Predicting disability in stroke--a critical review of the literature

Vagus Nerve Stimulation Paired With Upper Extremity Rehabilitation for Chronic Ischemic Stroke: Contribution of Dosage Parameters

BACKGROUND

Vagus nerve stimulation (VNS) combined with rehabilitation is a Food and Drug Administration approved intervention for moderate to severe upper extremity deficits in chronic ischemic stroke patients. Previous studies demonstrated that VNS improves upper extremity motor impairments, using the Fugl Meyer Assessment of Upper Extremity (FMA-UE); however, delineating where these improvements occur, and the role of VNS dosage parameters were not reported.

OBJECTIVE

This study explored the relationship between dosing (time over which task repetitions were executed and number of VNS stimulations) and changes within proximal and distal components of the FMA-UE.

METHODS

Participants underwent VNS implantation, with 1 group receiving VNS paired with rehabilitation (Active VNS) and the other group receiving rehabilitation with sham stimulation (Controls). Both groups received 6 weeks of in-clinic therapy followed by a 90-day at-home, self-rehabilitation program. Participants who completed at least 12 of 18 in-clinic sessions were included in the analyses (n = l06). Pearson correlations and analysis of covariance were used to investigate the relationship between dosing and FMA-UE outcome change along with the effect of covariates including baseline severity, time since stroke, age, and paretic side.

RESULTS

Compared to Controls, active VNS favorably influenced distal function with sustained improvement after the home program. Significant improvements were observed in only distal components (FMdist) at both post day-1 (1.80 points, 95% Cl [0.85, 2.73], P < .001) and post-day 90 (1.62 points, 95% CI [0.45, 2.80], P < .007).

CONCLUSIONS

VNS paired with rehabilitation resulted in significant improvements in wrist and hand impairment compared to Controls, despite similar in-clinic dosing across both groups.NCT03131960.

A comprehensive overview of post-stroke depression treatment options

Nearly one-third of all stroke patients develop depression at any time after a stroke, and its presence is associated with unfavorable outcomes. This narrative review aims to provide a synopsis of possible pharmacological and non-pharmacological treatment modalities for post-stroke depression (PSD). Several studies have demonstrated the efficacy and safety of selective serotonin reuptake inhibitors in treating the symptoms of this clinical condition. The treatment of PSD has been recently enhanced by innovative approaches, such as cognitive-behavioral therapy, virtual reality, telehealth, repetitive transcranial magnetic stimulation, and non-conventional therapies, which might improve depression treatment in stroke survivors. Future high-quality randomized controlled trials are necessary to confirm this hypothesis.

Therapists and patients perceptions of a mixed reality system designed to improve trunk control and upper extremity function

A prototype system aimed at improving arm function and trunk control after stroke has been developed that combines mixed-reality (MR) feedback with a mobile seat system (Holoreach). The purpose of this study was to assess the usability of Holoreach in a rehabilitation setting from both the patient and therapist perspective. Ten therapists (eight physiotherapists and two occupational therapists) used the device in their regular therapy programs for fifteen stroke patients with trunk control issues. Each patient received four individual therapy sessions with the device performed under the supervision of the therapist. Therapists and patients kept therapy diaries and used customized questionnaires. At the end of the study two focus groups were conducted to further assess usability. Generally, the prototype system is suitable for training trunk and arm control. The therapists expressed overall positive views on the impact of Holoreach. They characterized it as new, motivating, fresh, joyful, interesting, and exciting. All therapists and 80% of the patients agreed with the statement that training with Holoreach is beneficial for rehabilitation. Nonetheless, improvements are required in the hardware and software, and design. The prototype system contributes at various levels to the rapidly evolving advances in neurorehabilitation, particularly regarding the practical aspect of exercise delivery.

The Evolution of Hand Proprioceptive and Motor Impairments in the Sub-Acute Phase After Stroke

BACKGROUND

Hand proprioception is essential for fine movements and therefore many activities of daily living. Although frequently impaired after stroke, it is unclear how hand proprioception evolves in the sub-acute phase and whether it follows a similar pattern of changes as motor impairments.

OBJECTIVE

This work investigates whether there is a corresponding pattern of changes over time in hand proprioception and motor function as comprehensively quantified by a combination of robotic, clinical, and neurophysiological assessments.

METHODS

Finger proprioception (position sense) and motor function (force, velocity, range of motion) were evaluated using robotic assessments at baseline (<3 months after stroke) and up to 4 weeks later (discharge). Clinical assessments (among others, Box & Block Test [BBT]) as well as Somatosensory/Motor Evoked Potentials (SSEP/MEP) were additionally performed.

RESULTS

Complete datasets from 45 participants post-stroke were obtained. For 42% of all study participants proprioception and motor function had a dissociated pattern of changes (only 1 function considerably improved). This dissociation was either due to the absence of a measurable impairment in 1 modality at baseline, or due to a severe lesion of central somatosensory or motor tracts (absent SSEP/MEP). Better baseline BBT correlated with proprioceptive gains, while proprioceptive impairment at baseline did not correlate with change in BBT.

CONCLUSIONS

Proprioception and motor function frequently followed a dissociated pattern of changes in sub-acute stroke. This highlights the importance of monitoring both functions, which could help to further personalize therapies.

Usefulness of the GLIM criteria to predict recovery of activities of daily living in older adults with post-acute stroke

OBJECTIVES

The usefulness of malnutrition diagnosed using the Global Leadership Initiative on Malnutrition (GLIM) criteria as a predictor of recovery of activities of daily living is unclear. This study aimed to investigate whether baseline malnutrition diagnosed using the GLIM criteria was predictive of recovery of activities of daily living in older patients with post-acute stroke.

MATERIALS AND METHODS

A retrospective cohort study was conducted in patients aged ≥70 years with post-acute stroke. The outcome was activities of daily living measured using the motor domain of the Functional Independence Measure (FIM-motor) score at discharge. Participants were classified as malnourished or non-malnourished according to the GLIM criteria. Multivariate linear regression analyses were performed to determine whether baseline malnutrition diagnosed using the GLIM criteria was predictive of the FIM-motor score at discharge. The analysis was adjusted for clinically relevant covariates associated with rehabilitation outcomes after stroke.

RESULTS

A total of 236 patients (mean age, 80.0 years; female, 54.2%) were included in the analysis. On admission, 83 (35.2%) patients were diagnosed with malnutrition. Multivariate linear regression analyses showed that malnutrition diagnosed using the GLIM criteria was predictive of the FIM-motor score at discharge (β = -0.347, P < 0.001).

CONCLUSIONS

Identifying malnutrition using the GLIM criteria is useful for predicting recovery of activities of daily living in older patients with post-acute stroke.

Stroke Survivors and their Physiotherapists' Perceptions of Recovery: A Multiple Methods Approach

Purpose

This multiple-methods study examined perceptions of recovery among stroke survivors and their physiotherapists at discharge from an in-patient rehabilitation program.

Method

The Functional Independence Measure (FIM) and Chedoke McMaster Stroke Assessment Activity Inventory scores were collected from chart review and the following outcome measures were completed by interview: Stroke Impact Scale (SIS) global recovery, Hospital Anxiety Depression Scale, and Montreal Cognitive Assessment. Physiotherapists also completed the SIS global recovery for each participant. Spearman and Pearson correlations between SIS recovery and observed measures were completed. The stroke survivors had a short interview about their perception of recovery and what recovery meant to them, and their physiotherapists answered two written questions about each participant's recovery. Responses were coded and categorized based on the International Classification of Functioning.

Results

A total of 31 stroke survivors with a mean age of 66.6 years (SD 10.7) and six physiotherapists participated. Nineteen stroke survivors were interviewed. The stroke survivors' SIS recovery scores correlated with FIM-motor change (rs = 0.36 p = 0.04) and the SIS-recovery scores reported by the physiotherapists (r = 0.51; p < 0.01). In relation to the factors related to recovery, the physiotherapists' focus was therapeutic mainly considering motor recovery while the stroke survivors' responses were broad, including being able to achieve recovery goals and nutrition. However, both perceived recovery to include functional activities.

Conclusions

SIS global recovery question helps to measure the overall perceived percentage of recovery. However, the complete picture of recovery is only possible with the stroke survivors' and physiotherapists' perceptions of recovery and what recovery means to them.

Association between multimorbidity and informal long-term care use in China: a nationwide cohort study

BACKGROUND

The impact of multimorbidity on long-term care (LTC) use is understudied, despite its well-documented negative effects on functional disabilities. The current study aims to assess the association between multimorbidity and informal LTC use in China. We also explored the socioeconomic and regional disparities.

METHODS

The study included 10,831 community-dwelling respondents aged 45 years and older from the China Health and Retirement Longitudinal Study in 2011, 2015, and 2018 for analysis. We used a two-part model with random effects to estimate the association between multimorbidity and informal LTC use. Heterogeneity of the association by socioeconomic position (education and income) and region was explored via a subgroup analysis. We further converted the change of informal LTC hours associated with multimorbidity into monetary value and calculated the 95% uncertainty interval (UI).

