Telerehabilitation Initiated Early in Post-Stroke Recovery: A Feasibility Study

The mechanism of Sangdantongluo granule in treating post-stroke spasticity based on multimodal fMRI combined with TMS: Study protocol

Introduction

Post-stroke spasticity (PSS) is among the prevalent complications of stroke, greatly affecting motor function recovery and reducing patients' quality of life without timely treatment. Sangdantongluo granule, a modern traditional Chinese patent medicine, has significant clinical efficacy in treating PSS. However, the mechanism of Sangdantongluo granule in treating PSS is still unknown. We designed this study to explore the mechanism of Sangdantongluo granule in treating PSS through multimodal functional magnetic resonance imaging (fMRI) combined with transcranial magnetic stimulation (TMS).

Methods and analysis

In a single-center, randomized, double-blind, parallel placebo-controlled study, 60 PSS patients will be recruited in China and randomly assigned to either the experimental or control groups at a ratio of 1:1. For eight weeks, Sangdantongluo granule or placebo will be utilized for intervention. The main outcome is the Modified Ashworth Scale (MAS), the secondary outcome includes the Fugl-Meyer Assessment Scale-upper Extremity (FMA-UE), National Institute of Health Stroke Scale (NIHSS), and Modified Rankin Scale (mRS), the mechanism measure is the changes in cortical excitability and multimodal fMRI at baseline and after eight weeks.

Ethics and dissemination

This study was approved by the Ethics Committee of the Affiliated Hospital of Hunan Academy of Traditional Chinese Medicine (approval number: [202364]).

Clinical trial registration

Chinese Clinical Trial Registry, identifier: ChiCTR2300074793. Registered on 16 August 2023.

Telerehabilitation Following Stroke

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

Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review

BACKGROUND

Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions.

OBJECTIVE

This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT.

METHODS

Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1).

RESULTS

From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality.

CONCLUSIONS

Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation.

Outcome Measures Utilized to Assess the Efficacy of Telerehabilitation for Post-Stroke Rehabilitation: A Scoping Review

INTRODUCTION

Outcome measures using telerehabilitation (TR) in the context of post-stroke rehabilitation are an area of emerging research. The current review assesses the literature related to TR for patients requiring post-stroke rehabilitation. The purpose of this study is to survey the outcome measures used in TR studies and to define which parts of the International Organization of Functioning are measured in trials.

METHODS

TR studies were searched in Cochrane Central Register of Controlled Trials, PubMed, Embase, Scopus, Google Scholar, and Web of Science, The Cochrane Central Register of Controlled Trials (Cochrane Library), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Physiotherapy Evidence Database (PEDro) from 2016 to June 2023. Two reviewers individually assessed the full text. Discrepancies regarding inclusion or exclusion were resolved by an additional reviewer.

RESULTS

A total of 24 studies were included in the current review. The findings were synthesized and presented taking into account their implications within clinical practice, areas of investigation, and strategic implementation.

CONCLUSIONS

The scoping review has recognized a broad range of outcome measures utilized in TR studies, shedding light on gaps in the current literature. Furthermore, this review serves as a valuable resource for researchers and end users (such as clinicians and policymakers), providing insights into the most appropriate outcome measures for TR. There is a lack of studies examining the required follow-up after TR, emphasizing the need for future research in this area.

Advances in Stroke Neurorehabilitation

Stroke is one of the leading causes of disability worldwide despite recent advances in hyperacute interventions to lessen the initial impact of stroke. Stroke recovery therapies are crucial in reducing the long-term disability burden after stroke. Stroke recovery treatment options have rapidly expanded within the last decade, and we are in the dawn of an exciting era of multimodal therapeutic approaches to improve post-stroke recovery. In this narrative review, we highlighted various promising advances in treatment and technologies targeting stroke rehabilitation, including activity-based therapies, non-invasive and minimally invasive brain stimulation techniques, robotics-assisted therapies, brain-computer interfaces, pharmacological treatments, and cognitive therapies. These new therapies are targeted to enhance neural plasticity as well as provide an adequate dose of rehabilitation and improve adherence and participation. Novel activity-based therapies and telerehabilitation are promising tools to improve accessibility and provide adequate dosing. Multidisciplinary treatment models are crucial for post-stroke neurorehabilitation, and further adjuvant treatments with brain stimulation techniques and pharmacological agents should be considered to maximize the recovery. Among many challenges in the field, the heterogeneity of patients included in the study and the mixed methodologies and results across small-scale studies are the cardinal ones. Biomarker-driven individualized approaches will move the field forward, and so will large-scale clinical trials with a well-targeted patient population.

ICTs and interventions in telerehabilitation and their effects on stroke recovery

Telerehabilitation (TR) is a new model to provide rehabilitation services to stroke survivors. It is a promising approach to deliver mainstream interventions for movement, cognitive, speech and language, and other disorders. TR has two major components: information and communication technologies (ICTs) and stroke interventions. ICTs provide a platform on which interventions are delivered and subsequently result in stroke recovery. In this mini-review, we went over features of ICTs that facilitate TR, as well as stroke interventions that can be delivered via TR platforms. Then, we reviewed the effects of TR on various stroke disorders. In most studies, TR is a feasible and effective solution in delivering interventions to patients. It is not inferior to usual care and in-clinic therapy with matching dose and intensity. With new technologies, TR may result in better outcomes than usual care for some disorders. One the other hand, TR also have many limitations that could lead to worse outcomes than traditional rehabilitation. In the end, we discussed major concerns and possible solutions related to TR, and also discussed potential directions for TR development.