Patient-reported measures provide unique insights into motor function after stroke

Biofeedback Training for 3-Dimensional Finger Force Control to Improve Upper Limb Function Poststroke: An RCT

BACKGROUND

After stroke, impairment of hand sensorimotor control leads to improperly scaled and directed fingertip forces that disrupt object manipulation. The objective of this study was to determine the efficacy of finger force magnitude and direction training using 3-dimensional versus 1-dimensional biofeedback to enhance poststroke upper extremity motor recovery.

METHODS

A double-blind randomized controlled trial took place in the Veterans Affairs laboratory from 2020 to 2023. Forty-five stroke survivors were randomly assigned to the experimental or control group. Both groups received 18 training sessions to generate digit force in the target magnitude and direction. The experimental group trained with visual feedback on the digit force magnitude in 3 dimensions. The control group trained with 1-dimensional visual feedback on the digit force magnitude along the target direction only. The primary outcome was the change in upper extremity function assessed using the Action Research Arm Test post-intervention.

RESULTS

Baseline characteristics were comparable between the groups (mean age, 59 years, 60% male, 40% Black). The change between pretraining and posttraining Action Research Arm Test scores was significantly greater for the experimental group than for the control group (experimental mean, 3.5 [CI, 2.2-4.8] versus control mean, 0.8 [CI, -0.5 to 2.1]; P=0.005). This difference was maintained at 1-month follow-up. Secondary analysis showed that individuals in the experimental group whose stroke occurred within a year prior improved more (mean, 6.1 [CI, 4.0-8.3]) than others (P<0.003).

CONCLUSIONS

Force direction feedback led to improved upper extremity motor recovery in stroke survivors. This biofeedback-based treatment may provide the needed explicit training in force direction control for more effective hand rehabilitation.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03995069.

Long-Term Outcomes of Vagus Nerve Stimulation Paired With Upper Extremity Rehabilitation After Stroke

BACKGROUND

Persistent upper extremity (UE) impairment is common after stroke. Durable treatment benefits for chronic ischemic stroke are needed. The purpose of this report is to determine the long-term effects of vagus nerve stimulation paired with rehabilitation on impairment, activity, and participation in people with UE impairment after ischemic stroke.

METHODS

This is a post hoc analysis of data from the VNS-REHAB (A Pivotal Randomized Study Assessing Vagus Nerve Stimulation [VNS] During Rehabilitation for Improved Upper Limb Motor Function After Stroke) randomized clinical trial. Here, we report unblinded, partial crossover, and pooled 1-year outcomes. Initially, 108 participants across 19 sites with chronic ischemic stroke and moderate-to-severe UE impairment were enrolled in VNS-REHAB. Participants received 18 sessions of in-clinic intensive task-specific rehabilitation and 3 months of self-initiated home-based exercise with either real (active) or sham (control) vagus nerve stimulation. Thereafter, Control participants crossed over to receive in-clinic therapy paired with active stimulation. All participants performed home-based exercises paired with self-initiated active stimulation for 1 year. The Fugl-Meyer Assessment UE, Wolf Motor Function Test, and participation outcomes were assessed through 12 months.

RESULTS

Seventy-four participants (69%; 51 male; age, mean±SD, 59.6±8.9) completed 1-year follow-up and provided pooled data through 1 year. At 1 year, compared with baseline, there were improvements in impairment (Fugl-Meyer Assessment UE, 5.23 [95% CI, 4.08-6.39]; P<0.001) activity (Wolf Motor Function Test, 0.50 [95% CI, 0.41-0.59]; P<0.001) and patient-reported outcomes (Motor Activity Log-Quality of Movement: 0.64 [95% CI, 0.46-0.82], P<0.001; Motor Activity Log-Amount of Use: 0.64 [95% CI, 0.46-0.82], P<0.001; Stroke Impact Scale-Activities of Daily Living: 7.43 [95% CI, 5.09-9.77], P<0.001; Stroke Impact Scale-Hand: 17.89 [95% CI, 14.16-21.63], P<0.001; EQ-5D: 5.76 [95% CI, 2.08-9.45], P<0.05; and Stroke Specific-Quality of Life: 0.29 [95% CI, 0.19-0.39], P<0.001) compared with baseline.

CONCLUSIONS

People treated with paired vagus nerve stimulation maintained improvements in UE impairment, activity, participation, and quality-of-life measures at 1 year. Paired vagus nerve stimulation is a Food and Drug Administration-approved, beneficial treatment option for long-term benefit in individuals with chronic UE limitations after ischemic stroke.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03131960.

Depression drives perceived quality of life following minor stroke

BACKGROUND

Stroke outcomes are typically assessed using objective scales focused on severity and functional ability that may overlook subtle cognitive changes and fail to account for patients' perceptions of recovery and quality of life. This study aimed to compare patient-reported outcomes (PROs) to objective recovery metrics in patients with minor stroke and identify factors associated with perceived recovery and quality of life.

METHODOLOGY

Data from 134 patients with minor stroke were prospectively collected at 1-, 6-, and 12-months post-infarct. Objective assessments measured stroke severity, functional outcomes, activities of daily living, and global cognitive function. PROs included assessments of function, depression, fatigue, symptomatic improvement, and quality of life. Regression models were used to evaluate the relationship between subjective PROs and physician-obtained measures.

RESULTS

Analyses revealed an important role for mental health factors in subjective measures of recovery, though cognitive dysfunction was not significantly associated with either subjective improvement or quality of life despite being commonly endorsed. Depression and fatigue were inversely associated with both satisfaction and quality of life, along with stroke severity and overall functional impairment during both short- and long-term recovery periods. The impact of depression on quality of life increased over time, while stroke severity and functional status were associated with perceived symptomatic improvement at all time points.

CONCLUSIONS

For patients with minor stroke, depression is negatively associated with perception of symptomatic recovery and quality of life, particularly at later time points. Addressing post-stroke depression may improve patient-reported outcomes, though further research is needed to determine its impact on broader measures of post-stroke morbidity.

Distinct Constructs Underlie Patient-Reported and Performance-Rated Outcomes after Stroke

OBJECTIVE

Patient-reported outcome measures (PROMs), which capture patients' perspectives on the consequences of health and disease, are widely used in neurological care and research. However, it is unclear how PROMs relate to performance-rated impairments. Sociodemographic factors are known to affect PROMs. Direct damage to brain regions critical for self-awareness (i.e., parietal regions and the salience/ventral-attention network) may also impair self-report outcomes. This study examined the relationship between PROMs and performance-based measures in stroke survivors with arm motor impairments. We hypothesized that PROMs would be distinct from performance-based outcomes, influenced by sociodemographic factors, and linked to damage in brain circuits involved in self-perception.

METHODS

We longitudinally assessed 54 stroke survivors using patient-reported and performance-rated measures at 4 timepoints. We used factor analysis to reveal the outcome battery's factorial structure. Linear regression examined the association between classes of measures and sociodemographics. Voxel-lesion-symptom-mapping, region-of-interest-based analysis, and voxel-lesion-network-mapping investigated the relationship between classes of outcomes and stroke-related injury.

RESULTS

Performance-based and patient-reported measures formed distinct factors, consistent across recovery phases. Higher education (β1 = 0.36, p = 0.02) and income adequacy (β2 = 0.48, p = 0.05) were associated with patient-reported, but not performance-rated outcomes. Greater parietal lobe injury, irrespective of hemisphere, was associated with worse patient-reported outcomes; greater corticospinal tract injury related to worse performance-rated outcomes. Lesions with greater functional connectivity to the salience/ventral-attention network were associated with worse patient-reported outcomes (r = -0.35, p = 0.009).

INTERPRETATION

Our findings reveal important differences between performance-rated and patient-reported outcomes, each with specific associated factors and anatomy post-stroke. Incorporating sociodemographic and neuroanatomic characteristics into neurorehabilitation strategies may inform and optimize patient outcomes. ANN NEUROL 2025;97:242-253.

Advancing stroke rehabilitation: the role of wearable technology according to research experts

BACKGROUND

Advancements in wearable technology have created new opportunities to monitor stroke survivors' behaviors in daily activities. Research insights are needed to guide its adoption in clinical practice, address current gaps, and shape the future of stroke rehabilitation. This project aims to: (1) Understand stroke rehabilitation researchers' perspectives on the opportunities, challenges, and clinical relevance of wearable technology for stroke rehabilitation, and (2) Identify necessary next steps to integrate wearable technology in research and clinical practice.

METHODS

Using a phenomenological qualitative design, two 90-minute focus groups were conducted with 12 rehabilitation researchers. The focus groups consisted of semi-structured, open-ended questions on functional movement behavior, motor performance and benefits and pitfalls of wearable technology. The transcribed focus groups were analyzed using inductive thematic analysis.

RESULTS

Three main themes were derived from the analysis: (1) Assessing activity performance is critical to inform interventions, (2) The demonstrated benefit is not commensurate with the added hassle, (3) Collaboration is needed between the industry, academia and end-users. Necessary future steps were recognized including the identification of intuitive and actionable metrics, and the integration of sensor-derived data with electronic health records and into clinical workflow to support self-management strategies.

CONCLUSION

Wearable technology shows great potential to complement and support stroke rehabilitation. Many key barriers to clinical adoption remain which underscore the necessity to foster collaborations between industry, academia, and the participants we serve.

Race and ethnic disparities in rehabilitation services and functional recovery post-stroke

Objective

To identify race/ethnic disparities in rehabilitation services after stroke and characterize the independent associations of each of race/ethnicity and rehabilitation to functional recovery post-stroke.

