Motor recovery after stroke: a systematic review. Lancet Neurol. 2009;8:741-754. [PMID: 19608100 DOI: 10.1016/s1474-4422(09)70150-4]

Towards more effective robotic gait training for stroke rehabilitation: a review

Background

Stroke is the most common cause of disability in the developed world and can severely degrade walking function. Robot-driven gait therapy can provide assistance to patients during training and offers a number of advantages over other forms of therapy. These potential benefits do not, however, seem to have been fully realised as of yet in clinical practice.

Objectives

This review determines ways in which robot-driven gait technology could be improved in order to achieve better outcomes in gait rehabilitation.

Methods

The literature on gait impairments caused by stroke is reviewed, followed by research detailing the different pathways to recovery. The outcomes of clinical trials investigating robot-driven gait therapy are then examined. Finally, an analysis of the literature focused on the technical features of the robot-based devices is presented. This review thus combines both clinical and technical aspects in order to determine the routes by which robot-driven gait therapy could be further developed.

Conclusions

Active subject participation in robot-driven gait therapy is vital to many of the potential recovery pathways and is therefore an important feature of gait training. Higher levels of subject participation and challenge could be promoted through designs with a high emphasis on robotic transparency and sufficient degrees of freedom to allow other aspects of gait such as balance to be incorporated.

Randomized controlled trial of home rehabilitation for patients with ischemic stroke: impact upon disability and elderly depression

BACKGROUND

Patients with major stroke are often left with disability and may have depression and dementia during the recovery phase. Rehabilitation programmes have been shown to improve short-term physical outcome, but their long-term effectiveness and impact on dementia and depression are uncertain.

METHODS

We performed a 6-month randomized controlled trial of a home rehabilitation programme and compared it with the standard care patients with recent ischemic stroke receive. The intervention group received home-based physical therapy once a month for 6 months, along with educational support, counselling and audiovisual materials. The control group received rehabilitation as prescribed by a physician and educational materials upon discharge from hospital. The primary measurement was a change in Barthel Index. Secondary measurements were the Hospital Anxiety and Depression Scale (HADS) and Thai Mini-Mental State Examination.

RESULTS

Of the 68 screened patients, 60 patients were enrolled. At baseline, there was no significant difference in patient characteristics between the two groups. Over 2 years, the mean Barthel Index and Hospital Anxiety and Depression Scale were significantly improved in the intervention group compared to the control group (Barthel Index mean: from 31.7 ± 5.9 to 97.2 ± 2.8 vs from 33.2 ± 4.8 to 76.4 ± 9.4, P < 0.001; Hospital Anxiety and Depression Scale mean: from 16.1 ± 7.6 to 9.1 ± 0.3 vs 16.4 ± 4.9 to 9.1 ± 0.3, P= 0.003). Depression was strongly associated with being dependent on others. However, the Thai Mini-Mental State Examination in both groups did not significantly differ (Thai Mini-Mental State Examination mean: from 24.4 ± 2.0 to 24.6 vs 23.8 ± 1.9 to 24.1 ± 0.3, P= 0.068). There was no significant interaction between baseline characteristics and treatment outcome.

CONCLUSIONS

At 2 years follow-up, it was evident that a 6-month home rehabilitation programme after ischemic stroke improved functional outcome and reduced incidence of depression, but not dementia.

Event related desynchronization-modulated functional electrical stimulation system for stroke rehabilitation: a feasibility study

BACKGROUND

We developed an electroencephalogram-based brain computer interface system to modulate functional electrical stimulation (FES) to the affected tibialis anterior muscle in a stroke patient. The intensity of FES current increased in a stepwise manner when the event-related desynchronization (ERD) reflecting motor intent was continuously detected from the primary cortical motor area.

METHODS

We tested the feasibility of the ERD-modulated FES system in comparison with FES without ERD modulation. The stroke patient who presented with severe hemiparesis attempted to perform dorsiflexion of the paralyzed ankle during which FES was applied either with or without ERD modulation.

RESULTS

After 20 minutes of training, the range of movement at the ankle joint and the electromyography amplitude of the affected tibialis anterior muscle were significantly increased following the ERD-modulated FES compared with the FES alone.

CONCLUSIONS

The proposed rehabilitation technique using ERD-modulated FES for stroke patients was feasible. The system holds potentials to improve the limb function and to benefit stroke patients.

Upper limb stroke rehabilitation: the effectiveness of Stimulation Assistance through Iterative Learning (SAIL)

A novel system has been developed which combines robotic therapy with electrical stimulation (ES) for upper limb stroke rehabilitation. This technology, termed SAIL: Stimulation Assistance through Iterative Learning, employs advanced model-based iterative learning control (ILC) algorithms to precisely assist participant's completion of 3D tracking tasks with their impaired arm. Data is reported from a preliminary study with unimpaired participants, and also from a single hemiparetic stroke participant with reduced upper limb function who has used the system in a clinical trial. All participants completed tasks which involved moving their (impaired) arm to follow an image of a slowing moving sphere along a trajectory. The participants' arm was supported by a robot and ES was applied to the triceps brachii and anterior deltoid muscles. During each task, the same tracking trajectory was repeated 6 times and ILC was used to compute the stimulation signals to be applied on the next iteration. Unimpaired participants took part in a single, one hour training session and the stroke participant undertook 18, 1 hour treatment sessions composed of tracking tasks varying in length, orientation and speed. The results reported describe changes in tracking ability and demonstrate feasibility of the SAIL system for upper limb rehabilitation.

Effects of intensity of arm training on hemiplegic upper extremity motor recovery in stroke patients: a randomized controlled trial

OBJECTIVE

To investigate the effects of different intensities of arm rehabilitation training on the functional recovery of hemiplegic upper extremity.

DESIGN

A randomized controlled trial.

INTERVENTIONS

Thirty-two stroke patients meeting the enrolment criteria were randomly divided into three groups: group A (n = 11), group B (n = 10) and group C (n = 11). Each group received arm training for 1 hour, 2 hours and 3 hours a day respectively, 5 days per week, for a period of six weeks.

