Dual task measures in older adults with and without cognitive impairment: response to simultaneous cognitive-exercise training and minimal clinically important difference estimates.

BACKGROUND: Responsiveness and minimal clinically important difference (MCID) are critical indices to understand whether observed improvement represents a meaningful improvement after intervention. Although simultaneous cognitive-exercise training (SCET; e.g., performing memory tasks while cycling) has been suggested to enhance the cognitive function of older adults, responsiveness and MCID have not been established. Hence, we aimed to estimate responsiveness and MCIDs of two dual task performance involving cognition and hand function in older adults with and without cognitive impairment and to compare the differences in responsiveness and MCIDs of the two dual task performance between older adults with and without cognitive impairment. METHODS: A total of 106 older adults completed the Montreal Cognitive Assessment and two dual tasks before and after SCET. One dual task was a combination of Serial Sevens Test and Box and Block Test (BBT), and the other included frequency discrimination and BBT. We used effect size and standardized response mean to indicate responsiveness and used anchor- and distribution-based approaches to estimating MCID ranges. When conducting data analysis, all participants were classified into two cognitive groups, cognitively healthy (Montreal Cognitive Assessment ≥ 26) and cognitively impaired (Montreal Cognitive Assessment < 26) groups, based on the scores of the Montreal Cognitive Assessment before SCET. RESULTS: In the cognitively healthy group, Serial Seven Test performance when tasked with BBT and BBT performance when tasked with Serial Seven Test were responsive to SCET (effect size = 0.18-0.29; standardized response mean = 0.25-0.37). MCIDs of Serial Seven Test performance when tasked with BBT ranged 2.09-2.36, and MCIDs of BBT performance when tasked with Serial Seven Test ranged 3.77-5.85. In the cognitively impaired group, only frequency discrimination performance when tasked with BBT was responsive to SCET (effect size = 0.37; standardized response mean = 0.47). MCIDs of frequency discrimination performance when tasked with BBT ranged 1.47-2.18, and MCIDs of BBT performance when tasked with frequency discrimination ranged 1.13-7.62. CONCLUSIONS: Current findings suggest that a change in Serial Seven Test performance when tasked with BBT between 2.09 and 2.36 corrected number (correct responses - incorrect responses) should be considered a meaningful change for older adults who are cognitively healthy, and a change in frequency discrimination performance when tasked with BBT between 1.47 and 2.18 corrected number (correct responses - incorrect responses) should be considered a meaningful change for older adults who are cognitively impaired. Clinical practitioners may use these established MCIDs of dual tasks involving cognition and hand function to interpret changes following SCET for older adults with and without cognitive impairment. TRIAL REGISTRATION: NCT04689776, 30/12/2020.

Neuroplastic Changes Associated With Hybrid Exercise-Cognitive Training in Stroke Survivors With Mild Cognitive Decline: A Randomized Controlled Trial.

BACKGROUND: Exercise and cognitive training have been shown to induce neuroplastic changes and modulate cognitive function following stroke. However, it remains unclear whether hybridized exercise-cognitive training facilitates cortical activity and further influences cognitive function after stroke. OBJECTIVE: The study aimed to investigate the effects of 2 hybridized exercise-cognitive trainings on neuroplastic changes and behavioral outcomes in stroke survivors with mild cognitive decline. METHODS: This study was a single-blind randomized controlled trial. Stroke survivors were randomly assigned to 1 of 3 groups: (1) sequential exercise-cognitive training (SEQ), (2) dual-task exercise-cognitive training (DUAL), or (3) control group (CON). All groups underwent training 60 min per day, 3 days per week, for a total of 12 weeks. The primary outcome was the resting-state (RS) functional connectivity (FC) in functional magnetic resonance imaging. Secondary behavioral outcomes included cognitive and physical functions. RESULTS: After 12 weeks of training, patients in the SEQ group (n = 21) exhibited increased RS FC between the left occipital lobe and posterior cingulate gyrus with right parietal lobe, compared to the DUAL (n = 22) and CON (n = 20) groups. Additionally, patients in the DUAL group showed increased FC of the left temporal lobe. However, changes in behavioral outcome measures were non-significant among the 3 groups (all P's > .05). CONCLUSIONS: This study highlights the distinct neuroplastic mechanisms associated with 2 types of exercise-cognitive hybridized trainings. The pre-post functional magnetic resonance imaging measurements illustrated the time course of neural mechanisms for cognitive recovery in stroke survivors following different exercise-cognitive training approaches. Trial registration. NCT03230253.

