Stroke Rehabilitation Interventions Research Articles

Predicting improvement in biofeedback gait training using short-term spectral features from minimum foot clearance data.

Stroke rehabilitation interventions require multiple training sessions and repeated assessments to evaluate the improvements from training. Biofeedback-based treadmill training often involves 10 or more sessions to determine its effectiveness. The training and assessment process incurs time, labor, and cost to determine whether the training produces positive outcomes. Predicting the effectiveness of gait training based on baseline minimum foot clearance (MFC) data would be highly beneficial, potentially saving resources, costs, and patient time. This work proposes novel features using the Short-term Fourier Transform (STFT)-based magnitude spectrum of MFC data to predict the effectiveness of biofeedback training. This approach enables tracking non-stationary dynamics and capturing stride-to-stride MFC value fluctuations, providing a compact representation for efficient processing compared to time-domain analysis alone. The proposed STFT-based features outperform existing wavelet, histogram, and Poincaré-based features with a maximum accuracy of 95%, F1 score of 96%, sensitivity of 93.33% and specificity of 100%. The proposed features are also statistically significant (p 0.001) compared to the descriptive statistical features extracted from the MFC series and the tone and entropy features extracted from the MFC percentage index series. The study found that short-term spectral components and the windowed mean value (DC value) possess predictive capabilities regarding the success of biofeedback training. The higher spectral amplitude and lower variance in the lower frequency zone indicate lower chances of improvement, while the lower spectral amplitude and higher variance indicate higher chances of improvement.

The effect of body weight-supported Tai Chi Yunshou on upper limb motor function in stroke survivors based on neurobiomechanical analysis: a four-arm, parallel-group, assessors-blind randomized controlled trial protocol.

A series of functional disorders commonly occur after stroke, of which upper limb dysfunction is the most difficult to recover. The upper limb rehabilitation effect of Tai Chi Yunshou(TCY) in the later stage of stroke has been confirmed by research. Body weight support-Tai Chi Yunshou (BWS-TCY) is based on TCY exercise and robotic exoskeletons offers most flexibility in deweighting and control strategy. This study is aimed to explore the effect of BWS-TCY on upper limb motor function in stroke based on neurobiomechanics. A single-blind randomized controlled trial will be conducted on 36 stroke survivors who will be randomly assigned to three groups: experimental group, control group A and control group B. In addition, 12 healthy elderly people will be recruited into the healthy control group. Those in the experimental group will receive 20 min of CRT and 20 min of BWS-TCY training, while participants in the control group A will receive 20 min of CRT and 20 min of Robot-assisted training. Participants in the control group B will undergo 40 min of Conventional rehabilitation training (CRT) daily. All interventions will take place 5 days a week for 12 weeks, with a 12-week follow-up period. No intervention will be carried out for the healthy control group. Upper limb function will be assessed before and after the intervention using various rating scales (Fugl-Meyer Assessment, Wolf Motor Function Test, etc.), as well as neurobiomechanical analyses (surface electromyography, functional near-infrared brain function analysis system, and Xsens maneuver Capture System). Additionally, 10 healthy elderly individuals will be recruited for neurobiomechanical analysis, and the results will be compared with those of stroke survivors. The results of this study will offer initial evidence on the effectiveness and feasibility of BWS-TCY as an early intervention for stroke rehabilitation. Positive findings from this study could contribute to the development of guidelines for the use of BWS-TCY in the early stages of stroke. This study has been approved by the Research Ethics Committees of the seventh People's Hospital Affiliated to Shanghai University of Traditional Chinese Medicine (Study ID: 2022-7th-HIRB-022). The results of the study will be published in a peer-reviewed journal and presented at scientific conferences. https://clinicaltrials.gov/, ChiCTR 2200063150.

Effects of spinal mobilization on physical function in patients with stroke: a systematic review and meta-analysis.