MAIN MEASURES

Motor function was assessed by Fugl-Meyer Assessment, Action Research Arm Test and Barthel Index, carried out before treatment, two weeks, four weeks and six weeks after treatment.

RESULTS

When comparing the three groups, the Fugl-Meyer Assessment improvement was more significant in group C (20.50 ± 7.84) than that in group A (11.90 ± 6.52 ) and group B (13.80 ± 6.41) after four weeks of treatment (P < 0.05). The Action Research Arm Test score improvement was more significant in group C (7.30 ± 2.95) than in group A (3.30 ± 2.91 ) (P < 0.05). After six weeks of treatment, the Fugl-Meyer Assessment and Action Research Arm Test score improvements were more significant in group C (24.50 ± 7.96, 10.90 ± 3.60) and group B (19.70 ± 7.09, 8.70 ± 4.62) than in group A (13.00 ± 6.38, 5.30 ± 3.40) (P < 0.05). There were no significant differences of Barthel Index among the three groups (P > 0.05). In each group, Fugl-Meyer Assessment, Action Research Arm Test and Barthel Index scores increased significantly after six weeks of treatment (P < 0.05).

CONCLUSIONS

An increase in the intensity of arm training might improve the motor function of the arm after stroke.

Symptomatic and palliative care for stroke survivors

Stroke is the leading cause of disability and one of the most common causes of death worldwide. Outside the setting of acute management, secondary prevention and stroke rehabilitation, little has been written to address the ongoing symptomatic and palliative needs of these patients and their families. In this literature review, we look beyond secondary prevention with the aim of providing evidence-informed management guidelines for the myriad and often under-recognized symptomatic and palliative care needs of stroke survivors. Some of the most common and disabling post-stroke symptoms that are reviewed here include central post-stroke pain, hemiplegic shoulder pain, painful spasticity, fatigue, incontinence, post-stroke seizures, sexual dysfunction, sleep-disordered breathing, depression and emotionalism. We review the role of caregivers and explore ways to support them and, lastly, remind the reader to be perceptive to the patient's spiritual needs. The literature is most robust, including controlled trials, for central post-stroke pain and depression. Synthesis and discussion outside these areas are frequently limited to smaller studies, case reports and expert opinion. While some data exists to guide informed decision-making, there is an urgent need to document best practice and identify appropriate clinical standards for the full spectrum of symptoms experienced by stroke survivors. We present the current and established data to aid health care providers in symptomatic and palliative management of stroke survivors.

Modified constraint-induced movement therapy improved upper limb function in subacute poststroke patients: a small-scale clinical trial

BACKGROUND

Constraint-induced movement therapy (CIMT) has been advocated as a means of facilitating motor function in poststroke patients; however, the evidence for its efficacy is controversial.

OBJECTIVE

To evaluate the effect of modified CIMT on improving paretic arm function in poststroke patients during a subacute rehabilitation period.

METHODS

A single-blinded randomized controlled trial was conducted at the Loewenstein Rehabilitation Hospital, Israel. Twenty-eight subacute stroke patients with arm paresis after a first ischemic stroke in the middle cerebral artery area were randomized into a modified CIMT or control group by a 1:2 ratio. The modified CIMT group received 1-hour daily physical rehabilitation sessions for 2 weeks. The unaffected arm was restrained during the sessions. Subjects were encouraged to wear a restrictive mitten up to 4 hours a day. The control group received similar intensive regular rehabilitation. Three upper limb function tests, developed for this study, were used as outcome measures. The subjects were asked to perform the following tasks, with the affected hand for 30 seconds: (1) transfer pegs from a saucer to a pegboard; (2) grasp, carry, and release a hard rubber ball; and (3) "eating," using a spoon to remove the jelly from the plate, bring it towards the mouth, and then place it on another plate. The number of repetitions in each test was recorded as an outcome.

RESULTS

The modified CIMT group showed significantly higher changes in all 3 tests compared to the standard rehabilitation group.

CONCLUSION

Our study provides additional support for the use of modified CIMT during a subacute rehabilitation period of poststroke patients. CIMT may facilitate functional improvement of a plegic hand.

Stem Cells in Stroke Treatment: The Promise and the Challenges

Stroke, for some years now the neglected major indication in the pharmaceutical development cupboard, has recently become one of the hot areas for stem cell therapy development. This is driven by better understanding of potential therapeutic opportunities both in the acute and chronic phases and the launch of a series of new early phase clinical trials in a number of countries, driven by positive data in relevant animal models. In addition, the impetus for stem cell product development is motivated by patient demand, with thousands of victims seeking unproven treatments abroad. This article looks at the many challenges facing the development of a stem cell therapy for stroke. These range from product characterization and banking, through nonclinical safety and efficacy to the regulatory requirements for starting patient trials and beyond to maximizing value from carefully designed efficacy trials.

Us'em: the user-centered design of a device for motivating stroke patients to use their impaired arm-hand in daily life activities

Stroke leaves the majority of its survivors with an impairment of the upper extremity that affects their ability to live independently and their quality of life. Rehabilitation research shows that practice of everyday life activities in a natural context may sustain or even improve arm-hand performance, even during chronic stages after stroke. Based on this insight we designed, developed and evaluated Us'em; this consists of two watch-like accelerometry devices that provide feedback to stroke patients regarding the usage of their impaired versus their non-affected upper extremity. System usability and treatment credibility/expectancy were evaluated positively by therapists and patients.

Participation After Stroke: Do We Understand All the Components and Relationships As Categorised in the ICF?

