Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better?

Taking the Next Step in Neurologic Rehabilitation: Contributions of Intensity and Variability of Stepping Tasks During Locomotor Training

Research over the past 20 years indicates the amount of task-specific walking practice provided to individuals with stroke, brain injury, or incomplete spinal cord injury can strongly influence walking recovery. However, more recent data suggest that attention toward 2 other training parameters, including the intensity and variability of walking practice, may maximize walking recovery and facilitate gains in non-walking outcomes. The combination of these training parameters represents a stark contrast from traditional strategies, and confusion regarding the potential benefits and perceived risks may limit their implementation in clinical practice. The purpose of this perspective is to delineate the evidence regarding the contributions of intensity and variability of locomotor training to improve mobility outcomes in individuals with acute-onset brain and spinal cord injury. The rationale and evidence supporting the utility of these training parameters in controlled laboratory settings is first described by integrating concepts in the field of neuroscience, motor learning, biomechanics, and exercise physiology into a rehabilitation intervention. Subsequently, the evidence supporting the efficacy of this paradigm is addressed, including discussions of some of the misconceptions regarding perceived negative consequences of these strategies in an effort to mitigate common clinical concerns. Finally, the utility of these strategies implemented during inpatient rehabilitation is delineated to facilitate a more comprehensive understanding of the feasibility and potential benefits early following neurologic injury. A greater understanding of how and why to integrate higher intensity, variable stepping practice will support therapists to take the next step to maximize mobility in the patients they serve.

Protocol for a single-blind randomized controlled clinical trial to investigate the feasibility and safety of in-bed self-exercises based on electromyography sensor feedback in patients with subacute stroke

BACKGROUND

The dosage and intensity of physical therapy are crucial factors influencing the motor recovery of the hemiplegic lower limb in patients with subacute stroke. Biofeedback using wearable sensors may provide opportunities for patients with stroke to effectively guide self-exercises with monitoring of muscular activities in hemiplegic lower limbs. This study aims to explore the feasibility and safety of in-bed self-exercises based on electromyography sensor feedback in patients with subacute stroke.

METHODS

This is a pilot randomized controlled trial comparing conventional physical therapy with additional in-bed self-exercises based on electromyography sensor feedback and conventional physical therapy alone. The interventions will be adjusted according to the muscle strength and Brunnstrom recovery stage in the hemiplegic lower limbs. The primary outcome measure is the Pittsburgh Rehabilitation Participation Scale. The secondary outcome measures include the number and percentage of participating sessions, number and percentage of effortful sessions, number and percentage of successful sessions, mean amplitude of muscle contractions in a session, duration and percentage of participating sessions during self-exercises, Rivermead Motor Assessment, Manual Muscle Test, Brunnstrom recovery stage, Fugl-Meyer assessment, Berg Balance Scale, Functional Ambulation Category, modified Rankin scale, and Short-Form Health Survey 36 version 2.

RESULTS

The results will be described in future studies.

CONCLUSION

This clinical trial will estimate the feasibility and safety of in-bed self-exercises based on electromyography sensor feedback in patients with subacute stroke. If the expected results are achieved in this study, stroke rehabilitation methods will be enriched.

TRIAL REGISTRATION

clinicialtrials.gov, NCT05820815.

Trends in performance of thrombectomy for acute ischemic stroke patients in teaching and non-teaching hospitals

OBJECTIVES

The value of thrombectomy in patients with acute ischemic stroke cannot be understated. As such, whether these patients get access to this treatment can significantly impact their disease outcomes. We analyzed the trends in thrombectomy adoption between teaching and non-teaching hospitals in the United States, and their impact on overall patient care.

MATERIALS AND METHODS

We conducted a retrospective analysis of hospital admissions in the Nationwide Inpatient Sample with a diagnosis of acute ischemic stroke between 2012 and 2020. We compared the annual total number and proportion of patients undergoing thrombectomy between teaching and non-teaching hospitals, and their corresponding outcomes.

RESULTS

A total of 3,823,490 and 1,875,705 patients were admitted to teaching and non-teaching hospitals during the study duration, respectively. The proportion of patients who underwent thrombectomy increased from 1.60 % to 7.02 % (p-value for trend p < 0.001) in teaching hospitals and from 0.32 % to 2.20 % (p-value trend p < 0.001) in non-teaching hospitals. The absolute increase in the number of acute ischemic stroke patients undergoing thrombectomy was highest in teaching hospitals particularly those with large bed size, an increase from 3635 patients in 2012 to 24,730 patients in 2020. Higher rates of intravenous thrombolysis and patient transfer prior to thrombectomy were seen in teaching hospitals compared with non-teaching hospitals.

CONCLUSIONS

The study highlights disparities between teaching and non-teaching hospitals, with teaching hospitals showing a disproportionately higher rate of thrombectomy adoption in acute ischemic stroke patients. Further studies are needed to understand the barriers to the adoption of thrombectomy in non-teaching hospitals.

Computerized social cognitive training in the subacute phase after traumatic brain injury: A quasi-randomized controlled trial

OBJECTIVES

To assess the usefulness of a computerized tasks module designed for the rehabilitation of social cognition (SC) in acquired brain injury.

METHODS

Quasi-randomized controlled trial (ClinicalTrials.gov:NCT03479970) involving 45 patients with moderate-severe traumatic brain injury (TBI) in a subacute inpatient rehabilitation hospital. The experimental group (n = 28) received treatment with a computerized SC module in combination with a non-SC module. The control group (n = 26) only received a treatment with non-SC module.

RESULTS

Intragroup comparisons showed that the experimental group had better results for all SC measures, except for International Affective Picture System (IAPS). The control group improved for Facial Expressions of cEmotion-Stimuli and Tests (FEEST) and Moving Shapes Paradigm (MSP), showing no changes with respect to pretreatment in IAPS, MSP and Reading the Mind in the Eyes Test (RMET). Intergroup comparisons did not present differences between the two groups for pretreatment measures. Post-treatment comparison showed that the experimental group obtained better results for RMET than the control group.

CONCLUSION

The computerized SC module was useful for the rehabilitation of SC in patients with moderate-severe TBI in the subacute phase. The group that received combined rehabilitative treatment (SC + non-SC) obtained better results for SC than the group that received treatment intended only for non-SC.

Post Stroke Exercise Training: Intensity, Dosage, and Timing of Therapy

More intense, earlier exercise in rehabilitation results in improved motor outcomes following stroke. Timing and intensity of therapy delivery vary from study to study. For more intensive therapies, there are practical challenges in implementation. However, there are also opportunities for high intensity treatment through innovative approaches and new technologies. Timing of rehabilitation is important. As time post stroke increases, the dosage of therapy required to improve motor recovery outcomes increases. Very early rehabilitation may improve motor outcomes but should be delayed for at least 24 hours post stroke.

Gamma oscillations induced by 40-Hz visual-auditory stimulation for the treatment of acute-phase limb motor rehabilitation after stroke: study protocol for a prospective randomized controlled trial

BACKGROUND

The incidence of hemiparetic limb dysfunction reaches 85% in stroke patients, emerging as a critical factor influencing their daily lives. However, the effectiveness of current rehabilitation treatments is considerably limited, particularly in patients with upper extremity impairment. This study aims to conduct a prospective clinical trial to validate the safety and effectiveness of gamma oscillations induced by 40-Hz visual-auditory stimulation in treating post-stroke upper limb dysfunction and to explore the relevant mechanisms.

METHODS

This trial is a prospective, randomized controlled, double-blind study. All enrolled patients were randomly assigned to two groups. The experimental group received intervention through 40-Hz visual-auditory stimulation, while the control group underwent intervention with randomly matched visual-auditory stimulation frequencies. The primary efficacy endpoint is the change in motor function. Secondary efficacy endpoints include motor-evoked potentials, cerebral hemodynamic changes, neural network connectivity, and alterations in synaptic-related genes. Safety evaluation included major adverse events, all-cause mortality, and photosensitive epilepsy. Assessments will be conducted at baseline, after a 14-day treatment period, and during subsequent follow-up visits (at 3 and 6 months) post-treatment. The differences between the two groups will be compared.

