Exploring unsupervised feature extraction of IMU-based gait data in stroke rehabilitation using a variational autoencoder.

BACKGROUND: Variational AutoEncoders (VAE) might be utilized to extract relevant information from an IMU-based gait measurement by reducing the sensor data to a low-dimensional representation. The present study explored whether VAEs can reduce IMU-based gait data of people after stroke into a few latent features with minimal reconstruction error. Additionally, we evaluated the psychometric properties of the latent features in comparison to gait speed, by assessing 1) their reliability; 2) the difference in scores between people after stroke and healthy controls; and 3) their responsiveness during rehabilitation. METHODS: We collected test-retest and longitudinal two-minute walk-test data using an IMU from people after stroke in clinical rehabilitation, as well as from a healthy control group. IMU data were segmented into 5-second epochs, which were reduced to 12 latent-feature scores using a VAE. The between-day test-retest reliability of the latent features was assessed using ICC-scores. The differences between the healthy and the stroke group were examined using an independent t-test. Lastly, the responsiveness was determined as the number of individuals who significantly changed during rehabilitation. RESULTS: In total, 15,381 epochs from 107 people after stroke and 37 healthy controls were collected. The VAE achieved data reconstruction with minimal errors. Five latent features demonstrated good-to-excellent test-retest reliability. Seven latent features were significantly different between groups. We observed changes during rehabilitation for 21 and 20 individuals in latent-feature scores and gait speed, respectively. However, the direction of the change scores of the latent features was ambiguous. Only eleven individuals exhibited changes in both latent-feature scores and gait speed. CONCLUSION: VAEs can be used to effectively reduce IMU-based gait assessment to a concise set of latent features. Some latent features had a high test-retest reliability and differed significantly between healthy controls and people after stroke. Further research is needed to determine their clinical applicability.

Effect of tDCS combined with virtual reality for post-stroke cognitive impairment: a randomized controlled trial study protocol.

BACKGROUND: Post-stroke cognitive impairment (PSCI) not only increases patient mortality and disability, but also adversely affects motor function and the ability to perform routine daily activities. Current therapeutic approaches for, PSCI lack specificity, primarily relying on and medication and traditional cognitive therapy supplemented by a limited array of tools. Both transcranial direct current stimulation (tDCS) and virtual reality (VR) training have demonstrated efficacy in improving cognitive performance among PSCI patients. Previous findings across various conditions suggest that implementing a therapeutic protocol combining tDCS and VR (tDCS - VR) may yield superior in isolation. Despite this, to our knowledge, no clinical investigation combining tDCS and VR for PSCI rehabilitation has been conducted. Thus, the purpose of this study is to explore the effects of tDCS - VR on PSCI rehabilitation. METHODS: This 4-week, single-center randomized clinical trial protocol will recruit 200 patients who were randomly assigned to one of four groups: Group A (tDCS + VR), Group B (tDCS + sham VR), Group C (sham tDCS + VR), Group D (sham tDCS + sham VR). All four groups will receive conventional cognitive rehabilitation training. The primary outcome measurement utilizes the Mini-Mental State Examination (MMSE). Secondary outcome measures include the Montreal Cognitive Assessment, Frontal Assessment Battery, Clock Drawing Test, Digital Span Test, Logic Memory Test, and Modified Barthel Index. Additionally, S-YYZ-01 apparatus for diagnosis and treating language disorders assesses subjects' speech function. Pre- and post-four-week intervention assessments are conducted for all outcome measures. Functional near-infrared spectroscopy (fNIRS) is employed to observe changes in oxygenated hemoglobin (HbO), deoxy-hemoglobin (HbR), and total hemoglobin (HbT) in the cerebral cortex. DISCUSSION: Our hypothesis posits that the tDCS - VR therapy, in opposed to individual tDCS or VR interventions, could enhance cognitive function, speech ability and daily living skills in PSCI patients while concurrently augmenting frontal cortical activity. This randomized study aims to provide a robust theoretical foundation supported by scientific evidence for the practical implementation of the tDCS - VR combination as a secure and efficient PSCI rehabilitation approach. TRIAL REGISTRATION: Chictr.org.cn Identifier: ChiCTR2300070580. Registered on 17th April 2023.

A modified Delphi survey to build expert consensus on the structure and content of an enhanced care pathway for cognitive changes after stroke in the UK.

