Function In Chronic Stroke Patients Research Articles

Combining muscle-computer interface guided training with bihemispheric tDCS improves upper limb function in chronic stroke patients.

Transcranial direct current stimulation (tDCS) may facilitate neuroplasticity but with a limited effect when administered while stroke patients are at rest. Muscle-computer interface (MCI) training is a promising approach for training stroke patients even if they cannot produce overt movements. However, using tDCS to enhance MCI training has not been investigated. We combined bihemispheric tDCS with MCI training of the paretic wrist and examined the effect of this intervention in chronic stroke patients. A crossover, double-blind, randomized trial was conducted. Twenty-six chronic stroke patients performed MCI wrist training for three consecutive days at home while receiving either real tDCS or sham tDCS in counterbalanced order and separated by at least 8 months. The primary outcome measure was the Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE) which was measured one week before training, on the first training day, on the last training day, and one week after training. There was no significant difference in the baseline FMA-UE score between groups nor between intervention periods. Patients improved 3.9 ± 0.6 points in FMA-UE score when receiving real tDCS, and 1.0 ± 0.7 points when receiving sham tDCS (p = 0.003). Additionally, patients also showed continuous improvement in their motor control of the MCI tasks over the training days. Our study showed that the training paradigm could lead to functional improvement in chronic stroke patients. We argue that appropriate MCI training in combination with bihemispheric tDCS could be a useful adjuvant for neurorehabilitation in stroke patients.

Effects of Brain Computer Interface (BCI) rehabilitation robot on upper limb function in chronic stroke patients - A randomized controlled trial

Effects of Brain Computer Interface (BCI) rehabilitation robot on upper limb function in chronic stroke patients - A randomized controlled trial

Simultaneous high-definition transcranial direct current stimulation and robot-assisted gait training in stroke patients

This study investigates whether simultaneous high-definition transcranial direct current stimulation (HD-tDCS) enhances the effects of robot-assisted gait training in stroke patients. Twenty-four participants were randomly allocated to either the robot-assisted gait training with real HD-tDCS group (real HD-tDCS group) or robot-assisted gait training with sham HD-tDCS group (sham HD-tDCS group). Over four weeks, both groups completed 10 sessions. The 10 Meter Walk Test, Timed Up and Go, Functional Ambulation Category, Functional Reach Test, Berg Balance Scale, Dynamic Gait Index, Fugl-Meyer Assessment, and Korean version of the Modified Barthel Index were conducted before, immediately after, and one month after the intervention. The real HD-tDCS group showed significant improvements in the 10 Meter Walk Test, Timed Up and Go, Functional Reach Test, and Berg Balance Scale immediately and one month after the intervention, compared with before the intervention. Significant improvements in the Dynamic Gait Index and Fugl-Meyer Assessment were also observed immediately after the intervention. The sham HD-tDCS group showed no significant improvements in any of the tests. Application of HD-tDCS during robot-assisted gait training has a positive effect on gait and physical function in chronic stroke patients, ensuring long-term training effects. Our results suggest the effectiveness of HD-tDCS as a complementary tool to enhance robotic gait rehabilitation therapy in chronic stroke patients.

Effects of Circuit Class Training Versus Individual, Task Specific Training on Upper Extremity Function in Chronic Stroke Patients

Background: Stroke is a leading contributor to disability globally, emphasizing the need for effective rehabilitation techniques. Circuit class training (CCT) and individual, task-specific training (ITST) have emerged as potential approaches for enhancing upper extremity function in stroke survivors. Comparative analyses of their efficacy, especially among chronic stroke patients, are scant. Objective: This study aimed to evaluate and compare the impacts of CCT and ITST on upper extremity spasticity, motor function, and quality of life in individuals with chronic stroke. Methods: In a randomized controlled trial, 36 chronic stroke patients were allocated to either CCT or ITST groups. Participants were aged 45-70 years, had experienced a single stroke episode, and were at least 6 months post-stroke, with specific inclusion criteria regarding spasticity and motor function levels. The interventions were delivered for 1.5 hours daily, five days a week, over eight weeks. Outcomes were measured using the Modified Ashworth Scale (MAS) for spasticity, Functional Independence Measure for Upper Extremity (FMA-UE) for motor function, and Stroke-Specific Quality of Life (SS-QOL) scale for quality of life, analyzed using SPSS version 25. Results: Post-intervention, both CCT and ITST participants exhibited significant improvements in their outcomes. MAS scores showed a reduction in spasticity, with average improvements not significantly differing between the groups. FMA-UE scores increased by an average of 10 points in both groups, indicating enhanced motor function without a significant difference between the groups (p > 0.05). SS-QOL scores improved by an average of 20 points in each group, reflecting better quality of life, with no significant intergroup difference observed. Conclusion: The study concludes that CCT and ITST are equally effective in ameliorating upper extremity spasticity, motor function, and quality of life among chronic stroke patients. The selection between CCT and ITST can thus be personalized based on patient preferences, available resources, and logistical considerations, maintaining rehabilitation efficacy.