DISCUSSION

This study will evaluate the safety and efficacy of gamma oscillations induced by 40-Hz visual-auditory stimulation in treating patients with upper extremity dysfunction after an acute cerebral stroke. Concurrently, we will explore potential mechanisms, including changes in synaptic-related genes and neural network connectivity. This trial is expected to provide evidence for the effectiveness of this new technique in treating upper extremity dysfunction after a stroke and improving patients' quality of life.

TRIAL REGISTRATION

The study protocol has been registered with the Chinese Clinical Trial Registry (ChiCTR) under registration number ChiCTR2300076579 on October 12, 2023.

Guidelines: basic principles of neurorehabilitation for patients with acquired brain injury. Recommendations of the Spanish Society of Neurorehabilitation

INTRODUCTION

We present the Spanish Society of Neurorehabilitation's guidelines for adult acquired brain injury (ABI) rehabilitation. These recommendations are based on a review of international clinical practice guidelines published between 2013 and 2020.

DEVELOPMENT

We establish recommendations based on the levels of evidence of the studies reviewed and expert consensus on population characteristics and the specific aspects of the intervention or procedure under research.

CONCLUSIONS

All patients with ABI should receive neurorehabilitation therapy once they present a minimal level of clinical stability. Neurorehabilitation should offer as much treatment as possible in terms of frequency, duration, and intensity (at least 45-60minutes of each specific form of therapy that is needed). Neurorehabilitation requires a coordinated, multidisciplinary team with the knowledge, experience, and skills needed to work in collaboration both with patients and with their families. Inpatient rehabilitation interventions are recommended for patients with more severe deficits and those in the acute phase, with outpatient treatment to be offered as soon as the patient's clinical situation allows it, as long as intensity criteria can be maintained. The duration of treatment should be based on treatment response and the possibilities for further improvement, according to the best available evidence. At discharge, patients should be offered health promotion, physical activity, support, and follow-up services to ensure that the benefits achieved are maintained, to detect possible complications, and to assess possible changes in functional status that may lead the patient to need other treatment programmes.

The association between inpatient rehabilitation intensity and outcomes after stroke in Ontario, Canada

BACKGROUND

Several studies have demonstrated improved outcomes poststroke when higher intensity rehabilitation is provided. Canadian Stroke Best Practice Recommendations advise patients receive 180 min of therapy time per day; however, the exact amount required to reach benefit is unknown.

AIMS

The primary aim of this study was to determine the association between rehabilitation intensity (RI) and total Functional Independence Measure (FIM) Instrument change. Secondary aims included determining the association between RI and discharge location, 90-day home time, rehabilitation effectiveness, and motor and cognitive FIM change.

METHODS

A retrospective cohort study was conducted using available administrative databases of acute stroke patients discharged to inpatient rehabilitation facilities in Ontario, Canada, from January 2017 to December 2021. RI was defined as number of minutes per day of direct therapy by all providers divided by rehabilitation length of stay. The association between RI and the outcomes of interest were analyzed using regression models with restricted cubic splines.

RESULTS

A total of 12,770 individuals were included. Mean age of the sample was 72.6 years, 46.0% of individuals were female, and 87.6% had an ischemic stroke. Mean RI was 74.7 min (range: 5-162 min) per day. Increased RI was associated with an increase in mean FIM change. However, there was diminishing incremental increase after reaching 95 min/day. Increased RI was positively associated with motor and cognitive FIM change, rehabilitation effectiveness, 90-day home time, and discharge to preadmission setting. Higher RI was associated with a lower likelihood of discharge to long-term care.

CONCLUSIONS

None of the patients met the recommended RI of 180 min/day based on the Canadian Stroke Best Practice Recommendations. Despite this, higher intensity was associated with better outcomes. Given that most positive associations were observed with a RI ⩾95 min/day, this may be a more feasible target.

Effects of Tai Chi Yunshou on upper-limb function and balance in stroke survivors: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Physical rehabilitation plays an important role in the recovery of motor function after a stroke. This study aimed to evaluate the effects of Tai Chi Yunshou (TCY), a form of physical therapy, on upper-limb function and balance in stroke survivors.

METHODS

MEDLINE, Embase, CENTRAL and five Chinese databases were retrieved from inception to July 1, 2020 (updated on March 31, 2022). Randomized controlled trials of TCY versus no-treatment for stroke were included. The RoB-2 was used to evaluate the quality of included studies. Upper-limb motor impairment, balance, and activities of daily living (ADLs) were measured by Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE), Berg Balance Scale (BBS), and Barthel Index (BI), respectively. Data synthesis was performed using RevMan (v5.3), and expressed as mean difference (MD) with 95% confidence intervals (CI).

RESULTS

Seven studies with 529 participants were included. Compared with no-treatment, TCY improved FMA-UE (MD = 7.31, 95% CI: 5.86-8.77, minimal clinically important difference [MCID]: 9-10), BBS (MD = 4.68, 95% CI: 0.28-9.07, MCID: 4), and BI (MD = 4.12, 95% CI: 3.28-4.96, MCID: 1.85) in stroke survivors.

CONCLUSION

TCY may benefit balance and ADLs in rehabilitation after a stroke, but it may not improve upper-limb function clinically.

The Nursing Home Severity Index and Application to Pressure Injury Risk: Measure Development and Validation Study

BACKGROUND

An assessment tool is needed to measure the clinical severity of nursing home residents to improve the prediction of outcomes and provide guidance in treatment planning.

OBJECTIVE

This study aims to describe the development of the Nursing Home Severity Index, a clinical severity measure targeted for nursing home residents with the potential to be individually tailored to different outcomes, such as pressure injury.

METHODS

A retrospective nonexperimental design was used to develop and validate the Nursing Home Severity Index using secondary data from 9 nursing homes participating in the 12-month preintervention period of the Turn Everyone and Move for Ulcer Prevention (TEAM-UP) pragmatic clinical trial. Expert opinion and clinical literature were used to identify indicators, which were grouped into severity dimensions. Index performance and validation to predict risk of pressure injury were accomplished using secondary data from nursing home electronic health records, Minimum Data Sets, and Risk Management Systems. Logistic regression models including a resident's Worst-Braden score with/without severity dimensions generated propensity scores. Goodness of fit for overall models was assessed using C statistic; the significance of improvement of fit after adding severity components to the model was determined using the likelihood ratio chi-square test. The significance of each component was assessed with odds ratios. Validation based on randomly selected 65% training and 35% validation data sets was used to confirm the reliability of the severity measure. Finally, the discriminating ability of models was evaluated using propensity stratification to evaluate which model best discriminated between residents with/without pressure injury.

RESULTS

Data from 1015 residents without pressure injuries on admission were used for the Nursing Home Severity Index-Pressure Injury and included laboratory, weights/vitals/pain, underweight, and locomotion severity dimensions. Logistic regression C statistic measuring predictive accuracy increased by 19.3% (from 0.627 to 0.748; P<.001) when adding four severity dimensions to Worst-Braden scores. Significantly higher odds of developing pressure injuries were associated with increasing dimension scores. The use of the three highest propensity deciles predicting the greatest risk of pressure injury improved predictive accuracy by detecting 21 more residents who developed pressure injury (n=58, 65.2% vs n=37, 42.0%) when both severity dimensions and Worst-Braden score were included in prediction modeling.

CONCLUSIONS

The clinical Nursing Home Severity Index-Pressure Injury was successfully developed and tested using the outcome of pressure injury. Overall predictive capacity was enhanced when using severity dimensions in combination with Worst-Braden scores. This index has the potential to significantly impact the quality of care decisions aimed at improving individual pressure injury prevention plans.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02996331; http://clinicaltrials.gov/ct2/show/NCT02996331.

