Higher Doses Improve Walking Recovery During Stroke Inpatient Rehabilitation

High-intensity locomotor training during inpatient rehabilitation improves the discharge ambulation function of patients with stroke. A systematic review with meta-analysis

OBJECTIVE

To evaluate the evidence of high-intensity locomotor training on outcomes related to gait and balance for patients with stroke in inpatient rehabilitation.

METHODS

Four databases were searched (PubMed, CINAHL, Web of Science, and MedLINE) for articles published prior to 13 June 2023. Studies of adults (>18 years old) with a diagnosis of stroke who received a high-intensity locomotor intervention while admitted to an inpatient rehabilitation facility were included. A functional outcome in the domain of gait speed, gait endurance, or balance must have been reported. Following the screening of 1052 studies, 43 were selected for full-text review. Studies were assessed for risk of bias using the tool appropriate to the study type. Gait speed, gait endurance, and balance outcome data were extracted for further analysis.

RESULTS

Eight studies were selected with risk of bias ratings as moderate (4), high (2), and low (2). Six studies were analyzed in the meta-analysis (N = 635). A random-effects model analyzed between-group differences. Standard mean differences demonstrated that high-intensity locomotor training produces a moderate effect on gait endurance (0.50) and gait speed (0.41) and a negligible effect on balance (0.08) compared with usual care.

CONCLUSIONS

The meta-analysis supports the use of high-intensity locomotor training over usual care for improving gait speed and gait endurance during inpatient post-stroke. Future studies should investigate dose-response relationships of high-intensity locomotor training in this setting.

PROSPERO REGISTRATION

#CRD42022341329.

Improvement of gait and balance function in chronic post-stroke patients induced by Lower Extremity - Constraint Induced Movement Therapy: a randomized controlled clinical trial

OBJECTIVE

To evaluate the effects of Lower Extremity - Constraint Induced Movement Therapy on gait function and balance in chronic hemiparetic patients.

METHODS

Randomized, controlled, single-blinded study. We recruited chronic post stroke patients and allocated them to Lower Extremity - Constraint Induced Movement Tharapy (LE-CIMT) or Control Group. The LE-CIMT group received this protocol 2.5 hour/day for 15 followed days, including: 1) intensive supervised training, 2) use of shaping as a strategy for motor training, and 3) application of a transfer package. The control group received conventional physiotherapy for 2.5 hours/day for 15 followed days. Outcomes were assessed at baseline, after the interventions, and after 6 months, through 6-minute walk test and Mini-Balance Evaluation Systems Test; 10-meter walk test, Timed Up and Go, 3-D gait analysis, and Lower Extremity - Motor Activity Log.

RESULTS

LE-CIMT was superior on the Assistance and confidence subscale of Lower Extremity - Motor Activity Log, Mini-BESTest and 6-minute walk test. The effect size for all outcomes was small when comparing both groups. LE-CIMT showed clinically significant differences in daily activities, balance, and gait capacity, with no clinically significant difference for spatiotemporal parameters.

CONCLUSION

The LE-CIMT protocol had positive outcomes on balance, performance, and confidence perception.

Quadriceps muscle activity during walking with a knee ankle foot orthosis is associated with improved gait ability in acute hemiplegic stroke patients with severe gait disturbance

Introduction

A knee-ankle-foot orthosis (KAFO) prevents knee buckling during walking and enables gait training for acute hemiplegic stroke patients with severe gait disturbances. Although the goal of gait training with a KAFO is to improve gait ability, that is, to acquire walking with an ankle-foot orthosis (AFO), it is not clear how gait training with a KAFO contributes to improving gait ability. Therefore, this study aimed to investigate the relationship between muscle activities during walking with a KAFO and the improvement of gait ability in hemiplegic stroke patients with severe gait disturbance.

Methods

A prospective cohort study was conducted. Fifty acute hemiplegic stroke patients who could not walk with an AFO participated. Muscle activities of the paretic rectus femoris, biceps femoris, tibialis anterior, and soleus were assessed with surface electromyogram during walking with a KAFO. Electromyograms were assessed at the beginning of gait training and at the time the Ambulation Independence Measure score improved by 3 or higher, or discharge.

Results

Even in patients with complete hemiplegia, paretic rectus femoris, biceps femoris, and soleus showed periodic muscle activity during walking with a KAFO. Twenty-three patients improved to an Ambulation Independence Measure score of 3 or higher and were able to walk with an AFO (good recovery group). At the beginning of gait training, paretic rectus femoris muscle activity during the first double-limb support phase was significantly higher in the good recovery group than in the poor recovery group. The rectus femoris muscle activity significantly increased from before to after acute rehabilitation, which consisted mainly of gait training with a KAFO.

Discussion

For acute hemiplegic stroke patients with severe disturbance, the induction and enhancement of paretic quadriceps muscle activity during walking with a KAFO play an important role in acquiring walking with an AFO.

Post Stroke Exercise Training: Intensity, Dosage, and Timing of Therapy

More intense, earlier exercise in rehabilitation results in improved motor outcomes following stroke. Timing and intensity of therapy delivery vary from study to study. For more intensive therapies, there are practical challenges in implementation. However, there are also opportunities for high intensity treatment through innovative approaches and new technologies. Timing of rehabilitation is important. As time post stroke increases, the dosage of therapy required to improve motor recovery outcomes increases. Very early rehabilitation may improve motor outcomes but should be delayed for at least 24 hours post stroke.

The association between inpatient rehabilitation intensity and outcomes after stroke in Ontario, Canada

BACKGROUND

Several studies have demonstrated improved outcomes poststroke when higher intensity rehabilitation is provided. Canadian Stroke Best Practice Recommendations advise patients receive 180 min of therapy time per day; however, the exact amount required to reach benefit is unknown.

AIMS

The primary aim of this study was to determine the association between rehabilitation intensity (RI) and total Functional Independence Measure (FIM) Instrument change. Secondary aims included determining the association between RI and discharge location, 90-day home time, rehabilitation effectiveness, and motor and cognitive FIM change.

METHODS

A retrospective cohort study was conducted using available administrative databases of acute stroke patients discharged to inpatient rehabilitation facilities in Ontario, Canada, from January 2017 to December 2021. RI was defined as number of minutes per day of direct therapy by all providers divided by rehabilitation length of stay. The association between RI and the outcomes of interest were analyzed using regression models with restricted cubic splines.

RESULTS

A total of 12,770 individuals were included. Mean age of the sample was 72.6 years, 46.0% of individuals were female, and 87.6% had an ischemic stroke. Mean RI was 74.7 min (range: 5-162 min) per day. Increased RI was associated with an increase in mean FIM change. However, there was diminishing incremental increase after reaching 95 min/day. Increased RI was positively associated with motor and cognitive FIM change, rehabilitation effectiveness, 90-day home time, and discharge to preadmission setting. Higher RI was associated with a lower likelihood of discharge to long-term care.

CONCLUSIONS

None of the patients met the recommended RI of 180 min/day based on the Canadian Stroke Best Practice Recommendations. Despite this, higher intensity was associated with better outcomes. Given that most positive associations were observed with a RI ⩾95 min/day, this may be a more feasible target.

Moderate to Vigorous Intensity Locomotor Training After Stroke: A Systematic Review and Meta-analysis of Mean Effects and Response Variability

BACKGROUND AND PURPOSE

This meta-analysis quantified mean effects of moderate to vigorous intensity locomotor training (LT mv ) on walking outcomes in subacute and chronic stroke, and the magnitude of variability in LT mv response.

METHODS

Databases were searched for randomized trials comparing LT mv with no intervention, nongait intervention, or low-intensity gait training. Comfortable gait speed (CGS), fastest gait speed (FGS), 6-minute walk test (6MWT), walking activity (steps per day), and adverse effect/event (AE) data were extracted. Pooled estimates were calculated for mean changes, AE relative risks, and the standard deviation of response (SD response ) to LT mv versus control groups, stratified by study chronicity where possible.

RESULTS

There were 19 eligible studies (total N = 1096): 14 in chronic stroke (N = 839) and 5 in subacute stroke (N = 257). Compared with control interventions, LT mv yielded significantly greater increases in CGS (chronic, +0.06 m/s [95% confidence interval (CI), 0.01-0.10]; subacute, +0.16 [0.12-0.19]; subacute vs chronic, P = 0.03), FGS (chronic, +0.07 m/s [0.02-0.13]; subacute, +0.21 [0.01, 0.41]; P = 0.04), and 6MWT (chronic, +33 m [24-42]; subacute, +51 [26-77]; P = 0.054) but not steps/day (+260 [-1159 to 1679]). There were no treatment-related serious AEs among 398 LT mv participants in 14 AE-reporting studies. SD response estimates indicated substantial response variability: CGS, 0.11 m/s [0.00-0.15]; FGS, 0.14 m/s [-0.00 to 0.20]; and 6MWT, 41 m [27-51].

DISCUSSION AND CONCLUSIONS

LT mv improves mean walking capacity outcomes in subacute and chronic stroke and does not appear to have high risk of serious harm. Response magnitude varies within and between chronicity subgroups, and few studies have tested effects on daily walking activity or non-serious AEs.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A452 ).

