Telerehabilitation service impact on physical function and adherence compared to face-to-face rehabilitation in patients with stroke: A systematic review and meta-analysis.

OBJECTIVES: The purposes of this systematic review and meta-analysis were to (1) appraise the available evidence of telerehabilitation program effects on functional outcomes, adherence, and patient satisfaction compared to face-to-face programs after stroke; and (2) provide direction for future outcome measure selection and development for clinical research purposes. TYPE: Systematic review and meta analysis of randomized controlled trials. LITERATURE SURVEY: MEDLINE, CINAHL, Embase, Scopus, Proquest Theses and Dissertations, Physiotherapy Evidence Database (PEDro), and Clinicaltrials.gov were searched for studies published in English from 1964 to the end of April 2022. METHODOLOGY: A total of 6450 studies were identified, 13 were included in the systematic review, and 10 with at least 3 reported similar outcomes were included the meta-analysis. Methodological quality of results was evaluated using the PEDro checklist. SYNTHESIS: Telerehabilitation demonstrated equivalency in outcomes across several domains and was favored compared to conventional face to face alone or when paired with semisupervised physical therapy on Wolf Motor Function performance score (mean difference [MD] 1.69 points, 95% confidence interval [CI] 0.21-3.17) and time score (MD 2.07 seconds, 95% CI -4.04 to -0.10, Q test = 30.27, p < .001, I2 = 93%), and Functional Mobility Assessment in the upper extremities (MD 3.32 points, 95% CI 0.90-5.74, Q test = 5.60, p = .23, I2 = 29% alone or when paired with semisupervised physical therapy). The Barthel Index participation measures of function demonstrated improvement (MD 4.18 points, 95% CI, 1.79-6.57, Q test = 3.56, p = .31, I2 = 16%). Over half of summarized study ratings were determined to be of good to excellent quality (PEDro score 6.6 ± 2.3 points). Adherence varied in available studies from 75%-100%. Satisfaction levels of telerehabilitation were highly variable. CONCLUSIONS: Telerehabilitation can improve functional outcomes and promote therapy adherence after stroke. Therapy protocols and functional assessments need substantial refinement and standardization to improve interpretation and clinical outcomes.

Current status and trends in subspecialty certification in physical medicine and rehabilitation.

BACKGROUND: There is a need to better understand the overall state of sub-specialization in physical medicine and rehabilitation (PM&R). OBJECTIVE: To examine the status and trends in subspecialty certification for each of the seven subspecialties approved for American Board of Physical Medicine and Rehabilitation (ABPMR) diplomates. DESIGN/SETTING: Retrospective analysis of deidentified information from the ABPMR database. PARTICIPANTS: Physicians certified by ABPMR through 2019. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: For each subspecialty, we examined: (1) the number of certificates issued to ABPMR diplomates; (2) the recertification rate; (3) the yearly trends for total active, new, and expired certificates; and (4) for ABPMR-administered subspecialties, recertification rates for those entering the subspecialty through fellowship completion versus a "grandfathered" practice pathway. RESULTS: Of 11,421 ABPMR diplomates in the United States in 2019, a total of 3560 (31.2%) had 3985 active subspecialty certificates. Pain Medicine (PM) was the most common subspecialty certification (15.5% of all ABPMR diplomates) followed by Sports Medicine (SM, 6.6%), Brain Injury Medicine (BIM, 4.8%), Spinal Cord Injury Medicine (SCIM, 4.2%), Pediatric Rehabilitation Medicine (PRM, 2.5%), Neuromuscular Medicine (NMM, 0.7%), and Hospice and Palliative Medicine (HPM, 0.5%). For diplomates with more than one subspecialty certification, PM and SM was the most frequent combination. Both the recertification rate and the end of practice track eligibility influenced certification trends differently for individual subspecialties. The average number of new certificates added annually for every subspecialty was higher before than after the temporary practice track-based eligibility ended; the difference was statistically significant (p < .05) for SCIM, PM, SM, and NMM. The recertification rate for all subspecialties combined was 73.4%. For the subspecialties (SCIM, PRM) for which these data were available, fellowship candidates had higher recertification rates than those grandfathered through a practice track. CONCLUSION: This report informs stakeholders about the state and evolution of subspecialty certification in PM&R over time.

Trends in outpatient rehabilitation use for stroke survivors.