Methods

The Transitions of Care Stroke Disparities Study (TCSD-S) is a prospective cohort study designed to reduce disparities and to optimize the transitions of care for stroke survivors throughout the state of Florida. Participant characteristics were extracted from the American Heart Association's Get-With-The-Guidelines-Stroke dataset. Rehabilitation services, and modified Rankin Scale were recorded via follow up phone calls at 30- and 90-days after hospital discharge. Logistic regression models adjusted for potential confounders were used to determine: 1) race/ethnic differences in rehabilitation services received; 2) race/ethnic differences in functional change from discharge to 30- and 90-days, respectively; and 3) the influence of rehabilitation on functional change from discharge to 30- and 90-days.

Results

Of 1,083 individuals, 43% were female, 52% were Non-Hispanic White (NHW), 22% were Non-Hispanic Black (NHB), and were 22% Hispanic. Individuals who engaged in rehabilitation were more likely to show improvements [aOR=1.820, 95%CI (1.301,2.545)] at 90-days from hospital discharge. Irrespective of rehabilitation services, there were no differences in functional change between NHW and NHB individuals, yet Hispanic individuals were less likely to improve [aOR=0.647, 95%CI (0.425,0.983)] compared to NHW. Additionally, Hispanic individuals were significantly less likely to receive any rehabilitation services [aOR=0.626, 95%CI (0.442,0.886)] and were half as likely to receive outpatient services [aOR=0.543, 95%CI (0.368,0.800)] as compared to NHW.

Conclusions

Rehabilitation is key to functional improvement after stroke. We are making strides in health equity between NHW and NHB individuals, yet there remain disparities in functional outcomes and in rehabilitation services particularly for Hispanic individuals after stroke.

Patient-Reported Outcomes in Childhood Moyamoya Arteriopathy

BACKGROUND

Little is known about quality of life, sleep, and mental health in children with moyamoya arteriopathy (MMA). A better understanding of patient-reported outcomes may lead to improved treatment.

METHODS

Patients with MMA <26 years old and their caretakers completed validated, age-appropriate questionnaires including the Pediatric Quality of Life (PedsQL) Inventory and Patient-Reported Outcomes Measurement Information System (PROMIS) measuring health-related quality of life, sleep, anxiety, depression, and overall health.

RESULTS

All 21 caretaker-proxies and eight of 21 patients with MMA completed questionnaires. Median age of participants with MMA was 7.8 years. The MMA cohort included 10 children with moyamoya disease and 11 with moyamoya syndrome, and 11 participants (52.4%) had a prior clinical stroke. Nine siblings unaffected by moyamoya and 20 participants with perinatal stroke were enrolled as comparator groups. Participants with MMA had greater impairment in school/work quality of life compared with normative values on caretaker and child-reported PedsQL surveys (85.5 vs 62.3 [P < 0.001] and 78.6 vs 51.2 [P = 0.017], respectively). Participants with MMA did not have significantly different physical impairment compared with normative values and siblings on caretaker and child-reported surveys. Caretaker-proxy PROMIS scores revealed high rates of moderate-severe anxiety (57.1% vs 25%, P < 0.001), sleep impairment (47.6% vs 25%, P = 0.017), and fair-poor global health (76.2% vs 25%, P < 0.001) in participants with MMA compared with the general population.

CONCLUSIONS

Patients with MMA have high rates of school/work impairment, anxiety, sleep impairment, and fair-poor global health. Screening for patient-reported outcomes, even in the absence of stroke or physical impairment, may improve treatment.

Effects of a Wearable-Based Intervention on the Hemiparetic Upper Limb in Persons With Stroke: A Randomized Controlled Trial

INTRODUCTION

Wearables have emerged as a transformative rehabilitation tool to provide self-directed training in the home. Objective. In this study, we examined the efficacy of a novel wearable device, "Smart Reminder" (SR), to provide home-based telerehabilitation for hemiparetic upper limb (UL) training in persons with stroke.

METHODS

Forty stroke survivors from community support groups were randomized (stratified by the period after stroke onset and impairment severity) to either the SR group or the sham device group. Participants received either 20 hours of telerehabilitation using the SR device or training with pictorial handouts and a sham device over 4 weeks. In addition, all participants wore a standard accelerometer for 3 hours each day, 5 times a week, outside the prescribed training. Participants were assessed by a masked assessor at baseline, post-intervention (week 4), and follow-up (week 8). The outcome measures included Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Action Research Arm Test, Motor Activity Log, muscle strength, active range of motion and amount of movement of the UL, and compliance rate of training.

RESULTS

The SR group improved substantially in their FMA-UE scores after treatment (mean difference = 2.05, P = .036) compared to the sham group. Also, adherence to the training using the SR device was significantly higher, 97%, than the sham group, 82.3% (P = .038).

CONCLUSION

The 4-week telerehabilitation program using a "SR" device demonstrated potential efficacy in improving FMA-UE scores of the hemiparetic upper limb. However, it did not significantly enhance the performance of the affected limb in daily activities. The trial was registered on ClinicalTrial.gov (URL: http://www.clinicaltrials.gov) with the identifier NCT05877183.

Brain-Hand Function Relationships Based on Level of Grasp Function in Chronic Left-Hemisphere Stroke

BACKGROUND AND OBJECTIVE

The biomarkers of hand function may differ based on level of motor impairment after stroke. The objective of this study was to determine the relationship between resting state functional connectivity (RsFC) and unimanual contralesional hand function after stroke and whether brain-behavior relationships differ based on level of grasp function.

METHODS

Sixty-two individuals with chronic, left-hemisphere stroke were separated into three functional levels based on Box and Blocks Test performance with the contralesional hand: Low (moved 0 blocks), Moderate (moved >0% but <90% of blocks relative to the ipsilesional hand), and High (moved ≥90% of blocks relative to the ipsilesional hand).

RESULTS

RsFC in the ipsilesional and interhemispheric motor networks was reduced in the Low group compared to the Moderate and High groups. While interhemispheric RsFC correlated with hand function (grip strength and Stroke Impact Scale Hand) across the sample, contralesional RsFC correlated with hand function in the Low group and no measures of connectivity correlated with hand function in the Moderate and High groups. Linear regression modeling found that contralesional RsFC significantly predicted hand function in the Low group, while no measure correlated with hand function in the High group. Corticospinal tract integrity was the only predictor of hand function for the Moderate group and in an analysis across the entire sample.

CONCLUSIONS

Differences in brain-hand function relationships based on level of motor impairment may have implications for predictive models of treatment response and the development of intervention protocols aimed at improving hand function after stroke.

A Novel, Wearable Inertial Measurement Unit for Stroke Survivors: Validity, Acceptability, and Usability

OBJECTIVE

To establish the concurrent validity, acceptability, and sensor optimization of a consumer-grade, wearable, multi-sensor system to capture quantity and quality metrics of mobility and upper limb movements in stroke survivors.

DESIGN

Single-session, cross-sectional.

SETTING

Clinical research laboratory.

PARTICIPANTS

Thirty chronic stroke survivors (age 57 (10) years; 33% female) with mild to severe motor impairments participated.

INTERVENTIONS

Not Applicable.

MAIN OUTCOME MEASURES

Participants donned 5 sensors and performed standardized assessments of mobility and upper limb (UL) movement. True/false, positive/negative time in active movement for the UL were calculated and compared to criterion-standards using an accuracy rate. Bland-Altman plots and linear regression models were used to establish concurrent validity of UL movement counts, step counts, and stance time symmetry of MiGo against established criterion-standard measures. Acceptability and sensor optimization were assessed through an end-user survey and decision matrix.

RESULTS

Mobility metrics showed excellent association with criterion-standards for step counts (video: r=0.988, P<.001, IMU: r=0.921, P<.001) and stance-time symmetry (r=0.722, P<.001). In the UL, movement counts showed excellent to good agreement (paretic: r=0.849, P<.001, nonparetic: r=0.672, P<.001). Accuracy of active movement time was 85.2% (paretic) and 88.0% (nonparetic) UL. Most participants (63.3%) had difficulty donning/doffing the sensors. Acceptability was high (4.2/5).

CONCLUSIONS

The sensors demonstrated excellent concurrent validity for mobility metrics and UL movements of stroke survivors. Acceptability of the system was high, but alternative wristbands should be considered.

U-Rate-UE; Measuring Perceived Recovery of the Affected Upper Extremity in Adults Post-stroke

OBJECTIVE

To establish initial validity of "U-Rate-UE", a single-question scale regarding perceived recovery of the stroke affected upper extremity (UE).

DESIGN

A retrospective longitudinal study of data collected at rehabilitation admission, 6 weeks, and 6 months since stroke.

SETTING

Stroke rehabilitation and community-based.

PARTICIPANTS

A convenience sample of 87 individuals, median (interquartile range) age 71.5 (65-80) years, 15.0 (12-20) days post-stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The affected UE was assessed using the Fugl-Meyer Motor Assessment, grip strength, Action Research Arm Test, the Box and Block Test (BBT), and The Rating of Everyday Arm-Use in the Community and Home. Participants also rated how much they perceive that their affected UE recovered from the stroke using U-Rate-UE; 0-100 (no to full recovery). Longitudinal changes in U-Rate-UE ratings were assessed. In addition, at 6 weeks and 6 months post-stroke, the change in BBT was calculated and participants were grouped into achieved/did not achieve the minimal detectable change (MDC). Correlations between U-Rate-UE to the other UE assessments were assessed at all 3 timepoints.

RESULTS

Significant changes in U-Rate-UE were seen over time (P<.05). At 6 weeks and 6 months, participants who achieved BBT-MDC rated their recovery significantly higher than participants who did not. U-Rate-UE was moderately-strongly significantly correlated to UE assessments (rho=.61-.85, P<.001).

CONCLUSIONS

The U-Rate-UE is supported for use with UE assessments contributing to comprehensive clinical understanding of the recovery of the affected UE in adults post-stroke.

