Motor rehabilitation after stroke: European Stroke Organisation (ESO) consensus-based definition and guiding framework

Efficacy of robot-assisted gait training on lower extremity function in subacute stroke patients: a systematic review and meta-analysis

BACKGROUND

Robot-Assisted Gait Training (RAGT) is a novel technology widely employed in the field of neurological rehabilitation for patients with subacute stroke. However, the effectiveness of RAGT compared to conventional gait training (CGT) in improving lower extremity function remains a topic of debate. This study aimed to investigate and compare the effects of RAGT and CGT on lower extremity movement in patients with subacute stroke.

METHODS

Comprehensive search was conducted across multiple databases, including PubMed, Web of Science, Cochrane Library, EBSCO, Embase, Scopus, China National Knowledge Infrastructure, Wan Fang, SinoMed and Vip Journal Integration Platform. The database retrieval was performed up until July 9, 2024. Meta-analysis was conducted using RevMan 5.4 software.

RESULTS

A total of 24 RCTs were included in the analysis. The results indicate that, compared with CGT, RAGT led to significant improvements in the Fugl-Meyer Assessment for Lower Extremity [MD = 2.10, 95%CI (0.62, 3.59), P = 0.005], Functional Ambulation Category[MD = 0.44, 95%CI (0.23, 0.65), P < 0.001], Berg Balance Scale [MD = 4.55, 95%CI (3.00, 6.11), P < 0.001], Timed Up and Go test [MD = -4.05, 95%CI (-5.12, -2.98), P < 0.001], and 6-Minute Walk Test [MD = 30.66, 95%CI (22.36, 38.97), P < 0.001] for patients with subacute stroke. However, it did not show a significant effect on the 10-Meter Walk Test [MD = 0.06, 95%CI (-0.01, 0.14), P = 0.08].

CONCLUSIONS

This study provides evidence that RAGT can enhance lower extremity function, balance function, walking ability, and endurance levels compared to CGT. However, the quality of evidence for improvements in gait speed remains low.

Logistic regression analysis and machine learning for predicting post-stroke gait independence: a retrospective study

This study investigated whether machine learning (ML) has better predictive accuracy than logistic regression analysis (LR) for gait independence at discharge in subacute stroke patients (n = 843) who could not walk independently at admission. We developed prediction models using LR and five ML algorithms-specifically, the decision tree (DT), support vector machine, artificial neural network, ensemble learning, and k-nearest neighbor methods. Functional Independence Measure sub-items were used to evaluate the ability to walk independently. Model predictive accuracies were evaluated using areas under receiver operating characteristic curves (AUCs) as well as accuracy, precision, recall, F1 score, and specificity. The AUC for DT (0.812) was significantly lower than those for the other algorithms (p < 0.01); however, the AUC for LR (0.895) did not differ significantly from those for the other models (0.893-0.903). Other performance metrics showed no substantial differences between LR and ML algorithms. In conclusion, the DT algorithm had significantly low predictive accuracy, and LR showed no significant difference in predictive accuracy compared with the other ML algorithms. As its predictive accuracy is similar to that of ML, LR can continue to be used for predicting the prognosis of gait independence, with additional advantages of being easily understandable and manually computable.

Effectiveness of Physiotherapy for Improving Functionality, Participation, and Quality of Life after a Stroke: Study Protocol for a Randomized Controlled Clinical Trial

BACKGROUND

Stroke survivors experience significant alterations in their daily functionality that has a negative impact on their functionality, participation, and quality of life. Person-centered approaches in Physical Therapy interventions that are focused on functional and meaningful goals help to minimize the impact of the alterations. Therefore, the aim of this study is to assess the effectiveness of a Physical Therapy intervention based on a goal-oriented approach with task-specific training for improving functionality, participation, and quality of life for people with Stroke.

METHODS

A single-blinded randomized controlled clinical trial will be developed. Adults over 50 years old diagnosed with Stroke over 6 months will be included in this study. Participants (n = 62) will be randomly allocated into two groups: The experimental group (n = 31) will receive 30 sessions, three per week during 10 weeks, of Physical Therapy sessions of goal-directed and task-specific training. The control group (n = 31) will follow the same intervention intensity of their usual Physical Therapy treatment. The primary outcome variables quality of life (NewsQol), participation (Ox-PAQ), and gait functionality (FAC) and the secondary outcome variables functional disability (BI), postural control (PASS), dynamic trunk balance (TIS), and functional goals (GAS) will be measured at baseline, after group interventions (10 weeks), and 6 months after the baseline. Statistical analyses will include repeated-measures ANOVA, Student's t-test, or the Mann-Whitney U-test, with a 95% confidence interval and significance level of p < 0.05.