BACKGROUND: Enhancing long-term support for post-stroke cognitive impairment is a top research priority. Addressing current gaps in UK post-stroke cognitive care provision requires a pragmatic and scalable intervention that can be integrated within the existing stroke care pathway. This study aimed to develop consensus on an initial set of core features for a UK-based monitoring and psychoeducational intervention for cognitive changes after stroke. METHODS: An expert panel of UK healthcare professionals and researchers participated in an online modified Delphi survey. Candidate intervention features were identified from clinical guidelines, existing literature, research team/collaborator expertise, and PPI group lived experience. Survey participants indicated whether they agreed/disagreed/had no opinion about including each candidate feature in the intervention and free-text responses were invited. We analysed responses for consensus (≥ 75% agreement) using descriptive statistics, with items not reaching consensus carried into subsequent rounds. Template analysis was used to identify similarities/differences in viewpoints for items that did not reach consensus. RESULTS: Three survey rounds were completed by 36, 29 and 26 participants, respectively. Participants agreed reviews should include a stroke-specific cognitive screen (97% agree) and assessment of other psychological changes (low mood, anxiety, fatigue: 94%, 90%, 89% agree, respectively). They agreed stroke survivors should be offered at least one review, regardless of their cognitive profile in hospital. They agreed on the importance of various cognition-focused psychoeducation topics, and formal (100% agree) and informal (79% agree) training for those conducting reviews. Consensus was not reached on the review mode (in person/remote options: 67% agree), offering reviews one-year post-discharge to patients without acute cognitive impairments (68% disagree), or including a dementia screen (63% disagree) and/or neuropsychological assessment battery (58% disagree). However, there were similarities in participant viewpoints. For example, participants emphasised the importance of onwards referral where clinically indicated.   CONCLUSIONS: The UK-based post-stroke monitoring and psychoeducation intervention was originally conceptualised as a cognitive care pathway, but expert participants agreed on the importance of simultaneously addressing related psychological changes (e.g. low mood, anxiety). There was clear consensus on a minimum set of intervention features. Recommendations outlined here may usefully inform local service improvements.

Impact of whole-body vibration training on ankle joint proprioception and balance in stroke patients: a prospective cohort study.

BACKGROUND: Although whole-body vibration (WBV) training is acknowledged for its benefits in enhancing motor functions across several neurological disorders, its precise influence on ankle joint proprioception and balance in stroke patients is still not well understood. This research seeks to assess the impact of WBV training on ankle joint proprioception and balance in stroke patients, thereby filling this important research void. METHODS: In this prospective cohort study, thirty-five stroke patients were randomly assigned to either the WBV group (n = 17) or a control group (n = 18) using a random number table method. The control group received daily general rehabilitation for four weeks, while the WBV group received an additional 30 min of WBV training each day with the Trunsan S110 Vibration Training System. Blinded outcome assessments were conducted at baseline and post-treatment, utilizing the Berg balance scale (BBS), Functional reach test (FRT), Romberg test length (RTL) and area (RTA), and completion rates of ankle joint dorsiflexion-plantar flexion (DP) and inversion-eversion (IE) tests. Follow-up assessments were performed after four weeks of intervention, focusing on RTL, RTA, DP, and IE as primary outcomes. RESULTS: Analysis of intra-group changes from baseline to post-treatment revealed significant improvements across the BBS, FRT, RTL, RTA, and DP and IE assessments (p < 0.001). Notably, the WBV group showed significant enhancements compared to the control group in DP and IE (p < 0.001 and p < 0.05, respectively), with mean values increasing from 13.556 to 16.765 (23.7%) and from 5.944 to 8.118 (36.6%), respectively. However, WBV did not provide additional benefits over the control treatment for balance recovery parameters such as BBS, FRT, RTL, and RTA (p > 0.05). CONCLUSIONS: This study demonstrates that WBV therapy is equally effective as conventional methods in enhancing proprioception and balance in stroke patients, but it does not provide additional benefits for balance recovery. WBV significantly improves proprioceptive functions, particularly in DP and IE parameters. However, it does not surpass traditional rehabilitation methods in terms of balance recovery. These findings indicate that WBV should be incorporated into stroke rehabilitation primarily to enhance proprioception rather than to optimize balance recovery. TRIAL REGISTRATION: This study was retrospectively registered in the ISRCTN Registry on 29/07/2024 ( https://www.isrctn.com/ , ISRCTN64602845).

Chronic stroke survivors underestimate their upper limb motor ability in a simple 2D motor task.

