Rehabilitation of poststroke cognition

Using hypnotic suggestion in the rehabilitation of working memory capacity after acquired brain injury: study protocol for a randomized controlled trial

OBJECTIVES

Establishment of effective evidence-based interventions in rehabilitation of working memory (WM) deficits after acquired brain injury (ABI) is sorely needed. Despite robust evidence for the efficiency of clinical hypnosis in a wide range of clinical conditions, and improved understanding of mechanisms underlying its effects, the potential of clinical hypnosis in cognitive rehabilitation is underexplored. A recent study has shown large effects of hypnotic suggestion on WM capacity following ABI. This randomized controlled trial aims to evaluate and explore the replicability of these findings and examine the generalization of treatment effects. The study will also explore possible mechanisms of change.

METHODS

Ninety patients will be recruited from the Sunnaas Rehabilitation Hospital. Inclusion criteria are nonprogressive ABI, minimum 12-month post-injury, ongoing WM deficits, and age between 18 and 67 years. Patients will be randomized to either (a) an intervention group receiving four weekly 1-h sessions with induction and hypnosis, (b) an active control group receiving four weekly 1-h sessions of induction and mindfulness, or (c) a passive control group without intervention. The targeted procedure consists of suggestions about enhancing WM functions, for example through the instantiation of preinjury WM capacity in the present using age regression or through visualizations of brain plasticity. The non-targeted suggestions contain no explicit mention of ABI- or WM-related abilities. Each participant will be assessed at baseline, immediately after intervention, and 6 months after baseline. The primary outcome is the WM index from WAIS-IV and self- and informant-reported WM subscale from BRIEF-A, a questionnaire exploring executive functioning in everyday life. Secondary outcomes include a cognitive composite score derived from tests measuring processing speed, executive functions, learning capacity and memory, and self-reported measures of emotional distress, quality of life, and community integration. Exploratory measures include self-rated ABI and WM-related self-efficacy.

DISCUSSION

Rehabilitation of impaired WM after ABI has hitherto yielded limited transfer effects beyond the training material, i.e., improvement effects on everyday WM capacity, and clinical trials of new interventions are thus warranted. Long-standing empirical evidence demonstrates that hypnosis is an effective therapeutic technique in a wide range of conditions, and recent exploratory research has suggested a high efficacy of hypnosis in improving WM capacity in patients with ABI. However, these extraordinary findings need replication in studies applying scientifically rigorous designs. If successful, our ambition is to provide recommendations and materials to implement hypnotic suggestion as an adjunct treatment following ABI. Study findings may inform future studies exploring the use of clinical hypnosis in other areas of rehabilitation, such as mild TBI, and in other neurological conditions where WM deficit is prominent.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05287542. Registered on March 2022 PROTOCOL VERSION: Protocol version 2.0, December 2023.

A nomogram for individualized prediction of lower extremity deep venous thrombosis in stroke patients: A retrospective study

To develop and validate a nomogram for individualized prediction of lower extremity deep venous thrombosis (DVT) in stroke patients based on extremity function and daily living ability of stroke patients. In this study, 423 stroke patients admitted to the Rehabilitation Medical Center of the First Affiliated Hospital of Nanjing Medical University from December 2015 to February 2019 were taken as the subjects, who were divided into the DVT group (110) and No-DVT group (313) based on the existence of DVT. Inter-group comparison of baseline data was performed by 1-way Analysis of Variance, Kruskal-Wallis rank-sum test, or Pearson chi-square test. Data dimensions and predictive variables were selected by least absolute shrinkage and selection operator (LASSO); the prediction model was developed and the nomogram was prepared by binary logistics regression analysis; the performance of the nomogram was identified by the area under the receiver operating characteristic curve (AUC), Harrell's concordance index, and calibration curve; and the clinical effectiveness of the model was analyzed by clinical decision curve analysis. Age, Brunnstrom stage (lower extremity), and D-dimer were determined to be the independent predictors affecting DVT. The independent predictors mentioned above were developed and presented as a nomogram, with AUC and concordance index of 0.724 (95% confidence interval [CI]: 0.670-0.777), indicating the satisfactory discrimination ability of the nomogram. The P value of the results of the Hosmer-Lemeshow test was 0.732, indicating good fitting of the prediction model. Decision curve analysis showed that the clinical net benefit of this model was 6% to 50%. We developed a nomogram to predict lower extremity deep venous thrombosis in stroke patients, and the results showed that the nomogram had satisfactory prediction performance and clinical efficacy.