RESULTS

The reported prevalence of multimorbidity was 60·0% (95% CI: 58·9%, 61·2%) in 2018. We found multimorbidity was associated with an increased likelihood of receiving informal LTC (OR = 2·13; 95% CI: 1·97, 2·30) and more hours of informal LTC received (IRR = 1·20; 95% CI: 1·06, 1·37), ceteris paribus. Participants in the highest income quintile received more hours of informal LTC care (IRR = 1·62; 95% CI: 1·31, 1·99). The estimated monetary value of increased informal LTC hours among participants with multimorbidity was equivalent to 3·7% (95% UI: 2·2%, 5·4%) of China's GDP in 2018.

CONCLUSION

Our findings substantiate the threat of multimorbidity to LTC burden. It is imperative to strengthen LTC services provision, especially among older adults with multimorbidity and ensure equal access among those with lower income.

[A Structural Equation Model on Social Re-Adjustment of Stroke Patients: Based on Roy's Adaptation Model]

PURPOSE

This study aimed to develop and test a structural equation model on social re-adjustment of individuals with stroke based on a literature review and Roy's adaptation model.

METHODS

This study involved 321 participants who had a stroke and visited the outpatient department after discharge. The hypothetical model was developed based on Roy's adaptation model and a comprehensive review of previous literature on the topic. The model comprised four exogenous variables (neurological damage, gender [man], age, and social support) and five endogenous variables (activities of daily living, acceptance of disability, depression, rehabilitation motivation, and social re-adjustment). The data were analyzed using SPSS Windows software version 22.0 and AMOS 23.0.

RESULTS

Out of 28 research hypotheses, 18 were supported, and they indicated approximately 64% probability of social re-adjustment. Social re-adjustment is directly and significantly affected by age, social support, activities of daily living, and depression. Social re-adjustment is indirectly affected by neurological impairment, gender (men), age, social support, and rehabilitation motivation.

CONCLUSION

Continuous assistance and care should be provided for individuals with disabilities caused by sudden neurological damage to facilitate gradual improvement in their social re-adjustment. To enhance social re-adjustment, especially among older adults, newly developed interventions should focus on improving their activities of daily living, preventing depression, and enhancing support from family and healthcare personnel.

Clinical, Neuroimaging and Robotic Measures Predict Long-Term Proprioceptive Impairments following Stroke

Proprioceptive impairments occur in ~50% of stroke survivors, with 20-40% still impaired six months post-stroke. Early identification of those likely to have persistent impairments is key to personalizing rehabilitation strategies and reducing long-term proprioceptive impairments. In this study, clinical, neuroimaging and robotic measures were used to predict proprioceptive impairments at six months post-stroke on a robotic assessment of proprioception. Clinical assessments, neuroimaging, and a robotic arm position matching (APM) task were performed for 133 stroke participants two weeks post-stroke (12.4 ± 8.4 days). The APM task was also performed six months post-stroke (191.2 ± 18.0 days). Robotics allow more precise measurements of proprioception than clinical assessments. Consequently, an overall APM Task Score was used as ground truth to classify proprioceptive impairments at six months post-stroke. Other APM performance parameters from the two-week assessment were used as predictive features. Clinical assessments included the Thumb Localisation Test (TLT), Behavioural Inattention Test (BIT), Functional Independence Measure (FIM) and demographic information (age, sex and affected arm). Logistic regression classifiers were trained to predict proprioceptive impairments at six months post-stroke using data collected two weeks post-stroke. Models containing robotic features, either alone or in conjunction with clinical and neuroimaging features, had a greater area under the curve (AUC) and lower Akaike Information Criterion (AIC) than models which only contained clinical or neuroimaging features. All models performed similarly with regard to accuracy and F1-score (>70% accuracy). Robotic features were also among the most important when all features were combined into a single model. Predicting long-term proprioceptive impairments, using data collected as early as two weeks post-stroke, is feasible. Identifying those at risk of long-term impairments is an important step towards improving proprioceptive rehabilitation after a stroke.

Feasibility of a serious game system including a tangible object for post stroke upper limb rehabilitation: a pilot randomized clinical study

Introduction

Serious games can be used to provide intensive rehabilitation through attractive exercises as part of post-stroke rehabilitation. However, currently available commercial and serious games systems primarily train shoulder and elbow movements. These games lack the grasping and displacement components that are essential to improve upper limb function. For this reason, we developed a tabletop device that encompassed a serious game with a tangible object to rehabilitate combined reaching and displacement movements: the Ergotact system.

Objectives

The aim of this pilot study was to assess the feasibility and the short-term effects of a training program using the Ergotact prototype in individuals with chronic stroke.

Methods

Participants were assigned to one of two groups: a serious game training group (Ergotact) or a control training group (Self).

Results

Twenty-eight individuals were included. Upper limb function increased after the Ergotact training program, although not statistically significantly, and the program did not induce pain or fatigue, demonstrating its safety.

Conclusion

The Ergotact system for upper limb rehabilitation was well accepted and induced participant satisfaction. It complies with current recommendations for people with stroke to autonomously perform intensive active exercises in a fun context, in addition to conventional rehabilitation sessions with therapists.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03166020?term=NCT03166020&draw=2&rank=1, identifier NCT03166020.

Self-Reported Reasons for Activity Limitations According to Age and Sex in Community-Dwelling Stroke Survivors

We examined self-reported reasons for activity limitations among Korean community-dwelling stroke survivors, focusing on age and sex differences. Data from 1547 stroke survivors who participated in the Korean National Health and Nutrition Examination Survey were analysed. The study outcomes were the self-reported reasons for activity limitations, encompassing general medical factors and stroke-related problems. These reasons were compared by age (<65 vs. ≥65 years) and sex using a complex-sample chi-square test. Stroke survivors reported different musculoskeletal, medical, and neurological problems as reasons for activity limitations, which differed by age and sex. Older stroke survivors reported more problems related to dementia, memory loss, auditory problems, back or neck problems, arthritis, or leg pain than younger survivors. Women reported more psychiatric problems, headaches or dizziness, back or neck problems, arthritis, gastrointestinal problems, and dental or oral problems than men. Older and female stroke survivors reported a higher mean number of reasons for activity limitations compared to younger and male survivors. Thus, a tailored approach considering age and sex is necessary to help stroke survivors with activity limitations in the Korean community. This study highlights the importance of considering demographic factors when designing interventions to improve their quality of life.

Recalibrating prognostic models to improve predictions of in-hospital child mortality in resource-limited settings

BACKGROUND

In an external validation study, model recalibration is suggested once there is evidence of poor model calibration but with acceptable discriminatory abilities. We identified four models, namely RISC-Malawi (Respiratory Index of Severity in Children) developed in Malawi, and three other predictive models developed in Uganda by Lowlaavar et al. (2016). These prognostic models exhibited poor calibration performance in the recent external validation study, hence the need for recalibration.

OBJECTIVE

In this study, we aim to recalibrate these models using regression coefficients updating strategy and determine how much their performances improve.

METHODS

We used data collected by the Clinical Information Network from paediatric wards of 20 public county referral hospitals. Missing data were multiply imputed using chained equations. Model updating entailed adjustment of the model's calibration performance while the discriminatory ability remained unaltered. We used two strategies to adjust the model: intercept-only and the logistic recalibration method.

RESULTS

Eligibility criteria for the RISC-Malawi model were met in 50,669 patients, split into two sets: a model-recalibrating set (n = 30,343) and a test set (n = 20,326). For the Lowlaavar models, 10,782 patients met the eligibility criteria, of whom 6175 were used to recalibrate the models and 4607 were used to test the performance of the adjusted model. The intercept of the recalibrated RISC-Malawi model was 0.12 (95% CI 0.07, 0.17), while the slope of the same model was 1.08 (95% CI 1.03, 1.13). The performance of the recalibrated models on the test set suggested that no model met the threshold of a perfectly calibrated model, which includes a calibration slope of 1 and a calibration-in-the-large/intercept of 0.

CONCLUSIONS

Even after model adjustment, the calibration performances of the 4 models did not meet the recommended threshold for perfect calibration. This finding is suggestive of models over/underestimating the predicted risk of in-hospital mortality, potentially harmful clinically. Therefore, researchers may consider other alternatives, such as ensemble techniques to combine these models into a meta-model to improve out-of-sample predictive performance.

Derivation and Validation of an Algorithm to Detect Stroke Using Arm Accelerometry Data

Background Early diagnosis is essential for effective stroke therapy. Strokes in hospitalized patients are associated with worse outcomes compared with strokes in the community. We derived and validated an algorithm to identify strokes by monitoring upper limb movements in hospitalized patients. Methods and Results A prospective case-control study in hospitalized patients evaluated bilateral arm accelerometry from patients with acute stroke with lateralized weakness and controls without stroke. We derived a stroke classifier algorithm from 123 controls and 77 acute stroke cases and then validated the performance in a separate cohort of 167 controls and 33 acute strokes, measuring false alarm rates in nonstroke controls and time to detection in stroke cases. Faster detection time was associated with more false alarms. With a median false alarm rate among nonstroke controls of 3.6 (interquartile range [IQR], 2.1-5.0) alarms per patient per day, the median time to detection was 15.0 (IQR, 8.0-73.5) minutes. A median false alarm rate of 1.1 (IQR. 0-2.2) per patient per day was associated with a median time to stroke detection of 29.0 (IQR, 11.0-58.0) minutes. There were no differences in algorithm performance for subgroups dichotomized by age, sex, race, handedness, nondominant hemisphere involvement, intensive care unit versus ward, or daytime versus nighttime. Conclusions Arm movement data can be used to detect asymmetry indicative of stroke in hospitalized patients with a low false alarm rate. Additional studies are needed to demonstrate clinical usefulness.

