Assessment Of Stroke Patients Research Articles

Ηand dexterities assessment in stroke patients based on augmented reality and machine learning through a box and block test

A popular and widely suggested measure for assessing unilateral hand motor skills in stroke patients is the box and block test (BBT). Our study aimed to create an augmented reality enhanced version of the BBT (AR-BBT) and evaluate its correlation to the original BBT for stroke patients. Following G-power analysis, clinical examination, and inclusion–exclusion criteria, 31 stroke patients were included in this study. AR-BBT was developed using the Open Source Computer Vision Library (OpenCV). The MediaPipe's hand tracking library uses a palm and a hand landmark machine learning model to detect and track hands. A computer and a depth camera were employed in the clinical evaluation of AR-BBT following the principles of traditional BBT. A strong correlation was achieved between the number of blocks moved in the BBT and the AR-BBT on the hemiplegic side (Pearson correlation = 0.918) and a positive statistically significant correlation (p = 0.000008). The conventional BBT is currently the preferred assessment method. However, our approach offers an advantage, as it suggests that an AR-BBT solution could remotely monitor the assessment of a home-based rehabilitation program and provide additional hand kinematic information for hand dexterities in AR environment conditions. Furthermore, it employs minimal hardware equipment.

Interrater reliability of the Fugl-Meyer Motor assessment in stroke patients: a quality management project within the ESTREL study.

The Fugl-Meyer Motor Assessment (FMMA) is recommended for evaluating stroke motor recovery in clinical practice and research. However, its widespread use requires refined reliability data, particularly across different health professions. We therefore investigated the interrater reliability of the FMMA scored by a physical therapist and a physician using video recordings of stroke patients. The FMMA videos of 50 individuals 3 months post stroke (28 females, mean age 71.64 years, median National Institutes of Health Stroke Scale score 3.00) participating in the ESTREL trial (Enhancement of Stroke Rehabilitation with Levodopa: a randomized placebo-controlled trial) were independently scored by two experienced assessors (i.e., a physical therapist and a physician) with specific training to ensure consistency. As primary endpoint, the interrater reliability was calculated for the total scores of the entire FMMA and the total scores of the FMMA for the upper and lower extremities using intraclass correlation coefficients (ICC). In addition, Spearman's rank order correlation coefficients (Spearman's rho) were calculated for the total score and subscale levels. Secondary endpoints included the FMMA item scores using percentage agreement, weighted Cohen's kappa coefficients, and Gwet's AC1/AC2 coefficients. ICCs were 0.98 (95% confidence intervals (CI) 0.96-0.99) for the total scores of the entire FMMA, 0.98 (95% CI 0.96-0.99) for the total scores of the FMMA for the upper extremity, and 0.85 (95% CI 0.70-0.92) for the total scores of the FMMA for the lower extremity. Spearman's rho ranged from 0.61 to 0.94 for total and subscale scores. The interrater reliability at the item level of the FMMA showed (i) percentage agreement values with a median of 77% (range 44-100%), (ii) weighted Cohen's kappa coefficients with a median of 0.69 (range 0.00-0.98) and (iii) Gwet's AC1/AC2 coefficients with a median of 0.84 (range 0.42-0.98). The FMMA appears to be a highly reliable measuring instrument at the overall score level for assessors from different health professions. The FMMA total scores seem to be suitable for the quantitative measurement of stroke recovery in both clinical practice and research, although there is potential for improvement at the item level.

In-hospital stroke protocol outcomes before and after the implementation of neurological assessments by telemedicine: an observational case-control study.

