Effect of postural training using a whole-body tilt apparatus in subacute stroke patients with lateropulsion: A single-blinded randomized controlled trial

Immediate changes in standing and walking when placing a hanger around the head of a patient with body lateropulsion: a case report

INTRODUCTION

Body lateropulsion is a postural disorder characterized by involuntary leaning to one side and is a major symptom in individuals with Wallenberg syndrome. Although the hanger reflex has potential applications as a simple stimulus to control posture, there are no reports of its use in body lateropulsion cases. The case report aims to document the immediate effects of a wire hanger worn around the head on the center of foot pressure and gait pattern parameters.

CASE DESCRIPTION

The patient, a man in his 50s, exhibited no motor paralysis of the upper and lower extremities following the onset of stroke but demonstrated left lateropulsion. Assessments of center of pressure (COP) during standing, as well as evaluating spatiotemporal and kinematic factors through three-dimensional gait analysis, both with and without a hanger worn around the head.

OUTCOMES

The application of the hanger to the patient's head resulted in immediate improvements in postural control and walking ability. When the hanger was placed around the head, compared with the non-hanger condition, the deviation of the COP toward the lateropulsion side during the standing trial improved immediately. Additionally, placement of a hanger around the head increased hip adduction range of motion during the stance phase, decreased step width, and increased gait speed.

DISCUSSION

This case report suggests the need for further research regarding the effect and efficacy of a hanger worn around the head as a tool for understanding the pathophysiology of body lateropulsion and for providing enhancements in both standing posture and walking ability.

Effects of physical therapy modalities for motor function, functional recovery, and post-stroke complications in patients with severe stroke: a systematic review update

BACKGROUND

Physical therapy interventions play a crucial role in the daily care of patients recovering from severe stroke. However, the efficacy of these interventions and associated modalities, including duration, intensity, and frequency, have not been fully elucidated. In 2020, a systematic review reported the beneficial effects of physical therapy for patients with severe stroke but did not assess therapeutic modalities. We aim to update the current evidence on the effects of physical therapy interventions and their modalities in relation to the recovery phase in people with severe stroke in a hospital or inpatient rehabilitation facility.

METHODS

We searched CENTRAL, MEDLINE, Web of Science, and three other relevant databases between December 2018 and March 2021 and updated the search between April 2021 and March 2023.

CLINICALTRIALS

gov and ICTRP for searching trial registries helped to identify ongoing RCTs since 2023. We included individual and cluster randomized controlled trials in the English and German languages that compared physical therapy interventions to similar or other interventions, usual care, or no intervention in a hospital or rehabilitation inpatient setting. We screened the studies from this recent review for eligibility criteria, especially according to the setting. Critical appraisal was performed according to the Cochrane risk-of-bias tool 2.0. The data were synthesized narratively.

RESULTS

The update identified 15 new studies, cumulating in a total of 30 studies (n = 2545 participants) meeting the eligibility criteria. These studies reported 54 outcomes and 20 physical therapy interventions. Two studies included participants during the hyperacute phase, 4 during the acute phase,18 during the early subacute phase, and 3 in the late subacute phase. Three studies started in the chronic phase. Summarised evidence has revealed an uncertain effect of physical therapy on patient outcomes (with moderate to low-quality evidence). Most studies showed a high risk of bias and did not reach the optimal sample size. Little was stated about the standard care and their therapy modalities.

DISCUSSION

There is conflicting evidence for the effectiveness of physical therapy interventions in patients with severe stroke. There is a need for additional high-quality studies that also systematically report therapeutic modalities from a multidimensional perspective in motor stroke recovery. Due to the high risk of bias and the generally small sample size of the included studies, the generalizability of the findings to large and heterogeneous volumes of outcome data is limited.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021244285.

Validation of a laser visual feedback and core stability exercise programme to improve lateropulsion reduction and pushing intensity in stroke patients with pusher syndrome: A Delphi study

BACKGROUND

The patient with pusher syndrome (PS) is characterized by showing postural control alterations due to a lack of perception of his own body in the space. It appears when the patient actively pushes with his unaffected limbs towards the injured side, reacting with resistance to passive straightening towards the midline. Between 10% and 50% of strokes present PS. Nowadays, there is no clearly defined treatment for PS.

