ZOom Delivered Intervention Against Cognitive decline (ZODIAC) COVID-19 pandemic adaptations to the Post-Ischaemic Stroke Cardiovascular Exercise Study (PISCES): protocol for a randomised controlled trial of remotely delivered fitness training for brain health.

BACKGROUND: Stroke increases subsequent dementia risk yet there are no specific post-stroke therapies to protect cognition. Cardiorespiratory exercise is recommended for secondary prevention of stroke and may be neuroprotective. The Post Ischaemic Stroke Cardiovascular Exercise Study (PISCES) aims to reduce post-stroke secondary neurodegeneration and cognitive decline. During the pandemic, we pivoted to a ZOom Delivered Intervention Against Cognitive decline (ZODIAC) protocol, reducing pandemic-amplified barriers to exercise. METHODS: We present pandemic adaptions for a multicentre phase IIb assessor-blinded randomised controlled trial of ischaemic stroke survivors testing the efficacy and feasibility of an 8-week home-based exercise intervention delivered at 2 months post-stroke. We compare cardiorespiratory exercise (intervention arm) versus balance and stretching (active control arm). Participants are assessed with magnetic resonance imaging (MRI), fitness, blood, microbiome, and neuropsychological tests at three study visits: before and after the exercise intervention and at 12 months. Modifications to the original protocol include pre-exercise safety home visits, commercial delivery of exercise equipment to facilitate assessor blinding, and reconsideration of statistical plan to allow pooling of the studies. We have reduced in-person study visits from 27 to 3. Primary outcome remains between-group (intervention versus control) difference in brain volume change; secondary outcome is between-group difference in global cognitive ability to allow remote administration of a validated cognitive scale. DISCUSSION: Remotely delivered exercise interventions reduce participant burden and may reduce barriers to recruitment. A decrease in the number of in-person study visits can be supported by greater information capture via self-reported questionnaires and phone surveys. TRIAL REGISTRATION: Prospectively ACTRN12616000942459. Registered on July 2016.

Improving physical movement during stroke rehabilitation: investigating associations between sleep measured by wearable actigraphy technology, fatigue, and key biomarkers.

BACKGROUND: Sleep disturbance and fatigue are common in individuals undergoing inpatient rehabilitation following stroke. Understanding the relationships between sleep, fatigue, motor performance, and key biomarkers of inflammation and neuroplasticity could provide valuable insight into stroke recovery, possibly leading to personalized rehabilitation strategies. This study aimed to investigate the influence of sleep quality on motor function following stroke utilizing wearable technology to obtain objective sleep measurements. Additionally, we aimed to determine if there were relationships between sleep, fatigue, and motor function. Lastly, the study aimed to determine if salivary biomarkers of stress, inflammation, and neuroplasticity were associated with motor function or fatigue post-stroke. METHODS: Eighteen individuals who experienced a stroke and were undergoing inpatient rehabilitation participated in a cross-sectional observational study. Following consent, participants completed questionnaires to assess sleep patterns, fatigue, and quality of life. Objective sleep was measured throughout one night using the wearable Philips Actiwatch. Upper limb motor performance was assessed on the following day and saliva was collected for biomarker analysis. Correlation analyses were performed to assess the relationships between variables. RESULTS: Participants reported poor sleep quality, frequent awakenings, and difficulties falling asleep following stroke. We identified a significant negative relationship between fatigue severity and both sleep quality (r=-0.539, p = 0.021) and participants experience of awakening from sleep (r=-0.656, p = 0.003). A significant positive relationship was found between grip strength on the non-hemiplegic limb and salivary gene expression of Brain-derived Neurotrophic Factor (r = 0.606, p = 0.028), as well as a significant negative relationship between grip strength on the hemiplegic side and salivary gene expression of C-reactive Protein (r=-0.556, p = 0.048). CONCLUSION: The findings of this study emphasize the importance of considering sleep quality, fatigue, and biomarkers in stroke rehabilitation to optimize recovery and that interventions may need to be tailored to the individual. Future longitudinal studies are required to explore these relationships over time. Integrating wearable technology for sleep and biomarker analysis can enhance monitoring and prediction of outcomes following stroke, ultimately improving rehabilitation strategies and patient outcomes.