Although advances in stroke care have been shown to improve functional outcomes and survival, evidence suggests that stroke survivors continue to report restricted participation and dissatisfaction with life after returning home. There remains a need to identify ways to improve participation after stroke, considering the person within their context. The International Classification of Functioning, Disability and Health (ICF) provides a valuable framework that can be useful for categorising key components associated with participation. The two parts of the ICF — (a) Functioning and Disability and (b) Contextual Factors — encourage consideration of the functions/body structures, activity and participation, and personal and environmental factors, respectively. Previous research has identified links between body functions, structures and activity, with increasing attention being given to the ways in which these link with participation. Although some of the components influencing participation poststroke are well defined, there is a need to further develop our understanding of how personal and environmental factors may affect participation. In this article, stroke literature is categorised using the ICF and a range of personal and environmental factors are investigated as potential contributors to levels of participation poststroke. This article concludes that research investigating contextual factors and their interactions with participation is warranted.

Functional electrical stimulation mediated by iterative learning control and 3D robotics reduces motor impairment in chronic stroke

BACKGROUND

Novel stroke rehabilitation techniques that employ electrical stimulation (ES) and robotic technologies are effective in reducing upper limb impairments. ES is most effective when it is applied to support the patients' voluntary effort; however, current systems fail to fully exploit this connection. This study builds on previous work using advanced ES controllers, and aims to investigate the feasibility of Stimulation Assistance through Iterative Learning (SAIL), a novel upper limb stroke rehabilitation system which utilises robotic support, ES, and voluntary effort.

METHODS

Five hemiparetic, chronic stroke participants with impaired upper limb function attended 18, 1 hour intervention sessions. Participants completed virtual reality tracking tasks whereby they moved their impaired arm to follow a slowly moving sphere along a specified trajectory. To do this, the participants' arm was supported by a robot. ES, mediated by advanced iterative learning control (ILC) algorithms, was applied to the triceps and anterior deltoid muscles. Each movement was repeated 6 times and ILC adjusted the amount of stimulation applied on each trial to improve accuracy and maximise voluntary effort. Participants completed clinical assessments (Fugl-Meyer, Action Research Arm Test) at baseline and post-intervention, as well as unassisted tracking tasks at the beginning and end of each intervention session. Data were analysed using t-tests and linear regression.

RESULTS

From baseline to post-intervention, Fugl-Meyer scores improved, assisted and unassisted tracking performance improved, and the amount of ES required to assist tracking reduced.

CONCLUSIONS

The concept of minimising support from ES using ILC algorithms was demonstrated. The positive results are promising with respect to reducing upper limb impairments following stroke, however, a larger study is required to confirm this.

The use of exercise-based videogames for training and rehabilitation of physical function in older adults: current practice and guidelines for future research

Declines in physical or cognitive function are associated with age-related impairments to overall health. Functional impairment resulting from injury or disease contribute to parallel declines in self-confidence, social interactions and community involvement. Fear of a major incident such as a stroke or a bone-breaking fall can lead to the decision to move into a supported environment, which can be viewed as a major step in the loss of independence and quality of life. Novel use of videogame console technologies are beginning to be explored as a commercially available means for delivering training and rehabilitation programs to older adults in their own homes. We provide an overview of the main videogame console systems (Nintendo Wii™, Sony Playstation® and Microsoft Xbox®) and discuss some scenarios where they have been used for rehabilitation, assessment and training of functional ability in older adults. In particular, we focus on two issues that significantly impact functional independence in older adults, injury and disability resulting from stroke and falls.

Reduced-intensity modified constraint-induced movement therapy versus conventional therapy for upper extremity rehabilitation after stroke: a multicenter trial

BACKGROUND

Constraint-induced movement therapy (CIMT) is a rehabilitation approach for arm paresis consisting of an intensive schedule of treatment (6 h/d). The high demand of resources for CIMT is a critical issue for its implementation in the Italian health system.

OBJECTIVE

To compare the effects of a reduced-intensity modified CIMT (mCIMT) program that included splinting the unaffected arm for 12 hours daily with the effects of a conventional rehabilitation program for arm paresis in patients with stroke.

METHODS

Sixty-six participants with hemiparesis (3-24 months poststroke) who could extend the wrist and several fingers at least 10° were randomly assigned to mCIMT or conventional rehabilitation. Each group underwent 10 (2 h/d) treatment sessions (5 d/wk for 2 weeks). Patients were assessed with the Wolf Motor Function Test (WMFT-FA and WMFT-T), the Motor Activity Log (MAL-AOU and MAL-QOM), and the Ashworth Scale before and after treatment and 3 months later.

RESULTS

Between-groups analysis showed that the mCIMT group overall had greater improvement than the control group in terms of the WMFT-FA (P = .010), MAL-AOU (P < .001), and MAL-QOM (P < .001). Differences between groups were significant both after treatment (P < .01) and at the 3-month follow-up (P < .01), although 40% of participants did not complete the 3-month assessment. Furthermore, the mCIMT group showed a greater decrease of Ashworth Scale score than the control group at 3 months (P = .021).

CONCLUSION

Two hours of CIMT may be more effective than conventional rehabilitation in improving motor function and use of the paretic arm in patients with chronic stroke.

Functional magnetic resonance imaging evaluation of brain function reorganization in cerebral stroke patients after constraint-induced movement therapy

In this study, stroke patients received constraint-induced movement therapy for 3 weeks. Before and after constraint-induced movement therapy, the flexibility of their upper limbs on the affected side was assessed using the Wolf motor function test, and daily use of their affected limbs was assessed using the movement activities log, and cerebral functional reorganization was assessed by functional magnetic resonance imaging. The Wolf motor function test score and the movement activities log quantity and quality scores were significantly increased, while action performance time in the Wolf motor function test was significantly decreased after constraint-induced movement therapy. By functional magnetic resonance imaging examination, only scattered activation points were visible on the affected side before therapy. In contrast, the volume of the activated area was increased after therapy. The activation volume in the sensorimotor area was significantly different before and after therapy, and the activation area increased and appeared adjusted. In addition to the activated area around the lesions being decreased, there were also some new activated areas, including the supplementary movement area, premotor area and the ipsilateral sensorimotor area. Our findings indicate that constraint-induced movement therapy significantly improves the movement ability and daily use of the affected upper limbs in stroke patients and promotes cerebral functional reorganization.