A Pilot Randomized Controlled Trial of Botulinum Toxin Treatment Combined with Robot-Assisted Therapy, Mirror Therapy, or Active Control Treatment in Patients with Spasticity Following Stroke.

Effects of the combined task-oriented trainings with botulinum toxin A (BoNT-A) injection on improving motor functions and reducing spasticity remains unclear. This study aims to investigate effects of 3 task-oriented trainings (robot-assisted therapy (RT), mirror therapy (MT), and active control treatment (AC)) in patients with stroke after BoNT-A injection. Thirty-seven patients with chronic spastic hemiplegic stroke were randomly assigned to receive RT, MT, or AC following BoNT-A injection over spastic upper extremity muscles. Each session of RT, MT, and AC was 75 min, 3 times weekly, for 8 weeks. Outcome measures were assessed at pretreatment, post-treatment, and 3-month follow-up, involving the Fugl-Meyer Assessment (FMA), Modified Ashworth Scale (MAS), Motor Activity Log (MAL), including amount of use (AOU) and quality of movement (QOM), and arm activity level. All 3 combined treatments improved FMA, MAS, and MAL. The AC induced a greater effect on QOM in MAL at the 3-month follow-up than RT or MT. All 3 combined trainings induced minimal effect on arm activity level. Our findings suggest that for patients with stroke who received BoNT-A injection over spastic UE muscles, the RT, MT, or AC UE training that followed was effective in improving motor functions, reducing spasticity, and enhancing daily function.

Clinical efficacy of aerobic exercise combined with computer-based cognitive training in stroke: a multicenter randomized controlled trial.

PURPOSE: The objectives are to evaluate the effects of a sequential combination of aerobic exercise and cognitive training, compared with exercise or cognitive training alone, on cognitive function, physical function, daily function, quality of life, and social participation in stroke survivors with cognitive impairment. METHODS: This is a single-blind, parallel, randomized controlled trial. Stroke patients with mild cognitive impairment (n = 56) were randomly assigned to aerobic exercise training (n = 18), computerized cognitive training (n = 18), and the sequential combination of aerobic exercise and computerized cognitive training (n = 20) group. All groups underwent training 60 min/day, 3 days/week, for a total of 12 weeks. The primary outcomes included Montreal Cognitive Assessment (MoCA), Wechsler Memory Scale-Third Edition, and the Stroop color-word test. Secondary outcomes were the Timed Up and Go test, 6-Minute Walk Test, Functional Independence Measure, Lawton Instrumental Activities of Daily Living Scale, Community Integration Questionnaire, and Stroke Impact Scale. RESULTS: 56 participants completed the trial. Compared with a single type of aerobic exercise or cognitive training, the combined training group showed significant improvement in MoCA (P < .05, η2 = 0.13), and two sub-tests in WMS-III (both P's < 0.05) following the intervention. However, no between-group differences were observed for physical functions, daily function, quality of life, and social participation measures. CONCLUSIONS: The findings provide evidence for the potential synergistic intervention in stroke survivors. Future studies investigating the transfer effects and the optimal training parameters with a larger sample is needed.

The Effects of Distributed vs. Condensed Schedule for Robot-Assisted Training with Botulinum Toxin A Injection for Spastic Upper Limbs in Chronic Post-Stroke Subjects.