Early passive orthostatic training prevents diaphragm atrophy and dysfunction in intensive care unit patients on mechanical ventilation: A retrospective case‒control study

BACKGROUND

Intensive care unit (ICU) patients on mechanical ventilation (MV), who are always bedridden, easily develop diaphragm atrophy and dysfunction. However, few studies have assessed diaphragmatic thickness and functional changes after early passive orthostatic training.

OBJECTIVES

This is the first study to investigate the efficacy of early passive orthostatic training in preventing diaphragm atrophy and dysfunction in ICU patients on MV.

METHODS

In this randomized retrospective case‒control study, 81 ICU patients on MV for 8 days or longer were enrolled. Forty-four patients received early passive orthostatic training initiated within 72 h of MV initiation (training group), and 37 patients did not receive training (no-training group). The protocol was performed for seven days, once a day for 30 min. The primary outcomes were diaphragmatic thickness and diaphragm contractile fraction (TFdi). The ventilatory parameters were secondary outcomes.

RESULTS

This study included 81 (45 male) ICU patients on MV [(mean ± SD) age = (60.63 ± 7.88) years]. The training group had a larger diaphragmatic thickness at end-expiration (Tdi_,ee) and a smaller magnitude of decrease in Tdi_,ee and TFdi (p = 0.001, 0.029, and <0.001, respectively) than the no-training group after 7 days of training. The mean arterial pressure, fraction of inspired oxygen, and white blood cell levels were decreased in the training group compared with the no-training group (p = 0.003, 0.001, and 0.026, respectively), but lactic acid levels decreased slightly in the training group with no significant difference (p = 0.708).

CONCLUSIONS

Early passive orthostatic training is suitable to ameliorate diaphragm atrophy and dysfunction in ICU patients on MV.

Test-Retest Reliability and Agreement of Single Pulse Transcranial Magnetic Stimulation (TMS) for Measuring Activity in Motor Cortex in Patients With Acute Ischemic Stroke

Background

Transcranial magnetic stimulation (TMS) is often used to examine neurophysiology. We aimed to investigate the inter-rater reliability and agreement of single pulse TMS in hospitalised acute ischemic stroke patients.

Methods

Thirty-one patients with first-time acute ischemic stroke (median age 72 (IQR 64-75), 35% females) underwent TMS motor threshold (MT) assessment in 4 muscles bilaterally, conducted by 1 of 2 physiotherapists. Test-retest reliability was evaluated using a two-way random effects model (2,1) absolute agreement-type Interclass Correlation Coefficient (ICC). Standard Error of Measurement (SEM) and Smallest Detectable Change (SDC) were used to evaluate agreement.

Results

Reliability, SEM, and SDC of TMS was found to be moderate in right opponens pollicis (0.78 [CI 95% 0.55-0.89], SEM: 4.51, SDC: 12.51), good in right vastus medialis and tibial anterior (0.88 [CI 95% 0.72-0.96], SEM: 2.89, SDC: 8.01 and 0.88 [CI 95% 0.76-0.94], SEM: 2.88, SDC: 7.98 respectively), and excellent in right and left biceps brachii (0.98 [CI 95% 0.96-0.99], SEM: 1.79 SDC: 4.96, and 0.94 [CI 95% 0.89-0.97], SEM: 2.17 SDC: 6.01), opponens pollicis (0.92 [CI 95% 0.83-0.96], SEM: 2.68 SDC: 8.26, vastus medialis (0.92 [CI 95% 0.84-0.96], SEM: 2.87 SDC: 7.95), and tibial anterior (0.93 [CI 95% 0.86-0.96], SEM: 2.51 SDC: 6.95).

Conclusion

The TMS demonstrated moderate to excellent inter-rater reliability confirming the ability of these measures to reliably discriminate between individuals in the current study sample. Improvements of less than 4.96 to 12.51 could be a result of measurement error and may therefore not be considered a true change.

Rehabilitation of social cognition impairment after traumatic brain injury: a systematic review

INTRODUCTION

Many studies have described the presence of difficulty processing and generating social behaviour in patients who have suffered a traumatic brain injury (TBI). These difficulties in social cognition (SC) deteriorate personal relationships in the family, at work, or in the community. However, therapeutic programmes aiming to improve SC continue to be an outstanding issue in clinical practice. We performed a systematic review of the existing literature on the recovery of SC in patients with TBI, assessing the methodological quality of the included studies and the therapeutic effectiveness of the rehabilitation strategies used.

DEVELOPMENT

We performed a bibliographic search of papers published before June 2018 in the Medline/PubMed, Google Scholar, PsycINFO, and ClinicalTrials.gov databases. Of the 198 potentially relevant articles, 10 met our eligibility criteria. Two of the authors independently and blindly assessed the methodological quality of these studies using the PEDro scale.

CONCLUSIONS

The articles included in this systematic review essentially studied the effect of different interventions aimed at the rehabilitation of SC in patients with chronic TBIs. The analysis showed adequate methodological quality and an acceptable level of evidence. Future research should analyse the effect of these interventions in patients with TBIs in the sub- and post-acute phases.

Increasing the Amount and Intensity of Stepping Training During Inpatient Stroke Rehabilitation Improves Locomotor and Non-Locomotor Outcomes

BACKGROUND

The efficacy of traditional rehabilitation interventions to improve locomotion post-stroke, including providing multiple exercises targeting impairments and activity limitations, is uncertain. Emerging evidence rather suggests attempts to prioritize stepping practice at higher cardiovascular intensities may facilitate greater locomotor outcomes.

OBJECTIVE

The present study was designed to evaluate the comparative effectiveness of high-intensity training (HIT) to usual care during inpatient rehabilitation post-stroke.

METHODS

Changes in stepping activity and functional outcomes were compared over 9 months during usual-care (n = 131 patients < 2 months post-stroke), during an 18-month transition phase with attempts to implement HIT (n = 317), and over 12 months following HIT implementation (n = 208). The transition phase began with didactic and hands-on education, and continued with meetings, mentoring, and audit and feedback. Fidelity metrics included percentage of sessions prioritizing gait interventions and documenting intensity. Demographics, training measures, and outcomes were compared across phases using linear or logistic regression analysis, Kruskal-Wallis tests, or χ2 analysis.

RESULTS

Across all phases, admission scores were similar except for balance (usual-care>HIT; P < .02). Efforts to prioritize stepping and achieve targeted intensities during HIT vs transition or usual-care phases led to increased steps/day (P < .01). During HIT, gains in 10-m walk [HIT median = 0.13 m/s (interquartile range: 0-0.35) vs usual-care = 0.07 m/s (0-0.24), P = .01] and 6-min walk [50 (9.3-116) vs 2.1 (0-56) m, P < .01] were observed, with additional improvements in transfers and stair-climbing.

CONCLUSIONS

Greater efforts to prioritize walking and reach higher intensities during HIT led to increased steps/day, resulting in greater gains in locomotor and non-locomotor outcomes.

Effects of robotic rehabilitation on recovery of hand functions in acute stroke: A preliminary randomized controlled study

OBJECTIVE

The aim of this study was to investigate the effects of EMG-driven robotic rehabilitation on hand motor functions and daily living activities of patients with acute ischemic stroke.

MATERIALS & METHOD

A preliminary randomized-controlled, single-blind trial rectuited twenty-four patients with acute ischemic stroke (<1 month after cerebrovascular accident) and randomly allocated to experimental group (EG) and control group (CG). Neurophysiological rehabilitation program was performed to both EG and CG for 5 days a week and totally 15 sessions. The EG also received robotic rehabilitation with the EMG-driven exoskeleton hand robot (Hand of Hope®, Rehab-Robotics Company) 15 sessions over 3 weeks. Hand motor functions (Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT)), activities of daily living (Motor Activity Log (MAL)), force and EMG activities of extensor and flexor muscles for the cup test were evaluated before treatment (pretreatment) and after the 15th session (posttreatment).

