Stroke rehabilitation in urban and rural settings in the Philippines: Protocol for an interview and visual elicitation study.

INTRODUCTION: There is a lack of community-based rehabilitation for stroke in the Philippines, and research on this topic is limited. Different challenges may be encountered in urban and rural settings. The aim of the Tulong, Ugnayan ng Lingap At gabaY (TULAY) project is to develop a context-appropriate, community-based stroke support programme, consisting of self-management and training resources to augment the rehabilitation and recovery process. An important stage in the development of this programme is to qualitatively explore the experiences and needs of all stakeholders. MATERIALS AND METHODS: Using co-designed and evidence-based topic guides, in-depth semi-structured interviews will be conducted with people living with stroke, household carers and care providers. We will aim to gain a representation of different regions (within Luzon, Visayas, and Northern Mindanao), socioeconomic levels, and urban and rural locations. For people with stroke and household carers, interviews will be supplemented by auto-photography and visual elicitation to widen access for those that prefer to share their experiences visually or have communication problems. An interpretivist paradigm will be applied across all interview data and the consolidated criteria for reporting qualitative research (COREQ) will be followed. Thematic analysis will be undertaken using guidance by Braun and Clarke. DISCUSSION: To our knowledge, this study is the first of its kind in the Philippines. It has several methodological strengths, including the capture of perspectives from multiple stakeholders in diverse settings, the inclusion of people with communication difficulties, use of visual methods, and analysis in the native language. The findings will have various applications, including the potential to influence policy, practice and guidelines, and to inform the development of the TULAY stroke support programme.

Association between post-stroke depression and functional outcomes: A systematic review.

BACKGROUND: Post-stroke depression (PSD) is a frequent problem in stroke patients, affecting their rehabilitation process and functional outcomes. Several studies have investigated the relationship between PSD and functional outcomes, but the results have been inconsistent. OBJECTIVE: This systematic review of non-experimental studies aims to investigate the prevalence of post-stroke depression and the association between post-stroke depression and functional outcomes. METHOD: A search of PubMed, MEDLINE, Web of Science, and CINAHL Plus with Full Text was carried out from inception until January 2024. The literature was screened using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with relevant papers included. We extracted data from non-experimental studies that examined associations between PSD and functional outcomes. The Joanna Briggs Institute for systematic reviews was used for critical appraisal. RESULTS: Twenty-one studies met the study criteria, including sixteen cohort studies, four cross-sectional studies, and one case-control study. PSD prevalences ranged from 12.2% to 32.2% in the first two weeks, 17.9 to 35.5% in the first month, and 10.4% to 32.0% in the third month following a stroke. Functional outcomes were evaluated in four domains: degree of dependence, basic activity of daily living, instrumental activity of daily living, and physical and cognitive function. Significant associations between PSD and functional outcomes were identified after controlling potential factors such as age, comorbidities, and stroke severity. PSD had negative associations with functional outcomes in all four measure domains from one month to five years after a stroke. Depression treatment showed positive results on functional outcomes in stroke patients. CONCLUSION: PSD prevalence was high in the first three months after stroke. PSD is significantly associated with poor functional outcomes. PSD assessment and management should be performed on a frequent basis in the early stages of stroke to achieve the best possible functional recovery.

Effects of carbon versus plastic ankle foot orthoses on gait outcomes and energy cost in patients with chronic stroke.

OBJECTIVE: To compare the walking performances of hemiplegic subjects with chronic stroke under 3 conditions: with a new standard carbon fibre ankle foot orthosis (C-AFO), with a personal custom-made plastic AFO (P-AFO), and without any orthosis (No-AFO). DESIGN: Randomized, controlled crossover design. PATIENTS: Fifteen chronic patients with stroke (3 women  and 12 men, 59 [10] years, 13 [15] years since injury). METHODS: Patients performed 3 randomized sessions (with C-AFO, P-AFO, no-AFO), consisting of a 6-min walk test (6MWT) with VO2 measurement and a clinical gait analysis. Energy cost (Cw), walking speed, spatio-temporal, kinetic, and kinematic variables were measured. RESULTS: No significant differences were found between the C-AFO and P-AFO conditions. Distance and walking speed in the 6MWT increased by 12% and 10% (p < 0.001) and stride width decreased by -8.7% and -13% (p < 0.0001) with P-AFO and C-AFO compared with the No-AFO condition. Cw decreased by 15% (p < 0.002), stride length increased by 10% (p < 0.01), step length on affected leg increased by 8% (p < 0.01), step length on contralateral leg by 13% (p < 0.01), and swing time on the contralateral leg increased by 6% (p < 0.01) with both AFO compared with the No-AFO condition. CONCLUSION: The use of an off-the-shelf composite AFO (after a short habituation period) in patients with chronic stroke immediately improved energy cost and gait outcomes to the same extent as their usual custom-made AFO.

