Issues in selecting outcome measures to assess functional recovery after stroke

IMPROVING THE PREDICTION OF FUNCTIONAL RECOVERY IN OLDER ADULTS WITH STROKE IN GERIATRIC REHABILITATION USING AN INERTIAL MEASUREMENT UNIT COMBINED WITH THE UTRECHT SCALE FOR EVALUATION OF REHABILITATION

Background

Prediction of functional recovery in older adults recovering from stroke is typically based on observational scales, such as the Utrecht Scale for Evaluation of Rehabilitation (USER). Objectively measuring postural sway using inertial measurement devices (IMU) may complement or improve conventional approaches. The aim of this study was to evaluate whether integrating an IMU with USER data enhances the accuracy of predicting functional recovery at discharge.

Methods

This prospective cohort study included older adults (≥ 65 years) recovering from stroke. Postural sway was assessed using an IMU during 2 different balance conditions and analysed using principal component analysis (PCA). Using 3 different regression models, percentage explained variance was compared to assess predictive performance on functional recovery of USER vs an IMU.

Results

The 71 patients included had a mean age of 78 (SD 7.6) and a median time since stroke of 16 days (IQR 19-60). Of the 71 patients, 12 (16.9%) were unable to perform balance condition 2 due to insufficient balance. Of 35 postural sway features displaying reliability for both balance conditions, 12 were selected for PCA. Incorporation of principal components for both balance conditions in the final model increased the explained variance compared to a model in which only USER-mobility at admission was used to predict delta-USER at discharge (R 2 = 0.61 vs 0.30).

Conclusions

Sitting and standing balance as measured by an IMU improves the prediction of functional recovery at discharge compared to USER alone.

Comparing the Postural Assessment Scale for Stroke and Berg Balance Scale for predicting community walking ability at discharge in subacute stroke: a prospective cohort study

Background

Balance assessment is crucial for predicting community ambulation outcomes in subacute stroke patients undergoing rehabilitation. This study aims to compare the accuracy of the Postural Assessment Scale for Stroke Patients (PASS) and the Berg Balance Scale (BBS) in predicting community walking ability at discharge from rehabilitation.

Methods

This prospective cohort study included 47 stroke patients admitted to a 4-week inpatient rehabilitation program. Patients were assessed with PASS and BBS at admission. Discharge assessments included the Functional Ambulation Categories and 6-Min Walk Distance tests. Statistical analysis involved calculating the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, likelihood ratios, and cut-off scores.

Results

PASS and BBS demonstrated excellent predictive accuracy, with AUC values of 0.955 (95% CI [0.850-0.994]) for PASS and 0.991 (95% CI [0.906-1.000]) for BBS. Cut-off scores were >28 for PASS and >46 for BBS. Sensitivity was high for both (94.44%, 95% CI [72.7-99.9]), while BBS had superior specificity (96.43%, 95% CI [81.7-99.9]) compared to PASS (85.71%, 95% CI [67.3-96.0]). BBS also had a higher positive likelihood ratio (26.44 vs. 6.61). The difference in AUC values was non-significant (p = 0.093).

Conclusions

PASS and BBS assessed at admission are highly accurate tools for predicting community ambulation at discharge in subacute stroke patients, with BBS demonstrating a slight advantage, particularly in its positive predictive value. These findings support the use of both scales to guide rehabilitative clinical decision-making.

Investigating functional connectivity related to stroke recovery: A systematic review

INTRODUCTION

Stroke recovery is a complex process influenced by various factors, including specific neural reorganization. The objective of this systematic review was to identify important functional connectivity (FC) changes in resting-state fMRI data that were often correlated with motor, emotional, and cognitive outcome improvement.

METHOD

A systematic search using PubMed and SCOPUS databases was conducted to identify relevant studies published between 2010 and 2023.

RESULTS

A total of 766 studies were identified, of which 20 studies (602 S individuals) met the inclusion criteria. Fourteen studies focussed on motor recovery while six on cognitive recovery. All studies reported interhemispheric FC to be strongly associated with motor and cognitive recovery. The preservation and changes of M1-M1 (eight incidences) and M1-SMA (nine incidences) FC were found to be strongly correlated with motor function improvement. For cognitive recovery, restoration and preservation of FC with and between default mode network (DMN)-related regions were important for the process.

CONCLUSIONS

This review identified specific patterns of FC that were consistently reported with recovery of motor and cognitive function. The findings may serve in refining future management strategies to enhance patient outcomes.

Strategies to Manage Poorer Outcomes After Hip or Knee Arthroplasty: A Narrative Review of Current Understanding, Unanswered Questions, and Future Directions

PURPOSE

Although hip or knee arthroplasty is generally a successful intervention, it is documented that 15%-30% of patients undergoing arthroplasty report suboptimal outcomes. This narrative review aims to provide an overview of the key findings concerning the management of poorer outcomes after hip or knee arthroplasty.

METHOD

A comprehensive search of articles was conducted up to November 2023 across three electronic databases. Only studies written in English were included, with no limitations applied regarding study design and time.

RESULT

Efficiently addressing poorer outcomes after arthroplasty necessitates a thorough exploration of appropriate methods for assessing recovery following hip or knee arthroplasty, ensuring accurate identification of patients at risk or experiencing poorer recovery. When selecting appropriate outcome measure tools, various factors should be taken into consideration, including understanding patients' priorities throughout the recovery process, assessing psychometric properties of outcome measure tools at different time points after arthroplasty, understanding how to combine/reconcile provider-assessed and patient-reported outcome measures, and determining the appropriate methods to interpret outcome measure scores. However, further research in these areas is warranted. In addition, the identification of key modifiable factors affecting outcomes and the development of interventions to manage these factors are needed.

CONCLUSION

There is growing attention paid to delivering interventions for patients at risk or not optimally recovering following hip or knee arthroplasty. To achieve this, it is essential to identify the most appropriate outcome measure tools, factors associated with poorer recovery and management of these factors.

Effects of the intermittent theta burst stimulation on gait, balance and lower limbs motor function in stroke: study protocol for a double-blind randomised controlled trial with multimodal neuroimaging assessments

INTRODUCTION

Approximately, 50% of stroke survivors experience impaired walking ability 6 months after conventional rehabilitation and standard care. However, compared with upper limb motor function, research on lower limbs rehabilitation through non-invasive neuromodulation like repetitive transcranial magnetic stimulation (rTMS) has received less attention. Limited evidence exists regarding the effectiveness of intermittent theta-burst stimulation (iTBS), an optimised rTMS modality, on lower limbs rehabilitation after stroke. This study aims to evaluate the effects of iTBS on gait, balance and lower limbs motor function in stroke recovery while also exploring the underlying neural mechanisms using longitudinal analysis of multimodal neuroimaging data.

METHODS AND ANALYSIS

In this double-blinded randomised controlled trial, a total of 46 patients who had a stroke will be randomly assigned in a 1:1 ratio to receive either 15 sessions of leg motor area iTBS consisting of 600 pulses or sham stimulation over the course of 3 weeks. Additionally, conventional rehabilitation therapy will be administered following the (sham) iTBS intervention. The primary outcome measure will be the 10 m walking test. Secondary outcomes include the Fugl-Meyer assessment of the lower extremity, Timed Up and Go Test, Functional Ambulation Category Scale, Berg Balance Scale, modified Barthel Index, Mini-Mental State Examination, montreal cognitive assessment, tecnobody balance assessment encompassing both static and dynamic stability evaluations, surface electromyography recording muscle activation of the lower limbs, three-dimensional gait analysis focusing on temporal and spatial parameters as well as ground reaction force measurements, corticomotor excitability tests including resting motor threshold, motor evoked potential and recruitment curves and multimodal functional MRI scanning. Outcome measures will be collected prior to and after the intervention period with follow-up at 3 weeks.

ETHICS AND DISSEMINATION

The study has received approval from the Medical Research Ethics Committee of Wuxi Mental Health Center/Wuxi Central Rehabilitation Hospital (no. WXMHCCIRB2023LLky078). Results will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2300077431.

Estimating the minimal clinically important difference of upper extremity outcome measures in chronic stroke patients with moderate to severe impairment: a cross-sectional study

BACKGROUND

Approximately 70% of chronic stroke patients experience upper extremity (UE) functional impairments, and UE outcome measures are often used as quality-of-life indicators.