Adverse Events During Submaximal Aerobic Exercise Testing in People With Subacute Stroke: A Scoping Review

BACKGROUND AND PURPOSE

Concern for adverse cardiovascular events and limited guidance regarding how to conduct aerobic exercise (AEx) testing for individuals poststroke are key barriers to implementation by physical therapists in stroke rehabilitation. This study aimed to describe the nature and safety of submaximal AEx testing protocols for people with subacute stroke (PwSS) and the nature of comorbidity of PwSS who underwent submaximal AEx testing.

METHODS

We conducted a scoping review and searched MEDLINE, EMBASE, PsycINFO, CINAHL, and SPORTDiscus from inception to October 29, 2020. Studies involving submaximal AEx testing with PwSS, reporting on participant comorbidity and on adverse events during testing, were eligible. Two reviewers independently conducted title and abstract and full-text screening. One reviewer extracted data; a second reviewer verified data.

RESULTS

Thirteen studies involving 452 participants and 19 submaximal AEx testing protocols (10 field test, 7 incremental, and 2 constant load) were included. Hypertension (41%), diabetes (31%), and dyslipidemia (27%) were the most common comorbidities reported. No protocols resulted in a serious adverse event. The most common test termination criterion was a heart rate (HR) limit (9 protocols); a limit of 85% age-predicted maximal HR (APM-HR) most frequently reported. Average APM-HR achieved, computed using mean age and mean peak HR, ranged from 59% to 88% across 13 protocols.

DISCUSSION AND CONCLUSION

Diverse submaximal AEx testing protocols with conservative test termination criteria can be safely implemented with PwSS. Results can inform clinical practice guidelines and address physical therapists' concerns with the occurrence of serious adverse events during submaximal AEx testing.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A430 ).

Body-weight support gait training in neurological intensive care: safety, feasibility, and delays before walking with or without suspension

BACKGROUND

Early Mobilization in Intensive Care Units (ICUs) enhances patients' evolution, but has been rarely studied in neurological ICUs. The aim of this study was to assess gait training with body-weight support (BWS) in neuroICU, and to report on its safety, feasibility and on delays before walking with and without BWS.

METHODS

This study was an observational one-year single-center study. Inclusion criteria were adults with a neurological injury requiring mechanical ventilation. Exclusion criteria were early death or ICU transfer. After weaning from ventilation, patients were screened for indications of BWS walking using predefined criteria.

RESULTS

Patients' conditions were mostly brain injuries: 32% subarachnoid hemorrhages, 42% focal strokes, and 12% traumatic brain injuries. Out of 272 admissions, 136 patients were excluded, 78 were eligible, and 33 performed BWS walking. Among non-eligible patients, 36 walked unsuspended upon ventilation weaning, 17 presented too severe impairments. Among the 45 eligible patients who did not receive BWS training, main reasons were workload and weekends (31%), medical barriers (29%), and early ICU discharge (22%). 78 BWS sessions were performed on the 33 beneficiaries (median sessions per patient 2, max 10). Pre-session, most patients had inadequate response to pain, orders, or simple orientation questions. Sitting without support was impossible for 74%. Most pre-post changes in hemodynamic, respiratory, and pain parameters were small, and recovered spontaneously after the session. Eight sessions were interrupted; reasons were pain, fatigue or major imbalance (4), syncope (1), occurrence of stool (2), and battery failure (1). None of these adverse events required medical intervention, patients recovered upon session interruption. Median session duration was 31 min, patients walked on median 17 m. First BWS session occurred on median 3 days after ventilation weaning, and 11 days before patients were able to walk unsuspended.

CONCLUSIONS

Verticalization and walking using a suspension device in patients in neuroICU allows early gait training, despite challenging neurological impairments. It is safe and generally well tolerated.

TRIAL REGISTRATION

ClinicalTrials database (ID: NCT04300491).

Early and intensive Motor Training for people with spinal cord injuries (the SCI-MT Trial): description of the intervention

STUDY DESIGN

Descriptive.

OBJECTIVES

The primary objective is to describe the intervention that will be provided in a large multi-centre randomised controlled trial titled: Early and Intensive Motor Training for people with Spinal Cord Injuries (the SCI-MT Trial). The secondary objective is to describe the strategies that will be used to operationalise and standardise the Motor Training provided to participants while keeping the intervention person-centred.

METHODS

The paper focuses on the rationale and principles of Motor Training for people with spinal cord injuries (SCI). The description of the intervention is based on the Template for Intervention Description and Replication (TIDieR) checklist. Specifically, it addresses the following 6 criteria of the TIDieR checklist: why the effectiveness of Motor Training is being examined; what, how, where and when the Motor Training will be administered; and how much Motor Training will be provided.

RESULTS

A detailed intervention manual has been developed to help standardise the delivery of the intervention.

CONCLUSIONS

This paper describes the details of a complex intervention administered as part of a large randomised controlled trial. It will facilitate the subsequent interpretation of the trial results and enable the intervention to be reproduced in clinical practice and future trials.

Effects of multicomponent exercise on quality of life, depression and anxiety among stroke survivors: A systematic review and meta-analysis

BACKGROUND

Current guidelines stress the importance of exercise, especially multicomponent exercise to older adults with chronic conditions.

AIM

To critically synthesise evidence that evaluates the effects of multicomponent exercise on quality of life, depression and anxiety after stroke.

DESIGN

Systematic review and meta-analysis followed the PRISMA 2020 statement.

METHODS

A systematic search of PubMed, Embase, Web of Science, Cochrane Library, CINAHL and PsycINFO from inception to 12 June 2023 was performed. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2). Meta-analyses were conducted using Review Manager 5.4 and narrative syntheses were adopted whenever meta-analysis was inappropriate. The overall certainty of the evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Of 15,351 records identified, nine were eligible and data were available for seven randomised controlled trials, three of which were identified as having a high risk of bias, one as low risk, and five as having some concerns. Subgroup pooled analyses indicated that multicomponent exercise engaged in longer exercise sessions (>60 min) was effective in improving quality of life immediately post-intervention and through 3-6 months post-intervention. However, multicomponent exercise did not significantly affect depression and anxiety.

CONCLUSIONS

Multicomponent exercise with longer duration of exercise sessions has promising effects on both short- to medium-term quality of life among stroke survivors.

PATIENT OR PUBLIC CONTRIBUTION

This does not apply to our work as it is a review paper.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers could consider encouraging the patients to participate in multicomponent exercise sessions for more than 60 min. It is important to note that stroke survivors should be supervised by trained personnel at the beginning of the training.

REGISTRATION

The protocol was registered on PROSPERO.

Feasibility and outcomes of supplemental gait training by robotic and conventional means in acute stroke rehabilitation

INTRODUCTION

Practicality of implementation and dosing of supplemental gait training in an acute stroke inpatient rehabilitation setting are not well studied but can have positive impact on outcomes.

OBJECTIVES

To determine the feasibility of early, intense supplemental gait training in inpatient stroke rehabilitation, compare functional outcomes and the specific mode of delivery.

DESIGN AND SETTING

Assessor blinded, randomized controlled trial in a tertiary Inpatient Rehabilitation Facility.

PARTICIPANTS

Thirty acute post-stroke patients with unilateral hemiparesis (≥ 18 years of age with a lower limb MAS ≤ 3).

INTERVENTION

Lokomat® or conventional gait training (CGT) in addition to standard mandated therapy time.

MAIN OUTCOME MEASURES

Number of therapy sessions; adverse events; functional independence measure (FIM motor); functional ambulation category (FAC); passive range of motion (PROM); modified Ashworth scale (MAS); 5 times sit-to-stand (5x-STS); 10-m walk test (10MWT); 2-min walk test (2MWT) were assessed before (pre) and after training (post).

RESULTS

The desired supplemental therapy was implemented during normal care delivery hours and the patients generally tolerated the sessions well. Both groups improved markedly on several measures; the CGT group obtained nearly 45% more supplemental sessions (12.8) than the Lokomat® group (8.9). Both groups showed greater FIM improvement scores (discharge - admission) than those from a reference group receiving no supplemental therapy. An overarching statistical comparison between methods was skewed towards a differential benefit (but not significant) in the Lokomat® group with medium effect sizes. By observation, the robotic group completed a greater number of steps, on average. These results provide some evidence for Lokomat® being a more efficient tool for gait retraining by providing a more optimal therapy "dose".

CONCLUSIONS

With careful planning, supplemental therapy was possible with minimal intrusion to schedules and was well tolerated. Participants showed meaningful functional improvement with relatively little supplemental therapy over a relatively short time in study.

Blood pressure trajectory of inpatient stroke rehabilitation patients from the Determining Optimal Post-Stroke Exercise (DOSE) trial over the first 12 months post-stroke

Background

High blood pressure (BP) is the primary risk factor for recurrent strokes. Despite established clinical guidelines, some stroke survivors exhibit uncontrolled BP over the first 12 months post-stroke. Furthermore, research on BP trajectories in stroke survivors admitted to inpatient rehabilitation hospitals is limited. Exercise is recommended to reduce BP after stroke. However, the effect of high repetition gait training at aerobic intensities (>40% heart rate reserve; HRR) during inpatient rehabilitation on BP is unclear. We aimed to determine the effect of an aerobic gait training intervention on BP trajectory over the first 12 months post-stroke.

