Goal-oriented instructions increase the intensity of practice in stroke rehabilitation compared with non-specific instructions: a within-participant, repeated measures experimental study

Do Treatment Ingredients Targeting Working Alliance Improve Cognitive Rehabilitation Session Performance in Patients With Acquired Brain Injury?

PURPOSE

The purpose of this study was to experimentally evaluate the potential impact of clinician-driven therapy ingredients hypothesized to enhance working alliance (WA) and promote patient engagement during cognitive rehabilitation sessions. It was hypothesized that when the clinician introduced evidence-backed alliance enhancing ingredients, there would be a corresponding improvement in participants' (a) performance on attention drills paired with a metacognitive strategy, (b) learning the steps to use a phone application, and (c) adherence to a home exercise program. It was also hypothesized that patients would show perceptual shifts toward stronger alliance.

METHOD

Four adult participants who sustained moderate to severe acquired brain injuries with chronic cognitive deficits participated in the study. The study used a concurrent multiple-baseline design with randomization. Both visual and quantitative analyses were used to compare potential differences in performance on cognitive rehabilitation tasks when specific alliance enhancing behaviors were integrated into sessions.

RESULTS

Findings showed a strong effect for increased performance on attention span tasks when the clinician added the alliance enhancing treatment ingredients. Participants also learned more steps in the phone application task and either maintained or improved homework adherence in the experimental phase when the treatment ingredients were applied. The findings provided mixed results on participant perceptions of WA, as measured by a modified version of the Working Alliance Inventory.

CONCLUSIONS

This study provides some of the first experimental data demonstrating that alliance enhancing treatment ingredients can have a significant influence on patient performance during cognitive rehabilitation sessions. The article offers recommendations for building on this important line of study.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28727006.

Methods of Goal-Setting in Rehabilitation of Adults with Physical Dysfunctions-A Scoping Review

This scoping review utilized the JBI methodology to investigate methods of goal-setting used in the rehabilitation of adults with physical dysfunctions. Electronic databases were searched for articles published in the last 5 years. The inclusion of articles and data extraction were performed by two independent reviewers. Results were presented and synthesized numerically and thematically analyzed. Results suggest that goals should be client-centered and specific and long-term goals, should be complemented with medium and short-term goals. While various goal-setting methods are used in current practice, their full potential is often not realized due to improper implementation. Therefore, there is a need for educating clinicians to improve the goal-setting process and ensure its effectiveness.

Coaching stroke survivors to persevere with practice: An observational behavioural mapping study

ObjectiveTo quantitatively describe therapists' use of coaching with stroke survivors, in a hospital-based rehabilitation setting, to promote perseverance with longer-term practice.DesignProspective observational behavioural mapping study.SettingRehabilitation unit of a regional public hospital in Queensland, Australia.Main measuresA custom-designed behavioural mapping tool was used to collect rehabilitation session contextual data and therapists' use of coaching. Data were captured in 3-minute epochs for a maximum of 30 minutes. Data were analysed using descriptive statistics.ResultsThirty-six rehabilitation sessions, including 34 participants (therapists n = 22, stroke survivors n = 12) were observed. Rehabilitation sessions were mostly inpatient (n = 33, 91.7%), one-on-one (n = 30, 83.3%), and conducted in the physiotherapy (n = 160, 45.5%) or occupational therapy (n = 155, 44.0%) gym. Strategies to promote perseverance were used in 76.7% (n = 267) of observed epochs. The most frequently used strategy was monitoring the quality of practice and the least frequently used strategy was utilising a support person to facilitate practice.ConclusionCoaching that may promote perseverance with practice was regularly used by therapists during hospital-based rehabilitation sessions. Coaching that may enable longer-term perseverance beyond a therapist-dependent rehabilitation model was less commonly observed.

Stroke rehabilitation: from diagnosis to therapy

Stroke remains a significant global health burden, necessitating comprehensive and innovative approaches in rehabilitation to optimize recovery outcomes. This paper provides a thorough exploration of rehabilitation strategies in stroke management, focusing on diagnostic methods, acute management, and diverse modalities encompassing physical, occupational, speech, and cognitive therapies. Emphasizing the importance of early identification of rehabilitation needs and leveraging technological advancements, including neurostimulation techniques and assistive technologies, this manuscript highlights the challenges and opportunities in stroke rehabilitation. Additionally, it discusses future directions, such as personalized rehabilitation approaches, neuroplasticity concepts, and advancements in assistive technologies, which hold promise in reshaping the landscape of stroke rehabilitation. By delineating these multifaceted aspects, this manuscript aims to provide insights and directions for optimizing stroke rehabilitation practices and enhancing the quality of life for stroke survivors.

The Effectiveness of Goal-Oriented Dual Task Proprioceptive Training in Subacute Stroke: A Retrospective Observational Study

OBJECTIVE

To show the effectiveness of goal-oriented proprioceptive training in subacute stroke for balance, autonomy, and fall risk.

