Acute Stroke Rehabilitation Research Articles

Contribution of cognitive status on admission to mobility and balance at discharge from acute rehabilitation for stroke

Acute inpatient rehabilitation is crucial for improving mobility and balance for individuals with stroke. A potentially important factor in the recovery of mobility and balance is cognition. The purpose of this study was to determine the effect of cognition on mobility and balance in acute stroke rehabilitation. This was a longitudinal cohort study based on an inpatient rehabilitation unit at a large academic medical center. Participants were individuals with stroke admitted to acute rehabilitation after an acute care hospital stay (N = 281). Demographic data and predictor variables were collected on admission to the unit. Outcomes were collected at discharge from the unit. Multiple regression analyses were used to determine the associations between cognition (Montreal Cognitive Assessment) on mobility (Functional Independence Measure mobility subscale) and balance (Berg Balance Scale). Subtests from the Montreal Cognitive Assessment were also examined to determine if specific dimensions of cognition could predict balance after controlling for covariates. Dominance analysis was used to determine the relative importance of baseline predictors. In separate models, cognition was a significant predictor of mobility (B = 0.19) and balance (B = 0.28) at discharge after adjusting for admission mobility and balance, as well as age, sex, and length of stay. The most important predictors in both models were baseline mobility and balance, but cognition contributed to the models independently of baseline scores. Cognition was generally more important than age and sex while about equally important as length of stay. In separate models, the visuospatial/executive (B = 0.42) and the delayed recall (B = 0.37) subtests were also significant predictors of mobility. The models’ most important predictors were baseline mobility and balance scores. Cognition is a clinically relevant predictor of mobility and balance in acute stroke rehabilitation. Specific dimensions of cognition, such as executive function, visuospatial function, and delayed recall, may be especially important. Cognitive challenges and meta-cognitive strategies should be included in mobility and balance tasks when possible. Studies that evaluate the efficacy of dual-task training and meta-cognitive approaches are needed.

Handgrip Strength and Cognitive Recovery in Older Stroke Survivors: A Prospective Study

Background and Objectives: Handgrip strength (HGS) is an important indicator of overall physical capability and is linked to various health outcomes in older adults. Despite extensive research on the relationship between HGS and cognitive decline, longitudinal studies on poststroke cognitive changes in relation to HGS are scarce. This study aimed to observe whether HGS at discharge from acute stroke rehabilitation affects cognitive function 6–12 months after stroke onset and to compare cognitive outcomes between patients with normal and low HGS at discharge. Materials and Methods: This prospective cohort study was conducted in the Department of Rehabilitation Medicine at a tertiary care hospital. In agreement with the Asian Working Group for Sarcopenia 2019 criteria, low muscle strength was defined as an HGS of less than 28 kg for men and less than 18 kg for women, and participants were categorized into normal and low HGS groups. Neuropsychological evaluations were conducted before discharge (approximately one month after stroke onset) and between 6 and 12 months after stroke onset. Results: The low HGS group was older and had lower Montreal Cognitive Assessment scores. However, after adjusting for covariates, the linear mixed model analysis showed no significant differences between the groups in global cognition or specific cognitive domains, except for psychomotor speed during the subacute phase. Notable improvements in language ability were observed in both groups over time, while significant improvements in executive function were observed exclusively in the low HGS group. Conclusions: This longitudinal study is the first to explore the relationship between HGS and changes in cognitive function in older adults with stroke, providing insights into physical strength and cognitive recovery during stroke rehabilitation.

Behavioral Problems and Self-Feeding Independence Among Patients With Acute Stroke: A Single-Center Study.