Methods

This is a secondary analysis of the Determining Optimal Post-Stroke Exercise (DOSE) trial. Participants with stroke admitted to inpatient rehabilitation hospitals were recruited and randomized to usual care (n = 24), DOSE1 (n = 25; >2,000 steps, 40-60% HRR for >30 min/session, 20 sessions over 4 weeks), or DOSE2 (n = 25; additional DOSE1 session/day) groups. Resting BP [systolic (SBP) and diastolic (DBP)] was measured at baseline (inpatient rehabilitation admission), post-intervention (near inpatient discharge), 6- and 12-month post-stroke. Linear mixed-effects models were used to examine the effects of group and time (weeks post-stroke) on SBP, DBP and hypertension (≥140/90 mmHg; ≥130/80 mmHg, if diabetic), controlling for age, stroke type, and baseline history of hypertension.

Results

No effect of intervention group on SBP, DBP, or hypertension was observed. BP increased from baseline to 12-month post-stroke for SBP (from [mean ± standard deviation] 121.8 ± 15.0 to 131.8 ± 17.8 mmHg) and for DBP (74.4 ± 9.8 to 78.5 ± 10.1 mmHg). The proportion of hypertensive participants increased from 20.8% (n = 15/72) to 32.8% (n = 19/58). These increases in BP were statistically significant: an effect [estimation (95%CI), value of p] of time was observed on SBP [0.19 (0.12-0.26) mmHg/week, p < 0.001], DBP [0.09 (0.05-0.14) mmHg/week, p < 0.001], and hypertension [OR (95%CI): 1.03 (1.01-1.05), p = 0.010]. A baseline history of hypertension was associated with higher SBP by 13.45 (8.73-18.17) mmHg, higher DBP by 5.57 (2.02-9.12) mmHg, and 42.22 (6.60-270.08) times the odds of being hypertensive at each timepoint, compared to those without.

Conclusion

Blood pressure increased after inpatient rehabilitation over the first 12 months post-stroke, especially among those with a history of hypertension. The 4-week aerobic gait training intervention did not influence this trajectory.

Early and intensive motor training to enhance neurological recovery in people with spinal cord injury: trial protocol

STUDY DESIGN

Protocol for a multi-centre randomised controlled trial (the SCI-MT trial).

OBJECTIVES

To determine whether 10 weeks of intensive motor training enhances neurological recovery in people with recent spinal cord injury (SCI).

SETTING

Fifteen spinal injury units in Australia, Scotland, England, Italy, Netherlands, Norway, and Belgium.

METHODS

A pragmatic randomised controlled trial will be undertaken. Two hundred and twenty people with recent SCI (onset in the preceding 10 weeks, American Spinal Injuries Association Impairment Scale (AIS) A lesion with motor function more than three levels below the motor level on one or both sides, or an AIS C or D lesion) will be randomised to receive either usual care plus intensive motor training (12 h of motor training per week for 10 weeks) or usual care alone. The primary outcome is neurological recovery at 10 weeks, measured with the Total Motor Score from the International Standards for Neurological Classification of SCI. Secondary outcomes include global measures of motor function, ability to walk, quality of life, participants' perceptions about ability to perform self-selected goals, length of hospital stay and participants' impressions of therapeutic benefit at 10 weeks and 6 months. A cost-effectiveness study and process evaluation will be run alongside the trial. The first participant was randomised in June 2021 and the trial is due for completion in 2025.

CONCLUSIONS

The findings of the SCI-MT Trial will guide recommendations about the type and dose of inpatient therapy that optimises neurological recovery in people with SCI.

TRIAL REGISTRATION

ACTRN12621000091808 (1.2.2021).

TeleRehabilitation with Aims to Improve Lower extremity recovery in community-dwelling individuals who have had a stroke: protocol for a multisite, parallel group, assessor-blinded, randomised attention-controlled trial

INTRODUCTION

Telerehabilitation is an accessible service delivery model that may support innovative lower extremity rehabilitation programmes that extend the stroke recovery continuum into the community. Unfortunately, there is limited evidence on the provision of exercises for lower extremity recovery after stroke delivered using telerehabilitation. In response, we developed the TeleRehabilitation with Aims to Improve Lower extremity recovery poststroke (TRAIL) programme, a 4-week progressive exercise and self-management intervention delivered synchronously using video-conferencing technology. Our primary hypothesis is that individual within 1-year poststroke who participate in TRAIL will experience significantly greater improvements in functional mobility than individuals in an attention-controlled education programme (EDUCATION).

METHODS AND ANALYSIS

In this multisite, parallel group, assessor-blinded randomised attention-controlled trial, 96 community-living stroke survivors within 1-year poststroke will be recruited from five sites (Vancouver, Winnipeg, Toronto, London and Halifax, Canada) from the CanStroke Recovery Trials Platform which is a network of Canadian hospital sites that are affiliated with academic institutions to facilitate participant recruitment and quality trial practices. Participants will be randomised on a 1:1 basis to TRAIL or EDUCATION. Participants randomised to TRAIL will receive eight telerehabilitation sessions where they will perform exercises and receive self-management support to improve lower extremity recovery from a TRAIL physical therapist. The primary outcome will be measured using the Timed Up and Go. Secondary outcomes include lower extremity muscle strength, functional balance, motor impairment, balance self-efficacy, health-related quality of life and health service use for our economic evaluation. Measurements will be taken at baseline, immediately after the intervention, 3-month and 6-month postintervention.

ETHICS AND DISSEMINATION

Ethics approval for this research has been obtained by all participating sites. All study participants will provide their informed consent prior to enrolling them in the study. Findings from this trial will be disseminated in peer-reviewed journals and presentations at international scientific meetings.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, NCT04908241.

Higher intensity walking improves global cognition during inpatient rehabilitation: a secondary analysis of a randomized control trial

Cognitive deficits are common poststroke. Cognitive rehabilitation is typically used to improve cognitive deficits. It is unknown whether higher doses of exercise to promote motor recovery influence cognitive outcomes. Our recent trial, Determining Optimal Post-Stroke Exercise (DOSE), shows more than double the steps and aerobic minutes can be achieved during inpatient rehabilitation versus usual care, and translates to improved long-term walking outcomes. Thus, the secondary analysis aim was to determine the effect of the DOSE protocol on cognitive outcomes over 1-year poststroke. The DOSE protocol progressively increased step number and aerobic minutes during inpatient stroke rehabilitation over 20 sessions. The Montreal Cognitive Assessment (MoCA), Digit Symbol Substitution Test (DSST), and Trail Making Test B were completed at baseline, post-intervention, and 6- and 12-months poststroke, administered using standardized guidelines. Using the DOSE data, we used mixed-effect spline regression to model participants' trajectories of cognitive recovery, controlling for relevant covariates. Participants (Usual Care n = 25, DOSE n = 50) were 56.7(11.7) years old, and 27(10) days post stroke. For the MoCA, there were statistically significant Group × Trajectory(p = 0.019), and Group × ΔTrajectory (p = 0.018) interactions with a substantial clinically meaningful difference, from +5.44 points/month improvement of the DOSE group compared to +1.59 points/month improvement with Usual Care during the 4-week intervention. The DSST and Trails B improved over time but were not different between groups. Taking advantage of this early difference may lend support to continued efforts to increase intensity, during and after discharge from inpatient rehabilitation, to improve cognition. Clinical trial registration: www.clinicaltrials.gov, NCT01915368.

Interventions Using Wearable Activity Trackers to Improve Patient Physical Activity and Other Outcomes in Adults Who Are Hospitalized: A Systematic Review and Meta-analysis

Importance

Low levels of physical activity during hospitalization are thought to contribute to a range of poor outcomes for patients. Using wearable activity trackers during hospitalization may help improve patient activity, sedentary behavior, and other outcomes.

Objective

To evaluate the association of interventions that use wearable activity trackers during hospitalization with patient physical activity, sedentary behavior, clinical outcomes, and hospital efficiency outcomes.

Data Sources

OVID MEDLINE, CINAHL, Embase, EmCare, PEDro, SportDiscuss, and Scopus databases were searched from inception to March 2022. The Cochrane Central Register for Controlled trials, ClinicalTrials.gov, and World Health Organization Clinical Trials Registry were also searched for registered protocols. No language restrictions were imposed.

Study Selection

Randomized clinical trials and nonrandomized clinical trials of interventions that used wearable activity trackers to increase physical activity or reduce sedentary behavior in adults (aged 18 years or older) who were hospitalized were included.

Data Extraction and Synthesis

Study selection, data extraction, and critical appraisal were conducted in duplicate. Data were pooled for meta-analysis using random-effects models. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed.

Main Outcomes and Measures

The primary outcomes were objectively measured physical activity or sedentary behavior. Secondary outcomes included clinical outcomes (eg, physical function, pain, mental health), and hospital efficiency outcomes (eg, length of stay, readmission).

