Bilateral Sensorimotor Cortical Communication Modulated by Multiple Hand Training in Stroke Participants: A Single Training Session Pilot Study.

Bi-manual therapy (BT), mirror therapy (MT), and robot-assisted rehabilitation have been conducted in hand training in a wide range of stages in stroke patients; however, the mechanisms of action during training remain unclear. In the present study, participants performed hand tasks under different intervention conditions to study bilateral sensorimotor cortical communication, and EEG was recorded. A multifactorial design of the experiment was used with the factors of manipulating objects (O), robot-assisted bimanual training (RT), and MT. The sum of spectral coherence was applied to analyze the C3 and C4 signals to measure the level of bilateral corticocortical communication. We included stroke patients with onset <6 months (n = 6), between 6 months and 1 year (n = 14), and onset >1 year (n = 20), and their Brunnstrom recovery stage ranged from 2 to 4. The results showed that stroke duration might influence the effects of hand rehabilitation in bilateral cortical corticocortical communication with significant main effects under different conditions in the alpha and beta bands. Therefore, stroke duration may influence the effects of hand rehabilitation on interhemispheric coherence.

A Pilot Randomized Controlled Trial of Botulinum Toxin Treatment Combined with Robot-Assisted Therapy, Mirror Therapy, or Active Control Treatment in Patients with Spasticity Following Stroke.

Effects of the combined task-oriented trainings with botulinum toxin A (BoNT-A) injection on improving motor functions and reducing spasticity remains unclear. This study aims to investigate effects of 3 task-oriented trainings (robot-assisted therapy (RT), mirror therapy (MT), and active control treatment (AC)) in patients with stroke after BoNT-A injection. Thirty-seven patients with chronic spastic hemiplegic stroke were randomly assigned to receive RT, MT, or AC following BoNT-A injection over spastic upper extremity muscles. Each session of RT, MT, and AC was 75 min, 3 times weekly, for 8 weeks. Outcome measures were assessed at pretreatment, post-treatment, and 3-month follow-up, involving the Fugl-Meyer Assessment (FMA), Modified Ashworth Scale (MAS), Motor Activity Log (MAL), including amount of use (AOU) and quality of movement (QOM), and arm activity level. All 3 combined treatments improved FMA, MAS, and MAL. The AC induced a greater effect on QOM in MAL at the 3-month follow-up than RT or MT. All 3 combined trainings induced minimal effect on arm activity level. Our findings suggest that for patients with stroke who received BoNT-A injection over spastic UE muscles, the RT, MT, or AC UE training that followed was effective in improving motor functions, reducing spasticity, and enhancing daily function.

Practice effect and reliability of the motor-free visual perception test-4 over multiple assessments in patients with stroke.

PURPOSE: The Motor-Free Visual Perception Test-4 (MVPT-4) is a multidimensional measure of visual perception with five subscales (visual discrimination, figure-ground, visual memory, spatial relationships, and visual closure). The purpose of this study was to examine practice effect and test-retest reliability of the MVPT-4 over four serial assessments in patients with stroke. METHODS: We recruited outpatients with stroke with age above 20 years, able to follow instructions, and able to sign informed consent. We excluded patients who had visual neglect and visual deficits (e.g., diplopia, cataract, and glaucoma). Sixty patients completed the MVPT-4 four times, one week apart. Cumulative and plateau phases of the practice effect were evaluated across four assessments. Test-retest reliability was examined using the intraclass correlation coefficient (ICC). RESULTS: The MVPT-4 scale and five subscales showed cumulative phases. Only the spatial relationships subscale may have reached a plateau phase at the second assessment. The ICC values of the MVPT-4 scale and five subscales were 0.48-0.87. The minimum and maximum values of the 90% confidence interval (CI) of reliable change index modified for practice (RCIp) were: MVPT-4 scale [-5.0, 7.7]; visual discrimination [-1.7, 2.1]; figure-ground [-2.0, 2.6]; visual memory [-2.6, 3.2]; spatial relationships [-2.3, 3.0]; and visual closure [-2.5, 2.8]. CONCLUSIONS: The MVPT-4 scale and five subscales appeared increasing trends of practice effects and moderate to excellent test-retest reliability in patients with stroke. The minimum and maximum values of the 90% CI RCIp for the spatial relationships subscale which may have reached a plateau phase that can help clinicians and researchers to ascertain whether the real score change is occurred for an individual patient.Implications for rehabilitationThree multilevel regression models were conducted to evaluate the plateau phase of the practice effect over four assessments.The patterns of practice effects and evidences of test-retest reliability of the MVPT-4 scale and five subscales over four serial assessments can be used to follow the progress of patients with stroke.The minimum and maximum values of the 90% CI RCIp of the MVPT-4 can assist clinicians and researchers to explain score changes for an individual patient with stroke.