OBJECTIVE

The purpose of this study was to estimate minimal clinically important difference (MCID) values for UE outcome measures in chronic stroke patients with moderate to severe UE hemiplegia.

METHODS

This study was a cross-sectional study, conducted as a secondary analysis of data from the ReoGo-J study, a multicenter, prospective, randomized, parallel-group trial of robot-assisted self-training for UE hemiplegia in chronic stroke. The patients were randomized to 1 of 3 treatment groups. Treatment was provided 3 times a week for 10 weeks, and UE outcome measures were evaluated before and after treatment. The anchor-based method was used to estimate MCID values for UE outcome measures, with Stroke Impact Scale (SIS) subscales as anchors. MCID values were estimated by identifying cutoff values in a receiver operating characteristic (ROC) curve.

RESULTS

Between-group comparisons of UE outcome measures, based on the clinically important difference (CID) values of SIS subscales, revealed significant differences in both the Amount of Use (AOU) and Quality of Movement (QOM) components of the Motor Activity Log (MAL)-14. The estimated MCID values were 0.89 for the AOU component and 0.77 for the QOM component.

CONCLUSIONS

The estimated MCID values for the MAL-14 not only add information regarding the clinical characteristics of the MAL-14 but also facilitate interpretations of changing scores in chronic stroke patients with moderate to severe UE hemiplegia undergoing rehabilitation therapy.

STUDY REGISTRATION

https://www.umin.ac.jp/ctr/index.htm (UMIN000022509; 1 July 2016).

Clinical tools for evaluating the severity of overactive bladder: A systematic review of psychometric properties

OBJECTIVES

To systematically evaluate the evidence describing the psychometric properties of clinical measures for assessing overactive bladder symptoms (urinary urgency with or without urge urinary incontinence, urinary frequency and nocturia). To evaluate the quality of this evidence-base using the COnsensus-based Standards for selecting health status Measurement INstruments (COSMIN) checklist and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tools.

DATA SOURCES

Five electronic databases (CINAHL, EMBASE, MEDLINE, Scopus and Web of Science) were searched from dataset inception to August 2023.

REVIEW METHODS

Study screening, data extraction and quality appraisal were performed by two independent authors. Inclusion criteria were studies testing one or more psychometric properties of clinical tools for the assessment of overactive bladder symptoms among adults aged 18 years and older for both sexes. The methodological quality and quality of the evidence were evaluated using the COSMIN checklist and GRADE tools, respectively.

RESULTS

The search identified 40 studies totalling 10,634 participants evaluating the psychometric properties of 15 clinical tools. The COSMIN methodological quality was rated good for most measures, and the GRADE quality of evidence ranged from low (13%) to high (33%). The Overactive Bladder Symptom Score, Overactive Bladder Questionnaire and Neurogenic Bladder Symptom Score were of good methodological and high-GRADE evidence qualities.

CONCLUSION

Overactive Bladder Symptom Score, the Overactive Bladder Questionnaire and the Neurogenic Bladder Symptoms Score are promising psychometrically sound measures. The Overactive Bladder Symptom Score has been applied to the most culturally diverse populations supported by studies of good methodological and high-GRADE evidence quality.

Spectral exponent assessment and neurofilament light chain: a comprehensive approach to describe recovery patterns in stroke

Introduction

Understanding the residual recovery potential in stroke patients is crucial for tailoring effective neurorehabilitation programs. We propose using EEG and plasmatic Neurofilament light chain (NfL) levels as a model to depict longitudinal patterns of stroke recovery.

Methods

We enrolled 13 patients (4 female, mean age 74.7 ± 8.8) who underwent stroke in the previous month and were hospitalized for 2-months rehabilitation. Patients underwent blood withdrawal, clinical evaluation and high-definition EEG at T1 (first week of rehabilitation) and at T2 (53 ± 10 days after). We assessed the levels of NfL and we analyzed the EEG signal extracting Spectral Exponent (SE) values. We compared our variables between the two timepoint and between cortical and non-cortical strokes.

Results

We found a significant difference in the symmetry of SE values between cortical and non-cortical stroke at both T1 (p = 0.005) and T2 (p = 0.01). SE in the affected hemisphere showed significantly steeper values at T1 when compared with T2 (p = 0.001). EEG measures were consistently related to clinical scores, while NfL at T1 was related to the volume of ischemic lesions (r = 0.75; p = 0.003). Additionally, the combined use of NfL and SE indicated varying trends in longitudinal clinical recovery.

Conclusion

We present proof of concept of a promising approach for the characterization of different recovery patterns in stroke patients.

Estimation of minimal detectable change in the 10-meter walking test for patients with stroke: a study stratified by gait speed

Objective

This study aimed to classify and calculate the minimal detectable changes (MDC) in gait time and gait speed in a 10-meter walking test (10MWT) in patients with stroke classified according to their gait speed.

Methods

The participants were 84 patients with stroke. Their gait times were measured twice each at their comfortable gait speed (CGS) and maximum gait speed (MGS) on a 10-meter straight track, and gait speed was calculated using gait time. Participants were assigned to three speed groups based on their CGS: low-speed (<0.4 m/s; n = 19); moderate-speed (0.4-0.8 m/s; n = 29); and high-speed (>0.8 m/s; n = 36). For each group, first and second retest reliability and MDC of CGS and MGS were calculated using gait time and gait speed in the 10MWT.

Results

MDCs in the 10MWT at CGS were: low-speed group, gait time 5.25 s, gait speed 0.05 m/s; moderate-speed group, gait time 2.83 s, gait speed 0.11 m/s; and high-speed group, gait time 1.58 s, gait speed 0.21 m/s. MDCs in the 10MWT at MGS were: low-speed group, gait time 7.26 s, gait speed 0.04 m/s; moderate-speed group, gait time 2.48 s, gait speed 0.12 m/s; and high-speed group, gait time 1.28 s, gait speed 0.19 m/s.

Conclusion

Since the MDC of gait speed and gait time differ depending on the participant's gait speed, it is necessary to interpret the results according to the participant's gait speed when judging the effectiveness of therapeutic interventions.

The minimal clinically important difference of the motricity index score

INTRODUCTION

The Motricity Index (MI) can predict motor function after rehabilitation, but its minimal clinically important difference (MCID) has not been established. The primary study aim was to estimate the MCID value of the MI arm score.

METHODS

Between 2017 and 2018, 173 participants hospitalized with confirmed ischemic stroke were recruited into an observational rehabilitation study. Participants with motor weakness as measured by the Fugl-Meyer upper-extremity (FM-UE) and MI with complete baseline and follow-up assessments at 3 months were included in this analysis. The longitudinal recovery of the MI arm score was anchored to having a poor outcome based on the FM-UE recovery (<9) longitudinally. Results reported include the area-under-curve (AUC), along with sensitivity, specificity, and optimal cut-points based on maximizing the Youden statistic.

RESULTS

Sixty-nine patients (median [IQR] age 70 [18] years; 48% male; 54% white) were included in the final analysis. Mean ± standard deviation outcome scores at 3-months were: MI arm: 83.19 ± 22.80; FM-UE: 53.04 ± 17.26. For the primary results, the MI arm score optimal MCID cutoff for observed recovery was 13 points with a sensitivity of 80% (95% Confidence Interval (CI)(67.6%, 92.4%)) and a specificity of 69.0% (95% CI (52.1, 85.8%)), and the AUC was 0.8082 (0.7007, 0.9157).

CONCLUSIONS

This was the first study to report the MCID of the MI arm score, as anchored to the FM-UE recovery between acute evaluation and 3-months. The estimated optimal MCID of improvement in the MI arm score was 13 points.

Effects of a remote-handling-concept-based task-oriented arm training (ReHab-TOAT) on arm-hand skill performance in chronic stroke: a study protocol for a two-armed randomized controlled trial

BACKGROUND

Improving arm-hand skill performance is a major therapeutic target in stroke rehabilitation and needs intensive and varied training. However, guided treatment time is limited. Technology can assist in the training of patients, offering a higher intensity and more variety in content. A new task-oriented arm training approach was developed, using a 'Remote Handling concept based' device to provide haptic feedback during the performance of daily living activities (ReHab-TOAT). This study aims to investigate the effects of ReHab-TOAT on patients' arm-hand function and arm-hand skill performance, quality of life of both patients in the chronic phase after stroke and their caregivers and the patients' perception regarding the usability of the intervention.