CONCLUSION

Person-centered approaches in Physical Therapy interventions may yield better outcomes in functionality, participation, and quality of life for Stroke patients compared to standardized interventions.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06165666 (December 2023).

Performance of a prediction method for activities of daily living scores using influence coefficients in patients with stroke

Introduction

Recently, a method was developed to predict the motor Functional Independence Measure (FIM) score at discharge in patients with stroke by stratifying the effects of factors such as age and cognitive function and multiplying those by the influence coefficients of these factors. However, an evaluation of the predictive performance of the method is required for clinical application. The present study aimed to evaluate the predictive performance of this prediction method.

Methods

Patients with stroke discharged from a rehabilitation ward between April 2021 and September 2022 were included. Predicted values of the motor FIM score at discharge were calculated after data collection from the hospital's patient database. The concordance between predicted and actual values was evaluated using the interclass correlation coefficient; moreover, the residual values were calculated.

Results

In total, 207 patients were included in the analysis. The median age was 79 (69-85) years, and 112 (54.1%) patients were male. The interclass correlation coefficient between predicted and actual values was 0.84 (95% confidence interval 0.75-0.89) for the motor FIM score at discharge. Meanwhile, the median residual value was 5.3 (-2.0-10.3) for the motor FIM score at discharge.

Discussion

The prediction method was validated with good performance. However, the residual values indicated that some cases deviated from the prediction. In future studies, it will be necessary to improve the predictive performance of the method by clarifying the characteristics of cases that deviate from the prediction.

The association between dexterity and upper limb impairment during stroke recovery

Introduction

Stroke-induced upper limb disabilities can be characterized by both motor impairments and activity limitations, commonly assessed using Fugl-Meyer Motor Assessment for Upper Extremity (FMMA-UE) and Action Research Arm Test (ARAT), respectively. The relationship between the two assessments during recovery is largely unstudied. Expectedly they diverge over time when recovery of impairment (restitution) plateaus, but compensation-driven improvements still occur. The objective of this study is to evaluate the alignment between FMMA-UE and ARAT in defining upper limb functional recovery categories by ARAT scores. We aimed to establish cut-off scores for both measures from the acute/early subacute, subacute and chronic stages of stroke recovery.

Methods

Secondary analysis of four prospective cohort studies (acute/early subacute: n = 133, subacute: n = 113, chronic: n = 92) stages post-stroke. Receiver operating characteristic curves calculated the area under the curve (AUC) to establish optimal FMMA-UE cut-offs based on predefined ARAT thresholds distinguishing five activity levels from no activity to full activity. Weighted kappa was used to determine agreement between the two assessments. We used minimally clinically important difference (MCID) and minimal detectable change (MDC95) for comparison.

Results

FMMA-UE and ARAT scores showed no relevant divergence across all recovery stages. Results indicated similar cut-off scores in all recovery stages with variability below MCID and MDC95 levels. Cut-off scores demonstrated robust AUC values from 0.77 to 0.86 at every recovery stage. Only in highly functional patients at the chronic stage, we found a reduced specificity of 0.55. At all other times sensitivity ranged between 0.68 and 0.99 and specificity between 0.71 and 0.99. Weighted kappa at the acute/early subacute, subacute and chronic stages was 0.76, 0.83, and 0.81, respectively.

Discussion

Our research shows a strong alignment between FMMA-UE and ARAT cut-off scores throughout stroke recovery, except among the subgroup of highly recovered patients at the chronic stage. Discrepancies in specificity potentially stem from fine motor deficits affecting dexterity outcomes that are not captured by FMMA-UE. Additionally, the high congruence of both measures suggests they are not suited to distinguish between restitution and compensation. Calling for more comprehensive assessment methods to better understand upper limb functionality in rehabilitation.

'There are things I have learned the hard way' Patient experiences on lasting challenges 4 months after Transient Ischemic Attack: A qualitative study

BACKGROUND

Fatigue, depression, anxiety and cognitive difficulties are reported by 1/3 of patients following transient ischemic attack (TIA).

AIMS

To explore the timeline and how the diagnosis impacts individuals experiencing lasting challenges after TIA. Furthermore, to identify what they believed facilitated return to everyday life.