METHODS

Out a total of 35 patients, consistent in age (75.31±8.65 years), type of stroke (ischemic, 3 to 11 weeks before), and motor impairment, 18 patients underwent solely proprioceptive rehabilitation, the other 17 dual task exercises. The study assessed autonomy using Barthel Index, fall risk with Timed Up and Go Test (TUG), balance through Berg Balance Scale (BBS) and Tinetti test.

RESULTS

After two months, significant improvements were recorded in Barthel Index, BBS (p<0.0001), Tinetti test (p<0.0001 in dual task group, p=0.0029 in single task group), and TUG (p=0.0052 in dual task group, p=0.0020 in single task group) in both groups. Comparing the two groups, dual task group showed a significant difference in Tinetti balance assessment (p=0.0052), between the total score of Tinetti test and TUG in single (p=0.0271), and dual task (p=0.0235). Likewise, Tinetti gait test was significantly related to TUG in single (p=0.0536), and dual task (p=0.0466), while Tinetti balance test to Barthel Index (p=0.0394), BBS (p<0.0001), and TUG in single (p=0.0219), and dual task (p=0.0196). Lastly, there is a positive correlation of the use of aids with BBS (p=0.0074), and total score of Tinetti test (p=0.0160).

CONCLUSION

In subacute stroke, goal-oriented proprioceptive training improved balance, but only partially autonomy. Furthermore, the use of aids after dual-task exercises improved recovery of balance, but did not reduced falls.

Goal-setting and personalization under the International Classification of Functioning, Disability, and Health framework: Community reintegration program for post-stroke patients

Background

Body functions and structures, activities, and participation are the core components in the International Classification of Functioning, Disability, and Health (ICF) to identify post-stroke patients' health conditions. The specification of health conditions enhances the outcomes of post-stroke rehabilitation.

Purpose

This study aimed to explore the extent and the processes in an ICF-based post-stroke rehabilitation program (ICF-PSRP) that could enhance patients' community reintegration level.

Methods

Post-stroke patients who completed the ICF-PSRP participated in intake and pre-discharge individual face-to-face semi-structured interviews. In addition, case therapists were invited to a face-to-face semi-structured group interview. Clinician experts were invited to complete an interview with the same interview contents as case therapists but in an online format. All interview recordings were analyzed with the Framework analysis. Patients' treatment goals were mapped with the ICF Core Set for Stroke.

Results

Out of 37 invited post-stroke patients, thirty-three of them completed the interview. Three case therapists and five clinicians completed the interviews. The goals set by the patients and their caregivers showed a broadening of their scope over the course of the program. The changes in scope ranged from the activities to the participation and environmental components. Increases in patient-therapist interactions played an essential role in the goal-setting process, which were integral to personalizing the treatment content. These characteristics were perceived by all parties who contributed to the program outcomes.

Conclusion

The application of ICF's principles and core components offers a useful framework for enhancing post-stroke patients' community reintegration level. Future studies should explore the way in which patient-therapist interaction, exposure to environmental factors, and personalized interventions maximize the benefits of applying this framework to the community integration of post-stroke patients.

Motor Decision-Making as a Common Denominator in Motor Pathology and a Possible Rehabilitation Target

Despite the substantial progress in motor rehabilitation, patient involvement and motivation remain major challenges. They are typically addressed with communicational and environmental strategies, as well as with improved goal-setting procedures. Here we suggest a new research direction and framework involving Neuroeconomics principles to investigate the role of Motor Decision-Making (MDM) parameters in motivational component and motor performance in rehabilitation. We argue that investigating NE principles could bring new approaches aimed at increasing active patient engagement in the rehabilitation process by introducing more movement choice, and adapting existing goal-setting procedures. We discuss possible MDM implementation strategies and illustrate possible research directions using examples of stroke and psychiatric disorders.

Motivation as a Measurable Outcome in Stroke Rehabilitation: A Systematic Review of the Literature

Motivated behaviours are thought to lead to enhanced performances. In the neurorehabilitation field, motivation has been demonstrated to be a link between cognition and motor performance, therefore playing an important role upon rehabilitation outcome determining factors. While motivation-enhancing interventions have been frequently investigated, a common and reliable motivation assessment strategy has not been established yet. This review aims to systematically explore and provide a comparison among the existing motivation assessment tools concerning stroke rehabilitation. For this purpose, a literature search (PubMed and Google Scholar) was performed, using the following Medical Subject Headings terms: "assessment" OR "scale" AND "motivation" AND "stroke" AND "rehabilitation". In all, 31 randomized clinical trials and 15 clinical trials were examined. The existing assessment tools can be grouped into two categories: the first mirroring the trade-off between patients and rehabilitation, the latter reflecting the link between patients and interventions. Furthermore, we presented assessment tools which reflect participation level or apathy, as an indirect index of motivation. In conclusion, we are left to put forth a possible common motivation assessment strategy, which might provide valuable incentive to investigate in future research.