Memory rehabilitation: restorative, specific knowledge acquisition, compensatory, and holistic approaches

Memory impairment following an acquired brain injury can negatively impact daily living and quality of life—but can be reduced by memory rehabilitation. Here, we review the literature on four approaches for memory rehabilitation and their associated strategies: (1) the restorative approach, aimed at a return to pre-morbid functioning, (2) the knowledge acquisition approach, involving training on specific information relevant to daily life, (3) the compensatory approach, targeted at improving daily functioning, and (4) the holistic approach, in which social, emotional, and behavioral deficits are addressed alongside cognitive consequences of acquired brain injury. Each memory rehabilitation approach includes specific strategies such as drill and practice (restorative), spaced retrieval (knowledge acquisition), memory aids (compensatory), or a combination of psychotherapy and cognitive strategies (holistic). Past research has demonstrated mixed support for the use of restorative strategies to improve memory function, whereas knowledge acquisition strategies show promising results on trained tasks but little generalization to untrained tasks and activities of daily living. Compensatory strategies remain widely used but require intensive training to be effectively employed. Finally, the holistic approach is becoming more widespread due to improvements in psychosocial wellbeing, yet there are considerable resource and cost requirements. Several factors can influence rehabilitation outcomes including metacognition and emotional disturbances. Considerations for future research to improve the applicability of strategies for memory rehabilitation include assessing memory impairment severity, examining memory needs in daily life, and exploring the long-term effects of memory rehabilitation.

Effect of aerobic exercise on post-stroke cognitive function: a systematic review

Background/Aims

Literature suggests that aerobic exercise improves cognitive impairments post stroke. This systematic review was conducted to analyse evidence on the effectiveness of aerobic exercise in improving post-stroke cognitive impairments.

Methods

Online databases (PubMed, EMBASE and Web of Science) were systematically searched from inception until 13 July 2017 using the keywords stroke/exercise/cognition. Clinical trials that met the inclusion criteria were assessed for methodological quality using the PEDro scale. Extracted data were synthesised for evidence.

Results

A total of seven studies met the inclusion criteria. Participants in most of the studies were aged over 60 years and the majority had ischaemic stroke. The most commonly used measure for assessing cognition was the Mini Mental State Examination. The majority of studies included moderate to high intensity exercise (50–70% of VO2max) for 30–60 minutes three to five times per week. There is moderate evidence that aerobic exercise enhances global cognitive function, attention and working memory. Evidence that aerobic exercise improves memory, levels of brain-derived neurotrophic factor and executive function is conflicting and limited.

Conclusions

Aerobic exercise is moderately effective in improving post-stroke cognitive impairments. More clinical trials are needed in view of the methodological limitations and paucity of existing studies.

Designing robot-assisted neurorehabilitation strategies for people with both HIV and stroke

There is increasing evidence that HIV is an independent risk factor for stroke, resulting in an emerging population of people living with both HIV and stroke all over the world. However, neurorehabilitation strategies for the HIV-stroke population are distinctly lacking, which poses an enormous global health challenge. In order to address this gap, a better understanding of the HIV-stroke population is needed, as well as potential approaches to design effective neurorehabilitation strategies for this population. This review goes into the mechanisms, manifestations, and treatment options of neurologic injury in stroke and HIV, the additional challenges posed by the HIV-stroke population, and rehabilitation engineering approaches for both high and low resource areas. The aim of this review is to connect the underlying neurologic properties in both HIV and stroke to rehabilitation engineering. It reviews what is currently known about the association between HIV and stroke and gaps in current treatment strategies for the HIV-stroke population. We highlight relevant current areas of research that can help advance neurorehabilitation strategies specifically for the HIV-stroke population. We then explore how robot-assisted rehabilitation combined with community-based rehabilitation could be used as a potential approach to meet the challenges posed by the HIV-stroke population. We include some of our own work exploring a community-based robotic rehabilitation exercise system. The most relevant strategies will be ones that not only take into account the individual status of the patient but also the cultural and economic considerations of their respective environment.