BACKGROUND: Stroke survivors with residual disabling deficits who are medically stable may be recommended for acute rehabilitation or outpatient therapy, depending partly on the severity of their deficits. Here we sought to determine if the location at which patients needing rehabilitation post-stroke has shifted from inpatient to an outpatient setting. METHODS: For analysis, we used our Institutional Review Board-approved Get With The Guidelines®-Stroke Database to study stroke survivors discharged to receive either inpatient or outpatient rehabilitation services between 2014 and 2019. Logistic regression analysis was used to identify clinical factors associated with discharge type. Cochran-Armitage trend analysis was used to assess differences in rehabilitation services used over time. RESULTS: A total of 3293 patients were included. Trend analysis demonstrated a significant increase over time in the proportion of patients needing rehabilitation being discharged home with rehabilitation services (P < 0.0001). In addition, older age was associated with discharge to inpatient rehabilitation (OR = 1.018, 95%CI, 1.011-1.026), as was a higher National Institutes of Health Stroke Scale score (OR = 1.149, 95%CI, 1.130-1.168). CONCLUSIONS: We found that home discharges increased, highlighting outpatient rehabilitation as an expanding healthcare resource for reducing stroke-associated disability in adults.

Benefits of an interdisciplinary stroke clinic: addressing a gap in physical therapy at post-stroke neurology follow-up.

BACKGROUND AND PURPOSE: An interdisciplinary stroke clinic (ISC) can improve communication and identify people post-stroke who have not reached their full recovery potential. We describe the characteristics of participants who underwent physical therapy (PT) evaluation in addition to their outpatient neurology evaluation and identify the association of assessment scales that predicted referral for additional rehabilitation. METHODS: Participants' post-stroke seen in the ISC were included in the study. The PT evaluation included the Berg Balance Scale (BBS), Ten-Meter Walk Test (10MWT), Six-Minute Walk Test (6MWT), and Short Form-Stroke Impact Scale (SF-SIS). Multivariable logistic regression analysis was performed to identify factors associated with referral for additional rehabilitation. RESULTS: The study consisted of 148 participants with a mean age of 63 (SD ± 15) years; 58% were women and 76% were Whites. Additional rehabilitation was recommended for 59% of participants. In multivariate analysis, reduced speed on comfortable 10MWT (OR = 0.06; 95%CI = 0.01-0.51) and lower SF-SIS score (OR = 0.76; 95%CI = 0.66-0.87) were significantly associated with referral for additional PT or occupational therapy. CONCLUSION: A significant number of post-acute stroke survivors were found to be appropriate for additional rehabilitation when assessed clinically by a neurologic physical therapist in an ISC. The measures that most closely correlated with this in-person clinical evaluation were 10MWT and SF-SIS.IMPLICATIONS FOR REHABILITATIONAn interdisciplinary stroke clinic can improve communication and identify people post-stroke who have not reached their full recovery potential.In a pilot study, a significant number of post-acute stroke survivors were found to be appropriate for additional rehabilitation when assessed clinically by a neurologic physical therapist in an interdisciplinary stroke clinic.Reduced speed on comfortable Ten-Meter Walk Test and lower Short Form-Stroke Impact Scale scores were associated with referral for additional rehabilitation.

Social Determinants of Health in Physiatry: Challenges and Opportunities for Clinical Decision Making and Improving Treatment Precision.

Physiatry is a medical specialty focused on improving functional outcomes in patients with a variety of medical conditions that affect the brain, spinal cord, peripheral nerves, muscles, bones, joints, ligaments, and tendons. Social determinants of health (SDH) play a key role in determining therapeutic process and patient functional outcomes. Big data and precision medicine have been used in other fields and to some extent in physiatry to predict patient outcomes, however many challenges remain. The interplay between SDH and physiatry outcomes is highly variable depending on different phases of care, and more favorable patient profiles in acute care may be less favorable in the outpatient setting. Furthermore, SDH influence which treatments or interventional procedures are accessible to the patient and thus determine outcomes. This opinion paper describes utility of existing datasets in combination with novel data such as movement, gait patterning and patient perceived outcomes could be analyzed with artificial intelligence methods to determine the best treatment plan for individual patients in order to achieve maximal functional capacity.