Self-feeding independence is often the first goal in acute stroke rehabilitation. Attention deficits appear frequently after stroke, but neuropsychological tests may be difficult to perform in the acute phase, and the effect on self-feeding activities may be difficult to detect. Therefore, we aimed to clarify behavioral problems with self-feeding using the Moss Attention Rating Scale (MARS), a behavioral observational rating scale of attentional function, for a better understanding of the effects of self-feeding. To identify behavioral problems caused by attention deficits among patients with acute stroke who need assistance in self-feeding, using the MARS. Cross-sectional single-center study. St. Marianna University Yokohama Seibu Hospital, Kanagawa, Japan. A total of 96 patients (42 women and 54 men) were admitted to the hospital for stroke treatment. Patients' median age was 75.0 yr. The date of evaluation was a median of 3.0 days from admission. The primary outcome was the FIM® eating subscore. The secondary outcome was the MARS score. Significant differences were noted in the total raw MARS, logit, and three-factor scores for self-feeding independence (p < .01). The effect size of the consistent or sustained factor on independence was large (r = .83). Behavioral problems related to self-feeding dependence include the inability for sustained attention. Our results suggest that sustained concentration during self-feeding is necessary for eating independence. Rehabilitation focused on sustained attention is important for independent self-feeding. Plain-Language Summary: A patient's self-feeding independence is often the first goal in acute stroke rehabilitation. Patients frequently experience attention deficits after a stroke, but neuropsychological tests may be difficult to perform in the acute phase of rehabilitation, and the effect of attention deficits on self-feeding may be difficult to identify. To have a better understanding of the effects on self-feeding, this study aimed to identify behavioral problems using the Moss Attention Rating Scale (MARS). The study found that the MARS can be used to identify behavioral problems related to self-feeding independence, which can help occupational therapists to develop rehabilitation programs for their clients who have experienced a stroke.

A pilot cluster randomised controlled trial, of an IMPlicit learning approach versus standard care, on recovery of mobility following stroke (IMPS)

Objectives To evaluate the delivery of rehabilitation using implicit motor learning principles in an acute stroke setting. Design Pilot, assessor-blind, cluster randomised controlled trial with nested qualitative evaluation. Setting Eight inpatient stroke units, UK. Participants People within 14 days of stroke onset, presenting with lower limb hemiplegia. Interventions Participants at control clusters received usual care. Participants at intervention clusters received rehabilitation using an Implicit Learning Approach (ILA); primarily consisting of reduced frequency instructions/feedback, and promotion of an external focus of attention. Video recording was used to understand the ability of intervention site therapists to adhere to the implicit learning principles, and to compare differences between groups. Measures Ability to recruit and retain clusters/participants; suitability and acceptability of data collection processes; appropriateness of fidelity monitoring methods; and appropriateness of chosen outcome measures. Results Eight stroke units participated, with four assigned to each group (intervention/control). Fifty-one participants were enrolled (intervention group 21; control group 30). Mean time since stroke was 6 days (SD 3.42; 0–14); mean age was 73 years (SD 14, 25–94). Of those approached to take part, 72% agreed. We found clear differences between groups with respect to the frequency and type of instructional statement. The ILA was acceptable to both patients and therapists. Conclusion It is feasible to evaluate the application and effectiveness of motor learning principles within acute stroke rehabilitation, using a cluster randomised design. A larger study is required to evaluate the benefits of each approach; we provide a range of sample size estimates required for this.

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.

Weathering the storm: Effect of climate change on acute stroke care and stroke rehabilitation.

Climate change has deleterious effects on stroke recovery, disproportionately affecting populations with increased stroke incidence. These effects start prior to the acute care hospitalization, precipitated by environmental etiologies and are sustained throughout the life course of stroke survivors. Health care practitioners play a critical role in identifying these concerns and mitigating their impact through effective strategies at the patient level, interventions at the community level, and advocacy at the state and federal level. As the experts on improvement in function, quality of life, and the mitigation of disability, physiatrists have the opportunity to lead efforts in this space for stroke survivors and their caregivers.

Effects of Thermal Stimulation and Transcutaneous Electrical Nerve Stimulation on Sensory and Motor Function of Upper Extremity in Acute Stroke Survivors: A Randomized Controlled Pilot Study.

Objective Upper-limb coordination is crucial for daily activities, especially among stroke survivors who may encounter obstacles during upper-limb rehabilitation. This study aimed to investigate the effects of thermal stimulation (TS) and transcutaneous electrical nerve stimulation (TENS) on sensory and motor function during recovery in acute stroke patients. Design This is a parallel study with a randomized controlled design. The experiment was conducted in the E-Da Hospital Rehabilitation Department, Kaohsiung, Taiwan. Intervention Thirty participants were in-patients with acute stroke at the E-Da Hospital. Participants were randomly assigned tothree groups for a one-week intervention: exercise combined with TS, exercise combined with TENS, or conventional physical therapy with exercise alone. The Fugl-Meyer upper extremity scale, Brunnstrom stage, minimal current perception (MCP), and modified Ashworth scale were collected for the assessment. Results The outcomes demonstrated considerable improvement in MCP in all the groups after treatment. Specifically, the groups receiving TS and TENS showed significant improvements in the Brunnstrom stage, suggesting that both treatments improved distal motor recovery. Conclusion The results, following a one-week intervention period, suggested that both TS and TENS contributed to the improvement of motor and sensory function, with a significant impact on the Brunnstrom stage in the upper extremity, particularly in the distal region. The inclusion of TS or TENS in rehabilitation protocols improved distal motor function compared to baseline measures, suggesting these treatments as effective components in acute stroke rehabilitation.