Understanding the workflow of nurses in acute and subacute medical wards: A time and motion study.

AIMS AND OBJECTIVES: The aim of this study was to determine how much time nurses spend on direct and indirect patient care in acute and subacute hospital settings. BACKGROUND: Quantifying direct and indirect nursing care provided during inpatient stay is vital to optimise the quality of care and manage resources. DESIGN: Time and motion cross-sectional observational study and reported the study according to the STROBE guideline. METHODS: Nurses working in an acute or subacute medical wards of a single health service participated. Nurses were observed twice for 2 h on the same day with an observer break in between sessions. Real-time task-related data were digitally recorded using the Work Observation Method By Activity Timing (WOMBAT) tool by a single research assistant. Frequency and time spent on pre-determined tasks were recorded and included direct care, indirect care, documentation, medication-related tasks, communication (professional) and other tasks. Task interruptions and multitasking were also recorded. RESULTS: Twenty-one nurses (acute n = 12, subacute n = 9) were observed during shifts between 7 AM and 9 PM in May-July 2021. A total of 7240 tasks were recorded. Nurses spent a third of their time on direct patient care (27% direct care and 3% medication administration). A total of 556 task interruptions occurred, mostly during documentation, and medication-related tasks. A further 1385 tasks were performed in parallel with other tasks, that is multitasking. CONCLUSIONS: Time spent on tasks was similar regardless of the setting and was consistent with previous research. We found differences in the distribution of tasks throughout the day between settings, which could have implications for workforce planning and needs to be investigated further. Interruptions occurred during documentation, direct care and medication-related tasks. Local-level strategies should be in place and regularly revised to reduce interruptions and prevent errors. Relevance to clinical practice The association between interruption and increased risk of error is well-established and should be an ongoing area of attention including observations and education provided in local settings.

Measuring Sleep Quality in the Hospital Environment with Wearable and Non-Wearable Devices in Adults with Stroke Undergoing Inpatient Rehabilitation.

Sleep disturbances are common after stroke and may affect recovery and rehabilitation outcomes. Sleep monitoring in the hospital environment is not routine practice yet may offer insight into how the hospital environment influences post-stroke sleep quality while also enabling us to investigate the relationships between sleep quality and neuroplasticity, physical activity, fatigue levels, and recovery of functional independence while undergoing rehabilitation. Commonly used sleep monitoring devices can be expensive, which limits their use in clinical settings. Therefore, there is a need for low-cost methods to monitor sleep quality in hospital settings. This study compared a commonly used actigraphy sleep monitoring device with a low-cost commercial device. Eighteen adults with stroke wore the Philips Actiwatch to monitor sleep latency, sleep time, number of awakenings, time spent awake, and sleep efficiency. A sub-sample (n = 6) slept with the Withings Sleep Analyzer in situ, recording the same sleep parameters. Intraclass correlation coefficients and Bland-Altman plots indicated poor agreement between the devices. Usability issues and inconsistencies were reported between the objectively measured sleep parameters recorded by the Withings device compared with the Philips Actiwatch. While these findings suggest that low-cost devices are not suitable for use in a hospital environment, further investigations in larger cohorts of adults with stroke are needed to examine the utility and accuracy of off-the-shelf low-cost devices to monitor sleep quality in the hospital environment.

Poststroke White Matter Hyperintensities and Physical Activity: A CANVAS Study Exploratory Analysis.