Transcranial magnetic stimulation as an investigative tool for motor dysfunction and recovery in stroke: an overview for neurorehabilitation clinicians

RATIONALE

An improved understanding of motor dysfunction and recovery after stroke has important clinical implications that may lead to the design of more effective rehabilitation strategies for patients with hemiparesis.

SCOPE

Transcranial magnetic stimulation (TMS) is a safe and painless tool that has been used in conjunction with other existing diagnostic tools to investigate motor pathophysiology in stroke patients. Since TMS emerged more than two decades ago, its application in clinical and basic neuroscience has expanded worldwide. TMS can quantify the corticomotor excitability properties of clinically affected and unaffected muscles and can probe local cortical networks as well as remote but functionally related areas. This provides novel insight into the physiology of neural circuits underlying motor dysfunction and brain reorganization during the motor recovery process. This important tool needs to be used with caution by clinical investigators, its limitations need to be understood, and the results should to be interpreted along with clinical evaluation in this patient population.

SUMMARY

In this review, we provide an overview of the rationale, implementation, and limitations of TMS to study stroke motor physiology. This knowledge may be useful to guide future rehabilitation treatments by assessing and promoting functional plasticity.

The Neurorehabilitation Training Toolkit (NTT): A Novel Worldwide Accessible Motor Training Approach for At-Home Rehabilitation after Stroke

After stroke, enduring rehabilitation is required for maximum recovery, and ideally throughout life to prevent functional deterioration. Hence we developed a new concept for at-home low-cost motor rehabilitation, the NTT, an Internet-based interactive system for upper-limb rehabilitation. In this paper we present the NTT design concepts, its implementation and a proof of concept study with 10 healthy participants. The NTT brings together concepts of optimal learning, engagement, and storytelling to deliver a personalized training to its users. In this study we evaluate the feasibility of NTT as a tool capable of automatically assessing and adapting to its user. This is achieved by means of a psychometric study where we show that the NTT is able to assess movement kinematics-movement smoothness, range of motion, arm displacement and arm coordination-in healthy users. Subsequently, a modeling approach is presented to understand how the measured movement kinematics relate to training parameters, and how these can be modified to adapt the training to meet the needs of patients. Finally, an adaptive algorithm for the personalization of training considering motivational and performance aspects is proposed. In the next phase we will deploy and evaluate the NTT with stroke patients at their homes.

Systematic reviews identify important methodological flaws in stroke rehabilitation therapy primary studies: review of reviews

OBJECTIVE

A "review of reviews" was undertaken to assess methodological issues in studies evaluating nondrug rehabilitation interventions in stroke patients.

STUDY DESIGN AND SETTING

MEDLINE, CINAHL, PsycINFO, and the Cochrane Database of Systematic Reviews were searched from January 2000 to January 2008 within the stroke rehabilitation setting. Electronic searches were supplemented by reviews of reference lists and citations identified by experts. Eligible studies were systematic reviews; excluded citations were narrative reviews or reviews of reviews. Review characteristics and criteria for assessing methodological quality of primary studies within them were extracted.

RESULTS

The search yielded 949 English-language citations. We included a final set of 38 systematic reviews. Cochrane reviews, which have a standardized methodology, were generally of higher methodological quality than non-Cochrane reviews. Most systematic reviews used standardized quality assessment criteria for primary studies, but not all were comprehensive. Reviews showed that primary studies had problems with randomization, allocation concealment, and blinding. Baseline comparability, adverse events, and co-intervention or contamination were not consistently assessed. Blinding of patients and providers was often not feasible and was not evaluated as a source of bias.

CONCLUSIONS

The eligible systematic reviews identified important methodological flaws in the evaluated primary studies, suggesting the need for improvement of research methods and reporting.

How to improve walking, balance and social participation following stroke: a comparison of the long term effects of two walking aids--canes and an orthosis TheraTogs--on the recovery of gait following acute stroke. A study protocol for a multi-centre, single blind, randomised control trial

BACKGROUND

Annually, some 9000 people in Switzerland suffer a first time stroke. Of these 60% are left with moderate to severe walking disability. Evidence shows that rehabilitation techniques which emphasise activity of the hemiplegic side increase ipsilesional cortical plasticity and improve functional outcomes. Canes are commonly used in gait rehabilitation although they significantly reduce hemiplegic muscle activity. We have shown that an orthosis "TheraTogs" (a corset with elasticated strapping) significantly increases hemiplegic muscle activity during gait. The aim of the present study is to investigate the long term effects on the recovery of gait, balance and social participation of gait rehabilitation with TheraTogs compared to gait rehabilitation with a cane following first time acute stroke.

METHODS/DESIGN

Multi-centre, single blind, randomised trial with 120 patients after first stroke. When subjects have reached Functional Ambulation Category 3 they will be randomly allocated into TheraTogs or cane group. TheraTogs will be applied to support hip extensor and abductor musculature according to a standardised procedure. Cane walking held at the level of the radial styloid of the sound wrist. Subjects will walk throughout the day with only the assigned walking aid. Standard therapy treatments and usual care will remain unchanged and documented. The intervention will continue for five weeks or until patients have reached Functional Ambulation category 5. Outcome measures will be assessed the day before begin of intervention, the day after completion, 3 months, 6 months and 2 years.

PRIMARY OUTCOME

Timed "up and go" test, secondary outcomes: peak surface EMG of gluteus maximus and gluteus medius, activation patterns of hemiplegic leg musculature, temporo-spatial gait parameters, hemiplegic hip kinematics in the frontal and sagittal planes, dynamic balance, daily activity measured by accelerometry, Stroke Impact Scale. Significance levels will be 5% with 95% CI's. IntentionToTreat analyses will be performed. Descriptive statistics will be presented.

DISCUSSION

This study could have significant implications for the clinical practice of gait rehabilitation after stroke, particularly the effect and appropriate use of walking aids.The results could be important for the development of clinical guidelines and for the socio-economic costs of post-stroke care.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT01366729.

