Development and Feasibility Testing of Video Home Based Telerehabilitation for Stroke Survivors in Resource Limited Settings

Comparison of three kinematic gait event detection methods during overground and treadmill walking for individuals post stroke

In the United States, the incidence rate of new or recurrent stroke is approximately 795 000 per year, and stroke prevalence for individuals over the age of 20 years is estimated at 6.5 million.1 Mortality rates in the first 30 days after stroke have decreased because of advances in emergency medicine and acute stroke care. In addition, there is strong evidence that organized postacute, inpatient stroke care delivered within the first 4 weeks by an interdisciplinary healthcare team results in an absolute reduction in the number of deaths.2,3 Despite these positive achievements, stroke continues to represent the leading cause of long-term disability in Americans: An estimated 50 million stroke survivors worldwide currently cope with significant physical, cognitive, and emotional deficits, and 25% to 74% of these survivors require some assistance or are fully dependent on caregivers for activities of daily living (ADLs).4,5 Notwithstanding the substantial progress in acute stroke care over the past 15 years, the focus of stroke medical advances and healthcare resources has been on acute and subacute recovery phases, which has resulted in substantial health disparities in later phases of stroke care. Additionally, healthcare providers (HCPs) are often unaware of not only patients’ potential for improvement during more chronic recovery phases but also common issues that stroke survivors and their caregivers experience. Furthermore, even with evidence that documents neuroplasticity potential regardless of age and time after stroke,6 the mean lifetime cost of ischemic stroke (which accounts for 87% of all strokes) in the United States is an estimated $140 000 (for inpatient, rehabilitation, and follow-up costs), with 70% of first-year stroke costs attributed to acute inpatient hospital care1; therefore, fewer financial resources appear to be dedicated to providing optimal care during the later phases of stroke recovery. Because there remains a …

How to Address Physical Activity Participation After Stroke in Research and Clinical Practice.

Background: Physical activity is an effective modifiable behavior for preventing recurrent strokes. This study aims to determine the adherence to physical activity recommendations among stroke survivors in the United States. We further compared our findings with the adherence observed among myocardial infarction (MI) survivors. Methods: We utilized data from the 2011-2019 Behavioral Risk Factor Surveillance System, a nationally representative survey. To establish benchmarks, we referenced the physical activity recommendations outlined in 2011, 2014, and 2021 American Heart Association stroke prevention guidelines. Adherence to recommendations was determined by the respondents' self-reported intensity, duration, and frequency of physical activity. Multivariate logistic regression was used to compare adherence in stroke survivors, MI survivors, and healthy adults. Results: Among 48,222 stroke survivors in the United States, the overall adherence rates to 2011, 2014, and 2021 physical activity guidelines were 75.4%, 40.2%, and 69.2%. For independently mobile stroke survivors, the adherence rates increased to 78.1%, 42.1%, and 69.9%. When 2021 recommendations were used as a benchmark, older (≥65) stroke survivors were more likely to adhere to recommendations than younger survivors (71.9%vs.62.3%; p<0.0001). However, when the benchmark was changed to the 2011 and 2014 guidelines, which recommended longer exercise durations, the difference between younger and older stroke survivors dissipated. After adjusting for sociodemographic factors and comorbidities, non-Hispanic Black survivors were less likely to adhere to recommendations (aOR,0.81[95%CI,0.7–0.94]), whereas older and higher educated stroke survivors were more likely to adhere to recommendations. Geographically, stroke belt and non-rural residents were less likely to adhere to recommendations [(63.5%vs.67.9%;p<0.0001), (53.8%vs.58.7%;p<0.0001)]. Stroke and MI survivors were less likely to adhere to the latest recommendations than healthy adults (aOR,0.74[95%CI,0.69-0.8], (aOR,0.24[95%CI,0.22-0.26])). Conclusion: A substantial number of stroke survivors do not meet physical activity recommendations. Tailored interventions should be designed for at-risk populations, e.g., non-Hispanic Black survivors and lower educated stroke survivors.