Developing machine learning models to predict multi-class functional outcomes and death three months after stroke in Sweden.

Globally, stroke is the third-leading cause of mortality and disability combined, and one of the costliest diseases in society. More accurate predictions of stroke outcomes can guide healthcare organizations in allocating appropriate resources to improve care and reduce both the economic and social burden of the disease. We aim to develop and evaluate the performance and explainability of three supervised machine learning models and the traditional multinomial logistic regression (mLR) in predicting functional dependence and death three months after stroke, using routinely-collected data. This prognostic study included adult patients, registered in the Swedish Stroke Registry (Riksstroke) from 2015 to 2020. Riksstroke contains information on stroke care and outcomes among patients treated in hospitals in Sweden. Prognostic factors (features) included demographic characteristics, pre-stroke functional status, cardiovascular risk factors, medications, acute care, stroke type, and severity. The outcome was measured using the modified Rankin Scale at three months after stroke (a scale of 0-2 indicates independent, 3-5 dependent, and 6 dead). Outcome prediction models included support vector machines, artificial neural networks (ANN), eXtreme Gradient Boosting (XGBoost), and mLR. The models were trained and evaluated on 75% and 25% of the dataset, respectively. Model predictions were explained using SHAP values. The study included 102,135 patients (85.8% ischemic stroke, 53.3% male, mean age 75.8 years, and median NIHSS of 3). All models demonstrated similar overall accuracy (69%-70%). The ANN and XGBoost models performed significantly better than the mLR in classifying dependence with F1-scores of 0.603 (95% CI; 0.594-0.611) and 0.577 (95% CI; 0.568-0.586), versus 0.544 (95% CI; 0.545-0.563) for the mLR model. The factors that contributed most to the predictions were expectedly similar in the models, based on clinical knowledge. Our ANN and XGBoost models showed a modest improvement in prediction performance and explainability compared to mLR using routinely-collected data. Their improved ability to predict functional dependence may be of particular importance for the planning and organization of acute stroke care and rehabilitation.

Comparative Analysis of Physical Therapy Outcomes in Acute Ischemic and Hemorrhagic Stroke Rehabilitation

Background: Stroke rehabilitation demands an effective therapeutic approach to enhance functional recovery. This study aims to compare the outcomes of physical therapy in patients with acute ischemic and hemorrhagic stroke using the Motor Relearning Programme (MRP). Methodology: Based on stroke type, confirmed via CT thirty-eight participants were stratified into ischemic &amp; hemorrhagic stroke group. Eligible participants were over 35 years old, had a Glasgow Coma Scale score above 5, and presented with hemiplegia. Exclusion criteria included trauma-induced hemorrhage, cerebellar or brainstem stroke, severe cognitive impairment, or pre-existing disabilities. The participants underwent a standardized four-week physiotherapy regimen based on the MRP, with assessments using the Motor Assessment Scale (MAS) and Functional Independence Measure (FIM) to evaluate the outcomes. Results: These results underscore the significant improvements in the functional outcomes observed in both ischemic and hemorrhagic stroke patients following physical therapy, with hemorrhagic stroke patients showing more substantial gains in both MAS and FIM scores. Conclusion: Our study contributes to a nuanced understanding of stroke rehabilitation, emphasizing that while both ischemic and hemorrhagic stroke patients significantly benefit from structured physical therapy interventions like MRP, the specifics of their recovery processes vary.