This systematic review and meta-analysis aimed to identify, critically appraise, and synthesize current evidence regarding the effects of spinal mobilization on physical function in patients with stroke. Three databases, PubMed, Embase, and Scopus, were searched from inception to March 15, 2024. Randomized controlled trials comparing the effects of spinal mobilization to conventional therapy were eligible for inclusion. Methodological quality was assessed using the Physiotherapy Evidence Database scale. Meta-analyses were performed to determine the effects of spinal mobilization. Nine randomized controlled trials were included, with a total of 294 patients with stroke. All included studies were evaluated as good or above for quality assessment. No adverse events related to spinal mobilization were reported. Compared to conventional therapy, spinal mobilization demonstrated significantly improved forward head posture (SMD: 1.00, 95% CI: 0.53 to 1.46, p < 0.001); there were no between-group differences on forced vital capacity (SMD: 0.44, 95% CI: -0.01 to 0.88, p = 0.06), forced expiratory volume (SMD: 0.33, 95% CI: -0.12 to 0.77, p = 0.15), balance (SMD: 0.36, 95% CI: -0.04 to 0.77, p = 0.08), gait speed (SMD: 0.48, 95% CI: -0.44 to 1.40, p = 0.31), and trunk function (SMD: 0.79, 95% CI: -0.17 to 1.75, p = 0.11). Cervical mobilization significantly improved forward head posture; however, no significant differences were found in other outcomes. Clinicians may consider spinal mobilization as an adjunctive intervention in stroke rehabilitation to address posture-related impairments to expand treatment strategy and optimize quality of care.

Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review.

Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions. This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT. Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1). From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality. Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in 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.

Compensatory increase in ipsilesional supplementary motor area and premotor connectivity is associated with greater gait impairments: a personalized fMRI analysis in chronic stroke.

Balance and mobility impairments are prevalent post-stroke and a large number of survivors require walking assistance at 6 months post-stroke which diminishes their overall quality of life. Personalized interventions for gait and balance rehabilitation are crucial. Recent evidence indicates that stroke lesions in primary motor pathways, such as corticoreticular pathways (CRP) and corticospinal tract (CST), may lead to reliance on alternate motor pathways as compensation, but the current evidence lacks comprehensive knowledge about the underlying neural mechanisms. In this study, we investigate the functional connectivity (FC) changes within the motor network derived from an individualized cortical parcellation approach in 33 participants with chronic stroke compared to 17 healthy controls. The correlations between altered motor FC and gait deficits (i.e., walking speed and walking balance) were then estimated in the stroke population to understand the compensation mechanism of the motor network in motor function rehabilitation post-stroke. Our results demonstrated significant FC increases between ipsilesional medial supplementary motor area (SMA) and premotor in stroke compared to healthy controls. Furthermore, we also revealed a negative correlation between ipsilesional SMA-premotor FC and self-selected walking speed, as well as the Functional Gait Assessment (FGA) scores. The increased FC between the ipsilesional SMA and premotor regions could be a compensatory mechanism within the motor network following a stroke when the individual can presumably no longer rely on the more precise CST modulation of movements to produce a healthy walking pattern. These findings enhance our understanding of individualized motor network FC changes and their connection to gait and walking balance impairments post-stroke, improving stroke rehabilitation interventions.