Robot-assisted training (RT) combined with a Botulinum toxin A (BoNT-A) injection has been suggested as a means to optimize spasticity treatment outcomes. The optimal schedule of applying RT after a BoNT-A injection has not been defined. This single-blind, randomized controlled trial compared the effects of two predefined RT approaches as an adjunct to BoNT-A injections of spastic upper limbs in chronic post-stroke subjects. Thirty-six patients received a BoNT-A injection in the affected upper extremity and were randomly assigned to the condensed or distributed RT group. The condensed group received an intervention of four sessions/week for six consecutive weeks. The distributed group attended two sessions/week for 12 consecutive weeks. Each session included 45 min of RT using the InMotion 2.0 robot, followed by 30 min of functional training. The Fugl-Meyer Assessment, Modified Ashworth Scale, Wolf Motor Function Test, Motor Activity Log, and Stroke Self-Efficacy Questionnaire were assessed at pre-training, mid-term, post-training, and at 6 week follow-up, with the exception of the Motor Activity Log, which did not include mid-term measures. After the intervention, both groups had significant improvements in all outcome measures (within-group effects, p < 0.05), with the exception of the Wolf Motor Function Test time score. There were no significant differences between groups and interaction effects in all outcome measures. Our findings suggest that RT provided in a fixed dosage as an adjunct to a BoNT-A injection has a positive effect on participants' impairment and activity levels, regardless of treatment frequency. (ClinicalTrials.gov: NCT03321097).

Myoelectric analysis of upper-extremity muscles during robot-assisted bilateral wrist flexion-extension in subjects with poststroke hemiplegia.

BACKGROUND: Muscle co-contraction during the execution of motor tasks or training is common in poststroke subjects. EMG-derived muscular activation indexes have been used to evaluate muscle co-contractions during movements. In addition, robot-assisted bilateral arm training provides a repetitive and stable training method to improve arm movements. However, quantitative measures of muscle contractions during this training in poststroke subjects have not been described. METHODS: Seventeen subjects experiencing spastic hemiplegia after a stroke were recruited to perform robot-assisted bilateral wrist flexion and extension movements. The co-contraction index and two new indexes, temporal correlation and cross mutual information, which are derived from the EMGs of working muscles without the need for envelope normalization, are used to quantify intermuscular activation during wrist movements. FINDINGS: Higher temporal correlation as well as higher co-contraction index was demonstrated in the affected muscles, implying the recruitment of muscle co-contractions to complete the movement task. On the other hand, a higher value of cross mutual information was exhibited in the unaffected muscles which was attributed to their distinct, rhythmic muscle contractions. The plot of temporal correlation versus cross mutual information further defined affected, unaffected synergistic, and unaffected agonist-antagonist muscular regions. Moreover, with the modified Ashworth scale, multiple regression models based on the co-contraction index and cross mutual information had the highest R-squared value of 0.733. INTERPRETATION: EMG-derived intermuscular activation parameters demonstrated muscle co-contractions in the affected muscles and different types of intermuscular contractions during robot-assisted bilateral arm training. The modified Ashworth scale estimation based on multiple regression analysis of the activation indexes also demonstrated EMG-derived index a valuable method for assessing muscle spasticity in subjects with poststroke hemiplegia.

Low back pain-associated factors in female hospital-based personal care attendants.

BACKGROUND: Low back pain (LBP) is common in personal care attendants because this profession requires much physical work. Information about the prevalence of LBP and LBP-associated risk factors in this group is limited.OBJECTIVEThis study aimed to investigate the 1-year prevalence of LBP and identify LBP-associated factors in female hospital-based personal care attendants. METHODS: Forty-seven female hospital-based personal care attendants were recruited. The Nordic Musculoskeletal Questionnaire was used to investigate the prevalence of LBP during the recent 12 months. Participants completed a personal traits and associated factors questionnaire. Physical fitness and the knowledge test of body mechanics were assessed. Multivariable logistic regression analysis was used to explore LBP-associated factors. RESULTS: The 1-year prevalence of LBP was 46.8%. The strongest LBP-associated risk factor was poor abdominal muscle endurance, followed by insufficient knowledge on the test of body mechanics and higher psychological stress. CONCLUSIONS: The results demonstrate that the prevalence of LBP in female hospital-based personal care attendants appears to be high. Preventive programs should be initiated to reduce LBP-associated risk factors, such as improving abdominal muscle endurance, providing education in the proper use of body mechanics, and providing psychological intervention services for female hospital-based personal care attendants.