PURPOSE: White matter hyperintensities (WMHs) are associated with poststroke cognitive decline and mortality. Physical activity (PA) may decrease WMH risk by reducing vascular risk factors and promoting cerebral perfusion. However, the association between poststroke PA and WMH progression remains unclear. We examined the association between PA and WMH volume 12 months after stroke, and between PA and change in WMH volume between 3 and 12 months after stroke. METHODS: We included ischemic stroke survivors from the Cognition And Neocortical Volume After Stroke cohort with available brain magnetic resonance imaging and objective PA data. Total, periventricular, and deep WMH volumes (in milliliters) were estimated with manually edited, automated segmentations (Wisconsin White Matter Hyperintensities Segmentation toolbox). Moderate-to-vigorous intensity PA (MVPA) was estimated using the SenseWear® Armband. Participants with MVPA ≥30 min·d -1 were classified as "meeting PA guidelines." We used quantile regression to estimate the associations between PA (MVPA and meeting PA guidelines) with WMH volume at 12 months and change in WMH volume between 3 and 12 months after stroke. RESULTS: A total of 100 participants were included (median National Institutes of Health Stroke Scale 2; interquartile range, 1-4). MVPA was not associated with WMH volume. In univariable analysis, meeting PA guidelines was associated with lower total, periventricular, and deep WMH volumes by 3.0 mL (95% confidence interval (CI), 0.5-9.7 mL), 2.8 mL (95% CI, 0.5-7.1 mL), and 0.9 mL (95% CI, 0.1-3.0 mL), respectively. However, in multivariable analysis, meeting PA guidelines was not associated with WMH volume, and older age was associated with greater WMH volume at 12 months. PA was not associated with change in WMH volume. CONCLUSIONS: Meeting PA guidelines was associated with lower WMH volume at 12 months in univariable analysis, but not in multivariable analysis. Age consistently predicted greater WMH volume.

Pre-stroke Physical Activity and Cerebral Collateral Circulation in Ischemic Stroke: A Potential Therapeutic Relationship?

Favorable cerebral collateral circulation contributes to hindering penumbral tissue from progressing to infarction and is associated with positive clinical outcomes after stroke. Given its clinical importance, improving cerebral collateral circulation is considered a therapeutic target to reduce burden after stroke. We provide a hypothesis-generating discussion on the potential association between pre-stroke physical activity and cerebral collateral circulation in ischemic stroke. The recruitment of cerebral collaterals in acute ischemic stroke may depend on anatomical variations, capacity of collateral vessels to vasodilate, and individual risk factors. Physical activity is associated with improved cerebral endothelial and vascular function related to vasodilation and angiogenic adaptations, and risk reduction in individual risk factors. More research is needed to understand association between cerebral collateral circulation and physical activity. A presentation of different methodological considerations for measuring cerebral collateral circulation and pre-stroke physical activity in the context of acute ischemic stroke is included. Opportunities for future research into cerebral collateral circulation, physical activity, and stroke recovery is presented.

Maintenance of Cardiorespiratory Fitness in People With Stroke: A Systematic Review and Meta-analysis.

OBJECTIVE: To determine if improvements in cardiorespiratory fitness are maintained in the short-, medium- and long-term after a cardiorespiratory fitness intervention in people with stroke. DATA SOURCES: MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, (CENTRAL) Cochrane, Web of Science, Sports Discus, and Physiotherapy Evidence Database were searched from inception. STUDY SELECTION: Randomized controlled trials and cohort studies including (1) people with stroke; (2) cardiorespiratory fitness interventions; (3) a direct measure of cardiorespiratory fitness; and (4) short- (0 to <3 months), medium- (3-6 months), or long-term (>6 months) follow-up data. DATA EXTRACTION: Two reviewers independently screened full texts and extracted data, including study methods, participant demographic information, stroke type and severity, outcome measures, intervention information, follow-up time points, and results, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A lower limit of -1.0 mL•kg-1•min-1 was used to determine maintenance (ie, no change) of cardiorespiratory fitness. DATA SYNTHESIS: Fourteen studies (N=324 participants) were included. Participants completed cardiorespiratory fitness training 2-5 days per week over 4-13 weeks at moderate to high intensity (40%-70% heart rate reserve [HRR]; n=4 studies), high intensity (60% to <90% HRR; n=7 studies), and intervals of high intensity (85%-95% peak heart rate or maximal heart rate; n=3 studies). Most people with stroke did maintain cardiorespiratory fitness in the short- (-0.19 mL•kg-1•min-1 [95% CI, -1.66 to 1.28]), medium- (-0.61 mL•kg-1•min-1 [95% CI, -3.95 to 2.74]), and long-term (0.00 mL•kg-1•min-1 [95% CI, -2.23 to 2.23]) after completion of cardiorespiratory fitness interventions. CONCLUSIONS: People with stroke maintain cardiorespiratory fitness after a cardiorespiratory fitness intervention in the short-, medium-, and longer-term. However, little is known about the impact of participant and intervention characteristics on the long-term maintenance of cardiorespiratory fitness.