1095 Adaptation of SIESTA (Sleep for Inpatients: Empowering Staff to Act) Protocol for Acute Stroke Rehabilitation

1095 Adaptation of SIESTA (Sleep for Inpatients: Empowering Staff to Act) Protocol for Acute Stroke Rehabilitation

Effectiveness of reinforced feedback in virtual environment for upper limb rehabilitation in acute stroke

Background. Motor impairments following stroke result in loss of upper extremity function which is often persistent and disabling. Reinforced feedback in the virtual environment (RFVE) could activate mirror neuron systems which are stimulated during action observation and action execution. This study aims to evaluate the activation of proximal muscles in paretic upper limb following RFVE training. Methodology. Twenty-four stroke patients were included in the study, 12 in control group received impairment specific training and 12 in experimental group received RFVE training using Oculus quest 2 in addition to impairment specific exercise training. Surface electromyography (SEMG) of shoulder muscles of affected upper limb were recorded in both groups. Arm motor recovery was recorded using Chedoke - McMaster stroke assessment scale (CMSA). Results. Paired t-test was used to analyze the results within the group which showed improvement in the both groups and unpaired t-test was used to test the outcomes between the groups where RFVE group showed significant improvement in average muscle activity in anterior deltoid, middle deltoid and CMSA scores than control group (p &lt; 0.005*). Conclusion. The results of this study demonstrated the beneficial effects of RFVE in upper limb training which showed improvements in muscle activation in SEMG and arm recovery in CMSA scores. RFVE training is a safe and well-accepted effective intervention in acute stroke rehabilitation that could become a successful intervention for early functional recovery.

Comparing the Effect of Proprioceptive Neuromuscular Facilitation (PNF) Exercise and Focused Regimen Program to Assess Balance and Quality of Life for Acute Stroke Rehabilitation

Background: Stroke is a leading cause of long-term disability worldwide, resulting in significant physicalimpairments, including hemiparesis and loss of motor control. Rehabilitation plays a crucial role in aiding strokepatients’ recovery, and various approaches have been used to improve their functional abilities. Two widelypracticed methods are Proprioceptive Neuromuscular Facilitation (PNF) exercises and focused regimen programs.Purpose: To compare the effectiveness of PNF exercises and focused regimen programs in improving motorfunction, mobility and quality of life in stroke patients.Materials and Methods: The total of 30 subjects with acute stroke were taken from Saicharan physio Center-Arakkonam. The subjects are selected based on inclusion and exclusion criteria The intervention was given for 6weeks. The entire process was performed from November 2022 to February 2023.Result: According to the statistical analysis, PNF exercises revealed significant in improving both balance andquality of life measures for acute stroke patients compared to focused regimen program.Conclusion: This study finally concluded that the PNF exercises has a high impact in improving both balance andmay enhance neuroplasticity.

Evidence and Recommendations for Acute Stroke Rehabilitation from the Japan Stroke Society: Abridged Secondary Publication of the Japanese-language Version.

In Japan, acute stroke rehabilitation has been expanding more steadily than previously with the nationwide establishment of primary stroke centers. However, Japan previously had no established guidelines for the rehabilitation. Consequently, rehabilitation programs and the provision systems for acute stroke varied among the facilities. To equalize and standardize acute stroke rehabilitation in Japan, it is necessary to develop clinical recommendations for rehabilitation. Therefore, the rehabilitation project team of the Japan Stroke Society aimed to develop the first recommendations for acute stroke rehabilitation in Japan. The recommendations are based on the results of a survey on the current status of acute stroke rehabilitation at primary stroke centers in Japan, which was completed in 2022, and on a literature review conducted by the rehabilitation project team. The recommendations consist of 19 clinical questions regarding the following topics of acute stroke rehabilitation: (1) head elevation and mobilization training, (2) acute complications, (3) training time and frequency for acute stroke rehabilitation, (4) dysphagia in the acute phase, and (5) acute rehabilitation during pandemics of novel and re-emerging infections, particularly novel coronavirus disease 2019 (COVID-19). The team members agreed on all answers for these 19 clinical questions. These recommendations suggest broad principles of rehabilitative intervention in the acute phase of stroke. In the near future, it is expected that the dissemination of these recommendations will result in an increase in the quality of acute stroke rehabilitation in Japan.