Results

Fifteen studies with a total of 1911 participants were included, representing various surgical cohorts (4 studies), stroke rehabilitation (3 studies), orthopedic rehabilitation (3 studies), mixed rehabilitation (3 studies), and mixed medical (2 studies). All studies were included in meta-analyses. There was a significant association between wearable activity tracker interventions with higher overall physical activity (standardized mean difference, 0.35; 95% CI, 0.15 to 0.54; I2 = 72%; P < .002) and less sedentary behavior (mean difference, -35.46 min/d; 95% CI, -57.43 to -13.48 min/d; I2 = 0; P = .002), and a significant association between wearable activity tracker interventions with improvements in physical function (standardized mean difference, 0.27; 95% CI, 0.08 to 0.46; I2 = 0; P = .006) compared with usual care. There was no significant association between wearable activity tracker interventions with pain, mental health, length of stay, or readmission risk.

Conclusions and Relevance

In this systematic review and meta-analysis, interventions that used wearable activity trackers with patients who are hospitalized were associated with higher physical activity levels, less sedentary behavior, and better physical functioning compared with usual care.

Health-Related Quality of Life and Functional Status Following Intensive Neurorehabilitation in a Patient after Severe Head Injury with Spinal Epidural Hematoma: A Case Report

Spinal epidural hematoma (SEH) is a very rare condition associated with trauma or occurring as a complication of lumbar puncture and can appear spontaneously. It manifests with acute pain and neurological deficits, leading to severe and permanent complications. This study aimed to assess changes in health-related quality of life and functional status following long-term intensive neurorehabilitation in a patient after severe sport-related head injury with a related SEH. The 60-year-old male patient experienced bilateral weakness of lower limbs, loss of sensation, and sphincter dysfunction. A laminectomy was performed, followed by a slight superficial and deep sensation improvement. The patient underwent intensive neurological rehabilitation treatment. The proprioceptive neuromuscular facilitation (PNF) method, PRAGMA device exercises, and water rehabilitation were provided. The study outcomes were assessed using the validated questionaries World Health Organization Quality-of-Life Scale (WHOQOL-BREF) and Health-Related Quality of Life (HRQOL-14) for health-related quality of life as well as the Functional Independence Measure (FIM) and Health Assessment Questionnaire (HAQ) for functional status. A beneficial clinical improvement was observed following the intensive rehabilitation using PNF techniques, training with a PRAGMA device, and water exercises in the case of SEH. The patient's physical condition significantly improved, with an increase in the FIM score from 66 to 122 pts. (by 56 pts.) and in the HAQ score from 43 to 16 pts. (by 27 pts.). Additionally, the QOL level increased after rehabilitation, with an increase in the WHOQOL-BREF from 37 to 74 pts. (by 37 pts.) and a decrease in unhealthy or limited days, as assessed using the HRQOL-14, from 210 to 168 (by 42 days). In conclusion, the improvement in QOL and functional level in the SEH patient were associated with high-intensity rehabilitation, simultaneous integration of three therapeutic modalities, and committed patient cooperation.

Nonpharmacological Treatments for Hospitalized Patients with Stroke: A Nuanced Approach to Prescribing Early Activity

Stroke remains a leading cause of adult disability. To date, hyperacute revascularization procedures reach 5-10% of stroke patients even in high resource health systems. There is a limited time window for brain repair after stroke, and therefore, the activities such as prescribed exercise in the earliest period will likely have long-term significant consequences. Clinicians who provide care for hospitalized stroke patients make treatment decisions specific to activity often without guidelines to direct these prescriptions. This requires a balanced understanding of the available evidence for early post-stroke exercise and physiological principles after stroke that drive the safety of prescribed exercise. Here, we provide a summary of these relevant concepts, identify gaps, and recommend an approach to prescribing safe and meaningful activity for all patients with stroke. The population of thrombectomy-eligible stroke patients can be used as the exemplar for conceptualization.

Stroke Rehabilitation and Motor Recovery

OBJECTIVE

Up to 50% of the nearly 800,000 patients who experience a new or recurrent stroke each year in the United States fail to achieve full independence afterward. More effective approaches to enhance motor recovery following stroke are needed. This article reviews the rehabilitative principles and strategies that can be used to maximize post-stroke recovery.

LATEST DEVELOPMENTS

Evidence dictates that mobilization should not begin prior to 24 hours following stroke, but detailed guidelines beyond this are lacking. Specific classes of potentially detrimental medications should be avoided in the early days poststroke. Patients with stroke who are unable to return home should be referred for evaluation to an inpatient rehabilitation facility. Research suggests that a substantial increase in both the dose and intensity of upper and lower extremity exercise is beneficial. A clinical trial supports vagus nerve stimulation as an adjunct to occupational therapy for motor recovery in the upper extremity. The data remain somewhat mixed as to whether robotics, transcranial magnetic stimulation, functional electrical stimulation, and transcranial direct current stimulation are better than dose-matched traditional exercise. No current drug therapy has been proven to augment exercise poststroke to enhance motor recovery.

ESSENTIAL POINTS

Neurologists will collaborate with rehabilitation professionals for several months following a patient's stroke. Many questions still remain about the ideal exercise regimen to maximize motor recovery in patients poststroke. The next several years will likely bring a host of new research studies exploring the latest strategies to enhance motor recovery using poststroke exercise.

Principles into Practice: An Observational Study of Physiotherapists use of Motor Learning Principles in Stroke Rehabilitation

OBJECTIVE(S)

To describe a) how motor learning principles are applied during post stroke physiotherapy, with a focus on lower limb rehabilitation; and b) the context in which these principles are used, in relation to patient and/or task characteristics.

DESIGN

Direct non-participation observation of routine physiotherapy sessions, with data collected via video recording. A structured analysis matrix and pre-agreed definitions were used to identify, count and record: type of activity; repetitions; instructional and feedback statements (frequency and type); strategies such as observational learning and augmented feedback. Data was visualised using scatter plots, and analysed descriptively.

SETTING

6 UK Stroke Units PARTICIPANTS: 89 therapy sessions were observed, involving 55 clinicians and 57 patients.

RESULTS

Proportion of time spent active within each session ranged from 26% to 98% (mean 85, SD 19). The frequency of task repetition varied widely, with a median of 3.7 repetitions per minute (IQR 2.1-8.6). Coaching statements were common (mean 6.46 per minute), with 52% categorised as instructions, 14% as feedback, and 34% as verbal cues/motivational statements. 13% of instructions and 6% of feedback statements were externally focussed. Examining the use of different coaching behaviours in relation to patient characteristics found no associations. Overall, practice varied widely across the dataset.

CONCLUSIONS

To optimise the potential for motor skill learning, therapists must manipulate features of their coaching language (what they say, how much and when) and practice design (type, number, difficulty and variability of task). There is an opportunity to implement motor learning principles more consistently, to benefit motor skill recovery following stroke.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (NCT03792126). CONTRIBUTION OF THE PAPER.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Correlations between aerobic exercise time during physiotherapy and characteristics of patients with subacute stroke: A pilot cross-sectional study

BACKGROUND

The amount of aerobic exercise time (AET) is an important factor for improving physical function in patients with stroke. However, there is a lack of evidence regarding the factors for AET during physiotherapy, particularly in stroke patients.

OBJECTIVE

To investigate the correlation between AET during physiotherapy and characteristics of patients with subacute stroke.

METHODS

In this cross-sectional study, 61 hospitalized subacute stroke patients (age = 72 (11) years, (median (interquartile range)) were enrolled and their exercise intensity was measured by wearable sensors (Mio Alpha 2) worn during physiotherapy sessions. All patients were divided into two groups, non-ambulatory group (functional ambulation classification (FAC); 0-2) and ambulatory group (FAC; 3-5). The correlations between AET and patient characteristics were assessed in each group.

RESULTS

There was no significant difference in AET between the ambulatory and non-ambulatory groups (9 (12) min vs 5 (10) min, p = .27, respectively). There was a significant correlation between AET and the functional independent measures (FIM) motor score in the ambulatory group (r = 0.52, p = .005), and between AET and the FIM cognitive score in the non-ambulatory group (r = 0.44, p = .008).

CONCLUSION

Correlations between AET and patient characteristics were different according to ambulation capacity in patients with subacute stroke.

Effects of dynamic body weight support on functional independence measures in acute ischemic stroke: a retrospective cohort study

BACKGROUND

Stroke remains a major public health concern in the United States and a leading cause of long-term disability in adults. Dynamic body weight support (DBWS) systems are popular technology available for use in clinical settings such inpatient rehabilitation. However, there remains limited studies in such inpatient settings that compare DBWS to standard of care (SOC) using real world outcome measures. For survivors of acute ischemic stroke, we determine if incorporating a dynamic body weight support (DBWS) system into inpatient therapy offers greater improvement than standard of care (SOC).

METHODS

A retrospective chart review included 52 individuals with an acute ischemic stroke admitted to an inpatient rehabilitation facility. Functional Independence Measure (FIM) data, specifically changes in FIM at discharge, served as the primary outcome measure. Patient cohorts received either therapies per SOC or therapies incorporating DBWS. Regardless of cohort group, all patients underwent therapies for 3 h per day for 5 days a week.

RESULTS

For both groups, a statistically and clinically significant increase in total FIM (P < 0.0001) was observed at discharge compared to at admission. Improvements for the DBWS group were significantly greater than the SOC group as evidenced by higher gains in total FIM (p = 0.04) and this corresponded to a medium effect size (Cohen's d = 0.58). Among FIM subscores, the DBWS group achieved a significant increase in sphincter control while all other subscore changes remained non-significant.

