Stroke Rehabilitation Clinical Practice Guidelines in Low- and Middle-Income Countries: A Systematic Review of Quality and Unique Features.

INTRODUCTION: Efforts toward reducing stroke burden have been an immense challenge. One important reasons could be the scope and quality of clinical practice guidelines (CPGs) developed for stroke rehabilitation in low- and middle-income countries (LMICs), restricting its translation to clinical practice. This systematic review aimed to assess the availability, scope and quality of CPGs for stroke rehabilitation in LMICs. METHODS: Following PRISMA guidelines, CPGs for stroke rehabilitation in LMICs were searched across four major electronic databases (Medline, Embase, CINAHL, and PEDro). Additional studies were identified from grey literature and a hand search of key bibliographies and search engines. The availability and content of the CPGs were narratively summarized and quality of de novo CPGs was analyzed using "Appraisal of Guidelines REsearch and Evaluation" (AGREE) tools: version II & Recommendations Excellence (REX) version. Features of contextualizations/adaptations of non-de novo CPGs were narratively summarized. RESULTS: Twelve CPGs from 10 countries were included. CPGs from Pakistan, Sri Lanka, India, and China were developed de novo. CPGs from Kenya, Philippines, South Africa, Cameroon, Mongolia, and Ukraine were contextualized/adapted based on existing guidelines from high-income countries. Most contextualized CPGs had limited stakeholder involvement, local health systems/patient pathway analyses. All ten countries included recommendations for physiotherapy, seven for communication, swallowing, and five for occupational therapy services poststroke. Quality assessment using AGREE-REX and AGREE-II for de novo guidelines was poor, especially scoring low in development and applicability. CONCLUSION: Contextualized CPGs for stroke rehabilitation in LMICs were scarcely available and not meeting required quality. There is a need for development of context-specific, culturally relevant CPGs for stroke rehabilitation in LMICs to improve implementation/translation into clinical practice.

Strategies for specialty training of healthcare professionals in low-resource settings: a systematic review on evidence from stroke care.

BACKGROUND: The greatest mortality and disability from stroke occurs in low- and middle-income countries. A significant barrier to implementation of best stroke care practices in these settings is limited availability of specialized healthcare training. We conducted a systematic review to determine the most effective methods for the provision of speciality stroke care education for hospital-based healthcare professionals in low-resource settings. METHODS: We followed the PRISMA guidelines for systematic reviews and searched PubMed, Web of Science and Scopus for original clinical research articles that described or evaluated stroke care education for hospital-based healthcare professionals in low-resource settings. Two reviewers screened titles/abstracts and then full text articles. Three reviewers critically appraised the articles selected for inclusion. RESULTS: A total of 1,182 articles were identified and eight were eligible for inclusion in this review; three were randomized controlled trials, four were non-randomized studies, and one was a descriptive study. Most studies used several approaches to education. A "train-the-trainer" approach to education was found to have the most positive clinical outcomes (lower overall complications, lengths of stay in hospital, and clinical vascular events). When used for quality improvement, the "train-the-trainer" approach increased patient reception of eligible performance measures. When technology was used to provide stroke education there was an increased frequency in diagnosis of stroke and use of antithrombotic treatment, reduced door-to-needle times, and increased support for decision making in medication prescription was reported. Task-shifting workshops for non-neurologists improved knowledge of stroke and patient care. Multidimensional education demonstrated an overall care quality improvement and increased prescriptions for evidence-based therapies, although, there were no significant differences in secondary prevention efforts, stroke reoccurrence or mortality rates. CONCLUSIONS: The "train the trainer" approach is likely the most effective strategy for specialist stroke education, while technology is also useful if resources are available to support its development and use. If resources are limited, basic knowledge education should be considered at a minimum and multidimensional training may not be as beneficial. Research into communities of practice, led by those in similar settings, may be helpful to develop educational initiatives with relevance to local contexts.

Effect of task-based bilateral arm training on upper limb recovery after stroke: A systematic review and meta-analysis.