Physical activity is an effective modifiable behavior for preventing recurrent strokes. This study aims to determine the adherence to physical activity recommendations among stroke survivors in the United States. We further compared our findings with the adherence observed among myocardial infarction (MI) survivors and healthy adults, each assessed against distinct physical activity guidelines specific to their respective populations. We utilized data from the 2011 to 2019 Behavioral Risk Factor Surveillance System, a nationally representative survey. To establish benchmarks for stroke survivors, we referenced 3 different physical activity recommendations outlined in 2011, 2014, and 2021 American Heart Association stroke prevention guidelines. Similarly, for MI survivors and healthy adults, we used the 2011 guidelines for secondary prevention of coronary vascular diseases and the 2020 World Health Organization physical activity guidelines, respectively. Adherence to recommendations was determined by the respondents' self-reported intensity, duration, and frequency of physical activity. Multivariate logistic regression compared adherence in stroke survivors, MI survivors, and healthy adults. Among 48 222 stroke survivors in the United States, the overall adherence rates to 2011, 2014, and 2021 physical activity guidelines were 75.4%, 40.2%, and 69.2%. For independently mobile stroke survivors, the adherence rates increased to 78.1%, 42.1%, and 69.9%. Among MI survivors and healthy adults, the adherence rates were 42.7% and 72%. When 2021 recommendations were used as a benchmark, older (aged ≥65 years) stroke survivors were more likely to adhere to recommendations than younger survivors (71.9% versus 62.3%; P<0.0001). After adjusting for sociodemographic factors and comorbidities, non-Hispanic Black survivors were less likely to adhere to recommendations (adjusted odds ratio, 0.81 [95% CI, 0.7-0.94]), whereas older and higher educated stroke survivors were more likely to adhere to recommendations. Geographically, stroke belt and nonrural residents were less likely to adhere to recommendations ([63.5% versus 67.9%; P<0.0001]; [53.8% versus 58.7%; P<0.0001]). Stroke and MI survivors were less likely to adhere to the latest recommendations than healthy adults (adjusted odds ratio, 0.74 [95% CI, 0.69-0.8]; (adjusted odds ratio, 0.24 [95% CI, 0.22-0.26]). A substantial number of stroke survivors do not meet physical activity recommendations. Tailored interventions should be designed for at-risk populations, for example, non-Hispanic Black survivors and lower educated stroke survivors.

Young Stroke: Resources for Patients, Their Families, and Caregivers for Long-Term Community Living

Clinician's commentary.

Aim: To assess the feasibility of video game-based trunk exercises using the Valedo® system in a chronic stroke population. Method: Ten chronic stroke survivors (eight males and two females, mean age 63 ± 15 years) were asked to complete 18 intervention sessions, each lasting 45 min., over 6-8 weeks. Feasibility was evaluated quantitatively using the Psychosocial Impact of Assistive Devices Scale (PIADS) as well as through recruitment, retention, adherence, and safety measures. Qualitative data on feasibility were collected through post-intervention semi-structured interviews. Descriptive analysis was used to summarize participant characteristics, recruitment, retention, and adherence. Qualitative data were analyzed using thematic analysis of the interviews. Results: Twelve stroke survivors were recruited from Southampton (United Kingdom) and Riyadh (Kingdom of Saudi Arabia), with two participants dropping out after the baseline assessment session. The remaining ten participants completed the study with a mean adherence of 96.11% to the planned sessions. No serious adverse effects were reported, however, four participants did experience trunk muscle tightness and fatigue. Post-intervention interviews revealed that participants encountered some physical and cognitive challenges while playing the Valedo video games. However, they felt that the implementation of trunk exercises using video games was safe, as the exercises were performed in a secure environment and in safe positions. Conclusions: The findings suggest that the Valedo system is feasible for delivering trunk exercises to chronic stroke survivors. Several factors should be considered when implementing this type of intervention in the future.

Background Cognitive rehabilitation (CR) is an important component of stroke rehabilitation. Most of the strategies used for this purpose are not readily affordable. This is the protocol of a trial to investigate the effects of over-ground walking (OGW) exercise and CR on cognitive function among stroke survivors. Methods This is a three-centre, single blind, randomised controlled trial (RCT). Fifty-seven stroke survivors with mild to moderate cognitive impairments will be recruited from three healthcare facilities and randomly assigned into three groups. Group A will receive moderate intensity OGW exercise. Group B will receive CR using an adapted cognitive intervention comprising an attention and a memory tasks. Group C will receive combine OGW and CR exercise. All interventions will be thrice weekly for 8 weeks. Outcomes to be assessed at baseline, 4th and 8th week of interventions are cognition, brain-derived neurotrophic factor (BDNF), quality of life and participation using Mini-Mental State Examination, Melsin brand ELISA kit, stroke-specific quality of life and London Handicap Scale, respectively. Friedman and Kruskal–Wallis tests will be used for within-group and between-group comparison of data. Discussion This trial is the first to examine the effect of OGW exercise on cognition and BDNF among stroke survivors.

