Measuring myofascial shear strain in chronic shoulder pain with ultrasound shear strain imaging: a case report.

BACKGROUND: Dysfunctional gliding of deep fascia and muscle layers forms the basis of myofascial pain and dysfunction, which can cause chronic shoulder pain. Ultrasound shear strain imaging may offer a non-invasive tool to quantitatively evaluate the extent of muscular dysfunctional gliding and its correlation with pain. This case study is the first to use ultrasound shear strain imaging to report the shear strain between the pectoralis major and minor muscles in shoulders with and without chronic pain. CASE PRESENTATION: The shear strain between the pectoralis major and minor muscles during shoulder rotation in a volunteer with chronic shoulder pain was measured with ultrasound shear strain imaging. The results show that the mean ± standard deviation shear strain was 0.40 ± 0.09 on the affected side, compared to 1.09 ± 0.18 on the unaffected side (p<0.05). The results suggest that myofascial dysfunction may cause the muscles to adhere together thereby reducing shear strain on the affected side. CONCLUSION: Our findings elucidate a potential pathophysiology of myofascial dysfunction in chronic shoulder pain and reveal the potential utility of ultrasound imaging to provide a useful biomarker for shear strain evaluation between the pectoralis major and minor muscles.

Precision Rehabilitation: Optimizing Function, Adding Value to Health Care.

Precision medicine efforts are underway in many medical disciplines; however, the power of precision rehabilitation has not yet been explored. Precision medicine aims to deliver the right intervention, at the right time, in the right setting, for the right person, ultimately bolstering the value of the care that we provide. To date, precision medicine efforts have rarely focused on function at the level of a person, but precision rehabilitation is poised to change this and bring the focus on function to the broader precision medicine enterprise. To do this, subgroups of individuals must be identified based on their level of function via precise measurement of their abilities in the physical, cognitive, and psychosocial domains. Adoption of electronic health records, advances in data storage and analytics, and improved measurement technology make this shift possible. Here we detail critical components of the precision rehabilitation framework, including (1) the synergistic use of various study designs, (2) the need for standardized functional measurements, (3) the importance of precise and longitudinal measures of function, (4) the utility of comprehensive databases, (5) the importance of predictive analyses, and (6) the need for system and team science. Precision rehabilitation has the potential to revolutionize clinical care, optimize function for all individuals, and magnify the value of rehabilitation in health care; however, to reap the benefits of precision rehabilitation, the rehabilitation community must actively pursue this shift.

Enriched Music-supported Therapy for chronic stroke patients: a study protocol of a randomised controlled trial.

BACKGROUND: Residual motor deficits of the upper limb in patients with chronic stroke are common and have a negative impact on autonomy, participation and quality of life. Music-Supported Therapy (MST) is an effective intervention to enhance motor and cognitive function, emotional well-being and quality of life in chronic stroke patients. We have adapted the original MST training protocol to a home-based intervention, which incorporates increased training intensity and variability, group sessions, and optimisation of learning to promote autonomy and motivation. METHODS: A randomised controlled trial will be conducted to test the effectiveness of this enriched MST (eMST) protocol in improving motor functions, cognition, emotional well-being and quality of life of chronic stroke patients when compared to a program of home-based exercises utilizing the Graded Repetitive Arm Supplementary Program (GRASP). Sixty stroke patients will be recruited and randomly allocated to an eMST group (n = 30) or a control GRASP intervention group (n = 30). Patients will be evaluated before and after a 10-week intervention, as well as at 3-month follow-up. The primary outcome of the study is the functionality of the paretic upper limb measured with the Action Research Arm Test. Secondary outcomes include other motor and cognitive functions, emotional well-being and quality of life measures as well as self-regulation and self-efficacy outcomes. DISCUSSION: We hypothesize that patients treated with eMST will show larger improvements in their motor and cognitive functions, emotional well-being and quality of life than patients treated with a home-based GRASP intervention. TRIAL REGISTRATION: The trial has been registered at ClinicalTrials.gov and identified as NCT04507542 on 8 August 2020.

Ecology of musical performance as a model for evaluation and treatment of a musician with a playing related musculoskeletal disorder: A case report.