BACKGROUND: Stroke survivors can exhibit a mismatch between the actual motor ability of their affected upper limb and how much they use it in daily life. The resulting non-use of the affected upper limb has a negative impact on participation in neurorehabilitation and functional independence. The factors leading to non-use of the affected upper limb are poorly understood. One possibility is that non-use comes about through inappropriately low confidence in their own upper limb motor abilities. OBJECTIVE: We asked whether chronic stroke survivors underestimate the motor ability of their affected upper limb. METHODS: 20 chronic stroke survivors (Mean FM: 28.2 ± 10.5) completed a 2D reaching task using an exoskeleton robot. Target sizes were individually altered to ensure success rates were similar for both upper limbs. Prior to each reaching movement, participants rated their confidence about successfully hitting the target (estimated upper limb motor ability). RESULTS: Confidence ratings were significantly lower for the affected upper limb (estimated ability), even though it was equally successful in the reaching task in comparison to the less affected upper limb (actual ability). Furthermore, confidence ratings did not correlate with level of impairment. CONCLUSIONS: Our results demonstrate that chronic stroke survivors can underestimate the actual motor abilities of their affected upper limb, independent of impairment level. Low confidence in affected upper limb motor abilities should be considered as a therapeutic target to increase the incorporation of the affected upper limb into activities of daily living.

The dose effectiveness of extracorporeal shockwave on plantar flexor spasticity of ankle in stroke patients: a randomized controlled trial.

BACKGROUND: Extracorporeal shockwave therapy (ESWT) has been proven beneficial for post-stroke spasticity (PSS) of ankle plantar flexor muscles. This study aims to investigate the dose-response effectiveness of focused-ESWT and the duration of its effect on the treatment of ankle PSS in stroke patients. METHODS: In this double-blinded randomized controlled trial, stroke patients diagnosed with PSS in the ankle plantar flexor muscles were randomly assigned to two groups. The experimental group received double-dose ESWT (4000 pulses per session) targeting spastic calf muscles, while the control group received half the dose (2000 pulses per session). Both groups underwent four sessions over two weeks. The outcomes, including modified Ashworth Scale (MAS), modified Tardieu Scale (MTS), passive range of motion (PROM) of the ankle, Timed Up and Go (TUG) Test, Barthel index and strain elastography were evaluated at baseline, 1st, 4th, 12th, and 24th week after ESWT. RESULTS: Within-group analysis revealed significant improvements in MAS, PROM, TUG Test, and Barthel index for the double-dose ESWT group and improvements in Barthel index for the control group. Between-group analysis revealed greater improvements in TUG Test, Barthel Index and strain elastography for the double-dose ESWT group. Generalized estimating equations analysis indicated that the double-dose ESWT group achieved superior outcomes in the TUG Test, Barthel Index, and strain elastography across various time points and groups. CONCLUSIONS: Double-dose ESWT showed better functional improvement and elastography compared to the control group. ESWT demonstrated dose-response effectiveness for PSS of ankle-equinus. TRIAL REGISTRATION: NCT05878223.

Impact of diverse aerobic exercise plans on glycemic control, lipid levels, and functional activity in stroke patients with type 2 diabetes mellitus.

Aims: This study aimed to assess the effects of Low-to-Moderate Intensity Continuous Training (LMICT), Moderate-Intensity Interval Training (MIIT), and Reduced-Exertion High-Intensity Training (REHIT) on blood glucose regulation, functional recovery, and lipid levels in individuals who have experienced a stroke and are diagnosed with Type 2 Diabetes Mellitus (T2DM). Methods: Forty-two T2DM stroke patients were randomly allocated to four groups: LMICT, MIIT, REHIT, and a control group (CON). Participants continuously monitored their blood glucose levels throughout the intervention using continuous glucose monitoring (CGM) devices. The study comprised two exercise intervention cycles: the first lasting from Day 3 to Day 14 and the second from Day 15 to Day 28, with the initial two days serving as contrasting periods. Primary outcomes encompassed CGM-derived blood glucose measurements, the Barthel Index (BI), Fugl-Meyer Assessment lower-extremity subscale (FMA-LE), and alterations in triglycerides (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c), and low-density lipoprotein cholesterol (LDL-c). Results: Compared with the CON, the MIIT group showed significant improvements in mean glucose (MG), glucose standard deviation (SD), time above range (TAR), and time in range (TIR). The REHIT group exhibited significantly reduced time below range (TBR), glucose SD, and coefficient of variation (CV). Regarding lipid levels, although the REHIT group achieved a significant reduction in TG levels compared with the CON, the overall effects of LMICT, MIIT, and REHIT on lipid profiles were relatively modest. Concerning functional recovery, the REHIT group significantly improved the BI and FMA-LE. Conclusion: Although the short-term quantitative impact of exercise on lipid levels may be limited, both REHIT and MIIT significantly improved glycemic management and reduced glucose variability in post-stroke patients with Type 2 Diabetes Mellitus. Additionally, REHIT notably enhanced functional recovery.

Impact of the combination of virtual reality and noninvasive brain stimulation on the upper limb motor function of stroke patients: a systematic review and meta-analysis.