2020 Guideline for Prehospital Management, Emergency Evaluation and Treatment of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the Taiwan Society of Emergency Medicine and Taiwan Stroke Society.

To improve the clinical outcomes of patients with acute ischemic stroke, the public, pre-hospital care system, and hospitals should cooperate to achieve quick assessment and management for such patients and to start treatment as soon as possible. To reach the goal, the Consensus Group, including emergency physicians and neurologists in the Taiwan Society of Emergency Medicine and Taiwan Stroke Society, performed an updated review and discussion for the local guidelines. The guidelines consist of 12 parts, including public education program, evaluation and management in the emergency medical system, emergency medical system, assessment of stroke care capability of the hospital by independent parties, stroke team of the hospital, telemedicine, organization, and multifaceted integration, improvement of quality of care process of stroke system, initial clinical and imaging evaluations after arriving at the hospital, imaging evaluation for indications of intravenous thrombolysis, imaging evaluation for indications of endovascular thrombectomy, and other diagnostics. For detailed contents in Chinese, please refer to the Taiwan Stroke Society Guideline and Taiwan Emergency Medicine Bulletin.

Predictors of Clinically Important Improvements in Motor Function and Daily Use of Affected Arm after a Botulinum Toxin A Injection in Patients with Chronic Stroke.

Identifying patients who can gain minimal clinically important difference (MCID) in active motor function in the affected upper extremity (UE) after a botulinum toxin A (BoNT-A) injection for post-stroke spasticity is important. Eighty-eight participants received a BoNT-A injection in the affected UE. Two outcome measures, Fugl-Meyer Assessment Upper Extremity (FMA-UE) and Motor Activity Log (MAL), were assessed at pre-injection and after 24 rehabilitation sessions. We defined favorable response as an FMA-UE change score ≥5 or MAL change score ≥0.5.Statistical analysis revealed that the time since stroke less than 36 months (odds ratio (OR) = 4.902 (1.219-13.732); p = 0.023) was a significant predictor of gaining MCID in the FMA-UE. Medical Research Council scale -proximal UE (OR = 1.930 (1.004-3.710); p = 0.049) and post-injection duration (OR = 1.039 (1.006-1.074); p =0.021) were two significant predictors of MAL amount of use. The time since stroke less than 36 months (OR = 3.759 (1.149-12.292); p = 0.028), naivety to BoNT-A (OR = 3.322 (1.091-10.118); p = 0.035), and education years (OR = 1.282 (1.050-1.565); p = 0.015) were significant predictors of MAL quality of movement. The findings of our study can help optimize BoNT-A treatment planning.

Musculoskeletal disorders, psychosocial stress and associated factors among home-based migrant care workers.

BACKGROUND: Prevalence of musculoskeletal disorders (MSDs) and psychological stress in home-based female migrant care workers (MCWs) remain unknown. OBJECTIVE: To 1) investigate the prevalence of MSDs and psychological stress and associations between subjective questionnaires on MSDs/psychological stress and biomedical examinations, and 2) identify the risk factors related to MSDs and psychological stress. METHODS: This study recruited 85 MCWs. Data was collected using questionnaires, urine analysis and X-ray examinations. Correlations between subjective questionnaires and biomedical examinations were investigated. Multivariable logistic regression analyses were used to explore risk factors. RESULTS: The prevalence of MSDs and psychological stress were 70.6% and 37.6%, respectively. MSDs were commonly reported over the neck, lower back, shoulders, and upper back. There was a moderate correlation between MSDs and abnormal X-ray findings. Risk factors associated with MSDs included higher education level, frequent transferring and bedside care activities, lacking caregiver training in Taiwan, inadequate sleep, and drinking tea or coffee. Risk factors associated with psychological stress included inadequate salary, lacking caregiver training in Taiwan, and insufficient knowledge of body mechanics techniques. CONCLUSIONS: MSDs and psychological stress were common among home-based female MCWs. Educational level, frequent transferring and bedside care activities, and lack of caregiver training in Taiwan, were the most dominant risk factors.