OBJECTIVE

To design and validate an exercise program using visual feedback and specific core stability exercises (FeViCoS) for the treatment of patients with PS.

METHODS

Validation was conducted by expert consensus using the Delphi method. Thirteen neurorehabilitation experts participated in the process. An online questionnaire with 18 Likert-type questions was used to evaluate the designed program. Consensus was considered reached if there was convergence between the quartile 1 and 3 values (RIQ = Q1-Q3) or if the relative interquartile range (RIR) was less than 20%. The degree of agreement between experts was measured by calculating the Fleiss' kappa coefficient.

RESULTS

A total of 2 rounds were required to achieve 97.44% consensus with 100% participation. The RIR was less than or equal to 20% for all questions. The Fleiss' kappa index (0.831) showed that the degree of agreement between experts was excellent.

CONCLUSION

Neurorehabilitation experts considered FeViCoS valid for the therapeutic approach to patients with PS. Expert consensus suggests a novel strategy in physical therapy clinical practice to improve balance and postural orientation in patients with subacute stroke and PS.

Interventions for people with perceptual disorders after stroke: the PIONEER scoping review, Cochrane systematic review and priority setting project

Background

Stroke often affects recognition and interpretation of information from our senses, resulting in perceptual disorders. Evidence to inform treatment is unclear.

Objective

To determine the breadth and effectiveness of interventions for stroke-related perceptual disorders and identify priority research questions.

Methods

We undertook a scoping review and then Cochrane systematic review. Definitions, outcome prioritisation, data interpretation and research prioritisation were coproduced with people who had perceptual disorders post stroke and healthcare professionals. We systematically searched electronic databases (including MEDLINE, EMBASE, inception to August 2021) and grey literature. We included studies (any design) of interventions for people with hearing, smell, somatosensation, taste, touch or visual perception disorders following stroke. Abstracts and full texts were independently dual reviewed. Data were tabulated, synthesised narratively and mapped by availability, sense and interventions. Research quality was not evaluated. Our Cochrane review synthesised the randomised controlled trial data, evaluated risk of bias (including randomisation, blinding, reporting) and meta-analysed intervention comparisons (vs. controls or no treatment) using RevMan 5.4. We judged certainty of evidence using grading of recommendations, assessment, development and evaluation. Activities of daily living after treatment was our primary outcome. Extended activities of daily living, quality of life, mental health and psychological well-being perceptual functional and adverse event data were also extracted.

Results

We included 80 studies (n = 893): case studies (36/80) and randomised controlled trials (22/80). No stroke survivor or family stakeholder involvement was reported. Studies addressed visual (42.5%, 34/80), somatosensation (35%, 28/80), auditory (8.7%, 7/80) and tactile (7.5%, 6/80) perceptual disorders; some studies focused on 'mixed perceptual disorders' (6.2%, 5/80 such as taste-smell disorders). We identified 93 pharmacological, non-invasive brain stimulation or rehabilitation (restitution, substitution, compensation or mixed) interventions. Details were limited. Studies commonly measured perceptual (75%, 60/80), motor-sensorimotor (40%, 32/80) activities of daily living (22.5%, 18/80) or sensory function (15%, 12/80) outcomes.

Cochrane systematic review

We included 18 randomised controlled trials (n = 541) addressing tactile (3 randomised controlled trials; n = 70), somatosensory (7 randomised controlled trials; n = 196), visual (7 randomised controlled trials; n = 225) and mixed tactile-somatosensory (1 randomised controlled trial; n = 50) disorders. None addressed hearing, taste or smell disorders. One non-invasive brain stimulation, one compensation, 25 restitution and 4 mixed interventions were described. Risk of bias was low for random sequence generation (13/18), attrition (14/18) and outcome reporting (16/18). Perception was the most commonly measured outcome (11 randomised controlled trials); only 7 randomised controlled trials measured activities of daily living. Limited data provided insufficient evidence to determine the effectiveness of any intervention. Confidence in the evidence was low-very low. Our clinical (n = 4) and lived experience (n = 5) experts contributed throughout the project, coproducing a list of clinical implications and research priorities. Top research priorities included exploring the impact of, assessment of, and interventions for post-stroke perceptual disorders.