METHODS

A randomized clinical trial was designed. Adult chronic stroke patients suffering from hemiparesis and arm-hand problems, with an Utrechtse Arm-hand Test score of 1-3, will be invited to participate. Participants in the experimental group receive ReHab-TOAT additional to care as usual. ReHab-TOAT contains task-oriented arm training for stroke patients in combination with haptic feedback, generated by a remote handling device. They will train for 4 weeks, 3× per week, 1.5h per day. Participants in the control group will receive no additional therapy apart from care as usual. The Fugl-Meyer Assessment (FMA), measuring participants' motor performance of the affected arm, is used as the primary outcome measure. Secondary outcome measures are arm-hand capacity of the patient (ARAT), perceived arm-hand skill performance (MAL), actual arm-hand skill performance (accelerometry), patients' quality of life (EuoQol-5D) and caregivers' quality of life (CarerQoL). Participants' perception regarding the usability of the intervention, including both the developed approach and technology used, will be evaluated by the System Usability Scale and a questionnaire on the user experience of technology. Measurements will be performed at 1, 2, 3 and 4 weeks pre-intervention (baseline); immediately post-intervention; and 3, 6 and 9 months post-intervention. Statistical analysis includes linear mixed model analysis.

DISCUSSION

This study is designed to investigate the evidence regarding the effects of ReHab-TOAT on patients' performance at different levels of the International Classification of Functioning, disability and health (ICF) model, i.e. a framework measuring functioning and disability in relation to a health condition, and to provide insights on a successful development and research process regarding technology-assisted training in co-creation.

TRIAL REGISTRATION

Netherlands Trial Register NL9541. Registered on June 22, 2021.

Combined robot motor assistance with neural circuit-based virtual reality (NeuCir-VR) lower extremity rehabilitation training in patients after stroke: a study protocol for a single-centre randomised controlled trial

INTRODUCTION

Improving lower extremity motor function is the focus and difficulty of post-stroke rehabilitation treatment. More recently, robot-assisted and virtual reality (VR) training are commonly used in post-stroke rehabilitation and are considered feasible treatment methods. Here, we developed a rehabilitation system combining robot motor assistance with neural circuit-based VR (NeuCir-VR) rehabilitation programme involving procedural lower extremity rehabilitation with reward mechanisms, from muscle strength training, posture control and balance training to simple and complex ground walking training. The study aims to explore the effectiveness and neurological mechanisms of combining robot motor assistance and NeuCir-VR lower extremity rehabilitation training in patients after stroke.

METHODS AND ANALYSIS

This is a single-centre, observer-blinded, randomised controlled trial. 40 patients with lower extremity hemiparesis after stroke will be recruited and randomly divided into a control group (combined robot assistance and VR training) and an intervention group (combined robot assistance and NeuCir-VR training) by the ratio of 1:1. Each group will receive five 30 min sessions per week for 4 weeks. The primary outcome will be Fugl-Meyer assessment of the lower extremity. Secondary outcomes will include Berg Balance Scale, Modified Ashworth Scale and functional connectivity measured by resting-state functional MRI. Outcomes will be measured at baseline (T0), post-intervention (T1) and follow-ups (T2-T4).

ETHICS, REGISTRATION AND DISSEMINATION

The trial was approved by the Ethics Committee of Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Chinese Traditional Medicine (Grant No. 2019-014). The results will be submitted to a peer-reviewed journal or at a conference.

TRIAL REGISTRATION NUMBER

ChiCTR2100052133.

Informing the development of an outcome set and banks of items to measure mobility among individuals with acquired brain injury using natural language processing

BACKGROUND

The sheer number of measures evaluating mobility and inconsistencies in terminology make it challenging to extract potential core domains and items. Automating a portion of the data synthesis would allow us to cover a much larger volume of studies and databases in a smaller fraction of the time compared to the usual process. Thus, the objective of this study was to identify a comprehensive outcome set and develop preliminary banks of items of mobility among individuals with acquired brain injury (ABI) using Natural Language Processing (NLP).

METHODS

An umbrella review of 47 reviews evaluating the content of mobility measures among individuals with ABI was conducted. A search was performed on 5 databases between 2000 and 2020. Two independent reviewers retrieved copies of the measures and extracted mobility domains and items. A pre-trained BERT model (state-of-the-art model for NLP) provided vector representations for each sentence. Using the International Classification of Functioning, Disability, and Health Framework (ICF) ontology as a guide for clustering, a k-means algorithm was used to retrieve clusters of similar sentences from their embeddings. The resulting embedding clusters were evaluated using the Silhouette score and fine-tuned according to expert input.

RESULTS

The study identified 246 mobility measures, including 474 domains and 2109 items. Encoding the clusters using the ICF ontology and expert knowledge helped in regrouping the items in a way that is more closely related to mobility terminology. Our best results identified banks of items that were used to create a 24 comprehensive outcome sets of mobility, including Upper Extremity Mobility, Emotional Function, Balance, Motor Control, Self-care, Social Life and Relationships, Cognition, Walking, Postural Transition, Recreation, and Leisure Activities, Activities of Daily Living, Physical Functioning, Communication, Work/Study, Climbing, Sensory Functions, General Health, Fatigue, Functional Independence, Pain, Alcohol and Drugs Use, Transportation, Sleeping, and Finances.

CONCLUSION

The banks of items of mobility domains represent a first step toward establishing a comprehensive outcome set and a common language of mobility to develop the ontology. It enables researchers and healthcare professionals to begin exposing the content of mobility measures as a way to assess mobility comprehensively.

Quality of mobility measures among individuals with acquired brain injury: an umbrella review

BACKGROUND AND OBJECTIVE

While several mobility measures exist, there is large variability across measures in how mobility is conceptualized, the source of information and the measurement properties making it challenging to select relevant mobility measures for individuals with acquired brain injury (ABI). Therefore, the objective was to conduct a comprehensive synthesis of existing evidence on the measurement properties, the interpretability and the feasibility of mobility measures from various sources of information (patients, clinicians, technology) using an umbrella review of published systematic reviews among individuals with ABI.

METHODS

Ovid MEDLINE, CINHAL, Cochrane Library and EMBASE electronic databases were searched from 2000 to March 2020. Two independent reviewers appraised the methodological quality of the systematic reviews using the Joanna Briggs Institute critical appraisal checklist. Measurement properties and quality of evidence were applied according to COnsensus-based Standards for the Selection of Health Measurement Instrument (COSMIN) guidelines. Mobility measures were categorized using international standards with the international classification of functioning, disability and health (ICF).

RESULTS

Thirty-five systematic reviews were included covering 147 mobility measures, of which 85% were mapped to the ICF Activity and Participation component. Results showed an acceptable overall "sufficient" rating for reliability, construct validity and responsiveness for 132 (90%), 127 (86%) and 76 (52%) of the measures, respectively; however, among these measures, ≤ 25% of the methods for evaluating these properties were rated as 'high' quality of evidence. Also, there was limited information that supports measure feasibility and scoring interpretability.

CONCLUSIONS

Future systematic reviews should report measures' content validity to support the use of the measure in clinical care and research. More evaluations of the minimal important difference and floor and ceiling effects are needed to help guide clinical interpretation.

REGISTRATION INFORMATION

International Prospective Register of Systematic Reviews (PROSPERO); ID: CRD42018100068.

Resilience and Its Association With Activities of Daily Living 3 Months After Stroke

Independence in basic activities of daily living (ADL) is an important outcome after stroke. Identifying factors associated with independence can contribute to improve post-stroke rehabilitation. Resilience, which is the ability of coping with a serious event, might be such a factor. Still, the impact of resilience and its role in rehabilitation after stroke is poorly investigated. Hence, the purpose of this study was to assess whether resilience assessed early after stroke can be associated with independence in basic ADL 3 months later. Hospitalized patients with a diagnosed acute stroke and a modified Rankin Scale score ≤ 4 were included. Bivariate and multivariate linear regression were applied to assess whether resilience as measured by the Brief Resilience Scale within the first 2 weeks after stroke was associated with basic ADL measured by Barthel Index at 3-month follow-up. Age, sex, fatigue, stroke severity at admission and pre-stroke disability were added as covariates. Sixty-four participants (35 (54.7%) male), aged 75.9 (SD 8.6) years were included 4.3 (SD 2.8) days after stroke. There was no significant change in resilience from baseline 3.1 (SD 0.3) to 3 months later 3.2 (SD 0.5). Resilience was not associated with basic ADL in neither the bivariate (b = 2.01, 95% CI −5.21, 9.23, p = 0.580) nor in the multivariate regression models (b = 0.50, 95% CI −4.87, 6.88, p = 0.853). Our results showed that resilience remained stable during follow-up. Early measurement of resilience was not associated with independence in basic activities of daily living 3 months after stroke. These results, indicate that resilience is a personal trait not associated with the outcome of physical adversity. However, future research should investigate whether resilience is related to the outcomes of psychosocial adversity after a stroke.