A systematic review of discrete choice experiments in stroke rehabilitation

ABSTRACT Objectives Existing research qualitatively explores consumer preferences for stroke rehabilitation interventions. However, it remains unclear which intervention characteristics are most important to consumers, and how these preferences may influence uptake and participation. Discrete choice experiments (DCE) provide a unique way to quantitatively measure preferences for health and health care. This study aims to explore how DCEs have been used in stroke rehabilitation and to identify reported consumer preferences for rehabilitation interventions. Material and Methods A systematic review of published stroke rehabilitation DCEs was completed (PROSPERO registration: CRD42021282578). Six databases (including CINAHL, MEDLINE, EconLIT) were searched from January 2000-March 2023. Data extracted included topic area, sample size, aim, attributes, design process, and preference outcomes. Descriptive and thematic analyses were conducted, and two methodological checklists applied to review quality. Results Of 2,446 studies screened, five were eligible. Studies focused on exercise preference (n = 3), the structure and delivery of community services (n = 1), and self-management programs (n = 1). All had small sample sizes (range 50–146) and were of moderate quality (average score of 77%). Results indicated people have strong preferences for one-to-one therapy (over group-based), light-moderate intensity of exercise, and delivery by qualified therapists (over volunteers). Conclusions Few DCEs have been conducted in stroke rehabilitation, suggesting consumer preferences could be more rigorously explored. Included studies were narrow in the scope of attributes included, limiting their application to practice and policy. Further research is needed to assess the impact of differing service delivery models on uptake and participation.

Influence of Nutritional Interventions on Functional Outcomes in Stroke Rehabilitation: A Systematic Review.

Stroke, a major cause of disability worldwide, necessitates comprehensive rehabilitation, with nutrition playing a pivotal role in recovery. Our systematic review assesses the impact of nutritional interventions on stroke survivors' rehabilitation. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched PubMed, Embase, Web of Science, and Scopus, using keywords related to stroke rehabilitation and nutrition. Studies were selected based on criteria emphasizing dietary interventions and their effect on functional recovery in stroke patients. The review involved detailed data extraction and synthesis, covering study design, participant characteristics, interventions, and outcomes. Five studies met our inclusion criteria, encompassing longitudinal and prospective studies, retrospective cohorts, and randomized controlled trials. These studies highlighted the importance of early nutritional assessment, particularly for sarcopenic patients, and the role of energy and protein intake soon after a stroke. Findings indicated high nutritional risk correlated with poorer functional outcomes and increased inflammation. Tailored dietary support appeared beneficial for muscle mass maintenance and overall functional recovery, especially in older patients. Our review emphasizes the critical role of nutritional interventions in stroke rehabilitation. It suggests that personalized nutritional strategies can positively impact functional recovery, notably in older and nutritionally vulnerable stroke survivors. These insights underscore the necessity of integrating dietary assessments and interventions into standard stroke rehabilitation protocols, advocating a holistic approach to patient care.

What is Task-Oriented Training? A Scoping Review

Task-Oriented Training (TOT) is an proven stroke rehabilitation intervention with significant evidence-based research that supports its effectiveness. The absence of a clear definition has led to variability in research reporting and subsequent confusion with practical implementation. A consistent definition seeks to remedy this ambiguity to facilitate knowledge translation. The objective of this study was to determine a comprehensive definition of TOT that encapsulates previous definitions and descriptions in the literature. In order to derive this definition, a two stage scoping review process was conducted across four databases searching for articles on the use of TOT in adult stroke rehabilitation therapy. The analysis of this scoping review included 174 articles. Commonly found words used to define TOT included: repetitive, functional, task practice, task specific, task oriented, intensity, and client-centered. Other salient words that aligned with the principles of neuroplasticity and key components of TOT were meaningful, progressive, graded, variable, and feedback. Based on these findings, a comprehensive proposed definition is as follows: Task-oriented training is an effective stroke rehabilitation intervention that focuses on the use of client-centered, repetitive practice of activities that are of high intensity and meaningful to the client. In conclusion, although similar principles were described in the TOT literature, there was no consistent and comprehensive definition of TOT. This scoping review identified key concepts from TOT methodology, and discussion sections in rehabilitation literature to generate a proposed comprehensive definition of TOT to guide research and practice.

MoCA Domain-Specific Pattern of Cognitive Impairment in Stroke Patients Attending Intensive Inpatient Rehabilitation: A Prospective Study.