A structural analysis of the rail unit of an indoor assistive mobility system

BACKGROUND

Individuals with gait disturbances, such as that post-stroke, are discharged home to undergo outpatient rehabilitation. Rehabilitation in the community is not as effective as that in hospital, due to long travel times and short program duration.

OBJECTIVE

This study analyzed rail unit structure, with the aim of assisting home indoor assistive mobility system (HIAMS) development, allowing patients to undergo gait-related rehabilitation training at home.

METHODS

The HIAMS consists of a mobile rail running around the whole room, a turn-table for movement between rails, and a weight-supporting component. Structural analysis was performed using the Abaqus/CAE solution (Version 6.14, Dassault systems, Inc.) to verify device safety, according to the load applied to the rail and turn-table units. The load was applied vertically at 150 kg to reflect the weight of potential users.

RESULTS

Structural analysis was performed on the weight-supporting components, which was consist of turn-table case, bearing components (center, left), connective bracket and rail rollers. The safety factors of each components were estimated as 1.31, 5.39 (bearing, center), 8.45 (bearing, left), 1.43 and 3.61 in sequence.

CONCLUSION

We demonstrated a safety factor of ⩾ 1.3 for the key system units, suggesting this technology is safe for use in the home rehabilitation training of individuals with gait impairment post-ICU stay.

Robot-Assisted Rehabilitation Architecture Supported by a Distributed Data Acquisition System

Rehabilitation robotics aims to facilitate the rehabilitation procedure for patients and physical therapists. This field has a relatively long history dating back to the 1990s; however, their implementation and the standardisation of their application in the medical field does not follow the same pace, mainly due to their complexity of reproduction and the need for their approval by the authorities. This paper aims to describe architecture that can be applied to industrial robots and promote their application in healthcare ecosystems. The control of the robotic arm is performed using the software called SmartHealth, offering a 2 Degree of Autonomy (DOA). Data are gathered through electromyography (EMG) and force sensors at a frequency of 45 Hz. It also proves the capabilities of such small robots in performing such medical procedures. Four exercises focused on shoulder rehabilitation (passive, restricted active-assisted, free active-assisted and Activities of Daily Living (ADL)) were carried out and confirmed the viability of the proposed architecture and the potential of small robots (i.e., the UR3) in rehabilitation procedure accomplishment. This robot can perform the majority of the default exercises in addition to ADLs but, nevertheless, their limits were also uncovered, mainly due to their limited Range of Motion (ROM) and cost.

A cohort study on longitudinal changes in postural balance during the first year after stroke

INTRODUCTION

Many patients with strokes report increased incidence of fall that can be due to impaired postural balance. The recovery of balance in patients with varying degrees of impairments and activity limitations is less studied, and whether individuals with mild paresis can recover their balance faster is unclear. Better knowledge about factors influencing the recovery of postural balance can be used to guide clinical management after stroke to provide the right rehabilitation to the right person at the right time, and thus to avoid potential fall incidences.

OBJECTIVE

This study aims to examine longitudinal changes in postural balance during the first year after stroke.

METHODS

Postural balance was assessed using the Berg Balance Scale (BBS) within 5 days, 1, 2, and 3 months and 1-year post-stroke. Stroke severity was stratified using a cluster analysis by including multidimensional baseline measures. A longitudinal mixed-effect model was constructed to analyze changes in proportional balance impairment by stroke severity over time. Individuals with a cut-off of BBS below 45 scores were identified through a classification algorithm using baseline predictors.

RESULTS

A total of 135 patients were stratified to mild stroke (77 [57%] patients) or moderate stroke (58 [43%] patients). Ninety-three patients were included in the longitudinal analysis. Significant recovery was found at 1-year for moderate stroke (48% recovery from the initial impaired postural balance, adjusted P < 0.001), but not for mild stroke, after adjusting for age and cognition. Both stroke severities had a maximal recovery in postural balance at 3 months post-stroke, but the moderate stroke group deteriorated after that. Patients with higher age and worse cognition had more severe balance impairments. The classification model achieved a sensitivity of 0.95 (95% confidence interval [CI]: 0.91-0.98) and a specificity of 0.99 (95% CI: 0.98-1.0) for classifying individuals with BBS below 45 points.

CONCLUSIONS

This study indicates that continuous improvements in postural balance ends at 3 months regardless for mild or moderate stroke groups, and patients with moderate stroke significantly deteriorate in postural balance after 3 months.

Surface electromyographic activity of trunk muscles during trunk control exercises for people after stroke; effect of a mobile and stable seat for rehabilitation

The aim of this study was to explore differences in trunk muscle activity on a stable and mobile seat for people after stroke and healthy participants. Trunk control exercises are known to have a beneficial effect on trunk control, balance, and mobility after stroke. The effect of such exercises could be enhanced by the use of a mobile seat to provide further training stimuli. However, little research on the musculoskeletal effects of trunk training on mobile seats has been carried out. On a stable and a mobile seat, thirteen people after stroke and fifteen healthy participants performed two selective trunk control exercises, which were lateral flexion initiated by the pelvis and the thorax. The maximal surface electromyography relative to static sitting of the muscles multifidus, erector spinae, and obliquus externus was recorded bilaterally. The effects of group, seat condition, trunk control exercise, and muscle side were investigated employing within-subject linear-mixed-models. Compared to the stable seat, the maximal muscle activity of people after stroke on the mobile seat was higher during the thorax-initiated exercise and lower during the pelvis-initiated exercise. Healthy participants showed opposite results with higher muscle activity on the mobile seat during the pelvis-initiated exercise. For trunk control training on a mobile seat with high muscle activation people after stroke should perform trunk control exercises initiated by the thorax, for training with lower muscle activity people after stroke should initiate selective trunk movements by the pelvis. The results can support the planning of progressive trunk control rehabilitation programs.

Vitamin D serum level predicts stroke clinical severity, functional independence, and disability—A retrospective cohort study

Background

Stroke is a leading cause of mortality and disability and one of the most common neurological conditions globally. Many studies focused on vitamin D as a stroke risk factor, but only a few focused on its serum level as a predictor of stroke initial clinical severity and recovery with inconsistent results. The purpose of this study was to assess the relationship between serum vitamin D levels and stroke clinical severity at admission and functional independence and disability at discharge in Saudi Arabia.

Methodology

A retrospective cohort study of adult ischemic stroke patients who had their vitamin D tested and admitted within 7 days of exhibiting stroke symptoms at King Abdulaziz Medical City (KAMC) Jeddah, Saudi Arabia. Based on vitamin D level, the patients were categorized into normal [25(OH)D serum level ≥ 75 nmol/L], insufficient [25(OH)D serum level is 50–75 nmol/L], and deficient [25(OH)D serum level ≤ 50 nmol/L]. The primary outcome was to assess the vitamin D serum level of ischemic stroke patients’ clinical severity at admission and functional independence at discharge. The National Institute of Health Stroke Scale (NIHSS) was used to assess the clinical severity, whereas the modified Rankin scale (mRS) was used to assess functional independence and disability.

Results

The study included 294 stroke patients, out of 774, who were selected based on the inclusion and exclusion criteria. The mean age of the participants was 68.2 ± 13.4 years, and 49.3% were male. The patients’ distribution among the three groups based on their vitamin D levels is: normal (n = 35, 11.9%), insufficient (n = 66, 22.5%), and deficient (n = 196, 65.6%). After adjusting for potential covariates, regression analysis found a significant inverse relationship of NIHSS based on 25(OH)D serum level (beta coefficient: −0.04, SE: 0.01, p = 0.003). Patients with deficient serum vitamin D level also had significantly higher odds of worse functional independence in mRS score [OR: 2.41, 95%CI: (1.13–5.16), p = 0.023] when compared to participants with normal vitamin D level.

Conclusion

Low vitamin D levels were associated with higher severity of stroke at admission and poor functional independence and disability at discharge in patients with acute ischemic stroke. Further randomized clinical and interventional studies are required to confirm our findings.

Association between Baseline Cognitive Function and Longitudinal Functional Outcome Change after Ischemic Stroke

INTRODUCTION

Ischemic stroke can cause impairment of daily function and cognitive function. Higher cognitive function is reported in many studies to be associated with better functional outcomes; however, evidence from longitudinal study is lacking. Therefore, in the present study, the association between cognitive function and longitudinal changes of functional outcome was investigated based on stroke severity. Furthermore, whether the effect of cognitive function remained consistent after controlling for depression was investigated.

METHODS

The data of 423 stroke patients (292 minor strokes, 93 moderate strokes, and 38 severe strokes) were collected. Baseline Mini-Mental State Examination (MMSE) score was considered a predictor, and change of modified Rankin Scale (mRS) score during 12 months of follow-up was the outcome. First, the association between the baseline MMSE score and longitudinal change in the mRS score was analyzed using linear mixed-effects models. Fixed effects were MMSE score group, time, and MMSE score group × time interaction. Additional adjustment was made for the Geriatric Depression Scale (GDS) score.