Stroke is the second leading cause of global adult mortality and the primary cause of disability. A rapid assessment by a neurologist for general and reperfusion treatments in ischemic strokes is linked to decreased mortality and disability. Telestroke assessment is a strategy that allows for neurological consultations with experienced professionals, even in remote emergency contexts. No randomized studies have compared face-to-face neurological care outcomes with telestroke care. Whether neurologists in an institution achieve better results remotely than in person is also unknown. This study aimed to compare mortality and other outcomes commonly measured in stroke protocols for stroke patients assessed by a neurologist via face-to-face evaluations and telestroke assessment. Observational single-center retrospective study from August/2009 to February/2022, enrolling 2,689 patients with ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage. Group 1 (G1) comprised 2,437 patients with in-person neurological assessments, and Telemedicine Group 2 (G2) included 252 patients. The in-person group had higher admission NIHSS scores (G1, 3 (0; 36) vs. G2, 2 (0; 26), p < 0.001). The door-to-groin puncture time was lower in the in-person group than in the telestroke group (G1, 103 (42; 310) vs. G2, 151 (109; 340), p < 0.001). The telestroke group showed superior metrics for door-to-imaging time, symptomatic hemorrhagic transformation rate in ischemic stroke patients treated with intravenous thrombolysis, hospital stay duration, higher rates of intravenous thrombolysis and mechanical thrombectomy, and lower mortality. Symptomatic hemorrhagic transformation rate was smaller in the group evaluated via telestroke (G1, 5.1% vs. G2, 1.1%, p = 0.016). Intravenous thrombolysis and mechanical thrombectomy rates were significantly higher in telestroke group: (G1, 8.6% vs. G2, 18.2%, p < 0.001 and G1, 5.1% vs. G2, 10.4%, p = 0.002, respectively). Mortality was lower in the telestroke group than in the in-person group (G1, 11.1% vs. G2, 6.7%, p = 0.001). The percentage of patients with an mRS score of 0-2 at discharge was similar in both groups when adjusting for NIHSS score and age. The same neurological emergency team may assess stroke patients in-person or by telemedicine, with excellent outcome metrics. This study reaffirms telestroke as a safe tool in acute stroke care.

Abstract WP51: Bridging the Gap - Impact of Advanced Practice Nurse in the Community Hospital in Singapore

Background: Stroke is a debilitating condition and patients with acute stroke usually stays about a week in the acute hospital. Those patients with impaired physical function may be transferred to a Community Hospital (CH) for further rehabilitation to optimize their function. In this pilot project, we aimed to incorporate the Stroke Advanced Practice Nurses (APNs) in one of the Community Hospital (OCH) so that stroke care gaps can be identified and to optimize stroke care. Methodology: The Stroke APN obtained their clinical privileges to work in CH. The APN would identify stroke patients admitting to CH for further rehabilitation. APN performed a weekly consultation round to review stroke patients identified in CH. During the consultation round, the APN assessed stroke patients’ neurological function and stroke complications. She also reviewed patient’s vital signs, fluid balances, pending blood results, medications and management. With the information, the APN would recommend change in management accordingly after communicating with the neurology team from the original transferring acute hospital. Results: There were total of 51 issues identified from Aug 2020 to Aug 2021 from 125 patients were reviewed by the Stroke APNs. The Stroke APNs identified 27.5% (n= 14) medical related issues e.g. change in stroke etiology, lack of deep vein thrombosis prophylaxis. There were pharmacological changes in 21.5% (n= 11) of the patients reviewed. Drug changes were usually anti-hypertensives or anti-thrombotics. Post-stroke psychological issue was common and 21.5% (n= 11) of patients developed low mood. To empower patients with their own health, the Stroke APN had to reinforce stroke education in 13.7% (n= 7) of the patients and 7.8% (n= 4) required reinforcement of driving advice. 7 patients (13.7%) requested Information about community resources for them to transit back into the community. Outpatient appointments were streamlined and 7.8% (n= 4) had their appointment has been amended or cancelled. Conclusion: There were high incidence of issues detected during the Stroke APN visiting consultation. The Stroke APN played an important role to manage post-stroke patients appropriately in the CH.

Early identification of stroke through deep learning with multi-modal human speech and movement data

JOURNAL/nrgr/04.03/01300535-202501000-00031/figure1/v/2024-05-10T114357Z/r/image-tiff Early identification and treatment of stroke can greatly improve patient outcomes and quality of life. Although clinical tests such as the Cincinnati Pre-hospital Stroke Scale (CPSS) and the Face Arm Speech Test (FAST) are commonly used for stroke screening, accurate administration is dependent on specialized training. In this study, we proposed a novel multimodal deep learning approach, based on the FAST, for assessing suspected stroke patients exhibiting symptoms such as limb weakness, facial paresis, and speech disorders in acute settings. We collected a dataset comprising videos and audio recordings of emergency room patients performing designated limb movements, facial expressions, and speech tests based on the FAST. We compared the constructed deep learning model, which was designed to process multi-modal datasets, with six prior models that achieved good action classification performance, including the I3D, SlowFast, X3D, TPN, TimeSformer, and MViT. We found that the findings of our deep learning model had a higher clinical value compared with the other approaches. Moreover, the multi-modal model outperformed its single-module variants, highlighting the benefit of utilizing multiple types of patient data, such as action videos and speech audio. These results indicate that a multi-modal deep learning model combined with the FAST could greatly improve the accuracy and sensitivity of early stroke identification of stroke, thus providing a practical and powerful tool for assessing stroke patients in an emergency clinical setting.

