significant improvement in AROM in extension against the load of the robot (34.8° pre to 15.9° knee flexion post; p<0.05) and maximal flexion strength at 90° knee flexion (19.3 Nm pre to 31.7 Nm post; p<0.01). At the follow-up, the outcomes were found as similar results of post evaluation, e.g., 379m (p<0.05) in 6MWT, 51 (p<0.05) in BBS, and 5.2 Nm (p=0.05) in dorsiflexion strength.

Conclusions: In conclusions, robot-guided stretching and active movement training reduced impairments at the knee and ankle of stroke survivors resulting in improved mobility. Furthermore, the effect of training was maintained at the 6-weeks follow-up after the treatment.

A body machine interface based on inertial sensors

Spinal cord injury (SCI) survivors generally retain residual motor and sensory functions, which provide them with the means to control assistive devices. A body-machine interface (BoMI) establishes a mapping from these residual body movements to control commands for an external device. In this study, we designed a BoMI to smooth the way for operating computers, powered wheelchairs and other assistive technologies after cervical spinal cord injuries. The interface design included a comprehensive training paradigm with a range of diverse functional activities to enhance motor learning and retention. Two groups of SCI survivors and healthy control subjects participated in the study. The results indicate the effectiveness of the developed system as an alternative pathway for individuals with motor disabilities to control assistive devices while engaging in functional motor activity.

Energy Cost of Lower Body Dressing, Pop-Over Transfers, and Manual Wheelchair Propulsion in People with Paraplegia Due to Motor-Complete Spinal Cord Injury

BACKGROUND

Energy required for able-bodied individuals to perform common activities is well documented, whereas energy associated with daily activities among people with spinal cord injury (SCI) is less understood.

OBJECTIVE

To determine energy expended during several basic physical tasks specific to individuals with paraplegia due to motor-complete SCI.

METHODS

Sixteen adults with motor-complete SCI below T2 level and duration of paraplegia greater than 3 months were included. Oxygen consumption (VO2), caloric expenditure, and heart rate were measured at rest and while participants performed lower body dressing (LBD), pop-over transfers (POTs), and manual wheelchair propulsion (MWP) at a self-selected pace. These data were used to calculate energy expenditure in standard metabolic equivalents (METs), as defined by 1 MET = 3.5 mL O2/kg/min, and in SCI METs using the conversion 1 SCI MET = 2.7 mL O2/kg/min.

RESULTS

VO2 at rest was 3.0 ± 0.9 mL O2/kg/min, which equated to 0.9 ± 0.3 standard METs and 1.1 ± 0.4 SCI METs in energy expenditure. LBD required 3.2 ± 0.7 METs and 4.1 ± 0.9 SCI METs; POTs required 3.4 ± 1.0 METs and 4.5 ± 1.3 SCI METs; and MWP required 2.4 ± 0.6 METs and 3.1 ± 0.7 SCI METs.

CONCLUSIONS

Resting VO2 for adults with motor-complete paraplegia is 3.0 mL O2/kg/min, which is lower than standard resting VO2 in able-bodied individuals. Progressively more energy is required to perform MWP, LBD, and POTs, respectively. Use of the standard METs formula may underestimate the level of intensity an individual with SCI uses to perform physical activities.

Variable Intensive Early Walking Poststroke (VIEWS): A Randomized Controlled Trial

BACKGROUND

Converging evidence suggests that the amount of stepping practice is an important training parameter that influences locomotor recovery poststroke. More recent data suggest that stepping intensity and variability are also important, although such strategies are often discouraged early poststroke.

OBJECTIVE

The present study examined the efficacy of high-intensity, variable stepping training on walking and nonwalking outcomes in individuals 1 to 6 months poststroke as compared with conventional interventions. Methods Individuals with unilateral stroke (mean duration = 101 days) were randomized to receive ≤40, 1-hour experimental or control training sessions over 10 weeks. Experimental interventions consisted only of stepping practice at high cardiovascular intensity (70%-80% heart rate reserve) in variable contexts (tasks or environments). Control interventions were determined by clinical physical therapists and supplemented using standardized conventional strategies. Blinded assessments were obtained at baseline, midtraining, and posttraining with a 2-month follow-up. Results A total of 32 individuals (15 experimental) received different training paradigms that varied in the amount, intensity, and types of tasks performed. Primary outcomes of walking speed (experimental, 0.27 ± 0.22 m/s vs control, 0.09 ± 0.09 m/s) and distances (119 ± 113 m vs 30 ± 32 m) were different between groups, with stepping amount and intensity related to these differences. Gains in temporal gait symmetry and self-reported participation scores were greater following experimental training, without differences in balance or sit-to-stand performance. Conclusion Variable intensive stepping training resulted in greater improvements in walking ability than conventional interventions early poststroke. Future studies should evaluate the relative contributions of these training parameters.