Telerehabilitation Following Stroke

Stroke remains a major cause of disability. Intensive rehabilitation therapy can improve outcomes, but most patients receive limited doses. Telehealth methods can overcome obstacles to delivering intensive therapy and thereby address this unmet need. A specific example is reviewed in detail, focused on a telerehabilitation system that targets upper extremity motor deficits after stroke. Strengths of this system include provision of daily therapy associated with very high patient compliance, safety and feasibility in the inpatient or home setting, comparable efficacy to dose-matched therapy provided in-clinic, and a holistic approach that includes assessment, education, prevention, and activity-based therapy.

Cortical Sensorimotor Integration as a Neural Origin of Impaired Grip Force Direction Control following Stroke

BACKGROUND

Stroke is a major cause of disability worldwide. Upper limb impairment is prevalent after stroke. One of the post-stroke manifestations is impaired grip force directional control contributing to diminished abilities to grip and manipulate objects necessary for activities of daily living. The objective of this study was to investigate the neural origin of the impaired grip force direction control following stroke. Due to the importance of online adjustment of motor output based on sensory feedback, it was hypothesized that grip force direction control would be associated with cortical sensorimotor integration in stroke survivors.

METHODS

Ten chronic stroke survivors participated in this study. Cortical sensorimotor integration was quantified by short latency afferent inhibition (SAI), which represents the responsiveness of the primary motor cortex to somatosensory input. Grip force direction control was assessed during paretic grip.

RESULTS

Grip force direction control was significantly associated with SAI. This relationship was independent of sensory impairment level.

CONCLUSIONS

Cortical sensorimotor integration may play a significant role in the grip force direction control important for gripping and manipulating objects with the affected hand following stroke. This knowledge may be used to inform personalized rehabilitation treatment. For example, for patients with impaired grip force direction control, behavioral therapy focusing on feedback motor control, augmented by use of brain stimulation to reinforce cortical sensorimotor integration such as paired associative stimulation, may be applied.

Unilateral Spatial Neglect May Not Be Detected by Performance-Based Functional Neglect Assessment

IMPORTANCE

Unilateral spatial neglect (neglect) poststroke is disabling. It is critical that people with neglect are identified so that treatment can be provided to maximize independence. However, there is some evidence to suggest that existing assessments may not adequately measure neglect. It is unclear whether assessments also fail to identify people with neglect entirely.

OBJECTIVE

To determine whether there are stroke survivors who self-report neglect symptoms that are not detected by therapist-rated assessments and to compare self-report and therapist-ratings.

DESIGN

Cross-sectional study.

SETTING

U.S. university research center.

PARTICIPANTS

Unilateral stroke survivors (N = 133).

INTERVENTION

Not applicable.

OUTCOMES AND MEASURES

The Catherine Bergego Scale (CBS) was administered to participants and scored by a trained occupational therapist. The parallel self-evaluation anosognosia form was also administered to participants to self-report and rate neglect symptoms.

RESULTS

Forty-eight participants (36.1%) were classified as without neglect on the basis of therapist-rated total CBS scores, yet 30 (62.5%) of these 48 participants reported symptoms of neglect on the CBS self-evaluation anosognosia form. There was a significant difference (p < .001) between therapist-rated and self-rated total CBS scores.

CONCLUSIONS AND RELEVANCE

Our results indicate that many stroke survivors report some level of disability associated with neglect yet do not meet the criteria to be classified as having neglect according to a commonly used therapist-rated performance-based measure. Plain-Language Summary: The findings of this study contribute to the evidence that existing assessments used by occupational therapists to measure performance-based neglect may not always detect neglect symptoms comprehensively in people poststroke. The finding also suggest that we may be missing neglect symptoms entirely. Occupational therapists should consider using various methods to assess for neglect, including patient self-report and comprehensive occupational profiles. Clinicians should also thoroughly screen all clients with stroke for neglect, regardless of lesion location.

Wearable Technology to Capture Arm Use of People With Stroke in Home and Community Settings: Feasibility and Early Insights on Motor Performance

OBJECTIVE

The objectives of this study were to establish the short-term feasibility and usability of wrist-worn wearable sensors for capturing the arm and hand activity of people with stroke and to explore the association between factors related to the use of the paretic arm and hand.

METHODS

Thirty people with chronic stroke were monitored with wrist-worn wearable sensors for 12 hours per day for a 7-day period. Participants also completed standardized assessments to capture stroke severity, arm motor impairments, self-perceived arm use, and self-efficacy. The usability of the wearable sensors was assessed using the adapted System Usability Scale and an exit interview. Associations between motor performance and capacity (arm and hand impairments and activity limitations) were assessed using Spearman correlations.

RESULTS

Minimal technical issues or lack of adherence to the wearing schedule occurred, with 87.6% of days procuring valid data from both sensors. The average sensor wear time was 12.6 (standard deviation [SD] = 0.2) hours per day. Three participants experienced discomfort with 1 of the wristbands, and 3 other participants had unrelated adverse events. There were positive self-reported usability scores (mean = 85.4/100) and high user satisfaction. Significant correlations were observed for measures of motor capacity and self-efficacy with paretic arm use in the home and the community (Spearman correlation coefficients = 0.44-0.71).

CONCLUSIONS

This work demonstrates the feasibility and usability of a consumer-grade wearable sensor for capturing paretic arm activity outside the laboratory. It provides early insight into the everyday arm use of people with stroke and related factors, such as motor capacity and self-efficacy.

IMPACT

The integration of wearable technologies into clinical practice offers new possibilities to complement in-person clinical assessments and to better understand how each person is moving outside of therapy and throughout the recovery and reintegration phase. Insight gained from monitoring the arm and hand use of people with stroke in the home and community is the first step toward informing future research with an emphasis on causal mechanisms with clinical relevance.

Prevalence of Arm Weakness, Pre-Stroke Outcomes and Other Post-Stroke Impairments Using Routinely Collected Clinical Data on an Acute Stroke Unit

INTRODUCTION

The prevalence of upper limb motor weakness early post-stroke may be changing, which can have clinical and research implications. Our primary aim was to describe the prevalence of upper limb motor weakness early post-stroke, with a secondary aim to contextualize this prevalence by describing pre-stroke outcomes, other post-stroke impairments, functional activities, and discharge destination.

METHODS

This cross-sectional observational study extracted clinical data from confirmed stroke patients admitted to a metropolitan stroke unit over 15-months. The primary upper limb weakness measure was Shoulder Abduction and Finger Extension (SAFE) score. Demographics (eg, age), clinical characteristics (eg, stroke severity), pre-stroke outcomes (eg, clinical frailty), other post-stroke impairments (eg, command following), functional activities (eg, ambulation), and discharge destination were also extracted.

RESULTS

A total of 463 participants had a confirmed stroke and SAFE score. One-third of patients received ≥1 acute medical intervention(s). Nearly one-quarter of patients were classified as frail pre-stroke. Upper limb weakness (SAFE≤8) was present in 35% [95% CI: 30%-39%] at a median of 1-day post-stroke, with 22% presenting with mild-moderate weakness (SAFE5-8). The most common other impairments were upper limb coordination (46%), delayed recall (41%), and upper limb sensation (26%). After a median 3-day acute stroke stay, 52% of the sample were discharged home.

CONCLUSION

Upper limb weakness was present in just over a third (35%) of the sample early post-stroke. Data on pre-stroke outcomes and the prevalence of other post-stroke impairments highlights the complexity and heterogeneity of stroke recovery. Further research is required to tease out meaningful recovery phenotypes and their implications.

Wearable Sensor to Monitor Quality of Upper Limb Task Practice for Stroke Survivors at Home

Many stroke survivors experience persistent upper extremity impairment that limits performance in activities of daily living. Upper limb recovery requires high repetitions of task-specific practice. Stroke survivors are often prescribed task practices at home to supplement rehabilitation therapy. A poor quality of task practices, such as the use of compensatory movement patterns, results in maladaptive neuroplasticity and suboptimal motor recovery. There currently lacks a tool for the remote monitoring of movement quality of stroke survivors' task practices at home. The objective of this study was to evaluate the feasibility of classifying movement quality at home using a wearable IMU. Nineteen stroke survivors wore an IMU sensor on the paretic wrist and performed four functional upper limb tasks in the lab and later at home while videorecording themselves. The lab data served as reference data to classify home movement quality using dynamic time warping. Incorrect and correct movement quality was labeled by a therapist. The home task practice movement quality was classified with an accuracy of 92% and F1 score of 0.95 for all tasks combined. Movement types contributing to misclassification were further investigated. The results support the feasibility of a home movement quality monitoring system to assist with upper limb rehabilitation post stroke.

Error Enhancement for Upper Limb Rehabilitation in the Chronic Phase after Stroke: A 5-Day Pre-Post Intervention Study

A large proportion of chronic stroke survivors still struggle with upper limb (UL) problems in daily activities, typically reaching tasks. During three-dimensional reaching movements, the deXtreme robot offers error enhancement forces. Error enhancement aims to improve the quality of movement. We investigated clinical and patient-reported outcomes and assessed the quality of movement before and after a 5 h error enhancement training with the deXtreme robot. This pilot study had a pre-post intervention design, recruiting 22 patients (mean age: 57 years, mean days post-stroke: 1571, male/female: 12/10) in the chronic phase post-stroke with UL motor impairments. Patients received 1 h robot treatment for five days and were assessed at baseline and after training, collecting (1) clinical, (2) patient-reported, and (3) kinematic (KINARM, BKIN Technologies Ltd., Kingston, ON, Canada) outcome measures. Our analysis revealed significant improvements (median improvement (Q1-Q3)) in (1) UL Fugl-Meyer assessment (1.0 (0.8-3.0), p < 0.001) and action research arm test (2.0 (0.8-2.0), p < 0.001); (2) motor activity log, amount of use (0.1 (0.0-0.3), p < 0.001) and quality of use (0.1 (0.1-0.5), p < 0.001) subscale; (3) KINARM-evaluated position sense (-0.45 (-0.81-0.09), p = 0.030) after training. These findings provide insight into clinical self-reported and kinematic improvements in UL functioning after five hours of error enhancement UL training.

