Impact of automated data flow and reminders on adherence and resource utilization for remotely monitoring physical activity in individuals with stroke or chronic obstructive pulmonary disease.

As rehabilitation advances into the era of digital health, remote monitoring of physical activity via wearable devices has the potential to change how we provide care. However, uncertainties about patient adherence and the significant resource requirements needed create challenges to adoption of remote monitoring into clinical care. Here we aim to determine the impact of a novel digital application to overcome these barriers. The Rehabilitation Remote Monitoring Application (RRMA) automatically extracts data about physical activity collected via a Fitbit device, screens the data for adherence, and contacts the participant if adherence is low. We compare adherence and estimate the resources required (i.e., time and financial) to perform remote monitoring of physical activity with and without the RRMA in two patient groups. Seventy-three individuals with stroke or chronic obstructive pulmonary disease completed 28 days of monitoring physical activity with the RRMA, while 62 individuals completed 28 days with the data flow processes being completed manually. Adherence (i.e., the average percentage of the day that the device was worn) was similar between groups (p=0.85). However, the RRMA saved an estimated 123.8 minutes or $50.24 per participant month when compared to manual processes. These results demonstrate that automated technologies like the RRMA can maintain patient adherence to remote monitoring of physical activity while reducing the time and financial resources needed. Applications like the RRMA can facilitate the adoption of remote monitoring in rehabilitation by reducing barriers related to adherence and resource requirements.

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.

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.

AAPM&R consensus guidance on spasticity assessment and management.

BACKGROUND: The American Academy of Physical Medicine and Rehabilitation (AAPM&R) conducted a comprehensive review in 2021 to identify opportunities for enhancing the care of adult and pediatric patients with spasticity. A technical expert panel (TEP) was convened to develop consensus-based practice recommendations aimed at addressing gaps in spasticity care. OBJECTIVE: To develop consensus-based practice recommendations to identify and address gaps in spasticity care. METHODS: The Spasticity TEP engaged in a 16-month virtual meeting process, focusing on formulating search terms, refining research questions, and conducting a structured evidence review. Evidence quality was assessed by the AAPM&R Evidence, Quality and Performance Committee (EQPC), and a modified Delphi process was employed to achieve consensus on recommendation statements and evidence grading. The Strength of Recommendation Taxonomy (SORT) guided the rating of individual studies and the strength of recommendations. RESULTS: The TEP approved five recommendations for spasticity management and five best practices for assessment and management, with one recommendation unable to be graded due to evidence limitations. Best practices were defined as widely accepted components of care, while recommendations required structured evidence reviews and grading. The consensus guidance statement represents current best practices and evidence-based treatment options, intended for use by PM&R physicians caring for patients with spasticity. CONCLUSION: This consensus guidance provides clinicians with practical recommendations for spasticity assessment and management based on the best available evidence and expert opinion. Clinical judgment should be exercised, and recommendations tailored to individual patient needs, preferences, and risk profiles. The accompanying table summarizes the best practice recommendations for spasticity assessment and management, reflecting principles with little controversy in care delivery.

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.

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.

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.

Efficacy and safety of using auditory-motor entrainment to improve walking after stroke: a multi-site randomized controlled trial of InTandemTM.

Walking slowly after stroke reduces health and quality of life. This multi-site, prospective, interventional, 2-arm randomized controlled trial (NCT04121754) evaluated the safety and efficacy of an autonomous neurorehabilitation system (InTandemTM) designed to use auditory-motor entrainment to improve post-stroke walking. 87 individuals were randomized to 5-week walking interventions with InTandem or Active Control (i.e., walking without InTandem). The primary endpoints were change in walking speed, measured by the 10-meter walk test pre-vs-post each 5-week intervention, and safety, measured as the frequency of adverse events (AEs). Clinical responder rates were also compared. The trial met its primary endpoints. InTandem was associated with a 2x larger increase in speed (Δ: 0.14 ± 0.03 m/s versus Δ: 0.06 ± 0.02 m/s, F(1,49) = 6.58, p = 0.013), 3x more responders (40% versus 13%, χ2(1) ≥ 6.47, p = 0.01), and similar safety (both groups experienced the same number of AEs). The auditory-motor intervention autonomously delivered by InTandem is safe and effective in improving walking in the chronic phase of stroke.

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.