OBJECTIVE: Upper limb recovery is a crucial component of stroke rehabilitation aimed to maximize functional activities and reduce disability. Using both arms post stroke is essential to carry out many functional activities but the evidence on bilateral arm training (BAT) is understudied. To investigate the evidence for efficacy of task-based BAT on upper limb recovery, function, and participation post stroke. METHODS: We included 13 randomized controlled trials, and methodological quality was assessed using Cochrane risk of bias tool and the PEDro scale. The outcome measures such as Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), Box and Block Test (BBT), Modified Barthel Index (MBI), Functional Independence Measure (FIM), and Stroke Impact Scale (SIS) were synthesized and analysed based on ICF. RESULTS: When comparing BAT with control group, BAT showed improvement in the pooled standard mean difference (SMD) of FMA-UE (SMD= 0.62, 95% confidence interval (CI), 0.12 to 1.12, p = 0.01; I2=83%). The control group showed significant improvement in MAL-QOM (SMD= -0.10, 95%CI, -0.77 to 0.58, p = 0.78; I2=89%). Compared to conventional group, BAT showed a significant improvement in BBT (SMD= 0.52, 95%CI, 0.04 to 1.00, p = 0.03; I2=0%). When compared with BAT, unimanual training yielded a significant improvement (SMD= -0.60, 95%CI, -0.98 to -0.22, p = 0.002; I2=0%) in MAL-QOM. In real-life participation, the control group showed improvement in SIS (SMD= -0.17, 95% (CI), -0.70 to 0.37, p = 0.54; I2=48%) over BAT. CONCLUSIONS: Task-based BAT appears to improve upper limb motor function post stroke. The benefits of task-based BAT on activity performance and participation in real life are not statistically significant.

Do kinematic measures, added to clinical measures, better predict upper extremity motor impairments at three months post-stroke?

OBJECTIVE: Predicting post-stroke recovery through prediction models is crucial for choosing appropriate treatment options. However, the existing models predominantly incorporate clinical measures although measurement of movement quality using kinematic measures is essential for distinguishing various types of recovery. Thus, this study aimed at determining if, by considering varied aspects of recovery, adding kinematic measurements over clinical measures would better predict upper extremity (UE) motor impairments at three months post-stroke. MATERIALS AND METHODS: Eighty-nine stroke survivors (58.9 ± 11.8 years) were assessed for clinical predictors between 4 and 7 days, kinematic predictors within 1 month, and the impairment outcome of the Fugl Meyer Assessment of the UE (FM-UE) at three months post-stroke. Significant predictors (p<0.05) with a variation inflation factor (VIF) <10 were selected for model development. After performing further step-wise selection, three models incorporating clinical outcomes, kinematic measurements, and a combination of these two, respectively, were formulated. RESULTS: The clinical model (R2 = 0.70) included shoulder abduction finger extension (SAFE) scores, the National Institutes of Health Stroke Scale (NIHSS), and the Montreal Cognitive Assessment (MoCA). The kinematic model (R2 = 0.34) included total displacement, total time, and reaction time. The combined model (R2 = 0.72) comprised of SAFE score and shoulder flexion. All the models had a minimal mean squared error on cross validation, which indicated a good validity. CONCLUSION: The performance of clinical and combined prediction models for predicting three-month post-stroke UE motor recovery was nearly similar. However, in order to detect minimal changes over time and to understand all aspects of motor recovery, there is a need to add instrument-based kinematic measures.

Effect of post-stroke spasticity on voluntary movement of the upper limb.

BACKGROUND: Hemiparesis following stroke is often accompanied by spasticity. Spasticity is one factor among the multiple components of the upper motor neuron syndrome that contributes to movement impairment. However, the specific contribution of spasticity is difficult to isolate and quantify. We propose a new method of quantification and evaluation of the impact of spasticity on the quality of movement following stroke. METHODS: Spasticity was assessed using the Tonic Stretch Reflex Threshold (TSRT). TSRT was analyzed in relation to stochastic models of motion to quantify the deviation of the hemiparetic upper limb motion from the normal motion patterns during a reaching task. Specifically, we assessed the impact of spasticity in the elbow flexors on reaching motion patterns using two distinct measures of the 'distance' between pathological and normal movement, (a) the bidirectional Kullback-Liebler divergence (BKLD) and (b) Hellinger's distance (HD). These measures differ in their sensitivity to different confounding variables. Motor impairment was assessed clinically by the Fugl-Meyer assessment scale for the upper extremity (FMA-UE). Forty-two first-event stroke patients in the subacute phase and 13 healthy controls of similar age participated in the study. Elbow motion was analyzed in the context of repeated reach-to-grasp movements towards four differently located targets. Log-BKLD and HD along with movement time, final elbow extension angle, mean elbow velocity, peak elbow velocity, and the number of velocity peaks of the elbow motion were computed. RESULTS: Upper limb kinematics in patients with lower FMA-UE scores (greater impairment) showed greater deviation from normality when the distance between impaired and normal elbow motion was analyzed either with the BKLD or HD measures. The severity of spasticity, reflected by the TSRT, was related to the distance between impaired and normal elbow motion analyzed with either distance measure. Mean elbow velocity differed between targets, however HD was not sensitive to target location. This may point at effects of spasticity on motion quality that go beyond effects on velocity. CONCLUSIONS: The two methods for analyzing pathological movement post-stroke provide new options for studying the relationship between spasticity and movement quality under different spatiotemporal constraints.