Impact of early intervention with onabotulinumtoxinA treatment in adult patients with post-stroke lower limb spasticity: results from the double-blind, placebo-controlled, phase 3 REFLEX study.

The aim of this study in patients with post-stroke lower limb spasticity (PSLLS) was to evaluate the relationship between time of onabotulinumtoxinA treatment relative to stroke and efficacy outcomes. This was a phase 3, international, multicenter, randomized, 12-week, double-blind study, followed by a repeated treatment, open-label extension. Patients were aged 18-85 years with PSLLS (Modified Ashworth Scale [MAS] ≥ 3) of the ankle with the most recent stroke occurring ≥ 3 months before screening. Patients (double-blind phase) were randomized (n = 468) to onabotulinumtoxinA 300-400 U (300 U, mandatory ankle muscles (gastrocnemius, soleus, tibialis posterior); and ≤ 100 U, optional lower limb muscles (flexor digitorum longus, flexor hallucis longus, flexor digitorum brevis, extensor hallucis, and rectus femoris]) or placebo. Primary endpoint: MAS change from baseline (average score of weeks 4 and 6). Secondary endpoints: physician-assessed Clinical Global Impression of Change (CGI) average score of weeks 4 and 6 and physician-assessed Goal Attainment Scale (GAS; active and passive, weeks 8 and 12). When stratified by time since stroke (≤ 24 months, n = 153; > 24 months, n = 315, post hoc), patients treated ≤ 24 months post-stroke experienced greater improvements from baseline versus placebo in MAS (- 0.31 vs - 0.17), CGI (0.49 vs 0.12), and passive GAS scores (week 12, 0.37 vs 0.26). A ≥ - 1-point improvement in active (week 12; p = 0.04) and passive (week 8; p = 0.02) GAS scores versus placebo was achieved by more patients treated ≤ 24 months post-stroke; in patients treated > 24 months post-stroke, improvements were only observed in active scores (week 8; p = 0.04). OnabotulinumtoxinA 300-400 U was well tolerated, with no new safety findings.

Optimal Muscle Selection for OnabotulinumtoxinA Injections in Poststroke Lower-Limb Spasticity: A Randomized Trial.

OBJECTIVE: The aim of the study was to identify optimal muscle selection patterns for onabotulinumtoxinA treatment of poststroke lower-limb spasticity. DESIGN: Adults with poststroke lower-limb spasticity (ankle Modified Ashworth Scale ≥3) were randomized to onabotulinumtoxinA (300 U, mandatory ankle plantar flexors; ≤100 U, optional lower-limb muscles) or placebo. Post hoc analysis assessed the impact of muscle selection patterns on ankle Modified Ashworth Scale and physician-assessed Clinical Global Impression of Change based on change from baseline to average of weeks 4/6 versus placebo. RESULTS: Among 468 patients randomized, onabotulinumtoxinA improved ankle Modified Ashworth Scale (-0.81 vs -0.61, P = 0.01) and Clinical Global Impression of Change (0.86 vs 0.65, P = 0.012) versus placebo. Injection of mandatory muscles alone was not sufficient in improving ankle Modified Ashworth Scale (P = 0.255) or Clinical Global Impression of Change (P = 0.576) versus placebo but was adequate 24 mos or less after stroke (Modified Ashworth Scale, -1.13 vs -0.62, P = 0.019; Clinical Global Impression of Change, 1.24 vs 0.68, P = 0.006). Additional injections into toe muscles (flexor digitorum longus, flexor hallucis longus) improved ankle Modified Ashworth Scale (-0.98 vs -0.52, P = 0.002) and Clinical Global Impression of Change (0.80 vs 0.38, P = 0.023) versus placebo regardless of time since stroke. OnabotulinumtoxinA was well tolerated, with no new safety findings. CONCLUSIONS: Post hoc analyses suggested additional injections of onabotulinumtoxinA into toe flexors improved ankle Modified Ashworth Scale and Clinical Global Impression of Change scores versus mandatory muscles alone overall and with treatment initiation more than 24 mos after stroke.

Predictors of Performance on the American Board of Physical Medicine and Rehabilitation Maintenance of Certification Examination.