The Effects of Distributed vs. Condensed Schedule for Robot-Assisted Training with Botulinum Toxin A Injection for Spastic Upper Limbs in Chronic Post-Stroke Subjects.

Robot-assisted training (RT) combined with a Botulinum toxin A (BoNT-A) injection has been suggested as a means to optimize spasticity treatment outcomes. The optimal schedule of applying RT after a BoNT-A injection has not been defined. This single-blind, randomized controlled trial compared the effects of two predefined RT approaches as an adjunct to BoNT-A injections of spastic upper limbs in chronic post-stroke subjects. Thirty-six patients received a BoNT-A injection in the affected upper extremity and were randomly assigned to the condensed or distributed RT group. The condensed group received an intervention of four sessions/week for six consecutive weeks. The distributed group attended two sessions/week for 12 consecutive weeks. Each session included 45 min of RT using the InMotion 2.0 robot, followed by 30 min of functional training. The Fugl-Meyer Assessment, Modified Ashworth Scale, Wolf Motor Function Test, Motor Activity Log, and Stroke Self-Efficacy Questionnaire were assessed at pre-training, mid-term, post-training, and at 6 week follow-up, with the exception of the Motor Activity Log, which did not include mid-term measures. After the intervention, both groups had significant improvements in all outcome measures (within-group effects, p < 0.05), with the exception of the Wolf Motor Function Test time score. There were no significant differences between groups and interaction effects in all outcome measures. Our findings suggest that RT provided in a fixed dosage as an adjunct to a BoNT-A injection has a positive effect on participants' impairment and activity levels, regardless of treatment frequency. (ClinicalTrials.gov: NCT03321097).

Myoelectric analysis of upper-extremity muscles during robot-assisted bilateral wrist flexion-extension in subjects with poststroke hemiplegia.

BACKGROUND: Muscle co-contraction during the execution of motor tasks or training is common in poststroke subjects. EMG-derived muscular activation indexes have been used to evaluate muscle co-contractions during movements. In addition, robot-assisted bilateral arm training provides a repetitive and stable training method to improve arm movements. However, quantitative measures of muscle contractions during this training in poststroke subjects have not been described. METHODS: Seventeen subjects experiencing spastic hemiplegia after a stroke were recruited to perform robot-assisted bilateral wrist flexion and extension movements. The co-contraction index and two new indexes, temporal correlation and cross mutual information, which are derived from the EMGs of working muscles without the need for envelope normalization, are used to quantify intermuscular activation during wrist movements. FINDINGS: Higher temporal correlation as well as higher co-contraction index was demonstrated in the affected muscles, implying the recruitment of muscle co-contractions to complete the movement task. On the other hand, a higher value of cross mutual information was exhibited in the unaffected muscles which was attributed to their distinct, rhythmic muscle contractions. The plot of temporal correlation versus cross mutual information further defined affected, unaffected synergistic, and unaffected agonist-antagonist muscular regions. Moreover, with the modified Ashworth scale, multiple regression models based on the co-contraction index and cross mutual information had the highest R-squared value of 0.733. INTERPRETATION: EMG-derived intermuscular activation parameters demonstrated muscle co-contractions in the affected muscles and different types of intermuscular contractions during robot-assisted bilateral arm training. The modified Ashworth scale estimation based on multiple regression analysis of the activation indexes also demonstrated EMG-derived index a valuable method for assessing muscle spasticity in subjects with poststroke hemiplegia.

Low back pain-associated factors in female hospital-based personal care attendants.