STUDY DESIGN: Case report BACKGROUND: Musicians with playing related musculoskeletal disorders (PRMD) require complex decision making to interpret examination findings and develop a holistic treatment approach that considers the unique interaction with their instrument. The Ecology of Musical Performance (EMP) model is a novel comprehensive clinical model designed to provide guidance for musician-centered evaluation, goal setting, and intervention planning for musicians with PRMD. PURPOSE OF THE STUDY: To describe the application of EMP in the evaluation and treatment of a pianist with PRMD. METHODS: Clinical documentation and the patient's symptom logs provided data for this study. Special considerations unique to musicians in the initial evaluation as well as a timeline of interventions are presented to illustrate the application of the EMP model for a holistic approach to treatment. RESULTS AND DISCUSSION: The pianist showed an increase in grip strength and self-reported hand function both in daily activities and in piano performance and training. Pain free practice tolerance increased and the patient successfully returned to participation in piano training and performance. CONCLUSION: This case demonstrates how a treatment program can be customized to benefit musicians taking into consideration the complexity introduced by their relationship with music making as a primary meaningful occupation. EMP may support a person-centered approach to musicians with PRMD by aligning with the phenomenology of musical performance and facilitating collaborative goal setting and problem solving.

Conference report on contractures in musculoskeletal and neurological conditions.

Limb contractures are debilitating complications associated with various muscle and nervous system disorders. This report summarizes presentations at a conference at the Shirley Ryan AbilityLab in Chicago, Illinois, on April 19-20, 2018, involving researchers and physicians from diverse disciplines who convened to discuss current clinical and preclinical understanding of contractures in Duchenne muscular dystrophy, stroke, cerebral palsy, and other conditions. Presenters described changes in muscle architecture, activation, extracellular matrix, satellite cells, and muscle fiber sarcomeric structure that accompany or predispose muscles to contracture. Participants identified ongoing and future research directions that may lead to understanding of the intersecting factors that trigger contractures. These include additional studies of changes in muscle, tendon, joint, and neuronal tissues during contracture development with imaging, molecular, and physiologic approaches. Participants identified the requirement for improved biomarkers and outcome measures to identify patients likely to develop contractures and to accurately measure efficacy of treatments currently available and under development.

Wearable Inertial Sensors for Range of Motion Assessment.

This paper presents the design and development of wearable inertial sensors (WIS) for real-time simultaneous triplanar motion capture of the upper extremity (UE). The sensors simultaneously capture in the frontal, sagittal, and horizontal planes UE range of motion (ROM), which is critical to assess an individual's movement limitations and determine appropriate rehabilitative treatments. Off-the-shelf sensors and microcontrollers are used to develop the WIS system, which wirelessly streams real-time joint orientation for UE ROM measurement. Key developments include: 1) two novel approaches, using earth's gravity (EG approach) and magnetic field (EGM approach) as references, to correct misalignments in the orientation between the sensor and its housing to minimize measurement errors; 2) implementation of the joint coordinate system (JCS)-based method for triplanar ROM measurements for clinical use; and 3) an in-situ guided mounting technique for accurate sensor placement and alignment on human body. The results 1) compare computational time between two orientation misalignment correction approaches (EG approach = 325.05 µs and EGM approach = 92.05µs); 2) demonstrate the accuracy and repeatability of measurements from the WIS system (percent deviation of measured angle from applied angle is less than ±6.5% and percent coefficient of variation is less than 11%, indicating acceptable accuracy and repeatability, respectively); and 3) demonstrate the feasibility of using the WIS system within the JCS framework for providing anatomically-correct simultaneous triplanar ROM measurements of shoulder, elbow, and forearm movements during several upper limb exercises.

A loop-counting method for covariate-corrected low-rank biclustering of gene-expression and genome-wide association study data.

A common goal in data-analysis is to sift through a large data-matrix and detect any significant submatrices (i.e., biclusters) that have a low numerical rank. We present a simple algorithm for tackling this biclustering problem. Our algorithm accumulates information about 2-by-2 submatrices (i.e., 'loops') within the data-matrix, and focuses on rows and columns of the data-matrix that participate in an abundance of low-rank loops. We demonstrate, through analysis and numerical-experiments, that this loop-counting method performs well in a variety of scenarios, outperforming simple spectral methods in many situations of interest. Another important feature of our method is that it can easily be modified to account for aspects of experimental design which commonly arise in practice. For example, our algorithm can be modified to correct for controls, categorical- and continuous-covariates, as well as sparsity within the data. We demonstrate these practical features with two examples; the first drawn from gene-expression analysis and the second drawn from a much larger genome-wide-association-study (GWAS).

Research in the Acute Rehabilitation Setting: a Bridge Too Far?