Feedback control of heart rate during robotics-assisted tilt table exercise in patients after stroke: a clinical feasibility study.

BACKGROUND: Patients with neurological disorders including stroke use rehabilitation to improve cognitive abilities, to regain motor function and to reduce the risk of further complications. Robotics-assisted tilt table technology has been developed to provide early mobilisation and to automate therapy involving the lower limbs. The aim of this study was to evaluate the feasibility of employing a feedback control system for heart rate (HR) during robotics-assisted tilt table exercise in patients after a stroke. METHODS: This feasibility study was designed as a case series with 12 patients ( n = 12 ) with no restriction on the time post-stroke or on the degree of post-stroke impairment severity. A robotics-assisted tilt table was augmented with force sensors, a work rate estimation algorithm, and a biofeedback screen that facilitated volitional control of a target work rate. Dynamic models of HR response to changes in target work rate were estimated in system identification tests; nominal models were used to calculate the parameters of feedback controllers designed to give a specified closed-loop bandwidth; and the accuracy of HR control was assessed quantitatively in feedback control tests. RESULTS: Feedback control tests were successfully conducted in all 12 patients. Dynamic models of heart rate response to imposed work rate were estimated with a mean root-mean-square (RMS) model error of 2.16 beats per minute (bpm), while highly accurate feedback control of heart rate was achieved with a mean RMS tracking error (RMSE) of 2.00 bpm. Control accuracy, i.e. RMSE, was found to be strongly correlated with the magnitude of heart rate variability (HRV): patients with a low magnitude of HRV had low RMSE, i.e. more accurate HR control performance, and vice versa. CONCLUSIONS: Feedback control of heart rate during robotics-assisted tilt table exercise was found to be feasible. Future work should investigate robustness aspects of the feedback control system. Modifications to the exercise modality, or alternative modalities, should be explored that allow higher levels of work rate and heart rate intensity to be achieved.

Combining robotics and functional electrical stimulation for assist-as-needed support of leg movements in stroke patients: A feasibility study.

PURPOSE: Rehabilitation technology can be used to provide intensive training in the early phases after stroke. The current study aims to assess the feasibility of combining robotics and functional electrical stimulation (FES), with an assist-as-needed approach to support actively-initiated leg movements in (sub-)acute stroke patients. METHOD: Nine subacute stroke patients performed repetitions of ankle dorsiflexion and/or knee extension movements, with and without assistance. The assist-as-needed algorithm determined the amount and type of support needed per repetition. The number of repetitions and range of motion with and without assistance were compared with descriptive statistics. Fatigue scores were obtained using the visual analogue scale (score 0-10). RESULTS: Support was required in 44 % of the repetitions for ankle dorsiflexion and in 5 % of the repetitions of knee extension, The median fatigue score was 2.0 (IQR: 0.2) and 4.0 (IQR: 1.5) for knee and ankle, respectively, indicating mild to moderate perceived fatigue. CONCLUSION: This study demonstrated the feasibility of assist-as-needed assistance through combined robotic and FES support of leg movements in stroke patients. It proved particularly useful for ankle dorsiflexion. Future research should focus on implementing this approach in a clinical setting, to assess clinical applicability and potential effects on leg function.

Do proprioceptive training strategies with dual-task exercises positively influence gait parameters in chronic stroke? A systematic review.

OBJECTIVE: This study aims to assess the impact of proprioceptive training strategies with dual-task exercises on gait in people with chronic stroke. STUDY DESIGN: Systematic review. PATIENTS: Chronic stroke. METHODS: Searches were conducted in accordance with PRISMA guidelines and PICOS criteria. PubMed, Web of Science, and Scopus databases were systematically searched from November 2020 to February 2022, for eligible clinical trials. Two independent reviewers thoroughly screened potential articles for relevance and assessed the methodology quality. In accordance with the GRADE, PICOS criteria, and Cochrane risk of bias tools, the authors included articles concerning the effectiveness of dual-task in proprioceptive training on gait parameters in people with chronic stroke. RESULTS: Of 3075 identified studies, 11 articles met the inclusion criteria: 7 were randomized clinical trials, 1 was not randomized, and 3 were observational studies. The overall quality of evidence, assessed using the GRADE framework, was high, indicating a high level of confidence in the systematic review's findings. The papers involved 393 stroke patients; 241 underwent dual-task in proprioceptive training, with 152 participants in other stroke rehabilitation; within the dual-task group, 71 engaged in cognitive tasks, and 170 participated in motor tasks. dual-task in proprioceptive training improved gait speed, cadence, stride time, stride length, and step length. The best effects were observed with training 3 times a week for 4 weeks, with each session lasting 30 minutes, on speed, cadence, stride length, and step length. CONCLUSION: Current evidence suggests that proprioceptive training strategies with dual-task exercises improved walking abilities in people with chronic stroke. Specifically, it enhanced gait speed, a key indicator of clinical severity.