BACKGROUND: Stroke frequently results in upper limb motor dysfunction, with traditional therapies often failing to yield sufficient improvements. Emerging technologies such as virtual reality (VR) and noninvasive brain stimulation (NIBS) present promising new rehabilitation possibilities. OBJECTIVES: This study systematically reviews and meta-analyses the effectiveness of VR and NIBS in improving upper limb motor function in stroke patients. METHODS: Registered with PROSPERO (CRD42023494220) and adhering to the PRISMA guidelines, this study conducted a thorough search of databases including PubMed, MEDLINE, PEDro, REHABDATA, EMBASE, Web of Science, Cochrane, CNKI, Wanfang, and VIP from 2000 to December 1, 2023, to identify relevant studies. The inclusion criterion was stroke patients receiving combined VR and NIBS treatment, while exclusion criteria were studies with incomplete articles and data. The risk of bias was assessed using the Cochrane Collaboration tool. Statistical analysis was performed using Stata SE 15.0, employing either a fixed-effects model or a random-effects model based on the level of heterogeneity. RESULTS: A total of 11 studies involving 493 participants were included, showing a significant improvement in Fugl-Meyer Assessment Upper Extremity (FMA-UE) scores in the combined treatment group compared to the control group (SMD = 0.85, 95% CI [0.40, 1.31], p = 0.017). The Modified Ashworth Scale (MAS) scores significantly decreased (SMD = - 0.51, 95% CI [- 0.83, - 0.20], p = 0.032), the Modified Barthel Index (MBI) scores significantly increased (SMD = 0.97, 95% CI [0.76, 1.17], p = 0.004), and the Wolf Motor Function Test (WMFT) scores also significantly increased (SMD = 0.36, 95% CI [0.08, 0.64], p = 0.021). Subgroup analysis indicated that the duration of treatment influenced the outcomes in daily living activities. CONCLUSIONS: The combination of VR and NIBS demonstrates significant improvements in upper limb motor function in stroke patients. The duration of treatment plays a critical role in influencing the outcomes, particularly in activities of daily living. This systematic review has limitations, including language bias, unclear randomization descriptions, potential study omissions, and insufficient follow-up periods. Future studies should focus on exploring long-term effects and optimizing treatment duration to maximize the benefits of combined VR and NIBS therapy.

Effects of wearable device training on upper limb motor function in patients with stroke: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the effect of wearable device training on improving upper limb motor function in patients who experienced strokes. METHODS: The PubMed, Embase, Cochrane Library, Web of Science, MEDLINE, SCOPUS, China National Knowledge Infrastructure, WanFang, and VIP databases were searched for randomized controlled trials (RCTs) that assessed the effectiveness of wearable device training in improving upper limb motor function in patients with stroke. Two investigators independently screened studies by their titles and abstracts and cross-checked, downloaded, and evaluated the results. Disagreements were resolved by a third highly experienced researcher. Risk of bias was evaluated using the Cochrane risk-of-bias tool. This meta-analysis was registered in PROSPERO (registration No. CRD42023421633). RESULTS: This study comprised 508 patients from 14 RCTs. The experimental group assessed various wearable devices, including 3D-printed dynamic orthoses, inertial measurement unit (IMU) sensors, electrical stimulation devices, and virtual reality (VR) devices for virtual interactive training. The control group received traditional rehabilitation therapies, including physical and conventional rehabilitation. The experimental group scored better on the Fugl-Meyer Assessment (FMA-UE) scale (standardized mean difference [SMD] 0.26, 95% confidence interval [CI] 0.07, 0.45) and Box and Block Test (BBT) (SMD 0.43, 95% CI 0.17, 0.69) versus controls. No significant intergroup differences were observed in the Action Research Arm Test (SMD 0.20, 95% CI -0.15, 0.55), motor activity log (mean difference [MD] 0.32, 95% CI -0.54, 0.33), and modified Ashworth scale (MD -0.08, 95% CI -0.81, 0.64). The probability rankings of wearable devices that improved FMA-UE scores in patients with stroke were: orthotic devices, with the highest probability ranking of 0.45, followed by sensor devices at 0.23, electrical stimulation devices at 0.21, and VR devices at 0.11. CONCLUSIONS: Wearable device training was found to significantly improve upper limb motor function in patients with stroke, particularly for large-range movements. Improvements in FMA-UE and BBT scores reflected reduced impairment and enhanced manual dexterity, respectively. However, the training had no significant effect on hand movement frequency, fine motor skills, or spasticity. Among the different wearable devices tested, orthoses produced the most effective results.

The implementation of sex-and gender-based considerations in exercise-based randomized controlled trials in individuals with stroke: A cross-sectional study.