CONCLUSIONS

This preliminary evidence supports the benefit of using DBWS during inpatient rehabilitation in individuals who have experienced an acute ischemic stroke. This may be due to the greater intensity and repetitions of tasks allowed by DBWS. These preliminary findings warrant further investigations on the use of DBWS in inpatient settings.

Optimized Home Rehabilitation Technology Reduces Upper Extremity Impairment Compared to a Conventional Home Exercise Program: A Randomized, Controlled, Single-Blind Trial in Subacute Stroke

BACKGROUND

Upper extremity (UE) stroke rehabilitation requires patients to perform exercises at home, yet patients show limited benefit from paper-based home exercise programs.

OBJECTIVE

To compare the effectiveness of 2 home exercise programs for reducing UE impairment: a paper-based approach and a sensorized exercise system that incorporates recommended design features for home rehabilitation technology.

METHODS

In this single-blind, randomized controlled trial, 27 participants in the subacute phase of stroke were assigned to the sensorized exercise (n = 14) or conventional therapy group (n = 13), though 2 participants in the conventional therapy group were lost to follow-up. Participants were instructed to perform self-guided movement training at home for at least 3 hours/week for 3 consecutive weeks. The sensorized exercise group used FitMi, a computer game with 2 puck-like sensors that encourages movement intensity and auto-progresses users through 40 exercises. The conventional group used a paper book of exercises. The primary outcome measure was the change in Upper Extremity Fugl-Meyer (UEFM) score from baseline to follow-up. Secondary measures included the Modified Ashworth Scale for spasticity (MAS) and the Visual Analog Pain (VAP) scale.

RESULTS

Participants who used FitMi improved by an average of 8.0 ± 4.6 points on the UEFM scale compared to 3.0 ± 6.1 points for the conventional participants, a significant difference (t-test, P = .029). FitMi participants exhibited no significant changes in UE MAS or VAP scores.

CONCLUSIONS

A sensor-based exercise system incorporating a suite of recommended design features significantly and safely reduced UE impairment compared to a paper-based, home exercise program.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03503617.

Feasibility and efficacy of an activity-monitoring approach using pedometer in patients undergoing subacute rehabilitation: A pilot study

Wearable devices for the quantification of walking have recently been adopted for gait rehabilitation. To apply this method in subacute rehabilitation settings, this approach must be effective in these populations and implemented as a feasible method in terms of adherence and safety, especially the risk of falling. This study aimed to investigate the feasibility and efficacy of an activity monitoring approach in subacute rehabilitation using a commercially available pedometer validated with slow walking. This randomized controlled study with blinded assessors recruited 29 patients admitted to a rehabilitation ward. The participants were randomly assigned to either the feedback (intervention) or the no-feedback (control) group. Participants in both groups received at least 120 min of therapy sessions every day for 6 or 7 days per week while wearing pedometers on their unaffected ankles from the day they were permitted to walk independently till discharge. Only participants in the feedback group received weekly encouragement and the next goals. The primary outcome was the change in the 6-minute walking distance (Δ6MD). Feasibility (percentage of pedometer data acquisition days in the total observational period and the number of falls) and other efficacy outcomes (step counts, gait speed, 30-seconds chair stand test, Berg Balance Scale, and Timed Up and Go Test) were also evaluated. Regarding feasibility outcomes, the data acquisition rate was 94.1% and the number of falls during the observation period was one in the feedback group. Regarding efficacy outcomes, Δ6MD was not significantly greater in the feedback group [mean (standard deviation): 79.1 (51.7) m] than in the no-feedback group [86.1 (65.4) m] (p = 0.774) and the other five secondary outcomes showed no between-group difference. Considering the large number of steps per day in both groups [6,912 (4,751) and 5,600 (5,108) steps in the feedback and no-feedback group, respectively], the effect of the intended intervention might have been masked by the effect of simply wearing pedometers in the control group. This study revealed that the activity monitoring approach using an ankle-worn pedometer was practical in terms of adherence and safety. Further clinical trials are required to elucidate ways to effectively use wearable devices in subacute rehabilitation.

Implementation of increased physical therapy intensity for improving walking after stroke: Walk 'n watch protocol for a multisite stepped-wedge cluster-randomized controlled trial

RATIONALE

Clinical practice guidelines support structured, progressive protocols for improving walking after stroke. Yet, practice is slow to change, evidenced by the little amount of walking activity in stroke rehabilitation units. Our recent study (n = 75) found that a structured, progressive protocol integrated with typical daily physical therapy improved walking and quality-of-life measures over usual care. Research therapists progressed the intensity of exercise by using heart rate and step counters worn by the participants with stroke during therapy. To have the greatest impact, our next step is to undertake an implementation trial to change practice across stroke units where we enable the entire unit to use the protocol as part of standard of care.

AIMS

What is the effect of introducing structured, progressive exercise (termed the Walk 'n Watch protocol) to the standard of care on the primary outcome of walking in adult participants with stroke over the hospital inpatient rehabilitation period? Secondary outcomes will be evaluated and include quality of life.

METHODS AND SAMPLE SIZE ESTIMATES

This national, multisite clinical trial will randomize 12 sites using a stepped-wedge design where each site will be randomized to deliver Usual Care initially for 4, 8, 12, or 16 months (three sites for each duration). Then, each site will switch to the Walk 'n Watch phase for the remaining duration of a total 20-month enrolment period. Each participant will be exposed to either Usual Care or Walk 'n Watch. The trial will enroll a total of 195 participants with stroke to achieve a power of 80% with a Type I error rate of 5%, allowing for 20% dropout. Participants will be medically stable adults post-stroke and able to take five steps with a maximum physical assistance from one therapist. The Walk 'n Watch protocol focuses on completing a minimum of 30 min of weight-bearing, walking-related activities (at the physical therapists' discretion) that progressively increase in intensity informed by activity trackers measuring heart rate and step number.

STUDY OUTCOME(S)

The primary outcome will be the change in walking endurance, measured by the 6-Minute Walk Test, from baseline (T1) to 4 weeks (T2). This change will be compared across Usual Care and Walk 'n Watch phases using a linear mixed-effects model. Additional physical, cognitive, and quality of life outcomes will be measured at T1, T2, and 12 months post-stroke (T3) by a blinded assessor.

DISCUSSION

The implementation of stepped-wedge cluster-randomized trial enables the protocol to be tested under real-world conditions, involving all clinicians on the unit. It will result in all sites and all clinicians on the unit to gain expertise in protocol delivery. Hence, a deliberate outcome of the trial is facilitating changes in best practice to improve outcomes for participants with stroke in the trial and for the many participants with stroke admitted after the trial ends.

Daily steps are associated with walking ability in hospitalized patients with sub-acute stroke

Increased physical activity is required in patients with stroke that are hospitalized in the rehabilitation unit. This study investigated the association between the daily number of steps and walking independence in order to determine the cutoff value of daily number of steps that can predict walking independence in hospitalized patients with sub-acute stroke. This cross-sectional observational study included 85 stroke patients admitted to the rehabilitation unit. The average daily number of steps was measured using Fitbit One for 4 days starting at 30 days after stroke onset. 6-min walk test, and Fugl-Meyer assessment of the lower extremities were measured The category of walking independence was classified using the Functional Ambulation Category (FAC). The subjects were divided into two groups according to the FAC score: a walking independence group (FAC ≥ 4) and a walking non-independence group (FAC ≤ 3). Logistic regression analysis was conducted to investigate the association of daily number of steps with walking independence and a receiver operating characteristic curve was used to identify the cutoff value of daily number of steps for predicting walking independence. The daily number of steps (per 1000 steps) was independently associated with walking independence (odds ratio (OR); 2.53, 95% confidence interval (CI); 1.40–5.73, p = 0.009). The cutoff value of daily number of steps for predicting independent walking was 4286 steps (area under the curve = 0.914, sensitivity of 0.731, and specificity of 0.949). The daily number of steps was associated with independent walking in hospitalized patients with sub-acute stroke. The daily number of steps may be a useful target in rehabilitation for patients with sub-acute stroke.

Rate of change in longitudinal EMG indicates time course of an individual's neuromuscular adaptation in resistance-based muscle training

An individual's long-term neuromuscular adaptation can be measured through time-domain analyses of surface electromyograms (EMG) in regular resistance-based training. The perceived changes in recruitment, such as those measured during muscle fatigue, can subsequently prolong the recovery time in rehabilitation applications. Thus, by developing quantifiable methods for measuring neuromuscular adaptation, adjuvant treatments applied during neurorehabilitation can be improved to reduce recovery times and to increase patient quality of care. This study demonstrates a novel time-domain analysis of long-term changes in EMG captured neuromuscular activity that we aim to use to develop a quantified performance metric for muscle-based intervention training and optimization of an individual. We measure EMG of endurance and hypertrophy-based resistance exercises of healthy participants over 100 days to identify trends in long-term neuromuscular adaptation. Particularly, we show that the rate of EMG amplitude increase (motor recruitment) is dependent on the training modality of an individual. Particularly, EMG decreases over time with repetitive training – but the rate of decrease is different in hypertrophy, endurance, and control exercises. We found that the EMG peak contraction decreases across all subjects, on average, by 8.23 dB during hypertrophy exercise and 10.09 dB for endurance exercises over 100 days of training, while control participants showed negligible change. This represents approximately 2 dB difference EMG activity when comparing endurance and hypertrophy exercises, and >8 dB change when comparing to our control cases. As such, we show that the slope of the long-term EMG activity is related to the resistance-based exercise. We believe this can be used to identify person-specific performance metrics, and to create optimized interventions using a measured performance baseline of an individual.