Preclinical stroke research--advantages and disadvantages of the most common rodent models of focal ischaemia

This review describes the most commonly used rodent models and outcome measures in preclinical stroke research and discusses their strengths and limitations. Most models involve permanent or transient middle cerebral artery occlusion with therapeutic agents tested for their ability to reduce stroke-induced infarcts and improve neurological deficits. Many drugs have demonstrated preclinical efficacy but, other than thrombolytics, which restore blood flow, none have demonstrated efficacy in clinical trials. This failure to translate efficacy from bench to bedside is discussed alongside achievable steps to improve the ability of preclinical research to predict clinical efficacy: (i) Improvements in study quality and reporting. Study design must include randomization, blinding and predefined inclusion/exclusion criteria, and journal editors have the power to ensure statements on these and mortality data are included in preclinical publications. (ii) Negative and neutral studies must be published to enable preclinical meta-analyses and systematic reviews to more accurately predict drug efficacy in man. (iii) Preclinical groups should work within networks and agree on standardized procedures for assessing final infarct and functional outcome. This will improve research quality, timeliness and translational capacity. (iv) Greater uptake and improvements in non-invasive diagnostic imaging to detect and study potentially salvageable penumbral tissue, the target for acute neuroprotection. Drug effects on penumbra lifespan studied serially, followed by assessment of behavioural outcome and infarct within in the same animal group, will increase the power to detect drug efficacy preclinically. Similar progress in detecting drug efficacy clinically will follow from patient recruitment into acute stroke trials based on evidence of remaining penumbra.

Optimizing terminology for stroke motor rehabilitation: recommendations from the American Congress of Rehabilitation Medicine Stroke Movement Interventions Subcommittee

As knowledge and interest in stroke motor rehabilitation continue to increase, consistent terminologies that are specific to this discipline must be established. Such language is critical to effective rehabilitative team communication, and is important to facilitating communication among the diverse groups interested in the science and practice of stroke motor rehabilitation. The purpose of this article is to provide operational definitions for 3 concepts that are common-and commonly mislabeled-attributes of stroke motor rehabilitation interventions: intensity, duration, and frequency. In developing these guidelines, conceptual frameworks used in the pharmaceutical, exercise, and rehabilitative therapy realms were used. Implications of these definitions for research and clinical practice are also discussed.

Should body weight-supported treadmill training and robotic-assistive steppers for locomotor training trot back to the starting gate?

Body weight-supported treadmill training (BWSTT) and robotic-assisted step training (RAST) have not, so far, led to better outcomes than a comparable dose of progressive over-ground training (OGT) for disabled persons with stroke, spinal cord injury, multiple sclerosis, Parkinson's disease, or cerebral palsy. The conceptual bases for these promising rehabilitation interventions had once seemed quite plausible, but the results of well-designed, randomized clinical trials have been disappointing. The authors reassess the underpinning concepts for BWSTT and RAST, which were derived from mammalian studies of treadmill-induced hind-limb stepping associated with central pattern generation after low thoracic spinal cord transection, as well as human studies of the triple crown icons of task-oriented locomotor training, massed practice, and activity-induced neuroplasticity. The authors retrospectively consider where theory and practice may have fallen short in the pilot studies that aimed to produce thoroughbred interventions. Based on these shortcomings, the authors move forward with recommendations for the future development of workhorse interventions for walking. In the absence of evidence for physical therapists to employ these strategies, however, BWSTT and RAST should not be provided routinely to disabled, vulnerable persons in place of OGT outside of a scientifically conducted efficacy trial.

Recovery from ischemia in the middle-aged brain: a nonhuman primate model

Studies of recovery from stroke mainly utilize rodent models and focus primarily on young subjects despite the increased prevalence of stroke with age and the fact that recovery of function is more limited in the aged brain. In the present study, a nonhuman primate model of cortical ischemia was developed to allow the comparison of impairments in young and middle-aged monkeys. Animals were pretrained on a fine motor task of the hand and digits and then underwent a surgical procedure to map and lesion the hand-digit representation in the dominant motor cortex. Animals were retested until performance returned to preoperative levels. To assess the recovery of grasp patterns, performance was videotaped and rated using a scale adapted from human occupational therapy. Results demonstrated that the impaired hand recovers to baseline in young animals in 65-80 days and in middle-aged animals in 130-150 days. However, analysis of grasp patterns revealed that neither group recover preoperative finger thumb grasp patterns, rather they develop compensatory movements.

Theories and control models and motor learning: clinical applications in neuro-rehabilitation

INTRODUCTION

In recent decades there has been a special interest in theories that could explain the regulation of motor control, and their applications. These theories are often based on models of brain function, philosophically reflecting different criteria on how movement is controlled by the brain, each being emphasised in different neural components of the movement. The concept of motor learning, regarded as the set of internal processes associated with practice and experience that produce relatively permanent changes in the ability to produce motor activities through a specific skill, is also relevant in the context of neuroscience. Thus, both motor control and learning are seen as key fields of study for health professionals in the field of neuro-rehabilitation.

DEVELOPMENT

The major theories of motor control are described, which include, motor programming theory, systems theory, the theory of dynamic action, and the theory of parallel distributed processing, as well as the factors that influence motor learning and its applications in neuro-rehabilitation.

CONCLUSIONS

At present there is no consensus on which theory or model defines the regulations to explain motor control. Theories of motor learning should be the basis for motor rehabilitation. The new research should apply the knowledge generated in the fields of control and motor learning in neuro-rehabilitation.