Establishing the Minimal Clinically Important Differences for Sagittal Hip Range of Motion in Chronic Stroke Patients

Many researchers have pointed out that decreased sagittal range of motion (ROM) in the affected hip joint is a common consequence of stroke, and it adversely affects walking performance and walking speed. Nevertheless, the minimal clinically important differences (MCID) in hip-related kinematic gait parameters post-stroke have not yet been determined. The present study aimed to define MCID values for hip ROM in the sagittal plane i.e., flexion-extension (FE), for the affected and unaffected sides at a chronic stage post-stroke. Fifty participants with hemiparesis due to stroke were enrolled for the study. Four statistical methods were used to calculate MCID. According to the anchor-based approach, the mean change in hip FE ROM achieved by the MCID group on the affected/unaffected side amounted to 5.81°/2.86° (the first MCID estimate). The distribution-based analyses established that the standard error of measurement in the no-change group amounted to 1.56°/1.04° (the second MCID estimate). Measurements based on the third method established that a change of 4.09°/0.61° in the hip ROM corresponded to a 1.85-point change in the Barthel Index. The optimum cutoff value, based on ROC curve analysis, corresponded to 2.9/2.6° of change in the hip sagittal ROM for the affected/unaffected side (the fourth MCID estimate). To our knowledge, this is the first study to use a comprehensive set of statistical methods to determine the MCID for hip sagittal ROM for the affected and unaffected sides at a chronic stage post-stroke. According to our findings, the MCID of the hip FE ROM for the affected side amounts to 5.81° and for the unaffected side to 2.86°, in patients with chronic stroke. This indicator is extremely important because it allows clinical practitioners to assess the effects of interventions administered to patients, and to interpret the significance of improvements in sagittal kinematic parameters of the hip; ultimately, it may facilitate the process of designing effective gait reeducation programs.

Effect of Robot-Assisted Therapy on Participation of People with Limited Upper Limb Functioning: A Systematic Review with GRADE Recommendations

Background

Previous studies have suggested that robot-assisted therapy (RT) is effective in treating impairment and that it may also improve individuals' participation.

Objective

To investigate the effect of RT on the participation of individuals with limited upper limb functioning (PROSPERO: CRD42019133880). Data Sources: PEDro, Embase, MEDLINE, CINAHL, Cochrane, AMED, and Compendex. Inclusion Criteria. We selected randomized or quasirandomized controlled studies comparing the effects of RT with minimal or other interventions on participation of individuals with limited upper limb functioning. Data Extraction and Synthesis. Methodological quality of the included studies was assessed using the 0-10 PEDro scale, and effect estimates were reported using standardized mean differences (SMDs) with 95% confidence intervals (CIs), and the certainty of the current evidence was assessed using the GRADE.

Results

Twelve randomized controlled studies involving 845 participants were included. The estimates of medium effects between RT and minimal intervention (MI) at a short-term follow-up were pooled, but there are no short-term effects between RT and OI. Standardized differences in means were as follows: 0.6 (95% CI 0.1 to 1.2) and 0.2 (95% CI -0.0 to 0.4). There were also no effects of additional RT in the short- or medium-term follow-up periods. Standardized differences in means were as follows: -0.6 (95% CI -1.1 to -0.1) and 0.2 (95% CI -0.3 to 0.8). The methodological quality of the included studies potentially compromised the effect estimates of RT. The existing evidence was very low-quality with many confounding variables between studies.

Conclusions

For patients with upper limb neurological dysfunction, low-quality evidence supports RT over MI in terms of improving individual participation in the short term. The existing low- to very low-quality evidence does not support RT over OI in either the short- or medium-term follow-up periods with respect to community participation.

Immersive Virtual Reality to Improve Outcomes in Veterans With Stroke: Protocol for a Single-Arm Pilot Study

BACKGROUND

Over the last decade, virtual reality (VR) has emerged as a cutting-edge technology in stroke rehabilitation. VR is defined as a type of computer-user interface that implements real-time simulation of an activity or environment allowing user interaction via multiple sensory modalities. In a stroke population, VR interventions have been shown to enhance motor, cognitive, and psychological recovery when utilized as a rehabilitation adjunct. VR has also demonstrated noninferiority to usual care therapies for stroke rehabilitation.

OBJECTIVE

The proposed pilot study aims to (1) determine the feasibility and tolerability of using a therapeutic VR platform in an inpatient comprehensive stroke rehabilitation program and (2) estimate the initial clinical efficacy (effect size) associated with the VR platform using apps for pain distraction and upper extremity exercise for poststroke neurologic recovery.

METHODS

This study will be conducted in the Comprehensive Integrated Inpatient Rehabilitation Program at the James A Haley Veterans' Hospital. Qualitative interviews will be conducted with 10 clinical staff members to assess the feasibility of the VR platform from the clinician perspective. A prospective within-subject pretest-posttest pilot design will be used to examine the tolerability of the VR platform and the clinical outcomes (ie, upper extremity neurologic recovery, hand dexterity, pain severity) in 10 veteran inpatients. A VR platform consisting of commercially available pain distraction and upper extremity apps will be available at the participants' bedside for daily use during their inpatient stay (approximately 4-6 weeks). Clinician interviews will be analyzed using qualitative descriptive analysis. Cohen d effect sizes with corresponding 95% CIs will be calculated for upper extremity neurologic recovery, hand dexterity, and pain. The proportion of participants who achieve minimal clinically important difference after using the VR platform will be calculated for each clinical outcome.

RESULTS

This study was selected for funding in August 2020. Institutional review board approval was received in October 2020. The project start date was December 2020. The United States Department has issued a moratorium on in-person research activities secondary to COVID-19. Data collection will commence once this moratorium is lifted.

CONCLUSIONS

Our next step is to conduct a large multi-site clinical trial that will incorporate the lessons learned from this pilot feasibility study to test the efficacy of a VR intervention in inpatient rehabilitation and transition to home environments. When VR is used in patients' rooms, it serves to provide additional therapy and may reduce clinician burden. VR also presents an opportunity similar to home-based practice exercises. VR can be implemented in both clinical settings and people's own homes, where engagement in ongoing self-management approaches is often most challenging. This unique experience offers the potential for seamless transition from inpatient rehabilitation to the home.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/26133.

Gains Across WHO Dimensions of Function After Robot-Based Therapy in Stroke Subjects

BACKGROUND

Studies examining the effects of therapeutic interventions after stroke often focus on changes in loss of body function/structure (impairment). However, improvements in activities limitations and participation restriction are often higher patient priorities, and the relationship that these measures have with loss of body function/structure is unclear.

OBJECTIVE

This study measured gains across WHO International Classification of Function (ICF) dimensions and examined their interrelationships.

METHODS

Subjects were recruited 11 to 26 weeks after hemiparetic stroke. Over a 3-week period, subjects received 12 sessions of intensive robot-based therapy targeting the distal arm. Each subject was assessed at baseline and at 1 month after end of therapy.

RESULTS

At baseline, subjects (n = 40) were 134.7 ± 32.4 (mean ± SD) days poststroke and had moderate-severe arm motor deficits (arm motor Fugl-Meyer score of 35.6 ± 14.4) that were stable. Subjects averaged 2579 thumb movements and 1298 wrist movements per treatment session. After robot therapy, there was significant improvement in measures of body function/structure (Fugl-Meyer score) and activity limitations (Action Research Arm Test, Barthel Index, and Stroke Impact Scale-Hand), but not participation restriction (Stroke Specific Quality of Life Scale). Furthermore, while the degree of improvement in loss of body function/structure was correlated with improvement in activity limitations, neither improvement in loss of body function/structure nor improvement in activity limitations was correlated with change in participation restriction.

CONCLUSIONS

After a 3-week course of robotic therapy, there was improvement in body function/structure and activity limitations but no reduction in participation restriction.