RESULTS

Among the 423 subjects, the mean age was 73.5 years, and 43.4% were female. In the minor stroke group, the high MMSE score group had a decreased mRS score, and the low MMSE score group had an increased mRS score (p < 0.001). This association remained after additional adjustment of the GDS score. Association was not observed between cognitive function and functional recovery in the moderate or severe stroke group.

CONCLUSION

After ischemic stroke, higher baseline global cognitive function was a predictive factor for better functional recovery regardless of depression symptoms in the minor stroke group.

Oxidative Stress Status in Post Stroke Patients: Sex Differences

After a cerebral stroke insult, there is an overproduction of Reactive Oxygen Species (ROS), which overcome the antioxidant defenses, causing further tissues damage. The status of oxidative stress in stroke patients over time, particularly in those undergoing rehabilitation treatments, has been poorly investigated. We analyzed the oxidative stress status in 61 subacute stroke patients (33 females and 28 males) admitted to our rehabilitation center by measuring, in serum: hydroperoxides levels (d-ROMs), antioxidant activity (BAP test), and the relative antioxidant capacity (OSI index). We also analyzed patients for glucose levels and lipid profile. In addition, we analyzed the correlation between oxidative stress status biomarkers and motor deficits, disability, and pain. Almost all patients showed high or very high levels of d-ROMs, while BAP levels were apparently in the reference range of normality. Females had lower BAP values (females: 2478 ± 379; males: 2765 ± 590; p = 0.034) and lower OSI index (females: 5.7 ± 1.9; males: 6.8 ± 1.9; p = 0.043). Moreover, in the male group, the correlation with motor impairment and disability showed a worsened motor performance when oxidative stress is higher. Female group, on the other hand, had an unexpected different trend of correlation, probably due to an unbalanced systemic oxidative stress. Further research is needed to see if sex differences in oxidative stress status in subacute stroke patients persist after rehabilitation.

Ordinal Prediction Model of 90-Day Modified Rankin Scale in Ischemic Stroke

Background and Purpose: Prediction models for functional outcomes after ischemic stroke are useful for statistical analyses in clinical trials and guiding patient expectations. While there are models predicting dichotomous functional outcomes after ischemic stroke, there are no models that predict ordinal mRS outcomes. We aimed to create a model that predicts, at the time of hospital discharge, a patient's modified Rankin Scale (mRS) score on day 90 after ischemic stroke.

Methods: We used data from three multi-center prospective studies: CRISP, DEFUSE 2, and DEFUSE 3 to derive and validate an ordinal logistic regression model that predicts the 90-day mRS score based on variables available during the stroke hospitalization. Forward selection was used to retain independent significant variables in the multivariable model.

Results: The prediction model was derived using data on 297 stroke patients from the CRISP and DEFUSE 2 studies. National Institutes of Health Stroke Scale (NIHSS) at discharge and age were retained as significant (p < 0.001) independent predictors of the 90-day mRS score. When applied to the external validation set (DEFUSE 3, n = 160), the model accurately predicted the 90-day mRS score within one point for 78% of the patients in the validation cohort.

Conclusions: A simple model using age and NIHSS score at time of discharge can predict 90-day mRS scores in patients with ischemic stroke. This model can be useful for prognostication in routine clinical care and to impute missing data in clinical trials.

Neuromuscular Electrical Stimulation Improves Activities of Daily Living Post Stroke: A Systematic Review and Meta-analysis

Objectives

(1) To elucidate the effectiveness of neuromuscular electrical stimulation (NMES) toward improving activities of daily living (ADL) and functional motor ability post stroke and (2) to investigate the influence of paresis severity and the timing of treatment initiation for the effectiveness of NMES.

Data Sources

PubMed, MEDLINE, Embase, Physiotherapy Evidence Database (PEDro) and Cochrane Library searched for relevant articles from database inception to May 2020.

Study Selection

The inclusion criteria were randomized controlled trials exploring the effect of NMES toward improving ADL or functional motor ability in survivors of stroke. The search identified 6064 potential articles with 20 being included.

Data Extraction

Two independent reviewers conducted the data extraction. Methodological quality was assessed using the PEDro scale and the Cochrane Risk of Bias Tool.

Data Synthesis

Data from 428 and 659 participants (mean age, 62.4 years; 54% male) for outcomes of ADL and functional motor ability, respectively, were pooled in a random-effect meta-analysis. The analysis revealed a significant positive effect of NMES toward ADL (standardized mean difference [SMD], 0.41; 95% CI, 0.14-0.67; P=.003), whereas no effect on functional motor ability was evident. Subgroup analyses showed that application of NMES in the subacute stage (SMD, 0.44; 95% CI, 0.09-0.78; P=.01) and in the upper extremity (SMD, 0.34; 95% CI, 0.04-0.64; P=.02) improved ADL, whereas a beneficial effect was observed for functional motor abilities in patients with severe paresis (SMD, 0.41; 95% CI, 0.12-0.70; P=.005).

Conclusions

The results of the present meta-analysis are indicative of potential beneficial effects of NMES toward improving ADL post stroke, whereas the potential for improving functional motor ability appears less clear. Furthermore, subgroup analyses indicated that NMES application in the subacute stage and targeted at the upper extremity is efficacious for ADL rehabilitation and that functional motor abilities can be positively affected in patients with severe paresis.

ADL Outcome of Stroke by Stroke Type and Time from Onset to Admission to a Comprehensive Inpatient Rehabilitation Ward

OBJECTIVE

To examine the effect of onset to admission interval (OAI) and stroke type on activities of daily living (ADL) outcome.

MATERIALS AND METHODS

Stroke patients (n=3112) admitted to and discharged from comprehensive inpatient rehabilitation wards at Nanakuri Memorial Hospital were classified into 8 OAI segments and by stroke type [intracerebral hemorrhage (ICH) and cerebral infarction (CI)]. Motor subscore of the Functional Independence Measure (FIM-M) on admission, FIM-M at discharge, FIM-M gain, length of stay (LOS), and FIM-M efficiency in the ICH and CI group matched by OAI segment were compared using the Wilcoxon test. Multiple comparisons using the Steel-Dwass test of FIM-M on admission, FIM-M at discharge, FIM-M gain, LOS, and FIM-M efficiency by OAI segments were performed.

RESULTS

FIM-M on admission was lower in the ICH group than the CI group in matched OAI segments. However, FIM-M improvement was greater in the ICH group than the CI group, resulting in no difference in FIM-M between groups at discharge. In both groups, the longer the OAI, the lower the FIM-M on admission and at discharge. The distribution pattern of significant differences among OAI segments differed between the groups. LOS tended to be longer and FIM-M efficiency tended to be higher in the ICH group than in the CI group.

CONCLUSIONS

The brain mass effect at the time of admission was larger and took longer to decrease in the ICH group than in the CI group. These results may improve prediction of outcomes in comprehensive inpatient rehabilitation wards.

Prognostic Utility of Serum Biomarkers in Intracerebral Hemorrhage: A Systematic Review

Background. Intracerebral hemorrhage (ICH) accounts for 10-20% of all strokes and is associated with high morbidity and mortality. Recent studies have identified serum biomarkers as a means to improve outcome prognostication in poor grade ICH patients. Poor prognosis of ICH patients and complex pathophysiology of the disease necessitate prognostic serum biomarkers to help guide treatment recommendations. Objective. The objective is to systematically review all biomarkers used to predict long-term functional outcome in patients with spontaneous intracerebral hemorrhage. Results. We identified 36 studies investigating the predictive utility of 50 discrete biomarkers. Data from 4865 ICH patients were reviewed. Inflammatory biomarkers (11/50) were most often studied, followed by oxidative (8/50), then neuron and astrocyte-specific (7/50). S100 calcium binding protein B, white blood cell count, and copeptin were the most often studied individual biomarkers. The prognostic utility of 23 biomarkers was analyzed using receiver operating characteristic curves. Area under the curve (AUC) values for all available biomarkers except neutrophil/lymphocyte ratio were acceptable. Twenty of the 23 biomarkers were characterized by at least one excellent AUC value. Vascular endothelial growth factor, glial fibrillary astrocyte protein, and S100 calcium binding protein B were characterized by outstanding AUC. Conclusions. We identified the inflammatory and neuron and astrocyte-specific biomarker categories as having the greatest number of significant individual biomarker predictors of long-term outcome. Further investigation utilizing cross-validation of prediction models in a second independent group and blinded assessment of outcomes for the predictive utility of biomarkers in patients with ICH is warranted.

The relationship between sitting balance, trunk control and mobility with predictive for current mobility level in survivors of sub-acute stroke

Objective

To investigate the relationship between sitting balance, trunk control, and mobility, as well as whether the sitting balance and trunk control can predict mobility level in sub-acute stroke survivors.

Methods

This is a observational and cross-sectional study. Fifty-five hemiplegic stroke survivors were participated in this study. The Timed Up and Go Test (TUG) was used to estimate mobility, and the Sitting Balance Scale (SBS) was used to examining sitting balance. The Trunk Impairment Scale (TIS), Trunk Control Test (TCT), and Postural Assessment Scale for Stroke-trunk control (PASS-TC) were used for examining the trunk control. Spearman’s correlation was used to analyze the relationship between TUG, SBS, TIS, TCT, and PASS-TC.