RESULTS

Eleven patients (59.91 ± 14.20 yr) in the EG and 9 patients (70 ± 14.06 yr) in the CG completed the study. EG did not provide a significant advantage compared with the CG in FMA-UE, ARAT and MAL scores and cup-force and EMG activities (p > .05 for all).

CONCLUSION

In this preliminary study, improvement in motor functions, daily living activities and force were found in both groups. However, addition of the EMG-driven robotic treatment to the neurophysiological rehabilitation program did not provide an additional benefit to the clinical outcomes in 3 weeks in acute stroke patients.

Effects of computer-based cognitive rehabilitation on working memory in patients with acquired brain injury in the chronic phase, a pilot-study

BACKGROUND

Working memory impairment is common in patients in the chronic phase after acquired brain injury (ABI), and there is a need to develop efficacious rehabilitation methods. This trial explored the effects of two different computer-based cognitive rehabilitation (CBCR) programmes on working memory in the chronic phase after ABI, as well as the role of continuous support versus no support from a health professional on the efficacy of CBCR.

METHODS

A total of 72 patients were randomized into four different groups for a 12-week intervention: Two groups trained with the CBCR-programmes 'Cogmed' and 'Brain+ Health,' respectively, and one group completed active-control training. All three groups received continuous support from a health professional. The last group trained with the CBCR programme 'Brain+ Health' but received no support. Before and after the intervention, patients were tested with a neuropsychological battery of working memory, attention and executive functions.

RESULTS

Both CBCR-programmes improved working memory when administered with support from a health professional. The programmes improved different sub-components of working memory, possibly because of their individual content and design. None of the CBCR-programmes were more efficacious than sham-training with support. CBCR without support did not improve working memory in patients.

Contralesional plasticity following constraint-induced movement therapy benefits outcome: contributions of the intact hemisphere to functional recovery

Stroke is a leading cause of death and disability worldwide. A common, chronic deficit after stroke is upper limb impairment, which can be exacerbated by compensatory use of the nonparetic limb. Resulting in learned nonuse of the paretic limb, compensatory reliance on the nonparetic limb can be discouraged with constraint-induced movement therapy (CIMT). CIMT is a rehabilitative strategy that may promote functional recovery of the paretic limb in both acute and chronic stroke patients through intensive practice of the paretic limb combined with binding, or otherwise preventing activation of, the nonparetic limb during daily living exercises. The neural mechanisms that support CIMT have been described in the lesioned hemisphere, but there is a less thorough understanding of the contralesional changes that support improved functional outcome following CIMT. Using both human and non-human animal studies, the current review explores the role of the contralesional hemisphere in functional recovery of stroke as it relates to CIMT. Current findings point to a need for a better understanding of the functional significance of contralesional changes, which may be determined by lesion size, location, and severity as well stroke chronicity.

Neuromuscular Electric Stimulation in Addition to Exercise Therapy in Patients with Lower Extremity Paresis Due to Acute Ischemic Stroke. A proof-of-concept randomised controlled trial

INTRODUCTION

Exercise therapy and neuromuscular electrical stimulation (NMES) during the initial 14 days after stroke may benefit recovery of gait. We aimed to determine whether poststroke NMES of vastus medial and tibial muscles during exercise therapy is more effective than exercise therapy alone.

MATERIALS AND METHODS

In this proof-of-concept randomised trial patients with first-ever acute ischemic stroke and a leg paresis (40-85 years of age) were randomised (1:1) to 10 min of daily NMES + exercise therapy or exercise therapy alone. Primary outcome was the between-group difference in change in 6 min Walk Test (6MWT) at 90 days post stroke estimated with a mixed regression model. Secondary outcomes included 10 m Walk Test, Fugl-Meyer Motor Assessment, Guralnik Timed Standing Balance, Sit to Stand, Timed Up and Go, EQ-5D-5L, Montreal Cognitive Assessment and Becks Depression Inventory.

RESULTS

50 stroke survivors (25 in each group) with a mean age of 67 years (range 43-83) were included. An insignificant between-group difference in change of 28.3 m (95%CI -16.0 to 72.6, p = 0.23, adjusted for baseline) in 6MWT at 90-days follow-up was found, in favour of the NMES group. All secondary outcomes showed no statistically significant between-group difference. The conclusion was that adding NMES to exercise therapy had no effect on poststroke walking distance measured by the 6 MWT or any of the secondary outcomes.

CONCLUSIONS

In this proof-of-concept RCT, we demonstrated that NMES in addition to exercise therapy during the first 14 days after onset of ischemic stroke did not improve walking distance or any of the secondary outcomes. Future studies with a longer trial period, stratifying patients into subgroups with comparable patterns of expected spontaneous recovery - if possible within 48 h post stroke, and greater sample size, than in this study are suggestions of how rehabilitation research could go on exploring the potential for NMES as an amplifier in stroke recovery.

Motor stroke recovery after tDCS: a systematic review

The purpose of the present study was to investigate the effects of transcranial direct current stimulation (tDCS) on motor recovery in adult patients with stroke, taking into account the parameters that could influence the motor recovery responses. The second aim was to identify the best tDCS parameters and recommendations available based on the enhanced motor recovery demonstrated by the analyzed studies. Our systematic review was performed by searching full-text articles published before February 18, 2019 in the PubMed database. Different methods of applying tDCS in association with several complementary therapies were identified. Studies investigating the motor recovery effects of tDCS in adult patients with stroke were considered. Studies investigating different neurologic conditions and psychiatric disorders or those not meeting our methodologic criteria were excluded. The main parameters and outcomes of tDCS treatments are reported. There is not a robust concordance among the study outcomes with regard to the enhancement of motor recovery associated with the clinical application of tDCS. This is mainly due to the heterogeneity of clinical data, tDCS approaches, combined interventions, and outcome measurements. tDCS could be an effective approach to promote adaptive plasticity in the stroke population with significant positive premotor and postmotor rehabilitation effects. Future studies with larger sample sizes and high-quality studies with a better standardization of stimulation protocols are needed to improve the study quality, further corroborate our results, and identify the optimal tDCS protocols.

Quasi-Contextualized Speech Treatment in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge

OBJECTIVE

To evaluate the effect of providing quasi-contextualized speech therapy, defined as metacognitive, compensatory, or strategy training applied to cognitive and language impairments to facilitate the performance of future real-life activities, on functional outcomes up to 1 year following traumatic brain injury (TBI).

SETTING

Acute inpatient rehabilitation.

PARTICIPANTS

Patients enrolled during the TBI-Practice-Based Evidence (TBI-PBE) study (n = 1760), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received speech therapy in acute inpatient rehabilitation at one of 9 US sites, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation.

DESIGN

Propensity score methods applied to a database consisting of multisite, prospective, longitudinal observational data.

MAIN MEASURES

Participation Assessment with Recombined Tools-Objective-17, FIM Motor and Cognitive scores, Satisfaction With Life Scale, and Patient Health Questionnaire-9.

RESULTS

When at least 5% of therapy time employed quasi-contextualized treatment, participants reported better community participation during the year following discharge. Quasi-contextualized treatment was also associated with better motor and cognitive function at discharge and during the year after discharge. The benefit, however, may be dependent upon a balance of rehabilitation time that relied on contextualized treatment.

CONCLUSIONS

The use of quasi-contextualized treatment may improve outcomes. Care should be taken, however, to not provide quasi-contextualized treatment at the expense of contextualized treatment.

Effects of different rehabilitation provision systems on functional recovery in patients with subacute stroke

INTRODUCTION

The extent of rehabilitation is a key element in promoting functional recovery in patients with stroke. However, the type of rehabilitation therapy that should be provided to improve functional outcomes remains unclear.

OBJECTIVE

This study aimed to compare the effects of three different rehabilitation provision systems, namely conventional rehabilitation therapy, conventional rehabilitation therapy plus physical therapy (PT) on weekends, and conventional rehabilitation therapy plus PT and occupational therapy (OT) on weekends, on functional recovery in patients with subacute stroke.

DESIGN

Retrospective observational cohort study.