The cultural and linguistic adaptation of the Oxford Cognitive Screen to Tamil.

The Oxford Cognitive Screen (OCS) is a screening tool to assess stroke patients for deficits in attention, executive functions, language, praxis, numeric cognition, and memory. In this study, the OCS was culturally and linguistically adapted to Tamil, for use in India (OCS TA), considering the differences between formal and spoken versions of Tamil and consideration of its phonetic complexity. We adopted two-parallel form versions of the OCS and generated normative data for them. We recruited 181 healthy controls (Mean = 39.27 years, SD 16.52) (141 completed version A, 40 completed version B, 33 completed version A and B) and compared the data with the original UK normative sample. In addition, 28 native Tamil-speaking patients who had a stroke in the past three years (Mean = 62.76 years, SD 9.14) were assessed. Convergent validity was assessed with subtasks from Addenbrooke's Cognitive Examination III (ACE-III). We found significant differences between the UK normative group and the OCS TA normative group in age and education. Tamil-specific norms were used to adapt the cutoffs for the memory, gesture imitation, and executive function tasks. When domain-specific scores on the ACE-III were compared, OCS TA exhibited strong convergent validity. The OCS TA has shown the potential to be a useful screening tool for stroke survivors among Tamil speakers with the two-parallel forms demonstrating good equivalence. Further empirical evidence from larger studies is required to establish their psychometric performance and clinical validity.

Artificial intelligence applied in acute ischemic stroke: from child to elderly.

This review will summarize artificial intelligence developments in acute ischemic stroke in recent years and forecasts for the future. Stroke is a major healthcare concern due to its effects on the patient's quality of life and its dependence on the timing of the identification as well as the treatment. In recent years, attention increased on the use of artificial intelligence (AI) systems to help categorize, prognosis, and to channel these patients toward the right therapeutic procedure. Machine learning (ML) and in particular deep learning (DL) systems using convoluted neural networks (CNN) are becoming increasingly popular. Various studies over the years evaluated the use of these methods of analysis and prediction in the assessment of stroke patients, and at the same time, several applications and software have been developed to support the neuroradiologists and the stroke team to improve patient outcomes.

Nutritional Assessment in Stroke Patients

Nutritional Assessment in Stroke Patients

Test-retest reliability of fNIRS in resting-state cortical activity and brain network assessment in stroke patients.

Resting-state functional near infrared spectroscopy (fNIRS) scanning has attracted considerable attention in stroke rehabilitation research in recent years. The aim of this study was to quantify the reliability of fNIRS in cortical activity intensity and brain network metrics among resting-state stroke patients, and to comprehensively evaluate the effects of frequency selection, scanning duration, analysis and preprocessing strategies on test-retest reliability. Nineteen patients with stroke underwent two resting fNIRS scanning sessions with an interval of 24 hours. The haemoglobin signals were preprocessed by principal component analysis, common average reference and haemodynamic modality separation (HMS) algorithm respectively. The cortical activity, functional connectivity level, local network metrics (degree, betweenness and local efficiency) and global network metrics were calculated at 25 frequency scales × 16 time windows. The test-retest reliability of each fNIRS metric was quantified by the intraclass correlation coefficient. The results show that (1) the high-frequency band has higher ICC values than the low-frequency band, and the fNIRS metric is more reliable than at the individual channel level when averaged within the brain region channel, (2) the ICC values of the low-frequency band above the 4-minute scan time are generally higher than 0.5, the local efficiency and global network metrics reach high and excellent reliability levels after 4 min (0.5 < ICC < 0.9), with moderate or even poor reliability for degree and betweenness (ICC < 0.5), (3) HMS algorithm performs best in improving the low-frequency band ICC values. The results indicate that a scanning duration of more than 4 minutes can lead to high reliability of most fNIRS metrics when assessing low-frequency resting brain function in stroke patients. It is recommended to use the global correction method of HMS, and the reporting of degree, betweenness and single channel level should be performed with caution. This paper provides the first comprehensive reference for resting-state experimental design and analysis strategies for fNIRS in stroke rehabilitation.