A computational model of use-dependent motor recovery following a stroke: optimizing corticospinal activations via reinforcement learning can explain residual capacity and other strength recovery dynamics

This paper describes a computational model of use-dependent recovery of movement strength following a stroke. The model frames the problem of strength recovery as that of learning appropriate activations of residual corticospinal neurons to their target motoneuronal pools. For example, for an agonist/antagonist muscle pair, we assume the motor system must learn to activate preserved agonist-exciting corticospinal neurons and deactivate preserved antagonist-exciting corticospinal neurons. The model incorporates a biologically plausible reinforcement learning algorithm for adjusting cell activation patterns-stochastic search-using generated limb force as the teaching signal to adjust the synaptic weights that determine cell activations. The model makes predictions consistent with clinical and brain imaging data, such as that patients can achieve an increase in strength after appearing to reach a recovery plateau (i.e., "residual capacity"), that the differential effect of a dose of movement practice will be greater earlier in recovery, and that force-related brain activation will increase in secondary motor areas following a stroke. An interesting prediction that could be explored clinically is that temporarily inhibiting subpopulations of more powerfully connected corticospinal neurons during late movement training will allow the motor system to optimize corticospinal neurons with a weaker influence, whose optimization was blocked by the rapid optimization of more strongly connected neurons early in training.

The iScore predicts effectiveness of thrombolytic therapy for acute ischemic stroke

BACKGROUND AND PURPOSE

Tools to predict the clinical response after intravenous thrombolytic therapy (tPA) are scarce. The iScore is an existing validated tool to estimate outcomes after an acute ischemic stroke. The purpose of this study was to determine the ability of the iScore to predict clinical response and risk of hemorrhagic transformation after tPA.

METHODS

We applied the iScore (www.sorcan.ca/iscore) to patients presenting with an acute ischemic stroke at 11 stroke centers in Ontario, Canada, between 2003 and 2009 identified from the Registry of the Canadian Stroke Network. A cohort of patients with stroke treated at 154 centers in Ontario was used for external validation. We compared outcomes between patients receiving and not receiving tPA after adjusting for differences in baseline characteristics using propensity-score matching. Patients were stratified into 3 a priori defined groups according to stroke severity using the iScore.

RESULTS

Among 12 686 patients with an acute ischemic stroke, 1696 (13.4%) received intravenous thrombolysis. Higher iScores were associated with poor outcomes in both the tPA and non-tPA groups (P<0.001). Among those at low and medium risk based on their iScores, tPA use was associated with a benefit in the primary outcome (relative risk, 0.74 for those with low-risk iScores; 95% CI, 0.67-0.84; relative risk, 0.88 for those with medium risk iScores; 95% CI, 0.84-0.93). There was no difference in clinical outcomes between matched patients receiving and not receiving tPA in the highest iScore group (relative risk, 0.97; 95% CI, 0.94-1.01). Similar results were observed for disability at discharge and length of stay. The incident risk of neurological deterioration and hemorrhagic transformation (any or symptomatic) with tPA increased with the iScore risk. Results were similar in the validation cohort for risk of poor outcome with tPA by iScore level.

CONCLUSIONS

The iScore may be used to predict clinical response and risk of hemorrhagic complications after tPA for an acute ischemic stroke. Patients with high iScores may not have a clinically meaningful benefit from intravenous tPA at the time of carrying a higher risk of hemorrhagic complications.

Increased power generation in impaired lower extremities correlated with changes in walking speeds in sub-acute stroke patients

BACKGROUND

Establishing changes in net joint power in the lower extremity of patients during recovery of walking might direct gait training in early stroke rehabilitation. It is hypothesized that (1) net joint power in the lower extremity joints would increase in sub-acute stroke patients following gait rehabilitation, and (2) the improvements in net joint power would be significantly correlated with changes in walking speed.

METHODS

Thirteen sub-acute patients (<3 months from stroke onset) participated in the study. All patients completed 6 weeks of gait training (3 weeks of robotic gait training and 3 weeks of physiotherapy). The gait patterns were analyzed using 3D motion analysis before and after training. The assessed variables were; gait speed and the net peak joint power of the ankle plantar flexors, hip extensors, hip flexors, hip abductors, and knee extensors.

FINDINGS

Ankle plantar flexor power in the impaired limb and hip extensor power in the unimpaired limb increased significantly following training (133% and 77%, respectively; P<0.002). Improvements (from 20% to 133%) in net joint power of the ankle plantar flexors, hip extensors, hip flexors, and hip abductors of the impaired limb and ankle plantar flexors and hip abductors of the unimpaired limb significantly correlated with the recovery of walking speed following training (0.24 m/s to 0.51 m/s) (r=0.71-0.86).

INTERPRETATION

The findings suggested investigations for strengthening the plantar flexors, hip flexors, hip extensors, and hip abductors concentrically, and knee extensors eccentrically in the impaired limb to determine the effectiveness in improving gait performance.

[Fundamental theory and practice in stroke rehabilitation from acute stage to chronic stage]

One of the most important objects of stroke rehabilitation is motor recovery from acute stage to chronic stage. Reorganization theory of motor circuits in the cerebral cortex contributing to recovery following stroke is proposed. In acute stage motor recovery depends on residual corticospinal tract excitability from onset to 3 months (1(st) stage recovery) . In next stage alternative output system is used according to intracortical excitability depending on intracortical disinhibition at the peak of 3 months (2(nd) stage recovery) . At 6 months and beyond training-induced synaptic strengthening becomes better established, and new networks are better reorganized (3(rd)stage recovery) . Stroke rehabilitation programs from acute stage are required depending on this stage theory. With each stage to select and perform the most effective rehabilitation programs are necessary. Two obstruction factors of motor recovery are indicated. One of them is Wallerian degeneration of corticospinal tract. Early Wallerian degeneration of the corticospinal tract that is seen on diffusion weighted MRI was reported. The appearance of Wallerian degeneration at acute stage should be directed to more attention as motor recovery inhibition. Next obstruction factor is development of spasticity from acute stage. Spastic paresis is subjected over time to immobilization of the paretic body part and chronic disuse of the paretic body part, which are avoidable through early rehabilitation intervention. Recently various interventions were proposed for motor recovery. The combination of repetitive transcranial magnetic stimulation and intensive occupational therapy by Abo (2010) are recommended to recovery hand function at chronic stage as 3(rd) stage recovery.

A multi-center study on low-frequency rTMS combined with intensive occupational therapy for upper limb hemiparesis in post-stroke patients

Background

Both low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) have been recently reported to be clinically beneficial for post-stroke patients with upper limb hemiparesis. Based on these reports, we developed an inpatient combination protocol of these two modalities for the treatment of such patients. The aims of this pilot study were to confirm the safety and feasibility of the protocol in a large number of patients from different institutions, and identify predictors of the clinical response to the treatment.