SETTING

Convalescence Rehabilitation Hospital.

PATIENTS

Three hundred and one patients with subacute stroke (mean age, 69.7 ± 12.8 years).

INTERVENTIONS

Patients were classified into three groups according to rehabilitation therapy they received: a conventional group (only weekdays PT and OT; n = 70), an additional PT group (additional PT on weekends; n = 119), and an additional PT + OT group (additional PT and OT on weekends; n = 112).

MAIN OUTCOME MEASURE

Functional Independence Measure (FIM) effectiveness was calculated as (discharge FIM - admission FIM/maximum FIM - admission FIM) × 100. A multivariate general linear model was used to assess the difference in FIM effectiveness among the groups.

RESULTS

The mean FIM effectiveness in the conventional, additional PT, and additional PT + OT groups were 39.3 ± 30.1, 43.4 ± 33.2, and 54.3 ± 29.1, respectively. The multivariate analysis revealed a significant difference in FIM effectiveness among the three groups (P = 0.036), and the η_p ² was 0.02, indicating a small effect. The additional PT + OT group showed significantly greater improvements in FIM effectiveness than the conventional group (mean difference = 8.78, SE = 3.58, 95% confidence interval: 0.17-17.39).

CONCLUSIONS

This study showed that the additional PT + OT group had better functional recovery than did the conventional group. This indicates that increasing the amount of both PT and OT can promote post-stroke functional recovery. This article is protected by copyright. All rights reserved.

Effect of early intensive rehabilitation on the clinical outcomes of patients with acute stroke

AIM

Intensive rehabilitation effectively improves physical functions in patients with acute stroke, but the frequency of intervention and its cost-effectiveness are poorly studied. This study aimed to examine the effect of early high-frequency rehabilitation intervention on inpatient outcomes and medical expenses of patients with stroke.

METHODS

The study retrospectively included 1759 patients with acute stroke admitted to the Kobe City Medical Center General Hospital between 2013 and 2016. Patients with a transient ischemic attack, subarachnoid hemorrhage, and those who underwent urgent surgery were excluded. Patients were divided into two groups according to the frequency of rehabilitation intervention: the high-frequency intervention group (>2 times/day, n = 1105) and normal-frequency intervention group (<2 times/day, n = 654). A modified Rankin scale score ≤2 at discharge, immobility-related complications and medical expenses were compared between the groups.

RESULTS

The high-frequency intervention group had a significantly shorter time to first rehabilitation (median [interquartile range], 19.0 h [13.1-38.4] vs. 24.7 h [16.1-49.4], P < 0.001) and time to first mobilization (23.3 h [8.7-47.2] vs. 22.8 h [5.7-62.3], P = 0.65) than the normal-frequency intervention group. Despite higher disease severity, the high-frequency intervention group exhibited favorable outcomes at discharge (modified Rankin scale, ≤2; adjusted odds ratio, 1.89; 95% confidence interval, 1.25-2.85; P = 0.002). No significant differences were observed between the two groups concerning the rate of immobility-related complications and total medical expenses during hospitalization.

CONCLUSIONS

High-frequency intervention was associated with improved outcomes and decreased medical expenses in patients with stroke. Our results may contribute to reducing medical expenses by increasing the efficiency of care delivery. Geriatr Gerontol Int 2021; 21: 623-628.

Transitions of Care Coordination Intervention Identifies Barriers to Discharge in Hospitalized Stroke Patients

Background: Prolonged hospital lengths of stay increase costs, delay rehabilitation, and expose acute ischemic stroke patients to hospital-acquired infections. We designed and implemented a nurse-driven transitions of care coordinator (TOCC) program to facilitate the transition of care from the acute care hospital setting to rehabilitation centers and home.

Methods: This was a single-blinded, prospective, randomized pilot study of 40 participants to evaluate the feasibility of implementing a TOCC program led by a stroke nurse navigator in hospitalized acute ischemic stroke patients. The intervention consisted of a stroke nurse navigator completing eight specific tasks, including meeting with stroke patients and their families, facilitating communication between team members at multi-disciplinary rounds, assisting with referrals to rehabilitation facilities, providing stroke education, and arranging stroke clinic follow-up appointments, which were confirmed to be completed by independent study personnel. The primary outcome was to assess the feasibility of the program. The secondary outcomes included comparing hospital length of stay (LOS) and patient satisfaction between the TOCC and usual care groups. We also explored the association between patient-level variables and LOS.

Results: The TOCC program was feasible with all pre-specified components completed in 84.2% (95% CI: 60.4–96.6%) and was not significantly different from the assumed completion rate of 75% (p = 0.438). There was no significant difference in median LOS between the two groups [TOCC 5.95 days (4.02, 9.57) vs. usual care 4.01 days (2.00, 10.45), false discovery rate (FDR)-adjusted p = 0.138]. There was a trend toward higher patient median satisfaction in the TOCC group [TOCC 35.00 (33.00, 35.00) vs. usual care 30 (26.00, 35.00), FDR-adjusted p = 0.1] as assessed by a questionnaire at 30 days after discharge. The TOCC study allowed us to identify patient variables (gender, insurance, stroke severity, and discharge disposition) that were significantly associated with longer hospital LOS.

Conclusion: A TOCC program is feasible and can serve as a guide for future allocation of resources to facilitate transitions of care and avoid prolonged hospital stays.

Feasibility of a One Degree-of-Freedom Linear Robot for Bed-Bound Stroke Rehabilitation

A 1DOF lower limb rehabilitation robot is presented for delivering leg extension therapy to bed-bound stroke patients. Such a compact and minimal system may be beneficial in terms of compatibility with pre-existing hospital equipment, ease-of-use, safety, and cost. A set of design criteria was created based on the literature and on previous field work at a local hospital. The device uses admittance control to apply assistive or resistive forces, and can also use haptic feedback to increase user engagement. A pilot study on six healthy participants was used to determine the feasibility of such a minimal system in administering assistance or resistance through the leg extension exercise. Results indicate that a single DOF is capable of decreasing trajectory error with assistance and increasing user effort with resistance. Observations confirm that the minimal system is effective; however, extending the robot with additional DOFs so that it can target multiple bed-bound exercises may help to increase therapy duration.

Evidence for a Window of Enhanced Plasticity in the Human Motor Cortex Following Ischemic Stroke

BACKGROUND

In preclinical models, behavioral training early after stroke produces larger gains compared with delayed training. The effects are thought to be mediated by increased and widespread reorganization of synaptic connections in the brain. It is viewed as a period of spontaneous biological recovery during which synaptic plasticity is increased.

OBJECTIVE

To look for evidence of a similar change in synaptic plasticity in the human brain in the weeks and months after ischemic stroke.

METHODS

We used continuous theta burst stimulation (cTBS) to activate synapses repeatedly in the motor cortex. This initiates early stages of synaptic plasticity that temporarily reduces cortical excitability and motor-evoked potential amplitude. Thus, the greater the effect of cTBS on the motor-evoked potential, the greater the inferred level of synaptic plasticity. Data were collected from separate cohorts (Australia and UK). In each cohort, serial measurements were made in the weeks to months following stroke. Data were obtained for the ipsilesional motor cortex in 31 stroke survivors (Australia, 66.6 ± 17.8 years) over 12 months and the contralesional motor cortex in 29 stroke survivors (UK, 68.2 ± 9.8 years) over 6 months.

RESULTS

Depression of cortical excitability by cTBS was most prominent shortly after stroke in the contralesional hemisphere and diminished over subsequent sessions (P = .030). cTBS response did not differ across the 12-month follow-up period in the ipsilesional hemisphere (P = .903).

CONCLUSIONS

Our results provide the first neurophysiological evidence consistent with a period of enhanced synaptic plasticity in the human brain after stroke. Behavioral training given during this period may be especially effective in supporting poststroke recovery.