The feasibility of remotely monitoring physical, cognitive, and psychosocial function in individuals with stroke or chronic obstructive pulmonary disease.

Objective: Clinical implementation of remote monitoring of human function requires an understanding of its feasibility. We evaluated adherence and the resources required to monitor physical, cognitive, and psychosocial function in individuals with either chronic obstructive pulmonary disease or stroke during a three-month period. Methods: Seventy-three individuals agreed to wear a Fitbit to monitor physical function and to complete monthly online assessments of cognitive and psychosocial function. During a three-month period, we measured adherence to monitoring (1) physical function using average daily wear time, and (2) cognition and psychosocial function using the percentage of assessments completed. We measured the resources needed to promote adherence as (1) the number of participants requiring at least one reminder to synchronize their Fitbit, and (2) the number of reminders needed for each completed cognitive and psychosocial assessment. Results: After accounting for withdrawals, the average daily wear time was 77.5 ± 19.9% of the day and did not differ significantly between months 1, 2, and 3 (p = 0.30). To achieve this level of adherence, 64.9% of participants required at least one reminder to synchronize their device. Participants completed 61.0% of the cognitive and psychosocial assessments; the portion of assessments completed each month didnot significantly differ (p = 0.44). Participants required 1.13 ± 0.57 reminders for each completed assessment. Results did not differ by disease diagnosis. Conclusions: Remote monitoring of human function in individuals with either chronic obstructive pulmonary disease or stroke is feasible as demonstrated by high adherence. However, the number of reminders required indicates that careful consideration must be given to the resources available to obtain high adherence.

A Unified Model for Stroke Recovery and Rehabilitation: Why Now?

ABSTRACT: The current model of stroke care delivery in the United States and in many parts of the world is fragmented, resulting in lack of continuity of care, inability to track recovery meaningfully across the continuum, and lack of access to the frequency, intensity, and duration of high-quality rehabilitation necessary to optimally harness recovery processes. The process of recovery itself has been overshadowed by a focus on length of stay and the movement of patients across levels of care. Here, we describe the rationale behind the recent efforts at the Johns Hopkins Sheikh Khalifa Stroke Institute to define and coordinate an intensive, strategic effort to develop effective stroke systems of care across the continuum through the development of a unified Sheikh Khalifa Stroke Institute model of recovery and rehabilitation.

Development and Implementation of a Standard Assessment Battery Across the Continuum of Care for Patients After Stroke.

ABSTRACT: Stroke rehabilitation occurs across the continuum of care starting in the acute hospital and through the inpatient and outpatient settings. Rehabilitation aims to minimize impairments and maximize function in individuals after stroke. Because patients often undergo rehabilitation for extended periods, longitudinal assessment of impairment, activity, and participation can facilitate the evaluation of patients' progress toward recovery, as well as communication and decision making to guide clinical practice regarding the intervention(s) to be used and may also be leveraged for clinical research. However, the clinical implementation of a standard assessment battery that spans the continuum of care for patients after stroke is challenging because of operational and time constraints. Here, we describe the development and implementation of a standard assessment battery across the continuum of care by physical therapists, occupational therapists, and speech-language pathologists at the Sheikh Khalifa Stroke Institute. We specifically describe our experience in (1) identifying the core team to lead the process, (2) selecting the measures for the standard assessment battery, and the timeframe for administration, and (3) implementing the standard assessment battery in routine clinical practice.

A Learning Health System Infrastructure for Precision Rehabilitation After Stroke.

ABSTRACT: Functional recovery and the response to rehabilitation interventions after stroke are highly variable. Understanding this variability will promote precision rehabilitation for stroke, allowing us to deliver targeted interventions to the right person at the right time. Capitalizing on large, heterogeneous data sets, such as those generated through clinical care and housed within the electronic health record, can lead to understanding of poststroke variability. However, accessing data from the electronic health record can be challenging because of data quality, privacy concerns, and the resources required for data extraction. Therefore, creating infrastructure that overcomes these challenges and contributes to a learning health system is needed to achieve precision rehabilitation after stroke. We describe the creation of a Precision Rehabilitation Data Repository that facilitates access to systematically collected data from the electronic health record as part of a learning health system to drive precision rehabilitation. Specifically, we describe the process of (1) standardizing the documentation of functional assessments, (2) obtaining regulatory approval, (3) defining the patient cohort, and (4) extracting data for the Precision Rehabilitation Data Repository. The development of similar infrastructures at other institutions can help generate large, heterogeneous data sets to drive poststroke care toward precision rehabilitation, thereby maximizing poststroke function within an efficient healthcare system.