Results

The TUG is significantly correlated with SBS (r = -0.78), TIS (r = -0.76), TCT (r = -0.65), and PASS-TC (r = -0.67). In addition, the receiver operation characteristic (ROC) curve showed as cut-off value of SBS as >28.5, TIS > 16.5, TCT >82, and PASS-TC >10.5. The area under the ROC curve in each of the four tests is moderately accurate for predicting the mobility of sub-acute stroke survivors (0.84 ~0.90) (0.7 < AUC ≤ 9 (moderate informative)).

Implications

The SBS showed the highest correlation for mobility using TUG in the hemiplegic stroke survivors. Also, SBS was revealed as the most dominant examination tool predicting the mobility by TUG, it can be explained the sitting postural balance is the variable predicting the mobility in survivors of sub-acute stroke.

Restoration of motor function after CNS damage: is there a potential beyond spontaneous recovery?

What determines the effectiveness of neurorehabilitation approaches on the outcome of function in stroke or spinal cord injured subjects? Many studies claim that an improvement of function is based on the intensity of training, while some actual studies indicate no additional gain in function by a more intensive training after a stroke. Inherent factors seem to determine outcome, such as damage of specific tracts in stroke and level of lesion in spinal cord injured subjects, while the improvement of function achieved by an intensive training is small in relation to the spontaneous recovery. It is argued that an individual capacity of recovery exists depending on such factors. This capacity can be exploited by a repetitive execution of functional movements (supported as far as required), irrespective of the intensity and technology applied. Elderly subjects have difficulties to translate the recovery of motor deficit into function. Alternative, non-training approaches to restore motor function, such as epidural or deep brain stimulation as well as CNS repair are still in an early clinical or in a translational stage.

Trunk Impairment as a Predictor of Activities of Daily Living in Acute Stroke

Background and purpose: Trunk function plays a key role in performing activities of daily living (ADL) including locomotion and sitting. Sitting and ADL should be performed as early as possible especially during the acute phase of stroke rehabilitation. Therefore, this study aimed to assess trunk function among patients with acute stroke using the Trunk Impairment Scale (TIS) and to predict its functional outcomes.

Methods: Overall, 67 patients with acute stroke (i.e., within 2 days of occurrence of the stroke) were included. The following clinical assessment items were obtained within 48 h after stroke onset and on the day before discharge from the hospital. Trunk function was examined using TIS and Trunk Control Test (TCT). The motor function of the upper and lower extremities was assessed using the stroke impairment assessment set motor (SIAS-M) score, and ADL was assessed using functional independence measure motor (FIM-M) items.

Results: Multiple regression analysis was performed using the stepwise regression method, using the total FIM-M score following discharge as the dependent variable and age, TIS, TCT, SIAS-M, and FIM-M within 48 h after stroke onset as the independent variables. Age, TIS, and FIM-M within 48 h after stroke onset were selected as the input variables and showed a high-adjusted determination coefficient (R² = 0.79; P < 0.001).

Conclusion: TIS is a reliable method for evaluating trunk control function and is an early predictor of ADL among patients with acute stroke.

Relationship Between Motor Function, DTI, and Neurophysiological Parameters in Patients with Stroke in the Recovery Rehabilitation unit

OBJECTIVES

We investigated the relationship between pyramidal tract evaluation indexes (i.e., diffusion tensor imaging, transcranial magnetic stimulation (TMS)-induced motor-evoked potential (MEP), and central motor conduction time (CMCT) on admission to the recovery rehabilitation unit) and motor functions at discharge in patients with ischemic or hemorrhagic stroke.

MATERIALS AND METHODS

Seventeen patients were recruited (12 men; 57.9 ± 10.3 years). The mean fractional anisotropy (FA) values of the right and left posterior limbs of the internal capsule were estimated using a computer-automated method. We determined the ratios of FA values in the affected and unaffected hemispheres (rFA), TMS-induced MEP, and the ratios of CMCT in the affected and unaffected hemispheres (rCMCT) and examined their association with motor functions (Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT)) at discharge.

RESULTS

Higher rFA values of the posterior limb of the internal capsule on admission to the recovery rehabilitation unit led to a better recovery of upper limb function (FMA: r = 0.78, p < 0.001; ARAT: r = 0.74, p = 0.001). Patients without MEP had poorer recovery of upper limb function than those with MEP (FMA: p < 0.001; ARAT: p = 0.001). The higher the rCMCT, the poorer the recovery of upper limb function (ARAT: r = -0.93, p < 0.001). However, no association was observed between the pyramidal tract evaluation indexes and recovery of lower limb motor function.

CONCLUSIONS

Evaluating the pyramidal tract is useful for predicting upper limb function prognosis, but not for lower limb function prognosis.

Modeling and simulation to predict the degree of disability over time in acute ischemic stroke patients

Disability in patients with acute stroke varies over time, with the prediction of outcomes being critical for proper management. This study aimed to develop a model to predict the cumulative probability of each modified Rankin Scale (mRS) score over time with inclusion of significant covariates. Longitudinal data obtained from 193 patients, 1–24 months after onset of acute ischemic stroke, were included for a modeling analysis using nonlinear mixed‐effect modeling (NONMEM). After selecting a model that best described the time course of the probability of different mRS scores, potential covariates were tested. Visual predicted check plots, parameter estimates, and decreases in minimum objective function values were used for model evaluation. The inclusion of disease progression (DP) in the baseline proportional odds cumulative logit model significantly improved the model compared to the baseline model without DP. An inhibitory maximum effect (E_max) model was determined to be the best DP model for describing the probability of specific mRS scores over time. In the final model, DP was multiplied with the baseline cumulative logit probability with a baseline adjustment. In addition to differences in lesion volume (DLV), the final model included comorbid diabetes mellitus (DM) and baseline National Institutes of Health Stroke Scale (NIHSS) scores on E_max as statistically significant covariates. This study developed a model including DLV, NIHSS score, and comorbid DM for predicting the disability time course in patients with acute ischemic stroke. This model may help to predict disease outcomes and to develop more appropriate management plans for patients with acute stroke.

Intense Arm Rehabilitation Therapy Improves the Modified Rankin Scale Score: Association Between Gains in Impairment and Function

OBJECTIVE

To evaluate the effect of intensive rehabilitation on the modified Rankin Scale (mRS), a measure of activities limitation commonly used in acute stroke studies, and to define the specific changes in body structure/function (motor impairment) most related to mRS gains.

METHODS

Patients were enrolled >90 days poststroke. Each was evaluated before and 30 days after a 6-week course of daily rehabilitation targeting the arm. Activity gains, measured using the mRS, were examined and compared to body structure/function gains, measured using the Fugl-Meyer (FM) motor scale. Additional analyses examined whether activity gains were more strongly related to specific body structure/function gains.

RESULTS

At baseline (160 ± 48 days poststroke), patients (n = 77) had median mRS score of 3 (interquartile range, 2-3), decreasing to 2 [2-3] 30 days posttherapy (p < 0.0001). Similarly, the proportion of patients with mRS score ≤2 increased from 46.8% at baseline to 66.2% at 30 days posttherapy (p = 0.015). These findings were accounted for by the mRS score decreasing in 24 (31.2%) patients. Patients with a treatment-related mRS score improvement, compared to those without, had similar overall motor gains (change in total FM score, p = 0.63). In exploratory analysis, improvement in several specific motor impairments, such as finger flexion and wrist circumduction, was significantly associated with higher likelihood of mRS decrease.

CONCLUSIONS

Intensive arm motor therapy is associated with improved mRS in a substantial fraction (31.2%) of patients. Exploratory analysis suggests specific motor impairments that might underlie this finding and may be optimal targets for rehabilitation therapies that aim to reduce activities limitations.

CLINICAL TRIAL

Clinicaltrials.gov identifier: NCT02360488.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for patients >90 days poststroke with persistent arm motor deficits, intensive arm motor therapy improved mRS in a substantial fraction (31.2%) of patients.

Upper Limb Robotic Rehabilitation After Stroke: A Multicenter, Randomized Clinical Trial

BACKGROUND AND PURPOSE

After stroke, only 12% of survivors obtain complete upper limb (UL) functional recovery, while in 30% to 60% UL deficits persist. Despite the complexity of the UL, prior robot-mediated therapy research has used only one robot in comparisons to conventional therapy. We evaluated the efficacy of robotic UL treatment using a set of 4 devices, compared with conventional therapy.

METHODS

In a multicenter, randomized controlled trial, 247 subjects with subacute stroke were assigned either to robotic (using a set of 4 devices) or to conventional treatment, each consisting of 30 sessions. Subjects were evaluated before and after treatment, with follow-up assessment after 3 months. The primary outcome measure was change from baseline in the Fugl-Meyer Assessment (FMA) score. Secondary outcome measures were selected to assess motor function, activities, and participation.

RESULTS

One hundred ninety subjects completed the posttreatment assessment, with a subset (n = 122) returning for follow-up evaluation. Mean FMA score improvement in the robotic group was 8.50 (confidence interval: 6.82 to 10.17), versus 8.57 (confidence interval: 6.97 to 10.18) in the conventional group, with no significant between-groups difference (adjusted mean difference -0.08, P = 0.948). Both groups also had similar change in secondary measures, except for the Motricity Index, with better results for the robotic group (adjusted mean difference 4.42, P = 0.037). At follow-up, subjects continued to improve with no between-groups differences.