Concurrent tDCS-fMRI after stroke reveals link between attention network organization and motor improvement.

Restoring motor function after stroke necessitates involvement of numerous cognitive systems. However, the impact of damage to motor and cognitive network organization on recovery is not well understood. To discover correlates of successful recovery, we explored imaging characteristics in chronic stroke subjects by combining noninvasive brain stimulation and fMRI. Twenty stroke survivors (6 months or more after stroke) were randomly assigned to a single session of transcranial direct current stimulation (tDCS) or sham during image acquisition. Twenty healthy subjects were included as controls. tDCS was limited to 10 min at 2 mA to serve as a mode of network modulation rather than therapeutic delivery. Fugl-Meyer Assessments (FMA) revealed significant motor improvement in the chronic stroke group receiving active stimulation (p = 0.0005). Motor changes in this group were correlated in a data-driven fashion with imaging features, including functional connectivity (FC), surface-based morphometry, electric field modeling and network topology, focusing on relevant regions of interest. We observed stimulation-related changes in FC in supplementary motor (p = 0.0029), inferior frontal gyrus (p = 0.0058), and temporo-occipital (p = 0.0095) areas, though these were not directly related to motor improvement. The feature most strongly associated with FMA improvement in the chronic stroke cohort was graph topology of the dorsal attention network (DAN), one of the regions surveyed and one with direct connections to each of the areas with FC changes. Chronic stroke subjects with a greater degree of motor improvement had lower signal transmission cost through the DAN (p = 0.029). While the study was limited by a small stroke cohort with moderate severity and variable lesion location, these results nevertheless suggest a top-down role for higher order areas such as attention in helping to orchestrate the stroke recovery process.

Respiratory muscle strength in stroke: a case-control study.

AIM: The aim of the study was to determine the respiratory muscle strength of stroke patients and compare them with healthy individuals. METHOD: The study was conducted with 171 patients who had a stroke between 2017 and 2021 and 32 healthy controls. Respiratory muscle strength and inspiratory and expiratory mouth pressure (MIP and MEP) were measured using the portable MicroRPM device (Micro Medical, Basingstoke, UK). RESULTS: The stroke group exhibited significantly lower values in both MIP for men (p<0.001) and women (p=0.013) and maximal expiratory pressure for men (p<0.001) and women (p=0.042), compared with the healthy control group. Notably, there was a significant difference in the MIPmen (p=0.026) and MEPmen (p=0.026) values when comparing the reference values, which were calculated based on age and sex, with those of the healthy group. The baseline values calculated according to age for stroke patients were as follows: MIPmen 31.68%, MIPwomen 63.58%, MEPmen 22.54%, and MEPwomen 42.30%. CONCLUSION: This study highlights the significant respiratory muscle weakness experienced by stroke patients, with gender-specific differences. It highlights the importance of incorporating respiratory assessments and interventions into stroke rehabilitation protocols to improve the overall health and well-being of stroke patients.

Nutritional therapy for reducing disability and improving activities of daily living in people after stroke.