Emerging evidence suggests that sex-and gender-based factors may influence responses to exercise post-stroke. The Sex and Gender Equity in Research (SAGER) guidelines (2016) published international standards for terminology and considerations for research design and trial reporting. The extent to which sex- and gender-based considerations have been implemented in stroke exercise trials is currently unknown. The objective of this cross-sectional study was to compare the proportion of studies that have implemented sex/gender considerations before and after the publication of the SAGER guidelines. We conducted a comprehensive search of the literature to identify exercise-based trials in individuals with stroke. Study titles, abstracts, introductions (hypothesis statements), methods, results and discussions were assessed for adherence to the SAGER guidelines. The proportion of studies adhering to SAGER guidelines published prior to and including December 31, 2016 and from 2017-March 2023 were compared. Of the 245 studies identified, 150 were published before December 31, 2016, of which 0 (0%) titles/abstracts, 0 (0%) introductions, 21 (14.0%) methods, 8 (5.3%) results, and 7 (4.7%) discussion sections adhered to the SAGER guidelines, and 35 (23.3%) reported proper sex and gender terminology. Of the 95 studies published between 2017-2023, 0 (0%) title/abstracts, 1 (1.0%) introduction, 16 (16.8%) methods, 5 (5.3%) results, and 10 (10.5%) discussion sections adhered to the guidelines, and 37 (38.9%) of studies included proper terminology. The implementation of sex- and gender-based considerations in stroke exercise trials is low, but positively the reporting of proper terminology has increased since the publication of standardized reporting guidelines. This study serves as a call to action for stroke rehabilitation researchers to incorporate sex- and gender-based considerations in all stages of research studies, to improve the rigour and generalizability of findings, and promote health equity.

The RETurn to work After stroKE (RETAKE) trial: Findings from a mixed-methods process evaluation of the Early Stroke Specialist Vocational Rehabilitation (ESSVR) intervention.

INTRODUCTION: A key goal for working age stroke survivors is to return to work, yet only around 50% achieve this at 12 months. Currently, there is limited evidence of effectiveness of early stroke-specialist vocational rehabilitation (ESSVR) interventions from randomised controlled trials. This study examined fidelity to ESSVR and explored social and structural factors which may have influenced implementation in the RETurn to work After stroKE (RETAKE) randomised controlled trial. METHODS: Mixed-methods process evaluation assessing intervention fidelity and incorporating longitudinal case-studies exploring stroke survivors' experiences of support to return to work. Normalisation Process Theory, and the Conceptual Model for Implementation Fidelity, informed data collection and analysis. RESULTS: Sixteen sites across England and Wales participated in RETAKE. Forty-eight occupational therapists (OTs), supported by 6 mentors experienced in vocational rehabilitation (VR), delivered the intervention (duration 12 months) between February 2018 and April 2022. Twenty-six participants (15 ESSVR, 11 usual care (UC)) were included in longitudinal case-studies. An additional 18 participants (8 ESSVR and 10 UC) were interviewed once. Nineteen OTs, 6 mentors and 19 service managers were interviewed. Fidelity was measured for 39 ESSVR participants; mean fidelity score was 78.8% (SD:19.2%, range 31-100%). Comparison of the experiences of ESSVR and UC participants indicated duration and type of support to return to work were perceived to be better for ESSVR participants. They received early, co-ordinated support including employer liaison and workplace adjustments where appropriate. In contrast, UC participants reported limited or no VR or return to work support from health professionals. Typically, UC support lasted 2-8 weeks, with poor communication and co-ordination between rehabilitation providers. Mentor support for OTs appeared to increase fidelity. Service managers indicated ESSVR would enhance post-stroke services. CONCLUSIONS: ESSVR was valued by participants and was delivered with fidelity; implementation appeared to be facilitated by mentor support for OTs.

Deep brain stimulation versus vagus nerve stimulation for the motor function of poststroke hemiplegia: study protocol for a multicentre randomised controlled trial.