Walk the Talk: Current Evidence for Walking Recovery After Stroke, Future Pathways and a Mission for Research and Clinical Practice

Achieving safe, independent, and efficient walking is a top priority for stroke survivors to enable quality of life and future health. This narrative review explores the state of the science in walking recovery after stroke and potential for development. The importance of targeting walking capacity and performance is explored in relation to individual stroke survivor gait recovery, applying a common language, measurement, classification, prediction, current and future intervention development, and health care delivery. Findings are summarized in a model of current and future stroke walking recovery research and a mission statement is set for researchers and clinicians to drive the field forward to improve the lives of stroke survivors and their carers.

Using Sensor Technology to Measure Gait Capacity and Gait Performance in Rehabilitation Inpatients with Neurological Disorders

The aim of this study was to objectively assess and compare gait capacity and gait performance in rehabilitation inpatients with stroke or incomplete spinal cord injury (iSCI) using inertial measurement units (IMUs). We investigated how gait capacity (what someone can do) is related to gait performance (what someone does). Twenty-two inpatients (11 strokes, 11 iSCI) wore ankle positioned IMUs during the daytime to assess gait. Participants completed two circuits to assess gait capacity. These were videotaped to certify the validity of the IMU algorithm. Regression analyses were used to investigate if gait capacity was associated with gait performance (i.e., walking activity and spontaneous gait characteristics beyond therapy time). The ankle positioned IMUs validly assessed the number of steps, walking time, gait speed, and stride length (r ≥ 0.81). The walking activity was strongly (r ≥ 0.76) related to capacity-based gait speed. Maximum spontaneous gait speed and stride length were similar to gait capacity. However, the average spontaneous gait speed was half the capacity-based gait speed. Gait capacity can validly be assessed using IMUs and is strongly related to gait performance in rehabilitation inpatients with neurological disorders. Measuring gait performance with IMUs provides valuable additional information about walking activity and spontaneous gait characteristics to inform about functional recovery.

PrimSeq: A deep learning-based pipeline to quantitate rehabilitation training

Stroke rehabilitation seeks to accelerate motor recovery by training functional activities, but may have minimal impact because of insufficient training doses. In animals, training hundreds of functional motions in the first weeks after stroke can substantially boost upper extremity recovery. The optimal quantity of functional motions to boost recovery in humans is currently unknown, however, because no practical tools exist to measure them during rehabilitation training. Here, we present PrimSeq, a pipeline to classify and count functional motions trained in stroke rehabilitation. Our approach integrates wearable sensors to capture upper-body motion, a deep learning model to predict motion sequences, and an algorithm to tally motions. The trained model accurately decomposes rehabilitation activities into elemental functional motions, outperforming competitive machine learning methods. PrimSeq furthermore quantifies these motions at a fraction of the time and labor costs of human experts. We demonstrate the capabilities of PrimSeq in previously unseen stroke patients with a range of upper extremity motor impairment. We expect that our methodological advances will support the rigorous measurement required for quantitative dosing trials in stroke rehabilitation.

Stroke commonly damages motor function in the upper extremity (UE), leading to long-term disability and loss of independence in a majority of individuals. Rehabilitation seeks to restore function by training daily activities, which deliver repeated UE functional motions. The optimal number of functional motions necessary to boost recovery is unknown. This gap stems from the lack of measurement tools to feasibly count functional motions. We thus developed the PrimSeq pipeline to enable the accurate and rapid counting of building-block functional motions, called primitives. PrimSeq uses wearable sensors to capture rich motion information from the upper body, and custom-built algorithms to detect and count functional primitives in this motion data. We showed that our deep learning algorithm precisely counts functional primitives performed by stroke patients and outperformed other benchmark algorithms. We also showed patients tolerated the wearable sensors and that the approach is 366 times faster at counting primitives than humans. PrimSeq thus provides a precise and practical means of quantifying functional primitives, which promises to advance stroke research and clinical care and to improve the outcomes of individuals with stroke.

Is robot-assisted gait training intensity a determinant of functional recovery early after stroke? A pragmatic observational study of clinical care

Gait rehabilitation is a critical factor in functional recovery after a stroke. The aim of this pragmatic observational study was to identify the optimal dose and timing of robot-assisted gait training (RAGT) that can lead to a favourable outcome in a sample of subacute stroke survivors. Subacute patients with stroke who underwent a RAGT within a multidisciplinary rehabilitation program were enrolled. A set of clinical (i.e. age, type of stroke and time since stroke) and rehabilitation stay outcomes (length of stay and RAGT number of sessions) were recorded to evaluate their impact on functional outcome measures by functional independence measure (FIM) or functional ambulation category (FAC). We included 236 patients (62.73 ± 11.82 year old); 38.44% were females, and 59.32% were ischaemic stroke patients. Patients that received at least 14 RAGT sessions, had 15.83% more chance to be responders compared to those that receive less sessions (P = 0.006). Similarly, younger patients (≤60 years) were more prone to be responders (+15.1%). Lastly, an early rehabilitation (<6 weeks) was found to be more efficient (+21.09%) in determining responsiveness (P < 0.001). Becoming newly independent for gait, that refers to a FAC score ≥4, was related with age and RAGT sessions (P = 0.001). In conclusion, a younger age (≤60 years), an early rehabilitation (<6 weeks since stroke) and a higher RAGT dose (at least 14 sessions) were related to a favourable outcome in patients with subacute stroke.

Health-Related Quality of Life and Its Related Factors in Survivors of Stroke in Rural China: A Large-Scale Cross-Sectional Study

Background

Stroke is a major health threat and the leading cause of mortality and disability in China. The aims of this study were to identify the possible influencing factors of health-related quality of life (HRQoL) and its domain-specific contents in stroke patients in rural areas in China.

Methods

A total of 1,709 stroke patients aged 36–79 years from the baseline data of Henan Rural Cohort study (n = 39,259) were included in the cross-sectional study. The Chinese version of the European Quality of Life Five Dimension (including mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) Five Level Scale (EQ-5D-5L) and visual analog scale (VAS) were used to evaluate HRQoL in stroke patients. Tobit regression models, generalized linear models and binary logistic regression models were constructed to determine potential influencing factors of the EQ-5D utility index, as well as influencing factors of each domain and VAS score.

Results

The mean utility index and VAS scores of stroke patients were 0.885 (SD, 0.204), and 68.39 (SD, 17.31), respectively. Pain/discomfort (PD, 35.2%) and mobility (MO, 30.4%) were the most frequently reported issues. Regression models revealed that illiterate; a low monthly income; low physical activity intensity; and diabetes, anxiety, depression, or poor sleep quality were significantly associated with lower utility index and VAS scores among stroke patients. In addition, patients with stroke who were older, female, drinking, smoking, and consuming a high-fat diet, had a higher BMI, and lived with a stroke for a longer time, were also significantly associated with different dimensions of the EQ-5D.

Conclusion

Patients with stroke in rural areas in China had a low HRQoL. Factors associated with the EQ-5D utility index as well as each domain and VAS score, need to be considered by health providers in rural areas. Patients with stroke in rural areas need to be included in national basic public medical services and managed systematically by medical institutions.

Leveraging Factors of Self-Efficacy and Motivation to Optimize Stroke Recovery

The International Classification of Functioning, Disability and Health framework recognizes that an individual's functioning post-stroke reflects an interaction between their health condition and contextual factors encompassing personal and environmental factors. Personal factors significantly impact rehabilitation outcomes as they determine how an individual evaluates their situation and copes with their condition in daily life. A key personal factor is self-efficacy-an individual's belief in their capacity to achieve certain outcomes. Self-efficacy influences an individual's motivational state to execute behaviors necessary for achieving desired rehabilitation outcomes. Stroke rehabilitation practice and research now acknowledge self-efficacy and motivation as critical elements in post-stroke recovery, and increasing evidence highlights their contributions to motor (re)learning. Given the informative value of neuroimaging-based biomarkers in stroke, elucidating the neurological underpinnings of self-efficacy and motivation may optimize post-stroke recovery. In this review, we examine the role of self-efficacy and motivation in stroke rehabilitation and recovery, identify potential neural substrates underlying these factors from current neuroimaging literature, and discuss how leveraging these factors and their associated neural substrates has the potential to advance the field of stroke rehabilitation.

Virtual Arm Boot Camp (V-ABC): study protocol for a mixed-methods study to increase upper limb recovery after stroke with an intensive program coupled with a grasp count device

Background

Encouraging upper limb use and increasing intensity of practice in rehabilitation are two important goals for optimizing upper limb recovery post stroke. Feedback from novel wearable sensors may influence practice behaviour to promote achieving these goals. A wearable sensor can potentially be used in conjunction with a virtually monitored home program for greater patient convenience, or due to restrictions that preclude in-person visits, such as COVID-19. This trial aims to (1) determine the efficacy of a virtual behaviour change program that relies on feedback from a custom wearable sensor to increase use and function of the upper limb post stroke; and (2) explore the experiences and perceptions of using a program coupled with wearable sensors to increase arm use from the perspective of people with stroke.