Frequency of comorbidities and risk factors in acute stroke rehabilitation: multi-institutional registry study

Frequency of comorbidities and risk factors in acute stroke rehabilitation: multi-institutional registry study

A nationwide survey for the provision of acute stroke rehabilitation in Japan: initial dose and weekend/holiday rehabilitation

ObjectivesThe early initiation of acute stroke rehabilitation with a sufficient dose, including at weekends/holidays, is important to improve functional outcome. We investigated the status of acute stroke rehabilitation in Japan by using a nationwide survey. Materials and MethodsFacility features, rehabilitation dose provided in the first week in each stroke subtype, and weekend/holiday rehabilitation were investigated by using the results of a web-based survey among primary stroke centers. The relationships between facility features and weekend/holiday rehabilitation were also analyzed. ResultsA total of 639 stroke centers (66.6%) completed the questionnaire. The overall median dose was 2.0 (interquartile range, 1.7–3.0) U/day (1U = 20 min). After 7 days, the overall median dose increased to 4.0 (2.0–5.4) U/day. Almost 50% of facilities replied that they could not provide a sufficient dose of rehabilitation; the main reason was a lack of therapists (31%). For rehabilitation on long weekends, no rehabilitation was provided on 3-day weekends in 19% of facilities, and in 5% of facilities on ≥4-day weekends. The mean number of therapists was almost 50% less in the facilities that provided no rehabilitation on 3-day weekends compared to those that provided daily rehabilitation (19.4 vs. 36.2 therapists, respectively, p < 0.001). ConclusionsIn this survey, the provision of acute stroke rehabilitation, including non-working days, was clarified. According to the results, prospective interventional or observational studies are needed to design more effective rehabilitation programs to improve outcome. In particular, it is important to determine the optimal dose and intensity of acute stroke rehabilitation.

Comparing distributed versus massed practice on functional recovery and Brain-Derived Neurotrophic Factor (BDNF) in acute stroke subjects.

Globally, stroke is known to be one of the major health problems, resulting in disability among an aging population. Rehabilitation is a process of re-learning of skills, lost due to brain injury. Many factors influence motor learning post neurological insult and practice is one of the key factors which influence relearning or reacquisition of lost motor skills. Practice can be varied concerning order (blocked or random), scheduling (massed or distributed), or whole and part practice. The study observed the effect of variations in practice schedules on motor and functional recovery. Thirty-two acute stroke subjects were recruited and equally divided into two groups (16 in massed and 16 in distributed). Both groups received an accelerated skill acquisition program (ASAP) for six sessions a week for 2 weeks. Pre- and post-outcome measures included stroke rehabilitation assessment of movement (STREAM) for motor recovery, modified Barthel index (MBI) for functional recovery, and brain-derived neurotrophic factor (BDNF) for neuroplasticity. The median scores of participants in the massed practice group before the intervention, of STREAM total, MBI, and BDNF were 23.5, 19, and 0.65, respectively, whereas post values of STREAM total, MBI, and BDNF were 40.5, 60.5, and 0.75, respectively. The median scores of the distributed practice group of the pre-STREAM total, MBI, and BDNF were 23.5, 6.5, and 0.70, respectively, whereas the post-STREAM total, MBI, and BDNF were 41, 45.5, and 0.80, respectively. P-value was reported to be <0.05 while comparing pre- and post-values of STREAM, MBI, and BDNF within both intervention groups. The median change scores of STREAM, MBI, and BDNF reported P ≥ 0.05 when compared between the groups. Both the groups had significant recovery post-intervention designed based on ASAP, about impairment mitigation, pursuing skilled movement leading to significant functional gains. Appropriate timing along with optimal dosage became an active ingredient in functional recovery in acute stroke subjects. The distributed practice might have added effect of spacing, resulting in easier learning and accuracy of skills. The study reveals that distributed practice can be part of regular clinical practice to enhance functional recovery in acute stroke rehabilitation.

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

IntroductionPracticality 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.ObjectivesTo determine the feasibility of early, intense supplemental gait training in inpatient stroke rehabilitation, compare functional outcomes and the specific mode of delivery.Design and settingAssessor blinded, randomized controlled trial in a tertiary Inpatient Rehabilitation Facility.ParticipantsThirty acute post-stroke patients with unilateral hemiparesis (≥ 18 years of age with a lower limb MAS ≤ 3).InterventionLokomat® or conventional gait training (CGT) in addition to standard mandated therapy time.Main outcome measuresNumber 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).ResultsThe 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”.ConclusionsWith 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.