Upper Body-Based Power Wheelchair Control Interface for Individuals With Tetraplegia

Many power wheelchair control interfaces are not sufficient for individuals with severely limited upper limb mobility. The majority of controllers that do not rely on coordinated arm and hand movements provide users a limited vocabulary of commands and often do not take advantage of the user's residual motion. We developed a body-machine interface (BMI) that leverages the flexibility and customizability of redundant control by using high dimensional changes in shoulder kinematics to generate proportional control commands for a power wheelchair. In this study, three individuals with cervical spinal cord injuries were able to control a power wheelchair safely and accurately using only small shoulder movements. With the BMI, participants were able to achieve their desired trajectories and, after five sessions driving, were able to achieve smoothness that was similar to the smoothness with their current joystick. All participants were twice as slow using the BMI however improved with practice. Importantly, users were able to generalize training controlling a computer to driving a power wheelchair, and employed similar strategies when controlling both devices. Overall, this work suggests that the BMI can be an effective wheelchair control interface for individuals with high-level spinal cord injuries who have limited arm and hand control.

Safety and efficacy of medically performed tongue piercing in people with tetraplegia for use with tongue-operated assistive technology

BACKGROUND

Individuals with high-level spinal cord injuries need effective ways to perform activities.

OBJECTIVES

To develop and test a medically supervised tongue-piercing protocol and the wearing of a magnet-containing tongue barbell for use with the Tongue Drive System (TDS) in persons with tetraplegia.

METHODS

Volunteers with tetraplegia underwent initial screening sessions using a magnet glued on the tongue to activate and use the TDS. This was followed by tongue piercing, insertion of a standard barbell, a 4-week healing period, and an exchange of the standard barbell for a magnet-containing barbell. This was then used twice weekly for 6 to 8 weeks to perform computer tasks, drive a powered wheelchair, accomplish in-chair weight shifts, and dial a phone. Symptoms of intraoral dysfunction, change in tongue size following piercing, and subjective assessment of receiving and wearing a magnet-containing tongue barbell and its usability with the TDS were evaluated.

RESULTS

Twenty-one volunteers underwent initial trial sessions. Thirteen had their tongues pierced. One individual's barbell dislodged during healing resulting in tongue-tract closure. Twelve had the barbell exchanged for a magnet-containing barbell. One subject withdrew for unrelated issues. Eleven completed the TDS testing sessions and were able to complete the assigned tasks. No serious adverse events occurred related to wearing or using a tongue barbell to operate the TDS.

CONCLUSIONS

Using careful selection criteria and a medically supervised piercing protocol, no excess risk was associated with tongue piercing and wearing a tongue barbell in people with tetraplegia. Participants were able to operate the TDS.

Assessment of the Tongue-Drive System Using a Computer, a Smartphone, and a Powered-Wheelchair by People With Tetraplegia

Tongue-Drive System (TDS) is a wireless and wearable assistive technology that enables people with severe disabilities to control their computers, wheelchairs, and smartphones using voluntary tongue motion. To evaluate the efficacy of the TDS, several experiments were conducted, in which the performance of nine able-bodied (AB) participants using a mouse, a keypad, and the TDS, as well as a cohort of 11 participants with tetraplegia (TP) using the TDS, were observed and compared. Experiments included the Fitts' law tapping, wheelchair driving, phone-dialing, and weight-shifting tasks over five to six consecutive sessions. All participants received a tongue piercing, wore a magnetic tongue stud, and completed the trials as evaluable participants. Although AB participants were already familiar with the keypad, throughputs of their tapping tasks using the keypad were only 1.4 times better than those using the TDS. The completion times of wheelchair driving task using the TDS for AB and TP participants were between 157 s and 180 s with three different control strategies. Participants with TP completed phone-dialing and weight-shifting tasks in 81.9 s and 71.5 s, respectively, using tongue motions. Results showed statistically significant improvement or trending to improvement in performance status over the sessions. Most of the learning occurred between the first and second sessions, but trends did suggest that more practice would lead to increased improvement in performance using the TDS.

Seven-Year Trends in Stroke Rehabilitation: Patient Characteristics, Medical Complications, and Functional Outcomes

Studies of stroke trends have focused primarily on incidence, mortality, and hospitalization rates. There has been little evaluation of changes over time in the common patient characteristics, medical comorbidities, and functional outcomes of patients. The present study evaluated changes during a 7-year period. We found that while demographic variables, stroke severity, and most stroke characteristics remained relatively stable, disability levels at admission and discharge decreased and frequencies of both medical tube usage and many secondary medical complications increased over time. These changes have important implications for the clinical management of stroke patients in rehabilitation and for the organization and financing of stroke rehabilitation programs.