Methods

This mixed-methods study will utilize a prospective controlled trial with random allocation to immediate or 3-week delayed entry to determine the efficacy of a 3-week behaviour change program with a nested qualitative description study. The intervention, the Virtual Arm Boot Camp (V-ABC) features feedback from a wearable device, which is intended to increase upper limb use post stroke, as well as 6 virtual sessions with a therapist. Sixty-four adults within 1-year post stroke onset will be recruited from seven rehabilitation centres. All outcomes will be collected virtually. The primary outcome measure is upper limb use measured by grasp counts over 3 days from the wearable sensor (TENZR) after the 3-week intervention. Secondary outcomes include upper limb function (Arm Capacity and Movement Test) and self-reported function (Hand Function and Strength subscale from the Stroke Impact Scale). Outcome data will be collected at baseline, post-intervention and at 2 months retention. The qualitative component will explore the experiences and acceptability of using a home program with a wearable sensor for increasing arm use from the point of view of individuals with stroke. Semi-structured interviews will be conducted with participants after they have experienced the intervention. Qualitative data will be analysed using content analysis.

Discussion

This study will provide novel information regarding the efficacy and acceptability of virtually delivered programs to improve upper extremity recovery, and the use of wearable sensors to assist with behaviour change.

Trial registration

ClinicalTrials.govNCT04232163. January 18, 2020.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Step Monitor Accuracy During PostStroke Physical Therapy and Simulated Activities

Introduction/Purpose

The amount of stepping activity during rehabilitation post-stroke can predict walking outcomes, although the most accurate methods to evaluate stepping activity are uncertain with conflicting findings on available stepping monitors during walking assessments. Rehabilitation sessions also include non-stepping activities and the ability of activity monitors to differentiate these activities from stepping is unclear. The objective of this study was to examine the accuracy of different activity monitors worn by individuals post-stroke with variable walking speeds during clinical physical therapy (PT) and research interventions focused on walking.

Methods

In Part I, 28 participants post-stroke wore a StepWatch, ActiGraph with and without a Low Frequency Extension (LFE) filter, and Fitbit on paretic and non-paretic distal shanks at or above the ankle during clinical PT or research interventions with steps simultaneously hand counted. Mean absolute percent errors were compared between limbs and tasks performed. In Part II, 12 healthy adults completed 8 walking and 9 non-walking tasks observed during clinical PT or research. Data were descriptively analyzed and used to assist interpretation of Part I results.

Results

Part I results indicate most devices did not demonstrate an optimal limb configuration during research sessions focused on walking, with larger errors during clinical PT on the non-paretic limb. Using the limb that minimized errors for each device, the StepWatch had smaller errors than the ActiGraph and Fitbit (p<0.01), particularly in those who walked < 0.8 m/s. Conversely, errors from the ActiGraph-LFE demonstrated inconsistent differences in step counts between Fitbit and ActiGraph. Part II results indicate that errors observed during different stepping and non-stepping activities were often device-specific, with non-stepping tasks frequently detected as stepping.

Conclusions

The StepWatch and ActiGraph-LFE had smaller errors than the Fitbit or ActiGraph, with greater errors in those walking at slower speeds. Inclusion of non-stepping activities affected step counts and should be considered when measuring stepping activity in individuals post-stroke to predict locomotor outcomes following rehabilitation.

Step Number and Aerobic Minute Exercise Prescription and Progression in Stroke: A Roadmap

Background

While higher therapeutic intensity improves motor recovery after stroke, translating findings from successful studies is challenging without clear exercise intensity targets. We show in the DOSE trial¹ more than double the steps and aerobic minutes within a session can be achieved compared with usual care and translates to improved long-term walking outcomes.

Objective

We modeled data from this successful higher intensity multi-site RCT to develop targets for prescribing and progressing exercise for varying levels of walking impairment after stroke.

Methods

In twenty-five individuals in inpatient rehabilitation, twenty sessions were monitored for a total of 500 one-hour physical therapy sessions. For the 500 sessions, step number and aerobic minute progression were modeled using linear mixed effects regression. Using formulas from the linear mixed effects regression, targets were calculated.

Results

The model for step number included session number and baseline walking speed, and for aerobic minutes, session number and age. For steps, there was an increase of 73 steps per session. With baseline walking speed, for every 0.1 m/s increase, a corresponding increase of 302 steps was predicted. For aerobic minutes, there was an increase of .56 minutes of aerobic activity (ie, 34 seconds) per session. For every year increase in age, a decrease of .39 minutes (ie, 23 seconds) was predicted.

Conclusions

Using data associated with better walking outcomes, we provide step number and aerobic minute targets that future studies can cross-validate. As walking speed and age are collected at admission, these models allow for uptake of routine measurement of therapeutic intensity.

Registration: www.clinicaltrials.gov; NCT01915368.

Effectiveness of Self-Monitoring Approach Using Fitness Trackers to Improve Walking Ability in Rehabilitation Settings: A Systematic Review

Background: A self-monitoring approach utilizing fitness trackers that provide feedback regarding physical activities has been recently applied to rehabilitation patients to promote voluntary walking activities. Although this approach has been proven to increase physical activity, it is uncertain whether the intervention improves walking ability.

Aim: This review investigated whether the additional self-monitoring approach using activity trackers would improve walking ability in any type of rehabilitation setting.

Methods: A systematic search was performed in four databases [PubMed (MEDLINE), The Cochrane Library, SPORTDiscus, and Cumulative Index to Nursing and Allied Health Literature] to identify studies that examined the self-monitoring approach combined with rehabilitative intervention vs. the same rehabilitative intervention only in participants with any unhealthy conditions. Two review authors independently assessed the eligibility of all the retrieved English literature published from 2009 to 2019, then discussed the final inclusion. The risk of bias was assessed referring to the criteria of the Cochrane Risk of Bias tool. The key findings were synthesized using narrative synthesis. In addition, a quantitative synthesis was conducted when more than two studies investigating the same disease were identified.

Results: Eleven randomized controlled trials satisfied the eligibility criteria, nine of which had a lower risk of bias. The types of diseases included stroke, chronic obstructive pulmonary disease (COPD), cancer, Parkinson's disease, hemophilia, peripheral artery disease, post-total knee arthroplasty, and geriatric rehabilitation. Eight studies reported measures of walking endurance and four reported measures of gait speed. In the quantitative synthesis of two studies investigating COPD, there was a significant between-group difference in terms of changes in the 6-min walking distance from the baseline, which was favorable to the additional self-monitoring intervention group (mean difference: 13.1 m; 95% confidence interval, 1.8–24.5; 2 studies, 124 participants; p = 0.02; I² = 0%). Other available data revealed no consistent evidence regarding effectiveness of the intervention.

Conclusions: The findings indicate that there is little evidence suggesting the effectiveness of the self-monitoring approach in improving walking ability in rehabilitation settings. However, a weak recommendation for patients with stable COPD was implicated in the quantitative synthesis. Further research would be required to explore the best indications for this self-monitoring approach.

Systematic Review Registration: CRD 42020157695.

The effect of time spent in rehabilitation on activity limitation and impairment after stroke

BACKGROUND

Stroke affects millions of people every year and is a leading cause of disability, resulting in significant financial cost and reduction in quality of life. Rehabilitation after stroke aims to reduce disability by facilitating recovery of impairment, activity, or participation. One aspect of stroke rehabilitation that may affect outcomes is the amount of time spent in rehabilitation, including minutes provided, frequency (i.e. days per week of rehabilitation), and duration (i.e. time period over which rehabilitation is provided). Effect of time spent in rehabilitation after stroke has been explored extensively in the literature, but findings are inconsistent. Previous systematic reviews with meta-analyses have included studies that differ not only in the amount provided, but also type of rehabilitation.

OBJECTIVES

To assess the effect of 1. more time spent in the same type of rehabilitation on activity measures in people with stroke; 2. difference in total rehabilitation time (in minutes) on recovery of activity in people with stroke; and 3. rehabilitation schedule on activity in terms of: a. average time (minutes) per week undergoing rehabilitation, b. frequency (number of sessions per week) of rehabilitation, and c. total duration of rehabilitation.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, eight other databases, and five trials registers to June 2021. We searched reference lists of identified studies, contacted key authors, and undertook reference searching using Web of Science Cited Reference Search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adults with stroke that compared different amounts of time spent, greater than zero, in rehabilitation (any non-pharmacological, non-surgical intervention aimed to improve activity after stroke). Studies varied only in the amount of time in rehabilitation between experimental and control conditions. Primary outcome was activities of daily living (ADLs); secondary outcomes were activity measures of upper and lower limbs, motor impairment measures of upper and lower limbs, and serious adverse events (SAE)/death.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies, extracted data, assessed methodological quality using the Cochrane RoB 2 tool, and assessed certainty of the evidence using GRADE. For continuous outcomes using different scales, we calculated pooled standardised mean difference (SMDs) and 95% confidence intervals (CIs). We expressed dichotomous outcomes as risk ratios (RR) with 95% CIs.