Estimating Minimal Clinically Important Differences for Knee Range of Motion after Stroke

The importance of knee sagittal kinematic parameters, as a predictor of walking performance in post-stroke gait has been emphasised by numerous researchers. However, no studies so far were designed to determine the minimal clinically important differences (MCID), i.e., the smallest difference in the relevant score for the kinematic gait parameters, which are perceived as beneficial for patients with stroke. Studies focusing on clinically important difference are useful because they can identify the clinical relevance of changes in the scores. The purpose of the study was to estimate the MCID for knee range of motion (ROM) in the sagittal plane for the affected and unaffected side at a chronic stage post-stroke. Fifty individuals were identified in a database of a rehabilitation clinic. We estimated MCID values using: an anchor-based method, distribution-based method, linear regression analysis and specification of the receiver operating characteristic (ROC) curve. In the anchor-based study, the mean change in knee flexion/extension ROM for the affected/unaffected side in the MCID group amounted to 8.48°/6.81° (the first MCID estimate). In the distribution-based study, the standard error of measurement for the no-change group was 1.86°/5.63° (the second MCID estimate). Method 3 analyses showed 7.71°/4.66° change in the ROM corresponding to 1.85-point change in the Barthel Index. The best cut-off point, determined with ROC curve, was the value corresponding to 3.9°/3.8° of change in the knee sagittal ROM for the affected/unaffected side (the fourth MCID estimate). We have determined that, in chronic stroke, MCID estimates of knee sagittal ROM for the affected side amount to 8.48° and for the unaffected side to 6.81°. These findings will assist clinicians and researchers in interpreting the significance of changes observed in kinematic sagittal plane parameters of the knee. The data are part of the following clinical trial: Australian New Zealand Clinical Trials Registry: ACTRN12617000436370

A Novel Multiple-Cue Observational Clinical Scale for Functional Evaluation of Gait After Stroke - The Stroke Mobility Score (SMS)

Background

For future development of machine learning tools for gait impairment assessment after stroke, simple observational whole-body clinical scales are required. Current observational scales regard either only leg movement or discrete overall parameters, neglecting dysfunctions in the trunk and arms. The purpose of this study was to introduce a new multiple-cue observational scale, called the stroke mobility score (SMS).

Material/Methods

In a group of 131 patients, we developed a 1-page manual involving 6 subscores by Delphi method using the video-based SMS: trunk posture, leg movement of the most affected side, arm movement of the most affected side, walking speed, gait fluency and stability/risk of falling. Six medical raters then validated the SMS on a sample of 60 additional stroke patients. Conventional scales (NIHSS, Timed-Up-And-Go-Test, 10-Meter-Walk-Test, Berg Balance Scale, FIM-Item L, Barthel Index) were also applied.

Results

(1) High consistency and excellent inter-rater reliability of the SMS were verified (Cronbach’s alpha >0.9). (2) The SMS subscores are non-redundant and reveal much more nuanced whole-body dysfunction details than conventional scores, although evident correlations as e.g. between 10-Meter-Walk-Test and subscore “gait speed” are verified. (3) The analysis of cross-correlations between SMS subscores unveils new functional interrelationships for stroke profiling.

Conclusions

The SMS proves to be an easy-to-use, tele-applicable, robust, consistent, reliable, and nuanced functional scale of gait impairments after stroke. Due to its sensitivity to whole-body motion criteria, it is ideally suited for machine learning algorithms and for development of new therapy strategies based on instrumented gait analysis.

To Treat or Not to Treat: Importance of Functional Dependence in Deciding Intravenous Thrombolysis of "Mild Stroke" Patients

Intravenous thrombolysis (IVT) in patients with a low National Institutes of Health Stroke Scale (NIHSS) score of 0–5 remains controversial. IVT should be used in patients with mild but nevertheless disabling symptoms. We hypothesize that response to IVT of patients with “mild stroke” may depend on their level of functional dependence (FD) at hospital admission. The aims of our study were to investigate the effect of IVT and to explore the role of FD in influencing the response to IVT. This study was a retrospective analysis of a prospectively collected database, including 389 patients stratified into patients receiving IVT (IVT⁺) and not receiving IVT (IVT ⁻) just because of mild symptoms. Barthel index (BI) at admission was used to assess FD, dividing subjects with BI score < 80 (FD⁺) and with BI score ≥ 80 (FD⁻). The efficacy endpoints were the rate of positive disability outcome (DO⁺) (3-month mRS score of 0 or 1), and the rate of positive functional outcome (FO⁺) (mRS score of zero or one, plus BI score of 95 or 100 at 3 months). At the multivariate analysis, IVT treatment was an independent predictor of DO⁺ (OR 3.12, 95% CI 1.34−7.27, p = 0.008) and FO⁺ (OR: 4.70, 95% CI 2.38−9.26, p = 0.001). However, FD⁺ IVT⁺ patients had a significantly higher prevalence of DO⁺ and FO⁺ than those FD⁺ IVT^–. Differently, IVT treatment did not influence DO⁺ and FO⁺ in FD^– patients. In FD⁺ patients, IVT treatment represented the strongest independent predictor of DO⁺ (OR 6.01, 95% CI 2.59–13.92, p = 0.001) and FO⁺ (OR 4.73, 95% CI 2.29–9.76, p = 0.001). In conclusion, alteplase seems to improve functional outcome in patients with “mild stroke”. However, in our experience, this beneficial effect is strongly influenced by FD at admission.

Discriminatory power of Stroke Specific Quality of Life questionnaire items to evaluate the participation component of the International Classification of Functioning, Disability and Health

Background/aims

This study aimed to estimate the discriminatory power of 26 items on the Stroke Specific Quality of Life Scale questionnaire to evaluate the participation component of the International Classification of Functioning, Disability and Health.

Methods

A prospective study was conducted using accuracy procedures based on the Standards for Reporting Diagnostic Accuracy Studies to evaluate individuals with hemiparesis stemming from a stroke. Discriminatory power was estimated based on the area under the receiver operating characteristic curve with a 95% confidence interval. Two groups were defined for the analysis: community-dwelling and institutionalised individuals. A 5% level of significance (α=0.05) was considered for all analyses.

Results

The area under the receiver operating characteristic curve was 0.888 (95% confidence interval: 0.794–0.949; P=0.001). Analysis indicated a cut-off point of ≥80 with 73.9% sensitivity and 100% specificity.

Conclusions

The 26 items of the Stroke Specific Quality of Life questionnaire that evaluate the participation component of the International Classification of Functioning, Disability and Health demonstrate adequate discriminatory power. A cut-off point of ≥80 seems to best discriminate the perception of participation between community-dwelling and institutionalised stroke survivors.

Easily Conducted Tests During the First Week Post-stroke Can Aid the Prediction of Arm Functioning at 6 Months

Background: Prognostic models can estimate the recovery of arm functioning after stroke, guide the selection of individual training strategies, and inform patient selection in clinical trials. Several models for early prediction of arm recovery have been proposed, but their implementation has been hindered by insufficient external validation, limited evidence of their impact on patient outcomes, and reliance on predictors that are not feasible in regular clinical practice.

Objectives: To determine the predictive value of new and previously reported tests that can be easily conducted in regular clinical settings for early prognosis of two levels of favorable arm recovery at 6 months post-stroke.

Methods: We performed a secondary analysis of merged data (n = 223) from two Scandinavian prospective longitudinal cohorts. The candidate predictors were seven individual tests of motor function and the sensory function measured by the Fugl-Meyer Assessment of Upper Extremity within 7 days post-stroke, and the whole motor section of this assessment. For each candidate predictor, we calculated the adjusted odds ratio (OR) of two levels of residual motor impairment in the affected arm at 6 months post-stroke: moderate-to-mild (≥32 points on the motor section of the Fugl-Meyer Assessment of Upper Extremity, FMA-UE) and mild (FMA-UE ≥ 58 points).

Results: Patients with partial shoulder abduction (OR 14.6), elbow extension (OR 15.9), and finger extension (OR 9.5) were more likely to reach FMA-UE ≥ 32. Patients with full function on all individual motor tests (OR 5.5–35.3) or partial elbow extension, pronation/supination, wrist dorsiflexion and grasping ability (OR 2.1–18.3) were more likely to achieve FMA-UE ≥ 58 compared with those with absent function. Intact sensory function (OR 2.0–2.2) and moderate motor impairment on the FMA-UE (OR 7.5) were also associated with favorable outcome.