A domain-specific perspective to cognitive functioning in stroke patients may predict their cognitive recovery over time and target stroke rehabilitation intervention. However, data about domain-specific cognitive impairment after stroke are still scarce. This study prospectively investigated the domain-specific pattern of cognitive impairments, using the classification proposed by the Montreal Cognitive Assessment (MoCA), in a cohort of 49 stroke patients at admission (T0), discharge (T1), and six-month follow-up (T2) from subacute intensive rehabilitation. The predictive value of T0 cognitive domains cognitive impairment at T1 and T2 was also investigated. Patients' cognitive functioning at T0, T1, and T2 was assessed through the MoCA domains for executive functioning, attention, language, visuospatial, orientation, and memory. Different evolutionary trends of cognitive domain impairments emerged across time-points. Patients' impairments in all domains decreased from T0 to T1. Attention and executive impairments decreased from T0 to T2 (42.9% and 26.5% to 10.2% and 18.4%, respectively). Conversely, altered visuospatial, language, and orientation increased between T1 and T2 (16.3%, 36.7%, and 40.8%, respectively). Additionally, patients' global cognitive functioning at T1 was predicted by the language and executive domains in a subacute phase (p = 0.031 and p = 0.001, respectively), while in the long term, only attention (p = 0.043) and executive (p = 0.019) domains intervened. Overall, these results confirm the importance of a domain-specific approach to target cognitive recovery across time in stroke patients.

Contemporary issues in neuro rehabilitation

Stroke is prevailing as the third most common neurological condition on a global scale and an estimated 25.7 million people are those who have survived it. Stroke is one of the overburdening conditions in about 33% of all individuals affected by permanent disability. Because of the high incidence of risk factors especially in Asia (including Pakistan) with an approximation of 250 cases per one lac persons. Occurrence is mostly seen in the older population and is often found with certain other co-morbidities such as dementia. To enhance the post-stroke quality of life in the geriatric population, especially the ones with existing co-morbidities. Physical rehabilitation of stroke plays a vital role[1]. Studies have demonstrated that the rehabilitation of patients with stroke is a lifelong process during which the survivors sequentially develop new physical habits, and transform their activities of daily living[2]. Stroke rehabilitation treatment protocol lasts quite a long. Therefore, it is sometimes tiresome for the patients and their families because of frequent visits to healthcare settings. Additionally, due to a shortage of skilled and specialized rehabilitation professionals, there is a scarcity of quality treatment protocols and as a result, the objectives of most of the rehab programs are not practical and achievable. Thus, preventing the patients from making a significant recovery[3]. The evidence does not support guidelines that are being followed in the healthcare systems of our country regarding stroke management. While working with individuals recovering from stroke and other neurological disorders, rehabilitation generally focuses on strength training[4]. Despite the fact, that the urban population in developing nations like Pakistan has now access to medical facilities such as stroke rehabilitation, the country's rising population is resulting in an overburdening of the healthcare system leading to sloppiness of all the medical services including rehabilitation[3]. Although most rehabilitation professionals and physical therapists know the fact that the traditional techniques used in neuro rehab are not always effective, still they use them on their patients, this lack of evidence-based practice may be due to inaccessibility to authentic clinical practice guidelines and other physiotherapy databases[4]. For instance, relying on outdated techniques such as range of motion exercises and stretching exercises for treating stroke patients is not as effective as using proprioceptive neuromuscular facilitation exercises to improve the coordination and functional ability of patients, thereby improving motor function along with balance and gait[5]. Conventional approaches in rehabilitation management particularly in the domain of neurology are becoming ineffective due to the huge demand that chronic neurological illnesses are placing on our healthcare system. New creative techniques, including integrated care pathways, are needed to obtain better outcomes[6]. The process of governing skillful clinical and administrative pathways is needed to overcome situations associated with a rise in the number of admissions and long stays in hospitals or healthcare resources. Implementing more innovative approaches by management can achieve better outcomes with a reduction in admissions and shortened hospital stays. It will cohesively lead to effective treatment guidelines, greater patient satisfaction, and improved quality of life. Most of European countries are regulated by integrated rehabilitation services to help patients navigate healthcare services more effectively for an impressive, person-centered approach to rehabilitation care[6]. Unified rehabilitation at the current regional and national level with updated approaches and action plans along with evidence-based clinical practice guidelines is required to safeguard the delivery of person-centred rehabilitation care. Thus, we can conclude that there is a dire need to promote the development and implementation of standardized care in neuro-rehabilitation centers for enhancement in the quality of rehabilitation services. In addition to the use of digital media platforms for spreading awareness among the general masses, regulation and periodic reviews of rehabilitation services are also required.