There is evidence of a positive correlation between depressive disorders and poor cardiovascular health (CVH). Recently, the inclusion of psychological health assessments into Life's Essential 8 (LE8) has been put forward to enhance the foundation of CVH. We aimed to investigate the probable link between the innovative CVH assessment framework, Life's Crucial 9 (LC9), and overall mortality as well as mortality associated with cardiovascular disease (CVD) among stroke survivors, while also assessing its prognostic relevance regarding mortality in comparison to LE8. This study draws on a cohort of stroke survivors identified from the National Health and Nutrition Examination Survey (NHANES), spanning survey cycles from 2005 to 2018. The LE8 was assessed by the approach recommended by the American Heart Association. The LC9 framework incorporated an additional depression score, measured by Patient Health Questionnaire-9, into the LE8 assessment. To investigate the associations between LE8 and LC9 with all-cause and cardiovascular mortality in stroke survivors, we employed multivariable Cox proportional hazards regression analyses. After adjusting for covariates, each 10-point increase in LC9 was associated with a 24.5 and 30.1% reduction in all-cause and CVD mortality in stroke survivors, respectively. Participants in the highest quartile (Q4) of LC9 exhibited significantly lower mortality rates compared to those in the lowest quartile (Q1) (all-cause mortality: HR 0.412, p < 0.0001; CVD mortality: HR 0.327, p < 0.001). Similar associations were observed for LE8. Restricted cubic spline analysis indicated that both LC9 and LE8 demonstrated linearly associations with mortality post-stroke. Physical activity score, nicotine exposure score, and blood glucose score were significantly linked to all-cause and CVD mortality in stroke survivors. Adding depression score to LE8 significantly enhanced the prediction of all-cause mortality in stroke survivors (net reclassification improvement index = 9.6%, p = 0.033; ΔC index = 0.002, p = 0.0009; integrated discrimination improvement = 0.01, p = 0.007). The NRI of 9% (p = 0.086) for CVD mortality, while not statistically significant, suggests a trend toward improved classification. LC9 exhibited both linear and inverse correlations with all-cause and cardiovascular mortality among stroke survivors. Adding a depression score to the LE8 framework may improve the predictive accuracy for all-cause mortality in stroke survivors.

Stroke presents significant challenges for both survivors and caregivers, particularly in resource-limited settings like Zimbabwe. Identifying factors contributing to caregiver burden strain (CBS) is crucial to enhance support strategies. This longitudinal study identified caregiver and stroke survivor characteristics associated with CBS among caregivers in Harare, Zimbabwe. Altogether 188 stroke survivors and their caregivers participated with CBS assessed at 3 months and 12 months using the Caregivers Strain Index. Multiple linear regression was used to evaluate the association of explanatory variables with CBS. Model fit was evaluated using the Akaike's Information Criterion and R 2. Caregivers experiencing anxiety or depression showed increased CBS at 3 months (β = 2.46, p < 0.001) and 12 months (β = 2.73, p = 0.016). Work adjustments were associated with higher CBS at 3 months (β = 3.84, p < 0.001). Caregivers feeling overwhelmed had significantly higher CBS at 3 months (β = 3.36, p < 0.001). Stroke survivors' poor physical outcomes and reliance on health insurance were associated with CBS at 12 months (β = 4.34, p = 0.006). Caring for married stroke survivors was associated with reduced CBS (β = -2.83, p < 0.001). Caregiver anxiety, depression, work adjustments and poor physical and social outcomes in stroke survivors contributed to increased CBS. Targeted interventions addressing mental health and social support are essential to reduce CBS. Multifaceted interventions that address caregiver mental health and social support are vital to reduce CBS and improve outcomes in resource-constrained settings like Zimbabwe.