An evaluation of interventions to improve outcomes for hospitalized patients in isolation: A systematic review.

BACKGROUND: Isolation is effective in preventing transmission of infectious disease. However, it has been shown to have negative effects including increased anxiety and poor physical outcomes. OBJECTIVES: To summarize the effects of interventions to improve safety and outcomes for patients in isolation DESIGN: Systematic review (PROSPERO protocol registration - CRD42020222779). SETTING: Acute hospital PARTICIPANTS: Intervention studies including patients in preventative or protective isolation in a single room. METHODS: MEDLINE, Global Health, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Excerpta Medica database were searched from 1996-October 2020. Two independent reviewers screened references and assessed risk of bias. One reviewer extracted data and was checked by another. Main outcomes were Quality of Life and mortality. RESULTS: We identified 16,698 references and included 6 studies with different study designs. Average age ranged from 4-71 years. Samples sizes were small (range 10-49 participants) apart from one non-randomized controlled trial including >600 participants. Interventions were music therapy (n = 3), psychological counseling (n = 2) and exercise training (n = 1). One study reporting on Quality of Life and found no change after exercise. None of the studies reported on mortality. Due to heterogeneous results no meta-analyses were performed. CONCLUSIONS: There is a lack of high-quality evidence for effective comprehensive interventions to manage adverse effects associated with isolation. Future studies should investigate the effect of multi-component interventions using rigorous methods to improve outcomes for hospitalized isolated patients.

"Can you hear me now?" Video conference coping strategies and experience during COVID-19 and beyond.

BACKGROUND: During COVID-19 the workforce quickly adapted to using existing video-conferencing tools in order to work from home. OBJECTIVE: To explore use and experience of remote video-facilitated work practices in response to COVID-19: termed 'COVID Response Zoom-style Interactions (CRAZI)'. METHODS: A cross sectional study via a 66-item online survey for health and medical research and education sector workers. The survey included 8 sections: 1) pre-COVID video-conferencing meeting habits, 2) CRAZI meeting habits, 3) socialising, 4) CRAZI fashion, 5) behaviour standards, 6) family life, 7) future work, 8) participant demographics. Main outcomes were pre-COVID to CRAZI differences in frequency, length and type of video-based meetings, and video-conferencing experience. RESULTS: 202 participants, mostly Australian (median age 36-45, IQR 26-55 years) completed the survey. Women-to-men ratio was 3 : 1, 44.6%had children. COVID-19 changed video-conferencing frequency and maximum meeting size. Most participants found CRAZI meetings tiring and hard. Casual clothes dominated dress code (71.1%), pets were commonly seen. "Can you hear me now" was a commonly heard phrase. Good and bad behaviour were described, with formal codes of CRAZI conduct missing (58.7%) or unknown (21.9%). 76.6%of participants observed a child interrupting a CRAZI meeting, parents were mostly female. Despite challenges, most participants (76.6%) favoured video-conferencing post-pandemic, but preference for continuing to work from home varied. CONCLUSIONS: CRAZI work, while tiring, has fostered different work-practices that may continue beyond the pandemic. Working from home with children adds joy for others, but complexity for workers. Pets may help owners and co-workers cope with the pandemic.