DISCUSSION AND CONCLUSIONS

Robotic treatment using a set of 4 devices significantly improved UL motor function, activities, and participation in subjects with subacute stroke to the same extent as a similar amount of conventional therapy. Video Abstract is available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A291).

Effects of Trunk Exercise on Unstable Surfaces in Persons with Stroke: A Randomized Controlled Trial

Background: Improving balance-related ability is an important goal in stroke rehabilitation. Evidence is needed to demonstrate how this goal could be better achieved. Aim: Determine if trunk exercises on unstable surfaces would improve trunk control and balance for persons in the subacute stage of stroke. Design: An assessor-blind randomized controlled trial. Setting: Inpatients in the department of rehabilitation in a general hospital. Population: Patients who suffered a first-time stroke with onset from one to six months. Methods: Inpatients with stroke were assigned to upper limb exercises (control group, n = 17) or trunk exercises on unstable surfaces (experimental group, n = 18) to receive training twice a week for six weeks, in addition to their daily conventional stroke rehabilitation. Sensorimotor function tests, including hand grip, plantar sensitivity, stroke rehabilitation assessment of movement and Fugl-Meyer lower extremity motor scale, and clinical outcome assessments, including Trunk Impairment Scale and 6 m walk test, were conducted before and after six weeks of training. The center of the pressure area while maintaining static posture and peak displacement while leaning forward, as well as the average speed of raising the unaffected arm, were measured in sitting without foot support, sitting with foot support and standing to reflect trunk control, sitting balance and standing balance, respectively. Results: The between-group differences in the sensorimotor functions were nonsignificant before and after training. Compared with the control group, the experimental group had significantly greater forward leaning and faster arm raising in sitting without foot support, higher Trunk Impairment Scale total score, and shorter 6 m walking time after training, but not before training. Conclusion: Trunk exercises on unstable surfaces could further improve trunk control, the ability to raise the unaffected arm rapidly in sitting, and walking for persons in the subacute stage of stroke. This intervention may be considered to be included in stroke rehabilitation.

BDNF rs6265 Polymorphism and Its Methylation in Patients with Stroke Undergoing Rehabilitation

Brain-Derived Neurotrophic Factor (BDNF) and its rs6265 single nucleotide polymorphism (SNP) play an important role in post-stroke recovery. We investigated the correlation between BDNF rs6265 SNP and recovery outcome, measured by the modified Barthel index, in 49 patients with stroke hospitalized in our rehabilitation center at baseline (T0) and after 30 sessions of rehabilitation treatment (T1); moreover, we analyzed the methylation level of the CpG site created or abolished into BDNF rs6265 SNP. In total, 11 patients (22.4%) were heterozygous GA, and 32 (65.3%) and 6 (12.2%) patients were homozygous GG and AA, respectively. The univariate analysis showed a significant relationship between the BDNF rs6265 SNP and the modified Barthel index cut-off (χ²(1, N = 48) = 3.86, p = 0.049), considering patients divided for carrying (A+) or not carrying (A−) the A allele. A higher percentage of A− patients obtained a favorable outcome, as showed by the logistic regression model corrected by age and time since the stroke onset, compared with the A+ patients (OR: 5.59). At baseline (T0), the percentage of BDNF methylation was significantly different between GG (44.6 ± 1.1%), GA (39.5 ± 2.8%) and AA (28.5 ± 1.7%) alleles (p < 0.001). After rehabilitation (T1), only patients A− showed a significant increase in methylation percentages (mean change = 1.3, CI: 0.4–2.2, p = 0.007). This preliminary study deserves more investigation to confirm if BDNF rs6265 SNP and its methylation could be used as a biological marker of recovery in patients with stroke undergoing rehabilitation treatment.

Poststroke Fatigue at Admission is Associated With Independence Levels of Activities of Daily Living at Discharge From Subacute Rehabilitation Wards

OBJECTIVE

To determine whether poststroke fatigue at admission is associated with the degree of independence in activities of daily living in patients with stroke at discharge from subacute rehabilitation wards.

DESIGN

Retrospective cohort study.

SETTING

Subacute rehabilitation hospital.

PARTICIPANTS

A consecutive sample of patients (N=156) with stroke who were admitted to a subacute rehabilitation ward between December 2012 and November 2013 were enrolled in the study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Poststroke fatigue was assessed using the Fatigue Severity Scale within 2 weeks of admission. Poststroke fatigue was defined as the mean score of 4 points or more from among 9 items in the Fatigue Severity Scale. Functional outcome was assessed by using FIM motor items.

RESULTS

Fifty-six (35.9%) of the 156 participants had poststroke fatigue at admission. The scores of the FIM motor items at admission and discharge were significantly lower in the fatigue group than in the nonfatigue group (P<.05). Multiple regression analysis with potentially confounding variables revealed that poststroke fatigue was a significant independent factor for discharge FIM motor items score (P<.05).

CONCLUSION

Poststroke fatigue at admission was significantly associated with functional outcome at discharge from subacute rehabilitation wards. Our findings emphasize that rehabilitation professionals need to manage poststroke fatigue in addition to providing the interventions to improve daily activities in patients with subacute stroke.

Reliability and validity of the function in sitting test among non-ambulatory individuals with spinal cord injury

Context: Trunk impairment among non-ambulatory individuals with spinal cord injury (SCI) reduces the ability to maintain a functional sitting position and perform activities of daily living. Measuring functional sitting balance is complex and difficult in a clinical setting. The function in sitting test (FIST) is a clinical measure that includes the assessment of all the components of sitting balance. The purpose of this study is to assess the reliability and validity of the 14-item FIST among non-ambulatory individuals with SCI. Participants: Twenty-six individuals with chronic SCI. Outcome measures: Participants were evaluated with the FIST, the modified Functional Reach Test (lateral and forward mFRT) and a posturography assessment (virtual time to contact - VTC). The FIST was re-assessed during a second study visit 12 weeks later. Test-retest reliability was evaluated using intraclass coefficient correlation (ICC), the minimal detectable change (MDC) was calculated and the internal consistency reliability was assessed using Cronbach's coefficient-α. Concurrent validity of the FIST was also tested with the mFRT and the VTC. Results: Test-retest reliability was found to be excellent (ICC = 0.95) with a MDC of 4. The internal consistency was satisfactory (0.81). Moreover, the FIST correlates with the lateral mFRT (r = 0.64, P = 0.001) but not with the forward mFRT and the VTC. Conclusion: These observations provide evidence that the FIST is a reliable clinical measure with partially established validity for non-ambulatory individuals with SCI. Further studies are needed to strengthen the validity of the FIST and explore this measure in a larger sample.

Prognostic models for predicting in-hospital paediatric mortality in resource-limited countries: a systematic review

OBJECTIVES

To identify and appraise the methodological rigour of multivariable prognostic models predicting in-hospital paediatric mortality in low-income and middle-income countries (LMICs).

DESIGN

Systematic review of peer-reviewed journals.

DATA SOURCES

MEDLINE, CINAHL, Google Scholar and Web of Science electronic databases since inception to August 2019.

ELIGIBILITY CRITERIA

We included model development studies predicting in-hospital paediatric mortality in LMIC.

DATA EXTRACTION AND SYNTHESIS

This systematic review followed the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies framework. The risk of bias assessment was conducted using Prediction model Risk of Bias Assessment Tool (PROBAST). No quantitative summary was conducted due to substantial heterogeneity that was observed after assessing the studies included.

RESULTS

Our search strategy identified a total of 4054 unique articles. Among these, 3545 articles were excluded after review of titles and abstracts as they covered non-relevant topics. Full texts of 509 articles were screened for eligibility, of which 15 studies reporting 21 models met the eligibility criteria. Based on the PROBAST tool, risk of bias was assessed in four domains; participant, predictors, outcome and analyses. The domain of statistical analyses was the main area of concern where none of the included models was judged to be of low risk of bias.

CONCLUSION

This review identified 21 models predicting in-hospital paediatric mortality in LMIC. However, most reports characterising these models are of poor quality when judged against recent reporting standards due to a high risk of bias. Future studies should adhere to standardised methodological criteria and progress from identifying new risk scores to validating or adapting existing scores.

PROSPERO REGISTRATION NUMBER

CRD42018088599.

Subject-specific, Impairment-based Robotic Training of Functional Upper Limb Movements

Significant hand and upper-limb impairment is common post-stroke. Robotic training can administer a high-dose of repetitive movement training to stroke survivors, but its efficacy can be further improved by targeting specific impairments of individual patients. In this study, we developed a new robotic training protocol that identifies specific impairment patterns that degrade functional performance of individual patients and provide joint-specific assistance to counteract subject-specific impairments. The target tasks were also adjusted based on their task performance during training. Two chronic stroke survivors participated in a pilot training study to demonstrate the efficacy of the proposed impairment-based robotic training. Upper limb function of the participants was improved by the proposed training as shown in the clinical tests (6.5 ± 4.5 increase in Fugl-Meyer; 10 ± 6.9 increase in Action Research Arm Test), and the laboratory tests also showed improvement in their range of motion (hand) and voluntary reaching distance (arm). The impairment-based robotic training targeted (and improved) specific deficits of individual patients that hampered their task performance, which could have contributed to the observed functional improvement. The proposed training can enhance the rehabilitative outcome of robotic training by emphasizing the key components of effective rehabilitation, i.e., subject-specific, impairment-based training.Clinical Relevance- This study shows that impairment-based, 'subject-specific' robotic trainings can improve upper extremity function of stroke survivors.