BACKGROUND: Stroke patients often face disabilities that significantly interfere with their daily lives. Poor nutritional status is a common issue amongst these patients, and malnutrition can severely impact their functional recovery post-stroke. Therefore, nutritional therapy is crucial in managing stroke outcomes. However, its effects on disability, activities of daily living (ADL), and other critical outcomes have not been fully explored. OBJECTIVES: To evaluate the effects of nutritional therapy on reducing disability and improving ADL in patients after stroke. SEARCH METHODS: We searched the trial registers of the Cochrane Stroke Group, CENTRAL, MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1982), and AMED (from 1985) to 19 February 2024. We also searched trials and research registries (ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform) and reference lists of articles. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared nutritional therapy with placebo, usual care, or one type of nutritional therapy in people after stroke. Nutritional therapy was defined as the administration of supplemental nutrients, including energy, protein, amino acids, fatty acids, vitamins, and minerals, through oral, enteral, or parenteral methods. As a comparator, one type of nutritional therapy refers to all forms of nutritional therapies, excluding the specific nutritional therapy defined for use in the intervention group. DATA COLLECTION AND ANALYSIS: We used Cochrane's Screen4Me workflow to assess the initial search results. Two review authors independently screened references that met the inclusion criteria, extracted data, and assessed the risk of bias and the certainty of the evidence using the GRADE approach. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the odds ratio (OR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I2 statistic. The primary outcomes were disability and ADL. We also assessed gait, nutritional status, all-cause mortality, quality of life, hand and leg muscle strength, cognitive function, physical performance, stroke recurrence, swallowing function, neurological impairment, and the development of complications (adverse events) as secondary outcomes. MAIN RESULTS: We identified 52 eligible RCTs involving 11,926 participants. Thirty-six studies were conducted in the acute phase, 10 in the subacute phase, three in the acute and subacute phases, and three in the chronic phase. Twenty-three studies included patients with ischaemic stroke, three included patients with haemorrhagic stroke, three included patients with subarachnoid haemorrhage (SAH), and 23 included patients with ischaemic or haemorrhagic stroke including SAH. There were 25 types of nutritional supplements used as an intervention. The number of studies that assessed disability and ADL as outcomes were nine and 17, respectively. For the intervention using oral energy and protein supplements, which was a primary intervention in this review, six studies were included. The results for the seven outcomes focused on (disability, ADL, body weight change, all-cause mortality, gait speed, quality of life, and incidence of complications (adverse events)) were as follows: There was no evidence of a difference in reducing disability when 'good status' was defined as an mRS score of 0 to 2 (for 'good status': OR 0.97, 95% CI 0.86 to 1.10; 1 RCT, 4023 participants; low-certainty evidence). Oral energy and protein supplements may improve ADL as indicated by an increase in the FIM motor score, but the evidence is very uncertain (MD 8.74, 95% CI 5.93 to 11.54; 2 RCTs, 165 participants; very low-certainty evidence). Oral energy and protein supplements may increase body weight, but the evidence is very uncertain (MD 0.90, 95% CI 0.23 to 1.58; 3 RCTs, 205 participants; very low-certainty evidence). There was no evidence of a difference in reducing all-cause mortality (OR 0.57, 95% CI 0.14 to 2.28; 2 RCTs, 4065 participants; low-certainty evidence). For gait speed and quality of life, no study was identified. With regard to incidence of complications (adverse events), there was no evidence of a difference in the incidence of infections, including pneumonia, urinary tract infections, and septicaemia (OR 0.68, 95% CI 0.20 to 2.30; 1 RCT, 42 participants; very low-certainty evidence). The intervention was associated with an increased incidence of diarrhoea compared to usual care (OR 4.29, 95% CI 1.98 to 9.28; 1 RCT, 4023 participants; low-certainty evidence) and the occurrence of hyperglycaemia or hypoglycaemia (OR 15.6, 95% CI 4.84 to 50.23; 1 RCT, 4023 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: We are uncertain about the effect of nutritional therapy, including oral energy and protein supplements and other supplements identified in this review, on reducing disability and improving ADL in people after stroke. Various nutritional interventions were assessed for the outcomes in the included studies, and almost all studies had small sample sizes. This led to challenges in conducting meta-analyses and reduced the precision of the evidence. Moreover, most of the studies had issues with the risk of bias, especially in terms of the absence of blinding and unclear information. Regarding adverse events, the intervention with oral energy and protein supplements was associated with a higher number of adverse events, such as diarrhoea, hyperglycaemia, and hypoglycaemia, compared to usual care. However, the quality of the evidence was low. Given the low certainty of most of the evidence in our review, further research is needed. Future research should focus on targeted nutritional interventions to reduce disability and improve ADL based on a theoretical rationale in people after stroke and there is a need for improved methodology and reporting.

Early Occupational Therapy Intervention post-stroke (EOTIPS): A randomized controlled trial.