Limitations

Results are limited by the small number of studies identified and the small sample sizes, with a high proportion of single-participant studies. There was limited description of the perceptual disorders and intervention(s) evaluated. Few studies measured outcomes relating to functional impacts. There was limited investigation of hearing, smell, taste and touch perception disorders.

Conclusion

Evidence informing interventions for perceptual disorders after stroke is limited for all senses.

Future work

Further research, including high-quality randomised controlled trials, to inform clinical practice are required.

Study registration

This study is registered as PROSPERO CRD42019160270.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128829) and is published in full in Health Technology Assessment; Vol. 28, No. 69. See the NIHR Funding and Awards Website for further award information.

rTMS for Poststroke Pusher Syndrome: A Randomized, Patient-Blinded Controlled Clinical Trial

BACKGROUND

Patients with poststroke pusher syndrome (PS) require longer duration of rehabilitation and more supplemental care after discharge. Effective treatment of PS remains a challenge. The role of repetitive transcranial magnetic stimulation (rTMS) for PS has not been examined.

OBJECTIVE

Assess the efficacy of rTMS for patients with poststroke PS in reducing pushing behavior, enhancing motor recovery and improving mobility.

METHODS

A randomized, patient- and assessor-blinded sham-controlled trial with intention-to-treat analysis was conducted. Thirty-four eligible patients with poststroke PS were randomly allocated to receive either rTMS or sham rTMS for 2 weeks. Pushing behavior on the Burke lateropulsion scale and scale for contraversive pushing, motor function on Fugl-Meyer assessment scale-motor domain (FMA-m) and mobility on modified Rivermead mobility index were measured at baseline, 1 and 2 weeks after intervention. Repeated-measures analysis of covariance was used for data analysis.

RESULTS

There was no significant interaction between intervention and time on Burke lateropulsion scale (F = 2.747, P = .076), scale for contraversive pushing (F = 1.583, P = .214), or change of modified Rivermead mobility index (F = 1.183, P = .297). However, a significant interaction between intervention and time was observed for FMA-m (F = 5.464, P = .019). Post hoc comparisons of FMA-m show better improvement in rTMS group with mean differences of 12.7 (95% CI -7.3 to 32.7) and 15.7 (95% CI -4.6 to 36.0) at post-treatment week 1 and week 2 respectively.

CONCLUSIONS

rTMS did not demonstrate significant efficacy in improving pushing behavior and mobility in patients with PS. However, rTMS might have potential effect in enhancing motor function for patients with PS.

REGISTRATION

The study was registered in the Chinese Clinical Trial Registry (registration No. ChiCTR2200058015 at http://www.chictr.org.cn/searchprojen.aspx) on March 26, 2022.

Improving orientation with respect to gravity enhances balance and gait recovery after stroke: DOBRAS cohort

BACKGROUND

Lateropulsion is a deficit in body orientation with respect to gravity, frequent after stroke. Although it is a primary factor affecting mobility, the impact of its attenuation on balance and gait recovery has never been investigated. Moreover, most studies on the lateropulsion time-course focus on severe forms suspected to have a poor recovery, which is not proven.

OBJECTIVES

To investigate lateropulsion attenuation and test 2 hypotheses: 1) lateropulsion attenuation greatly contributes to balance and gait recovery and 2) severe forms of lateropulsion recover slower than moderate forms.

METHODS

This longitudinal study involved individuals included in the Determinants of Balance Recovery After Stroke (DOBRAS) cohort, after a first-ever hemispheric stroke, with data collected on day 30 (D30), D60 and D90 post-stroke. Body orientation with respect to gravity was assessed using the Scale for Contraversive Pushing (both scores and severity grouping), in parallel with balance (Postural Assessment Scale for Stroke) and gait (modified Fugl-Meyer Gait Assessment).

RESULTS

Among the 106 eligible individuals (mean age 66.5 [SD 9.7] years), on D30, 43 (41%) were considered upright and 63 (59%) showed lateropulsion: 30 (28%) moderate and 33 (31%) severe. Most individuals with lateropulsion (73%) improved their body orientation, progressing from severe to moderate lateropulsion, or becoming upright. However, half were still not upright on D90. The improvement in body orientation had a large impact on mobility, especially in individuals with severe lateropulsion, in whom it explained about 50% of balance and gait recovery between D30 and D60, then 20% (D60-D90). For moderate lateropulsion, its attenuation explained about 20% of balance and gait recovery until D90. Lateropulsion attenuation was not slower in individuals with severe forms.