Concurrent deficits of soleus and gastrocnemius muscle fascicles and Achilles tendon post stroke

Calf muscles and Achilles tendon play important roles in functional activities. However, it is not clear how biomechanical properties of the uniarticular soleus (SOL) and biarticular gastrocnemius muscle and Achilles tendon, including the fascicle length, pennation angle, and stiffness, change concurrently post stroke. Biomechanical properties of the medial gastrocnemius (GM) and soleus muscles were evaluated bilaterally in 10 hemiparetic stroke survivors using combined ultrasonography-biomechanical measurements. Biomechanical properties of the Achilles tendon including the length, cross-sectional area (CSA), stiffness, and Young's modulus were evaluated, together with calf muscle biomechanical properties. Gastrocnemius and SOL contributions were separated using flexed and extended knee positions. The impaired side showed decreased fascicle length (GM: 6%, P = 0.002 and SOL: 9%, P = 0.03, at full knee extension and 0° ankle dorsiflexion) and increased fascicular stiffness (GM: 64%, P = 0.005 and SOL: 19%, P = 0.012, at a common 50 N force level). In contrast, Achilles tendon on the impaired side showed changes in the opposite direction as the muscle fascicles with increased tendon length (5%, P < 0.001), decreased tendon CSA (5%, P = 0.04), decreased tendon stiffness (42%, P < 0.001) and Young's modulus (30%, P < 0.001) compared with the unimpaired side. The fascicle and tendon stiffness changes were correlated negatively to the corresponding fascicle and tendon length changes, and decrease in Achilles tendon stiffness was correlated to the increases of SOL and GM fascicular stiffness (P < 0.05). Characterizations of calf muscle fascicles and Achilles tendon biomechanical properties help us better understand concurrent changes of fascicles and tendon as part of the calf muscle-tendon unit and facilitate development of more effective treatments.

Rehabilitation Medicine Summit: Building Research Capacity

The general objective of the "Rehabilitation Medicine Summit: Building Research Capacity" was to advance and promote research in medical rehabilitation by making recommendations to expand research capacity. The five elements of research capacity that guided the discussions were 1) researchers; 2) research culture, environment, and infrastructure; 3) funding; 4) partnerships; and 5) metrics. The 100 participants included representatives of professional organizations, consumer groups, academic departments, researchers, governmental funding agencies, and the private sector. The small group discussions and plenary sessions generated an array of problems, possible solutions, and recommended actions. A post-Summit, multi-organizational initiative is called to pursue the agendas outlined in this report.

Abstract W MP57: Effects of Wearable Robotic Training of Ankle and Mobility Rehabilitation in Acute Stroke

Background and Purpose: Stroke is the fourth leading cause of death in the US and is a leading cause of adult disability. It was reported that the first few months post stroke is critical in neural plasticity and motor recovery. Presently, effective treatment options for ankle impairment and mobility are limited, especially for in-bed acute stroke rehabilitation. In this study, wearable robotic training involving passive stretching and active movement training was investigated to determine its efficacy in improving stroke outcome.

Methods: Eleven patients with acute stroke participated. This was completed in a clinical in-patient setting (45 min/session, 3~5х/week, total 18 session). Participants were aged 53.7±17.4 (mean±SD); robotic treatment was given averaged 40.5 days of stroke onset. They continued receiving standard inpatient physical therapy during the study. One way repeated measures ANOVA was used to compare clinical and biomechanical outcome measures across the repeated measures.

Results: Preliminary results showed an improvement after the multiple sessions of training with F-M in LE increased from 14.8 ± 8.8 and 19.4 ± 8.2 (p<.01), STREAM score in LE from 32.1±21.4 to 47.9±30.1 (p=.02), the BBS increased from 35.2±17.8 to 38.0±18.2. Ankle active range of motion (AROM) in dorsiflexion increased from -5.7 ± 7.2° to 2.3 ± 8.1°(p=.004), ankle passive ROM in dorsiflexion from 14.0 ± 7.1° to 19.9 ± 5.3° (p=.002). Dorsiflexor strength increased from 0 ± 2.2 N m before training to 2.4 ±3.5 N m after training (p=.003). Plantarflexor strength increased from 6.7±9.9 Nm, to 12.6 ± 11.4 Nm (p=.004). Other measures showed no significant improvements, such as 6MWT increased from 302.0 ± 416.4 and 540.6 ± 563.4 feet, the MAS of ankle was 2.2 ± 1.1 to 1.6 ± 1.2.

Conclusions: The use of robotic device demonstrated improvements in selected outcome measures in hospital settings, and it was efficiently administer in the clinic. The results suggest that impaired lower limbs of acute stroke can respond to controlled stretching and movement training in terms of muscle biomechanical properties and improve lower extremity functional activities in acute rehabilitation.The limitation of this study was its small sample size and lack of a control group.