Conclusions: Easily conducted motor tests can be useful for early prediction of arm recovery. The added value of this study is the prediction of two levels of a favorable functional outcome from simple motor tests. This knowledge can be used in the development of prognostic models feasible in regular clinical settings, inform patient selection and stratification in future trials, and guide clinicians in the selection of individualized training strategies for improving arm functioning after stroke.

Clinical Trial Registration:ClinicalTrials.gov: NCT02250365, NCT01115348.

Life Expectancy after Stroke Based On Age, Sex, and Rankin Grade of Disability: A Synthesis

BACKGROUND

Stroke is a leading cause of death and disability in the developed world. The major factor affecting long term survival (other than age) is known to be the severity of disability. Yet to our knowledge there are no studies reporting life expectancies stratified by both age and severity. Remaining life expectancy is a key measure of health.

METHODS

We identified 11 long-term follow-up studies of stroke patients that reported the multivariate effects of age, sex, the modified Rankin Scale (mRS) grade of disability, and other factors. From these we computed the composite effects of these factors on survival, then used these to calculate age-, sex-, and mRS-specific mortality rates. Finally we used the rates to construct life tables, and hence obtain life expectancies.

RESULTS

Life expectancy varies by age, sex, and mRS. The life expectancies of males age 70, for example, were 13, 13, 11, 8, 6, and 5 years for Rankin Grades 0-5, respectively, representing reductions of 1, 1, 3, 6, 8, and 9 years from the corresponding general population figure.

CONCLUSIONS

These figures demonstrate the importance of rehabilitation following stroke, and can be used in discussion of public policy and benchmarking of future results.

Methodological considerations for kinematic analysis of upper limbs in healthy and poststroke adults Part II: a systematic review of motion capture systems and kinematic metrics

Background and purpose: To review the methods used to analyze the kinematics of upper limbs (ULs) of healthy and poststroke adults, namely the motion capture systems and kinematic metrics. Summary of review: A database of articles published in the last decade was compiled using the following search terms combinations: ("upper extremity" OR "upper limb" OR arm) AND (kinematic OR motion OR movement) AND (analysis OR assessment OR measurement). The articles included in this review: (1) had the purpose to analyze objectively three-dimension kinematics of ULs, (2) studied functional movements or activities of daily living involving ULs, and (3) studied healthy and/or poststroke adults. Fourteen articles were included (four studied a healthy sample, three analyzed poststroke patients, and seven examined both poststroke and healthy participants). Conclusion: Most articles used optoelectronic systems with markers; however, the presentation of laboratory and task-specific errors is missing. Markerless systems, used in some studies, seem to be promising alternatives for implementation of kinematic analysis in hospitals and clinics, but the literature proving their validity is scarce. Most articles analyzed "joint kinematics" and "end-point kinematics," mainly related with reaching. The different stroke locations of the samples were not considered in their analysis and only three articles described their psychometric properties. Implication of key findings: Future research should validate portable motion capture systems, document their specific error at the acquisition place and for the studied task, include grasping and manipulation analysis, and describe psychometric properties.

Identification of categories of the International Classification of Functioning, Disability and Health in functional assessment measures for stroke survivors: a systematic review

Objective: Perform a systematic review to identify the categories of the International Classification of Functioning, Disability and Health linked to the concepts measured by functional assessment tools validated for Brazilian Portuguese: Timed Up and Go test, Functional Independence Measure, Barthel Index, and Rivermead Mobility Index and Modified Rankin Scale.Methods: The Medline, Embase and CINAHL databases were consulted using a standardized search strategy. The studies were summarized using a pre-established set of specific criteria for the adequate linkage between the concepts identified in the assessment measures and the International Classification of Functioning, Disability and Health categories. Two independent reviewers performed the selection of the studies, data extraction and evaluation of the results.Results: The search of the databanks led to the retrieval of 99 studies. However, only six articles were included in the present review. The linkage results of the studies included in the review were divergent, likely due to the taxonomic complexity of the International Classification of Functioning, Disability and Health, the difficulty in clearly relating the concepts of the assessment measures to the classifications and the fact that not all linkage rules were followed. "Activities and participation" was the most evaluated component, with mobility the most frequently covered category in the measures, followed by self-care. Among the measures analyzed, the Functional Independence Measure addresses a greater number of categories and therefore has the most concepts related to the International Classification of Functioning, Disability and Health, followed by the Barthel Index, Modified Rankin Scale, Rivermead Mobility Index and Timed Up and Go test. The Modified Rankin Scale was the assessment tool that most evaluated categories related to environmental factors.Conclusion: The Functional Independence Measure has more concepts related to the International Classification of Functioning, Disability and Health, since it addresses a greater number of categories. These findings can help guide health professionals in the selection of assessment tools for the evaluation of post-stroke functioning, making viable the use of the International Classification of Functioning, Disability and Health categories in clinical practice and public health services.Implications for rehabilitationThis study standardized identification of the International Classification of Functioning, Disability and Health categories in the main outcome measures used to assess post-stroke functional capacity.Functional Independence Measure has more concepts related to the International Classification of Functioning, Disability and Health compared to other functional assessment instruments.Findings can enable physiotherapists and researchers choose the most appropriate measure that best corresponds to their field of interest.These results facilitate the implementation of the International Classification of Functioning, Disability and Health in clinical practice.Use of International Classification of Functioning, Disability and Health categories can standardize information on functional health.

The effects of mental practice based on motor imagery for mobility recovery after subacute stroke: Protocol for a randomized controlled trial

BACKGROUND AND PURPOSE

Mental practice of motor imagery has shown beneficial effects in stroke recovery. However, there are few clinical trials investigating it on the subacute phase. This study will investigate the effects of mental practice in the mobility of patients with subacute stroke.

MATERIALS AND METHODS

Randomized controlled trial including persons with subacute stroke (<3 months). All participants will receive physical exercises and will be randomly allocated into an experimental group (Mental Practice) or into a control group (cognitive training) for 4 weeks(12 sessions).

RESULTS

Primary outcomes will be assessed at baseline and after intervention and will be related to mobility, using Timed Up and Go test and 5 m walking speed test. Whereas secondary outcomes will be muscular strength, biomechanical strategies, mental health and quality of life.

CONCLUSION

The beneficial effects that may be found in this trial can be greatly relevant in clinical practice, justifying this scientific question.

Rasch analysis of the upper-limb subscale of the stroke rehabilitation assessment of movement (STREAM) tool in an acute stroke cohort Rasch analysis of the upper-limb subscale of the STREAM tool in an acute stroke population

BACKGROUND

Stroke is a leading cause of disability worldwide. The most common impairment resulting from stroke is upper-limb weakness.

OBJECTIVES

To determine the usefulness and psychometric validity of the upper-limb subscale of the STREAM in an acute stroke population.

METHODS

Rasch Analysis, including unidimensionality assumption testing, determining model fit, and analysis of: reliability, residual correlations, and differential item functioning.

RESULTS

125 individuals were assessed using the upper-limb subscale of the Stroke Rehabilitation Assessment of Movement (STREAM) tool. Rasch analysis suggests the STREAM is a unidimensional measure. However, when scored using the originally proposed method (0-2), or using the response pattern (0-5) neither variant fit the Rasch model (p < 0.05). Although, the reliability was good (Person-Separation Index - 0.847 and 0.903, respectively). Correcting for the disordered thresholds, and thereby producing the new scoring pattern, led to substantial improvement in the overall fit (chi-square probability of fit - 22%), however, the reliability was slightly reduced (PSI - 0.806).

CONCLUSIONS

The study proposes a new scoring method for the upper-limb subscale of the STREAM outcome measure in the acute stroke population.

Effectiveness of Faradic and Russian currents on plantar flexor muscle spasticity, ankle motor recovery, and functional gait in stroke patients

BACKGROUND AND PURPOSE

Spasticity is a major disabling symptom in patients post stroke. Though studies have demonstrated that electrical stimulation (ES) can reduce spasticity and improve passive ankle range of motion (ROM), not many studies have evaluated the effectiveness of ES on active ankle ROM. The purpose of this study was to determine the effectiveness of Faradic and Russian currents in the reduction of ankle plantar-flexor spasticity and improving motor recovery in patients post stroke.

