Sub-acute Phases Of Stroke Recovery Research Articles

Neurovascular coupling is preserved in chronic stroke recovery after targeted photothrombosis

Functional neuroimaging, which measures hemodynamic responses to brain activity, has great potential for monitoring recovery in stroke patients and guiding rehabilitation during recovery. However, hemodynamic responses after stroke are almost always altered relative to responses in healthy subjects and it is still unclear if these alterations reflect the underlying brain physiology or if the alterations are purely due to vascular injury. In other words, we do not know the effect of stroke on neurovascular coupling and are therefore limited in our ability to use functional neuroimaging to accurately interpret stroke pathophysiology. To address this challenge, we simultaneously captured neural activity, through fluorescence calcium imaging, and hemodynamics, through intrinsic optical signal imaging, during longitudinal stroke recovery. Our data suggest that neurovascular coupling was preserved in the chronic phase of recovery (2 weeks and 4 weeks post-stoke) and resembled pre-stroke neurovascular coupling. This indicates that functional neuroimaging faithfully represents the underlying neural activity in chronic stroke. Further, neurovascular coupling in the sub-acute phase of stroke recovery was predictive of long-term behavioral outcomes. Stroke also resulted in increases in global brain oscillations, which showed distinct patterns between neural activity and hemodynamics. Increased neural excitability in the contralesional hemisphere was associated with increased contralesional intrahemispheric connectivity. Additionally, sub-acute increases in hemodynamic oscillations were associated with improved sensorimotor outcomes. Collectively, these results support the use of hemodynamic measures of brain activity post-stroke for predicting functional and behavioral outcomes.

A Tailored Occupational Therapist-Led Vocational Intervention for People With Stroke: Protocol for a Pilot Randomized Controlled Trial.

Resuming work after stroke is a common goal of working-age adults, yet there are few vocational rehabilitation programs designed to address the unique challenges faced following stroke. The Work intervention was developed to address these gaps. This paper presents a protocol that outlines the steps that will be undertaken to pilot both the intervention and trial processes for the Work trial. The Work trial is a 2-arm, prospective, randomized, blinded-assessor study with intention-to-treat analysis. A total of 54 adults of working age who have experienced a stroke <4 months prior will be randomized 1:1 to either (1) an experimental group who will receive a 12-week early vocational intervention (Work intervention) plus usual clinical rehabilitation or (2) a control group who will receive only their usual clinical rehabilitation. Outcomes include study and intervention feasibility and intervention benefit. In addition to evaluating the feasibility of delivering vocational intervention early after stroke, benefit will be assessed by measuring rates of vocational participation and quality-of-life improvements at the 3- and 6-month follow-ups. Process evaluation using data collected during the study, as well as postintervention individual interviews with participants and surveys with trial therapists, will complement quantitative data. The results of the trial will provide details on the feasibility of delivering the Work intervention embedded within the clinical rehabilitation context and inform future trial processes. Pilot data will enable a future definitive trial to determine the clinical effectiveness of vocational rehabilitation when delivered in the early subacute phase of stroke recovery. Australian New Zealand Clinical Trials Registry ACTRN12619001164189; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378112&isReview=true. DERR1-10.2196/40548.

Effectiveness of Supplemental Upper Extremity Training With Specialty Therapist for Patients With Stroke in Inpatient Rehabilitation

<h3>Research Objectives</h3> To investigate the potential benefits of supplemental training for the upper extremity on patient's arm and hand function during subacute stroke recovery. <h3>Design</h3> Retrospective cohort study over 6 month duration. <h3>Setting</h3> Inpatient Rehabilitation Hospital. <h3>Participants</h3> All participants received conventional occupational therapy (COT) during their inpatient rehabilitation for an admitting diagnosis of stroke. The control group consisted of 34 participants that were not referred to a specialty therapist. The 33 patients in the study group were referred by primary therapist to a specialty therapist for upper extremity motor recovery. <h3>Interventions</h3> Patients treated 1-3x weekly, 60 minute sessions. - Clinical consultation including plan of care recommendations specific to upper extremity impairments. - Treatment by specialty therapist including: 1. Upper extremity robotics 2. Gravity eliminated motor retraining 3. Virtual reality 4. Functional electrical stimulation 5. Constraint induced movement therapy <h3>Main Outcome Measures</h3> Fugl Meyer Assessment - Upper Extremity (FMA-UE), Box and Blocks Test (BBT). <h3>Results</h3> Patients in both groups were stratified into severe, moderate and mild impairment categories using the FMA-UE score collected at inpatient admission. Patients in control group with a severe impairment had an average change score of 8 on FMA-UE and 2 on BBT. Comparatively, the severe experimental group achieved an average change score of 21.9 on FMA-UE and 13.7 on BBT. Effects of supplemental training on mild impairment groups were not seen in FMA-UE. However, the BBT change score for mild control group was 8 versus 16.8 for experimental group. The supplemental training failed to show a significant increase for moderate group in FMA-UE or BBT. <h3>Conclusions</h3> Supplemental upper extremity training along with COT in the subacute phase of stroke recovery may improve gross and fine motor functioning for patients with severe impairment. For patients with mild impairment, supplemental training may serve to improve fine motor function. The effect of specialty therapist intervention on upper extremity function warrants further study due to current small sample size and interaction of selection bias due to reliance on therapist's referral for consultation. <h3>Author(s) Disclosures</h3> None.