The relationship between trunk acceleration parameters and kinematic characteristics during walking in patients with stroke.

[Purpose] Limited literature has investigated the relationships between acceleration-based gait characteristics and kinematic information from motion analysis systems in gait analysis. The purpose of this study is to determine whether acceleration-based gait characteristics were associated with gait characteristics by motion analysis systems in patients with stroke. [Participants and Methods] Seventeen patients with stroke walked along a 10-m-long walkway at their comfortable speed. Trunk acceleration was measured with an accelerometer. Several reflective markers over bony landmarks on the lower extremities were used to capture movements. We evaluated the correlations of variables calculated between the trunk accelerometers and the motion analysis system. [Results] Walking speed was positively correlated with harmonic ratios along the anteroposterior axis and stride regularity along the vertical and anteroposterior axes. Harmonic ratios were associated with the stance phase percent on the unaffected side. Stride regularity was associated with the stance phase percent on both sides. Smaller interstride variability was associated with smaller peak ankle plantarflexion during both phases and greater peak ankle dorsiflexion during swing phase. Stride regularity is positively associated with maximal knee flexion during swing phase. [Conclusion] Relationships with spatiotemporal and joint kinematic parameters from the motion analysis system support the potential use of accelerometers.

Comparison of Kinect2Scratch game-based training and therapist-based training for the improvement of upper extremity functions of patients with chronic stroke: a randomized controlled single-blinded trial.

BACKGROUND: Virtual reality and interactive video games could decrease the demands on the time of the therapists. However, the cost of a virtual reality system and the requirement for technical support limits the availability of these systems. Commercial exergames are not specifically designed for therapeutic use, most patients with hemiplegic stroke are either too weak to play the games or develop undesirable compensatory movements. AIM: To develop Kinect2Scratch games and compare the effects of training with therapist-based training on upper extremity (UE) function of patients with chronic stroke. DESIGN: A randomized controlled single-blinded trial. SETTING: An outpatient rehabilitation clinic of a tertiary hospital. POPULATION: Thirty-three patients with chronic hemiplegic stroke. METHODS: We developed 8 Kinect2Scratch games. The participants were randomly assigned to either a Kinect2Scratch game group or a therapist-based training group. The training comprised 24 sessions of 30 minutes over 12 weeks. The primary outcome measure was the Fugl-Meyer UE scale and the secondary outcome measures were the Wolf Motor Function Test and Motor Activity Log. Patients were assessed at baseline, after intervention, and at the 3-month follow-up. We used the Pittsburgh participation scale (PPS) to assess the participation level of patients at each training session and an accelerometer to assess the activity counts of the affected UE of patients was used at the 12th and 24th training sessions. RESULTS: Seventeen patients were assigned to the Kinect2Scratch group and 16 were assigned to the therapist-based training group. There were no differences between the two groups for any of the outcome measures postintervention and at the 3-month follow-up (all P>0.05). The level of participation was higher in the Kinect2Scratch group than in the therapist-based training group (PPS 5.25 vs. 5.00, P=0.112). The total activity counts of the affected UE was significantly higher in the Kinect2Scratch group than in the therapist-based training group (P<0.001). CONCLUSIONS: Kinect2Scratch game training was feasible, with effects similar to those of therapist-based training on UE function of patients with chronic stroke. CLINICAL REHABILITATION IMPACT: Kinect2Scratch games are low-cost and easily set-up games, which may serve as a complementary strategy to conventional therapy to decrease therapists' work load.