BACKGROUND: Low back pain (LBP) is common in personal care attendants because this profession requires much physical work. Information about the prevalence of LBP and LBP-associated risk factors in this group is limited.OBJECTIVEThis study aimed to investigate the 1-year prevalence of LBP and identify LBP-associated factors in female hospital-based personal care attendants. METHODS: Forty-seven female hospital-based personal care attendants were recruited. The Nordic Musculoskeletal Questionnaire was used to investigate the prevalence of LBP during the recent 12 months. Participants completed a personal traits and associated factors questionnaire. Physical fitness and the knowledge test of body mechanics were assessed. Multivariable logistic regression analysis was used to explore LBP-associated factors. RESULTS: The 1-year prevalence of LBP was 46.8%. The strongest LBP-associated risk factor was poor abdominal muscle endurance, followed by insufficient knowledge on the test of body mechanics and higher psychological stress. CONCLUSIONS: The results demonstrate that the prevalence of LBP in female hospital-based personal care attendants appears to be high. Preventive programs should be initiated to reduce LBP-associated risk factors, such as improving abdominal muscle endurance, providing education in the proper use of body mechanics, and providing psychological intervention services for female hospital-based personal care attendants.

Predictors of Clinically Important Improvements in Motor Function and Daily Use of Affected Arm after a Botulinum Toxin A Injection in Patients with Chronic Stroke.

Identifying patients who can gain minimal clinically important difference (MCID) in active motor function in the affected upper extremity (UE) after a botulinum toxin A (BoNT-A) injection for post-stroke spasticity is important. Eighty-eight participants received a BoNT-A injection in the affected UE. Two outcome measures, Fugl-Meyer Assessment Upper Extremity (FMA-UE) and Motor Activity Log (MAL), were assessed at pre-injection and after 24 rehabilitation sessions. We defined favorable response as an FMA-UE change score ≥5 or MAL change score ≥0.5.Statistical analysis revealed that the time since stroke less than 36 months (odds ratio (OR) = 4.902 (1.219-13.732); p = 0.023) was a significant predictor of gaining MCID in the FMA-UE. Medical Research Council scale -proximal UE (OR = 1.930 (1.004-3.710); p = 0.049) and post-injection duration (OR = 1.039 (1.006-1.074); p =0.021) were two significant predictors of MAL amount of use. The time since stroke less than 36 months (OR = 3.759 (1.149-12.292); p = 0.028), naivety to BoNT-A (OR = 3.322 (1.091-10.118); p = 0.035), and education years (OR = 1.282 (1.050-1.565); p = 0.015) were significant predictors of MAL quality of movement. The findings of our study can help optimize BoNT-A treatment planning.

Musculoskeletal disorders, psychosocial stress and associated factors among home-based migrant care workers.

BACKGROUND: Prevalence of musculoskeletal disorders (MSDs) and psychological stress in home-based female migrant care workers (MCWs) remain unknown. OBJECTIVE: To 1) investigate the prevalence of MSDs and psychological stress and associations between subjective questionnaires on MSDs/psychological stress and biomedical examinations, and 2) identify the risk factors related to MSDs and psychological stress. METHODS: This study recruited 85 MCWs. Data was collected using questionnaires, urine analysis and X-ray examinations. Correlations between subjective questionnaires and biomedical examinations were investigated. Multivariable logistic regression analyses were used to explore risk factors. RESULTS: The prevalence of MSDs and psychological stress were 70.6% and 37.6%, respectively. MSDs were commonly reported over the neck, lower back, shoulders, and upper back. There was a moderate correlation between MSDs and abnormal X-ray findings. Risk factors associated with MSDs included higher education level, frequent transferring and bedside care activities, lacking caregiver training in Taiwan, inadequate sleep, and drinking tea or coffee. Risk factors associated with psychological stress included inadequate salary, lacking caregiver training in Taiwan, and insufficient knowledge of body mechanics techniques. CONCLUSIONS: MSDs and psychological stress were common among home-based female MCWs. Educational level, frequent transferring and bedside care activities, and lack of caregiver training in Taiwan, were the most dominant risk factors.

Comparison of Kinect2Scratch game-based training and therapist-based training for the improvement of upper extremity functions of patients with chronic stroke: a randomized controlled single-blinded trial.