Clinical Use of Surface Electromyography to Track Acute Upper Extremity Muscle Recovery after Stroke: A Descriptive Case Study of a Single Patient.

Arm recovery varies greatly among stroke survivors. Wearable surface electromyography (sEMG) sensors have been used to track recovery in research; however, sEMG is rarely used within acute and subacute clinical settings. The purpose of this case study was to describe the use of wireless sEMG sensors to examine changes in muscle activity during acute and subacute phases of stroke recovery, and understand the participant’s perceptions of sEMG monitoring. Beginning three days post-stroke, one stroke survivor wore five wireless sEMG sensors on his involved arm for three to four hours, every one to three days. Muscle activity was tracked during routine care in the acute setting through discharge from inpatient rehabilitation. Three- and eight-month follow-up sessions were completed in the community. Activity logs were completed each session, and a semi-structured interview occurred at the final session. The longitudinal monitoring of muscle and movement recovery in the clinic and community was feasible using sEMG sensors. The participant and medical team felt monitoring was unobtrusive, interesting, and motivating for recovery, but desired greater in-session feedback to inform rehabilitation. While barriers in equipment and signal quality still exist, capitalizing on wearable sensing technology in the clinic holds promise for enabling personalized stroke recovery.

Stroke core revealed by tissue scattering using spatial frequency domain imaging

Ischemic stroke leads to a reduction or complete loss of blood supply causing injury to brain tissue, which ultimately leads to behavioral impairment. Optical techniques are widely used to study the structural and functional changes that result as a consequence of ischemic stroke both in the acute and chronic phases of stroke recovery. It is currently a challenge to accurately estimate the spatial extent of the infarct without the use of histological parameters however, and in order to follow recovery mechanisms longitudinally at the mesoscopic scale it is essential to know the spatial extent of the stroke core. In this paper we first establish optical coherence tomography (OCT) as a reliable indicator of the stroke core by analyzing signal attenuation and spatially correlating it with the infarct, determined by staining with triphenyl-tetrazolium chloride (TTC). We then introduce spatial frequency domain imaging (SFDI) as a mesoscopic optical technique that can be used to accurately measure the infarct spatial extent by exploiting changes in optical scattering that occur as a consequence of ischemic stroke. Additionally, we follow the progression of ischemia through the acute and sub-acute phases of stroke recovery using both OCT and SFDI and show a consistently high spatial overlap in estimating infarct location. The use of SFDI in assessing infarct location will allow longitudinal studies targeted at following functional recovery mechanisms on a mesoscopic level without having to sacrifice the mouse acutely.

Effects of home-based physical activity incitation and education program in subacute phase of stroke recovery after 6 months of monitoring

The aim of the study was to evaluate the effect of physical activity incitation and education program at home on functional capacity, fatigue and depression levels in subacute phase of stroke recovery. Eighty-four volunteers post-stroke patients participated in this randomized clinical trial (Mean ± SD; Age: 62 ± 13 years; Barthel Index: 95.4 ± 9.1; Weight: 76.8 ± 15 Kg; Stroke delay: 77.6 ± 45.7 days). Participants were divided into a Home-based Physical Activity Incitation group (HBPAI, n = 42) and Control group (CG, n = 42). HBPAI follow the physical activity incitation program during six months. The 6 minutes walking test (6MWT), Functional Ambulation Classification (FAC), Hospital Anxiety Depression Scale (HADS) and Multidimensional Fatigue Inventory questionnaire (MFI-20) were measured at baseline (T0), after 6 months (T1) and 12 months (T2). 6MWT (m) performed by HBPAI and CG group at T0, T1 and T2 was (374 ± 141.1; 454 ± 134.8; 437.8 ± 146.4) and (372.5 ± 149.4; 385 ± 157.8; 400.1 ± 153) respectively. Distance walked during 6MWT significantly increased in HBPAI than CG ( P < 0.05) at T1, but not at T2. Score of general fatigue significantly decreased between T0 and T1 (11.9 ± 3.1 and 10.5 ± 2.9; P < 0.004) and T2 (9.6 ± 4.1; P < 0.001) in HBPAI. Depression score significantly decreased between T0 and T2 (8.6 ± 3.2 and 6.5 ± 3.7; P < 0.01) in HBPAI. Increasing physical activity after stroke could improve post-stroke common functional problems. However, the efficacy of physical activity programs at home is still unknown (Jones et al., 2015). Furthermore, there is limited information about the effects of PA on fatigue levels after stroke (Duncan et al., 2012). HBPAI program could be a good strategy to improve the walking distance and decrease fatigue and depression scores in subacute phase of stroke recovery.