Maximizing stroke recovery with advanced technologies: A comprehensive assessment of robot-assisted, EMG-Controlled robotics, virtual reality, and mirror therapy interventions

Inconvenience caused by stroke brings physical disability found in many people which restricts their daily life activities. Globally, it was predicted that the prevalence of stroke will rise to 21.9 % by 2030. To improve the sensory and motor recovery of the stroke survivors, they required high attention for their controllability and adaptability. About 80 % of stroke victims have upper-limb motor deficits which affects their daily living activities. Due to technological advancement in rehabilitation engineering with new interventions, traditional physical therapy for stroke patients now translates into new rehabilitation strategies which help in fast recovery of motor tasks with intention motions. Electromyography (EMG) based stroke rehabilitation now being developed for enhancement and assessment of motion control in clinical settings. The integration of EMG-based intervention provides the feasibility to use the concept of myoelectric control with therapeutic settings. In this paper, the use of EMG-based robot aided therapy has been discussed and highlights the contribution of interventions for stroke rehabilitation. Furthermore, discussion also emphasis on virtual reality and mirror therapy and their latest interventions and approaches carried out by different investigators for the evaluations and assessment of stroke rehabilitation in lieu of considerations for improved functional motor task. The most widely used functional outcome measures for conducting clinical assessment of stroke patients in randomized control trials (RCTs) are Fugl-meyer assessment-upper extremity (FMA-UE), a score range from 0 to 66points, Fugl-meyer assessment for lower extremity (FMA-LE) has a score from 0 to 34 points, the Action Research Arm Test (ARAT), a scale from 0 to 57 points, the Functional independence measure (FIM) has a scale of 18–126 points, Modified Ashworth Scale (MAS), a scale from 0 to 5 points and Box and block test (BBT). Furthermore, in most of the RCTs the statistical significance was set at p < 0.05 (95 % confidence interval). Moreover, future directions suggested that for real time autonomous detection of motion intentions, the EMG-based machine learning must be involved with robots, virtual reality and mirror therapy-based interventions to achieve 95 % accuracy that could leads to the development of intelligent rehabilitation interventions for stroke survivors.

A scoping review of scientific concepts concerning motor recovery after stroke as employed in clinical trials.

The scientific literature on poststroke rehabilitation is remarkably vast. Over the last decades, dozens of rehabilitation approaches have been investigated. However, sometimes it is challenging to trace new experimental interventions back to some of the known models of motor control and sensorimotor learning. This scoping review aimed to investigate motor control models' diffusion among the literature on motor recovery after stroke. We performed a literature search on Medline, Cochrane, Web of Science, Embase, and Scopus databases. The last search was conducted in September 2023. This scoping review included full-text articles published in English in peer-reviewed journals that provided rehabilitation interventions based on motor control or motor learning frameworks for at least one individual with stroke. For each study, we identified the theoretical framework the authors used to design the experimental treatment. To this aim, we used a previously proposed classification of the known models of motor control, dividing them into the following categories: neuroanatomy, robotics, self-organization, and ecological context. In total, 2,185 studies were originally considered in this scoping review. After the screening process, we included and analyzed 45 studies: 20 studies were randomized controlled trials, 12 were case series, 4 were case reports, 8 were observational longitudinal pilot studies, and 1 was an uncontrolled trial. Only 10 studies explicitly declared the reference theoretical model. Considering their classification, 21 studies referred to the robotics motor control model, 12 to the self-organization model, 8 to the neuroanatomy model, and 4 to the ecological model. Our results showed that most of the rehabilitative interventions purposed in stroke rehabilitation have no clear theoretical bases on motor control and motor learning models. We suggest this is an issue that deserves attention when designing new experimental interventions in stroke rehabilitation.