BACKGROUND: Virtual reality and interactive video games could decrease the demands on the time of the therapists. However, the cost of a virtual reality system and the requirement for technical support limits the availability of these systems. Commercial exergames are not specifically designed for therapeutic use, most patients with hemiplegic stroke are either too weak to play the games or develop undesirable compensatory movements. AIM: To develop Kinect2Scratch games and compare the effects of training with therapist-based training on upper extremity (UE) function of patients with chronic stroke. DESIGN: A randomized controlled single-blinded trial. SETTING: An outpatient rehabilitation clinic of a tertiary hospital. POPULATION: Thirty-three patients with chronic hemiplegic stroke. METHODS: We developed 8 Kinect2Scratch games. The participants were randomly assigned to either a Kinect2Scratch game group or a therapist-based training group. The training comprised 24 sessions of 30 minutes over 12 weeks. The primary outcome measure was the Fugl-Meyer UE scale and the secondary outcome measures were the Wolf Motor Function Test and Motor Activity Log. Patients were assessed at baseline, after intervention, and at the 3-month follow-up. We used the Pittsburgh participation scale (PPS) to assess the participation level of patients at each training session and an accelerometer to assess the activity counts of the affected UE of patients was used at the 12th and 24th training sessions. RESULTS: Seventeen patients were assigned to the Kinect2Scratch group and 16 were assigned to the therapist-based training group. There were no differences between the two groups for any of the outcome measures postintervention and at the 3-month follow-up (all P>0.05). The level of participation was higher in the Kinect2Scratch group than in the therapist-based training group (PPS 5.25 vs. 5.00, P=0.112). The total activity counts of the affected UE was significantly higher in the Kinect2Scratch group than in the therapist-based training group (P<0.001). CONCLUSIONS: Kinect2Scratch game training was feasible, with effects similar to those of therapist-based training on UE function of patients with chronic stroke. CLINICAL REHABILITATION IMPACT: Kinect2Scratch games are low-cost and easily set-up games, which may serve as a complementary strategy to conventional therapy to decrease therapists' work load.

Validation of the Test of Visual Perceptual Skills-Third Edition in patients with stroke.

PURPOSE: The Test of Visual Perceptual Skills-Third Edition (TVPS-3) with seven subscales has been used to assess visual perception in patients with stroke. The purpose of this study was to investigate ecological validity, convergent validity, and discriminative validity of the TVPS-3 in patients with stroke. METHODS: One hundred patients were assessed with the TVPS-3, two measures of activities of daily living, and two cognitive measures. To examine ecological validity, we calculated correlations (Pearson's r) among the TVPS-3 and two measures of activities of daily living. To examine convergent validity, correlations (r) were estimated among the TVPS-3 and two cognitive measures. To examine discriminative validity, independent t-test was used to compare the two groups with different levels of disability and to detect whether there were statistically significant differences in the TVPS-3 between these groups. RESULTS: The correlations were 0.21-0.48 among the TVPS-3 and two measures of activities of daily living. The correlations were 0.29-0.68 among the TVPS-3 and two cognitive measures. Between the two groups, the t-test results showed statistically significant difference (p < 0.05) for the overall scale and the five subscales of the TVPS-3. CONCLUSIONS: The TVPS-3 has acceptable convergent validity, ecological validity, and discriminative validity and is useful to assess the visual perception in patients with stroke. Implications for rehabilitation The Test of Visual Perceptual Skills-Third Edition is a motor free visual perception test, which is an adequate tool for use in patients with stroke. The Test of Visual Perceptual Skills-Third Edition showed acceptable ecological validity, convergent validity, and discriminative validity in patients with stroke.

Low Persistence of Antithrombotic Agents is Associated with Poor Outcomes after First-ever Acute Ischemic Stroke.

OBJECTIVE: This study investigated the time-trend persistence with antithrombotic agents (AT) and assessed the impact of AT persistence on outcome events and adverse events (AE) within two years after first-ever acute ischemic stroke (IS). METHODS: Using Taiwan's National Health Insurance claims dataset, 7,341 IS subjects hospitalized between 2001 and 2005 with AT prescribed at discharge and survived at least 3 months were followed up for 2 years. Time-trends of AT usage were analyzed. Medication persistence was assessed as the proportion of days covered (PDC) for filled prescription, and categorized into low, intermediate and high persistence. Multivariate logistic regression analysis and multivariate Cox proportional hazard regression models were performed to identify factors associated with AT persistence and its impact on vascular outcomes. RESULTS: AT persistence rates declined sharply from 81% to 52% during the first 6 months. In addition to patient and facility-level characteristics, occurrence of AE (e.g., GI bleeding/ulceration, fractures/ major trauma, and iatrogenic/unspecific illness) was inversely related to AT persistence. Compared with patients with low persistence, the composite risk of recurrent stroke, cardiovascular disease, or death from any cause was significantly lower in patients with intermediate (Hazard Ratio [HR] 0.64, 0.57-0.71) or high AT persistence (0.74, 0.66-0.83).