Effects of visual feedback balance training with the Pro-kin system on walking and self-care abilities in stroke patients

Some scholars' studies have demonstrated that Pro-kin balance system training is able to promote the recovery of the balance function in stroke patients. The present study has expanded on those studies, and was not merely limited to studying balance, but also encompassed walking and self-care abilities of the patients; furthermore, the association among balance and walking and self-care abilities was also explored.A total of 40 stroke patients were randomly and equally divided into 2 groups: the control group (n = 20) and the treatment group (n = 20). Both groups underwent conventional balance training, although the treatment group also underwent visual feedback balance training with the Pro-kin system. The balance function was assessed using the Berg Balance Scale (BBS), the Timed "Up & Go" (TUG) test, and Pro-kin system parameters. The Pro-kin system parameters included the perimeter and ellipse area, which were both tested once with eyes open (EO) and eyes closed (EC). Walking ability was assessed using the Holden Walking Ability Scale, according to the Functional Ambulation Classification (FAC). The self-care abilities were assessed with the Barthel Index (BI). The tests were conducted prior to training, and 3 weeks after the end of the training programme.No significant differences were noted among the groups before the training. After 3 weeks of training, for both the groups, significant improvements in balance and the walking and self-care abilities were noted: The BBS value was significantly increased (P < .05), whereas the TUG, perimeter, and ellipse area with EO and EC measurements were significantly decreased after treatment (P < .05). The FAC and BI readings were significantly increased after treatment (P < 0.05), and the treatment group outperformed the control group (P < .05). Furthermore, the balance function was shown to be strongly correlated with the walking and self-care abilities (P < .01).The present study has demonstrated that the use of the Pro-kin visual feedback balance training system in combination with conventional training is a viable method for improving walking and self-care abilities of stroke patients.

Effect of Care Capacity on Stroke Patients' Recovery in Activities of Daily Living: A Multi-Hospital Study

BACKGROUND

This study aimed to investigate whether care capacity for patients following stroke contributes to improved activities of daily living (ADL) at discharge from hospital based on the degree of stroke severity.

DESIGN

Retrospective, observational, longitudinal study.

SETTING

Acute phase hospitals.

PARTICIPANTS

From 2005 to 2011, 5006 patients with stroke at acute phase hospitals were registered in a database. There were 2501 individuals from 11 hospitals who met the following four criteria: (1) a pre-stroke modified Rankin Scale (mRS) score of 0-3; (2) admission to hospital within 7 days of suffering a stroke; (3) ischemic or hemorrhagic stroke; and (4) staying in hospital for 8-60 days.

MAIN OUTCOME MEASURES

The main outcome measure was the Functional Independence Measure (FIM, version 3.0) score at discharge. The FIM is an internationally used scale, which is used as an ADL outcome assessment scale for after rehabilitation.

RESULTS

Among patients with stroke, those with care capacity had higher FIM scores at hospital discharge than did those without care capacity (unstandardized coefficient = 2.3, P = 0.015). Examination of this relationship by stroke severity showed that the FIM score at discharge was only significantly higher in patients who suffered from a moderate to severe stroke (unstandardized coefficient = 7.0, P = 0.040). No associations were observed in patients who suffered from minor, moderate, or severe stroke.

CONCLUSIONS

These results suggest that care capacity facilitates total recovery of the FIM, especially among patients who suffer from a moderate to severe stroke.

Vojta therapy improves postural control in very early stroke rehabilitation: a randomised controlled pilot trial

Background

It is still unclear, which physiotherapeutic approaches are most effective in stroke recovery. Vojta therapy is a type of physiotherapy that was originally developed for children and adolescents with cerebral palsy. Vojta therapy has been reported to improve automatic control of body posture. Because acute stroke patients are characterised by a disturbance in the ability to adapt to changes in body position, requiring automatic postural adjustment, we decided to investigate Vojta therapy in the early rehabilitation of stroke patients. Aim of the trial was to test the hypothesis that Vojta therapy - as a new physiotherapeutic approach in early stroke recovery - improves postural control and motor function in patients with acute ischaemic stroke (AIS) or intracerebral haemorrhage (ICH).

Methods

This prospective, randomised controlled trial included patients with imaging-confirmed AIS or ICH, severe hemiparesis and randomly assigned them to Vojta therapy or standard physiotherapy within 72 h after stroke onset. Main exclusion criterion was restricted ability to communicate. Primary endpoint was the improvement of postural control measured by the Trunk Control Test (TCT) on day 9 after admission. Secondary endpoint among others was improvement of arm function (measured with Motor Evaluation Scale for Upper Extremity in Stroke Patients [MESUPES]).

Results

Forty patients (20 per group) were randomised into the trial. Median age was 75 (66-80) years, 50% were women. The median improvement in TCT within 9 days was 25.5 points (=25.5%) (interquartile range [IQR] 12.5-42.5) in the Vojta group and 0 (IQR 0-13) in the control group (p = 0.001). Patients treated with Vojta therapy achieved a greater improvement in the MESUPES than patients in the control group (20% vs 10%, p = 0.006).

Conclusion

This first randomised controlled trial of Vojta therapy in acute stroke patients demonstrates improvement of postural control through Vojta therapy compared to standard physiotherapy. Although this trial has some methodical weaknesses, Vojta therapy might be a promising approach in early stroke rehabilitation and should be studied in larger trials.

Trial registration

ClinicalTrials.gov; Unique identifier: NCT03035968. Registered 30 January 2017 - Retrospectively registered; http://www.clinicaltrials.gov.

Development of a Diagnosis and Evaluation System for Hemiplegic Patients Post-Stroke Based on Motion Recognition Tracking and Analysis of Wrist Joint Kinematics

An inexperienced therapist lacks the analysis of a patient's movement. In addition, the patient does not receive objective feedback from the therapist due to the visual subjective judgment. The aim is to provide a guide for in-depth rehabilitation therapy in virtual space by continuously tracking the user's wrist joint during Leap Motion Controller (LMC) activities and present the basic data to confirm steady therapy results in real-time. The conventional Box and Block Test (BBT) is commonly used in upper extremity rehabilitation therapy. It was modeled in proportion to the actual size and Auto Desk Inventor was used to perform the 3D modeling work. The created 3D object was then implemented in C # through Unity5.6.2p4 based on LMC. After obtaining a wrist joint motion value, the motion was analyzed by 3D graph. Healthy subjects (23 males and 25 females, n = 48) were enrolled in this study. There was no statistically significant counting difference between conventional BBT and system BBT. This indicates the possibility of effective diagnosis and evaluation of hemiplegic patients post-stroke. We can keep track of wrist joints, check real-time continuous feedback in the implemented virtual space, and provide the basic data for an LMC-based quantitative rehabilitation therapy guide.

Predicting independence of gait by assessing sitting balance through sitting posturography in patients with subacute hemiplegic stroke

BACKGROUND

Post-stroke sitting balance is a known predictor of independence of gait after stroke. However, previous studies used only qualitative scales or measured static or dynamic sitting balance alone.

OBJECTIVES

To investigate whether quantitative parameters of sitting posturography at post-stroke 1 month can predict independent gait.

METHODS

In this prospective cohort study, we enrolled patients with first-ever stroke who could hold a sitting posture at post-stroke 1 month. Sitting balance was assessed using posturography at post-stroke 1 month. Independence of gait was assessed using functional ambulation categories at post-stroke 2 months. We predicted mobility independence at post-stroke 2 months according to sitting balance at post-stroke 1 month. We also assessed the correlation between sitting posturography parameters and clinical scales.

RESULTS

We enrolled 27 patients. The limit of stability deviation predicted independent gait at post stroke 2 months (cutoff, 78.4%). Further, there was a high degree of correlation between sitting posturography parameters (weight-bearing distribution deviation and limit of stability deviation) and Berg Balance Scale (ρ = 0.763, ρ = 0.777; p < .001, respectively), Scale for Assessment and Rating of Ataxia (ρ = -0.853, ρ = -0.929; p < .001, respectively), and Fugl-Meyer Assessment scale (upper extremities: ρ = 0.520, ρ = 0.480 [p = .005, p = .011, respectively]; lower extremities: ρ = 0.744, ρ = 0.564 [p < .001, p = .002, respectively]) scores.

CONCLUSIONS

Sitting posturography parameters is clinically useful because they can quantitatively assess post-stroke balance and neurological impairment and predict post-stroke independence of gait even when patients cannot reach their arms forward or stand upright.

Influence of hematoma volume and age on cognitive functions and ADL after putaminal hemorrhage

BACKGROUND AND OBJECTIVE

After cerebral hemorrhage, cognitive functions and activities of daily living (ADL) are affected by various factors, including hematoma volume and patient age. In the present study, we investigated the effect of age and hematoma volume on cognitive functions and on ADL.