CONCLUSIONS

Lateropulsion attenuation enhances balance and gait recovery in individuals after stroke suggesting that specific rehabilitation of body orientation with respect to gravity might help to recover mobility.

REGISTRATION

NCT03203109.

Interventions for perceptual disorders following stroke

BACKGROUND

Perception is the ability to understand information from our senses. It allows us to experience and meaningfully interact with our environment. A stroke may impair perception in up to 70% of stroke survivors, leading to distress, increased dependence on others, and poorer quality of life. Interventions to address perceptual disorders may include assessment and screening, rehabilitation, non-invasive brain stimulation, pharmacological and surgical approaches.

OBJECTIVES

To assess the effectiveness of interventions aimed at perceptual disorders after stroke compared to no intervention or control (placebo, standard care, attention control), on measures of performance in activities of daily living.  SEARCH METHODS: We searched the trials registers of the Cochrane Stroke Group, CENTRAL, MEDLINE, Embase, and three other databases to August 2021. We also searched trials and research registers, reference lists of studies, handsearched journals, and contacted authors.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adult stroke survivors with perceptual disorders. We defined perception as the specific mental functions of recognising and interpreting sensory stimuli and included hearing, taste, touch, smell, somatosensation, and vision. Our definition of perception excluded visual field deficits, neglect/inattention, and pain.

DATA COLLECTION AND ANALYSIS

One review author assessed titles, with two review authors independently screening abstracts and full-text articles for eligibility. One review author extracted, appraised, and entered data, which were checked by a second author. We assessed risk of bias (ROB) using the ROB-1 tool, and quality of evidence using GRADE.  A stakeholder group, comprising stroke survivors, carers, and healthcare professionals, was involved in this review update.

MAIN RESULTS

We identified 18 eligible RCTs involving 541 participants. The trials addressed touch (three trials, 70 participants), somatosensory (seven trials, 196 participants) and visual perception disorders (seven trials, 225 participants), with one (50 participants) exploring mixed touch-somatosensory disorders. None addressed stroke-related hearing, taste, or smell perception disorders. All but one examined the effectiveness of rehabilitation interventions; the exception evaluated non-invasive brain stimulation. For our main comparison of active intervention versus no treatment or control, one trial reported our primary outcome of performance in activities of daily living (ADL):  Somatosensory disorders: one trial (24 participants) compared an intervention with a control intervention and reported an ADL measure.  Touch perception disorder: no trials measuring ADL compared an intervention with no treatment or with a control intervention.  Visual perception disorders: no trials measuring ADL compared an intervention with no treatment or control.  In addition, six trials reported ADL outcomes in a comparison of active intervention versus active intervention, relating to somatosensation (three trials), touch (one trial) and vision (two trials).   AUTHORS' CONCLUSIONS: Following a detailed, systematic search, we identified limited RCT evidence of the effectiveness of interventions for perceptual disorders following stroke. There is insufficient evidence to support or refute the suggestion that perceptual interventions are effective. More high-quality trials of interventions for perceptual disorders in stroke are needed. They should recruit sufficient participant numbers, include a 'usual care' comparison, and measure longer-term functional outcomes, at time points beyond the initial intervention period. People with impaired perception following a stroke should continue to receive neurorehabilitation according to clinical guidelines.

rTMS for poststroke pusher syndrome: study protocol for a randomised, patient-blinded controlled clinical trial

INTRODUCTION

Poststroke pusher syndrome (PS) prevalence is high. Patients with PS require longer rehabilitation with prolonged length of stay. Effective treatment of PS remains a challenge for rehabilitation professionals. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation technique that is effective and recommended in the clinical guidelines of stroke rehabilitation. However, the role of rTMS for PS has not been examined. The study is to assess the efficacy of a specific rTMS programme for patients with PS in reducing pushing behaviour, enhancing motor recovery and improving mobility, as well as testing the safety of rTMS for patients with PS.