Timing and Dose of Upper Limb Motor Intervention After Stroke: A Systematic Review.

This systematic review aimed to investigate timing, dose, and efficacy of upper limb intervention during the first 6 months poststroke. Three online databases were searched up to July 2020. Titles/abstracts/full-text were reviewed independently by 2 authors. Randomized and nonrandomized studies that enrolled people within the first 6 months poststroke, aimed to improve upper limb recovery, and completed preintervention and postintervention assessments were included. Risk of bias was assessed using Cochrane reporting tools. Studies were examined by timing (recovery epoch), dose, and intervention type. Two hundred and sixty-one studies were included, representing 228 (n=9704 participants) unique data sets. The number of studies completed increased from one (n=37 participants) between 1980 and 1984 to 91 (n=4417 participants) between 2015 and 2019. Timing of intervention start has not changed (median 38 days, interquartile range [IQR], 22-66) and study sample size remains small (median n=30, IQR 20-48). Most studies were rated high risk of bias (62%). Study participants were enrolled at different recovery epochs: 1 hyperacute (<24 hours), 13 acute (1-7 days), 176 early subacute (8-90 days), 34 late subacute (91-180 days), and 4 were unable to be classified to an epoch. For both the intervention and control groups, the median dose was 45 (IQR, 600-1430) min/session, 1 (IQR, 1-1) session/d, 5 (IQR, 5-5) d/wk for 4 (IQR, 3-5) weeks. The most common interventions tested were electromechanical (n=55 studies), electrical stimulation (n=38 studies), and constraint-induced movement (n=28 studies) therapies. Despite a large and growing body of research, intervention dose and sample size of included studies were often too small to detect clinically important effects. Furthermore, interventions remain focused on subacute stroke recovery with little change in recent decades. A united research agenda that establishes a clear biological understanding of timing, dose, and intervention type is needed to progress stroke recovery research. Prospective Register of Systematic Reviews ID: CRD42018019367/CRD42018111629.

Effects of Aerobic Exercise on Serum Biomarkers of Neuroplasticity and Brain Repair in Stroke: A Systematic Review.

OBJECTIVE: To provide a novel overview of the literature and to summarize the evidence for the effects of aerobic exercise (AE) on serum biomarkers neuroplasticity and brain repair in survivors of stroke. DATA SOURCES: We conducted a systematic review and searched MEDLINE, Embase, and Cochrane CENTRAL using terms related to AE, neuroplasticity, brain repair, and stroke. STUDY SELECTION: Titles, abstracts, and selected full texts were screened by 2 independent reviewers against the following inclusion criteria: including adult survivors of stroke, completing an AE intervention working within the AE capacity, and measuring at least 1 blood biomarker outcome of interest. DATA EXTRACTION: Two independent reviewers extracted data and assessed risk of bias using Risk of Bias in Nonrandomized Studies-of Interventions and Cochrane's Risk of Bias 2 tools. DATA SYNTHESIS: Nine studies (n=215 participants) were included, reporting on the following outcomes: brain-derived neurotrophic factor (BDNF), insulin-like growth factor 1 (IGF-1), vascular endothelial growth factor (VEGF), cortisol, interleukin 6, and myeloperoxidase. A single bout of high-intensity interval training significantly increased BDNF, IGF-1, and VEGF levels, and a 40-45-minute, 24-session, continuous 8-week AE training program significantly increased BDNF levels. No significant difference in response to any other AE intervention was found in other serum biomarkers. CONCLUSIONS: AE can significantly increase BDNF, IGF-1, and VEGF across different AE protocols in survivors of stroke. However, more research is needed to determine the optimal exercise intensity and modalities, specifically in survivors of acute and subacute stroke, and how this may relate to functional outcomes.

Pre-stroke physical activity and admission stroke severity: A systematic review.