The Active Ingredient of Cognitive Restoration: A Multicenter Randomized Controlled Trial of Sequential Combination of Aerobic Exercise and Computer-Based Cognitive Training in Stroke Survivors With Cognitive Decline.

OBJECTIVE: To investigate the efficacy of a sequential combination of aerobic exercise and cognitive training on cognitive function and other health-related outcomes in stroke survivors with cognitive decline. DESIGN: Intervention study and randomized controlled trial. SETTING: Hospital-based rehabilitation units. PARTICIPANTS: Survivors of stroke with cognitive decline (N=30) were randomized to sequential combination training (SEQ) (n=15) or an active control (n=15) group. INTERVENTIONS: The SEQ group received 30 minutes of aerobic exercise, followed by 30 minutes of computerized cognitive training. The control group received 30 minutes of nonaerobic physical exercise, followed by 30 minutes of unstructured mental activities. MAIN OUTCOME MEASURES: The primary outcome measure was cognitive function. Secondary outcome measures included physical function, social participation, and quality of life. RESULTS: Compared with the control group, the SEQ group had significantly improved Montreal Cognitive Assessment scores (P=.03) and Wechsler Memory Scale span scores (P=.012) after training. The endurance and mobility level measured by the 6-minute walk test (P=.25) was also enhanced in the SEQ group relative to the control group. However, the transfer of sequential training to social participation (Community Integration Questionnaire) and quality of life (EuroQoL questionnaire) was limited (P>.05 for both). CONCLUSIONS: Aerobic exercise combined with computerized cognitive training has better effects on the cognitive functional status of survivors of stroke than an active control. The cognitive functional status of stroke survivors was better after participation in aerobic exercise combined with computerized training than after active control therapy, demonstrating the clinical significance of this combination therapy.

Mirror Illusion Modulates M1 Activities and Functional Connectivity Patterns of Perceptual-Attention Circuits During Bimanual Movements: A Magnetoencephalography Study.

We differentiated the influence of mirror-induced visual conflicts on the perceptual-attention-motor control process by examining the variation of primary motor cortex (M1) activities and the functional connectivity among five brain regions associated with perceptual, motor, and attentional processes. Magnetoencephalography (MEG) was recorded under three conditions: both hands kept stationary with the forearms supinated (resting condition), in-phase bimanual movements with congruent visual feedback [symmetry (Sym) condition], and out-of-phase bimanual movements with incongruent visual feedback [asymmetry (Asy) condition]. We found that compared with the resting state, the decrease in beta oscillation was greater in the Sym than in the Asy condition, suggesting a greater activation of M1 when implementing hand movement without visual conflict. The results of functional connectivity patterns showed that the alpha band functional connectivity between V1 and superior temporal gyrus (STG) and the gamma band functional connectivity between the precuneus and posterior cingulate cortex (PCC) triggered greater or slightly greater coherence strength in the Asy condition than in the Sym condition. However, the beta band functional connectivity showed no difference between the two conditions in all pairs of the brain regions. These findings confirm and extend the previous findings to provide evidence that mirror visual feedback engages the functional networks associated with the perceptual-attentional process and triggers M1 activation, although the M1 activation is functionally independent of other brain regions unrelated to motor function. In summary, this study demonstrated a concrete functional connectivity pattern for motor control in the face of visual conflicts, and providing a foundation for future research to examine the dynamic functional networks of mirror illusion in motor control.

Low Persistence of Antithrombotic Agents is Associated with Poor Outcomes after First-ever Acute Ischemic Stroke.