Revisiting dose and intensity of training: Opportunities to enhance recovery following stroke

PURPOSE

Stroke is a global leading cause of adult disability with survivors often enduring persistent impairments and loss of function. Both intensity and dosage of training appear to be important factors to help restore behavior. However, current practice fails to achieve sufficient intensity and dose of training to promote meaningful recovery. The purpose of this review is to propose therapeutic solutions that can help achieve a higher dose and/or intensity of therapy. Raising awareness of these intensive, high-dose, treatment strategies might encourage clinicians to re-evaluate current practice and optimize delivery of stroke rehabilitation for maximal recovery.

METHODS

Literature that tested and evaluated solutions to increase dose or intensity of training was reviewed. For each therapeutic strategy, we outline evidence of clinical benefit, supporting neurophysiological data (where available) and discuss feasibility of clinical implementation.

RESULTS

Possible therapeutic solutions included constraint induced movement therapy, robotics, circuit therapy, bursts of training, gaming technologies, goal-oriented instructions, and cardiovascular exercise.

CONCLUSION

Our view is that clinicians should evaluate current practice to determine how intensive high-dose training can be implemented to promote greater recovery after stroke.

Ankle resistance with a unilateral soft exosuit increases plantarflexor effort during pushoff in unimpaired individuals

BACKGROUND

Ankle-targeting resistance training for improving plantarflexion function during walking increases rehabilitation intensity, an important factor for motor recovery after stroke. However, understanding of the effects of resisting plantarflexion during stance on joint kinetics and muscle activity-key outcomes in evaluating its potential value in rehabilitation-remains limited. This initial study uses a unilateral exosuit that resists plantarflexion during mid-late stance in unimpaired individuals to test the hypotheses that when plantarflexion is resisted, individuals would (1) increase plantarflexor ankle torque and muscle activity locally at the resisted ipsilateral ankle, but (2) at higher forces, exhibit a generalized response that also uses the unresisted joints and limb. Further, we expected (3) short-term retention into gait immediately after removal of resistance.

METHODS

Ten healthy young adults walked at 1.25 m s-1 for four 10-min discrete bouts, each comprising baseline, exposure to active exosuit-applied resistance, and post-active sections. In each bout, a different force magnitude was applied based on individual baseline ankle torques. The peak resistance torque applied by the exosuit was 0.13 ± 0.01, 0.19 ± 0.01, 0.26 ± 0.02, and 0.32 ± 0.02 N m kg-1, in the LOW, MED, HIGH, and MAX bouts, respectively.

RESULTS

(1) Across all bouts, participants increased peak ipsilateral biological ankle torque by 0.13-0.25 N m kg-1 (p < 0.001) during exosuit-applied resistance compared to corresponding baselines. Additionally, ipsilateral soleus activity during stance increased by 5.4-11.3% (p < 0.05) in all but the LOW bout. (2) In the HIGH and MAX bouts, vertical ground reaction force decreased on the ipsilateral limb while increasing on the contralateral limb (p < 0.01). Secondary analysis found that the force magnitude that maximized increases in biological ankle torque without significant changes in limb loading varied by subject. (3) Finally, peak ipsilateral plantarflexion angle increased significantly during post-exposure in the intermediate HIGH resistance bout (p < 0.05), which corresponded to the greatest average increase in soleus activity (p > 0.10).

CONCLUSIONS

Targeted resistance of ankle plantarflexion during stance by an exosuit consistently increased local ipsilateral plantarflexor effort during active resistance, but force magnitude will be an important parameter to tune for minimizing the involvement of the unresisted joints and limb during training.

Effects of a Goal-Oriented Intervention on Self-Management Behaviors and Self-Perceived Burden After Acute Stroke: A Randomized Controlled Trial

Background: Stroke generates significant health and social burdens. Self-management has potential importance for supporting individuals in coping and continuing to progress after stroke. However, there is a lack of targeted programs to enhance self-management and reduce self-perceived burden (SPB) following stroke.

Purpose: To evaluate the effects of a goal-oriented intervention on self-management behaviors and SPB among patients after acute stroke.

Methods: This was a randomized controlled trial with a 4-weeks intervention. Participants were randomly allocated to the intervention (n = 48) or control group (n = 48). The intervention and control groups received eight sessions of goal-oriented self-management intervention based on Pender's health promotion model and control care, respectively. Self-management behaviors and SPB were evaluated and compared between the two groups.

Results: After the 1-month follow-up, there were significant differences in the total self-management behaviors score and the scores of six of the self-management dimensions, excluding diet management, between the intervention group and the control group (t = −7.891– −2.815; p ≤ 0.006). Compared to the control group, the intervention group showed a significant decrease in the physical burden, emotional burden, and total SPB scores (t = 2.102–2.071; p = 0.015–0.041). The economic burden score was not significantly different between the two groups (t = 1.707; p = 0.091).

Conclusion: The goal-oriented intervention based on Pender's health promotion model can effectively improve self-management behaviors and reduce physical and emotional SPB among stroke survivors.