BACKGROUND: Occupational therapy (OT) is an effective evidence-based intervention that positively influences stroke patients'independence recovery, leading to new opportunities for better quality of life outcomes. OBJECTIVES: To explore the effectiveness of an early OT intervention program (EOTIPS) in the process of hospital to home discharge after stroke in Spain. MATERIAL AND METHODS: We conducted a prospective, randomized controlled clinical trial that included 60 adults who suffered a stroke and were discharged home. Participants assigned to the experimental group (n = 30) were included in EOTIPS and compared with a control group (n = 30). Evaluations assessed quality of life (Stroke and Aphasia Quality of Life Scale [SAQOL-39]), functional independence (Modified Rankin Scale [mRS], Barthel Index [BI] and Stroke Impact Scale-16 [SIS-16]), perceptual-cognitive skills (Montreal Cognitive Assessment [MoCA]), upper limb function (Fugl Meyer Assessment [FMA]), mobility (Berg Balance Scale [BBS] and Timed Up & Go [TUG]), communication skills (Communicative Activity Log [CAL]) and mood disorders (Beck Depression Inventory-II [BDI-II] and Hamilton Anxiety Scale [HAM-A]); they were completed within two weeks post-stroke and after three months follow-up. Statistical analysis included intent-to-treat analysis, considering all participants (dropouts as failures), and efficacy analysis, considering only end-of-treatment participants. RESULTS: Participants in the intervention group showed a significant better evolution in the main outcome measure of quality of life (SAQOL-39 p = .029), as well as for independence (mRSp = .004), perceptual-cognitive skills (MoCA p = .012)and symptoms of depression (BDI-II p = .011) compared to the control group. CONCLUSIONS: EOTIPS was effective in improving quality of life, as well as enhancing perceptual-cognitive skills, independence and reducing levels of depression for patients who suffered a stroke in a Spanish cohort and could be considered as an applicable non-pharmacologic therapeutic tool that can lead to patients' positive outcomes after stroke. This study was registered on ClinicalTrials.gov with the identifier NCT04835363.

Automatic rehabilitation exercise task assessment of stroke patients based on wearable sensors with a lightweight multichannel 1D-CNN model.

Approximately 75% of stroke survivors have movement dysfunction. Rehabilitation exercises are capable of improving physical coordination. They are mostly conducted in the home environment without guidance from therapists. It is impossible to provide timely feedback on exercises without suitable devices or therapists. Human action quality assessment in the home setting is a challenging topic for current research. In this paper, a low-cost HREA system in which wearable sensors are used to collect upper limb exercise data and a multichannel 1D-CNN framework is used to automatically assess action quality. The proposed 1D-CNN model is first pretrained on the UCI-HAR dataset, and it achieves a performance of 91.96%. Then, five typical actions were selected from the Fugl-Meyer Assessment Scale for the experiment, wearable sensors were used to collect the participants' exercise data, and experienced therapists were employed to assess participants' exercise at the same time. Following the above process, a dataset was built based on the Fugl-Meyer scale. Based on the 1D-CNN model, a multichannel 1D-CNN model was built, and the model using the Naive Bayes fusion had the best performance (precision: 97.26%, recall: 97.22%, F1-score: 97.23%) on the dataset. This shows that the HREA system provides accurate and timely assessment, which can provide real-time feedback for stroke survivors' home rehabilitation.

Patient-Reported Variables Affecting Self-Perceived Overall Recovery Among People With Subacute Stroke.

IMPORTANCE: Patients' perception of overall recovery is a critical outcome for stroke rehabilitation. However, the perception of overall recovery cannot be obtained using multidimensional measures, because satisfaction in most domains of life does not guarantee satisfaction in overall recovery. A single overall recovery score seems a straightforward measure. However, the clinical implications of overall scores are restricted, because factors affecting patients' overall recovery are unclear, which can be prioritized to optimize the effectiveness of rehabilitation. OBJECTIVE: To examine patient-reported variables affecting overall recovery scores in patients with differing stroke severity. DESIGN: The 59 items of the Stroke Impact Scale 3.0 were selected using regression analysis with a forward selection to explain the overall recovery score (0% = no recovery; 100% = full recovery). Stroke severity was determined with the National Institutes of Health Stroke Scale. SETTING: Hospitals. PARTICIPANTS: Data of 950 patients collected 90 days after stroke. RESULTS: The models explained about 55% of the variance of the overall recovery scores with five to nine variables, but merely 16% of the variance was explained for patients with moderate stroke. As stroke severity increased, the number of identified variables decreased. Most identified variables were related to social participation and self-care activities (e.g., ability to help others, control the bowels, and dress the torso). Differences in the remaining variables depended on stroke severity. CONCLUSIONS AND RELEVANCE: Patients' priorities differ depending on stroke severity. The identified variables may be set as treatment goals to optimize patients' self-perceived overall recovery. Plain-Language Summary: How patients perceive their overall recovery after a stroke is a critical outcome for their stroke rehabilitation. This study demonstrated that patients with different stroke severity may have different priorities that influence their self-perceived levels of overall recovery. The variables identified in this study may help occupational therapy practitioners identify meaningful goals to optimize patients' self-perceived overall recovery.