Portable rehabilitation system with brain-computer interface for inpatients with acute and subacute stroke: A feasibility study

The feasibility and safety of brain-computer interface (BCI) systems for patients with acute/subacute stroke have not been established. The aim of this study was to firstly demonstrate the feasibility and safety of a bedside BCI system for inpatients with acute/subacute stroke in a small cohort of inpatients. Four inpatients with early-phase hemiplegic stroke (7-24 days from stroke onset) participated in this study. The portable BCI system showed real-time feedback of sensorimotor rhythms extracted from scalp electroencephalograms (EEGs). Patients attempted to extend the wrist on their affected side, and neuromuscular electrical stimulation was applied only when the system detected significant movement intention-related changes in EEG. Between 120 and 200 training trials per patient were successfully and safely conducted at the bedside over 2-4 days. Our results clearly indicate that the proposed bedside BCI system is feasible and safe. Larger clinical studies are needed to determine the clinical efficacy of the system and its effect size in the population of patients with acute/subacute post-stroke hemiplegia.

Association of Therapy Time and Cognitive Recovery in Stroke Patients in Post-Acute Rehabilitation

OBJECTIVES

Cognitive impairment is highly prevalent after stroke, with 77% of people having impairment in at least 2 cognitive domains. The purpose of this study is to describe the association between therapy minutes per length of stay (LOS) day and cognitive recovery in patients receiving rehabilitation services in inpatient post-acute care facilities following a stroke.

DESIGN

Secondary analyses of data collected in inpatient rehabilitation and skilled nursing facilities from 2005 to 2010 for an observational cohort study.

SETTING AND PARTICIPANTS

Participants were adults aged ≥65 years with Medicare insurance and primary diagnosis of stroke (N = 100). Participants who met criteria for dementia (n = 5) were excluded from analyses. We calculated therapy minutes per LOS day for occupational therapy, physical therapy, speech-language pathology, and all therapies combined; therapy times were dichotomized into high or low minutes per LOS day (MLD). We used an ordinary least squares regression model for cognitive outcome at discharge to control for cognitive status at admission, therapy intensity by discipline, and LOS.

RESULTS

At baseline, participants were classified as having severe (n = 11), moderate (n = 39), or mild (n = 45) cognitive impairment. Impairment groups were not significantly different on any demographic variables. The adjusted regression model showed that high occupational therapy MLD (>50 minutes per LOS day) (P = .028) was significantly associated with cognitive measure at discharge compared with low occupational therapy MLD when controlling for cognitive impairment group at baseline (P < .001). Neither high physical therapy MLD nor speech-language pathology MLD was significantly associated with cognitive outcome relative to their respective low TMLD groups.

CONCLUSIONS AND IMPLICATIONS

Our results show that higher-intensity occupational therapy services were associated with better cognitive outcome at discharge from inpatient rehabilitation after stroke. Findings also suggest that volume of therapy alone does not necessarily produce optimal outcomes. Both amount and type of therapy should be tailored to meet the needs of individual patients.

Movement Matters, and So Does Context: Lessons Learned From Multisite Implementation of the Movement Matters Activity Program for Stroke in the Comprehensive Postacute Stroke Services Study

The purpose of this Special Communication is to discuss the rationale and design of the Movement Matters Activity Program for Stroke (MMAP) and explore implementation successes and challenges in home health and outpatient therapy practices across the stroke belt state of North Carolina. MMAP is an interventional component of the Comprehensive Postacute Stroke Services Study, a randomized multicenter pragmatic trial of stroke transitional care. MMAP was designed to maximize survivor health, recovery, and functional independence in the community and to promote evidence-based rehabilitative care. MMAP provided training, tools, and resources to enable rehabilitation providers to (1) prescribe physical activity and exercise according to evidence-based guidelines and programs, (2) match service setting and parameters with survivor function and benefit coverage, and (3) align treatment with quality metric reporting to demonstrate value-based care. MMAP implementation strategies were aligned with the Expert Recommendations for Implementing Change project, and MMAP site champion and facilitator survey feedback were thematically organized into the Consolidated Framework for Implementation Research domains. MMAP implementation was challenging, required modification and was affected by provider- and system-level factors. Program and study participation were limited and affected by practice priorities, productivity standards, and stroke patient volume. Sites with successful implementation appeared to have empowered MMAP champions in vertically integrated systems that embraced innovation. Findings from this broad evaluation can serve as a road map for the design and implementation of other comprehensive, complex interventions that aim to bridge the currently disconnected realms of acute care, postacute care, and community resources.

Factors predicting rehabilitation outcomes after severe acquired brain injury in trauma, stroke and anoxia populations: A cohort study

Severe acquired brain injury has long-term physical and cognitive effects. Identifying patient variables predictive of recovery in different brain injury populations would generate improved prognostic information and help rehabilitation teams set appropriate therapeutic goals. This cohort study of 447 NHS neurorehabilitation inpatients aimed to identify functional and cognitive predictors of recovery following severe acquired brain injury caused by trauma, stroke and anoxia. Motor and cognitive impairment ratings were collected at admission and discharge using the Functional Independence Measure and Functional Assessment Measure (FIM+FAM), and injury-related and demographic data were collated from medical records. Predictors of physical, cognitive and overall recovery were identified via hierarchical regression analyses. Several key findings emerged. Firstly, on-admission motor skills predicted functional and overall outcomes across groups. Secondly, on-admission social interaction skills predicted cognitive discharge outcomes in stroke and trauma, and overall outcomes for stroke, but did not predict anoxia outcomes. Thirdly, age predicted all forms of recovery for stroke only. Further group-specific factors were also identified as predicting motor and cognitive recovery, indicating that factors key to the rehabilitation trajectory may differ between populations. These variables should be considered in rehabilitation goal planning, although further research is required to explore their contributions to recovery.

Systematic review and meta-analysis of the effect of cognitive impairment on the risk of admission to long-term care after stroke

Introduction: Admission to long-term care (LTC) post-stroke can be a significant source of costs. Studies evaluating the effect of cognitive impairment (CI) and dementia on risk of LTC admission post-stroke have not been systematically reviewed. The aim of this paper was to conduct a systematic review and meta-analysis of studies of the association between post-stroke CI/dementia and admission to LTC. Patients and methods: PubMed, PsycInfo and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched for peer-review articles in English published January 2000-June 2018. Included studies were population-based or hospital-based studies assessing the relationship between CI or dementia, and admission to LTC post-stroke. Abstracts were screened, followed by full-text review of potentially relevant articles. Relevant data was extracted using a standard form and the Crowe Critical Appraisal Tool was used for quality appraisal. Results were pooled using random-effects meta-analysis and heterogeneity was assessed using the I² statistic. Results: 18 articles were included in the review and 12 in a meta-analysis. 14/18 studies adjusted for covariates including functional impairment. Increased odds of admission to LTC was associated with post-stroke CI [Odds Ratio (CI 95%): 2.36 (1.18, 4.71), I²=77%] and post-stroke dementia [Odds Ratio (CI 95%): 2.58 (1.38 to 4.82), I²=60%]. Discussion and conclusion: Post-stroke CI and dementia increase odds of admission to LTC post-stroke, independent of functional impairment. This indicates the potential for interventions that reduce post-stroke CI and dementia to also reduce risk of admission to LTC post-stroke, and ultimately costs.

Modafinil in Recovery after Stroke (MIRAS): A Retrospective Study

BACKGROUND AND PURPOSE

Acute rehabilitation is known to enhance stroke recovery. However, poststroke lethargy and fatigue can hinder participation in rehabilitation therapies. We hypothesized that in patients with moderate to severe stroke complicated by poststroke fatigue and lethargy early stimulant therapy with modafinil increases favorable discharge disposition defined as transfer to acute inpatient rehabilitation or home.