METHODS

The sample comprised 274 patients (183 men and 91 women; mean age 58.2 ± 12.5 years) with putaminal hemorrhage who were hospitalized in a convalescent rehabilitation ward. Hematoma volume was estimated from computed tomography imaging at stroke onset. Cognitive functions were evaluated using Raven's Colored Progressive Matrices test (RCPM) and the Mini-Mental State Examination (MMSE) at hospital admission, while ADL score was assessed at discharge using the Functional Independence Measure motor subscale (FIM-M). In the present study, we classified the patients into six groups according to whether they were non-elderly or elderly (cutoff age, 60 years) and whether their hematoma was small, medium, or large (cutoff volumes, 20 and 40 mL, respectively). Subsequently, the scores on the RCPM, MMSE, and FIM-M were compared among the groups.

RESULTS

In both age groups, patients with a larger hematoma volume had lower RCPM and MMSE scores. Patients <60 years old exhibited different trends in their RCPM and MMSE scores, such that the RCPM score showed a step-wise decrease according to hematoma volume, while a difference in the MMSE score was only observed at the 20 mL boundary. Most of the younger patients (<60 years of age) attained high FIM-M scores at discharge, as long as their hematoma volume was either medium or small (<40 mL). This age group had higher RCPM scores on admission, which may have contributed to their higher FIM-M scores on discharge.

CONCLUSIONS

In the present study, we demonstrated that advancing age increases the effect of hematoma volume on RCPM and MMSE scores and identified differences in the effects observed on these two scores. Thus, it may be important to use the RCPM alongside the MMSE for patient assessment.

The impact of availability and identity of the caregiver on the post-stroke patient

Background

After having a stroke, most patients are helped by a caregiver with activities that they cannot perform by themselves. The caregiver presence and actions are an important variable that may affect rehabilitation in many ways. The aim of this review study was to evaluate the impact of caregiver presence (or absence) and identity (spouse, family, or foreign domestic worker) on therapeutic exercise performance, depression symptoms, patient–spouse relations and total functional outcomes of stroke patients. Assessing these effects may help health care professionals and families to prioritise/choose the caregiver for their patient/family member.

Methods

A narrative literature review was conducted, focusing on one-direction effects (caregiver on patient effects) on the topics of interest mentioned, in a post-stroke population. PubMed, CINAHL, PEDro, Trip database, and Google Scholar were searched, and included studies of most designs and research qualities. The search strategy had not been specified before commencing the review. Each study was analysed individually with the purpose of synthesising the available evidence to achieve a greater understanding of this topic.

Results

A total of 17 relevant papers were included: six randomised controlled trials, six observational studies, two systematic reviews, two survey-based studies, and one case series. Trials were consistent with the positive effect that caregivers have on therapeutic exercise performance. Studies have shown a positive effect of caregivers on the patient's depressive symptoms, but only at the chronic phase after stroke. A spouse caregiver seems to more positively affect the patient–spouse relations in the acute phase of rehabilitation, while foreign domestic workers can improve these relations at more chronic phases. The presence of a caregiver is shown to decrease functional outcomes within institutionalised rehabilitation centres, while it is necessary and positively affects functionality at more chronic phases within community settings.

Conclusions

The advantages and disadvantages of employing a caregiver depend in many cases on the rehabilitation phase. The caregiver might be beneficial or harmful to the patient's functional progress, depressive symptoms and marital relationship depending on the rehabilitation phase. More studies are needed to assess the caregiver effects on post-stroke patients' rehabilitation and quality of life.

Altered Corticomuscular Coherence (CMCoh) Pattern in the Upper Limb During Finger Movements After Stroke

Background: Proximal compensation to the distal movements is commonly observed in the affected upper extremity (UE) of patients with chronic stroke. However, the cortical origin of this compensation has not been well-understood. In this study, corticomuscular coherence (CMCoh) and electromyography (EMG) analysis were adopted to investigate the corticomuscular coordinating pattern of proximal UE compensatory activities when conducting distal UE movements in chronic stroke.

Method: Fourteen chronic stroke subjects and 10 age-matched unimpaired controls conducted isometric finger extensions and flexions at 20 and 40% of maximal voluntary contractions. Electroencephalogram (EEG) data were recorded from the sensorimotor area and EMG signals were captured from extensor digitorum (ED), flexor digitorum (FD), triceps brachii (TRI), and biceps brachii (BIC) to investigate the CMCoh peak values in the Beta band. EMG parameters, i.e., the EMG activation level and co-contraction index (CI), were analyzed to evaluate the compensatory muscular patterns in the upper limb.

Result: The peak CMCoh with statistical significance (P < 0.05) was found shifted from the ipsilesional side to the contralesional side in the proximal UE muscles, while to the central regions in the distal UE muscle in chronic strokes. Significant differences (P < 0.05) were observed in both peak ED and FD CMCohs during finger extensions between the two groups. The unimpaired controls exhibited significant intragroup differences between 20 and 40% levels in extensions for peak ED and FD CMCohs (P < 0.05). The stroke subjects showed significant differences in peak TRI and BIC CMCohs (P < 0.01). No significant inter- or intra-group difference was observed in peak CMCoh during finger flexions. EMG parameters showed higher EMG activation levels in TRI and BIC muscles (P < 0.05), and higher CI values in the muscle pairs involving TRI and BIC during all the extension and flexion tasks in the stroke group than those in the control group (P < 0.05).

Conclusion: The post-stroke proximal muscular compensations from the elbow to the finger movements were cortically originated, with the center mainly located in the contralesional hemisphere.

The Impact of One's Sex and Social Living Situation on Rehabilitation Outcomes After a Stroke

OBJECTIVE

The aim of the study was to investigate sex differences and the impact of social living situation on individual functional independence measure outcomes after stroke rehabilitation.

DESIGN

A retrospective observational study using Medicare fee-for-service beneficiaries (N = 125,548) who were discharged from inpatient rehabilitation facilities in 2013 and 2014 after a stroke. Discharge individual functional independence measure score, dichotomized as ≥5 and <5, was the primary outcome measure. A two-step generalized linear mixed model was used to measure the effect of sex on each functional independence measure item while controlling for many clinical and sociodemographic covariates.

RESULTS

After adjusting for sociodemographic and clinical factors, females had higher odds of reaching a supervision level for 14 of 18 functional independence measure items. Males had higher odds of reaching a supervision level on 2 of 18 functional independence measure items. Individuals who lived alone before their stroke had higher odds of reaching a supervision level than individuals who lived with a caregiver or with family for all functional independence measure items.

CONCLUSIONS

When sociodemographic and clinical factors are controlled, females are more likely to discharge from inpatient rehabilitation at a supervision level or better for most functional independence measure items. Individuals who live alone before their stroke have higher odds of discharging at a supervision level or better.

Prediction of Independent Gait in Acute Stroke Patients with Hemiplegia Using the Ability for Basic Movement Scale II Score

INTRODUCTION

Since independent gait is an important factor for home discharge, early prediction of independent gait after stroke is essential. The revised version of the Ability for Basic Movement Scale II (ABMS II) has been developed and validated for assessment of basic movements poststroke.

OBJECTIVE

The purpose of this study was to investigate the predictive value of the ABMS II score for independent gait in acute stroke patients with hemiplegia.

METHODS

We included 67 patients with first stroke and a unilateral lesion who were admitted to the stroke care unit. We evaluated the gait on the 14th and 90th days from admission.

RESULTS

The ABMS II score was significantly higher in patients with independent gait on both the 14th and 90th days from admission. On receiver operating characteristic curve analysis, a minimum score of 26 points was predictive of independent gait on the 14th day from admission. Similarly, a score of 15 points was predictive of independent gait on the 90th day from admission.

CONCLUSIONS

The ABMS II score is a useful predictor of independent gait in acute stroke patients with hemiplegia.

Obesity and diabetes are jointly associated with functional disability in stroke survivors

BACKGROUND

Stroke is the most common cause of complex disability. Obesity and diabetes increase risk for functional disability in the general population, but their contribution to functional disability in stroke survivors is unknown.

OBJECTIVE

To investigate the joint association of obesity and diabetes with functional disability in stroke survivors.

METHODS

Cross-sectional data from 34,376 stroke survivors from the 2015 and 2017 Behavioral Risk Factor Surveillance System (BRFSS) surveys were examined. Weighted and age-adjusted prevalence estimates and adjusted odds ratios (AOR, adjusted for sociodemographic characteristics) with 95% confidence intervals (CIs) were calculated to compare prevalence and odds for self-reported functional disability, stratified by obesity-diabetes status (i.e., neither condition, obesity only, diabetes only, both conditions).

RESULTS

Prevalence of functional disability increased across obesity-diabetes categories in the total sample: neither condition (45.4%, 95% CI: 43.4%-47.4%), obesity only (55.3%, 95% CI: 52.7%-58.0%), diabetes only (60.8%, 95% CI: 57.5%-64.1%), and both conditions (70.3%, 95% CI: 67.7%-72.9%). Compared to respondents with neither condition, those with both obesity and diabetes had 2.62 (95% CI: 2.23-3.08) higher odds for functional disability; odds were also increased for respondents with obesity only (1.52, 95% CI: 1.32-1.76) and diabetes only (1.71, CI: 1.45-2.01).

CONCLUSIONS

Our findings indicated a joint effect of obesity and diabetes on functional disability that exceeded either condition alone, placing stroke survivors with both health conditions at greatest risk for diminished functional capacity. Recognizing obesity and diabetes as modifiable risk factors may be useful for identifying stroke sub-populations that could benefit from lifestyle intervention.