OBJECTIVE: This study investigated the time-trend persistence with antithrombotic agents (AT) and assessed the impact of AT persistence on outcome events and adverse events (AE) within two years after first-ever acute ischemic stroke (IS). METHODS: Using Taiwan's National Health Insurance claims dataset, 7,341 IS subjects hospitalized between 2001 and 2005 with AT prescribed at discharge and survived at least 3 months were followed up for 2 years. Time-trends of AT usage were analyzed. Medication persistence was assessed as the proportion of days covered (PDC) for filled prescription, and categorized into low, intermediate and high persistence. Multivariate logistic regression analysis and multivariate Cox proportional hazard regression models were performed to identify factors associated with AT persistence and its impact on vascular outcomes. RESULTS: AT persistence rates declined sharply from 81% to 52% during the first 6 months. In addition to patient and facility-level characteristics, occurrence of AE (e.g., GI bleeding/ulceration, fractures/ major trauma, and iatrogenic/unspecific illness) was inversely related to AT persistence. Compared with patients with low persistence, the composite risk of recurrent stroke, cardiovascular disease, or death from any cause was significantly lower in patients with intermediate (Hazard Ratio [HR] 0.64, 0.57-0.71) or high AT persistence (0.74, 0.66-0.83).

Effects and mechanism of the HECT study (hybrid exercise-cognitive trainings) in mild ischemic stroke with cognitive decline: fMRI for brain plasticity, biomarker and behavioral analysis.

PURPOSE: Cognitive decline after stroke is highly associated with functional disability. Empirical evidence shows that exercise combined cognitive training may induce neuroplastic changes that modulate cognitive function. However, it is unclear whether hybridized exercise-cognitive training can facilitate cortical activity and physiological outcome measures and further influence on the cognitive function after stroke. This study will investigate the effects of two hybridized exercise-cognitive trainings on brain plasticity, physiological biomarkers and behavioral outcomes in stroke survivors with cognitive decline. METHODS AND SIGNIFICANCE: This study is a single-blind randomized controlled trial. A target sample size of 75 participants is needed to obtain a statistical power of 95% with a significance level of 5%. Stroke survivors with mild cognitive decline will be stratified by Mini-Mental State Examination scores and then randomized 1:1:1 to sequential exercise-cognitive training, dual-task exercise-cognitive training or control groups. All groups will undergo training 60 min/day, 3 days/week, for a total of 12 weeks. The primary outcome is the resting-state functional connectivity and neural activation in the frontal, parietal and occipital lobes in functional magnetic resonance imaging. Secondary outcomes include physiological biomarkers, cognitive functions, physical function, daily functions and quality of life. This study may differentiate the effects of two hybridized trainings on cognitive function and health-related conditions and detect appropriate neurological and physiological indices to predict training effects. This study capitalizes on the groundwork for a non-pharmacological intervention of cognitive decline after stroke.

Effects of Home-Based Versus Clinic-Based Rehabilitation Combining Mirror Therapy and Task-Specific Training for Patients With Stroke: A Randomized Crossover Trial.

OBJECTIVE: We investigated the treatment effects of a home-based rehabilitation program compared with clinic-based rehabilitation in patients with stroke. DESIGN: A single-blinded, 2-sequence, 2-period, crossover-designed study. SETTING: Rehabilitation clinics and participant's home environment. PARTICIPANTS: Individuals with disabilities poststroke. INTERVENTIONS: During each intervention period, each participant received 12 training sessions, with a 4-week washout phase between the 2 periods. Participants were randomly allocated to home-based rehabilitation first or clinic-based rehabilitation first. Intervention protocols included mirror therapy and task-specific training. MAIN OUTCOME MEASURES: Outcome measures were selected based on the International Classification of Functioning, Disability and Health. Outcomes of impairment level were the Fugl-Meyer Assessment, Box and Block Test, and Revised Nottingham Sensory Assessment. Outcomes of activity and participation levels included the Motor Activity Log, 10-meter walk test, sit-to-stand test, Canadian Occupational Performance Measure, and EuroQoL-5D Questionnaire. RESULTS: Pretest analyses showed no significant evidence of carryover effect. Home-based rehabilitation resulted in significantly greater improvements on the Motor Activity Log amount of use subscale (P=.01) and the sit-to-stand test (P=.03) than clinic-based rehabilitation. The clinic-based rehabilitation group had better benefits on the health index measured by the EuroQoL-5D Questionnaire (P=.02) than the home-based rehabilitation group. Differences between the 2 groups on the other outcomes were not statistically significant. CONCLUSIONS: The home-based and clinic-based rehabilitation groups had comparable benefits in the outcomes of impairment level but showed differential effects in the outcomes of activity and participation levels.