Home-based physical activity incentive and education program in subacute phase of stroke recovery (Ticaa\u2019dom): study protocol for a randomized controlled trial

BackgroundStroke causes functional decline, psychological disorders and cognitive impairments that affect activities of daily living and quality of life. Although physical activity (PA) is beneficial in stroke recovery, PA recommendations are rarely met after hospital discharge. There is presently no standard strategy for monitoring and inciting PA at home during the subacute phase of stroke recovery. The main aim of this study is to evaluate the effects of a home-based physical activity incentive and education program (Ticaa’dom) on functional capacity in subacute stroke patients.MethodsThis study is a comparative prospective, observer-blinded, monocentric, parallel, randomized controlled clinical trial. This study will include 84 patients: 42 patients in the home-based physical activity incentive group (HB-PAI) and 42 in the control group (CG). The intervention group will follow the HB-PAI program over 6 months: their PA will be monitored with an accelerometer during the day at home while they record their subjective perception of PA on a chart; they will observe a weekly telephone call and a home visit every three weeks. The CG will receive traditional medical care over 12 months. The main study outcome will be the distance on a 6-minute walk test. Secondary outcomes will include measurements of lower limb strength, independence level, body composition, cardiac analysis, fatigue and depression state.DiscussionThe results of this trial will demonstrate the value of implementing the Ticaa’dom program during the subacute phase of stroke recovery.Trial registrationClinicalTrials.gov, NCT01822938. Registered on 25 March 2013.

A qualitative study exploring patients', with mild to moderate stroke, and their carers' perceptions of healthy lifestyles

Background/Aims: To explore patients', with mild to moderate stroke, and their carers' experiences after a stroke and to explore their perceptions of healthy lifestyles. Methods: A qualitative study using semi-structured interviews was undertaken with 20 people (12 males and 8 females) with mild to moderate stroke or transient ischaemic attack (1 week to 6 months' post event) and seven of their carers. Each interview was transcribed and a thematic analysis approach guided the analytic process. Results: Patients with sub-acute, mild to moderate stroke were positive about healthy lifestyles and their ability to achieve them post stroke. Three core themes were identified: perceptions related to exercise; perceptions related to other lifestyle factors; and understanding of stroke and healthy lifestyles. Conclusions: In the sub-acute phase of stroke recovery, barriers to exercise such as lack of motivation do not appear to be an issue. People with stroke have a lack of understanding of healthy guidelines, risk factors and cause of their stroke. It is not clear if this is due to a lack of information provision or a lack of recall. They also do not appear to make the link between lifestyle choices and the cause of their stroke.

Physical activity and inactivity level of stroke patients including in physical activity incitation program

Physical activity (PA) and exercise are two successful approaches to reduce sedentary behavior and risk managing in stroke patients. The aims of the study are to evaluate PA and physical inactivity levels in post-stroke patients and to correlate PA parameters with gait performance, fatigue, anxiety, and anthropometry parameters in subacute phase of stroke recovery. Preliminary analysis of 24 patients in PA incitation program (mean age: 61.3 ± 13.85 years; weight 78.2 ± 12.8 kg; stroke delay: 76.5 ± 37.7 days). Each patient achieved 6 minutes walking test (6MWT), hospital anxiety and depression scale (HADS), multidimensional fatigue inventory questionnaire (MFI-20) and body composition assessment before the hospital discharge. Total energy expenditure (TEE), number of steps (NS), sitting time (ST), activity energy expenditure (> 3 MET) (AEE) and physical activity time (PAT) per day were collected at home by the SenseWear Armband monitor system during the first (T1) and sixth (T6) month of PA incitation program. ST and PAT reduced significantly between T1 and T6 respectively (65.6 ± 89.5 and 35.3 ± 48.6 min, p = 0.048) and (94.7 ± 67.3 and 75.5 ± 56.7 min, P = 0.049). In contrast, NS increased significantly between T1 and T6 (3750 ± 2440 and 4415 ± 3810 steps, P = 0.044). TEE were positively associated with 6MWT and HADS ( r = 0.488, P = 0.0182 and r = −0.401, P = 0.04 respectively) at T1. Furthermore, PAT was positively associated with the body lean mass ( r = 0.48, P = 0,017) and weight ( r = −0.502, P = 0.0124) at T1 and ( r = −0.524, P = 0,008) at T6. In addition, there is positive correlation between AEE and the percentage of muscular mass at T6 ( r = 0.513, P = 0.0123). Finally TEE, NS, AEE and PAT were correlated with MFI at T6 ( r = −0.463, r = −0.457, r = −0.527, r = −0.594, P < 0.05). These preliminary results revealed that stroke patients included in PA incitation program decreased ST and increased NS despite PAT reduction. Even the presence of PA incitation program, PA is higher in patients with a few physical limitations than patients with a physical and psychological impairments.