PURPOSE OF REVIEW: The goal of this paper is to critically examine the challenges to clinical practice in acute neurorehabilitation settings to provide evidence-based recommendations for conducting research on neurologic recovery. RECENT FINDINGS: Recent changes in health care have dramatically challenged post-acute care by reducing the length of stay and increasing transitions in care with resulting loss of continuity of care and follow-up. These challenges hinder research and undermine progress in neurorehabilitation. Based on recent evidence, a hub and spoke model is proposed to bridge and facilitate continuity of care from acute to subacute to community settings to meet these challenges head on and facilitate research on mechanisms of functional recovery from neurologic conditions.

Emotion regulation after acquired brain injury: a study of heart rate variability, attentional control, and psychophysiology.

Primary objective: To examine the efficacy of heart rate variability biofeedback (HRV-BF) to treat emotional dysregulation in persons with acquired brain injury. Design: A secondary analysis of a quasi-experimental study which enrolled 13 individuals with severe chronic acquired brain injury participating in a community-based programme. Response-to-treatment was measured with two HRV resonance indices (low frequency activity [LF] and low frequency/high frequency ratio [LF/HF]). Main outcome: Behavior Rating Inventory of Executive Function-informant report (emotional control subscale [EC]). Results: Results show significant correlation between LF and EC with higher LF activity associated with greater emotional control; the association between LF/HF pre-post-change score and EC is not statistically significant. A moderation model, however, demonstrates a significant influence of attention on the relation between LF/HF change and EC when attention level is high, with an increase in LF/HF activity associated with greater emotional control. Conclusions: HRV-BF is associated with large increases in HRV, and it appears to be useful for the treatment of emotional dysregulation in individuals with severe acquired brain injury. Attention training may enhance an individual's emotional control.

The Role of Social Interactions in Motor Performance: Feasibility Study Toward Enhanced Motivation in Telerehabilitation.

BACKGROUND: Robot-mediated telerehabilitation has the potential to provide patient-tailored cost-effective rehabilitation. However, compliance with therapy can be a problem that undermines the prospective advantages of telerehabilitation technologies. Lack of motivation has been identified as a major factor that hampers compliance. Exploring various motivational interventions, the integration of citizen science activities in robotics-based rehabilitation has been shown to increase patients' motivation to engage in otherwise tedious exercises by tapping into a vast array of intrinsic motivational drivers. Patient engagement can be further enhanced by the incorporation of social interactions. OBJECTIVE: Herein, we explored the possibility of bolstering engagement in physical therapy by leveraging cooperation among users in an environmental citizen science project. Specifically, we studied how the integration of cooperation into citizen science influences user engagement, enjoyment, and motor performance. Furthermore, we investigated how the degree of interdependence among users, such that is imposed through independent or joint termination (JT), affects participation in citizen science-based telerehabilitation. METHODS: We developed a Web-based citizen science platform in which users work in pairs to classify images collected by an aquatic robot in a polluted water canal. The classification was carried out by labeling objects that appear in the images and trashing irrelevant labels. The system was interfaced by a haptic device for fine motor rehabilitation. We recruited 120 healthy volunteers to operate the platform. Of these volunteers, 98 were cooperating in pairs, with 1 user tagging images and the other trashing labels. The other 22 volunteers performed both tasks alone. To vary the degree of interdependence within cooperation, we implemented independent and JTs. RESULTS: We found that users' engagement and motor performance are modulated by their assigned task and the degree of interdependence. Motor performance increased when users were subjected to independent termination (P=.02), yet enjoyment decreased when users were subjected to JT (P=.005). A significant interaction between the type of termination and the task was found to influence productivity (P<.001) as well as mean speed, peak speed, and path length of the controller (P=.01, P=.006, and P<.001, respectively). CONCLUSIONS: Depending on the type of termination, cooperation was not always positively associated with engagement, enjoyment, and motor performance. Therefore, enhancing user engagement, satisfaction, and motor performance through cooperative citizen science tasks relies on both the degree of interdependence among users and the perceived nature of the task. Cooperative citizen science may enhance motivation in robotics-based telerehabilitation, if designed attentively.

Traumatic brain injury results in altered physiologic, but not subjective responses to emotional stimuli.