Effects of Neuromuscular Electrical Stimulation on Spasticity and Walking Performance among Individuals with Chronic Stroke: A Pilot Randomized Clinical Trial.

Stroke and its associated complications are a major cause of long-term disability worldwide, with spasticity being a common and severe issue. Physical therapy, involving stretching exercises and electrical stimulation, is crucial for managing spasticity. Therefore, this study aimed to evaluate the effects of neuromuscular electrical stimulation (NMES) combined with a conventional rehabilitation program (CRP) on plantarflexor muscle spasticity and walking performance among individuals with chronic stroke. A pilot randomized clinical trial (RCT) with two groups (active NMES and placebo) was conducted at the physical therapy departments of King Fahad Specialist Hospital, Buraydah, and Sultan Bin Abdulaziz Humanitarian City, Riyadh, Saudi Arabia (November 2020). The assessor and participants were blinded for the group assignment. The active NMES group received exercise and stimulation at the dorsiflexor muscles on the paretic leg for 30 min for 12 sessions. The placebo group received exercise and sham stimulation at the same position and duration as the active group. Of interest were the outcomes for plantarflexor muscle spasticity measured by the modified Ashworth scale (MAS), gait speed measured by 10 m walk test (10-MWT), and functional mobility measured by functional ambulatory category (FAC). Nineteen participants were randomized into active NMES (n = 10) and sham NMES (n = 9) groups, with no significant baseline differences. Within the active NMES group, significant improvements were observed in MAS (p = 0.008), 10-MWT (p = 0.028), and FAC (p = 0.046), while only 10-MWT time improved significantly in the sham NMES group (p = 0.011). Between-group analysis showed that only MAS was significantly lower in the active NMES group (p = 0.006). Percent change analysis indicated a significantly higher increase in percent change for MAS in the active NMES group compared to the sham NMES group (p = 0.035), with no significant differences in other outcome measures. This study showed that NMES in the active group led to significant improvements in spasticity, walking performance, and functional ambulation. Further research is needed to determine the ideal parameters, protocols, and patient selection criteria for NMES interventions in stroke rehabilitation.

Evaluation of a carepartner-integrated telehealth gait rehabilitation program for persons with stroke: study protocol for a feasibility study

BackgroundDespite family carepartners of individuals post-stroke experiencing high levels of strain and reduced quality of life, stroke rehabilitation interventions rarely address carepartner well-being or offer training to support their engagement in therapeutic activities. Our group has developed creative intervention approaches to support families during stroke recovery, thereby improving physical and psychosocial outcomes for both carepartners and stroke survivors. The purpose of this study is to test the feasibility of an adapted, home-based intervention (Carepartner Collaborative Integrative Therapy for Gait-CARE-CITE-Gait) designed to facilitate positive carepartner involvement during home-based training targeting gait and mobility.MethodsThis two-phased design will determine the feasibility of CARE-CITE-Gait, a novel intervention that leverages principles from our previous carepartner-focused upper extremity intervention. During the 4-week CARE-CITE-Gait intervention, carepartners review online video-based modules designed to illustrate strategies for an autonomy-supportive environment during functional mobility task practice, and the study team completes two 2-h home visits for dyad collaborative goal setting. In phase I, content validity, usability, and acceptability of the CARE-CITE-Gait modules will be evaluated by stroke rehabilitation content experts and carepartners. In phase II, feasibility (based on measures of recruitment, retention, intervention adherence, and safety) will be measured. Preliminary effects of the CARE-CITE-Gait will be gathered using a single-group, quasi-experimental design with repeated measures (two baseline visits 1 week apart, posttest, and 1-month follow-up) with 15 carepartner and stroke survivor dyads. Outcome data collectors will be blinded. Outcomes include psychosocial variables (family conflict surrounding stroke recovery, strain, autonomy support, and quality of life) collected from carepartners and measures of functional mobility, gait speed, stepping activity, and health-related quality of life collected from stroke survivors.DiscussionThe findings of the feasibility testing and preliminary data on the effects of CARE-CITE-Gait will provide justification and information to guide a future definitive randomized clinical trial. The knowledge gained from this study will enhance our understanding of and aid the development of rehabilitation approaches that address both carepartner and stroke survivor needs during the stroke recovery process.Trial registrationClinicalTrials.gov, NCT 05257928. Registered 25 February 2022.Trial statusThis trial was registered on ClinicalTrials.gov (NCT 05257928) on March 25, 2022. Recruitment of participants was initiated on May 18, 2022.