DESIGN

Qualitative exploratory study with a phenomenological-hermeneutic approach.

METHODS

Individual semi-structured interviews and thematic analysis.

RESULTS

Fifteen patients were included. Four themes were identified; (1) 'They say it is transient - no, not for me' where all participants described lasting challenges emphasizing invalidating fatigue and impaired social participation, (2) 'I am a changed person; how does this impact my future?' which reflects altered identity and elevated alertness to symptoms, (3) 'Time has been my ally and new perspectives have evolved' where most participants described improvement over time and a few considered the diagnosis a wake-up call to change lifestyle. Lastly (4) 'What would have helped me recover?' which unfolds that close, trustful relations influence positively. In addition, the system often failed to support. Participants described pressure to return to work and lack of trust and negative experiences when involving their general practitioner.

CONCLUSIONS

During the 4 months since diagnosis, participants experienced limitations impacting physical, psychological and social domains. They felt uninformed that lasting challenges could affect them. Different coping strategies were activated, and participants with close, supportive relations managed better. A pressure to return to work and a lack of trust in the general practitioner affected their recovery negatively. Overall, return to everyday life after TIA was considered stressful and appropriate support lacking.

RELEVANCE TO CLINICAL PRACTICE

To be able to support patients with challenges following TIA, we as healthcare professionals need to understand the identified impact and life changing circumstances. Currently the system seemingly is not able to provide timely, sufficient and competent support.

IMPACT (ADDRESSING)

WHAT PROBLEM DID THE STUDY ADDRESS?: We know from the literature that up to 1/3 of patients following transient ischemic attack experience lasting challenges measured on a variety of questionnaires. This is paradoxical to a diagnosis defined by focal neurological symptoms that resolve within 24 h. It is unknown how patients with lasting challenges experience the timeline from diagnosis and until 4 months after, how the diagnosis impacts the lives of these individuals, and what they believe as beneficial in returning to their everyday life. WHAT WERE THE MAIN FINDINGS?: These participants with self-reported lasting challenges experienced substantial impacts on physical, psychological and social domains. Further, they felt alone with their struggles and when in need of support from the healthcare system, it failed to provide this. A pressure to return to work and a lack of trust in the general practitioner affected return to everyday life negatively, whereas close and supportive relations facilitated positively. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: This study will have an impact on the healthcare professionals that provide support and the (limited) follow-up services to patients after TIA. These healthcare professionals are often specialized nurses who need to know what these patients experience and need in order to act upon their struggles and provide timely support.

REPORTING METHOD

The Standards of Reporting Qualitative Research (SRQR).

PATIENT OR PUBLIC CONTRIBUTION

Patients with TIA was involved in planning this study. They participated in a panel to plan a prospective observational cohort study and emphasized the importance of exploring the subjective perspectives of impact and prognosis for those patients struggling in a longer term (through qualitative interviews).

Impact of the COVID-19 Pandemic on Acute Stroke Rehabilitation in Japanese Primary Stroke Centers: A Nationwide Cross-Sectional Study Using a Web-Based Questionnaire Survey

INTRODUCTION

Acute stroke rehabilitation is crucial for achieving good functional recovery, even during the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to clarify the impact of the COVID-19 pandemic on acute stroke rehabilitation and identify which components in the acute stroke rehabilitation provision system were susceptible to the pandemic.

METHODS

A web-based questionnaire survey was conducted in all primary stroke centers (PSCs) in Japan between February 7 and April 21, 2022. The survey included questions about the current status of acute stroke rehabilitation and the influence of the pandemic. We classified the influences and investigated the relationship between the influence of the pandemic and the provision of rehabilitation. Additionally, we investigated a group of prefectures divided according to the grade of the pandemic.

RESULTS

The survey response rate was 67% (639 of 959 PSCs). Among them, 387 PSCs (61%) reported that the COVID-19 pandemic affected acute stroke rehabilitation. In PSCs affected by the pandemic, more rehabilitation-related staff were working, and the proportion of weekend/holiday rehabilitation implementation was higher compared to those unaffected. In PSCs from highly infected prefectures, no significant relationship was observed between the influence of the pandemic and the rehabilitation provision system.

CONCLUSIONS

PSCs that provide denser acute stroke rehabilitation may be affected to a greater extent by the pandemic. We conclude that stroke hospitals should formulate infection control procedures for acute stroke rehabilitation in advance, depending on the conditions of the region and facility.