Beyond Traditional Therapy: A Novel Multimodal Regimen for Stroke-Related Hand Dysfunction.

Objective: The study aims to explore the effect of a blended multimodal practice aregimen on enhancing upper extremity function in chronic stroke patients. Specifically, we seek to investigate the potential benefits of incorporating MMP into the existing rehabilitation protocols for stroke survivors and assess its effectiveness in improving motor outcomes. Methods: The study utilized a randomized controlled trial design with chronic stroke patients who experienced upper extremity impairments. The participants were provided multimodal physical practice, multimodal mental practice, and blended multimodal practice regimen for three months. Results: The ANOVA analysis revealed a significant difference among the groups for the MMPG measure, indicating that the Blended Multimodal Practice Group (BMPG) performed significantly better compared to the Multimodal Physical Practice Group (MPPG) and the Multimodal Mental Practice Group (MMPG). Conclusion: The findings of this study suggest that incorporating multimodal mental practice approaches into stroke rehabilitation programs can enhance upper extremity function in chronic stroke patients.

Efficacy of MCIMT with Auditory Cueing in order to Augment Functional Motor Recovery of Chronic Hemiparetic Arm

Background: Stroke is a leading cause of functional impairments globally, often resulting in long-term disability and a substantial impact on individuals, families, and caregivers. Learned nonuse, a phenomenon where motor deficits persist after a stroke due to central nervous system suppression, is a significant challenge in stroke rehabilitation. Constraint-Induced Movement Therapy (CIMT) is a well-established neurorehabilitation approach based on behavioural training, which includes repetitive task-specific training, behavioural techniques, and constraining the use of the more affected upper extremity. CIMT has been successful in improving functionality in chronic hemiparetic stroke patients, promoting cortical reorganization and neural plasticity.
 Method: This study involved 60 stroke survivors aged 20 or older, selected purposively and meeting specific criteria. Participants underwent an 8-week Modified CIMT (M-CIMT) program with auditory cueing for the hemiparetic upper limb. Data collection included pre-test and post-test assessments using the Wolf Motor Function Test (WMFT) and the Motor Activity Log (MAL) to evaluate functional activity. The M-CIMT program comprised warm-up sessions, M-CIMT protocols, and cool-down exercises, conducted five days a week.
 Results: Following participation in the M-CIMT program, significant improvements were observed in WMFT and MAL scores. The mean pre-test score of 46.60 seconds decreased to a mean post-test score of 16.85 seconds, with highly significant t-values of 14.292 and -51.356 and a p-value of 0.0, indicating a strong correlation between the two datasets. The analysis revealed that M-CIMT effectively enhanced upper extremity function in chronic stroke patients.
 Conclusion: This study highlights the effectiveness of the Modified CIMT protocol, emphasizing repeated use and a distributed practice schedule, in reducing upper-limb impairment and improving upper-limb use and function in chronic stroke patients. The significant improvement in post-test scores underscores the promise of M-CIMT as a valuable approach for upper extremity rehabilitation following chronic stroke, offering hope for enhanced recovery and improved quality of life for affected individuals.
 Keywords: Stroke; Rehabilitation; Upper Extremity; Constraint-Induced Movement Therapy; Motor Activity

A bidirectional fabric-based soft robotic glove for hand function assistance in patients with chronic stroke