MAIN RESULTS

The quantitative synthesis of this review comprised 21 parallel RCTs, involving analysed data from 1412 participants.  Time in rehabilitation varied between studies. Minutes provided per week were 90 to 1288. Days per week of rehabilitation were three to seven. Duration of rehabilitation was two weeks to six months. Thirteen studies provided upper limb rehabilitation, five general rehabilitation, two mobilisation training, and one lower limb training. Sixteen studies examined participants in the first six months following stroke; the remaining five included participants more than six months poststroke. Comparison of stroke severity or level of impairment was limited due to variations in measurement. The risk of bias assessment suggests there were issues with the methodological quality of the included studies. There were 76 outcome-level risk of bias assessments: 15 low risk, 37 some concerns, and 24 high risk. When comparing groups that spent more time versus less time in rehabilitation immediately after intervention, we found no difference in rehabilitation for ADL outcomes (SMD 0.13, 95% CI -0.02 to 0.28; P = 0.09; I2 = 7%; 14 studies, 864 participants; very low-certainty evidence), activity measures of the upper limb (SMD 0.09, 95% CI -0.11 to 0.29; P = 0.36; I2 = 0%; 12 studies, 426 participants; very low-certainty evidence), and activity measures of the lower limb (SMD 0.25, 95% CI -0.03 to 0.53; P = 0.08; I2 = 48%; 5 studies, 425 participants; very low-certainty evidence). We found an effect in favour of more time in rehabilitation for motor impairment measures of the upper limb (SMD 0.32, 95% CI 0.06 to 0.58; P = 0.01; I2 = 10%; 9 studies, 287 participants; low-certainty evidence) and of the lower limb (SMD 0.71, 95% CI 0.15 to 1.28; P = 0.01; 1 study, 51 participants; very low-certainty evidence). There were no intervention-related SAEs. More time in rehabilitation did not affect the risk of SAEs/death (RR 1.20, 95% CI 0.51 to 2.85; P = 0.68; I2 = 0%; 2 studies, 379 participants; low-certainty evidence), but few studies measured these outcomes. Predefined subgroup analyses comparing studies with a larger difference of total time spent in rehabilitation between intervention groups to studies with a smaller difference found greater improvements for studies with a larger difference. This was statistically significant for ADL outcomes (P = 0.02) and activity measures of the upper limb (P = 0.04), but not for activity measures of the lower limb (P = 0.41) or motor impairment measures of the upper limb (P = 0.06).

AUTHORS' CONCLUSIONS

An increase in time spent in the same type of rehabilitation after stroke results in little to no difference in meaningful activities such as activities of daily living and activities of the upper and lower limb but a small benefit in measures of motor impairment (low- to very low-certainty evidence for all findings). If the increase in time spent in rehabilitation exceeds a threshold, this may lead to improved outcomes. There is currently insufficient evidence to recommend a minimum beneficial daily amount in clinical practice. The findings of this study are limited by a lack of studies with a significant contrast in amount of additional rehabilitation provided between control and intervention groups. Large, well-designed, high-quality RCTs that measure time spent in all rehabilitation activities (not just interventional) and provide a large contrast (minimum of 1000 minutes) in amount of rehabilitation between groups would provide further evidence for effect of time spent in rehabilitation.

Efficacy of an exoskeleton-based physical therapy program for non-ambulatory patients during subacute stroke rehabilitation: a randomized controlled trial

BACKGROUND

Individuals requiring greater physical assistance to practice walking complete fewer steps in physical therapy during subacute stroke rehabilitation. Powered exoskeletons have been developed to allow repetitious overground gait training for individuals with lower limb weakness. The objective of this study was to determine the efficacy of exoskeleton-based physical therapy training during subacute rehabilitation for walking recovery in non-ambulatory patients with stroke.

METHODS

An assessor-blinded randomized controlled trial was conducted at 3 inpatient rehabilitation hospitals. Patients with subacute stroke (< 3 months) who were unable to walk without substantial assistance (Functional Ambulation Category rating of 0 or 1) were randomly assigned to receive exoskeleton-based or standard physical therapy during rehabilitation, until discharge or a maximum of 8 weeks. The experimental protocol replaced 75% of standard physical therapy sessions with individualized exoskeleton-based sessions to increase standing and stepping repetition, with the possibility of weaning off the device. The primary outcome was walking ability, measured using the Functional Ambulation Category. Secondary outcomes were gait speed, distance walked on the 6-Minute Walk Test, days to achieve unassisted gait, lower extremity motor function (Fugl-Meyer Assessment), Berg Balance Scale, Patient Health Questionnaire, Montreal Cognitive Assessment, and 36-Item Short Form Survey, measured post-intervention and after 6 months.

RESULTS

Thirty-six patients with stroke (mean 39 days post-stroke) were randomized (Exoskeleton = 19, Usual Care = 17). On intention-to-treat analysis, no significant between-group differences were found in the primary or secondary outcomes at post-intervention or after 6 months. Five participants randomized to the Exoskeleton group did not receive the protocol as planned and thus exploratory as-treated and per-protocol analyses were undertaken. The as-treated analysis found that those adhering to exoskeleton-based physical therapy regained independent walking earlier (p = 0.03) and had greater gait speed (p = 0.04) and 6MWT (p = 0.03) at 6 months; however, these differences were not significant in the per-protocol analysis. No serious adverse events were reported.

CONCLUSIONS

This study found that exoskeleton-based physical therapy does not result in greater improvements in walking independence than standard care but can be safely administered at no detriment to patient outcomes. Clinical Trial Registration The Exoskeleton for post-Stroke Recovery of Ambulation (ExStRA) trial was registered at ClinicalTrials.gov (NCT02995265, first registered: December 16, 2016).

Implementing Robotic-Assisted Gait Training in Acute Inpatient Stroke Rehabilitation: A Quality Improvement Initiative

Background

The recovery of independent walking is one of the major goals of stroke rehabilitation; however, due to the current acute inpatient rehabilitation care paradigm, the intensity of walking practice provided has been far below that recommended for motor recovery to occur. A quality improvement initiative was implemented to encourage the physical therapist (PT) to incorporate various robotic gait training devices as part of the standard allotted PT sessions to improve the intensity of gait training.

Materials and Methods

After 6 months, a retrospective review was performed to assess the feasibility of the robotic-assisted gait training (RAGT) intervention in limited-ambulatory stroke patients and determine preliminary efficacy of the RAGT program by analyzing Functional Index Measure (FIM) motor gain and accelerometer-based daily step counts in patients who received the RAGT versus a group treated with conventional therapy.

Results

About 30% of limited-ambulatory patients admitted to the stroke rehabilitation unit received consistent integrated RAGT without safety concerns. Compared to those who received conventional treatment, these patients showed greater mean FIM motor gain (32.30 versus 17.88) at discharge (P < 0.005) and higher number of step counts in PT sessions (P < 0.005). Age, gender, or admission FIM motor were not associated with FIM motor gain.

Conclusions

Across a 6-month initial implementation period, RAGT was feasible and was associated with higher repetition of walking practice and also with improved FIM motor scores in limited-ambulatory individuals in an acute inpatient stroke rehabilitation program. However, the frequency of RAGT and the percentage of patients participating need to further improve. Some strategies to address these concerns were identified.

Development of priorities for a Canadian strategy to advance activity-based therapies after spinal cord injury

Study Design

Participatory design.

Objectives

Activity-based therapies (ABT) have physical and psychosocial benefits for individuals with spinal cord injury (SCI). A Canadian ABT summit was held to: (1) identify methods used in stroke rehabilitation that may be appropriate for SCI; (2) understand the current state of ABT activities in Canada; and (3) identify priorities for ABT research and care for the next five years.

Setting

Stakeholder-engaged meeting at a tertiary rehabilitation hospital.

Methods

Thirty-nine stakeholders, including individuals with SCI, frontline clinicians, healthcare administrators, researchers, funders and health policy experts, attended. Two participants were note-takers. Priority identification occurred through input from stakeholder groups, followed by individual voting. Conventional content analysis was used to synthesize the information in the meeting notes.

Results

The strengths of ABT in stroke rehabilitation included clear and clinically feasible definitions, measurements and interventions, and recognized requirements for implementation (e.g. behavior change, partnerships). Knowledge gaps concerning ABT activities in Canada were identified for acute and community settings, non-traumatic populations, and the interventions, equipment and standardized measures (i.e. upper limb, activity levels) used. Five priorities for ABT across the continuum of care were identified: (1) Identify current ABT activities; (2) Create a network to facilitate dialog; (3) Track engagement in ABT activities; (4) Develop and implement best practice recommendations; and (5) Study optimal timing, methods, and dose of ABT. Working groups were formed to address priorities 1–3.

Conclusions

The priorities will guide SCI research and care activities in Canada over the next five years.

Sponsorship

Praxis Spinal Cord Institute.

Advances in Stroke: Therapies Targeting Stroke Recovery

Stroke recovery therapies promote favorable neural plasticity, both during spontaneous recovery and the chronic phase. Activity-based therapies based on intense practice, some aided by integration of computers and telehealth, have shown promise. These studies emphasize key therapeutic variables such as dose, intensity, and timing. Preclinical drug studies have shown promise, but human translation has been challenged by identifying the target patient subgroup, requirements for concomitant training, and aligning biomarkers with preclinical evidence.