Recommendations for Upper Limb Motor Recovery: An Overview of the UK and European Rehabilitation after Stroke Guidelines (2023)

Upper limb impairment is common after stroke, with a significant impact on the stroke survivor's function, social participation and quality of life. Clinical guidelines are needed to inform clinical practise, tailor interventions to improve outcomes and address unresolved research questions. This review contributes to the evidence guiding clinical practise for upper limb motor recovery after stroke by summarising the recommendations from the UK rehabilitation guidelines (National Institute for Health and Care Excellence (NICE) and the Intercollegiate Stroke Working Party (ISWP)) and the European Stroke Organisation (ESO) guidelines, all published in 2023. All three guidelines target researchers, clinical practitioners, stroke survivors and their social networks. An important feature in all three guidelines was therapeutic intensity, with all guidelines recommending increased therapeutic intensity. Unlike the ESO, the NICE and ISWP additionally include specific research recommendations. While the NICE guidelines seem more holistic and target a wider audience, the three guidelines are complimentary. We recommend that a future consensus statement should be developed in partnership between all three organisations, agreeing on scope and using the same terminology, on recommendations to improve stroke rehabilitation in the UK and Europe.

Technology Use for Home-Based Stroke Rehabilitation in Switzerland From the Perspectives of Persons Living With Stroke, Informal Caregivers, and Therapists: Qualitative Interview and Focus Group Study

BACKGROUND

Stroke is a leading cause for long-term disability, requiring both inpatient and outpatient rehabilitation and self-training in the home environment. Technology-based tools are gradually gaining acceptance as additional and suitable options for extending the rehabilitation process. While the experiences of persons living with stroke, therapists, and informal caregivers with respect to technology use have already been investigated in other countries, this topic is underexplored in the Swiss context.

OBJECTIVE

We aimed to explore the experiences and needs of persons living with stroke, informal caregivers, and therapists in using technology-based tools in a home environment for stroke rehabilitation in Switzerland.

METHODS

This study followed a qualitative descriptive methodology, including semistructured interviews and focus group discussions. We applied a deductive template analysis alongside the accessibility, adaptability, accountability, and engagement framework to analyze the qualitative data sets for technology-assisted solutions for poststroke rehabilitation.

RESULTS

We collected the experiences and needs of persons living with stroke (7/23, 30%), informal caregivers (4/23, 17%), and therapists (occupational and physical therapists; 12/23, 52%). The 4 categories we used to organize the analysis and results were accessibility to quality rehabilitation, adaptability to patient differences, accountability or compliance with rehabilitation, and engagement with rehabilitation. Persons living with stroke stated that they use various tools within their rehabilitation process depending on their specific needs. They felt that there is a plethora of tools available but sometimes felt overwhelmed with the selection process. Informal caregivers indicated that they generally felt underserved and insufficiently informed throughout the rehabilitation process. They reported that they use technology-based tools to support their relatives affected by stroke in becoming more independent. Therapists appreciate the numerous possible applications of technology-based tools in rehabilitation. At the same time, however, they express dissatisfaction with the lack of clarity in Switzerland regarding cost coverage, recommendations, and training opportunities.

CONCLUSIONS

Persons living with stroke, informal caregivers, and therapists in Switzerland reported varied and unique experiences and needs with the use of technology-based tools in outpatient stroke rehabilitation. Written recommendations, the assumption of financial costs, and the provision of information and education could foster increased confidence in the use of technology-based tools for patients and therapists.

Biomechanical Assessment Methods Used in Chronic Stroke: A Scoping Review of Non-Linear Approaches

Non-linear and dynamic systems analysis of human movement has recently become increasingly widespread with the intention of better reflecting how complexity affects the adaptability of motor systems, especially after a stroke. The main objective of this scoping review was to summarize the non-linear measures used in the analysis of kinetic, kinematic, and EMG data of human movement after stroke. PRISMA-ScR guidelines were followed, establishing the eligibility criteria, the population, the concept, and the contextual framework. The examined studies were published between 1 January 2013 and 12 April 2023, in English or Portuguese, and were indexed in the databases selected for this research: PubMed®, Web of Science®, Institute of Electrical and Electronics Engineers®, Science Direct® and Google Scholar®. In total, 14 of the 763 articles met the inclusion criteria. The non-linear measures identified included entropy (n = 11), fractal analysis (n = 1), the short-term local divergence exponent (n = 1), the maximum Floquet multiplier (n = 1), and the Lyapunov exponent (n = 1). These studies focused on different motor tasks: reaching to grasp (n = 2), reaching to point (n = 1), arm tracking (n = 2), elbow flexion (n = 5), elbow extension (n = 1), wrist and finger extension upward (lifting) (n = 1), knee extension (n = 1), and walking (n = 4). When studying the complexity of human movement in chronic post-stroke adults, entropy measures, particularly sample entropy, were preferred. Kinematic assessment was mainly performed using motion capture systems, with a focus on joint angles of the upper limbs.