Posterior Ankle Decompression With Os Trigonum or Stieda Process Resection in Dancers: Case Series Report and Review of the Literature.

This case series reports the outcome of posterior ankle decompression and os trigonum or Stieda process resection utilizing an open posterolateral approach in 54 professional, pre-professional, and dedicated recreational dancers. All procedures were performed by a single surgeon at the same facility between 2008 and 2018. The surgical technique is described in detail. Data related to results of the surgery were gathered via follow-up questionnaire and verified by referencing the patients' medical records. Outcomes were self-assessed in terms of categories ranging from excellent through moderate to poor. Eighty-nine percent of the dancers (N = 48 of 54) chose excellent or good, 11% (N = 6) chose moderate, and none selected poor. These results were compared with those achieved in 17 previous studies reporting the use of both open (posterolateral and posteromedial) and arthroscopic/endoscopic techniques in dancers. This comparison found similarly favorable reported outcomes, but also great variation in methodology for determining patient reported outcomes (PROs). While the preferred surgical technique for posterior ankle decompression remains controversial, the open posterolateral approach utilized in this series resulted in high expectation of return to dance with minimal complications. The need for a dancer-specific PRO tool is discussed.

Effect of Transcutaneous Electrical Nerve Stimulation on Spasticity in Adults With Stroke: A Systematic Review and Meta-analysis.

OBJECTIVES: (1) To determine the effect of transcutaneous electrical nerve stimulation (TENS) on poststroke spasticity. (2) To determine the effect of different parameters (intensity, frequency, duration) of TENS on spasticity reduction in adults with stroke. (3) To determine the influence of time since stroke on the effectiveness of TENS on spasticity. DATA SOURCES: PubMed, PEDro, CINAHL, Web of Science, CENTRAL, and EMBASE databases were searched from inception to March 2017. STUDY SELECTION: Randomized controlled trial (RCT), quasi-RCT, and non-RCT were included if (1) they evaluated the effects of TENS for the management of spasticity in participants with acute or subacute or chronic stroke using clinical and neurophysiological tools; and (2) TENS was delivered either alone or as an adjunct to other treatments. DATA EXTRACTION: Two authors independently screened and extracted data from 15 of the 829 studies retrieved through the search using a pilot tested pro forma. Disagreements were resolved through discussion with other authors. Quality of studies was assessed using Cochrane risk of bias criteria. DATA SYNTHESIS: Meta-analysis was performed using a random-effects model that showed (1) TENS along with other physical therapy treatments was more effective in reducing spasticity in the lower limbs compared to placebo TENS (SMD -0.64; 95% confidence interval [95% CI], -0.98 to -0.31; P=.0001; I2=17%); and (2) TENS, when administered along with other physical therapy treatments, was effective in reducing spasticity when compared to other physical therapy interventions alone (SMD -0.83; 95% CI, -1.51 to -0.15; P=.02; I2=27%). There were limited studies to evaluate the effectiveness of TENS for upper limb spasticity. CONCLUSION: There is strong evidence that TENS as an adjunct is effective in reducing lower limb spasticity when applied for more than 30 minutes over nerve or muscle belly in chronic stroke survivors (review protocol registered at PROSPERO: CRD42015020151).

Efficacy of Trunk Regimes on Balance, Mobility, Physical Function, and Community Reintegration in Chronic Stroke: A Parallel-Group Randomized Trial.