Correlation between kinetic and kinematic measures, clinical tests and subjective self-evaluation questionnaires of the affected upper limb in people after stroke

Introduction

Assessment of stroke recovery should include multiple sources of information in order to obtain a complete understanding of the individual's rehabilitation progress. Self-evaluation questionnaires' scores do not always correspond to the scores of commonly used clinical evaluation tools. The purpose of this study was to assess the relationship between self-evaluation questionnaires, clinical tests, and kinematic and kinetic analyses of the affected upper limb after stroke, and to determine the correlation between these measures and self-reported general function 2-4 years after the stroke.

Methods

Twenty-six subjects recovering from stroke were included in the study. Spearman's correlation coefficient was used to measure the correlation between Stroke Impact Scale (SIS), Motor activity Log (MAL), Fugl-Meyer Assessment (FMA) and Action Reach Arm Test (ARAT) scores, and kinematic and kinetic analyses. A logistic regression was used to assess the extent to which these measures may predict the participants' functional self-reported status 2-4 years post stroke.

Results

Sections regarding hand function, hand force and general ADL of the self-evaluation questionnaires correlated with kinematic variables. However, only questionnaires that focus on hand function correlated with clinical tests. Mean and maximal hand velocity had the strongest correlations with self-evaluation questionnaires and with the clinical tests, more than other kinematic variables. Self-evaluation questionnaires and clinical tests were found to be correlated with hand kinetic metrics force-to-time ratio and number of force peaks. SIS hand force domain, mean velocity and maximal velocity predicted self-reported general function 2-4 years after the stroke.

Conclusion

Self-evaluation questionnaires should be considered for wider use in the clinical evaluation of a patient's stroke recovery, since they add important information on the individual's functional status, which is not reflected in the clinical tests.

Predicting motor gains with home-based telerehabilitation after stroke

INTRODUCTION

Telerehabilitation (TR) may be useful for rehabilitation therapy after stroke. However, stroke is a heterogeneous condition, and not all patients can be expected to derive the same benefit from TR, underscoring the need to identify predictors of response to TR.

METHODS

A prior trial provided patients with 6 weeks of intensive rehabilitation therapy targeting arm movement, randomly assigned to be provided in the home via TR (current focus) or in clinic. Eligible patients had moderate arm motor deficits and were in the subacute-chronic stage post stroke. Behavioral gains were measured as change in the arm motor Fugl-Meyer score from baseline to 30 days post therapy. To delineate predictors of TR response, multivariable linear regression was performed, advancing the most significant predictor from each of eight categories: patient demographics, stroke characteristics, medical history, rehabilitation therapy outside of study procedures, motivation, sensorimotor impairment, cognitive/affective deficits, and functional status.

RESULTS

The primary focus was on patients starting TR >90 days post stroke onset (n = 44), among whom female sex, less spasticity, and less visual field defects predicted greater motor gains. This model explained 39.3% of the variance in treatment-related gains. In secondary analysis that also included TR patients enrolled ≤90 days post stroke (total n = 59), only female sex was a predictor of treatment gains. A separate secondary analysis examined patients >90 days post stroke (n = 34) randomized to in-clinic therapy, among whom starting therapy earlier post stroke and less ataxia predicted greater motor gains.

DISCUSSION

Response to TR varies across patients, emphasizing the need to identify characteristics that predict treatment-related behavioral gain. The current study highlights factors that might be important to patient selection for home-based TR after stroke.

Wearable technology to capture arm use of stroke survivors in home and community settings: feasibility and early insights on motor performance

Objective

To establish short-term feasibility and usability of wrist-worn wearable sensors to capture arm/hand activity of stroke survivors and to explore the association between factors related to use of the paretic arm/hand.

Methods

30 chronic stroke survivors were monitored with wrist-worn wearable sensors during 12h/day for a 7-day period. Participants also completed standardized assessments to capture stroke severity, arm motor impairments, self-perceived arm use and self-efficacy. Usability of the wearable sensors was assessed using the adapted System Usability Scale and an exit interview. Associations between motor performance and capacity (arm/hand impairments and activity limitations) were assessed using Spearman's correlations.

Results

Minimal technical issues or lack of adherence to the wearing schedule occurred, with 87.6% of days procuring valid data from both sensors. Average sensor wear time was 12.6 (standard deviation: 0.2) h/day. Three participants experienced discomfort with one of the wristbands and three other participants had unrelated adverse events. There were positive self-reported usability scores (mean: 85.4/100) and high user satisfaction. Significant correlations were observed for measures of motor capacity and self-efficacy with paretic arm use in the home and the community (Spearman's correlation ρs: 0.44-0.71).

Conclusions

This work demonstrates the feasibility and usability of a consumer-grade wearable sensor to capture paretic arm activity outside the laboratory. It provides early insight into stroke survivors' everyday arm use and related factors such as motor capacity and self-efficacy.

Impact

The integration of wearable technologies into clinical practice offers new possibilities to complement in-person clinical assessments and to better understand how each person is moving outside of therapy and throughout the recovery and reintegration phase. Insights gained from monitoring stroke survivors arm/hand use in the home and community is the first step towards informing future research with an emphasis on causal mechanisms with clinical relevance.

Data mining versus manual screening to select papers for inclusion in systematic reviews: a novel method to increase efficiency

Systematic reviews rely on identification of studies, initially through electronic searches yielding potentially thousands of studies, and then reviewer-led screening studies for inclusion. This standard method is time- and resource-intensive. We designed and applied an algorithm written in Python involving computer-aided identification of keywords within each paper for an exemplar systematic review of arm impairment after stroke. The standard method involved reading each abstract searching for these keywords. We compared the methods in terms of accuracy in identification of keywords, abstracts' eligibility, and time taken to make a decision about eligibility. For external validation, we adapted the algorithm for a different systematic review, and compared eligible studies using the algorithm with those included in that review. For the exemplar systematic review, the algorithm failed on 72 out of 2,789 documents retrieved (2.6%). Both methods identified the same 610 studies for inclusion. Based on a sample of 21 randomly selected abstracts, the standard screening took 1.58 ± 0.26 min per abstract. Computer output screening took 0.43 ± 0.14 min per abstract. The mean difference between the two methods was 1.15 min ( P  < 0.0001), saving 73% per abstract. For the other systematic review, use of the algorithm resulted in the same studies being identified. One study was excluded based on the interpretation of the comparison intervention. Our purpose-built software was an accurate and significantly time-saving method for identifying eligible abstracts for inclusion in systematic reviews. This novel method could be adapted for other systematic reviews in future for the benefit of authors, reviewers and editors.

Associating Functional Neural Connectivity and Specific Aspects of Sensorimotor Control in Chronic Stroke

Hand sensorimotor deficits often result from stroke, limiting the ability to perform daily living activities. Sensorimotor deficits are heterogeneous among stroke survivors. Previous work suggests a cause of hand deficits is altered neural connectivity. However, the relationships between neural connectivity and specific aspects of sensorimotor control have seldom been explored. Understanding these relationships is important for developing personalized rehabilitation strategies to improve individual patients' specific sensorimotor deficits and, thus, rehabilitation outcomes. Here, we investigated the hypothesis that specific aspects of sensorimotor control will be associated with distinct neural connectivity in chronic stroke survivors. Twelve chronic stroke survivors performed a paretic hand grip-and-relax task while EEG was collected. Four aspects of hand sensorimotor grip control were extracted, including reaction time, relaxation time, force magnitude control, and force direction control. EEG source connectivity in the bilateral sensorimotor regions was calculated in α and β frequency bands during grip preparation and execution. Each of the four hand grip measures was significantly associated with a distinct connectivity measure. These results support further investigations into functional neural connectivity signatures that explain various aspects of sensorimotor control, to assist the development of personalized rehabilitation that targets the specific brain networks responsible for the individuals' distinct sensorimotor deficits.

Essential Role of Social Context and Self-Efficacy in Daily Paretic Arm/Hand Use After Stroke: An Ecological Momentary Assessment Study With Accelerometry

OBJECTIVE

To determine the momentary effect of social-cognitive factors, in addition to motor capability, on post-stroke paretic arm/hand use in the natural environment.

DESIGN

A 5-day observational study in which participants were sent 6 Ecological Momentary Assessment (EMA) prompts/day.

SETTING

Participants' daily environment.

PARTICIPANTS

Community-dwelling, chronic stroke survivors with right-dominant, mild-moderate upper extremity paresis (N=30).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Time duration of bimanual and unimanual paretic arm/hand use indexed by accelerometry; social-cognitive factors (social context, self-efficacy, mood) captured by EMA; motor capability of the paretic limb measured by Fugl-Meyer Upper Extremity Motor Assessment (FM).

RESULTS

After accounting for participants' motor capability, we found that momentary social context (alone or not) and self-efficacy significantly predicted post-stroke paretic arm/hand use behavior in the natural environment. When participants were not alone, paretic arm/hand movement increased both with and without the less-paretic limb (bimanual and unimanual movements, P=.018 and P<.001, respectively). Importantly, participants were more likely to use their paretic arm/hand (unimanually) if they had greater self-efficacy for limb use (P=.042). EMA repeated-measures provide a real-time approach that captures the natural dynamic ebb and flow of social-cognitive factors and their effect on daily arm/hand use. We also observed that people with greater motor impairments (FM<50.6) increase unimanual paretic arm/hand movements when they are not alone, regardless of motor capability.

CONCLUSIONS

In addition to motor capability, stroke survivors' momentary social context and self-efficacy play a role in paretic arm/hand use behavior. Our findings suggest the development of personalized rehabilitative interventions which target these factors to promote daily paretic arm/hand use. This study highlights the benefits of EMA to provide real-time information to unravel the complexities of the biopsychosocial (ie, motor capability and social-cognitive factors) interface in post-stroke upper extremity recovery.