INTRODUCTION: Deep brain stimulation (DBS) and vagus nerve stimulation (VNS) can improve motor function in patients with poststroke hemiplegia. No comparison study exists. METHODS AND ANALYSIS: This is a randomised, double-blind, controlled clinical trial involving 64 patients who had their first stroke at least 6 months ago and are experiencing poststroke limb dysfunction. These patients must receive necessary support at home and consent to participate. The aim is to evaluate the effectiveness and safety of DBS and VNS therapies. Patients are excluded if they have implantable devices that are sensitive to electrical currents, severe abnormalities in their lower limbs or are unable to comply with the trial procedures. The study has two parallel, distinct treatment arms: the Stimulation Group and the Sham Group. Initially, the Stimulation Group will undergo immediate electrical stimulation postsurgery, while the Sham Group will receive non-stimulation 1 month later. After 3 months, these groups will swap treatments, with the Stimulation Group discontinuing stimulation and the Sham Group initiating stimulation. Six months later, both groups will resume active stimulation. Our primary outcomes will meticulously assess motor function improvements, using the Fugl-Meyer Assessment, and safety, monitored by tracking adverse reaction rates. Furthermore, we will gain a comprehensive view of patient outcomes by evaluating secondary measures, including clinical improvement (National Institutes of Health Stroke Scale), surgical complications/side effects, quality of life (36-item Short Form Questionnaire) and mental health status (Hamilton Anxiety Rating Scale/Hamilton Depression Rating Scale). To ensure a thorough understanding of the long-term effects, we will conduct follow-ups at 9 and 12 months postsurgery, with additional long-term assessments at 15 and 18 months. These follow-ups will assess the sustained performance and durability of the treatment effects. The statistical analysis will uncover the optimal treatment strategy for poststroke hemiplegia, providing valuable insights for clinicians and patients alike. ETHICS AND DISSEMINATION: This study was reviewed and approved by the Ethical Committee of Chinese PLA General Hospital (S2022-789-01). The findings will be submitted for publication in peer-reviewed journals with online accessibility, ensuring adherence to the conventional scientific publishing process while clarifying how the research outcomes will be disseminated and accessed. TRIAL REGISTRATION NUMBER: NCT06121947.

Rehabilitation Transition Program to Improve Community Participation Among Stroke Survivors: A Randomized Clinical Trial.

Importance: Interventions are needed to support the long-term needs of stroke survivors when they transition from inpatient rehabilitation to home, where they face new home and community environmental barriers. Objective: To compare the efficacy of a novel, enhanced rehabilitation transition program with attentional control to improve community participation and activity of daily living (ADL) performance and to reduce environmental barriers in the home and community after stroke. Design, Setting, and Participants: This phase 2b, parallel randomized clinical trial assessed patients 50 years or older who had experienced an acute ischemic stroke or intracerebral hemorrhage, were independent in ADLs before stroke, and planned to be discharged home. Patients were assessed at an inpatient rehabilitation facility in St Louis, Missouri, and their homes from January 9, 2018, to December 20, 2023. Intervention: Community Participation Transition after Stroke (COMPASS), including home modifications and strategy training. Main Outcomes and Measures: The primary outcome was community participation (Reintegration to Normal Living Index). Secondary outcomes were daily activity performance (Stroke Impact Scale ADL domain and the In-Home Occupational Performance Evaluation [I-HOPE] activity, performance, and satisfaction scores) and environmental barriers in the home (I-HOPE environmental barriers score). Results: A total of 185 participants (mean [SD] age, 66.3 [9.0] years; 105 [56.8%] male) were randomized (85 to the COMPASS group and 100 to the control group). The COMPASS and control participants experienced similar improvements in community participation by 12 months, with no significant group (mean difference, 0.3; 95% CI, -4.6 to 5.2; P = .91) or group × time interaction (between-group differences in changes over time, 1.3; 95% CI, -7.1 to 9.6; P = .76) effects. Improvements in I-HOPE performance and satisfaction scores were greater for COMPASS participants than control participants at 12 months (between-group differences in changes for performance: 0.39; 95% CI, 0.01-0.77; P = .046; satisfaction: 0.52; 95% CI, 0.08-0.96; P = .02). The COMPASS participants had greater improvements for I-HOPE environmental barriers than the control participants (P = .003 for interaction), with the largest differences at 6 months (between-group differences in changes: -15.3; 95% CI -24.4 to -6.2). Conclusions and Relevance: In this randomized clinical trial of stroke survivors, participants in both groups experienced improvements in community participation. COMPASS participants had greater improvements in self-rated performance and satisfaction with performing daily activities as well as a greater reduction in environmental barriers than control participants. COMPASS reduced environmental barriers and improved performance of daily activities for stroke survivors as they transitioned from inpatient rehabilitation to home. Trial Registration: ClinicalTrials.gov Identifier: NCT03485820.

Time-course for acquiring transfer independence in patients with subacute stroke: a prospective cohort study.

OBJECTIVE: To clarify the time-course of longitudinal changes in the independence level of subtasks composing bed-wheelchair transfer among patients with stroke. DESIGN: Single-institution prospective cohort study. PATIENTS: A total of 137 consecutive post-stroke patients using wheelchair on admission to the subacute rehabilitation wards. METHODS: The independence degree in each of the 25 transfer-related subtasks was assessed using the Bed-Wheelchair Transfer Tasks Assessment Form on a three-level scale every two weeks, from admission to the endpoint (either discharge or when achieving independent transfer). Patients were classified based on admission and endpoint assessment form scores using two-step cluster analysis. RESULTS: Patients were classified into three clusters. The first cluster included 50 patients who exhibited a greater independence level in all subtasks on admission (52.0-100% of patients performed each subtask independently) and at the endpoint (64.0-100%). The second included 30 patients who showed less independence on admission (0-27.8%) but achieved greater independence levels at the endpoint (44.4-97.2%). The third included 51 patients whose independence level remained low in many subtasks from admission (0-5.8%) until the endpoint (0-29.4%). CONCLUSION: The independence level and its changing process during transfer were categorized into three time-courses, each requiring different intervention strategies.