OBJECTIVE: The study objective was to examine the efficacy of plinth and Swiss ball-based trunk exercise regimes on balance, mobility, physical function, and community reintegration compared with standard physiotherapy in chronic stroke. SUBJECTS AND METHODS: This observer-blinded parallel-group randomized trial was conducted in outpatient stroke units. People with chronic stroke aged between 30 and 75 years, first onset of unilateral cortical lesion, poor trunk performance, 10 m independent walking ability with or without walking aids, and absence of pusher syndrome were included. Trunk Impairment Scale 2.0, Brunel Balance Assessment, Tinetti scale, gait speed, Stroke Impact Scale-16, and Reintegration to Normal Living Index were the measures. Experimental interventions involved the practice of selective upper and lower trunk movements using either plinth or Swiss ball. Control group received standard physiotherapy. All the patients practiced 1 hour exercise session, 3 sessions a week over a duration of 6 weeks and followed up after 3 and 12 months. RESULTS: Of 108 patients allocated into 3 groups, baseline characteristics were similar. Postintervention compared with control group, the plinth, and Swiss ball groups showed significant mean changes in the outcome measures: trunk impairment scale 2.0 (3.6;4.1 points), Brunel Balance Assessment (1-level), Tinetti scale (5;5.2 points), gait speed (.06;.08 m/s), Stroke Impact Scale-16 (8.7;7.2 points), and community reintegration (7.6;8.8 points). These improvements were retained during 3-12 months' follow-up. Statistical significant was set at P < .05. CONCLUSION: Plinth and Swiss ball-based trunk exercise regimes showed significant improvements in balance, mobility, physical function, and community reintegration in chronic stroke as against standard physiotherapy.

Response abilities of children with Down Syndrome and other intellectual developmental disorders.

Efficiency with which a task is performed results from the precise timing and force with which the task is executed. We aimed at assessing the influence of change in task constructs on the response abilities of children who are known to have impaired perceptual motor control. To answer this question, we assessed the response abilities in terms of response time(RT) and response force(RF) among children with Down Syndrome(DS), intellectual developmental disorders(IDD) and those who are typically developing. A response analyzer was used to assess their response abilities across a variety of task constructs namely while performing a simple response task, dual task (i.e. passive and active dual tasks), force modulation task and choice response task. Across all tasks, it was seen that their RT increased while RF decreased as the tasks became more complex in nature. The number of participants in the DS and IDD group diminished as the task complexity increased, reflecting their inherent difficulty in learning new tasks and executing a common expected response under different task conditions. The response abilities of the DS and IDD group was comparable across tasks and varied significantly from the TDC group. The study enables us to understand the influence of task difficulties on the response abilities and participation across groups of children with and without disabilities. The results of the study necessitate the need to evaluate and find methods to train the response abilities of children with DS and IDD, which has considerable implications towards the performance of their daily life skills.

Predicting changes in systolic blood pressure using longitudinal patient records.

OBJECTIVE: This paper introduces a model that predicts future changes in systolic blood pressure (SBP) based on structured and unstructured (text-based) information from longitudinal clinical records. METHOD: For each patient, the clinical records are sorted in chronological order and SBP measurements are extracted from them. The model predicts future changes in SBP based on the preceding clinical notes. This is accomplished using least median squares regression on salient features found using a feature selection algorithm. RESULTS: Using the prediction model, a correlation coefficient of 0.47 is achieved on unseen test data (p<.0001). This is in contrast to a baseline correlation coefficient of 0.39.

Training Response Abilities of Children With Intellectual Disabilities: A Randomized Controlled Trial.

Response abilities, i.e., response time (RT) and response force (RF), which are essential for efficient motor control, are impaired in children with intellectual disabilities (ID). The study aimed to evaluate the effects of object control skills training, computer-based games training, or standard care on the RT and RF of children with ID when measured across task conditions. A randomized controlled trial was conducted in a special education school where 75 children with ID, between 9 and 17 years of age, were randomly assigned to object control skills training, computer-based games training, or standard care, where intervention groups were provided thrice a week for four weeks. The RT and RF were measured using a response analyzer for simple response task, (passive and active) dual-task, and choice response task at baseline, post-intervention, and four-week follow-up. The RT significantly reduced with object control skills training (ηp2= .325) and computer-based games training (ηp2= .159). Participants who received the object control skills training had greater stability in force production than the other groups. With training, children with ID take less time and show better stability in their ability to modulate force in various task settings, with more pronounced effects with the object control skills training.

Transcranial direct current stimulation for fatigue in neurological conditions: A systematic scoping review.