Application of Prognostic Nutritional Index in the Predicting of Prognosis in Young Adults with Acute Ischemic Stroke

The incidence of ischemic stroke in young adults (18-45years old) is increasing gradually. However, performing nutritional assessment in stroke patients is often challenging due to the lack of an accepted standard for nutritional assessment. Two hundred sixty young stroke patients were recruited in this study and 144 cases in the good prognosis group and 116 cases in the poor prognosis group were scored according to the modified Rankin scale 90days after treatment. The National Institutes of Health Stroke Scale was performed on admission and discharge of patients. Serum interleukin 6 and high-sensitivity C-reactive protein were detected at patient presentation. The Prognostic Nutritional Index (PNI) was assessed on admission. Calculation formula of PNI score: serum albumin (g/L)+5× total lymphocyte count (109/L). The PNI at admission of young stroke patients with poor prognosis was higher than that of those with good prognosis. PNI at admission was significantly negatively correlated with National Institutes of Health Stroke Scale at discharge and modified Rankin scale score after 90days in young stroke patients. PNI at admission was also significantly negatively correlated with serum levels of high-sensitivity C-reactive protein and interleukin -6 at admission. PNI has a statistically predictive value for the 90-day prognosis of young stroke patients.

Stroke mimics in a Brazilian stroke center: a retrospective cohort in a Brazilian stroke unit

This study assessed stroke patients in a Brazilian unit to describe the prevalence, clinical presentation, etiology, and treatment outcomes of cases initially diagnosed as stroke mimics (SM). SM refers to conditions that mimic stroke but are not caused by cerebrovascular events. Misdiagnosis can lead to unnecessary and potentially harmful treatments. The study examined patients admitted between October 2012 and September 2013. Among patients with symptoms onset within four hours, 7.1% (10 patients) were classified as SM. Six of these patients received intravenous thrombolysis, a treatment for acute ischemic stroke. The main clinical presentations among SM cases were motor symptoms (90%), dysarthria, and sensory symptoms (60%). The etiology of SM cases varied, with functional disorders being the most common (60%). The findings reveal a significant percentage of patients admitted to the stroke unit were ultimately diagnosed as SM, highlighting the need for improved diagnostic strategies to differentiate between stroke and SM. The study underscores the importance of developing well-defined guidelines to assess SM risk and utilize imaging methods for distinguishing between stroke and SM. Further research is necessary to address these issues and enhance stroke diagnosis accuracy.

Computed tomography derived cervical fat-free muscle fraction as an imaging-based outcome marker in patients with acute ischemic stroke: a pilot study

BackgroundOutcome assessment in stroke patients is essential for evidence-based stroke care planning. Computed tomography (CT) is the mainstay of diagnosis in acute stroke. This study aimed to investigate whether CT-derived cervical fat-free muscle fraction (FFMF) as a biomarker of muscle quality is associated with outcome parameters after acute ischemic stroke.MethodsIn this retrospective study, 66 patients (mean age: 76 ± 13 years, 30 female) with acute ischemic stroke in the anterior circulation who underwent CT, including CT-angiography, and endovascular mechanical thrombectomy of the middle cerebral artery between August 2016 and January 2020 were identified. Based on densitometric thresholds, cervical paraspinal muscles covered on CT-angiography were separated into areas of fatty and lean muscle and FFMF was calculated. The study cohort was binarized based on median FFMF (cutoff value: < 71.6%) to compare clinical variables and outcome data between two groups. Unpaired t test and Mann-Whitney U test were used for statistical analysis.ResultsNational Institute of Health Stroke Scale (NIHSS) (12.2 ± 4.4 vs. 13.6 ± 4.5, P = 0.297) and modified Rankin scale (mRS) (4.3 ± 0.9 vs. 4.4 ± 0.9, P = 0.475) at admission, and pre-stroke mRS (1 ± 1.3 vs. 0.9 ± 1.4, P = 0.489) were similar between groups with high and low FFMF. NIHSS and mRS at discharge were significantly better in patients with high FFMF compared to patients with low FFMF (NIHSS: 4.5 ± 4.4 vs. 9.5 ± 6.7; P = 0.004 and mRS: 2.9 ± 2.1 vs.3.9 ± 1.8; P = 0.049). 90-day mRS was significantly better in patients with high FFMF compared to patients with low FFMF (3.3 ± 2.2 vs. 4.3 ± 1.9, P = 0.045).ConclusionCervical FFMF obtained from routine clinical CT might be a new imaging-based muscle quality biomarker for outcome prediction in stroke patients.