A comprehensive guide to BCI-based stroke neurorehabilitation interventions

Brain-Computer Interfaces (BCIs) offer the potential to facilitate neurorehabilitation in stroke patients by decoding user intentions from the central nervous system, thereby enabling control over external devices. Despite their promise, the diverse range of intervention parameters and technical challenges in clinical settings have hindered the accumulation of substantial evidence supporting the efficacy and effectiveness of BCIs in stroke rehabilitation. This article introduces a practical guide designed to navigate through these challenges in conducting BCI interventions for stroke rehabilitation. Applicable regardless of infrastructure and study design limitations, this guide acts as a comprehensive reference for executing BCI-based stroke interventions. Furthermore, it encapsulates insights gleaned from administering hundreds of BCI rehabilitation sessions to stroke patients.•Presents a comprehensive methodology for implementing BCI-based upper extremity therapy in stroke patients.•Provides detailed guidance on the number of sessions, trials, as well as the necessary hardware and software for effective intervention.

Control intervention design for preclinical and clinical trials: Consensus-based core recommendations from the third Stroke Recovery and Rehabilitation Roundtable.

Control comparator selection is a critical trial design issue. Preclinical and clinical investigators who are doing trials of stroke recovery and rehabilitation interventions must carefully consider the appropriateness and relevance of their chosen control comparator as the benefit of an experimental intervention is established relative to a comparator. Establishing a strong rationale for a selected comparator improves the integrity of the trial and validity of its findings. This Stroke Recovery and Rehabilitation Roundtable (SRRR) taskforce used a graph theory voting system to rank the importance and ease of addressing challenges during control comparator design. "Identifying appropriate type of control" was ranked easy to address and very important, "variability in usual care" was ranked hard to address and of low importance, and "understanding the content of the control and how it differs from the experimental intervention" was ranked very important but not easy to address. The CONtrol DeSIGN (CONSIGN) decision support tool was developed to address the identified challenges and enhance comparator selection, description, and reporting. CONSIGN is a web-based tool inclusive of seven steps that guide the user through control comparator design. The tool was refined through multiple rounds of pilot testing that included more than 130 people working in neurorehabilitation research. Four hypothetical exemplar trials, which span preclinical, mood, aphasia, and motor recovery, demonstrate how the tool can be applied in practice. Six consensus recommendations are defined that span research domains, professional disciplines, and international borders.

Control intervention design for preclinical and clinical trials: Consensus-based core recommendations from the third Stroke Recovery and Rehabilitation Roundtable.

Control comparator selection is a critical trial design issue. Preclinical and clinical investigators who are doing trials of stroke recovery and rehabilitation interventions must carefully consider the appropriateness and relevance of their chosen control comparator as the benefit of an experimental intervention is established relative to a comparator. Establishing a strong rationale for a selected comparator improves the integrity of the trial and validity of its findings. This Stroke Recovery and Rehabilitation Roundtable (SRRR) taskforce used a graph theory voting system to rank the importance and ease of addressing challenges during control comparator design. "Identifying appropriate type of control" was ranked easy to address and very important, "variability in usual care" was ranked hard to address and of low importance, and "understanding the content of the control and how it differs from the experimental intervention" was ranked very important but not easy to address. The CONtrol DeSIGN (CONSIGN) decision support tool was developed to address the identified challenges and enhance comparator selection, description, and reporting. CONSIGN is a web-based tool inclusive of seven steps that guide the user through control comparator design. The tool was refined through multiple rounds of pilot testing that included more than 130 people working in neurorehabilitation research. Four hypothetical exemplar trials, which span preclinical, mood, aphasia, and motor recovery, demonstrate how the tool can be applied in practice. Six consensus recommendations are defined that span research domains, professional disciplines, and international borders.