METHODS

Eighty-three patients (29 females and 54 males; mean age of 57.12 years) were randomly assigned to Group 1 (task-oriented exercises), Group 2 (Faradic current for 10 min and task-oriented exercises), and Group 3 (Russian current for 10 min and task-oriented exercises) for a period of 5 sessions per week for 6 weeks. All patients were assessed for soleus and gastrocnemius muscles spasticity measured by modified modified Ashworth scale; active and passive range ROM measured by goniometer; and functional ambulation measured by modified Emory Functional Ambulation Profile at the time of recruitment to study and after 6 weeks.

RESULTS

Both the types of stimulation and exercises were not associated with improvements in modified Emory Functional Ambulation Profile (p > 0.05). The results showed that all the groups are effective in improving passive ankle ROM (p < 0.05) and reducing soleus and gastrocnemius muscles spasticity (p < 0.05). Though all the groups were effective in improving active ankle ROM, no group was found to be superior to another after treatment CONCLUSION: Adding ES to exercises are associated with low to medium effect sizes (<0.5) in reducing spasticity and improving ankle ROM.

Group- and Individual-Level Responsiveness of the 3-Point Berg Balance Scale and 3-Point Postural Assessment Scale for Stroke Patients

OBJECTIVES

To examine both group- and individual-level responsiveness of the 3-point Berg Balance Scale (BBS-3P) and 3-point Postural Assessment Scale for Stroke Patients (PASS-3P) in patients with stroke, and to compare the responsiveness of both 3-point measures versus their original measures (Berg Balance Scale [BBS] and Postural Assessment Scale for Stroke Patients [PASS]) and their short forms (short-form Berg Balance Scale [SFBBS] and short-form Postural Assessment Scale for Stroke Patients [SFPASS]) and between the BBS-3P and PASS-3P.

DESIGN

Data were retrieved from a previous study wherein 212 patients were assessed at 14 and 30 days after stroke with the BBS and PASS.

SETTING

Medical center.

PARTICIPANTS

Patients (N=212) with first onset of stroke within 14 days before hospitalization.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Group-level responsiveness was examined by the standardized response mean (SRM), and individual-level responsiveness was examined by the proportion of patients whose change scores exceeded the minimal detectable change of each measure. The responsiveness was compared using the bootstrap approach.

RESULTS

The BBS-3P and PASS-3P had good group-level (SRM, .60 and SRM, .56, respectively) and individual-level (48.1% and 44.8% of the patients with significant improvement, respectively) responsiveness. Bootstrap analyses showed that the BBS-3P generally had superior responsiveness to the BBS and SFBBS, and the PASS-3P had similar responsiveness to the PASS and SFPASS. The BBS-3P and PASS-3P were equally responsive to both group and individual change.

CONCLUSIONS

The responsiveness of the BBS-3P and PASS-3P was comparable or superior to those of the original and short-form measures. We recommend the BBS-3P and PASS-3P as responsive outcome measures of balance for individuals with stroke.

Development of a psychological intervention for fatigue after stroke

Background and aim

Post-stroke fatigue (PSF) is common and distressing, but there is insufficient evidence to recommend any effective treatment for it. Psychological interventions are effective in treating fatigue in other conditions. This paper describes the development and evaluation of the feasibility of a psychological intervention for PSF.

Methods

Based on psychological correlates of PSF and evidence-based psychological interventions for fatigue in other medical conditions, we developed a manualised psychological intervention for PSF, with input from stroke clinicians, psychological therapists, and stroke survivors. The intervention was delivered by a clinical psychologist to 12 participants with PSF to test its acceptability and feasibility. According to the feedback from participants and therapists, the intervention was refined for future use.

Results

The intervention consisted of six individual, face-to-face treatment sessions, and one follow-up, telephone-delivered booster session. It included psycho-education and discussion of strategies to promote physical and social activities and to challenge unhelpful thoughts. Four participants dropped out and the remaining eight participants completed the intervention. These eight participants also completed all assessments and feedback and reported fatigue levels as lower at the end of the study than at the baseline. All participants reported favourable opinions on the intervention and suggested that the last two treatment sessions be combined and the booster session be delivered in person as opposed to telephone.

Conclusions

This psychological intervention was acceptable to stroke patients and was feasible in the local health service. These findings suggest that a randomised controlled trial to test efficacy is warranted.

Enhancing the Alignment of the Preclinical and Clinical Stroke Recovery Research Pipeline: Consensus-Based Core Recommendations From the Stroke Recovery and Rehabilitation Roundtable Translational Working Group

Stroke recovery research involves distinct biological and clinical targets compared to the study of acute stroke. Guidelines are proposed for the pre-clinical modeling of stroke recovery and for the alignment of pre-clinical studies to clinical trials in stroke recovery.

Enhancing the alignment of the preclinical and clinical stroke recovery research pipeline: Consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable translational working group

Stroke recovery research involves distinct biological and clinical targets compared to the study of acute stroke. Guidelines are proposed for the pre-clinical modeling of stroke recovery and for the alignment of pre-clinical studies to clinical trials in stroke recovery.

Racial Differences in Patient-Reported Post-Stroke Disability in Older Adults

Longstanding disparities have been reported in stroke-related outcomes with blacks experiencing more post-stroke disabilities. Little is known about long-term disability outcomes among older stroke survivors. This study was a retrospective analysis of data from the 2015 National Health Interview Survey (NHIS). A group of 655 stroke survivors (541 white and 114 black) age 65 and older were asked to rate their ability to complete 10 functional tasks without special equipment. Univariate comparisons were completed using t-tests and chi-square statistics for racial comparisons of disability reports. Multinomial logistic regression was used to determine odds of reporting disability after controlling for relevant covariates. The mean age of the sample was 76.6 years. After controlling for relevant covariates, white stroke survivors were less likely to report the following tasks being "very difficult/can't do at all" without using special equipment compared to blacks: reach overhead (OR = 0.39, 95% CI 0.23⁻0.65; p = 0.000) and grasp small objects (OR = 0.42, 95% CI 0.25⁻0.73; p = 0.002). Both black and white older stroke survivors experience significant post-stroke disability across a range of functional tasks. Slightly greater long term post-stroke disability appears to exist among older blacks.

Validation and reliability of the Spanish version of the Function in Sitting Test (S-FIST) to assess sitting balance in subacute post-stroke adult patients

BACKGROUND

Function in Sitting Test (FIST) is a clinical functional assessment of sitting balance validated in adults with stroke. For a major use of this, the test is recommended to be translated in Spanish-speaking countries.

OBJECTIVES

Translate to Spanish the FIST and determine its intra-rater and inter-rater reliabilities and concurrent validity as a measure of sitting balance in adult individuals with stroke.

METHODS

The original version was translated into Spanish and was agreed by a team of experts. A back-translation into English was subsequently performed and sent to the original author, who approved this version named from now Spanish version of Function in Sitting Test (S-FIST). Sixty post-stroke patients' performance was recorded on a videotape. These videos were then used to carry out four measurements to assess the intra-rater and inter-rater reliabilities; two of these were performed by the same rater and the third and fourth by a second and third rater.

RESULTS

The S-FIST meets the following requirements: good construct validity and high correlation with Spanish version of Trunk Impairment Scale 2.0 (S-TIS 2.0) scores (r = 0.791) Spearman's rank, high internal consistency (Cronbach's α-coefficient = 0.97), and high intra-rater and inter-rater reliabilities for the summed scores assessed by intra-class correlation coefficient were 0.999 and 0.997, respectively.

CONCLUSIONS

The S-FIST is valid and reliable and can be recommended for use in the evaluation of dynamic and sitting balance and trunk control in future research and clinical practice on post-stroke patients. Guidelines for treatment and level of quality of trunk activity can be derived from its use.

A Short and Distinct Time Window for Recovery of Arm Motor Control Early After Stroke Revealed With a Global Measure of Trajectory Kinematics

BACKGROUND

Studies demonstrate that most arm motor recovery occurs within three months after stroke, when measured with standard clinical scales. Improvements on these measures, however, reflect a combination of recovery in motor control, increases in strength, and acquisition of compensatory strategies.

OBJECTIVE

To isolate and characterize the time course of recovery of arm motor control over the first year poststroke.