The effects of cycling on walking outcomes in adults with stroke: a systematic review

BACKGROUND

Stationary cycling is often prescribed for survivors of stroke as a safe means of aerobic exercise to improve cardiovascular health. While cycling is typically not prescribed to restore ambulatory function, improvements in measures of walking after cycling interventions have been reported in the literature.

OBJECTIVE

To investigate the effects of cycling on walking outcomes in adults with stroke.

METHODS

Relevant databases were searched through 15 August. Walking-related outcomes were extracted. Correlation coefficients were computed to measure the relationship between exercise protocol parameters and change in walking outcomes.

RESULTS

Eleven articles were included in the review. Eight studies representing nine cycling intervention groups reported change in walking capacity measured by the six-minute walk test with improvements ranging from 6.1 to 63.0 m. Seven studies measured gait velocity, reporting improvements ranging from 0.01 to 0.21 m/sec. Protocols that yielded the greatest improvement in walking capacity prescribed moderate- to high-intensity aerobic training. Significant positive correlations were measured between change in gait velocity and number of exercise sessions and total minutes of exercise prescribed.

CONCLUSION

Considerable heterogeneity was observed across cycling protocols with respect to intensity, frequency, exercise duration and protocol duration. However, none of the studies reported declines in walking outcomes and improvements were measured in the absence of task-specific gait training. Cycling interventions employing moderate- to high-intensity aerobic training and 24 sessions or more may be optimal in improving gait velocity and walking capacity.

Upper limb movement quality measures: comparing IMUs and optical motion capture in stroke patients performing a drinking task

Introduction

Clinical assessment of upper limb sensorimotor function post-stroke is often constrained by low sensitivity and limited information on movement quality. To address this gap, recent studies proposed a standardized instrumented drinking task, as a representative daily activity combining different components of functional arm use. Although kinematic movement quality measures for this task are well-established, and optical motion capture (OMC) has proven effective in their measurement, its clinical application remains limited. Inertial Measurement Units (IMUs) emerge as a promising low-cost and user-friendly alternative, yet their validity and clinical relevance compared to the gold standard OMC need investigation.

Method

In this study, we conducted a measurement system comparison between IMUs and OMC, analyzing 15 established movement quality measures in 15 mild and moderate stroke patients performing the drinking task, using five IMUs placed on each wrist, upper arm, and trunk.

Results

Our findings revealed strong agreement between the systems, with 12 out of 15 measures demonstrating clinical applicability, evidenced by Limits of Agreement (LoA) below the Minimum Clinically Important Differences (MCID) for each measure.

Discussion

These results are promising, suggesting the clinical applicability of IMUs in quantifying movement quality for mildly and moderately impaired stroke patients performing the drinking task.

Telerehabilitation for Stroke: A Personalized Multi-Domain Approach in a Pilot Study

Stroke, a leading cause of long-term disability worldwide, manifests as motor, speech language, and cognitive impairments, necessitating customized rehabilitation strategies. In this context, telerehabilitation (TR) strategies have emerged as promising solutions. In a multi-center longitudinal pilot study, we explored the effects of a multi-domain TR program, comprising physiotherapy, speech therapy, and neuropsychological treatments. In total, 84 stroke survivors (74 analyzed) received 20 tailored sessions per domain, addressing individual impairments and customized to their specific needs. Positive correlations were found between initial motor function, cognitive status, independence in activities of daily living (ADLs), and motor function improvement after TR. A lower initial health-related quality of life (HRQoL) perception hindered progress, but improved ADL independence and overall health status, and reduced depression correlated with a better QoL. Furthermore, post-treatment improvements were observed in the entire sample in terms of fine motor skills, upper-limb functionality, balance, independence, and cognitive impairment. This multi-modal approach shows promise in enhancing stroke rehabilitation and highlights the potential of TR in addressing the complex needs of stroke survivors through a comprehensive support and interdisciplinary collaboration, personalized for each individual's needs.