METHODS

We retrospectively reviewed a cohort of patients with acute stroke admitted to the stroke service over a 3-year period. All patients 18 years or older with confirmed ischemic or hemorrhagic stroke, an NIHSS greater than or equal to 5 and documentation of fatigue/lethargy in clinical documentation were included. We compared patients that were treated with modafinil 50-200 mg to those managed with standard care. The primary outcome measure was discharge disposition. Secondary outcome was 90 day modified Rankin score (mRS). Statistical significance was determined using chi-square test for association and logistic regression models. Logistic regression models were derived in 2 ways with both raw data and an adjusted model that accounted for age, sex, and NIHSS score to account for the lack of randomization.

RESULTS

This study included 199 stroke patients (145 ischemic, 54 hemorrhagic). Seventy-two (36.2%) were treated with modafinil and 129 (64.8%) were discharged to acute inpatient rehabilitation, while none were recommended for discharge home. Median NIHSS for modafinil patients was 13.5 versus 11 for standard care patients (P = .059). In adjusted models, modafinil was associated with higher odds of favorable discharge disposition (OR 2.00, 95% CI 1.01-3.95). Favorable outcome at 90 days defined as mRS less than or equal to 2 occurred more frequently with modafinil (5.6% versus 3.3%) but this did not achieve statistical significance (P > .1). These results occurred despite the modafinil group requiring longer ICU stays and having more in-hospital complications such as infections and need for percutaneous gastrostomy tubes. The benefit of modafinil was seen across all subgroups except those with severe stroke (NIHSS ≥ 15). There were no significant adverse events associated with modafinil administration.

CONCLUSIONS

Modafinil use in acute in-hospital stroke patients with moderate stroke complicated by lethargy and fatigue was associated with improved discharge disposition. Randomized controlled trials are needed to further study the safety, efficacy, and long-term effects of modafinil in this patient population.

Effects of bodyweight support and guidance force on muscle activation during Locomat walking in people with stroke: a cross-sectional study

BACKGROUND

Locomat is a robotic exoskeleton providing guidance force and bodyweight support to facilitate intensive walking training for people with stroke. Although the Locomat has been reported to be effective in improving walking performance, the effects of training parameters on the neuromuscular control remain unclear. This study aimed to compare the muscle activities between Locomat walking and treadmill walking at a normal speed, as well as to investigate the effects of varying bodyweight support and guidance force on muscle activation patterns during Locomat walking in people with stroke.

METHODS

A cross-sectional study design was employed. Participants first performed an unrestrained walking on a treadmill and then walked in the Locomat with different levels of bodyweight support (30% or 50%) and guidance force (40% or 70%) at the same speed (1.2 m/s). Surface electromyography (sEMG) of seven muscles of the affected leg was recorded. The sEMG envelope was time-normalised and averaged over gait cycles. Mean sEMG amplitude was then calculated by normalising the sEMG amplitude with respect to the peak amplitude during treadmill walking for statistical analysis. A series of Non-parametric test and post hoc analysis were performed with a significance level of 0.05.

RESULTS

Fourteen participants with stroke were recruited at the Yangzhi Affiliated Rehabilitation Hospital of Tongji University (female n = 1; mean age 46.1 ± 11.1 years). Only the mean sEMG amplitude of vastus medialis oblique during Locomat walking (50% bodyweight support and 70% guidance force) was significantly lower than that during treadmill walking. Reducing both bodyweight and guidance increased muscle activity of gluteus medius and tibialis anterior. Activity of vastus medialis oblique muscle increased as bodyweight support reduced, while that of rectus femoris increased as guidance force decreased.

CONCLUSIONS

The effects of Locomat on reducing muscle activity in people with stroke were minimized when walking at a normal speed. Reducing bodyweight support and guidance force increased the activity of specific muscles during Locomat walking. Effects of bodyweight support, guidance force and speed should be taken into account when developing individualized Locomat training protocols for clients with stroke.

Perspectives of inpatient neurological rehabilitation in elderly patients

Demographic data record an increasing number of people aged over 65 years, with specific health conditions and a high probability to suffer from chronic diseases, cognitive impairment or loss of autonomy, and with limited functional reserve. The prevalence of disability increases with age, affecting 33% of men and 42% of women aged over 85 years. Many neurodegenerative disorders increase in prevalence with age. Thus, the need for rehabilitation treatment in this segment of population is very high, loss of functioning being the most prominent condition for admitting elderly persons in rehabilitation facilities. Rehabilitation in the elderly is an important tool in regaining autonomy, associated with substantial reduction in the burden of health and social costs. Patients aged over 80 years need a comprehensive geriatric assessment (CGA) to establish the global capabilities of the person for inclusion in a coordinated therapy plan and a long term follow-up. CGA will identify patients with severe or complicated medical conditions and important disability who require a multidisciplinary team and a coordinated rehabilitation program, accessible only in rehabilitation hospitals. Rehabilitation treatment should start from the intensive care unit, and continues until the patient reaches a plateau of maximal functional improvement. The most useful therapeutic interventions in old people are physical and occupational therapy, and, for selected and stable patients, therapy in a balnear resort is an option to improve their quality of life. Key words: geriatric population, rehabilitation, loss of autonomy, old patients,

Improvements in balance reaction impairments following reactive balance training in individuals with sub-acute stroke: A prospective cohort study with historical control

Background: Reactive balance training (RBT) has been previously found to reduce fall risk in individuals with sub-acute stroke; however, our understanding of the effects of RBT on specific balance impairments is lacking.Objective: To quantify changes in common balance reaction impairments in individuals with sub-acute stroke resulting from RBT, relative to traditional balance training, using a prospective cohort study design with a historical control group.Methods: Individuals with sub-acute stroke completed either RBT or traditional balance training as part of their routine care during physiotherapy in inpatient rehabilitation. Reactive balance control was assessed using lean-and-release perturbations pre-intervention, post-intervention, and 6-months post-intervention (follow-up). Individuals with impaired balance reactions (delayed foot-off times, slide steps, and/or a preference for stepping with the preferred limb) at the pre-intervention assessment were identified using video and force plate data. Outcome measures (foot-off times, frequency of trials with slide steps, and stepping with the preferred limb) from the RBT participants with impaired reactions were compared for each of the three assessments to the mean values for the participants with impaired reactions in the historical control group.Results: Improvements were observed in all outcome measures for the RBT participants between pre-intervention and post-intervention, and/or between post-intervention and follow-up. These improvements were generally equivalent to, if not better than, the improvements demonstrated by the historical control group.Conclusions: Findings further support the use of RBT for post-stroke inpatient rehabilitation, and provide insight into specific balance reaction impairments that are improved by RBT.

Effects of transcranial random noise stimulation combined with Graded Repetitive Arm Supplementary Program (GRASP) on motor rehabilitation of the upper limb in sub-acute ischemic stroke patients: a randomized pilot study

We evaluated the combined use of transcranial random noise stimulation (tRNS) with the Graded Repetitive Arm Supplementary Program (GRASP) in sub-acute ischemic stroke patients suffering from arm impairment. Eighteen ischemic stroke patients with upper limb disability were randomly assigned to either the GRASP + tRNS or GRASP + Sham stimulation group. Fugl-Meyer Assessment-Upper extremity (FMA-UE) was performed to evaluate upper limb impairment before treatment (T0), after the last stimulation (T1) and after 30 days (T2). At T1 and T2, beneficial effects in the tRNS group correlated with better FMA-UE score than sham stimulation group (p < 0.001) and these results did not correlate to stroke severity, because no associations were observed between National Institute of Health Stroke Scale and FMA UE T1 and T2. This study displayed a good feasibility and was the first to evaluate the use of tRNS in association with Grasp in sub-acute stroke survivors having arm impairment to improve arm motor recovery.

Inpatient Rehabilitation Care in Alberta: How Much Does Stroke Severity and Timing Matter?

BACKGROUND

We examined the impact of stroke severity and timing to inpatient rehabilitation admission on length of stay (LOS), functional gains, and discharge destination.

METHODS

Alberta inpatient stroke rehabilitation data between April 2013 and March 2017 were analyzed. We evaluated the impact of stroke severity, as measured by the Functional Independence Measure (FIM), on timing to inpatient rehabilitation, functional gains, LOS, and discharge destination. Further, we examined whether timing to inpatient rehabilitation impacted the latter three factors.