Addressing the Operational Challenges for Outpatient Stroke Rehabilitation.

ABSTRACT: The traditional model of rehabilitation services includes clear requirements for provision of services in the acute inpatient rehabilitation setting. However, there are fewer guidelines on the frequency and duration of rehabilitation services beyond the acute setting. Recent research has suggested that neurorehabilitation interventions that are provided frequently enough upon discharge from acute inpatient rehabilitation to facilitate repeated practice and feedback improve long-term stroke outcomes. However, it is challenging to provide high-frequency outpatient rehabilitation, as the logistics of scheduling and insurance limitations often do not allow it. The Sheikh Khalifa Stroke Institute at Johns Hopkins Medicine innovated a new model to provide the appropriate frequency of therapy for stroke rehabilitation in the outpatient setting. This article describes the restructured operational infrastructure for outpatient stroke rehabilitation to facilitate high-frequency transdisciplinary stroke rehabilitation in the real world, including the development of the outpatient postacute therapy programs and the identification of appropriate patients for each program, the development of scheduling matrices and treating teams to deliver the postacute therapy programs, the implementation of transdisciplinary neurorehabilitation, and the steps taken to empower patients to engage in rehabilitation at home and address barriers to accessing the programs. We assessed the effect of the operational restructuring on schedule utilization, no-show rates, and cancellation rates in the 3 mos before and after implementation of the program and show that it increased schedule utilization and reduced no-show rates and cancellation rates, suggesting that it may increase compliance with rehabilitation. It is possible to create the infrastructure needed to bridge the continuum of care for poststroke recovery and rehabilitation.

A Novel Way to Objectively Review Emerging Rehabilitation Technologies.

ABSTRACT: Technology-enhanced rehabilitation can improve access to training activities in multiple care delivery settings and may improve patient outcomes. However, the rate at which rehabilitation technology is being developed makes it difficult for healthcare systems to keep pace with the volume of products emerging in this space. Formal processes are needed to help healthcare systems review products as they emerge and to determine whether they should be incorporated into clinical practice. Here, we describe an approach to reviewing emerging rehabilitation technologies as performed by the Center for Emerging Rehabilitation Technology at our institution. Developed using an iterative approach, the rehabilitation technology review process used by the Center for Emerging Rehabilitation Technology team classifies technologies into the following three categories: (1) for clinical deployment, (2) for innovation in product development/product-market fit testing, and (3) for research, for example, a sponsored clinical trial. We describe the processes used to evaluate, categorize, investigate, and integrate rehabilitation technology, share our experience with the review process, and make recommendations for other institutions who may wish to implement rehabilitation technology into clinical practice.

Alterations in motor modules and their contribution to limitations in force control in the upper extremity after stroke.

The generation of isometric force at the hand can be mediated by activating a few motor modules. Stroke induces alterations in motor modules underlying steady-state isometric force generation in the human upper extremity (UE). However, how the altered motor modules impact task performance (force production) remains unclear as stroke survivors develop and converge to the three-dimensional (3D) target force. Thus, we tested whether stroke-specific motor modules would be activated from the onset of force generation and also examined how alterations in motor modules would induce changes in force representation. During 3D isometric force development, electromyographic (EMG) signals were recorded from eight major elbow and shoulder muscles in the paretic arm of 10 chronic hemispheric stroke survivors and both arms of six age-matched control participants. A non-negative matrix factorization algorithm identified motor modules in four different time windows: three "exploratory" force ramping phases (Ramps 1-3; 0-33%, 33-67%, and 67-100% of target force magnitude, respectively) and the stable force match phase (Hold). Motor module similarity and between-force coupling were examined by calculating the scalar product and Pearson correlation across the phases. To investigate the association between the end-point force representation and the activation of the motor modules, principal component analysis (PCA) and multivariate multiple linear regression analyses were applied. In addition, the force components regressed on the activation profiles of motor modules were utilized to model the feasible force direction. Both stroke and control groups developed exploratory isometric forces with a non-linear relationship between EMG and force. During the force matching, only the stroke group showed abnormal between-force coupling in medial-lateral and backward-forward and medial-lateral and downward-upward directions. In each group, the same motor modules, including the abnormal deltoid module in stroke survivors, were expressed from the beginning of force development instead of emerging during the force exploration. The PCA and the multivariate multiple linear regression analyses showed that alterations in motor modules were associated with abnormal between-force coupling and limited feasible force direction after stroke. Overall, these results suggest that alterations in intermuscular coordination contribute to the abnormal end-point force control under isometric conditions in the UE after stroke.