BACKGROUND AND PURPOSE: Fatigue following neurological conditions negatively impacts daily activities, reducing overall quality of life. Transcranial direct current stimulation (tDCS) for fatigue management is still underexplored. This scoping review explores its use in managing fatigue among various neurological conditions. METHODS: A thorough literature search was carried out using PubMed, Scopus, CINAHL, Web of Science, Embase, ProQuest, and the Cochrane Library. Google Scholar and clinicaltrials.gov were manually searched for gray literature and ongoing trials, respectively. Regardless of the study design, all studies utilizing tDCS for the management of fatigue in various neurological conditions were considered. Two reviewers independently screened all the studies, following which the data were retrieved. RESULTS: Studies employing tDCS for fatigue management across neurological conditions is as follows: Multiple sclerosis (MS) (n = 28, 66%), stroke (n = 5, 12%), Parkinson's disease (PD) (n = 4, 10%), post-polio syndrome (PPS) (n = 2, 5%), traumatic brain injury (TBI) (n = 2, 5%), and amyotrophic lateral sclerosis (n = 1, 2%). All the studies used anodal stimulation, with the common stimulation site being the left dorsolateral prefrontal cortex for MS, stroke, and PD. A stimulation intensity of 1.0-4.0 mA with a duration ranging from 15 to 30 min in 1 to 24 sessions were commonly reported. The Fatigue Severity Scale (n = 21) and Modified Fatigue Impact Scale (n = 17) were frequently implemented outcome measures. Regardless of the study design, 36/42 (85.7%) studies reported an improvement in fatigue scores in the tDCS group. The common adverse events noted were tingling (n = 8, 35%), headache (n = 6, 26%), and itching (n = 6, 26%). DISCUSSION: Application of tDCS for fatigue was explored in individuals with stroke, PD, PPS, and TBI after MS. Even though a wide range of treatment parameters and outcome measures were adopted to assess and target fatigue, tDCS proves to have a promising role in alleviating this symptom.

Video parameters for action observation training in stroke rehabilitation: a scoping review.

PURPOSE: Action observation training (AOT) is a therapeutic approach used in stroke rehabilitation. Videos form the core of AOT, and knowledge of constituent parameters is essential to make the intervention robust and generalizable. Currently, there is a dearth of available information on video parameters to be used for AOT. Our purpose was to identify and describe the parameters that constitute AOT videos for stroke rehabilitation. METHOD: Electronic databases like PubMed, CINAHL, Scopus, Web of Science, ProQuest, and Ovid SP from inception to date according to PRISMA-ScR guidelines. Title, abstract, and full-text screening were done independently by two authors, with a third author for conflict resolution. Data on video parameters like length, quality, perspective, speed, screen size and distance, sound, and control videos were extracted. RESULTS: Seventy studies were included in this review. The most-reported parameters were video length (85.71%) and perspective of view (62.85%). Movement speed (7.14%) and sound (8.57%) were the least reported. Static landscapes or geometrical patterns were found suitable as control videos. CONCLUSION: Most video parameters except for length and perspective of view remain underreported in AOT protocols. Future studies with better descriptions of video parameters are required for comprehensive AOT interventions and result generalisation.

Videos shorter than 5 min may be preferred during action observation training (AOT) intervention in post-stroke.Egocentric view may be better for upper limb dexterity function and allocentric view for gross actions like walking.Choice of video disseminating device depends on its dimension as well as observer distance.Movement speed, video sound, and quality must be considered to obtain more comprehensive AOT videos.

Effect of high-definition transcranial direct current stimulation among late-subacute and chronic stroke survivors with fatigue: A randomized-controlled crossover trial protocol.

Post-stroke fatigue (PSF) is a commonly overlooked symptom that impacts daily functioning and quality of life. It is caused by altered functional connectivity within the brain networks, which can potentially be influenced by neuromodulation. Multiple cortical regions have been targeted to reduce PSF, but the most efficient ones remain uncertain. Therefore, we aim to identify the most appropriate cortical stimulation site to reduce PSF. Twenty participants with PSF will be included in this cross-over trial. Each participant will receive one session of active anodal high definition- transcranial direct current stimulation (HD-tDCS) over three different cortical areas and one session of sham tDCS in a cross-over manner, with a two-week of washout period in between. Pre- and post- fatigue will be assessed using Fatigue Severity Scale and fatigability using electromyography by determining the time to task failure. Resting-state electroencephalography will be performed before and after each stimulation session to determine the functional connectivity of the cortical areas stimulated.

Research, education and practice of tele-neurorehabilitation in low and middle-income countries: A Scoping Review.