METHODS AND ANALYSIS

A randomised, patient and assessor blinded sham-controlled trial with two parallel groups will be conducted. Thirty-four eligible patients with PS will be randomly allocated to receive either rTMS or sham rTMS for 3 weeks. The primary assessment outcome is the pushing behaviour measured by the Burke Lateropulsion Scale and Scale for Contraversive Pushing. The secondary outcomes are the motor functions and mobility measured by the Fugl-Meyer Assessment Scale (motor domain) and Modified Rivermead Mobility Index, and any adverse events. Assessment will be performed at baseline and 1 week, 2 weeks and 3 weeks after intervention. Repeated-measures analysis of variance will be used for data analysis with the level of significance level set at 0.05.

ETHICS AND DISSEMINATION

The protocol has been approved by the Biomedical Ethics Committee of West China Hospital, Sichuan University on 23 March 2022 (2022-133). The trial findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR2200058015).

Lateropulsion Prevalence after Stroke: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Lateropulsion is a deficit of active body orientation with respect to gravity in the frontal plane, mostly observed after a stroke. It magnifies mobility limitations and so represents an emerging target in rehabilitation. Efforts to design specific interventional studies require some basic knowledge of epidemiology, which is insufficient today because many studies focused on a few severe forms in individuals called pushers. The objectives of this study were to bridge this gap.

METHODS

We systematically searched MEDLINE, EMBASE, CINAHL, and Cochrane Clinical Trials up to 31 May 2021 for original research reporting a prevalence or incidence of post-stroke lateropulsion. We followed MOOSE and PRISMA guidelines. Eligibility for inclusion, data extraction, and study quality (Joanna Briggs Institute guidelines) were evaluated by two reviewers who used a standardized protocol: PROSPERO (CRD42020175037). A random-effects meta-analysis was used to obtain the pooled prevalence, whose heterogeneity was investigated by subgroup analysis (stroke locations and post-stroke phases) and meta-regression.

RESULTS

We identified 22 studies (5125 individuals; mean age 68.5 years; 42.6% female; assessed 24 days, on average, after stroke), most published after 2000. The studies' quality was adequate, with only 8 (36.4%) showing risk of bias. The pooled lateropulsion prevalence was 55.1% (95% confidence interval [CI] [35.9-74.2]) and was consistent across assessment tools. After supratentorial stroke, lateropulsion prevalence was 41% (95%CI [33.5-48.5]), and only 12.5% (95%CI [9.2-15.9]) in individuals with severe lateropulsion, called pushers. Meta-regression did not reveal any effect of age, sex, geographic region, publication year, or study quality. Lateropulsion prevalence progressively decreased from 52.8% (95%CI [40.7-65]) in the acute phase to 37% (95%CI [26.3-47.7]) in the early subacute phase and 22.8% (95%CI [0-46.3]) in the late subacute phase. The ratio of right- to left-hemispheric stroke with lateropulsion increased as a function of time: 1.7 in the acute phase to 7.7 in the late subacute phase. After infratentorial stroke, lateropulsion prevalence was very high, reaching 83.2% (95%CI [63.9-100.3]).

CONCLUSIONS

Post-stroke lateropulsion prevalence is high, which appeals for its systematic detection to guide early interventions. Uprightness is predominantly controlled from the right hemisphere.

Comparison of Core Muscle Asymmetry Using Spine Balance 3D in Patients with Arthroscopic Shoulder Surgery: A STROBE-Compliant Cross-Sectional Study

Background and Objectives: Joint immobilization after shoulder surgery can cause an imbalance in the periscapular muscles and affect the kinetic chain throughout the body. There is a difference in core muscle stability because of the asymmetry of the lower extremity muscles. However, the difference due to the asymmetry of the upper-extremity muscles has not been studied extensively. The purpose of this study is to investigate the effect of joint immobilization on the symmetry of the core muscles involved in proximal stability for distal mobility. Materials and Methods: Fifty-five patients who underwent arthroscopic shoulder surgery participated in this study. Core muscle asymmetry (CMA) was measured using a body tilt device. The evaluation variables were analyzed according to the surgical site based on the direction of the core muscle ratio and core muscle state ratio. Results: No differences in CMA were found based on the surgical site (p > 0.05). As a result of the additional subanalysis, significant differences in sex and postoperative day were established (p < 0.05). CMA was low during the intensive postoperative rehabilitation period. However, sex-related differences were greater in males than in females. Conclusions: The clinical results suggest that core muscle training is necessary to reduce CMA during rehabilitation after the immobilization period has elapsed.