Longitudinal Analysis of Quality of Life for Stroke Survivors Using Latent Curve Models

For the survivors, activities of daily living, handicap, and depression have a significant impact on health-related quality of life (HRQOL). How the dynamic changes of these variables relate to HRQOL over time in the subacute phase of stroke recovery has not been investigated. The objective of this study was to study longitudinal behaviors of HRQOL of the stroke survivors in relation to the changes in activities of daily living, handicap, and depression after stroke. This was a prospective cohort study of first disabling patients with stroke. Subjects were interviewed at 3, 6, and 12 months after stroke for modified Barthel Index, London Handicap Scale, Geriatric Depression Scale, and the World Health Organization Quality of Life questionnaire (abbreviated Hong Kong version). A latent curve model was developed to analyze how the dynamic changes in activities of daily living, handicap, and depressive mood related to the changes in HRQOL. Two hundred forty-seven of 303 patients (82%) followed up at 3 months after stroke could complete the quality-of-life questionnaire. Their mean age was 68.8 years. The latent curve model analysis revealed that initial physical health HRQOL was independently associated with activities of daily living, handicap, and depression. The other 3 HRQOL domain scores were primarily associated with depression only. The rates of change in all 4 domains of HRQOL were significantly and inversely associated with rate of change in the Geriatric Depression Scale only. Change in mood in the postacute phase of stroke recovery is the most significant determinant of change in HRQOL. More attention should be paid to the detection and management of poststroke depression.

Upper-Extremity Functional Electric Stimulation–Assisted Exercises on a Workstation in the Subacute Phase of Stroke Recovery

Kowalczewski J, Gritsenko V, Ashworth N, Ellaway P, Prochazka A. Upper-extremity functional electric stimulation−assisted exercises on a workstation in the subacute phase of stroke recovery. Objective To test the efficacy of functional electric stimulation (FES)−assisted exercise therapy (FES-ET) on a workstation in the subacute phase of recovery from a stroke. Design Single-blind, randomly controlled comparison of high- and low-intensity treatment. Setting Laboratory in a rehabilitation hospital. Participants Nineteen stroke survivors (10 men, 9 women; mean age ± standard deviation, 60.6±5.8y), with upper-extremity hemiplegia (mean poststroke time, 48±17d). The main inclusion criteria were: stroke occurred within 3 months of onset of trial and resulted in severe upper-limb dysfunction, and FES produced adequate hand opening. Intervention An FES stimulator and an exercise workstation with instrumented objects were used by 2 groups to perform specific motor tasks with their affected upper extremity. Ten subjects in the high-intensity FES-ET group received FES-ET for 1 hour a day on 15 to 20 consecutive workdays. Nine subjects in the low-intensity FES-ET group received 15 minutes of sensory electric stimulation 4 days a week and on the fifth day they received 1 hour of FES-ET. Main Outcome Measures Primary outcome measure included the Wolf Motor Function Test (WMFT). Secondary outcome measures included the Motor Activity Log (MAL), the upper-extremity portion of the Fugl-Meyer Assessment (FMA), and the combined kinematic score (CKS) derived from workstation measurements. The WMFT, MAL, and FMA were used to assess function in the absence of FES whereas CKS was used to evaluate function assisted by FES. Results Improvements in the WMFT and CKS were significantly greater in the high-intensity group (post-treatment effect size, .95) than the low-intensity group (post-treatment effect size, 1.3). The differences in MAL and FMA were not statistically significant. Conclusions Subjects performing high-intensity FES-ET showed significantly greater improvements on the WMFT than those performing low-intensity FES-ET. However, this was not reflected in subjects’ self-assessments (MAL) or in their FMA scores, so the clinical significance of the result is open to debate. The CKS data suggest that high-intensity FES-ET may be advantageous in neuroprosthetic applications.