BACKGROUND: Tele-neurorehabilitation (TNR) allows for remote delivery of rehabilitation services for those with neurological disabilities. Despite growing global interest and uptake, its adoption remains challenging in Low-and-Middle-Income-Countries (LMICs). OBJECTIVE: To explore available literature on the nature of training and education, research and practice of TNR in LMICs. METHODS: Following PRISMA-ScR guidelines and predefined selection criteria, four databases were screened. Quality assessment was performed using the Joanna Briggs Institute tools. Relevant data was extracted to using a data extraction form in Microsoft Excel and were narratively synthesised under Education/training, Research and Clinical Practice of TNR. RESULTS: We identified no formal structured training courses/programs for TNR users/providers. Sessions were mainly delivered as part of a research project. The included studies highlighted the need to engage stakeholders in TNR research and improve digital-literacy among healthcare providers/users. Development and use of clinical decision-making-tools, models of TNR suitable for varied populations and prior area-mapping were a few suggestions for clinical/research practice. CONCLUSION: There is an immense need to develop academic/structured programs for TNR to build capacity among providers/users in LMICs. Practice must adhere to principles of safety, effectiveness, and based on high quality clinical-guidelines suitable to the context to ensure optimal uptake and practice of TNR in LMICs.

Criteria and Indicators for Centers of Clinical Excellence in Stroke Recovery and Rehabilitation: A Global Consensus Facilitated by ISRRA.

BACKGROUND: The aim of the International Stroke Recovery and Rehabilitation Alliance is to create a world where worldwide collaboration brings major breakthroughs for the millions of people living with stroke. A key pillar of this work is to define globally relevant criteria for centers that aspire to deliver excellent clinical rehabilitation and generate exceptional outcomes for patients. OBJECTIVES: This paper presents consensus work conducted with an international group of expert stroke recovery and rehabilitation researchers, clinicians, and people living with stroke to identify and define criteria and measurable indicators for Centers of Clinical Excellence (CoCE) in stroke recovery and rehabilitation. These were intentionally developed to be ambitious and internationally relevant, regardless of a country's development or income status, to drive global improvement in stroke services. METHODS: Criteria and specific measurable indicators for CoCE were collaboratively developed by an international panel of stroke recovery and rehabilitation experts from 10 countries and consumer groups from 5 countries. RESULTS: The criteria and associated indicators, ranked in order of importance, focused upon (i) optimal outcome, (ii) research culture, (iii) working collaboratively with people living with stroke, (iv) knowledge exchange, (v) leadership, (vi) education, and (vii) advocacy. Work is currently underway to user-test the criteria and indicators in 14 rehabilitation centers in 10 different countries. CONCLUSIONS: We anticipate that use of the criteria and indicators could support individual organizations to further develop their services and, more widely, provide a mechanism by which clinical excellence can be articulated and shared to generate global improvements in stroke care.

Non-therapeutic strategies to promote physical activity of stroke survivors in hospital settings: A systematic review.

OBJECTIVE: To systematically summarize the evidence of strategies other than therapy to promote physical activity in hospital settings. METHODS: Studies testing the various strategies to promote the physical activity of stroke survivors in different hospital settings, including stroke units, hospitals and rehabilitation centres were included. Two independent reviewers screened, extracted data, and assessed the study quality. Quality assessments were performed using standardized checklists. Data synthesis was done from the selected articles and results were reported. RESULTS: Of the 3396 records retrieved from database searches, 12 studies (n = 529 participants) were included. All the studies were of moderate to good quality. The strategies were grouped into five categories: i) physical environment, ii) device-based feedback, iii) self-management approaches, iv) family presence, and v) education. Physical environmental and device-based feedback were the most common strategies to promote physical activity after a stroke in a hospital setting. Strategies such as family presence and education improved physical activity levels, whereas device-based feedback showed mixed results. CONCLUSION: Despite the importance of physical activity in early stroke, there is limited literature present to enhance activity levels. Physical environment and device-based feedback were the two most common strategies used in acute stroke survivors. The impact of these strategies remain suboptimal to be considered as effective intervention methods to enhance physical activity.

Clinical Practice Guidelines (CPGs) for stroke rehabilitation from Low- and Middle-Income Countries (LMICs): Protocol for systematic review.