Developing a Suite of Motion-Controlled Games for Upper Extremity Training in Children with Cerebral Palsy: A Proof-of-Concept Study.

AIM: The Scratch programming language allows learner developers to write games. The Kinect2Scratch extension makes Scratch games with bodily motion control possible by connecting to Microsoft's Kinect sensor. This study examined the feasibility and possible efficacy of a suite of motion-controlled games designed for upper extremity (UE) training in children with cerebral palsy (CP) using Kinect2Scratch. MATERIALS AND METHODS: This is a proof-of-concept study. We developed three games, requiring three UE movement patterns (shoulder holding, reaching, and handclap), for use in children with CP. The primary outcome was feasibility, addressed by adherence, engagement, satisfaction, and safety. The secondary outcome was efficacy, which was evaluated by Quality of Upper Extremities Skills Test (QUEST), Box and Block Test (BBT), Melbourne Assessment 2 (MA2) test, and ABILHAND-kids score. RESULTS: Thirteen children with CP (mean age 6.9 years) received 24 sessions of training (30 minutes per session). The adherence rate was 100%. During the first 2 weeks of training, children had a significantly higher level of participation in Kinect2Scratch training than in conventional rehabilitation [Pittsburgh Participation Scale, median (interquartile range [IQR]), 6 (3-6) vs. 4 (3-6) P = 0.04]. However, during the last 2 weeks of training, there was no significant difference in participation between the Kinect2Scratch and conventional training [Pittsburgh Rehabilitation Participation Scale, median (IQR), 4 (3-5) vs. 4 (3-6) P = 0.55]. Most children enjoyed playing the games. The mean score of enjoyment was 4.54 ± 0.66. There were no adverse events during the training periods. The children had significant improvement in total score of QUEST and MA2. There were no significant improvements in BBT and ABILHAND-kids score. CONCLUSION: Using Kinect2Scratch games for UE training is a feasible adjunctive program for children with CP.

Effects and mechanism of the HECT study (hybrid exercise-cognitive trainings) in mild ischemic stroke with cognitive decline: fMRI for brain plasticity, biomarker and behavioral analysis.

PURPOSE: Cognitive decline after stroke is highly associated with functional disability. Empirical evidence shows that exercise combined cognitive training may induce neuroplastic changes that modulate cognitive function. However, it is unclear whether hybridized exercise-cognitive training can facilitate cortical activity and physiological outcome measures and further influence on the cognitive function after stroke. This study will investigate the effects of two hybridized exercise-cognitive trainings on brain plasticity, physiological biomarkers and behavioral outcomes in stroke survivors with cognitive decline. METHODS AND SIGNIFICANCE: This study is a single-blind randomized controlled trial. A target sample size of 75 participants is needed to obtain a statistical power of 95% with a significance level of 5%. Stroke survivors with mild cognitive decline will be stratified by Mini-Mental State Examination scores and then randomized 1:1:1 to sequential exercise-cognitive training, dual-task exercise-cognitive training or control groups. All groups will undergo training 60 min/day, 3 days/week, for a total of 12 weeks. The primary outcome is the resting-state functional connectivity and neural activation in the frontal, parietal and occipital lobes in functional magnetic resonance imaging. Secondary outcomes include physiological biomarkers, cognitive functions, physical function, daily functions and quality of life. This study may differentiate the effects of two hybridized trainings on cognitive function and health-related conditions and detect appropriate neurological and physiological indices to predict training effects. This study capitalizes on the groundwork for a non-pharmacological intervention of cognitive decline after stroke.

Effects of Home-Based Versus Clinic-Based Rehabilitation Combining Mirror Therapy and Task-Specific Training for Patients With Stroke: A Randomized Crossover Trial.