Cortical activity in patients with high-functioning ischemic stroke during the Purdue Pegboard Test: insights into bimanual coordinated fine motor skills with functional near-infrared spectroscopy.

After stroke, even high-functioning individuals may experience compromised bimanual coordination and fine motor dexterity, leading to reduced functional independence. Bilateral arm training has been proposed as a promising intervention to address these deficits. However, the neural basis of the impairment of functional fine motor skills and their relationship to bimanual coordination performance in stroke patients remains unclear, limiting the development of more targeted interventions. To address this gap, our study employed functional near-infrared spectroscopy to investigate cortical responses in patients after stroke as they perform functional tasks that engage fine motor control and coordination. Twenty-four high-functioning patients with ischemic stroke (7 women, 17 men; mean age 64.75 ± 10.84 years) participated in this cross-sectional observational study and completed four subtasks from the Purdue Pegboard Test, which measures unimanual and bimanual finger and hand dexterity. We found significant bilateral activation of the sensorimotor cortices during all Purdue Pegboard Test subtasks, with bimanual tasks inducing higher cortical activation than the assembly subtask. Importantly, patients with better bimanual coordination exhibited lower cortical activation during the other three Purdue Pegboard Test subtasks. Notably, the observed neural response patterns varied depending on the specific subtask. In the unaffected hand task, the differences were primarily observed in the ipsilesional hemisphere. In contrast, the bilateral sensorimotor cortices and the contralesional hemisphere played a more prominent role in the bimanual task and assembly task, respectively. While significant correlations were found between cortical activation and unimanual tasks, no significant correlations were observed with bimanual tasks. This study provides insights into the neural basis of bimanual coordination and fine motor skills in high-functioning patients after stroke, highlighting task-dependent neural responses. The findings also suggest that patients who exhibit better bimanual performance demonstrate more efficient cortical activation. Therefore, incorporating bilateral arm training in post-stroke rehabilitation is important for better outcomes. The combination of functional near-infrared spectroscopy with functional motor paradigms is valuable for assessing skills and developing targeted interventions in stroke rehabilitation.

Neurophysiological characterization of stroke recovery: Alongitudinal TMS and EEG study.

Understanding the neural mechanisms underlying stroke recovery is critical to determine effective interventions for stroke rehabilitation. This study aims to systematically explore how recovery mechanisms post-stroke differ between individuals with different levels of functional integrity of the ipsilesional corticomotor pathway and motor function. Eighty-one stroke survivors and 15 age-matched healthy adults participated in this study. We used transcranial magnetic stimulation (TMS), electroencephalography (EEG), and concurrent TMS-EEG to investigate longitudinal neurophysiological changes post-stroke, and their relationship with behavioral changes. Subgroup analysis was performed based on the presence of paretic motor evoked potentials and motor function. Functional connectivity was increased dramatically in low-functioning individuals without elicitable motor evoked potentials (MEPs), which showed a positive effect on motor recovery. Functional connectivity was increased gradually in higher-functioning individuals without elicitable MEP during stroke recovery and influence from the contralesional hemisphere played a key role in motor recovery. In individuals with elicitable MEPs, negative correlations between interhemispheric functional connectivity and motor function suggest that the influence from the contralesional hemisphere may be detrimental to motor recovery. Our results demonstrate prominent clinical implications for individualized stroke rehabilitation based on both functional integrity of the ipsilesional corticomotor pathway and motor function.