Methods

The study subjects were 204 post-stroke patients with upper limb hemiparesis (mean age at admission 58.5 ± 13.4 years, mean time after stroke 5.0 ± 4.5 years, ± SD) from five institutions in Japan. During 15-day hospitalization, each patient received 22 treatment sessions of 20-min low-frequency rTMS and 120-min intensive OT daily. Low-frequency rTMS of 1 Hz was applied to the contralesional hemisphere over the primary motor area. The intensive OT, consisting of 60-min one-to-one training and 60-min self-exercise, was provided after the application of low-frequency rTMS. Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) were performed serially. The physiatrists and occupational therapists involved in this study received training prior to the study to standardize the therapeutic protocol.

Results

All patients completed the protocol without any adverse effects. The FMA score increased and WMFT log performance time decreased significantly at discharge, relative to the respective values at admission (change in FMA score: median at admission, 47 points; median at discharge, 51 points; p < 0.001. change in WMFT log performance time: median at admission, 3.23; median at discharge, 2.51; p < 0.001). These changes were persistently seen up to 4 weeks after discharge in 79 patients. Linear regression analysis found no significant relationship between baseline parameters and indexes of improvement in motor function.

Conclusions

The 15-day inpatient rTMS plus OT protocol is a safe, feasible, and clinically useful neurorehabilitative intervention for post-stroke patients with upper limb hemiparesis. The response to the treatment was not influenced by age or time after stroke onset. The efficacy of the intervention should be confirmed in a randomized controlled study including a control group.

Rehabilitation after stroke in older people

Stroke is a leading cause of disability and therefore rehabilitation is a major part of patient care. Most interventions do not target aged patient but there is unequivocal evidence to promote rehabilitation in multidisciplinary stroke units or integrated care of a multidisciplinary team in the community. Most research has focused on the effect of interventions on recovery in different forms of impairment and disability. The most promising options for motor recovery of the arm include constraint-induced movement therapy and robotic-assisted strategies. Interventions to improve postural stability and gait include fitness training, high-intensity therapy, and repetitive-task training. However, information about the clinical effect of various strategies of cognitive rehabilitation and strategies for aphasia and dysarthria is scarce. Several large trials of rehabilitation practice are underway to test these interventions in the elderly, either alone or in combination with early mobilisation, cardiorespiratory fitness training and physical exercise.

The Influence of Hand Use on Dressing Outcome in Cognitively Impaired Stroke Survivors

Introduction:

The daily task of dressing oneself requires multiple complex skills, which are often taken for granted by those free from ill-health or disability. Independence in dressing allows an individual to maintain a sense of dignity and choice over his or her appearance. Occupational therapy aims to restore independent functional performance in daily activities. Dressing independence requires both physical and cognitive skills. For survivors of stroke, impairment of such skills can pose great difficulty to their dressing performance.

Method:

The aim of this study was to examine the effect of arm paresis and cognitive impairment on upper body dressing ability using a cognitively impaired cohort of stroke participants (n = 70), and to explore the importance of bimanual activity when dressing in the presence of cognitive impairment. Dressing ability was assessed at baseline and immediately following a 6-week period of dressing practice with an occupational therapist.

Results:

Thirty-six participants were able to use a bimanual dressing method at baseline. The chi-square test for independence indicated a strong association between dressing method (bimanual or unimanual) and independence in upper body dressing, p<0.001. The dressing success of the bimanual group was significantly greater than that of the unimanual group at both assessment time points.

Conclusion:

Cognitively impaired stroke survivors do perform better at upper body dressing when they are able to use both hands as compared with one, but those with arm paresis preventing bimanual activity may still improve their dressing performance significantly with practice.

Transcranial magnetic stimulation in mild to severe hemiparesis early after stroke: a proof of principle and novel approach to improve motor function

Low-frequency repetitive transcranial magnetic stimulation (rTMS) of the unaffected hemisphere can enhance function of the paretic hand in patients with mild motor impairment. Effects of low-frequency rTMS to the contralesional motor cortex at an early stage of mild to severe hemiparesis after stroke are unknown. In this pilot, randomized, double-blind clinical trial we compared the effects of low-frequency rTMS or sham rTMS as add-on therapies to outpatient customary rehabilitation, in 30 patients within 5-45 days after ischemic stroke, and mild to severe hand paresis. The primary feasibility outcome was compliance with the interventions. The primary safety outcome was the proportion of intervention-related adverse events. Performance of the paretic hand in the Jebsen-Taylor test and pinch strength were secondary outcomes. Outcomes were assessed at baseline, after ten sessions of treatment administered over 2 weeks and at 1 month after end of treatment. Baseline clinical features were comparable across groups. For the primary feasibility outcome, compliance with treatment was 100% in the active group and 94% in the sham group. There were no serious intervention-related adverse events. There were significant improvements in performance in the Jebsen-Taylor test (mean, 12.3% 1 month after treatment) and pinch force (mean, 0.5 Newtons) in the active group, but not in the sham group. Low-frequency rTMS to the contralesional motor cortex early after stroke is feasible, safe and potentially effective to improve function of the paretic hand, in patients with mild to severe hemiparesis. These promising results will be valuable to design larger randomized clinical trials.

The iScore Predicts Poor Functional Outcomes Early After Hospitalization for an Acute Ischemic Stroke

Background and Purpose—

The iScore is a prediction tool originally developed to estimate the risk of death after hospitalization for an acute ischemic stroke. Our objective was to determine whether the iScore could also predict poor functional outcomes.