OBJECTIVE: We investigated the treatment effects of a home-based rehabilitation program compared with clinic-based rehabilitation in patients with stroke. DESIGN: A single-blinded, 2-sequence, 2-period, crossover-designed study. SETTING: Rehabilitation clinics and participant's home environment. PARTICIPANTS: Individuals with disabilities poststroke. INTERVENTIONS: During each intervention period, each participant received 12 training sessions, with a 4-week washout phase between the 2 periods. Participants were randomly allocated to home-based rehabilitation first or clinic-based rehabilitation first. Intervention protocols included mirror therapy and task-specific training. MAIN OUTCOME MEASURES: Outcome measures were selected based on the International Classification of Functioning, Disability and Health. Outcomes of impairment level were the Fugl-Meyer Assessment, Box and Block Test, and Revised Nottingham Sensory Assessment. Outcomes of activity and participation levels included the Motor Activity Log, 10-meter walk test, sit-to-stand test, Canadian Occupational Performance Measure, and EuroQoL-5D Questionnaire. RESULTS: Pretest analyses showed no significant evidence of carryover effect. Home-based rehabilitation resulted in significantly greater improvements on the Motor Activity Log amount of use subscale (P=.01) and the sit-to-stand test (P=.03) than clinic-based rehabilitation. The clinic-based rehabilitation group had better benefits on the health index measured by the EuroQoL-5D Questionnaire (P=.02) than the home-based rehabilitation group. Differences between the 2 groups on the other outcomes were not statistically significant. CONCLUSIONS: The home-based and clinic-based rehabilitation groups had comparable benefits in the outcomes of impairment level but showed differential effects in the outcomes of activity and participation levels.

Rehabilitation Reduced Readmission and Mortality Risks in Patients With Stroke or Transient Ischemic Attack: A Population-based Study.

BACKGROUND: It remains unclear whether rehabilitation has an impact on reducing the long-term risk of mortality or readmission following stroke or transient ischemic attack (TIA). OBJECTIVES: To investigate the association between the dosage and continuation of rehabilitation and the risk of outcome events (OEs) after stroke or TIA. RESEARCH DESIGN: A retrospective cohort study using Taiwan's National Health Insurance database. SUBJECTS: In total, 4594 patients admitted with first-ever acute stroke or TIA were followed-up for 32 months. MEASURES: The occurrence of 3 OEs: (1) vascular readmissions/all-cause mortality [vascular event (VE)], (2) all-cause readmissions/mortality (OE1), and (3) all-cause mortality (OE2), in model 1: none, low-intensity, and high-intensity rehabilitation; and model 2: inpatient plus/or outpatient rehabilitation. RESULTS: Comparing with patients without rehabilitation, in model 1, patients receiving low-intensity rehabilitation had a lower risk of VE [Hazard ratio (HR), 0.77; 95% CI, 0.68-0.87] and OE1 (HR, 0.77; CI, 0.71-0.84), but not OE2 (HR, 0.91; CI, 0.77-1.07). Patients receiving high-intensity rehabilitation had lower risks of all VE (HR, 0.68; CI, 0.58-0.79), OE1 (HR, 0.79; CI, 0.71-0.88), and OE2 (HR, 0.56; CI, 0.44-0.71). In model 2, patients receiving inpatient plus outpatient rehabilitation had a lowest risk of VE (HR, 0.55; CI, 0.47-0.65), OE1 (HR, 0.65; CI, 0.58-0.72), and OE2 (HR, 0.45; CI, 0.35-0.59). Sensitivity analysis with TIA excluded rendered the similar trend. Subgroup analyses found that the positive effect was not demonstrated in hemorrhagic stroke patients. CONCLUSIONS: Rehabilitation use was associated with reduction of readmissions/mortality risks following stroke or TIA. The optimal intensity and duration of rehabilitation and the discrepancy shown in hemorrhagic stroke need further clarification.

Validity of the Wisconsin Card Sorting Test in patients with stroke.