BACKGROUND: Maintenance of certification (MOC) in Physical Medicine and Rehabilitation is a process of lifelong learning that begins after successfully completing an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency and passing the American Board of Physical Medicine and Rehabilitation (ABPMR) Part I and Part II Examinations. We seek to identify factors predictive of successful MOC Examination performance. OBJECTIVE: To identify characteristics predictive of successful completion on the ABPMR MOC Examination. DESIGN: Retrospective review. SETTING: American Board of Physical Medicine and Rehabilitation database review. PARTICIPANTS: 4,545 diplomates who completed the MOC Examination between January 2006 and December 2017. METHODS: MOC Examination performance was the primary outcome variable. Performance on Part I and Part II Examinations were independent variables. Additional potential predictors evaluated included year of MOC cycle in which examination was taken, years of practice since residency completion, age, and subspecialty certification. MAIN OUTCOME MEASURES: Performance on MOC Examination. RESULTS: Age at time of MOC Examination was inversely correlated with examination score (r = -0.14, P < .001). Similarly, as time since completion of residency training increased, MOC scores declined. Passing the Part I Examination on first attempt predicted a 98% MOC pass rate, compared to 90% for those who failed initially. MOC performance was highly correlated with Part I performance (r = 0.59, P < .001) and Part II performance (r = 0.32, P < .001). Although MOC performance was similar for those taking the examination in years 7 - 10 of their cycle (97% pass rate), those taking the examination after more than 10 years of the cycle had a significantly lower performance (85% pass rate, P < .01). CONCLUSIONS: Better performance on the MOC Examination is associated with better performance on Part I and Part II Examinations, taking the examination earlier in the 10 year cycle, younger age, and less time since completion of training. Diplomates who are at higher risk for failing the examination may need to prepare differently for MOC Exam than those who are more likely to pass. LEVEL OF EVIDENCE: III.

Long-Term Follow-up to a Randomized Controlled Trial Comparing Peroneal Nerve Functional Electrical Stimulation to an Ankle Foot Orthosis for Patients With Chronic Stroke.

BACKGROUND: Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle foot orthoses (AFO) for treatment of foot drop poststroke, but few long-term, randomized controlled comparisons exist. OBJECTIVE: Compare changes in gait quality and function between FES and AFOs in individuals with foot drop poststroke over a 12-month period. METHODS: Follow-up analysis of an unblinded randomized controlled trial (ClinicalTrials.gov #NCT01087957) conducted at 30 rehabilitation centers comparing FES to AFOs over 6 months. Subjects continued to wear their randomized device for another 6 months to final 12-month assessments. Subjects used study devices for all home and community ambulation. Multiply imputed intention-to-treat analyses were utilized; primary endpoints were tested for noninferiority and secondary endpoints for superiority. Primary endpoints: 10 Meter Walk Test (10MWT) and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test (6MWT), GaitRite Functional Ambulation Profile, and Modified Emory Functional Ambulation Profile (mEFAP). RESULTS: A total of 495 subjects were randomized, and 384 completed the 12-month follow-up. FES proved noninferior to AFOs for all primary endpoints. Both FES and AFO groups showed statistically and clinically significant improvement for 10MWT compared with initial measurement. No statistically significant between-group differences were found for primary or secondary endpoints. The FES group demonstrated statistically significant improvements for 6MWT and mEFAP Stair-time subscore. CONCLUSIONS: At 12 months, both FES and AFOs continue to demonstrate equivalent gains in gait speed. Results suggest that long-term FES use may lead to additional improvements in walking endurance and functional ambulation; further research is needed to confirm these findings.

The effects of peroneal nerve functional electrical stimulation versus ankle-foot orthosis in patients with chronic stroke: a randomized controlled trial.

BACKGROUND: Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle-foot orthoses (AFO) for treatment of foot drop poststroke, but few randomized controlled comparisons exist. OBJECTIVE: To compare changes in gait and quality of life (QoL) between FES and an AFO in individuals with foot drop poststroke. METHODS: In a multicenter randomized controlled trial (ClinicalTrials.gov #NCT01087957) with unblinded outcome assessments, 495 Medicare-eligible individuals at least 6 months poststroke wore FES or an AFO for 6 months. Primary endpoints: 10-Meter Walk Test (10MWT), a composite of the Mobility, Activities of Daily Living/Instrumental Activities of Daily Living, and Social Participation subscores on the Stroke Impact Scale (SIS), and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test, GaitRite Functional Ambulation Profile (FAP), Modified Emory Functional Ambulation Profile (mEFAP), Berg Balance Scale (BBS), Timed Up and Go, individual SIS domains, and Stroke-Specific Quality of Life measures. Multiply imputed intention-to-treat analyses were used with primary endpoints tested for noninferiority and secondary endpoints tested for superiority. RESULTS: A total of 399 subjects completed the study. FES proved noninferior to the AFO for all primary endpoints. Both the FES and AFO groups improved significantly on the 10MWT. Within the FES group, significant improvements were found for SIS composite score, total mFEAP score, individual Floor and Obstacle course time scores of the mEFAP, FAP, and BBS, but again, no between-group differences were found. CONCLUSIONS: Use of FES is equivalent to the AFO. Further studies should examine whether FES enables better performance in tasks involving functional mobility, activities of daily living, and balance.