BackgroundChronic stroke patients usually experience reduced hand functions, impeding their ability to perform activities of daily living (ADLs) independently. Additionally, improvements in hand functions by physical therapy beyond six months after the initial onset of stroke are much slower than in the earlier months. As such, chronic stroke patients could benefit from an assistive device to enhance their hand functions, allowing them to perform ADLs independently daily. In recent years, soft robotics has provided a novel approach to assistive devices for motor impaired individuals, offering more compliant and lightweight alternatives to traditional robotic devices. The scope of this study is to demonstrate the viability of a fabric-based soft robotic (SR) glove with bidirectional actuators in assisting chronic stroke study participants with hand impairments in performing ADLs.MethodsForce and torque measurement tests were conducted to characterize the SR Glove, and hand functional tasks were given to eight chronic stroke patients to assess the efficacy of the SR Glove as an assistive device. The tasks involved object manipulation tasks that simulate ADLs, and the series of tasks was done by the participants once without assistance for baseline data, and once while using the SR Glove. A usability questionnaire was also given to each participant after the tasks were done to gain insight into how the SR Glove impacts their confidence and reliance on support while performing ADLs.ResultsThe SR Glove improved the participants’ manipulation of objects in ADL tasks. The difference in mean scores between the unassisted and assisted conditions was significant across all participants. Additionally, the usability questionnaire showed the participants felt more confident and less reliant on support while using the SR Glove to perform ADLs than without the SR Glove.ConclusionsThe results from this study demonstrated that the SR Glove is a viable option to assist hand function in chronic stroke patients who suffer from hand motor impairments.

Effects of Dual Motor Task Gait Training on Balance and Gait Function in Chronic Stroke Patients

Effects of Dual Motor Task Gait Training on Balance and Gait Function in Chronic Stroke Patients

Feasibility of challenging treadmill speed-dependent gait and perturbation-induced balance training in chronic stroke patients with low ambulation ability: a randomized controlled trial.

Treadmill training shows advantages in the specificity, amount, and intensity of gait and balance practice for the rehabilitation of stroke patients. To investigate the feasibility and effectiveness of challenging treadmill speed-dependent gait and perturbation-induced balance training in chronic stroke patients with low ambulation ability. For this randomized controlled trial (Chinese Clinical Trials.gov registration number ChiCTR-IOR-16009536) with blinded testers, we recruited 33 ambulatory stroke participants with restricted community ambulation capacity and randomly assigned them into two groups: the experimental group with 2 week treadmill speed-dependent gait training combined with 2 week treadmill perturbation-induced balance training (EXP) or the control group with traditional gait and balance training (CON). Various variables were recorded during EXP training, including the rating of perceived exertion, heart rate, causes of pauses, treadmill speed, and perturbation intensity. Outcome measures were examined before training and at 2 and 4 weeks after training. They included gait velocity during five-meter walk test at comfortable and fast speed and reactive balance ability in the compensatory stepping test as primary outcome measures, as well as dynamic balance ability (timed up-and-go test and 5 times sit-to-stand test) and balance confidence as secondary outcome measures. All participants completed the study. The treadmill speed and perturbation intensity significantly increased across training sessions in the EXP group, and no adverse effects occurred. The normal and fast gait velocities showed significant time and group interaction effects. They significantly increased after 2 and 4 weeks of training in the EXP group (p < 0.05) but not in the CON group (p > 0.05). Likewise, dynamic balance ability measured using the timed up-and-go test at a fast speed significantly improved after 2 and 4 weeks of training in the EXP group (p < 0.05) but not in the CON group (p > 0.05), although without a significant time and group interaction effect. Surprisingly, the reactive balance ability did not show improvement after treatment in the EXP group (p > 0.05). Challenging treadmill speed-dependent gait and treadmill perturbation-induced balance training is feasible and effective to improve ambulation function in chronic stroke patients with low ambulation ability.

열자극을 병행한 가상현실훈련이 만성 뇌졸중 환자의 위팔 능동가동범위와 기능에 미치는 영향

열자극을 병행한 가상현실훈련이 만성 뇌졸중 환자의 위팔 능동가동범위와 기능에 미치는 영향

Abstract 147: First-in-human Phase 1/2a Study Of Intracerebral Transplantation Using Embryonic-derived Neural Stem Cells (NR1) For Chronic Ischemic Stroke