BACKGROUND: The Wisconsin Card Sorting Test (WCST) is the most widely used measure for assessing executive functions in patients with stroke. However, no study has examined the ecological, discriminative and convergent validities of the WCST in patients with stroke. This study aimed to examine the above validities of the WCST in patients with stroke. METHODS: Ninety-eight patients were administered the WCST, two measures of activities of daily living and one cognitive measure. Seven indexes of the WCST were used in this study. RESULTS: Two WCST indexes ("total number correct" and "number of categories completed") had moderate correlations with two measures of activities of daily living (Pearson's r = 0.39-0.49). The other indexes showed low or moderate correlations with two measures of activities of daily living (r = 0.26-0.53). The results of independent t-test showed statistically significant difference between patients with and without disability for the seven WCST indexes (p = 0.001-0.013) and nonsignificant differences between patients with different affected regions of the brain (p > 0.05). Moderate correlations (r = 0.35-0.54) were found among the seven WCST indexes and one cognitive measure. CONCLUSIONS: The WCST has poor to adequate ecological validity, acceptable discriminative validity and acceptable convergent validity in patients with stroke. The two WCST indexes ("total number correct" and "number of categories completed") are recommended for use to reflect the degree of living independence in patients with stroke. Implications for rehabilitation The Wisconsin Card Sorting Test showed poor to adequate ecological validity, acceptable discriminative validity, and acceptable convergent validity in patients with stroke. Two indexes of the Wisconsin Card Sorting Test (i.e., "total number correct" and "number of categories completed") can adequately reveal the degrees of living independence in patients with stroke.

Synergistic effects of aerobic exercise and cognitive training on cognition, physiological markers, daily function, and quality of life in stroke survivors with cognitive decline: study protocol for a randomized controlled trial.

BACKGROUND: Aerobic exercise and cognitive training have been effective in improving cognitive functions; however, whether the combination of these two can further enhance cognition and clinical outcomes in stroke survivors with cognitive decline remains unknown. This study aimed to determine the treatment effects of a sequential combination of aerobic exercise and cognitive training on cognitive function and clinical outcomes. METHODS/DESIGN: Stroke survivors (n = 75) with cognitive decline will be recruited and randomly assigned to cognitive training, aerobic exercise, and sequential combination of aerobic exercise and cognitive training groups. All participants will receive training for 60 minutes per day, 3 days per week for 12 weeks. The aerobic exercise group will receive stationary bicycle training, the cognitive training group will receive cognitive-based training, and the sequential group will first receive 30 minutes of aerobic exercise, followed by 30 minutes of cognitive training. The outcome measures involve cognitive functions, physiological biomarkers, daily function and quality of life, physical functions, and social participation. Participants will be assessed before and immediately after the interventions, and 6 months after the interventions. Repeated measures of analysis of variance will be used to evaluate the changes in outcome measures at the three assessments. DISCUSSION: This trial aims to explore the benefits of innovative intervention approaches to improve the cognitive function, physiological markers, daily function, and quality of life in stroke survivors with cognitive decline. The findings will provide evidence to advance post-stroke cognitive rehabilitation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02550990 . Registered on 6 September 2015.

Cognitive effects of weight-shifting controlled exergames in patients with chronic stroke: a pilot randomized comparison trial.

BACKGROUND: The exergaming training involves motor as well as cognitive stimulation. Although exergame studies have been reported to have benefits in motor function, the effects of exergames on improving cognitive function remain inconclusive. Moreover, no study has been reported in stroke patients. AIM: The objective of this study was to compare the cognitive effects of 2 weight-shifting controlled exergaming systems and conventional weight- shifting training in patients with chronic stroke. DESIGN: This was a single-blind randomized controlled trial. SETTING: All participants were recruited from a rehabilitation department of a tertiary hospital. POPULATION: Patients (N.=37) with chronic hemiplegic stroke. METHODS: Patients were randomly allocated to one of the Wii Fit, Tetrax biofeedback, or conventional weight-shifting training groups. All interventions were administered 30 minutes per session, twice a week for 12 weeks. We used total score and the 9 domain scores of Cognitive Abilities Screening Instrument Chinese version (CASI C-2.0), and Berg Balance Scale (BBS) as the outcome measures. The outcome measures were assessed before and after training, and at 3 months follow-up. RESULTS: There were no significant differences among the 3 groups in the percentage of change in CASI total score and BBS, either post intervention or at the 3-month follow-up. At assessing the percentage of change in each domain of CASI, we found significant differences among the 3 groups in the abstraction/judgment domain after intervention (Wii Fit 16.25 [9.77, 37.50]% vs. Tetrax 0.00 [-10.00, 0.00]% vs. weight-shift 11.00 [0.00, 14.38]%, P=0.01], and at the 3-month follow-up (Wii Fit 20.00 [10.83, 31.25]% vs. Tetrax -10.00 [-11.11, 10.00]% vs. weight-shifting 0.00 [-2.27, 11.46]%, P=0.01). The differences came from the differences between Wii Fit and Tetrax mainly. There were significant differences among the 3 groups in language domain after intervention (Wii Fit 0.00 [0.00, 5.54]% vs. Tetrax 0.00 [-3.00, 0.00]% vs. weight-shift 0.00 [0.00, 0.00]%, P=0.045), but not at the 3-month follow-up (P=0.13). There was no correlation between the percentage of change in BBS and CASI total score postintervention ( r=-0.15 P=0.38). CONCLUSIONS: Wii Fit games training might be beneficial in some cognitive functions, such as abstraction/judgment, language in patients with chronic stroke. Wii Fit games, the commercial entertainment exergames, had superior effect in abstract/judgment and language domains as compared to the rehabilitation exergame (Tetrax balance system). Hence, Wii Fit games might be considered as a tool in post-stroke cognitive rehabilitation programs.