METHODS

Longitudinal study of 18 participants with acute ischemic stroke. Motor control was evaluated using a global kinematic measure derived from a 2-dimensional reaching task designed to minimize the need for antigravity strength and prevent compensation. Arm impairment was evaluated with the Fugl-Meyer Assessment of the upper extremity (FMA-UE), activity limitation with the Action Research Arm Test (ARAT), and strength with biceps dynamometry. Assessments were conducted at: 1.5, 5, 14, 27, and 54 weeks poststroke.

RESULTS

Motor control in the paretic arm improved up to week 5, with no further improvement beyond this time point. In contrast, improvements in the FMA-UE, ARAT, and biceps dynamometry continued beyond 5 weeks, with a similar magnitude of improvement between weeks 5 and 54 as the one observed between weeks 1.5 and 5.

CONCLUSIONS

Recovery after stroke plateaued much earlier for arm motor control, isolated with a global kinematic measure, compared to motor function assessed with clinical scales. This dissociation between the time courses of kinematic and clinical measures of recovery may be due to the contribution of strength improvement to the latter. Novel interventions, focused on the first month poststroke, will be required to exploit the narrower window of spontaneous recovery for motor control.

Decreased Brain-Derived Neurotrophic Factor Serum Concentrations in Chronic Post-Stroke Subjects

BACKGROUND

Brain-derived neurotrophic factor (BDNF) plays a critical role in sensorimotor recovery after a stroke. However, few studies have assessed the circulating BDNF levels in post-stroke humans to understand its changes. This study was conducted to measure BDNF serum concentrations in subjects with chronic hemiparesis, as well as to correlate serum concentrations with age, post-stroke time, total score of Stroke Specific Quality of Life Scale (SS-QOL), mobility subscale score, and motor function of SS-QOL.

METHODS

Seventeen chronic post-stroke subjects matched by age and gender with healthy controls took part in the study. Personal data (age, hemiparesis side, and post-stroke time) were collected, and a physical examination (weight, height, body mass index) and SS-QOL assessment were carried out. On the same day, after the initial evaluation, venous blood samples were collected from the chronic post-stroke subjects and the healthy subjects. The BDNF serum concentrations were measured blindly by enzyme-linked immunosorbent assay.

RESULTS

Subjects with chronic hemiparesis presented a decrease in BDNF serum compared with healthy subjects (P < .01). There was no correlation between BDNF serum levels with post-stroke time, age or quality of life, mobility, and the upper extremity motor function (P > .05). BDNF concentrations are related to structural and functional recovery after stroke; thus, this reduction is important to understand the rehabilitation process more clearly. However, more studies are needed considering the genetic variations and other tools to assess motor impairment and functional independence.

CONCLUSION

Chronic post-stroke subjects presented a decrease in BDNF serum concentrations, without a correlation with post-stroke time, age, and quality of life.

Effects of repetitive transcranial magnetic stimulation on lower extremity spasticity and motor function in stroke patients

PURPOSE

To investigate the effect of low-frequency repetitive transcranial magnetic stimulation (rTMS) on lower extremity (LE) spasticity, motor function and motor neurone excitability in chronic stroke patients.

METHOD

This study was a randomised sham-controlled cross-over trial with 1-week follow-up. A total of 20 post-stroke patients were randomised to receive active (n = 10) or sham (n = 10) rTMS. Fourteen of them (7 in each group) crossed over to the sham or active rTMS after a washout period of 1 month. Interventions consist of five consecutive daily sessions of active or sham rTMS to the unaffected lower extremity motor area (1000 pulses; 1 Hz; 90% of the tibialis anterior motor threshold). Outcome measures were modified modified ashworth scale (MMAS), the H-reflex, lower extremity section of Fugl-Mayer assessment (LE-FMA) and timed UP and GO (TUG) test. All outcomes were measured at three levels in each intervention period: pre- and post-intervention and 1-week follow-up.

RESULTS

Friedman's test revealed significant improvement in MMAS score only after active rTMS. This improvement lasted for one week after the active rTMS. Repeated measure analysis of variance (ANOVA) showed significant time*intervention interaction for LE-FMA. There are no differences between groups for the MMAS and LE-FMA. No significant change in Hmax/Mmax ratio and TUG test was noted.

CONCLUSION

Low-frequency rTMS over the LE motor area can improve clinical measures of muscle spasticity and motor function. More studies are needed to clarify the changes underlying this improvement in spasticity. Implications for Rehabilitation Spasticity is a common disorder and one of the causes of long-term disability after stroke. Physical therapy modalities, oral medications, focal intervention and surgical procedures have been used for spasticity reduction. Beneficial effect of the repetitive transcranial magnetic stimulation (rTMS) for post-stroke upper extremity spasticity reduction and motor function improvement was demonstrated in previous studies. This study shows amelioration of lower extremity spasticity and motor function improvement after five daily sessions of inhibitory rTMS to the unaffected brain hemisphere which lasted for at least 1 week following the intervention.

How to Measure Recovery? Revisiting Concepts and Methods for Stroke Studies

In clinical trials, assessing efficacy is based on validated scales, and the primary endpoint is usually based on a single scale. The aim of the review is to revisit the concepts and methods to design and analyze studies focused on restoration, recovery and or compensation. These studies are becoming more frequent with the development of restorative medicine. After discussing the definitions of recovery, we address the concept of recovery as the regain of lost capabilities, when the patient reaches a new equilibrium. Recovery is a dynamic process which assessment includes information from initial and final status, their difference, the difference between the final status of the patient and normality, and the speed of restoration. Finally, recovery can be assessed either for a specific function (focal restoration) or for a more global restoration. A single scale is not able to assess all the facets of a skill or a function, therefore complementary information should be collected and analyzed simultaneously to be tested in a single analysis. We are suggesting that recovery should be considered as a latent variable and therefore cannot be measured in pure form. We are also suggesting to customize the data collection and analysis according to the characteristics of the subjects, the mechanisms of action and consequences of the intervention. Moreover, recovery trials should benefit from latent variable analysis methods. Structural equation modeling is likely the best candidate for this approach applicable in pre-clinical and clinical studies.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Factors Associated with the Choice of Peritoneal Dialysis in Patients with End-Stage Renal Disease

Background. The purpose of this study was to analyze the factors associated with receiving peritoneal dialysis (PD) in patients with incident end-stage renal disease (ESRD) in a hospital in Southern Taiwan. Methods. The study included all consecutive patients with incident ESRD who participated in a multidisciplinary predialysis education (MPE) program and started their first dialysis therapy between January 1, 2008, and June 30, 2013, in the study hospital. We provided small group teaching sessions to advanced CKD patients and their family to enhance understanding of various dialysis modalities. Multivariate logistic regression models were used to analyze the association of patient characteristics with the chosen dialysis modality. Results. Of the 656 patients, 524 (80%) chose hemodialysis and 132 chose PD. Our data showed that young age, high education level, and high scores of activities of daily living (ADLs) were positively associated with PD treatment. Patients who received small group teaching sessions had higher percentages of PD treatment (30.5% versus 19.5%; P = 0.108) and preparedness for dialysis (61.1% versus 46.6%; P = 0.090). Conclusion. Young age, high education level, and high ADL score were positively associated with choosing PD. Early creation of vascular access may be a barrier for PD.

A pilot study on the effects of low frequency repetitive transcranial magnetic stimulation on lower extremity spasticity and motor neuron excitability in patients after stroke

PURPOSE

To evaluate the effect of low frequency, repetitive transcranial magnetic stimulation (rTMS) on the lower extremity spasticity and motor neuron excitability in patients after stroke.

METHODS

Seven patients after stroke aged 42-78 years were included in this pretest-posttest clinical trial. The rTMS at 1 Hz and duration of 20 min was applied to the intact leg motor cortex for five consecutive sessions. Primary outcome measures were the Modified Modified Ashwoth Scale (MMAS) and the H(max)/M(max) ratio. Measurements were taken at baseline (T0), after the last treatment (5th) session (T1), and at 1 week follow up (T2).

RESULTS

Clinically assessed ankle plantar flexor spasticity (p = 0.05) improved significantly after treatment at T1. Knee extensor spasticity scored 0 after treatment at T1 and T2. The H(max)/M(max) ratio showed no statistically significant improvement after treatment.

CONCLUSION

The pilot data indicate that the inhibitory rTMS of the intact leg motor cortex in patients after stroke may improve the lower extremity spasticity.

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

BACKGROUND

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

OBJECTIVE

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