Direction-dependency of the kinematic indices in upper extremities motor assessment of stroke patients.

Kinematic indices (KIs) are frequently used as objective measures to assess the upper extremities motor performance in post stroke patients. The clinimetric analysis of these indices has been mostly limited to their averaged values over different directions of reaching movements. Recent studies indicate direction dependencies of such motor performances due to neural and/or biomechanical causes. The direction dependencies of such indices and their clinimetric parameters remains to be investigated. An apparatus was built to perform and measure planar point-to-point reaching tasks in 8 directions using a virtual reality environment. 24 stroke and 18 healthy individuals participated in the study. 24 kinematic indices were calculated. Reliability (ICC), construct validity (Spearman correlation), and responsiveness (paired t-test pre and post intervention) were analyzed in each direction. The clinimetric parameters were found highly direction dependent. The reliability of the indices were strongest when moving away and towards the body. The validity (Spearman&gt;0.75) and responsiveness (p&lt;0.05) were most pronounced when moving in the NW-SE direction. These findings are in compliance with some previous neuro-musculoskeletal observations. While smoothness parameters are relatively uniform in all directions, speed and accuracy are direction dependent. The clinimetrics of the kinematic indices also depend on the direction and show stronger values in the NW-SE direction which is therefore proposed as the most accurate and responsive direction for kinematic assessment in stroke patients.

Gait deviation index to quantify the effect of functional surgery on walking kinematics in stroke patients

The Gait Deviation Index (GDI) summarizes on a 0-100 basis the distance of a patient’s kinematic from the normal reference pattern [1]. It has been developed and used to assess the effect of functional surgery (FS) supported by gait analysis (GA) in large cohorts of children with cerebral palsy [2]. The use of GDI and the computation of effect sizes are suggested to allow for the conduction of systematic reviews on the impact of GA on treatment outcomes [3]. Despite of the increasing use of FS in adults with acquired joint deformities consequent to a stroke, there are no studies in literature using the GDI to investigate the effects FS on walking kinematics in these patients. The databases of two laboratories were retrospectively analyzed to extract data from patients with the following inclusion criteria: hemiparesis consequent to ischemic or hemorrhagic stroke, referral to the laboratories for clinical and instrumental assessment – gait analysis (GA) with EMG – preliminary to FS, lower limb FS performed by the same surgeon (author PZ), available GA data before and three months after FS, available informed consent. Gait kinematics was acquired using a commercial system (BTS Smart DX, BTS Bioengineering) and the so-called Conventional Protocol. GDI was computed by the GA system as in [1]. GDI values of the affected side were compared before and three months after surgery using the paired t-test. The Cohen’s d (effect size) with its 95% confidence interval was computed. Preliminary results are presented, related to a two-year period. Twenty-nine patients met the inclusion criteria. Of these, 8 needed an orthosis to walk and had a presurgical EMG assessment only. The remaining 21 patients, 56.4(10.3) years, 6/15 M/F, 19/2 L/R affected side, were included in the study. Preoperative walking speed was 0.30(0.18) m/s. Median FAC was 4 (range 2-7), WHS was 4 (2-6), and RMI was 11 (5-14). Three to eight gait trials per session were used for GDI computation. At the three- months mark, GDI significantly increased from 72(11) to 75(11) (p=0.004), with a moderate effect size of 0.71 (95%IC 0.22–1.12). The relationship between pre- and post-operative values is presented in Fig. 1. A subgroup of subjects had an increase in GDI, irrespective of their initial condition, a subgroup of patients had no variations in GDI while a few patients had a worsening in GDI. For the first time in literature, we used the GDI to investigate the effect of FS on gait kinematics in adults with stroke. Our results confirm, on average, the efficacy of FS in improving walking ability. GDI allowed easily merging data from different laboratories. It could be used to identify clusters of improved/not improved patients to further investigate their characteristics. In clinical trials, GDI could be used to compare the efficacy of different of different treatments, e.g. FS v. focal inhibition or of different surgical approaches, e.g. with and without preoperative GA, as in [4]. Positive results would promote the use of GA in the assessment of stroke patients and support its reimbursement by both national health systems and private insurances.