Psychometric properties of the Chinese (Cantonese) version of the Upper Extremity Functional Index in people with chronic stroke

Objective

To culturally adapt and examine the psychometric properties of the Chinese (Cantonese) version of the Upper Extremity Functional Index (C-UEFI) in people with chronic stroke.

Design

Cross-sectional study.

Settings

University-affiliated neurorehabilitation research laboratory.

Participants

The participants (N = 151) were people with chronic stroke (N = 101) and healthy controls (n = 50).

Main outcome measures

We assessed the C-UEFI, Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Wolf Motor Function Test (WMFT), Six-Minute Walk Test (6MWT), Motor Activity Log (MAL), Activity-Specific Balance Confidence (ABC) scale, Lawton Instrumental Activities of Daily Living (IADL) scale, Survey of Activities and Fear of Falling in the Elderly (SAFFE), Stroke Impact Scale (SIS) and Community Integration Measure (CIM) as outcome measures.

Results

The C-UEFI items demonstrated good test-retest reliability (intraclass correlation coefficient [ICC]_{3, 1} = 0.872) and excellent internal consistency (Cronbach's α = 0.922). People with chronic stroke had poorer C-UEFI scores than the healthy controls. The overall C-UEFI mean score of 101 people with stroke was significantly correlated with the mean scores of the FMA-UE, WMFT, MAL, ABC scale, IADL scale, SAFFE, SIS and CIM and the distance covered in the 6MWT. The C-UEFI cut-off score to distinguish between people with chronic stroke and healthy older adults according to upper extremity function was 57.5 out of 59 (sensitivity: 88.1%; specificity: 84%). The C-UEFI had good content validity, with an acceptable fit to the two-factor structure model.

Conclusions

The C-UEFI is reliable and valid for assessing functional recovery of upper extremity activity in Chinese people with chronic stroke.

Clinical interpretation and cutoff scores for manual ability measured by the ABILHAND questionnaire in people with stroke

BACKGROUND

The ABILHAND questionnaire is recommended to assess perceived manual ability after stroke; however, more knowledge on interpretability is needed to improve the clinical applicability.

OBJECTIVES

To determine clinically meaningful cutoff scores for different levels of perceived manual ability, assessed by ABILHAND, corresponding to established observed and perceived upper extremity assessments post stroke.

METHODS

This cross-sectional study, part of the Stroke Arm Longitudinal Study (SALGOT) at the University of Gothenburg, included 80 participants with upper extremity impairments after stroke. The self-reported upper extremity functioning was assessed with ABILHAND and Stroke Impact Scale Hand (SIS Hand), and the observed functioning was assessed by Fugl-Meyer Assessment for Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT) at 3 months after stroke. Receiver operating characteristic curve, sensitivity, and specificity analyses were used to determine the cutoffs.

RESULTS

The overall discriminating accuracy was excellent (AUC > 0.90) for most of the cutoffs and sensitivity and specificity values ranged from 0.73 to 1.0. The ABILHAND cutoff score 1.78 discriminated well between low and good functioning resulting in a 95% match with SIS Hand and 87.5% match with ARAT and FMA-UE.

CONCLUSIONS

The determined cutoff scores of the ABILHAND, validated through established upper extremity assessments, will provide a useful tool to clinicians when interpreting the logit scores and when selecting individualized treatment options. ABILHAND matched well with self-reported SIS Hand, but discrepancies found with observed scales implies that self-perceived assessments should be complemented with observed assessments.

Subjective and objective assessments are associated for physical function but not cognitive function in community-dwelling stroke survivors

PURPOSE

To investigate the relation between subjectively and objectively assessed cognitive and physical functioning among community-dwelling stroke survivors, and to examine the association of stroke severity with subjectively and objectively assessed cognitive and physical impairments.

MATERIALS AND METHODS

Secondary data analysis was conducted with 127 community-dwelling stroke survivors. For cognitive functioning, objective measures included the NIH Toolbox Cognition Battery and the Executive Function Performance Test; subjective measures included the Quality of Life in Neurological Disorders Applied Cognition. Objective and subjective physical functioning was measured by the NIH Toolbox 2-Minute Walk Test and the Patient-Reported Outcomes Measurement Information System Physical Function, respectively.

RESULTS

A positive correlation was observed between subjective and objective physical functioning, whereas the correlation between subjective and objective cognitive functioning was nonsignificant. Stroke severity was associated with objective cognitive impairment and objective and subjective physical impairment, but not subjective cognitive impairment.

CONCLUSIONS

The lack of association between objective and subjective cognitive functioning challenges the conventional assumption that perceived functioning reflects actual performance. We recommend using both objective and subjective measures to accurately identify cognitive and physical impairment following stroke.Implications for RehabilitationSubjective cognitive functioning is not associated with objective cognitive functioning, suggesting that solely relying on stroke patients' reports is inadequate and may inaccurately estimate patients' actual deficits.Both objective and subjective measures should be used to accurately identify cognitive and physical impairment following stroke.Practitioners should be cognizant of stroke patients' behavioral signs associated with underlying cognitive problems that warrant further evaluation.

Assessment of Upper Extremity Function in People With Stroke Based on the Framework of the ICF: A Narrative Review

Although there are many assessment tools for upper extremity (UE) function, it is still difficult to select an appropriate outcome measurement for the rehabilitation process of individuals with stroke. This review aims to classify each tool within the International Classification of Functioning, Disability and Health (ICF) framework and provide an overview of UE assessments. Through a comprehensive understanding of assessments based on ICF, health care professionals will be able to choose suitable measurement tools for individuals, facilitating their rehabilitation.

Bilateral Movement-based Computer Games Improve Sensorimotor Functions in Subacute Stroke Survivors

BACKGROUND

Previous studies have reported that movement-based computer gaming is more effective than conventional intervention in enhancing upper limb rehabilitation.

OBJECTIVE

To evaluate whether the use of bilateral movement-based computer games could augment the effects of conventional intervention in improving the upper limb motor function, grip strength and health-related quality of life of subacute stroke survivors.

METHODS

A total of 93 subjects with subacute stroke were randomized into 2 groups receiving one of two 3.5-h interventions for 2 days per week over 8 weeks: (i) "bilateral movement-based computer games + conventional rehabilitation"; and (ii) "video-directed exercise + conventional rehabilitation" (control group).

RESULTS

A total of 83 subjects completed the interventions and follow-up assessments. Compared with video-directed exercise + conventional rehabilitation, bilateral movement-based computer games + conventional rehabilitation produced greater improvements in upper limb motor impairment from midtreatment to follow-up 1 month post-intervention, greater improvements in upper limb function from post-intervention to 1 month follow-up, and earlier improvements in grip strength (paretic) from midintervention to follow-up 1 month post-intervention. Subjects who received bilateral movement-based computer games + conventional rehabilitation also continued to improve in motor function from postintervention to 1 month post-intervention.

CONCLUSION

Bilateral movement-based computer games may serve as an adjuvant therapy to conventional rehabilitation programmes for improving upper limb recovery among stroke survivors.

Use of an EMG-Controlled Game as a Therapeutic Tool to Retrain Hand Muscle Activation Patterns Following Stroke: A Pilot Study

BACKGROUND/PURPOSE

To determine the feasibility of training with electromyographically (EMG) controlled games to improve control of muscle activation patterns in stroke survivors.

METHODS

Twenty chronic stroke survivors (>6 months) with moderate hand impairment were randomized to train either unilaterally (paretic only) or bilaterally over 9 one-hour training sessions. EMG signals from the unilateral or bilateral limbs controlled a cursor location on a computer screen for gameplay. The EMG muscle activation vector was projected onto the plane defined by the first 2 principal components of the activation workspace for the nonparetic hand. These principal components formed the x- and y-axes of the computer screen.

RESULTS

The recruitment goal (n = 20) was met over 9 months, with no screen failure, no attrition, and 97.8% adherence rate. After training, both groups significantly decreased the time to move the cursor to a novel sequence of targets (P = 0.006) by reducing normalized path length of the cursor movement (P = 0.005), and improved the Wolf Motor Function Test (WMFT) quality score (P = 0.01). No significant group difference was observed. No significant change was seen in the WMFT time or Box and Block Test.

DISCUSSION/CONCLUSIONS

Stroke survivors could successfully use the EMG-controlled games to train control of muscle activation patterns. While the nonparetic limb EMG was used in this study to create target EMG patterns, the system supports various means for creating target patterns per user desires. Future studies will employ training with the EMG-controlled games in conjunction with functional task practice for a longer intervention duration to improve overall hand function.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A379).

Upper extremity self-efficacy correlates with daily hand-use of individuals with high functional capacity post-stroke

PURPOSE

To understand the role of affected upper extremity (UE) self-efficacy for explaining daily-hand-use in individuals post-stroke. Specifically, to describe UE self-efficacy and to assess the associations between UE self-efficacy to UE motor and functional capacity and daily hand-use.

MATERIALS AND METHODS

This cross-sectional study included individuals post-stroke receiving rehabilitation with high UE functional capacity [Action Research Arm Test (ARAT) > 50]. The Rating of Everyday Arm-Use in the Community and Home (REACH) assessed perceived UE daily use and the Confidence in Arm and Hand Movement scale (CAHM) assessed UE self-efficacy. Functional capacity was assessed by the ARAT and the Fugl-Meyer-motor-assessment assessed motor impairment. Correlations between measures were assessed.

RESULTS

Twenty-two individuals, aged 19-80, with high UE functional capacity [median (IQR) ARAT-56.5 (54-57)] and varying UE self-efficacy [median (IQR) CAHM-76.7 (58-84.4)], were included. UE self-efficacy was significantly correlated with the ARAT (r_s = 0.53, p < 0.01) and REACH (r_s = 0.51, p < 0.01) but ARAT was not significantly correlated with REACH.