BACKGROUND: Admission stroke severity is an important clinical predictor of stroke outcomes. Pre-stroke physical activity contributes to stroke prevention and may also be associated with reduced stroke severity. Summarizing the evidence to date will inform strategies to reduce burden after stroke. AIMS: To summarize the published evidence for the relationship between pre-stroke physical activity and admission stroke severity and to provide recommendations for future research. SUMMARY OF REVIEW: MEDLINE, Embase, Emcare, CENTRAL, and gray literature databases were searched on 14 February 2020 using search terms related to stroke and pre-stroke physical activity in adult stroke survivors. We screened 8,152 references and assessed 172 full-text references for eligibility. We included seven studies (n = 41,800 stroke survivors). All studies were observational, assessed pre-stroke physical activity using self-reported questionnaires, and assessed admission stroke severity using the National Institute of Health Stroke Scale. Analyses were categorized as the presence of pre-stroke physical activity (four studies) or dose-response (five studies). In three studies, presence of pre-stroke physical activity was associated with milder stroke severity, and no association in one study. Greater pre-stroke physical activity duration and intensity (two studies) or amount (three studies) were associated with milder stroke severity. Studies ranged between moderate to critical risk of bias, primarily due to confounding factors. Pre-stroke physical activity may be associated with reduced risk factors for severe stroke, distal occlusion, smaller infarcts, and shorter time-to-treatment delivery. CONCLUSION: Pre-stroke physical activity may be associated with reduced admission stroke severity. Lack of randomized controlled trials limited causality conclusions. Future research recommendations were provided.

Feedback of patient-reported outcomes to healthcare professionals for comparing health service performance: a scoping review.

OBJECTIVE: Patient-reported outcomes (PROs) provide self-reported patient assessments of their quality of life, daily functioning, and symptom severity after experiencing an illness and having contact with the health system. Feeding back summarised PROs data, aggregated at the health-service level, to healthcare professionals may inform clinical practice and quality improvement efforts. However, little is known about the best methods for providing these summarised data in a way that is meaningful for this audience. Therefore, the aim of this scoping review was to summarise the emerging approaches to PROs data for 'service-level' feedback to healthcare professionals. SETTING: Healthcare professionals receiving PROs data feedback at the health-service level. DATA SOURCES: Databases selected for the search were Embase, Ovid Medline, Scopus, Web of Science and targeted web searching. The main search terms included: 'patient-reported outcome measures', 'patient-reported outcomes', 'patient-centred care', 'value-based care', 'quality improvement' and 'feedback'. Studies included were those that were published in English between January 2009 and June 2019. PRIMARY AND SECONDARY OUTCOME MEASURES: Data were extracted on the feedback methods of PROs to patients or healthcare providers. A standardised template was used to extract information from included documents and academic publications. Risk of bias was assessed using Joanna Briggs Institute Levels of Evidence for Effectiveness. RESULTS: Overall, 3480 articles were identified after de-duplication. Of these, 19 academic publications and 22 documents from the grey literature were included in the final review. Guiding principles for data display methods and graphical formats were identified. Seven major factors that may influence PRO data interpretation and use by healthcare professionals were also identified. CONCLUSION: While a single best format or approach to feedback PROs data to healthcare professionals was not identified, numerous guiding principles emerged to inform the field.

Determining Maximal Tolerable Aerobic Training Intensity in the Acute Phase after Stroke: a Novel Dose Ranging Trial Protocol.