Can rehabilitation adherence among stroke patients be measured using a single item?

To assess the concurrent validity between logbooks and a single-item rehabilitation adherence measurement for patients with stroke. Agreement between caregivers and patients and between caregivers and physical therapists regarding a single-item measurement was investigated, and its predictive validity was explored. Adherence to therapy is a primary determinant of treatment success. There are no standard instruments for measuring rehabilitation adherence available for stroke patients. Prospective longitudinal study. Seventy-five patients with stroke were recruited, measured four times and followed for 6 months. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used to ensure comprehensive reporting. Adherence was documented in logbooks, and single-item measurements were compared. Predictive validity was explored by assessing associations between adherence levels, self-care ability and health-related quality of life. The Spearman's correlation coefficients, weighted kappa, and generalised estimating equations statistics were used to explore the concurrent validity, measurement agreement, and predictive validity, respectively. Logbook records had a fair correlation (rs =.23, p=.04) with the single-item rehabilitation adherence measurements. There was moderate agreement (kappa=0.42, p < .001) between caregiver and patient assessments and fair agreement (kappa=0.29, p=.017) between caregiver and physical therapist assessments of patients' rehabilitation adherence levels. Perfect rehabilitation adherence, based on the logbook and single-item measurements, predicted better scores for self-care ability and quality of life than imperfect rehabilitation adherence during 6months after inclusion. There was fair concurrent validity between logbooks and single-item rehabilitation adherence measurements and moderate and fair adherence measure agreement between caregivers and patients and caregivers and physical therapists, respectively. Logbooks and single-item rehabilitation adherence measurements had adequate predictive validity. Single-item rehabilitation adherence measurement is a workable and straightforward method to assess stroke patients' rehabilitation adherence in busy clinical care settings. Caregivers can represent stroke patients regarding their reported rehabilitation adherence. Patients were diagnosed with stroke in the study hospital. Rehabilitation physicians transferred patients to a research nurse who then screened them for the inclusion criteria and invited them and their family caregivers to participate in this study if they met the requirements. We also recruited seven physical therapists responsible for the physical therapy of the study participants. After participants signed informed consent, the research nurse encouraged participants to respond to research questions face to face, including rehabilitation adherence data, daily physical function, and quality of life. Each participant was measured four times at baseline and at 1, 3, and 6months after inclusion in this study. Physical therapists had to score their patients' rehabilitation adherence levels before discharge. Not applicable.

Intra- and inter-rater reliability of the Italian Fugl-Meyer assessment of upper and lower extremity

Purpose To assess the intra- and inter-rater reliability motor and sensory functioning, balance, joint range of motion and joint pain subscales of the Italian Fugl-Meyer Assessment (FMA) Upper Extremity (FMA-UE) and Lower Extremity (FMA-LE) at the item- subtotal- and total-level in patients with sub-acute stroke. Materials and methods The FMA was administered to 60 patients with sub-acute stroke (mean age ± SD = 75.4 ± 10.7 years; 58.3% men) and independently rated by two physiotherapists on two consecutive days. Intra- and inter-reliability was studied by a rank-based statistical method for paired ordinal data to detect any systematic or random disagreement. Results The item-level intra- and inter-rater reliability was satisfactory (>70%). Reliability level >70% was achieved at subscale and total score level when one- or two-points difference was considered. Systematic disagreements were reported for five items of the FMA-UE, but not for FMA-LE. Conclusions The Italian version of the FMA showed to be a reliable instrument that can therefore be recommended for clinical and research purposes. Implications for rehabilitation The FMA is the gold standard for assessing stroke patients’ sensorimotor impairment worldwide. The Italian Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Lower Extremity (FMA-LE) is substantially reliable within and between two raters at the item, subtotal, and total score level in patients with sub-acute stroke. The use of FMA in the Italian context will provide an opportunity for international comparisons and research collaborations.