Rehabilitation Reduced Readmission and Mortality Risks in Patients With Stroke or Transient Ischemic Attack: A Population-based Study.

BACKGROUND: It remains unclear whether rehabilitation has an impact on reducing the long-term risk of mortality or readmission following stroke or transient ischemic attack (TIA). OBJECTIVES: To investigate the association between the dosage and continuation of rehabilitation and the risk of outcome events (OEs) after stroke or TIA. RESEARCH DESIGN: A retrospective cohort study using Taiwan's National Health Insurance database. SUBJECTS: In total, 4594 patients admitted with first-ever acute stroke or TIA were followed-up for 32 months. MEASURES: The occurrence of 3 OEs: (1) vascular readmissions/all-cause mortality [vascular event (VE)], (2) all-cause readmissions/mortality (OE1), and (3) all-cause mortality (OE2), in model 1: none, low-intensity, and high-intensity rehabilitation; and model 2: inpatient plus/or outpatient rehabilitation. RESULTS: Comparing with patients without rehabilitation, in model 1, patients receiving low-intensity rehabilitation had a lower risk of VE [Hazard ratio (HR), 0.77; 95% CI, 0.68-0.87] and OE1 (HR, 0.77; CI, 0.71-0.84), but not OE2 (HR, 0.91; CI, 0.77-1.07). Patients receiving high-intensity rehabilitation had lower risks of all VE (HR, 0.68; CI, 0.58-0.79), OE1 (HR, 0.79; CI, 0.71-0.88), and OE2 (HR, 0.56; CI, 0.44-0.71). In model 2, patients receiving inpatient plus outpatient rehabilitation had a lowest risk of VE (HR, 0.55; CI, 0.47-0.65), OE1 (HR, 0.65; CI, 0.58-0.72), and OE2 (HR, 0.45; CI, 0.35-0.59). Sensitivity analysis with TIA excluded rendered the similar trend. Subgroup analyses found that the positive effect was not demonstrated in hemorrhagic stroke patients. CONCLUSIONS: Rehabilitation use was associated with reduction of readmissions/mortality risks following stroke or TIA. The optimal intensity and duration of rehabilitation and the discrepancy shown in hemorrhagic stroke need further clarification.

A genome-wide association study links small-vessel ischemic stroke to autophagy.

Genome-wide association studies (GWAS) can serve as strong evidence in correlating biological pathways with human diseases. Although ischemic stroke has been found to be associated with many biological pathways, the genetic mechanism of ischemic stroke is still unclear. Here, we performed GWAS for a major subtype of stroke-small-vessel occlusion (SVO)-to identify potential genetic factors contributing to ischemic stroke. GWAS were conducted on 342 individuals with SVO stroke and 1,731 controls from a Han Chinese population residing in Taiwan. The study was replicated in an independent Han Chinese population comprising an additional 188 SVO stroke cases and 1,265 controls. Three SNPs (rs2594966, rs2594973, rs4684776) clustered at 3p25.3 in ATG7 (encoding Autophagy Related 7), with P values between 2.52 × 10-6 and 3.59 × 10-6, were identified. Imputation analysis also supported the association between ATG7 and SVO stroke. To our knowledge, this is the first GWAS to link stroke and autophagy. ATG7, which has been implicated in autophagy, could provide novel insights into the genetic basis of ischemic stroke.