A randomized controlled trial of low-frequency repeated transcranial magnetic stimulation in patients with poststroke neurogenic bladder.

Urinary incontinence is a common complication in stroke survivors for whom new interventions are needed. This study investigated the therapeutic effect of low-frequency (LF) repeated transcranial magnetic stimulation (rTMS) on the contralesional primary motor cortex (M1) in patients with poststroke urinary incontinence (PSI). A total of 100 patients were randomly assigned to the rTMS group or sham-rTMS group on basis of the intervention they received. Both groups underwent five treatment sessions per week for 4 weeks. Data from the urodynamic examination were used as the primary outcome. The secondary outcome measures were questionnaires and pelvic floor surface electromyography. After 4 weeks of intervention, the maximum cystometric capacity (MCC), maximum detrusor pressure (Pdet.max), residual urine output, overactive bladder score (OABSS) (including frequency, urgency, and urgency urinary incontinence), and the ICIQ-UI SF improved significantly in the rTMS group compared with those in the sham-rTMS group (P < 0.05). However, no changes in pelvic floor muscle EMG were detected in patients with PSI (both P > 0.05). Our data confirmed that 4 weeks of LF-rTMS stimulation on the contralateral M1 positively affects poststroke urinary incontinence in several aspects, such as frequency, urgency urinary incontinence, MCC, end-filling Pdet, OABSS, and ICIQ-UI SF scores.

Effectiveness of mixed reality-based rehabilitation on hands and fingers by individual finger-movement tracking in patients with stroke.

BACKGROUND: Mixed reality (MR) is helpful in hand training for patients with stroke, allowing them to fully submerge in a virtual space while interacting with real objects. The recognition of individual finger movements is required for MR rehabilitation. This study aimed to assess the effectiveness of updated MR-board 2, adding finger training for patients with stroke. METHODS: Twenty-one participants with hemiplegic stroke (10 with left hemiplegia and 11 with right hemiplegia; nine female patients; 56.7 ± 14.2 years of age; and onset of stroke 32.7 ± 34.8 months) participated in this study. MR-board 2 comprised a board plate, a depth camera, plastic-shaped objects, a monitor, a palm-worn camera, and seven gamified training programs. All participants performed 20 self-training sessions involving 30-min training using MR-board 2. The outcome measurements for upper extremity function were the Fugl-Meyer assessment (FMA) upper extremity score, repeated number of finger flexion and extension (Repeat-FE), the thumb opposition test (TOT), Box and Block Test score (BBT), Wolf Motor Function Test score (WMFT), and Stroke Impact Scale (SIS). One-way repeated measures analysis of variance and the post hoc test were applied for the measurements. MR-board 2 recorded the fingers' active range of motion (AROM) and Dunnett's test was used for pairwise comparisons. RESULTS: Except for the FMA-proximal score (p = 0.617) and TOT (p = 0.005), other FMA scores, BBT score, Repeat-FE, WMFT score, and SIS stroke recovery improved significantly (p < 0.001) during MR-board 2 training and were maintained until follow-up. All AROM values of the finger joints changed significantly during training (p < 0.001). CONCLUSIONS: MR-board 2 self-training, which includes natural interactions between humans and computers using a tangible user interface and real-time tracking of the fingers, improved upper limb function across impairment, activity, and participation. MR-board 2 could be used as a self-training tool for patients with stroke, improving their quality of life. TRIAL REGISTRATION NUMBER: This study was registered with the Clinical Research Information Service (CRIS: KCT0004167).

Effectiveness of a Virtual Reality rehabilitation in stroke patients with sensory-motor and proprioception upper limb deficit: A study protocol.

INTRODUCTION: Stroke is the second leading cause of death in Europe. In the case of stroke survival (almost 70%), only 25% of patients recover completely, while the remaining 75% will undergo a rehabilitation phase that varying from months to years. The primary outcomes of a stroke involve motor impairment in the upper limbs, resulting in a partial or complete inability to move the limb on the right or left side, depending on the affected hemisphere. Furthermore, the motor deficit distorts the proprioception of the body and the embodiment ability of the injured limb. This could be rehabilitated through the paradigm of body illusion that modulates the motor rehabilitation. The present protocol aims to investigate the effectiveness of a Virtual Reality system for sensorimotor and proprioception upper limb deficit compared to a traditional upper limb rehabilitation program. METHOD: This study has a randomized and controlled design with control and experimental groups, and 4 measurement times: pre-intervention, immediately after the intervention, and two follow-ups (at 6 and 12 months). The inclusion criteria are: (a) Being 18 to 85 years old, both males and females; (b) Suffering from ischemic or haemorrhagic stroke; (c) The stroke event must have occurred from two to eighteen months before recruitment; (d) Patients must have moderate to severe upper limb motor deficit, and the alteration of sensorimotor and proprioception abilities of the injury upper limb; (e) Patients must understand and sign the written consent for enrolment. The rehabilitation last four weeks with three sessions per week at Bellaria Hospital of Bologna (Italy). The VR protocol uses two types of technology: immersive and non-immersive, and the control group follow the traditional rehabilitation program.