Hemodynamic signal changes and swallowing improvement of repetitive transcranial magnetic stimulation on stroke patients with dysphagia: A randomized controlled study.

ObjectiveOur study aims to measure the cortical correlates of swallowing execution in patients with dysphagia after repetitive transcranial magnetic stimulation (rTMS) therapy using functional near-infrared spectroscopy (fNIRS), and observe the change of pattern of brain activation in stroke patients with dysphagia after rTMS intervention. In addition, we tried to analyze the effect of rTMS on brain activation in dysphagia patients with different lesion sides. This study also concentrated on the effect of stimulating the affected mylohyoid cortical region by 5 Hz rTMS, providing clinical evidence for rTMS therapy of dysphagia in stroke patients.MethodsThis study was a sham-controlled, single-blind, randomized controlled study with a blinded observer. A total of 49 patients completed the study, which was randomized to the rTMS group (n = 23) and sham rTMS group (n = 26) by the random number table method. The rTMS group received 5 Hz rTMS stimulation to the affected mylohyoid cortical region of the brain and the sham rTMS group underwent rTMS using the same parameters as the rTMS group, except for the position of the coil. Each patient received 2 weeks of stimulation followed by conventional swallowing therapy. Standardized Swallowing Assessment (SSA), Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS), Penetration-Aspiration Scale (PAS), and functional oral intake status were assessed at two times: baseline (before treatment) and 2 weeks (after intervention). Meanwhile, we use the fNIRS system to measure the cerebral hemodynamic changes during the experimental procedure.ResultsThe rTMS group exhibited significant improvement in the SSA scale, FEDSS scale, and PAS scale after rTMS therapy (all P < 0.001). The sham rTMS group had the same analysis on the same scales (all P < 0.001). There was no significant difference observed in clinical assessments at 2 weeks after baseline between the rTMS group and sham rTMS group (all P > 0.05). However, there were statistically significant differences between the two groups in the rate of change in the FEDSS score (P = 0.018) and PAS score (P = 0.004), except for the SSA score (P = 0.067). As for the removal rate of the feeding tube, there was no significant difference between the rTMS group and sham rTMS group (P = 0.355), but there was a significant difference compared with the baseline characteristics in both groups (PrTMS < 0.001, PshamrTMS = 0.002). In fNIRS analysis, the block average result showed differences in brain areas RPFC (right prefrontal cortex) and RMC (right motor cortex) significantly between the rTMS group and sham rTMS group after intervention (Pchannel30 = 0.046, Pchannel16 = 0.006). In the subgroup analysis, rTMS group was divided into left-rTMS group and right-rTMS group and sham rTMS group was divided into sham left-rTMS group and sham right-rTMS group. The fNIRS results showed no significance in block average and block differential after intervention between the left-rTMS group and sham left-rTMS group, but differences were statistically significant between the right-rTMS group and sham right-rTMS group in block average: channel 30 (T = −2.34, P = 0.028) in LPFC (left prefrontal cortex) and 16 (T = 2.54, P = 0.018) in RMC. After intervention, there was no significance in left-rTMS group compared with baseline, but in right-rTMS group, channel 27 (T = 2.18, P = 0.039) in LPFC and 47 (T = 2.17, P = 0.039) in RPFC had significance in block differential. In the sham rTMS group, neither sham left-rTMS group and sham right-rTMS group had significant differences in block average and block differential in each brain area after intervention (P > 0.05).ConclusionsThe present study confirmed that a 5-Hz rTMS is feasible at the affected mylohyoid cortical region in post-stroke patients with dysphagia and rTMS therapy can alter cortical excitability. Based on previous studies, there is a dominant hemisphere in swallowing and the results of our fNIRS analysis seemed to show a better increase in cortical activation on the right side than on the left after rTMS of the affected mylohyoid cortical region. However, there was no difference between the left and right hemispheres in the subgroup analysis. Nevertheless, the present study provides a novel and feasible method of applying fNIRS to assessment in stroke patients with dysphagia.

Intra-rater and inter-rater reliability of pressure pain threshold assessment in stroke patients.