INTRODUCTION: Stroke rehabilitation guidelines promoteclinical decision making, enhance quality of healthcare delivery, minimize healthcare costs, and identify gaps in current knowledge to guide future research. However, there are no published reviews that have exclusively evaluated the quality of existing Clinical Practice Guidelines (CPGs) for stroke rehabilitation from Low- and Middle-Income Countries (LMICs) or provided any insights into the cultural variation, adaptations, or gaps in implementation specific to LMICs. OBJECTIVES: To identify CPGs developed by LMICs for stroke rehabilitation and evaluate their quality using AGREE-II and AGREE-REX tool. METHODS: The review protocol is prepared in accordance with the PRISMA-P guidelines and the review was registered in PROSPERO (CRD42022382486). The search was run in Medline, EMBASE, CINHAL, PEDro for guidelines published between 2000 till July 2022. Additionally, SUMSearch, Google, and other guideline portals and gray literature were searched. The included studies were then subjected to data extraction for the following details: Study ID, title of the CPG, country of origin, characteristics of CPG (Scope-national/regional, level of care, multidisciplinary/uni-disciplinary), and information on stroke rehabilitation relevant recommendations. The quality of the included CPGs will be subsequently evaluated using AGREE-II and AGREE-REX tool. RESULTS & CONCLUSION: This systematic review aims to explore the gaps in existing CPGs specific to LMICs and will aid in development/adaptation/contextualization of CPGs for implementation in LMICs.

ENHANCE proof-of-concept three-arm randomized trial: effects of reaching training of the hemiparetic upper limb restricted to the spasticity-free elbow range.

Post-stroke motor recovery processes remain unknown. Timescales and patterns of upper-limb (UL) recovery suggest a major impact of biological factors, with modest contributions from rehabilitation. We assessed a novel impairment-based training motivated by motor control theory where reaching occurs within the spasticity-free elbow range. Patients with subacute stroke (≤ 6 month; n = 46) and elbow flexor spasticity were randomly allocated to a 10-day UL training protocol, either personalized by restricting reaching to the spasticity-free elbow range defined by the tonic stretch reflex threshold (TSRT) or non-personalized (non-restricted) and with/without anodal transcranial direct current stimulation. Outcomes assessed before, after, and 1 month post-intervention were elbow flexor TSRT angle and reach-to-grasp arm kinematics (primary) and stretch reflex velocity sensitivity, clinical impairment, and activity (secondary). Results were analyzed for 3 groups as well as those of the effects of impairment-based training. Clinical measures improved in both groups. Spasticity-free range training resulted in faster and smoother reaches, smaller (i.e., better) arm-plane path length, and closer-to-normal shoulder/elbow movement patterns. Non-personalized training improved clinical scores without improving arm kinematics, suggesting that clinical measures do not account for movement quality. Impairment-based training within a spasticity-free elbow range is promising since it may improve clinical scores together with arm movement quality.Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique Identifier: NCT02725853; Initial registration date: 01/04/2016.

Motor rehabilitation after stroke: European Stroke Organisation (ESO) consensus-based definition and guiding framework.

PURPOSE: To propose a consensus-based definition and framework for motor rehabilitation after stroke. METHODS: An expert European working group reviewed the literature, attaining internal consensus after external feedback. FINDINGS: Motor rehabilitation is defined as a process that engages people with stroke to benefit their motor function, activity capacity and performance in daily life. It is necessary for people with residual motor disability whose goal is to enhance their functioning, independence and participation. Motor rehabilitation operates through learning- and use-dependent mechanisms. The trajectory of motor recovery varies across patients and stages of recovery. Early behavioral restitution of motor function depends on spontaneous biological mechanisms. Further improvements in activities of daily living are achieved by compensations. Motor rehabilitation is guided by regular assessment of motor function and activity using consensus-based measures, including patient-reported outcomes. Results are discussed with the patient and their carers to set personal goals. During motor rehabilitation patients learn to optimize and adapt their motor, sensory and cognitive functioning through appropriately dosed repetitive, goal-oriented, progressive, task- and context-specific training. Motor rehabilitation supports people with stroke to maximize health, well-being and quality of life. The framework describes the International Classification of Functioning, Disability and Health in the context of stroke, describes neurobiological mechanisms of behavioral restitution and compensation, and summarizes recommendations for clinical assessment, prediction tools, and motor interventions with strong recommendations from clinical practice guidelines (2016-2022). CONCLUSIONS: This definition and framework may guide clinical educators, inform clinicians on current recommendations and guidelines, and identify gaps in the evidence base.