Introduction: Currently, no treatment exists to restore function in chronic stroke patients. Several prior intracerebral stem cell trials showed safety, but are not being further developed. Objective: NR1 is a human embryonic derived neural stem cell that improved motor-sensory function in rodent stroke models, and was expanded to produce GMP cryopreserved Cell Lots (P18). The aim is to assess the safety, tolerability and efficacy using intracerebral transplantation of NR1 cells in chronic stroke patients (NCT04631406). Methods: Inclusion Criteria: 18-75 yo; 6-60 months post-ischemic subcortical MCA stroke; mRS 3-4. Subjects are transplanted with NR1 (2.5M, 5M, 10M or 20M). Primary Outcomes: Adverse events 0-6 mos; Change in Fugl-Meyer (FM) motor score (maximum FM 100) compared to baseline at 6 months (≥10 points improvement considered “clinically meaningful”). Other outcomes: Barthel Index, NIHSS, Gait Speed test, mRS, MRI DTI, FLAIR, Resting State fMRI and [18F] FDG PET. Results: Six patients have been transplanted. Adverse events included headache and worsened speech, all resolving spontaneously. At 6 mos post-transplant: FM improved 15, 13 and 9 points in patients 1, 2 and 3 (all with faster gait); Barthel Index improved 5, 10 and 15 points. At 3 months FM improved 15 points (with faster gait) in patient 4. NIHSS improved 2 points in 2 patients and worsened 1 point in 1 patient. There was no change in mRS. All 6 patients demonstrated a new transient FLAIR signal in premotor cortex at d7, that resolved by 2 mos, which in prior studies was highly correlated with sustained neurologic recovery. An increase in regional homogeneity (ReHo) and fractional amplitude of low-frequency fluctuations (fALFFs) was observed in the sensorimotor network ipsilateral to the chronic infarction in patients with clinical improvement. Six additional patients are scheduled in the next 6 months. Conclusions: Intraparenchymal transplantation with NR1 cells in chronic stroke patients appears safe and well tolerated. Early results suggest improved motor function at 1-6 months post-implant.

Enhancing Upper Extremity Function in Chronic Stroke Patients: Exploration of the Impact of Multimodal Mental Practice Approach

Objective: The present study aims to explore the impact of a multimodal mental practice approach on enhancing upper extremity function in chronic stroke patients. Specifically, we seek to investigate the potential benefits of incorporating MMP into the existing rehabilitation protocols for stroke survivors and assess its effectiveness in improving motor outcomes. Methods: The study utilized a randomized controlled trial design with chronic stroke patients who experienced upper extremity impairments. The participants were provided multimodal physical practice, multimodal mental practice, and blended multimodal practice regimen for three months. Results: The ANOVA analysis revealed a significant difference among the groups for the MMPG measure, indicating that the Blended Multimodal Practice Group (BMPG) performed significantly better compared to the Multimodal Physical Practice Group (MPPG) and the Multimodal Mental Practice Group (MMPG). Conclusion: The findings of this study suggest that incorporating multimodal mental practice approaches into stroke rehabilitation programs can enhance upper extremity function in chronic stroke patients.

Applying Action Observation During a Brain-Computer Interface on Upper Limb Recovery in Chronic Stroke Patients

The study aimed to compare the effects of combined action observation and motor imagery (AOMI) and motor imagery (MI)-based brain-computer interface (BCI) training on upper limb recovery, cortical excitation, and cognitive task performance in chronic stroke patients. 17 chronic stroke patients were recruited and randomly assigned to AOMI-based BCI (n = 9) and MI-based BCI groups (n = 8). The AOMI-based BCI group received AOMI-based BCI training via functional electrical stimulation (FES) feedback, whereas the MI-based BCI group obtained MI-based BCI training via FES feedback. Both groups participated in training for 12 sessions (3 days/week, consecutive four weeks). To evaluate upper limb function recovery, the Fugl–Meyer Assessment for upper extremity (FMA-UE) was employed. Event-related desynchronization (ERD) and online classification accuracy were utilized to measure cortical excitation of the affected sensorimotor hand region and cognitive task performance, respectively. Both AOMI and MI-based BCI training improved upper limb function in chronic stroke patients. However, the AOMI-based BCI group showed significantly greater motor gain than the MI-based BCI group. In addition, the AOMI-based BCI group demonstrated significantly greater cortical excitation of the affected sensorimotor hand region and cognitive task performance. The correlation analysis revealed that higher cognitive task performance during AOMI-based BCI training may promote greater cortical excitation of the affected sensorimotor hand region, which contributes to greater upper limb function improvement compared to MI-based BCI training.