Effects of a nurse-led motor function rehabilitation training program for patients with ischemic stroke and family caregivers: study protocol for a randomized controlled trial.

BACKGROUND: Both individuals and society bear a considerable burden from ischemic stroke (IS), not only do patients continue suffering from motor dysfunction after discharge from hospital, but their caregivers also undertake the principal responsibility of assisting them in reintegrating into the family and society. To better improve the IS patients' limb function and daily life activities, their caregivers should also be involved in the training of the motor function rehabilitation during the period transitioning from hospital back home. This study mainly aims to investigate the effects of a nurse-led training for IS patients and their family caregivers on the improvement of the patients' physical function and the burden of caregivers. METHODS/DESIGN: A randomized controlled trial with blind assessment will be conducted in hospitals and during the follow-ups at home. Fifty-eight pairs of adults diagnosed with ischemic stroke and their primary caregivers will be included. Participants will be randomly given with (1) a nurse-led, home-based motor rehabilitation training participated by caregivers (intervention group) or (2) routine self-care (control group). Both groups will receive assessment and health guidance on the day of discharge, and the intervention group will receive an additional home-based training program and supervision. These two groups will be followed up every week after discharge. The primary results are drawn from the evaluation of physical function and caregiver-related burden, and the secondary results derived from statistics of the modified Barthel index, stroke-specific quality of life, and National Institutes of Health Stroke Scale. Differences between the two groups will be measured by two-way repeated measures ANOVA, considering the data at baseline and at 1-week and 4-week follow-up after training. DISCUSSION: Results may provide novel and valuable information on the effects of this culturally appropriate, caregiver-involved, and home-based rehabilitation training on the physical function of IS patients and caregiver-related burden. TRIAL REGISTRATION: Chinese Clinical Trial Registry (chictr.org.cn) ChiCTR2300078798. Registered on December 19, 2023.

Movement Diversity and Complexity Increase as Arm Impairment Decreases After Stroke: Quality of Movement Experience as a Possible Target for Wearable Feedback.

Upper extremity (UE) impairment is common after stroke resulting in reduced arm use in daily life. A few studies have examined the use of wearable feedback of the quantity of arm movement to promote recovery, but with limited success. We posit that it may be more effective to encourage an increase in beneficial patterns of movement practice - i.e. the overall quality of the movement experience - rather than simply the overall amount of movement. As a first step toward testing this idea, here we sought to identify statistical features of the distributions of daily arm movements that become more prominent as arm impairment decreases, based on data obtained from a wrist IMU worn by 22 chronic stroke participants during their day. We identified several measures that increased as UE Fugl-Meyer (UEFM) score increased: the fraction of movements achieved at a higher speed, forearm postural diversity (quantified by kurtosis of the tilt-angle), and forearm postural complexity (quantified by sample entropy of tilt angle). Dividing participants into severe, moderate, and mild impairment groups, we found that forearm postural diversity and complexity were best able to distinguish the groups (Cohen's D =1.1, and 0.99, respectively) and were also the best subset of predictors for UEFM score. Based on these findings coupled with theories of motor learning that emphasize the importance of variety and challenge in practice, we suggest that using these measures of diversity and complexity in wearable rehabilitation could provide a basis to test whether the quality of the daily movement experience is therapeutic.

The influence of scaffolding on intrinsic motivation and autonomous adherence to a game-based, sparsely supervised home rehabilitation program for people with upper extremity hemiparesis due to stroke. A randomized controlled trial.