Stroke is one of the most common causes of disability worldwide. In recent years, diverse telehealth programmes for stroke survivors have suggested that this mode of rehabilitation could improve stroke survivors' abilities to perform activities of daily living (ADLs) and maintain balance. Although increasingly utilised in clinical and community settings, the effectiveness of telehealth interventions in stroke survivors remains inconclusive. This warrants investigation so that telehealth interventions are evidence-based and are not merely modalities of convenience. To identify the effects of telehealth interventions on the ability to perform ADLs and maintain balance in stroke survivors. A systematic literature review and meta-analysis were conducted in accordance with PRISMA guidelines. A systematic literature search was performed using seven databases for literature dated up to April 25, 2021. The revised Cochrane risk of bias tool for randomised trials was used to assess the methodological quality of the included studies. A meta-analysis was performed using a random-effects model to calculate the pooled effects of telehealth interventions. Stata 16.0 was used for the statistical analyses. A total of 14studies with 1,367 participants were included in the analysis. Overall, telehealth interventions were effective in improving stroke survivors' abilities to carry out their ADLs (standardised mean difference: .45; 95% confidence interval: .12 to .78); however, no significant effects were found on balance. Telehealth interventions are beneficial for improving stroke survivors' performance of their ADLs. Future telehealth intervention trials should focus on identifying essential intervention delivery components that facilitate intervention adoption by clinicians and stroke survivors and sustain the positive effects on stroke survivors' performance of their ADLs in different settings. It is essential to build flexibility in the telehealth-based intervention delivery protocol to meet individual stroke survivors' needs to motivate and enhance their ADL performance.

BackgroundLow levels of habitual physical activity and high levels of sedentary behaviour are commonly observed post-stroke. We aimed to assess the feasibility, acceptability and fidelity of a multifaceted, theory- and evidence-informed supported self-management intervention targeting physical activity and sedentary behaviour after stroke: Physical Activity Routines After Stroke (PARAS).MethodsAdult stroke survivors and healthcare professionals were recruited from North East England stroke services. Stroke survivor physical activity and sedentary behaviour were targeted by a self-management behavioural intervention supported by healthcare professionals trained in intervention delivery. The main outcomes were protocol and intervention acceptability and feasibility and fidelity of intervention delivery.ResultsEleven healthcare professionals (9 physiotherapists; 2 occupational therapists) participated in the study. Stroke survivor recruitment was lower than anticipated (19 versus target of up to 35). The healthcare professional training programme was feasible, with fidelity assessment of delivery supporting this finding. Data completeness was acceptable according to a priori criteria (>60%), except for stroke survivor questionnaire return rate (59%) and interview uptake (52%). No serious adverse events occurred. Healthcare professionals and stroke survivors perceived intervention delivery to be feasible and acceptable with minor modifications highlighted including the potential for earlier delivery in the stroke pathway.ConclusionsThe study protocol and intervention delivery were feasible and acceptable to stroke survivors and healthcare professionals with modifications required before large-scale evaluation.Trial registrationISRCTN35516780. Registered on October 24, 2018

Key milestones and participant engagement strategies in research with HIV-affected adolescents and young adults from low-to-middle income countries.

Use of VR-games is considered a promising treatment approach in stroke rehabilitation. However, there is little knowledge on the use and expectations of patients and health professionals regarding the use of treadmill walking in a fully immersive virtual environment as a rehabilitation tool for gait training for stroke survivors. The objectives of the current study were to determine whether stroke survivors can use fully immersive VR utilizing modern HMDs while walking on a treadmill without adverse effects, and to investigate the experiences of stroke survivors and clinicians after testing with focus on acceptability and potential utilization in rehabilitation. A qualitative research design with semi-structured interviews was used to collect data. Five stroke survivors and five clinicians participated in the study and tested a custom-made VR-game on the treadmill before participating in individual semi-structured interview. Data were analyzed through thematic analysis. The analysis of the interview data identified two main categories: (1) experiencing acceptability through safety and motivation, and (2) implementing fully immersive VR in rehabilitation. Both stroke survivors' and clinicians enjoyed the treadmill-based VR-game and felt safe when using it. The stroke survivors experienced motivation for exercising and achievement by fulfilling tasks during the gaming session as the VR-game was engaging. The clinicians found additional motivation by competing in the game. Both groups saw a potential for use in gait rehabilitation after stroke, on the premise of individual adaptation to each patient's needs, and the technology being easy to use. The findings from this qualitative study suggest that a fully immersive treadmill-based VR-game is acceptable and potentially useful as part of gait rehabilitation after stroke, as it was positively received by both stroke survivors and clinicians working within stroke rehabilitation. The participants reported that they experienced motivation in the game through safety, engagement and achievement. They also saw the potential of implementing such a setup in their own rehabilitation setting. Elements that enable safety and engaging experience are important to maintain when using a fully immersive VR-game in stroke rehabilitation.