BACKGROUND: While the cognitive sequelae of traumatic brain injury (TBI) are well known, emotional impairments after TBI are suboptimally characterized. Lack of awareness of emotional difficulties can make self-report unreliable. However, individuals with TBI demonstrate involuntary changes in heart rate variability which may enable objective quantification of emotional dysfunction. METHODS: Sixteen subjects with chronic TBI and 10 age-matched controls were tested on an emotional function battery during which they watched a series of film clips normed to elicit specific positively and negatively valenced emotions: amusement, sexual amusement, sadness, fear and disgust. Subjective responses to the emotional stimuli were also obtained. Additionally, surface electrodes measured cardiac and respiratory signals to compute heart rate variability (HRV), from which measures of parasympathetic activity, the respiratory frequency area (RFA) and sympathetic activity, the low frequency area (LFA), of the HRV frequency spectrum were derived. The Neurobehavioral Rating Scale-Revised (NRS-R) and the King-Devick (KD) test were administered to assess neurobehavioral dysfunction. RESULTS: The two groups showed no differences in subjective ratings of emotional intensity. Subjects with TBI showed significantly decreased sympathetic activity when viewing amusing stimuli and significantly increased sympathetic activity when viewing sad stimuli compared to controls. Most of the subjects did not show agitation, anxiety, depression, blunted affect, emotional withdrawal, decreased motivation or mental fatiguability on the NRS-R. However, 13/16 subjects with TBI demonstrated attention difficulty on the NRS-R which was positively correlated with the increased sympathetic activity during sad stimuli. Both attention difficulty and abnormal autonomic responses to sad stimuli were correlated with the timing on the KD test, which reflected difficulty with visual attention shifting. CONCLUSIONS: The HRV spectrum may be useful to identify subclinical emotional dysfunction in individuals with TBI. Attention difficulites, specifically impairment in visual attention shifting, may contribute to abnormal reactivity to sad stimuli that may be detected and potentially treated to improve emotional function.

Effect of blocking tactile information from the fingertips on adaptation and execution of grip forces to friction at the grasping surface.

Adaptation of fingertip forces to friction at the grasping surface is necessary to prevent use of inadequate or excessive grip forces. In the current study we investigated the effect of blocking tactile information from the fingertips noninvasively on the adaptation and efficiency of grip forces to surface friction during precision grasp. Ten neurologically intact subjects grasped and lifted an instrumented grip device with 18 different frictional surfaces under three conditions: with bare hands or with a thin layer of plastic (Tegaderm) or an additional layer of foam affixed to the fingertips. The coefficient of friction at the finger-object interface of each surface was obtained for each subject with bare hands and Tegaderm by measuring the slip ratio (grip force/load force) at the moment of slip. We found that the foam layer reduced sensibility for two-point discrimination and pressure sensitivity at the fingertips, but Tegaderm did not. However, Tegaderm reduced static, but not dynamic, tactile discrimination. Adaptation of fingertip grip forces to surface friction measured by the rate of change of peak grip force, and grip force efficiency measured by the grip-load force ratio at lift, showed a proportional relationship with bare hands but were impaired with Tegaderm and foam. Activation of muscles engaged in precision grip also varied with the frictional surface with bare hands but not with Tegaderm and foam. The results suggest that sensitivity for static tactile discrimination is necessary for feedforward and feedback control of grip forces and for adaptive modulation of muscle activity during precision grasp.

Quantifying feedforward control: a linear scaling model for fingertip forces and object weight.

The ability to predict the optimal fingertip forces according to object properties before the object is lifted is known as feedforward control, and it is thought to occur due to the formation of internal representations of the object's properties. The control of fingertip forces to objects of different weights has been studied extensively by using a custom-made grip device instrumented with force sensors. Feedforward control is measured by the rate of change of the vertical (load) force before the object is lifted. However, the precise relationship between the rate of change of load force and object weight and how it varies across healthy individuals in a population is not clearly understood. Using sets of 10 different weights, we have shown that there is a log-linear relationship between the fingertip load force rates and weight among neurologically intact individuals. We found that after one practice lift, as the weight increased, the peak load force rate (PLFR) increased by a fixed percentage, and this proportionality was common among the healthy subjects. However, at any given weight, the level of PLFR varied across individuals and was related to the efficiency of the muscles involved in lifting the object, in this case the wrist and finger extensor muscles. These results quantify feedforward control during grasp and lift among healthy individuals and provide new benchmarks to interpret data from neurologically impaired populations as well as a means to assess the effect of interventions on restoration of feedforward control and its relationship to muscular control.

Effects of emotionally charged auditory stimulation on gait performance in the elderly: a preliminary study.