A reliable and valid assessment of upper limb movement quality after stroke: the observational Drinking Task Assessment.

OBJECTIVE: To develop and evaluate the reliability and validity of a new observational Drinking Task Assessment (DTA) designed to assess quality of movement in task performance after stroke. DESIGN: Reliability and validity. METHODS: The DTA measures movement time and movement quality (smoothness, trunk, shoulder, elbow, and grasp movements) on a 4-level ordinal scale. Thirty participants with chronic stroke were assessed independently by 2 therapists. Intra-class correlation (ICC), standard error of measurement (SEM) and minimal real difference (MRD), weighted kappa, percentage of agreement, and Svensson method were used for reliability assessment. Motion capture-based kinematics and established clinical scales were used to evaluate validity. RESULTS: The absolute SEM and MRD for movement time were 0.4 and 1 s (11%), respectively. The ICC (≥ 0.93) and weighted kappa (0.71-1.0) showed good to excellent agreement for intra- and inter-rater reliability. DTA showed strong correlations with Fugl-Meyer Assessment (0.74), Action Research Arm Test (0.93), and kinematic measures of smoothness (0.93), trunk displacement (0.91), elbow extension (0.73), and shoulder movements (0.56), indicating good construct validity. CONCLUSIONS: The new DTA proved to be a reliable and valid tool for assessment of movement quality during task performance after stroke.

Feasibility, Fidelity and Acceptability of a Person-Centred Care Transition Support Intervention for Stroke Survivors: A Non-Randomised Controlled Study.

BACKGROUND: Care transitions from hospital to home are a critical period for patients and their families, especially after a stroke. The aim of this study was to assess the feasibility, fidelity and acceptability of a co-designed care transition support for stroke survivors. METHODS: A non-randomised controlled feasibility study recruiting patients who had had stroke and who were to be discharged home and referred to a neurorehabilitation team in primary healthcare was conducted. Data on the feasibility of recruitment and fidelity of the intervention were collected continuously during the study with screening lists and checklists. Data on the perceived quality of care transition were collected at 1-week post-discharge with the Care Transition Measure. Data on participant characteristics, disease-related data and outcomes were collected at baseline (hospitalisation), 1 week and 3 months post-discharge. Data on the acceptability of the intervention from the perspective of healthcare professionals were collected at 3 months using the Normalisation Measure Development Questionnaire. RESULTS: Altogether, 49 stroke survivors were included in the study: 28 in the intervention group and 21 in the control group. The recruitment and data collection of patient characteristics, disease-related data, functioning and outcomes were feasible. The fidelity of the intervention differed in relation to the different components of the co-designed care transition support. The intervention was acceptable from the perspective of healthcare professionals. Concerns were raised about the fidelity of the intervention. A positive direction of effects of the intervention on the perceived quality of the care transition was found. CONCLUSION: The study design, data collection, procedures and intervention were deemed feasible and acceptable. Modifications are needed to improve intervention fidelity by supporting healthcare professionals to apply the intervention. The feasibility study showed a positive direction of effect on perceived quality with the care transition, but a large-scale trial is needed to determine its effectiveness. PATIENT OR PUBLIC CONTRIBUTION: Stroke survivors, significant others and healthcare professionals were involved in a co-design process, including the joint development of the intervention's components, contextual factors to consider, participant needs and important outcomes to target. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT0292587.

Positive effects of lower extremity constraint-induced movement therapy on balance, leg strength and dual-task ability in stroke patients: a longitudinal cohort study.

OBJECTIVE: To investigate whether high-intensity lower extremity constraint-induced movement therapy can improve balance, leg strength, and dual-task ability. DESIGN: A longitudinal cohort study in a real-world outpatient clinic. PATIENTS: 147 community-dwelling participants in the subacute and chronic poststroke phases. METHODS: Participants received lower extremity constraint-induced movement therapy for 6 hours/day during 2 consecutive weeks, including balance, strength, and functional training. The Berg Balance Scale (BBS), Single-Leg-Stance (SLS) bilaterally, one Repetition Maximum (1RM) in a leg press, symmetry of leg strength (Diff-1RM), Timed Up and Go (TUG), and the TUG Manual test were assessed before, after, and 3 months after lower extremity constraint-induced movement therapy. RESULTS: Compared with preintervention data, statistically significant improvements after lower extremity constraint-induced movement therapy (p < 0.001) were demonstrated for balance with an absolute value in BBS at 1.9 points (effect size 0.38) and SLS at 2.4 s (effect size 0.24), and for leg strength at 10.2 kg (effect size 0.54) for the affected leg. Diff 1RM decreased significantly at 5.8 kg (effect size 0.39) and improvements on dual-task ability at 2.7 s were significant (effect size 0.14). The effects persisted at the 3-month follow-up. CONCLUSIONS: High-intensity lower extremity constraint-induced movement therapy may be a feasible treatment option for middle-aged stroke patients to affect balance, leg strength, and dual-task ability positively in an out-patient clinical setting.