CONCLUSIONS

UE self-efficacy is correlated with perceived daily hand-use in individuals with high functional capacity. Further research and a deeper understanding of the clinical implications of UE self-efficacy are warranted. UE self-efficacy should perhaps be assessed during rehabilitation. IMPLICATIONS FOR REHABILITATIONIndividuals with stroke with high affected upper extremity functional capacity do not necessarily use this hand for daily living.Upper extremity self-efficacy is correlated with perceived daily hand-use in individuals with high functional capacity; participants with higher upper extremity self-efficacy also reported more daily hand-use.Upper extremity self-efficacy seems to be upper extremity task or situation-specific.Upper extremity self-efficacy should be assessed during rehabilitation and the clinical implications of (low) upper extremity self-efficacy should be further researched.

Changes in upper limb capacity and performance in the early and late subacute phase after stroke

BACKGROUND

The course of spontaneous biological recovery indicates that no essential improvements in upper limb (UL) capacity should be expected 3 months after stroke. Likewise, UL performance as assessed with accelerometers does not seem to increase. However, this plateau may not apply to all patients with stroke.

OBJECTIVES

This study aimed to investigate the changes in UL capacity and performance from 3 to 6 months post-stroke, and the association between patients' UL capacity and actual UL performance.

METHODS

This study was a secondary analysis of a prospective longitudinal cohort study. Patients with UL impairment and first or recurrent stroke were included. Their UL capacity was assessed at 3 and 6 months with the Action Research Arm Test (ARAT) and UL performance was examined with accelerometry and expressed as a use ratio. The association between ARAT and use ratio was examined with multiple regression analyses.

RESULTS

Data from 67 patients were analyzed. It was shown that UL capacity as assessed with ARAT still improved from 3 to 6 months. A clinically meaningful improvement (≥ 6 points on ARAT) was found in 16 (46%) of the 35 patients whose scores allowed for such an increase. Improvements were mainly observed for patients with ARAT scores in the range of 15-51 at 3 months. Conversely, UL performance did not change. Three and 6 months after stroke respectively 69% and 64% of the variation in use ratio was explained by ARAT.

CONCLUSION

While a substantial part of patients improved their UL capacity, UL performance did not change from 3 to 6 months post-stroke. Strategies to remind patients of including their affected UL may encourage the transfer from better capacity to increased performance.

Effect of novel training to normalize altered finger force direction post-stroke: study protocol for a double-blind randomized controlled trial

BACKGROUND

Functional task performance requires proper control of both movement and force generation in three-dimensional space, especially for the hand. Control of force in three dimensions, however, is not explicitly treated in current physical rehabilitation. To address this gap in treatment, we have developed a tool to provide visual feedback on three-dimensional finger force. Our objective is to examine the effectiveness of training with this tool to restore hand function in stroke survivors.

METHODS

Double-blind randomized controlled trial. All participants undergo 18 1-h training sessions to practice generating volitional finger force of various target directions and magnitudes. The experimental group receives feedback on both force direction and magnitude, while the control group receives feedback on force magnitude only. The primary outcome is hand function as measured by the Action Research Arm Test. Other outcomes include the Box and Block Test, Stroke Impact Scale, ability to direct finger force, muscle activation pattern, and qualitative interviews.

DISCUSSION

The protocol for this clinical trial is described in detail. The results of this study will reveal whether explicit training of finger force direction in stroke survivors leads to improved motor control of the hand. This study will also improve the understanding of neuromuscular mechanisms underlying the recovery of hand function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03995069 . Registered on June 21, 2019.

Concomitant sensory stimulation during therapy to enhance hand functional recovery post stroke

Background

Post-stroke hand impairment is prevalent and persistent even after a full course of rehabilitation. Hand diminishes stroke survivors’ abilities for activities of daily living and independence. One way to improve treatment efficacy is to augment therapy with peripheral sensory stimulation. Recently, a novel sensory stimulation, TheraBracelet, has been developed in which imperceptible vibration is applied during task practice through a wrist-worn device. The objective of this trial is to determine if combining TheraBracelet with hand task practice is superior to hand task practice alone.

Methods

A double-blind randomized controlled trial will be used. Chronic stroke survivors will undergo a standardized hand task practice therapy program (3 days/week for 6 weeks) while wearing a device on the paretic wrist. The device will deliver TheraBracelet vibration for the treatment group and no vibration for the control group. The primary outcome is hand function measured by the Wolf Motor Function Test. Other outcomes include the Box and Block Test, Action Research Arm Test, upper extremity use in daily living, biomechanical measure of the sensorimotor grip control, and EEG-based neural communication.

Discussion

This research will determine clinical utility of TheraBracelet to guide future translation. The TheraBracelet stimulation is delivered via a wrist-worn device, does not interfere with hand motion, and can be easily integrated into clinical practice. Enhancing hand function should substantially increase stroke survivors' independence and quality of life and reduce caregiver burden.

Trial registration

NCT04569123. Registered on September 29, 2020

Association of Modified Rankin Scale With Recovery Phenotypes in Patients With Upper Extremity Weakness After Stroke

BACKGROUND

Precise measurement of outcomes is essential for stroke trials and clinical care. Prior research has highlighted conceptual differences between global outcome measures such as the Modified Rankin Scale (mRS) and domain-specific measures (e.g. motor, sensory, language or cognitive function). This study related motor phenotypes to the mRS, specifically aiming to (1) determine whether mRS levels distinguish motor impairment and function phenotypes, and (2) compare mRS outcomes to meaningful changes in impairment and function from acute to subacute recovery after stroke.

METHODS

Patients with upper extremity weakness after ischemic stroke were assessed with a battery of impairment and functional measures within the first week and at 90-days post-stroke. Impairment and functional outcomes were examined in relation to 90-day mRS scores. Clinically meaningful changes in motor impairment, activities of daily living, and mobility were examined in relation to 90-day mRS.

RESULTS

In this cohort of n = 73 stroke patients, impairment and functional outcomes were associated with 90-day mRS scores but showed substantial variability within individual mRS levels: within mRS level 2, upper extremity impairment ranged from near hemiplegia (with an upper extremity Fugl-Meyer 8) to no deficits (upper extremity Fugl-Meyer 66). Overall, there were few differences in impairment and functional outcomes between adjacent mRS levels. While some outcome measures were significantly different between mRS levels 3 and 4 (Nine-Hole Peg, Leg Motor, Gait Velocity, Timed Up and Go, National Institutes of Health Stroke Scale, and Barthel Index), none of the outcome measures differed between mRS levels 1 and 2. Fugl-Meyer and Grip Strength were not different between any adjacent mRS levels. A substantial number of patients experienced clinically meaningful changes in impairment and function in the first 90 days post-stroke but did not achieve good mRS outcome (mRS ≤ 2).

CONCLUSIONS

The mRS broadly relates to domain-specific outcomes after stroke confirming its established value in stroke trials, but it does not precisely distinguish differences in impairment and function nor does it sufficiently capture meaningful clinical changes across impairment, ADL status, and mobility. These findings underscore the potential utility of incorporating detailed phenotypic measures alongside the mRS in future stroke trials.

Effect of Sensory Impairment on Hand Functional Improvement with Therapy and Sensory Stimulation

Sensory impairment may impact individual stroke survivors' motor recovery as well as their response to peripheral sensory stimulation treatment. The objective of this study was to determine the effect of sensory impairment level of individual stroke survivors on motor improvement with therapy and peripheral sensory stimulation. A secondary analysis of a pilot triple-blind randomized controlled trial was used. Twelve chronic stroke survivors were randomly assigned to the treatment group receiving peripheral sensory stimulation or the control group receiving no stimulation during 2-week hand task practice therapy. Sensory impairment level was quantified as the pre-intervention sensory threshold. Motor improvement was assessed as change in the Box and Block Test score from pre- to post-intervention. The association between sensory impairment level and motor improvement was examined using a regression analysis, accounting for groups. This study found that participants with better sensation (i.e., with lower sensory threshold) had better motor improvement than patients with worse sensation (i.e., with higher sensory threshold). Sensory impairment level did not alter the effect of peripheral sensory stimulation. These findings suggest that the level of sensory impairment may predict recovery potentials and direct rehabilitation treatment for stroke survivors.

Sensory-Based Priming for Upper Extremity Hemiparesis After Stroke: A Scoping Review

Sensory priming is a technique to facilitate neuroplasticity and improve motor skills after injury. Common sensory priming modalities include peripheral nerve stimulation/somatosensory electrical stimulation (PNS/SES), transient functional deafferentation (TFD), and vibration. The aim of this study was to determine whether sensory priming with a motor intervention results in improved upper limb motor impairment or function after stroke. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and EMBASE were the databases used to search the literature in July 2020. This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and recommendations for the Cochrane collaboration. In total, 30 studies were included in the analysis: three studies examined TFD, 16 examined PNS/SES, 10 studied vibration, and one combined the three stimulation techniques. Most studies reported significant improvements for participants receiving sensory priming. Given the low risk, it may be advantageous to use sensory-based priming prior to or concurrent with upper limb training after stroke.

Using Subthreshold Vibratory Stimulation During Poststroke Rehabilitation Therapy: A Case Series

Subthreshold vibratory stimulation to the paretic wrist has been shown to prime the sensorimotor cortex and improve 2-week upper extremity (UE) therapy outcomes. The objective of this work was to determine feasibility, safety, and preliminary efficacy of the stimulation over a typical 6-week therapy duration. Four chronic stroke survivors received stimulation during 6-week therapy. Feasibility/safety/efficacy were assessed at baseline, posttherapy, and 1-month follow-up. For feasibility, all participants wore the device throughout therapy and perceived the stimulation comfortable/safe. Regarding safety, no serious/moderate intervention-related adverse events occurred. For efficacy, all participants improved in Wolf Motor Function Test and UE use in daily living based on accelerometry and stroke impact scale. Mean improvements at posttherapy/follow-up were greater than the minimal detectable change/clinically important difference and other trials with similar therapy without stimulation. In conclusion, the stimulation was feasible/safe for 6-week use. Preliminary efficacy encourages a larger trial to further evaluate the stimulation as a therapy adjunct.