OBJECTIVES: To evaluate the effect of a novel divided attention task-walking under auditory constraints-on gait performance in older adults and to determine whether this effect was moderated by cognitive status. DESIGN: Validation cohort. SETTING: General community. PARTICIPANTS: Ambulatory older adults without dementia (N=104). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: In this pilot study, we evaluated walking under auditory constraints in 104 older adults who completed 3 pairs of walking trials on a gait mat under 1 of 3 randomly assigned conditions: 1 pair without auditory stimulation and 2 pairs with emotionally charged auditory stimulation with happy or sad sounds. RESULTS: The mean age of subjects was 80.6±4.9 years, and 63% (n=66) were women. The mean velocity during normal walking was 97.9±20.6cm/s, and the mean cadence was 105.1±9.9 steps/min. The effect of walking under auditory constraints on gait characteristics was analyzed using a 2-factorial analysis of variance with a 1-between factor (cognitively intact and minimal cognitive impairment groups) and a 1-within factor (type of auditory stimuli). In both happy and sad auditory stimulation trials, cognitively intact older adults (n=96) showed an average increase of 2.68cm/s in gait velocity (F1.86,191.71=3.99; P=.02) and an average increase of 2.41 steps/min in cadence (F1.75,180.42=10.12; P<.001) as compared with trials without auditory stimulation. In contrast, older adults with minimal cognitive impairment (Blessed test score, 5-10; n=8) showed an average reduction of 5.45cm/s in gait velocity (F1.87,190.83=5.62; P=.005) and an average reduction of 3.88 steps/min in cadence (F1.79,183.10=8.21; P=.001) under both auditory stimulation conditions. Neither baseline fall history nor performance of activities of daily living accounted for these differences. CONCLUSIONS: Our results provide preliminary evidence of the differentiating effect of emotionally charged auditory stimuli on gait performance in older individuals with minimal cognitive impairment compared with those without minimal cognitive impairment. A divided attention task using emotionally charged auditory stimuli might be able to elicit compensatory improvement in gait performance in cognitively intact older individuals, but lead to decompensation in those with minimal cognitive impairment. Further investigation is needed to compare gait performance under this task to gait on other dual-task paradigms and to separately examine the effect of physiological aging versus cognitive impairment on gait during walking under auditory constraints.

Top-Down and Bottom-Up Mechanisms of Motor Recovery Poststroke.

Stroke remains a leading cause of disability. Motor recovery requires the interaction of top-down and bottom-up mechanisms, which reinforce each other. Injury to the brain initiates a biphasic neuroimmune process, which opens a window for spontaneous recovery during which the brain is particularly sensitive to activity. Physical activity during this sensitive period can lead to rapid recovery by potentiating anti-inflammatory and neuroplastic processes. On the other hand, lack of physical activity can lead to early closure of the sensitive period and downstream changes in muscles, such as sarcopenia, muscle stiffness, and reduced cardiovascular capacity, and blood flow that impede recovery.

Music Upper Limb Therapy - Integrated (MULT-I) supports a positive transformation in sense of self post stroke: a thematic analysis.

PURPOSE: To understand how the experience of Music Upper Limb Therapy - Integrated (MULT-I) interconnects with the experience of stroke. METHODS: Thematic analysis of semi-structured interviews and video-recorded MULT-I sessions from a larger mixed-methods study. Thirty adults with post-stroke hemiparesis completed pre-intervention interviews, of whom fifteen participated in MULT-I. Thirteen of the participants in MULT-I completed post-intervention interviews. RESULTS: The experience of stroke was characterized by five themes: (1) sudden loss of functional abilities, (2) disrupted participation, (3) desire for independence, (4) emotional distress and the need for support, and (5) difficulty negotiating changes in sense of self. The experience of MULT-I was characterized by three themes: (1) MULT-I activated movement and empowered personal choice, (2) MULT-I created a safe place to process emotional distress and take on challenges, and (3) MULT-I fostered a sense of belonging and a positive transformation in sense of self. These themes combined create a framework which illustrates the process by which MULT-I addressed each challenge described by survivors of stroke, facilitating a positive transformation in sense of self. CONCLUSION: MULT-I promotes physical, emotional, and social wellbeing following a stroke. This integrated approach supports a positive transformation in sense of self. These findings have implications for improving psychosocial well-being post stroke.

The experience of stroke is characterized by disruptions in physical, emotional, and social well-beingSurvivors of stroke describe difficulty obtaining support for emotional distress and experience negative perceptions of their sense of selfMULT-I addresses functional needs post stroke through motivating physical movement and participation, while also supporting autonomy and providing psychosocial support that facilitates a positive transformation in sense of self.