BACKGROUND: This parallel, randomized controlled trial examined intrinsic motivation, adherence and motor function improvement demonstrated by two groups of subjects that performed a 12-week, home-based upper extremity rehabilitation program. Seventeen subjects played scaffolded games, presenting eight to twelve discrete levels of increasing difficulty. Sixteen subjects performed the same activities controlled by success algorithms that modify game difficulty incrementally. METHODS: 33 persons 20-80 years of age, at least 6 months post stroke with moderate to mild hemiparesis were randomized using a random number generator into the two groups. They were tested using the Action Research Arm Test, Upper Extremity Fugl Meyer Assessment, Stroke Impact Scale and Intrinsic Motivation Inventory pre and post training. Adherence was measured using timestamps generated by the gaming system. Subjects had the Home Virtual Rehabilitation System (Qiu in J Neuroeng Rehabil 17: 1-10, 2020) placed in their homes and were taught to perform rehabilitation games using it. Subjects were instructed to train twenty minutes per day but were allowed to train as much as they chose. Subjects trained for 12 weeks without appointments and received intermittent support from study staff. Group outcomes were compared using ANOVA. Correlations between subject demographics and adherence, as well as motor outcome, were evaluated using Pearson Correlation Coefficients. RESULTS: There were 5 dropouts and no adverse events. The main effect of time was statistically significant for four of the five clinical outcome measures. There were no significant training group by time interactions. Measures of adherence did not differ significantly between groups. The combined groups improved their UEFMA scores on average by 5.85 (95% CI 4.73-6.98). 21 subjects from both groups demonstrating improvements in UEFMA scores of at least 5 points, exceeding the minimal clinically important difference of 4.25. IMI scores were stable pre to post training. CONCLUSIONS: Scaffolding challenges during game based rehabilitation did not elicit higher levels of adherence when compared to algorithm control of game difficulty. Both sparsely supervised programs of game-based treatment in the home were sufficient to elicit statistically significant, clinically meaningful improvements in motor function and activities of daily living. TRIAL REGISTRATION: Clinical Trials.gov-NCT03985761, Registered June 14, 2019.

Heart rate variability biofeedback enhances cognitive, motor, psychological, and autonomic functions in post-stroke rehabilitation.

Post-stroke patients often experience psychological distress and autonomic nervous system (ANS) dysregulation, impacting their well-being. This study evaluated the effectiveness of heart rate variability (HRV) biofeedback on cognitive, motor, psychological, and ANS functions in sixty-two ischemic stroke patients (43 males, mean age = 60.1) at a Medical Center in southern Taiwan. To prevent interaction, we allocated patients to the HRV biofeedback or control (usual care) group based on their assigned rehabilitation days, with 31 patients in each group. Assessments conducted at baseline, three, and six months included the Montreal Cognitive Assessment (MoCA), Fugl-Meyer Assessment for Upper Extremities (FMA-UE), Perceived Stress Scale, Hospital Anxiety and Depression Scales (HADS), and HRV indices. Mixed-effect models were used to analyze Group by Time interactions. The results revealed significant interactions across all functions. At 3 months, significant improvements in the HRV biofeedback group were observed only in MoCA, FMA-UE, and HADS-depression scores compared to the control group. By 6 months, all measured outcomes demonstrated significant improvements in the biofeedback group relative to the control group. These results suggest that HRV biofeedback may be an effective complementary intervention in post-stroke rehabilitation, warranting further validation.

Feasibility of a self-management intervention to improve mobility in the community after stroke (SIMS): A mixed-methods pilot study.

OBJECTIVE: To evaluate the feasibility of implementing a self-management intervention to improve mobility in the community for stroke survivors. METHODS: A two-phase sequential mixed methods design was used (a pilot randomised controlled trial and focus groups). Participants were adult stroke survivors within six months post discharge from hospital with functional and cognitive capacity for self-management. The intervention included education sessions, goal setting and action planning, group sessions, self-monitoring and follow up. The control group received usual care and both groups enrolled for 3 months in the study. Feasibility outcomes (recruitment and retention rates, randomisation and blinding, adherence to the intervention, collection of outcome measures, and the fidelity and acceptability of the intervention). Participants assessed at baseline, 3 months and 6 months for functional mobility and walking, self-efficacy, goal attainment, cognitive ability, and general health. A descriptive analysis was done for quantitative data and content analysis for the qualitative data. Findings of quantitative and qualitative data were integrated to present the final results of the study. RESULTS: Twenty-four participants were recruited and randomised into two groups (12 each). It was feasible to recruit from hospital and community and to deliver the intervention remotely. Randomisation and blinding were successful. Participants were retained (83%) at 3 months and (79.2%) at 6 months assessments. Adherence to the intervention varied due to multiple factors. Focus groups discussed participants' motivations for joining the programme, their perspectives on the intervention (fidelity and acceptability) and methodology, perceived improvements in mobility, facilitators and challenges for self-management, and suggestions for improvement. CONCLUSION: The self-management intervention seems feasible for implementation for stroke survivors in the community. Participants appreciated the support provided and perceived improvement in their mobility. The study was not powered enough to draw a conclusion about the efficacy of the program and a future full-scale study is warranted.