Stroke and neurodegenerative disorders. 1. Acute stroke evaluation, management, risks, prevention, and prognosis.

UNLABELLED: This self-directed learning module highlights recent developments in the acute care of stroke patients, prediction of outcome after stroke, evaluation of risk factors, secondary prevention of stroke, and the evaluation of the young adult with stroke. It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article contains sections on the acute evaluation and management of the stroke patient, prediction of functional outcome after stroke, and secondary prevention of stroke. Special emphasis is given to the evaluation of the young adult with stroke. OVERALL ARTICLE OBJECTIVES: (a) To summarize the acute evaluation and management of stroke, particularly in the young stroke patient; and (b) to review the risk factors for stroke and secondary prevention measures.

Stroke and neurodegenerative disorders. 2. Stroke: comorbidities and complications.

UNLABELLED: This self-directed learning module highlights diagnosis and treatment of comorbidities and complications encountered by patients with stroke. It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on cardiopulmonary complications and examines neurologic sequelae, risk factors for falls, and prevention strategies. It also discusses upper-limb pain, fatigue, and depression and highlights diagnosis and management of genitourinary complications. OVERALL ARTICLE OBJECTIVE: To summarize common comorbidities and complications encountered by patients after stroke.

Stroke and neurodegenerative disorders. 3. Stroke: rehabilitation management.

UNLABELLED: This self-directed learning module highlights common rehabilitation issues in stroke survivors. Topics include spasticity, constraint-induced movement therapy, partial body weight-supported treadmill training, virtual reality training, vestibular retraining, aphasia treatment, and cognitive retraining. It is part of the study chapter on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. OVERALL ARTICLE OBJECTIVES: (a) To identify and review the treatment options for poststroke spasticity; (b) to review the use of body weight-supported treadmill training in stroke patients; (c) to describe virtual reality training as an adjunct in stroke rehabilitation; (d) to review vestibular rehabilitation; (e) to discuss advances in aphasia treatment; (f) to discuss cognitive retraining; and (g) to provide an update on treatment of neglect syndromes.

Stroke and neurodegenerative disorders. 4. Neurodegenerative disorders.

UNLABELLED: This self-directed learning module highlights diagnosis, treatment, and rehabilitation issues in patients with neurodegenerative disorders, including multiple sclerosis (MS), Parkinson's disease, and amyotrophic lateral sclerosis (ALS). It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the differential diagnosis, diagnostic evaluation, medical management, and rehabilitation issues in MS. Similarly, the differential diagnosis treatment and rehabilitation in Parkinson's disease is discussed. Electrodiagnosis, pharmacologic treatment, and rehabilitation options for ALS are also discussed. OVERALL ARTICLE OBJECTIVES: To review the differential diagnosis, evaluation, medical treatment, and rehabilitation management of patients with MS, Parkinson's disease, and ALS.

Rehabilitation of movement disorders.

UNLABELLED: This self-directed learning module highlights several movement disorders. These include dystonia, chorea, tremors, and myoclonus. A description of the clinical presentation and associated disease processes is presented. Although the discussion on treatment focuses on pharmacologic intervention, surgical options are presented when appropriate. Other movement disorders (ie, parkinsonism) are discussed elsewhere in the Study Guide. OVERALL ARTICLE OBJECTIVES: (a) To define the various symptoms and etiologies of dystonia; (b) to define chorea and its treatment; (c) to define tremors, including associated neurologic disorders, plus pharmacologic and potential surgical interventions; and (d) to describe the symptoms, classification, and treatment of primary and secondary myoclonus.