As pain is a common symptom following a stroke, pressure pain threshold (PPT) assessment can be used to evaluate pain status or pain sensitivity of patients. However, the reliability of PPT test in stroke patients is still unknown. To examine the intra- and inter-rater reliability of PPT measurements in poststroke survivors and explore their factors. An observational study. The setting of the study is a rehabilitation hospital. The population of the study was represented by a total of 54 patients after stroke. The study included 16 measured points on the affected and unaffected sides. PPT was assessed by two raters in turn. Intra- and inter-rater reliability was evaluated by intraclass correlation coefficients (ICC). All intra-rater (ICC=0.84-0.97) and inter-rater (ICC=0.83-0.95) reliability for PPT assessment were good or excellent in stroke patients. Of the 16 points, 12 showed higher intra-rater ICC values than inter-rater, whereas no evident difference was observed between the affected and unaffected sides. Furthermore, patients who were male, ischemic, or with higher motor function generally performed higher ICC values than those who were female (24 out of 32 results), hemorrhagic (28 out of 32 results), or mobility dysfunction (26 out of 32 results), respectively. PPT assessment with good or excellent reliability can be used in stroke patients. Neither of the two sides (affected or unaffected) affects PPT reliability, and intra-rater reliability is better than inter-rater reliability. In addition, gender, stroke type, and motor function can affect the reliability of measuring mechanical pain threshold in poststroke survivors. The pressure algometer can be used as a reliable and portable tool to assess the mechanical pain tolerance and sensory function in stroke patients in clinics.

EFFECT OF MELATONIN IN POST-STROKE RECOVERY

Objective: Stroke is the second main cause of death worldwide. Recovery from a stroke differs from person to person. Melatonin is a neuroprotective agent with low adverse effects. The limitation of melatonin studies on human and other clinical bases made us keen to took up this research work to explore its full potential as a neuroprotective agent. The purpose of this research was to evaluate the effect of melatonin in stroke recovery inpatients. Methods: This was a present prospective observational study carried out at the Department of Neurology of tertiary care hospital over 6 months. The patient data were collected through history interview and from the case sheets. Continuous variables were presented as the minimum, maximum, median, mean, and standard error of the mean (SEM). Categorical variables were presented as frequencies and percentages. Results: A total of 80 patients were included in this study based on inclusion criteria. A significant difference was not found in the age and gender between the two study groups. There is a statistically significant difference in the percentage of improvement of modified Rankin Scale (mRS), Communication Disability Scale (CDS), and Cognitive Assessment of Stroke Patients (CASP) scores between the study groups. Conclusion: Our study concluded that patients received melatonin along with first-line treatment which has shown better efficacy in treating post-recovery stroke patients when compared with patients received first-line treatment alone. Melatonin served as an excellent neuroprotectant in patients of acute ischemic stroke with improvement in the motor, speech, and cognitive functions.

The Role of Doctors in Ambulance Management of Stroke Patients in Emergency Medical Services

BACKGROUND: Strokes are one of the most common of all neurological diseases and can be found in all genders and ages. Emergency medical services (EMS) are the first line of care with access to stroke patients from on the scene assessment to initial treatment. However, currently there are no studies regarding the role doctors play in initial ambulance contact to assess stroke patients.&#x0D; AIM: To analyze the role of doctors in ambulances managing stroke patients in EMS.&#x0D; METHODS: This was a retrospective study over a five-year period (2017-2021) at Srinagarind Hospital EMS units. The information from the EMS database was transferred completely into the data record form and imported into the computer system for further data analysis.&#x0D; RESULTS: A total of 10,329 EMS operations were examined. The mean age of the patients was 52.10 ± 10.24 years. A total of 64.4% (n = 6650) of them were male. The afternoon shift was the most common time for EMS operations with doctors in the stroke group (42.9%) and non-stroke group (59.3%). The distance from hospital to the scene in the stroke group was 12.6 ± 3.2 km. The average response time for stroke group and non-stroke group were 7.05 minutes and 9.50 minutes, respectively&#x0D; CONCLUSIONS: The role of doctors in the ambulance to manage stroke patients in EMS directly resulted in a decrease in time in arriving at the scene to diagnose, arriving at the laboratory, and arriving at the scene to activate the special team.