Impact of Ergonomics on Muscle Fatigue During Surgical Drilling Using Surface Electromyography.

OBJECTIVE: To investigate the relationship between ergonomic positions and electromyographic muscle activity during otologic drilling. STUDY DESIGN: Cross-over experimental trial. SETTING: Tertiary Academic Medical Center. METHODS: Surgeon participants were tasked with delicate eggshell drilling in 3 different seated positions: "neutral," "slouched," and "craned." Surface electromyography (sEMG) sensors recorded the amplitude and frequency of muscle activity. The joint analysis of spectrum and amplitude (JASA) method, which combines temporal trends in frequency and amplitude, was used to identify trials that exhibited patterns of fatigue. RESULTS: The sEMG amplitude and frequency responses demonstrated wide temporal changes. In a majority of experiments, amplitude increased over the course of the experiment, while frequency remained more stable. On analysis of variance testing, only the mean frequency of the deltoid differed significantly between postures (P = .02). Under the JASA framework, external carpi radialis and upper trapezius experienced fatigue in nearly half of the trials regardless of position (47% vs 49%). The upper trapezius demonstrated fatigue during 46% and 69% of the "craned" and "slouched" trials, respectively, compared to just 31% of the "neutral" trials. Fewer attendings demonstrated upper trapezius fatigue compared to trainees (33% vs 62%). Female surgeons experienced fatigue in more trials than male counterparts (73% vs 25%). CONCLUSION: This study highlights a first step in quantifying the relationship between operating postures and muscle fatigue. Results suggest that specific muscle groups are more susceptible to fatigue; gender and experience may also impact muscle activity.

The effect of post-acute rehabilitation setting on 90-day mobility after stroke: A difference-in-difference analysis.

Background: After discharged from the hospital for acute stroke, individuals typically receive rehabilitation in one of three settings: inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home with community services (i.e., home health or outpatient clinics). The initial setting of post-acute care (i.e., discharge location) is related to mortality and hospital readmission; however, the impact of this setting on the change in functional mobility at 90-days after discharge is still poorly understood. The purpose of this work was to examine the impact of discharge location on the change in functional mobility between hospital discharge and 90-days post-discharge. Methods: In this retrospective cohort study, we used the electronic health record to identify individuals admitted to Johns Hopkins Medicine with an acute stroke and who had measurements of mobility [Activity Measure for Post Acute Care Basic Mobility (AM-PAC BM)] at discharge from the acute hospital and 90-days post-discharge. Individuals were grouped by discharge location (IRF=190 [40%], SNF=103 [22%], Home with community services=182 [(38%]). We compared the change in mobility from time of discharge to 90-days post-discharge in each group using a difference-in-differences analysis and controlling for demographics, clinical characteristics, and social determinants of health. Results: We included 475 individuals (age 64.4 [14.8] years; female: 248 [52.2%]). After adjusting for covariates, individuals who were discharged to an IRF had a significantly greater improvement in AM-PAC BM from time of discharge to 90-days post-discharge compared to individuals discharged to a SNF or home with community services (ß=-3.5 (1.4), p=0.01 and ß=-8.2 (1.3), p=<0.001, respectively). Conclusions: These findings suggest that the initial post-acute rehabilitation setting impacts the magnitude of functional recovery at 90-days after discharge from the acute hospital. These findings support the need for high-intensity rehabilitation and for policies that facilitate the delivery of high-intensity rehabilitation after stroke.

Mechanisms and benefits of cardiac rehabilitation in individuals with stroke: emerging role of its impact on improving cardiovascular and neurovascular health.

Human and animal studies have demonstrated the mechanisms and benefits of aerobic exercise for both cardiovascular and neurovascular health. Aerobic exercise induces neuroplasticity and neurophysiologic reorganization of brain networks, improves cerebral blood flow, and increases whole-body VO2peak (peak oxygen consumption). The effectiveness of a structured cardiac rehabilitation (CR) program is well established and a vital part of the continuum of care for people with cardiovascular disease. Individuals post stroke exhibit decreased cardiovascular capacity which impacts their neurologic recovery and extends disability. Stroke survivors share the same risk factors as patients with cardiac disease and can therefore benefit significantly from a comprehensive CR program in addition to neurorehabilitation to address their cardiovascular health. The inclusion of individuals with stroke into a CR program, with appropriate adaptations, can significantly improve their cardiovascular health, promote functional recovery, and reduce future cardiovascular and cerebrovascular events thereby reducing the economic burden of stroke.