Evolution and prediction of mismatch between observed and perceived upper limb function after stroke: a prospective, longitudinal, observational cohort study

BACKGROUND

A previously shown 'mismatch' group of patients with good observed upper limb (UL) motor function but low perceived UL activity at six months post stroke tends to use the affected UL less in daily life than would be expected based on clinical tests, and this mismatch may also be present at 12 months. We aimed to confirm this group in another cohort, to investigate the evolution of this group from six to 12 months, and to determine factors on admission to inpatient rehabilitation and at 6 months that can discriminate between mismatch and good match groups at 12 months.

METHODS

Persons after stroke were recruited on rehabilitation admission and re-assessed at six and 12 months. Observed UL function was measured with the upper extremity subscale of the Fugl-Meyer Assessment (FMA-UE) and perceived UL activity by the hand subscale of the Stroke Impact Scale 3.0 (SIS-Hand). We defined mismatch as good observed UL function (FMA-UE > 50/66) but low perceived activity (SIS-Hand≤75/100). Potential discriminators at admission and 6 months (demographic characteristics, stroke characteristics, UL somatosensory function, cognitive deficits, mental function and activity) were statistically compared for match and mismatch groups at 12 months.

RESULTS

We included 60 participants (female: 42%) with mean (SD) age of 65 (12) years. We confirmed a mismatch group of 11 (18%) patients at 6 months, which increased to 14 (23%) patients at 12 months. In the mismatch group compared to the good match group at 12 months, patients had a higher stroke severity and more somatosensory impairments on admission and at 6 months.

CONCLUSIONS

We confirmed a group of patients with good observed UL function but low perceived activity both at six and at 12 months post stroke. Assessment of stroke severity and somatosensory impairments on admission into rehabilitation could determine mismatch at 12 months and might warrant intervention. However, large differences in clinical outcomes between patients in the mismatch group indicate the importance of tailoring training to the individual needs.

Brain-Computer Interface Training With Functional Electrical Stimulation: Facilitating Changes in Interhemispheric Functional Connectivity and Motor Outcomes Post-stroke

While most survivors of stroke experience some spontaneous recovery and receive treatment in the subacute setting, they are often left with persistent impairments in upper limb sensorimotor function which impact autonomy in daily life. Brain-Computer Interface (BCI) technology has shown promise as a form of rehabilitation that can facilitate motor recovery after stroke, however, we have a limited understanding of the changes in functional connectivity and behavioral outcomes associated with its use. Here, we investigate the effects of EEG-based BCI intervention with functional electrical stimulation (FES) on resting-state functional connectivity (rsFC) and motor outcomes in stroke recovery. 23 patients post-stroke with upper limb motor impairment completed BCI intervention with FES. Resting-state functional magnetic resonance imaging (rs-fMRI) scans and behavioral data were collected prior to intervention, post- and 1-month post-intervention. Changes in rsFC within the motor network and behavioral measures were investigated to identify brain-behavior correlations. At the group-level, there were significant increases in interhemispheric and network rsFC in the motor network after BCI intervention, and patients significantly improved on the Action Research Arm Test (ARAT) and SIS domains. Notably, changes in interhemispheric rsFC from pre- to both post- and 1 month post-intervention correlated with behavioral improvements across several motor-related domains. These findings suggest that BCI intervention with FES can facilitate interhemispheric connectivity changes and upper limb motor recovery in patients after stroke.

Baseline Characteristics of Patients With Cavernous Angiomas With Symptomatic Hemorrhage in Multisite Trial Readiness Project

BACKGROUND AND PURPOSE

Brain cavernous angiomas with symptomatic hemorrhage (CASH) have a high risk of neurological disability from recurrent bleeding. Systematic assessment of baseline features and multisite validation of novel magnetic resonance imaging biomarkers are needed to optimize clinical trial design aimed at novel pharmacotherapies in CASH.

METHODS

This prospective, multicenter, observational cohort study included adults with unresected, adjudicated brain CASH within the prior year. Six US sites screened and enrolled patients starting August 2018. Baseline demographics, clinical and imaging features, functional status (modified Rankin Scale and National Institutes of Health Stroke Scale), and patient quality of life outcomes (Patient-Reported Outcomes Measurement Information System-29 and EuroQol-5D) were summarized using descriptive statistics. Patient-Reported Outcomes Measurement Information System-29 scores were standardized against a reference population (mean 50, SD 10), and one-sample t test was performed for each domain. A subgroup underwent harmonized magnetic resonance imaging assessment of lesional iron content with quantitative susceptibility mapping and vascular permeability with dynamic contrast-enhanced quantitative perfusion.

RESULTS

As of May 2020, 849 patients were screened and 110 CASH cases enrolled (13% prevalence of trial eligible cases). The average age at consent was 46±16 years, 53% were female, 41% were familial, and 43% were brainstem lesions. At enrollment, ≥90% of the cohort had independent functional outcome (modified Rankin Scale score ≤2 and National Institutes of Health Stroke Scale score <5). However, perceived health problems affecting quality of life were reported in >30% of patients (EuroQol-5D). Patients had significantly worse Patient-Reported Outcomes Measurement Information System-29 scores for anxiety (P=0.007), but better depression (P=0.002) and social satisfaction scores (P=0.012) compared with the general reference population. Mean baseline quantitative susceptibility mapping and permeability of CASH lesion were 0.45±0.17 ppm and 0.39±0.31 mL/100 g per minute, respectively, which were similar to historical CASH cases and consistent across sites.

CONCLUSIONS

These baseline features will aid investigators in patient stratification and determining the most appropriate outcome measures for clinical trials of emerging pharmacotherapies in CASH.

Daily Life Upper Limb Activity for Patients with Match and Mismatch between Observed Function and Perceived Activity in the Chronic Phase Post Stroke

We investigated actual daily life upper limb (UL) activity in relation to observed UL motor function and perceived UL activity in chronic stroke in order to better understand and improve UL activity in daily life. In 60 patients, we collected (1) observed UL motor function (Fugl-Meyer Assessment (FMA-UE)), (2) perceived UL activity (hand subscale of the Stroke Impact Scale (SIS-Hand)), and (3) daily life UL activity (bilateral wrist-worn accelerometers for 72 h) data. Data were compared between two groups of interest, namely (1) good observed (FMA-UE >50) function and good perceived (SIS-Hand >75) activity (good match, n = 16) and (2) good observed function but low perceived (SIS-Hand ≤75) activity (mismatch, n = 15) with Mann-Whitney U analysis. The mismatch group only differed from the good match group in perceived UL activity (median (Q1-Q3) = 50 (30-70) versus 93 (85-100); p < 0.001). Despite similar observed UL motor function and other clinical characteristics, the affected UL in the mismatch group was less active in daily life compared to the good match group (p = 0.013), and the contribution of the affected UL compared to the unaffected UL for each second of activity (magnitude ratio) was lower (p = 0.022). We conclude that people with chronic stroke with low perceived UL activity indeed tend to use their affected UL less in daily life despite good observed UL motor function.

Obstacle Avoidance and Dual-Tasking During Reaching While Standing in Patients With Mild Chronic Stroke

Background. Poststroke individuals use their paretic arms less often than expected in daily life situations, even when motor recovery is scored highly in clinical tests. Real-world environments are often unpredictable and require the ability to multitask and make decisions about rapid and accurate arm movement adjustments. Objective. To identify whether and to what extent cognitive-motor deficits in well-recovered individuals with stroke affect the ability to rapidly adapt reaching movements in changing cognitive and environmental conditions. Methods. Thirteen individuals with mild stroke and 11 healthy controls performed an obstacle avoidance task in a virtual environment while standing. Subjects reached for a virtual juice bottle with their hemiparetic arm as quickly as possible under single- and dual-task conditions. In the single-task condition, a sliding glass door partially obstructed the reaching path of the paretic arm. A successful trial was counted when the subject touched the bottle without the hand colliding with the door. In the dual-task condition, subjects repeated the same task while performing an auditory-verbal working memory task. Results. Individuals with stroke had significantly lower success rates than controls in avoiding the moving door in single-task (stroke: 51.8 ± 21.2%, control: 70.6 ± 12.7%; P = .018) and dual-task conditions (stroke: 40.0 ± 27.6%, control: 65.3 ± 20.0%; P = .015). Endpoint speed was lower in stroke subjects for successful trials in both conditions. Obstacle avoidance deficits were exacerbated by increased cognitive demands in both groups. Individuals reporting greater confidence using their hemiparetic arm had higher success rates. Conclusion. Clinically well-recovered individuals with stroke may have persistent deficits performing a complex reaching task.

The role of goal adjustment during rehabilitation from stroke

We investigated motivational regulation involving adjustment of recovery goals in post-stroke rehabilitation via standard in-clinic physiotherapy and in-home telerehabilitation (TR). We used a secondary dataset collected at 11 US sites as part of a clinical trial using video games and game control pads designed to induce certain arm movements required for recovery (n = 124; M_age  = 61.44, SD = 13.30). Participants were randomly assigned to either the TR or in-clinic condition and underwent 36 therapy sessions, reporting on their activity-inherent enjoyment for 6-8 weeks. Compared with the in-clinic patients and TR patients with high game performance, TR patients with lower game performance reported lower activity-inherent enjoyment, which is an important motivational resource for successful recovery. The results suggest that these differences occur because TR patients become discouraged by low game score feedback, which may have signaled a poor prospect for recovery. However, the results also suggest that low game performers who successfully adjusted their recovery goals were resilient to the impact of low game score feedback on their motivational resources and satisfaction with therapy. The findings suggest that goal adjustment may be particularly beneficial when patients are discouraged by feedback indicating suboptimal recovery prospects.