A Study of Different Frequencies of Repetitive Transcranial Magnetic Stimulation on Upper Extremity Muscle Activity and Hand Function in Chronic Stroke Patients

The purpose of this study was to compare the use of different frequencies of repetitive transcranial magnetic stimulation (rTMS) on the upper extremity muscle activity and hand function of chronic stroke patients. The study subjects comprised 18 chronic stroke patients: the 5 Hz rTMS group (HFG), which included nine patients who received rTMS to the affected cerebral hemisphere, and the 1 Hz low-frequency group (LFG), which had nine patients who received rTMS to the nonaffected cerebral hemisphere. The intervention was conducted three times a week for four weeks. Electromyography was used to check muscle activity, and the stroke upper extremity function test (MFT) and grip strength test were performed to check hand function. Pre- and post-evaluations were performed for both groups. A comparison between the two groups showed a significant difference in the activity of the trapezius anterior and triceps brachii muscle for the muscle activities in the HFG group (p 0.05) as well as a significant difference in the MFT results for hand function (p 0.05). In the LFG group, a significant difference was noted in the triceps brachii muscle for muscle activity (p 0.05), but no significant difference was evident in hand function (p 0.05). The comparison of the two groups showed a significant difference in muscle activity in the triceps brachii muscle (p 0.05) but no significant difference in hand function (p 0.05). This study confirmed that high-frequency rTMS has a positive effect on upper extremity muscle activity and hand function in chronic stroke patients.

A Comparative Study of 5 Hz Repetitive Transcranial Magnetic Stimulation on Cortical Activity and Upper Limb Function in Chronic Stroke Patients with Different Stroke Etiologies: A Case Study

The purpose of this study was to investigate the effect of 5Hz repetitive transcranial magnetic stimulation (rTMS) on cortical activity and upper limb function in the etiology of chronic stroke patients. 2 patients with ischemic stroke and 2 patients with hemorrhagic stroke who satisfied the selection criteria were selected using the ABA’ single subjective design. The study period was applied 18 times in all 4 patients: 3 times at baseline (A), 12 times in intervention period (B), and 3 times in baseline (A

Effect of compressive therapy on sensorimotor function of the more affected upper extremity in chronic stroke patients: A randomized clinical trial.

Background:Common upper extremity (UE) physical impairments after stroke include paresis, abnormal muscle tone, and somatosensory affection. This study evaluated the effect of passive somatosensory stimulation using compressive therapy on sensorimotor function of the more affected UE in chronic stroke patients.Methods:Forty chronic stroke patients were enrolled in this study. They were randomized into 2 groups: Gr1 and Gr2. Three patients dropped out leaving us with a total of 37 patients completing the study. Gr1 received UE motor program for the more affected UE along with sham electrical stimulation while Gr2 had the same UE motor program along with passive somatosensory stimulation. The session duration in both groups was 85 min. Gr1 and Gr2 received a total of 36 sessions for 6 successive weeks. UE function in Gr1 and Gr2 was examined, before and after treatment using Box and Block test (BBT) and Perdue Pegboard test (PPBT) as measures of motor of both the more affected and less affected UE while the Nottingham sensory assessment (NSA) scale was used as a measure of sensory function of the more affected UE.Results:There were significant improvements in motor and sensory function of the more affected UE compared to the less affected UE in both groups, measured by the BBT, PPBT, and NSA scales post-treatment (P < .05). However, the comparison between both groups regarding improvement revealed no significant change (P > .05).Conclusion:Upper extremity motor and passive somatosensory stimulation techniques are effective in improving sensorimotor function of the more affected UE, but none of them had the advantage over the other, in terms of improving motor and sensory function in chronic stroke patients.