RESULTS

The 2404 adults were subcategorized as mild (1237), moderate (1031), or severe (136) based on FIM at inpatient rehabilitation admission. Length of time to rehabilitation admission was not significantly (p = 0.232) different between stroke severities. Mean length of time (days) to rehabilitation admission was 19.79 (20.3 SD) for mild, 27.7 (35.7 SD) for moderate, and 37.70 (56.8 SD) for severe stroke. Mean FIM change for mild (M = 16.3, 9.9 SD) differed significantly (p = 5.1 × 10-9) from moderate (M = 30.4, 16.4 SD) and severe (M = 31.0, 25.7 SD) stroke. The mean LOS for mild stroke (M = 41.3, 31.9 SD) was significantly (p = 5.1 × 10-9) different from moderate stroke (M = 86.8, 76.4 SD) and severe stroke (M = 126.1, 104.2 SD). Time to inpatient rehabilitation admission showed a small, significant impact on FIM change (p = 1.4 × 10-9, partial η2 0.022) and LOS (p = 1.1 × 10-19, partial η2 0.042). Shorter times to rehabilitation admission and mild stroke were associated with discharging home without needing homecare.

CONCLUSION

Stroke severity has a significant impact on the conduct of inpatient rehabilitation. Yet, despite suggestions shortening timing to rehabilitation should improve outcomes, the impact on functional gains and rehabilitation LOS was small.

Visual Biofeedback of Force Information for Eccentric Training of Hemiplegic Patients

Motor learning issues for hemiplegics not only include motor impairments such as spastic paralysis, but reportedly also an inability to appropriately recognize somatic sensations. In this regard, biofeedback of movement information through visual information and auditory information has been found effective as a method for drawing attention to appropriate somatic sensations. In this context, here, we propose a novel eccentric training system utilizing visual biofeedback of force information. We first develop a compact and highly portable rehabilitation robot for home use. The robot estimates the force on the tiptoe without the use of a force sensor, and a display connected to the robot presents the force information to the trainee. Clinical trials with two chronic hemiplegics have been conducted. The results show that the timed up and go tests of both trainees are shortened after training twice a week for three weeks (six times in total). Simultaneously, the co-contraction index scores of the tibialis anterior and gastrocnemius muscles decrease. These findings in conjunction with previous results suggest that training with visual biofeedback of force information may enhance reciprocal inhibition of the tibialis anterior muscle and reduces co-contraction.

Associations Between Adherence to the Physical Activity and Exercise Program Applied in the LAST Study and Functional Recovery After Stroke

OBJECTIVE

To investigate the associations between participants' adherence to a physical activity and exercise program after stroke and functional recovery 18 months after inclusion.

DESIGN

Secondary analyses of the intervention arm in the multisite randomized controlled trial Life After Stroke (LAST).

SETTING

Primary health care services in 3 Norwegian municipalities.

PARTICIPANTS

Of the participants enrolled (N=380), 186 (48.9%) were randomized to the intervention. The study sample comprised community dwelling individuals included 3 months after stroke, with mean age of 71.7 ± 11.9 years and 82 (44.1%) women. According to the National Institutes of Health Stroke Scale, 97.3% were diagnosed as having mild (National Institutes of Health Stroke Scale<8) and 2.7% with moderate (8-16 on the National Institutes of Health Stroke Scale) stroke.

INTERVENTION

Monthly coaching by physiotherapists encouraging participants to adhere to 30 minutes of daily physical activity and 45-60 minutes of weekly exercise.

MAIN OUTCOME MEASURES

The primary outcome was Motor Assessment Scale (MAS). Secondary outcome measures were 6-minute walk test, Timed Up and Go (TUG), Berg Balance Scale (BBS), and the physical domains of the Stroke Impact Scale (SIS). Adherence was assessed by combining participants' training diaries and physiotherapists' reports.

RESULTS

The relationship between adherence and functional recovery was analyzed with simple and multiple linear regression models. Adjusted for age, sex, dependency, and cognition, results showed statistically significant associations between adherence and functional outcomes after 18 months, as measured by MAS, TUG, BBS, and SIS (P≤.026).

CONCLUSIONS

Increased adherence to physical activity and exercise was associated with improved functional recovery after mild to moderate stroke. This emphasizes the importance of developing adherence-enhancing interventions. Dose-response studies are recommended for future research.

Can robot-based measurements improve prediction of motor performance after robot-assisted upper-limb rehabilitation in patients with moderate-to-severe sub-acute stroke?

PURPOSE

Patients with moderate-to-severe stroke-related upper limb impairment can benefit from repetitive robot-assisted training. However, predicting motor performance in these patients from baseline measurements, including robot-based parameters would help clinicians to provide optimal treatments for each individual.

METHODS

Forty-six patients with sub-acute stroke underwent a 16-session upper limb rehabilitation combining usual care and robotic therapy. Motor outcomes (Fugl-Meyer Assessment Upper Extremity (FMA) score) were retrospectively analysed and potential predictors of motor outcome (including baseline FMA scores, kinematics and number of repetitions performed in the first session etc.) were determined.

RESULTS

The 16-sessions upper limb combined training program led to significantly improved clinical outcomes (gains of 13.8±11.2 for total FMA score and 7.3±6.7 for FMA Shoulder/Elbow score). For the prediction model, time since stroke poorly explained the FMA total score (R2 < 35%). The model however found that time since stroke and initial value of FMA Shoulder/Elbow score were predictors of the FMA Shoulder/Elbow score: (R2 = 59.6%).

CONCLUSION

This study found that clinical prediction of motor outcomes after moderate-to-severe upper-limb paresis is limited. However, initial proximal motor impairment severity predicted proximal motor performance. The value of baselines kinematics and of the number of repeated movements at initiation in the prediction would need further studies.

Distal versus proximal - an investigation on different supportive strategies by robots for upper limb rehabilitation after stroke: a randomized controlled trial

Background

Different mechanical supporting strategies to the joints in the upper extremity (UE) may lead to varied rehabilitative effects after stroke. This study compared the rehabilitation effectiveness achieved by electromyography (EMG)-driven neuromuscular electrical stimulation (NMES)-robotic systems when supporting to the distal fingers and to the proximal (wrist-elbow) joints.

Methods

Thirty subjects with chronic stroke were randomly assigned to receive motor trainings with NMES-robotic support to the finger joints (hand group, n = 15) and with support to the wrist-elbow joints (sleeve group, n = 15). The training effects were evaluated by the clinical scores of Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), and Modified Ashworth Scale (MAS) before and after the trainings, as well as 3 months later. The cross-session EMG monitoring of EMG activation level and co-contraction index (CI) were also applied to investigate the recovery progress of muscle activations and muscle coordination patterns through the training sessions.

Results

Significant improvements (P < 0.05) in FMA full score, FMA shoulder/elbow (FMA-SE) and ARAT scores were found in both groups, whereas significant improvements (P < 0.05) in FMA wrist/hand (FMA-WH) and MAS scores were only observed in the hand group. Significant decrease of EMG activation levels (P < 0.05) of UE flexors was observed in both groups. Significant decrease in CI values (P < 0.05) was observed in both groups in the muscle pairs of biceps brachii and triceps brachii (BIC&TRI) and the wrist-finger flexors (flexor carpi radialis-flexor digitorum) and TRI (FCR-FD&TRI). The EMG activation levels and CIs of the hand group exhibited faster reductions across the training sessions than the sleeve group (P < 0.05).

Conclusions

Robotic supports to either the distal fingers or the proximal elbow-wrist could achieve motor improvements in UE. The robotic support directly to the distal fingers was more effective than to the proximal parts in improving finger motor functions and in releasing muscle spasticity in the whole UE.

Clinical trial registration

ClinicalTrials.gov, identifier NCT02117089; date of registration: April 10, 2014. https://clinicaltrials.gov/ct2/show/NCT02117089