Nonlinear functional muscle network based on information theory tracks sensorimotor integration post stroke.

Sensory information is critical for motor coordination. However, understanding sensorimotor integration is complicated, especially in individuals with impairment due to injury to the central nervous system. This research presents a novel functional biomarker, based on a nonlinear network graph of muscle connectivity, called InfoMuNet, to quantify the role of sensory information on motor performance. Thirty-two individuals with post-stroke hemiparesis performed a grasp-and-lift task, while their muscle activity from 8 muscles in each arm was measured using surface electromyography. Subjects performed the task with their affected hand before and after sensory exposure to the task performed with the less-affected hand. For the first time, this work shows that InfoMuNet robustly quantifies changes in functional muscle connectivity in the affected hand after exposure to sensory information from the less-affected side. > 90% of the subjects conformed with the improvement resulting from this sensory exposure. InfoMuNet also shows high sensitivity to tactile, kinesthetic, and visual input alterations at the subject level, highlighting its potential use in precision rehabilitation interventions.

Efficacy of contralaterally controlled functional electrical stimulation compared to cyclic neuromuscular electrical stimulation and task-oriented training for recovery of hand function after stroke: study protocol for a multi-site randomized controlled trial.

BACKGROUND: Multi-site studies in stroke rehabilitation are important for determining whether a technology and/or treatment can be successfully administered by sites other than the originating site and with similar positive outcomes. This study is the first multi-site clinical trial of a novel intervention for post-stroke upper limb rehabilitation called contralaterally controlled functional electrical stimulation (CCFES). Previous pilot and single-site studies showed positive effects of CCFES on upper limb impairment and hand dexterity in stroke survivors. The main purpose of this study is to confirm and demonstrate the efficacy of CCFES in a larger group of most likely responders across multiple clinical sites. METHODS: Up to 129 stroke survivors with moderate to severe upper extremity hemiparesis at 4 clinical trial sites will be randomized to CCFES, cyclic neuromuscular electrical stimulation (cNMES), or task-oriented-training (TOT). Participants will receive 12 weeks of group-specific therapy. Blinded assessments of upper limb impairment and activity limitation, quality of life, and neurophysiology will be used to compare outcomes at baseline, after treatment, and up to 6 months post-treatment. The primary endpoint is change in dexterity from baseline to 6 months post-treatment. DISCUSSION: Loss of hand function following stroke is a major rehabilitation problem affecting millions of people per year globally. More effective rehabilitation therapies are needed to restore hand function in these individuals. This study will determine whether CCFES therapy produces greater improvements in upper extremity function than cNMES or TOT, and will begin to elucidate the different mechanisms underlying each of the three treatments. This multi-site study is a critical step in advancing a novel method of rehabilitation toward clinical translation and widespread dissemination. TRIAL REGISTRATION: ClinicalTrials.gov NCT03574623 . Registered prior to first enrollment; July 2, 2018.

Densification: Hyaluronan Aggregation in Different Human Organs.

Hyaluronan (HA) has complex biological roles that have catalyzed clinical interest in several fields of medicine. In this narrative review, we provide an overview of HA aggregation, also called densification, in human organs. The literature suggests that HA aggregation can occur in the liver, eye, lung, kidney, blood vessel, muscle, fascia, skin, pancreatic cancer and malignant melanoma. In all these organs, aggregation of HA leads to an increase in extracellular matrix viscosity, causing stiffness and organ dysfunction. Fibrosis, in some of these organs, may also occur as a direct consequence of densification in the long term. Specific imaging evaluation, such dynamic ultrasonography, elasto-sonography, elasto-MRI and T1ρ MRI can permit early diagnosis to enable the clinician to organize the treatment plan and avoid further progression of the pathology and dysfunction.