The role of mirror mechanism in the recovery, maintenance, and acquisition of motor abilities

While it is well documented that the motor system is more than a mere implementer of motor actions, the possible applications of its cognitive side are still under-exploited, often remaining as poorly organized evidence. Here, we will collect evidence showing the value of action observation treatment (AOT) in the recovery of impaired motor abilities for a vast number of clinical conditions, spanning from traumatological patients to brain injuries and neurodegenerative diseases. Alongside, we will discuss the use of AOT in the maintenance of appropriate motor behavior in subjects at risk for events with dramatic physical consequences, like fall prevention in elderly people or injury prevention in sports. Finally, we will report that AOT can help to tune existing motor competencies in fields requiring precise motor control. We will connect all these diverse dots into the neurophysiological scenario offered by decades of research on the human mirror mechanism, discussing the potentialities for individualization. Empowered by modern technologies, AOT can impact individuals' safety and quality of life across the whole lifespan.

N-Acetylaspartate Biomarker of Stroke Recovery: A Case Series Study

BACKGROUND AND PURPOSE

Strong experimental neurobehavioral evidence suggests that intensive training improves arm motor disability after stroke. Yet, we still have only limited understanding why some patients recover more completely and others do not. This is in part due to our limited knowledge of the neurobiological principles of recovery from stroke. Mounting evidence suggests that functional and structural remapping of the primary motor cortex (M1) plays a major role in arm recovery after stroke. We used MR Spectroscopy to test the hypothesis that therapy-related arm improvement is associated with changes in levels of a putative marker of neuronal integrity (N-acetylaspartate, NAA) in M1 controlling the paretic arm (ipsilesional M1) in chronic stroke patients (n=5).

METHODS

Patients (1 female, age, mean ± SD, 58.4 ± 5.8 years) underwent 4-week arm-focused motor training (1080 repetitions of a reach-to-grasp task) at 13.6 ± 5.3 months after stroke onset. NAA levels in the ipsilesional M1 and arm impairment (Fugl-Meyer, FM, 66=normal; proximal FM, FM_p, 30=normal) were assessed prior to and immediately after training.

RESULTS

At baseline, patients exhibited moderate-to-mild arm impairment (FM, 47.2 ± 18.8, FM_p, 22.2 ± 8.6) and showed lower levels of NAA compared with age/sex-matched healthy controls (10.2 ± 0.9 mM in patients vs. 11.6 ± 1.6 mM in controls, p=0.03). After training, arm impairment improved (FM by 7%, 50.6 ± 17.5, p=0.01; FMp, by 5%, 23.4 ± 8.2, p=0.2) and NAA levels increased by 10.5% (11.2 ± 1.2 mM, p=0.1). Changes in NAA positively correlated with changes in FM (r=0.63, p=0.2) and FM_p (r=0.93, p=0.03), suggesting that patients who show greater neuronal changes have a better chance of recovery.

CONCLUSIONS

Our data suggest the potential use of M1 NAA as a biomarker of motor recovery after stroke. However, because of our small sample, these preliminary results should be interpreted cautiously. Further work with larger sample sizes is warranted.

A Novel Combination of Accelerometry and Ecological Momentary Assessment for Post-Stroke Paretic Arm/Hand Use: Feasibility and Validity

Use of the paretic arm and hand is a key indicator of recovery and reintegration after stroke. A sound methodology is essential to comprehensively identify the possible factors impacting daily arm/hand use behavior. We combined ecological momentary assessment (EMA), a prompt methodology capturing real-time psycho-contextual factors, with accelerometry to investigate arm/hand behavior in the natural environment. Our aims were to determine (1) feasibility and (2) measurement validity of the combined methodology. We monitored 30 right-dominant, mild-moderately motor impaired chronic stroke survivors over 5 days (6 EMA prompts/day with accelerometers on each wrist). We observed high adherence for accelerometer wearing time (80.3%), EMA prompt response (84.6%), and generally positive user feedback upon exit interview. The customized prompt schedule and the self-triggered prompt option may have improved adherence. There was no evidence of EMA response bias nor immediate measurement reactivity. An unexpected small but significant increase in paretic arm/hand use was observed over days (12–14 min), which may be the accumulated effect of prompting that provided a reminder to choose the paretic limb. Further research that uses this combined methodology is needed to develop targeted interventions that effectively change behavior and enable reintegration post-stroke.

Remedial Training of the Less-Impaired Arm in Chronic Stroke Survivors With Moderate to Severe Upper-Extremity Paresis Improves Functional Independence: A Pilot Study

The ipsilesional arm of stroke patients often has functionally limiting deficits in motor control and dexterity that depend on the side of the brain that is lesioned and that increase with the severity of paretic arm impairment. However, remediation of the ipsilesional arm has yet to be integrated into the usual standard of care for upper limb rehabilitation in stroke, largely due to a lack of translational research examining the effects of ipsilesional-arm intervention. We now ask whether ipsilesional-arm training, tailored to the hemisphere-specific nature of ipsilesional-arm motor deficits in participants with moderate to severe contralesional paresis, improves ipsilesional arm performance and generalizes to improve functional independence. We assessed the effects of this intervention on ipsilesional arm unilateral performance [Jebsen–Taylor Hand Function Test (JHFT)], ipsilesional grip strength, contralesional arm impairment level [Fugl–Meyer Assessment (FM)], and functional independence [Functional independence measure (FIM)] (N = 13). Intervention occurred over a 3 week period for 1.5 h/session, three times each week. All sessions included virtual reality tasks that targeted the specific motor control deficits associated with either left or right hemisphere damage, followed by graded dexterity training in real-world tasks. We also exposed participants to 3 weeks of sham training to control for the non-specific effects of therapy visits and interactions. We conducted five test-sessions: two pre-tests and three post-tests. Our results indicate substantial improvements in the less-impaired arm performance, without detriment to the paretic arm that transferred to improved functional independence in all three posttests, indicating durability of training effects for at least 3 weeks. We provide evidence for establishing the basis of a rehabilitation approach that includes evaluation and remediation of the ipsilesional arm in moderately to severely impaired stroke survivors. This study was originally a crossover design; however, we were unable to complete the second arm of the study due to the COVID-19 pandemic. We report the results from the first arm of the planned design as a longitudinal study.

Factors related to daily use of the paretic upper limb in patients with chronic hemiparetic stroke-A retrospective cross-sectional study

AIMS

The present study aimed to determine factors associated with the frequency of paralyzed upper extremity (UE) use in chronic stroke patients with severe UE functional deficiency.

METHODS

We retrospectively reviewed the medical records of 138 consecutive patients, and 117 was analyzed (median age, 55 [range, 18-85] years; median stroke duration, 24.5 [range, 7-302] months) with chronic hemiparetic stroke who were admitted to our hospital for intensive upper extremity rehabilitation. The mean Fugl-Meyer Assessment (FMA) UE score was 28.6. All of them are independent in their activity of daily living (ADL) and without remarkable cognitive deficits. Amount-of-use score of Motor Activity Log-14 (MAL-AOU) was applied as the index of daily use of affected UE. The following parameters were examined as the explanatory variables: demographics, proximal and distal sub-scores of FMA UE, Modified Ashworth Scale (MAS), and sensory function scores in the Stroke Impairment Assessment Set (SIAS).

RESULTS

The median MAL-AOU score was 0.57 [range, 0.28-0.80]. Ordinal regression analysis revealed that FMA proximal, FMA distal, and SIAS sensory function (touch) were associated with AOU score of MAL-14 (Pseudo R-square = 0.460).

CONCLUSION

Not only motor but also sensory function, especially tactile sensation, play a crucial role in the daily use of affected UE in chronic stroke patients with severe UE hemiparesis.

Health-related quality of life, anxiety and depression up to 12 months post-stroke: Influence of sex, age, stroke severity and atrial fibrillation - A longitudinal subanalysis of the Find-AFRANDOMISED trial

BACKGROUND

Stroke can negatively impact the health-related quality of life (HRQoL). Anxiety or depression after stroke have been associated with poorer HRQoL, higher mortality and greater dependence in activities of daily living. We aimed to analyze HRQoL, anxiety and depressive symptoms in patients with and without atrial fibrillation (AF) up to 12 months post-stroke.

METHODS

Find-AF_RANDOMISED was a prospective, randomized multicenter study, which included 398 patients ≥60 years with acute cerebral ischemia. HRQoL data were collected using the 3-level EuroQol-5D (EQ-5D-3L) and Stroke Impact Scale (SIS-16). Anxiety and depressive symptoms were measured using the Hospital Anxiety and Depression Scale (HADS). The severity of stroke was measured using the modified Rankin Scale (mRS).

RESULTS

In this study (mean age 72.7 ± 7.5 years, 40.2% females), there was a significant improvement in HRQoL using EQ-5D-3L after 3 months (β = 0.37, p < .01), 6 months (β = 0.43, p < .01) and 12 months (β = 0.44, p < .01) post-stroke compared to baseline. HADS anxiety scores after 3 months (β = -0.22, p < .01) and 12 months (β = -0.28, p < .01) were significantly reduced. Older patients reported reduced HRQoL and more depressive symptoms. Females indicated lower HRQoL and more anxiety. mRS score at baseline was an independent predictor for HRQoL. There was a significant but small effect of AF on EQ-5D-3L and on HADS anxiety.

CONCLUSIONS

Patients showed significant improvement in HRQoL and reduced anxiety after 3 and 12 months after stroke. We could demonstrate that the severity of stroke as well as sex and age impact long-term post-stroke HRQoL.

CLINICAL TRIAL REGISTRATION

Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01855035.