Rate of return to work in patients with stroke under the health and employment support program of Rosai hospitals in Japan

To facilitate return to work (RTW) in patients with stroke, a health and employment support (HES) program was started at Rosai hospitals in Japan. This study aimed to determine the rate of RTW in patients with stroke under this support program. We collected demographic and clinical data of patients with stroke from the implementation reports of the HES program. The program provided coordinated dual support, such as acute medical treatments, and stroke and vocational rehabilitation on the medical side, and management and support on the workplace side. The primary endpoint was RTW. Successful and unsuccessful RTW were examined using the χ2 test. The RTW rate curves were analyzed using the Kaplan–Meier method. We enrolled 483 patients; 355 (73%) and 128 (27%) patients had successful and unsuccessful RTW, respectively. Stroke types, neurological findings, and activities of daily living were significant factors for RTW. The Kaplan–Meier method revealed that left hemiplegia, right hemiplegia, and neuropsychological deficits, except for combined disability (hemiplegia with neuropsychological deficits), had similar RTW curves with an RTW rate of > 70%.

Understanding implementation of a complex intervention in a stroke rehabilitation research trial: A qualitative evaluation using Normalisation Process Theory.

The Implicit Learning in Stroke study was a pilot cluster randomised controlled trial, investigating the use of different motor learning strategies in acute stroke rehabilitation. Participating Stroke Units (n = 8) were from the South East/West regions of the UK, with the experimental intervention (implicit learning) being delivered by clinical teams. It required therapists to change how they gave instructions and feedback to patients during rehabilitation. This paper reports the processes underpinning implementation of the implicit learning intervention. The evaluation aimed to i) understand how therapists made sense of, engaged with and interpreted the effects of the intervention; ii) compare this to the experience reported by patients; iii) extrapolate learning of broader relevance to the design and conduct of research involving complex interventions in stroke rehabilitation. Qualitative evaluation, with data collected through focus groups with clinical staff (n = 20) and semi structured interviews with people with stroke (n = 19). Mixed inductive and theory driven analysis, underpinned by Normalisation Process Theory. How therapists made sense of and experienced the intervention impacted how it was implemented. The intervention was delivered by individual therapists, and was influenced by their individual values, beliefs and concerns. However, how teams worked together to build a shared (team) understanding, also played a key role. Teams with a more "flexible" interpretation, reported the view that the intervention could have benefits in a wide range of scenarios. Those with a more fixed, "rule based" interpretation, found it harder to implement, and perceived the benefits to be more limited. Therapists' concerns that the intervention may impair therapeutic relationships and patient learning were not reflected in how patients experienced it. Changing practice, whether in a research study or in the "real world", is complex. Understanding the process of implementation is crucial to effective research delivery. Implementation frameworks facilitate understanding, and subsequently the systematic and iterative development of strategies for this to be addressed. How teams (rather than individuals) work together is central to how complex interventions are understood and implemented. It is possible that new complex interventions work best in contexts where there are 'flexible' cultures. Researchers should consider, and potentially measure this, before they can effectively implement and evaluate an intervention. Clinical Trials - NCT03792126.

Safety and Feasibility Study of the Medical Care Pit Walking Support System for Rehabilitation of Acute Stroke Patients.

Stroke rehabilitation with mechanical assistance improves outcomes by facilitating repetition and relieving the care burden of therapy staff. Here, we tested the Medical Care Pit (MCP) walking assistance training device in the rehabilitation of eight acute stroke patients (median age 60.7 ± 16.3 years) who had recently suffered ischemic (three) or hemorrhagic (five) stroke (14.1 ± 6.5 days). Patients received standard rehabilitation approximately 5 days per week (weekdays only), plus MCP therapy twice a week, totaling four MCP sessions over 2 weeks. Fugl-Meyer Assessment-Lower Extremities (FMA-LE), Functional Ambulation Category (FAC), and other gait-associated parameters were measured. Over the 10.5 ± 1.6 days of therapy, MCP qualitatively assisted in gait analysis and real-time patient feedback while independent walking scores significantly improved (FAC 2.2 ± 0.8 to 3.1 ± 1.3, p = 0.020). FMA-LE scores also slightly improved but not to significance (p = 0.106). Objective burden on patients, as measured by modified Borg scale, was significantly improved (2.7 ± 1.6 to 2.0 ± 1.6, p = 0.014). In terms of questionnaires, anxiety scores for the physical therapist regarding gait training and falling with MCP significantly decreased (3.8 ± 2.3 to 1.0 ± 1.6; p = 0.027 and 3.1 ± 2.2 to 0.8 ± 1.3; p = 0.045) from the first to fourth sessions. Taken together, MCP, in addition to the usual rehabilitation program, was effective in gait rehabilitation for independent walking and relieved burdens on the patients. Such walking support systems may be an important part of acute stroke rehabilitation.