Effect of mediolateral leg perturbations on walking balance in people with chronic stroke: A randomized controlled trial.

Many people with chronic stroke (PwCS) exhibit deficits in step width modulation, an important strategy for walking balance. A single exposure to swing leg perturbations can temporarily strengthen this modulation. The objective of this parallel, double-blinded, randomized controlled trial was to investigate whether repeated perturbations cause sustained increases in step modulation (NCT02964039; funded by the VA). 54 PwCS at the Medical University of South Carolina were randomly assigned to one of three intervention groups: Control (n = 18), with minimal forces; Assistive (n = 18), pushing the swing leg toward a mechanically appropriate location; Perturbing (n = 18), pushing the swing leg away from a mechanically appropriate location. All intervention groups included 24 training sessions over 12-weeks with up to 30-minutes of treadmill walking while interfaced with a novel force-field and a 12-week follow-up period, with five interspersed assessment sessions. Our primary outcome measure was paretic step width modulation, the partial correlation between step width and pelvis displacement (ρSW). Secondarily, we quantified swing and stance leg contributions to step modulation, clinical assessments of walking balance and confidence, and real-world falls. Outcomes were analyzed for participants who completed all assessment sessions (n = 44). Only the Perturbing group exhibited significant increases in paretic ρSW, which were present after 4-weeks of training and sustained through follow-up (t = 2.42-3.17). These changes were due to improved control of paretic swing leg positioning. However, perturbation-induced changes in step modulation were not always significantly greater than those in the Control group, and clinical assessments were similar across intervention groups. Participants in the Perturbing group experienced a lower fall rate than those in the Control group (incidence rate ratio = 0.53), although our small sample size warrants caution. The present results indicate that perturbations can cause sustained modifications of targeted biomechanical characteristics of post-stroke gait, although such changes alone may be insufficient to change more complex clinical assessments.

Bimanual Arm Trainer Versus Traditional Occupational Therapy Services in Upper Extremity Function.

IMPORTANCE: Upper extremity (UE) dysfunction resulting from stroke significantly affects a person's ability to complete self-care activities, consequently diminishing functional independence. Effective interventions that improve UE function in persons with stroke are needed. OBJECTIVE: To explore the effectiveness of the Bimanual Arm Trainer (BAT) compared with traditional occupational therapy treatment sessions (i.e., a control group) on improving UE function after acute ischemic stroke. DESIGN: Clinical trial, two-group, nonrandomized repeated-measures design. SETTING: Inpatient rehabilitation facility. PARTICIPANTS: Twenty-seven persons with ischemic stroke and an Action Research Arm Test (ARAT) score ≤17. INTERVENTION: Minimum of three 10-min sessions on the BAT. OUTCOMES AND MEASURES: ARAT, Upper Extremity Fugl-Meyer Assessment of Motor Recovery after Stroke (FMA-UE). RESULTS: Both the intervention and control groups showed significant improvement on the ARAT from evaluation to discharge (main effect of time: p = .02). There was no statistically significant main effect of group and no significant Time × Group interaction (p = .63). FMA-UE scores also improved significantly in the intervention group from evaluation to discharge (p < .001). FMA-UE scores were not available for the control group. CONCLUSIONS AND RELEVANCE: Both the intervention and control groups demonstrated significant improvements in UE function from evaluation to discharge. There were no statistically significant differences between groups, indicating that the BAT results in similar improvements in UE function, as would be expected in traditional occupational therapy. Further research is warranted to examine additional BAT programs, use different outcome measures, and assess participants over a longer time span. Plain-Language Summary: The Bimanual Arm Trainer (BAT) is a novel device that can be used in occupational therapy to improve arm function among stroke patients. There is limited research on BAT's effectiveness in improving arm function among stroke patients. In an acute inpatient rehabilitation setting, we compared outcome scores of patients who received traditional occupational therapy services with those who also used the BAT. Both groups achieved significant improvements in arm function from evaluation to discharge. We found that the addition of the BAT interventions did not significantly affect the outcome measure scores for either group. We conclude that more research is needed to examine additional BAT programs, use different outcome measures, and assess participants over a longer period of time.