Malnutrition in Acute Stroke Patients Stratified by Stroke Severity- A Hospital Based Study.

BACKGROUND: Stroke results in high mortality with tremendous health care burden. Malnutrition is frequently observed in patients after stroke. This study was designed to explore the nutritional status in the acute stage of stroke aiming at exploring factors related to malnutrition after stroke. METHODS: This was a hospital based, prospective, observational study recruiting cerebrovascular diseases patients hospitalized for acute management. Patients suffered from all kinds of cerebrovascular diseases hospitalized for management within 30 days after onset were consecutively recruited in the study hospitals. Stroke severity was evaluated by National Institutes of Health Stroke Scale, functional status by Barthel index, and global outcome by modified Rankin Scale. Cognitive function was evaluated by Mini-Mental State Examination. Nutritional status was assessed by Mini Nutritional Assessment (MNA), stratified by 1) adequate nutritional status, MNA ≥ 24; 2) protein-calorie malnutrition, MNA less than 17; 3) at risk of malnutrition, MNA between 17 and 23.5. RESULTS: There were 231 cerebral infarction patients recruited at 13.5 days (25-75%: 5.0-17.0) after stroke onset with mild stroke severity 71.4% and severe 10.4% with nasogastric tube insertion in 14%. Malnutrition was identified in 12.1% with 54.1% at risk of malnutrition. Factor related to malnutrition was severe stroke severity with dependency. Patients with old age, hypertension, and diabetes mellitus tended to have malnutrition or risk of malnutrition. CONCLUSION: Nutritional status was poor in stroke patients across all stroke severities within weeks. Further longitudinal outcome studies to identify the poor outcome and the evolution of nutritional status are warranted.

Test-Retest Reliability and Minimal Detectable Change of the Test of Visual Perceptual Skills-Third Edition in Patients With Stroke.

OBJECTIVES: To examine the test-retest reliability, calculate minimal detectable change (MDC), and report internal consistency of the Test of Visual Perceptual Skills-Third Edition (TVPS-3) in patients with stroke. DESIGN: Repeated-measures design (at an interval of 2wk). SETTING: Medical center. PARTICIPANTS: Patients (N=50) with chronic stroke who completed the TVPS-3. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: TVPS-3 that contains 7 subscales, namely, visual discrimination, visual memory, spatial relations, form constancy, sequential memory, visual figure-ground, and visual closure. RESULTS: The intraclass correlation coefficient value of the overall scale was .92 and those of the 7 subscales were .53 to .82. The MDC values of the overall scale and the subscales were 18.1 and 5.4 to 7.1, respectively. The MDC% value of the overall scale was 16.2% (<30%), showing acceptable random measurement error. However, the MDC% values of the subscales were 33.7% to 44.1% (>30%), indicating substantial random measurement errors. The Cronbach α of the 7 subscales were .71 to .89, indicating good internal consistency. CONCLUSIONS: Our results showed that the overall scale of the TVPS-3 had satisfactory test-retest reliability. However, the subscales demonstrated insufficient test-retest reliability. Therefore, the subscales should be used cautiously to explain the test results over repeated assessments in patients with stroke.