Methods—

We applied the iScore to patients presenting with an acute ischemic stroke at multiple hospitals in Ontario, Canada, between 2003 and 2008, who had been identified from the Registry of the Canadian Stroke Network regional stroke center database (n=3818) and from an external data set, the Registry of the Canadian Stroke Network Ontario Stroke Audit (n=4635). Patients were excluded if they were included in the sample used to develop and validate the initial iScore. Poor functional outcomes were defined as: (1) death at 30 days or disability at discharge, in which disability was defined as having a modified Rankin Scale 3 to 5; and (2) death at 30 days or institutionalization at discharge.

Results—

The prevalence of poor functional outcomes in the Registry of the Canadian Stroke Network and the Ontario Stroke Audit, respectively, were 55.7% and 44.1% for death at 30 days or disability at discharge and 16.9% and 16.2%, respectively, for death at 30 days or institutionalization at discharge. The iScore stratified the risk of poor outcomes in low- and high-risk individuals. Observed versus predicted outcomes showed high correlations: 0.988 and 0.940 for mortality or disability and 0.985 and 0.993 for mortality or institutionalization in the Registry of the Canadian Stroke Network and Ontario Stroke Audit cohorts.

Conclusions—

The iScore can be used to estimate the risk of death or a poor functional outcome after an acute ischemic stroke.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability.

OBJECTIVES

To determine whether fitness training after stroke reduces death, dependence, and disability. The secondary aims were to determine the effects of training on physical fitness, mobility, physical function, quality of life, mood, and incidence of adverse events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched April 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, July 2010), MEDLINE (1966 to March 2010), EMBASE (1980 to March 2010), CINAHL (1982 to March 2010), SPORTDiscus (1949 to March 2010), and five additional databases (March 2010). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both, with no intervention, a non-exercise intervention, or usual care in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality, and extracted data. We analysed data using random-effects meta-analyses. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 32 trials, involving 1414 participants, which comprised cardiorespiratory (14 trials, 651 participants), resistance (seven trials, 246 participants), and mixed training interventions (11 trials, 517 participants). Five deaths were reported at the end of the intervention and nine at the end of follow-up. No dependence data were reported. Diverse outcome measures made data pooling difficult. The majority of the estimates of effect were not significant. Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 8.66 metres per minute, 95% confidence interval (CI) 2.98 to 14.34), preferred gait speed (MD 4.68 metres per minute, 95% CI 1.40 to 7.96) and walking capacity (MD 47.13 metres per six minutes, 95% CI 19.39 to 74.88) at the end of the intervention. These training effects were retained at the end of follow-up. Mixed training, involving walking, increased preferred walking speed (MD 2.93 metres per minute, 95% CI 0.02 to 5.84) and walking capacity (MD 30.59 metres per six minutes, 95% CI 8.90 to 52.28) but effects were smaller and there was heterogeneity amongst the trial results. There were insufficient data to assess the effects of resistance training. The variability in the quality of included trials hampered the reliability and generalizability of the observed results.

AUTHORS' CONCLUSIONS

The effects of training on death, dependence, and disability after stroke are unclear. There is sufficient evidence to incorporate cardiorespiratory training involving walking within post-stroke rehabilitation programmes to improve speed, tolerance, and independence during walking. Further well-designed trials are needed to determine the optimal exercise prescription and identify long-term benefits.

Effects of Augmented Exercise Therapy on Outcome of Gait and Gait-Related Activities in the First 6 Months After Stroke

Background and Purpose—

The purpose of this study was to determine the effects of augmented exercise therapy on gait, gait-related activities, and (basic and extended) activities of daily living within the first 6 months poststroke.

Methods—

A systematic literature search in electronic databases from 1990 until October 2010 was performed. Randomized controlled trials were included in which the experimental group spent augmented time in lower-limb exercise therapy compared with the control group. Outcomes were gait, gait-related activities, and (extended) activities of daily living. Results from individual studies were pooled by calculating the summary effect sizes. Subgroup analyses were applied for a treatment contrast of ≥16 hours, timing poststroke, type of control intervention, and methodological quality.

Results—

Fourteen (N=725) of 4966 identified studies were included. Pooling resulted in small to moderate significant summary effect sizes in favor of augmented exercise therapy for walking ability, comfortable and maximum walking speed, and extended activities of daily living. No significant effects were found for basic activities of daily living. Subgroup analysis did not show a significant effect modification.

Conclusions—

Dose–response trials in stroke rehabilitation are heterogeneous. The present meta-analysis suggests that increased time spent on exercise of gait and gait-related activities in the first 6 months poststroke results in significant small to moderate effects in terms of walking ability, walking speed, and extended activities of daily living. High-quality dose–response exercise therapy trials are needed with identical treatment goals but incremental levels of intensity.

Stroke Therapy through Motion-Based Games

In the United States alone, more than five million people are living with long term motor impairments caused by a stroke. Recently, video games with affordable motion-based input devices have been proposed as a part of therapy to help people recover lost range of motion and motor control. While researchers have demonstrated the potential utility of therapeutic games through controlled studies, relatively little work has explored their long-term home-based use. We conducted a six-week home study with a 62-year-old woman who was seventeen years post-stroke. She played therapeutic games for approximately one hour a day, five days a week. Over the six weeks, she recovered significant motor abilities, which is unexpected given the time since her stroke. We explore detecting such improvements early, using game logs for daily measurements of motor ability to complement the standard measurements that are taken less often. Through observations and interviews, we present lessons learned about the barriers and opportunities that arise from long-term home-based use of therapeutic games.

Physical activity in the prevention and treatment of stroke

The role of physical activity in the prevention of stroke is of great interest due to the high mortality and significant impact of stroke-related morbidity on the individual and on healthcare resources. The use of physical activity as a therapeutic strategy to maximise functional recovery in the rehabilitation of stroke survivors has a growing evidence base. This narrative review examines the existing literature surrounding the use of exercise and physical therapy in the primary and secondary prevention of stroke. It explores the effect of gender, exercise intensities and the duration of observed benefit. It details the most recent evidence for physical activity in improving functional outcome in stroke patients. The review summaries the current guidelines and recommendations for exercise therapy and highlights areas in which further research and investigation would be useful to determine optimal exercise prescription for effective prevention and rehabilitation in stroke.