Effectiveness of water aerobics in improving chest mobility and pulmonary function in chronic stroke patients

Introduction and Aim: Stroke is one of the prominent causes of long-term disability. Stroke affects everyone uniquely depending on the level and location of the area affected in the brain and how long the brain tissue was deprived of oxygen. Individuals with stroke usually demonstrate changes in breathing patterns, decreased strength of respiratory muscles, and decreased ventilatory function. The aim of the study is to assess the effects of water aerobics on the pulmonary function of people with stroke. Materials and Methods: This study was conducted in a clinical setup. A total number of 16 subjects were selected based on the inclusion and exclusion criteria. All the subjects received water aerobic exercises for 40minutes sessions for 4days per week for 12weeks. Pre- and Post-treatment assessments were done by measuring chest expansion and forced vital capacity. Results: All the 16 subjects completed the 12 weeks water aerobics intervention. After 12 weeks post treatment assessments were taken. The outcome measures, of chest expansion and forced vital capacity showed a significant improvement. Conclusion: The results of this study show that there is a significant improvement in the chest expansion and pulmonary function after giving water aerobics intervention.

EEG-Based Brain Network Analysis of Chronic Stroke Patients After BCI Rehabilitation Training.

Traditional rehabilitation strategies become difficult in the chronic phase stage of stroke prognosis. Brain–computer interface (BCI) combined with external devices may improve motor function in chronic stroke patients, but it lacks comprehensive assessments of neurological changes regarding functional rehabilitation. This study aimed to comprehensively and quantitatively investigate the changes in brain activity induced by BCI–FES training in patients with chronic stroke. We analyzed the EEG of two groups of patients with chronic stroke, one group received functional electrical stimulation (FES) rehabilitation training (FES group) and the other group received BCI combined with FES training (BCI–FES group). We constructed functional networks in both groups of patients based on direct directed transfer function (dDTF) and assessed the changes in brain activity using graph theory analysis. The results of this study can be summarized as follows: (i) after rehabilitation training, the Fugl–Meyer assessment scale (FMA) score was significantly improved in the BCI–FES group (p < 0.05), and there was no significant difference in the FES group. (ii) Both the global and local graph theory measures of the brain network of patients with chronic stroke in the BCI–FES group were improved after rehabilitation training. (iii) The node strength in the contralesional hemisphere and central region of patients in the BCI–FES group was significantly higher than that in the FES group after the intervention (p < 0.05), and a significant increase in the node strength of C4 in the contralesional sensorimotor cortex region could be observed in the BCI–FES group (p < 0.05). These results suggest that BCI–FES rehabilitation training can induce clinically significant improvements in motor function of patients with chronic stroke. It can improve the functional integration and functional separation of brain networks and boost compensatory activity in the contralesional hemisphere to a certain extent. The findings of our study may provide new insights into understanding the plastic changes of brain activity in patients with chronic stroke induced by BCI–FES rehabilitation training.

Effects of Respiratory Muscle Strengthening Training on the Pulmonary Function in Chronic Stroke Patients on an Unstable Support Surface

Effects of Respiratory Muscle Strengthening Training on the Pulmonary Function in Chronic Stroke Patients on an Unstable Support Surface

A Novel Perspective on the Proactive and Reactive Controls of Executive Function in Chronic Stroke Patients.

ObjectivesTo investigate the proactive and reactive control process when executing a complex task in patients with stroke. Proactive control is the preparatory process before the target stimulus, whereas reactive control is an imperative resolution of interference after the target stimulus.MethodsIn total, 17 patients with chronic stroke and 17 healthy individuals were recruited. The proactive and reactive control of executive function was assessed by the task-switching paradigm and the AX version of the Continuous Performance Task (AX-CPT). The general executive function was assessed by Color Trial Test (CTT) and Stroop Test. The behavioral data of the task-switching paradigm were analyzed by a three-way repeated-measures ANOVA, and the AX-CPT data were analyzed by two-way repeated-measures ANOVA.ResultsFor efficiency scores in the task-switching paradigm, trial (repeat vs. switch) × group (stroke or control group) interaction effect was significant. Post-hoc analysis on trial × group effect showed a significant between-trial difference in accuracy rates in the repeat trial in the control group regardless of 100 or 50% validity. For the AX-CPT, the main effects of condition and group on response time were statistically significant. The interaction effect of condition (AY or BX) × group (stroke or control group) was also significant. Post-hoc analysis for condition × group indicated that the stroke group had a significantly longer response time in the BX condition than the control group and longer completion time in CTT2 and larger word interference for completion time in the Stroop test than the control cohort.ConclusionsPost-stroke survivors showed deficits in the performance of proactive control but not in the performance of reactive control. Deficits in proactive control may be related to the impairment of working memory. Interventions that focus on proactive control may result in improved clinical outcomes.