INTRODUCTION: There is strong evidence that cardiorespiratory fitness (CRF) training improves fitness and mobility after stroke. Despite the large number of studies, the most efficacious dose is yet to be determined. Furthermore, the safety of early post-stroke training, while theoretically beneficial, remains uncertain. The aim of this study is to determine the maximum safe and tolerable intensity of CRF training early post-stroke. METHODS: This is a stratified (low to moderate exercise capacity), Phase I, 5+5 dose ranging trial protocol. Participants will be recruited within one month post-stroke and stratified by their exercise-capacity (i.e. low and moderate capacity). Cohorts of five participants will perform 12 interval-based training sessions for four-weeks at a pre-determined target-intensity. The intensity will increase in each consecutive cohort, in each stratum according to pre-defined rules until the maximum safe and tolerable intensity is reached, as determined by the occurrence of dose-limiting events and occurrence of adverse events. Dose-limiting events are defined as symptoms indicative of over-training including pain and inability to perform usual activities. STUDY OUTCOME: Maximum safe and tolerable intensity of CRF training in stroke survivors with low and moderate exercise capacity. DISCUSSION: This study is a first step in the systematic development of a CRF training intervention. We believe similar dose ranging designs may be useful for development of other rehabilitation interventions in different study populations.

Cerebral haemodynamics with head position changes post-ischaemic stroke: A systematic review and meta-analysis.

The effects of upright postures on the cerebral circulation early post-ischaemic stroke are not fully understood. We conducted a systematic review and meta-analysis to investigate the effects of head positioning on cerebral haemodynamics assessed by imaging methods post-ischaemic stroke. Of the 21 studies included (n = 529), 15 used transcranial Doppler. Others used near-infrared, diffuse correlation spectroscopy and nuclear medicine modalities. Most tested head positions between 0° and 45°. Seventeen studies reported changes in CBF parameters (increase at lying-flat or decrease at more upright) in the ischaemic hemisphere with position change. However, great variability was found and risk of bias was high in many studies. Pooled data of two studies ≤24 h (n = 28) showed a mean increase in cerebral blood flow (CBF) velocity of 8.5 cm/s in the ischaemic middle cerebral artery (95%CI,-2.2-19.3) from 30° to 0°. The increase found ≤48 h (n = 50) was of 2.3 cm/s (95%CI,-4.6-9.2), while ≤7 days (n = 38) was of 8.4 cm/s (95%CI, 1.8-15). Few very early studies (≤2 days) tested head positions greater than 30° and were unable to provide information about the response of acute stroke patients to upright postures (sitting, standing). These postures are part of current clinical practice and knowledge on their effects on cerebral haemodynamics is required.

Physical fitness training for stroke patients.

BACKGROUND: Levels of physical activity and physical fitness are low after stroke. Interventions to increase physical fitness could reduce mortality and reduce disability through increased function. OBJECTIVES: The primary objectives of this updated review were to determine whether fitness training after stroke reduces death, death or dependence, and disability. The secondary objectives were to determine the effects of training on adverse events, risk factors, physical fitness, mobility, physical function, health status and quality of life, mood, and cognitive function. SEARCH METHODS: In July 2018 we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, and four additional databases. We also searched ongoing trials registers and conference proceedings, screened reference lists, and contacted experts in the field. SELECTION CRITERIA: Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses and assessed the quality of the evidence using the GRADE approach. Diverse outcome measures limited the intended analyses. MAIN RESULTS: We included 75 studies, involving 3017 mostly ambulatory participants, which comprised cardiorespiratory (32 studies, 1631 participants), resistance (20 studies, 779 participants), and mixed training interventions (23 studies, 1207 participants). Death was not influenced by any intervention; risk differences were all 0.00 (low-certainty evidence). There were few deaths overall (19/3017 at end of intervention and 19/1469 at end of follow-up). None of the studies assessed death or dependence as a composite outcome. Disability scores were improved at end of intervention by cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% CI 0.19 to 0.84; 8 studies, 462 participants; P = 0.002; moderate-certainty evidence) and mixed training (SMD 0.23, 95% CI 0.03 to 0.42; 9 studies, 604 participants; P = 0.02; low-certainty evidence). There were too few data to assess the effects of resistance training on disability. Secondary outcomes showed multiple benefits for physical fitness (VO2 peak and strength), mobility (walking speed) and physical function (balance). These physical effects tended to be intervention-specific with the evidence mostly low or moderate certainty. Risk factor data were limited or showed no effects apart from cardiorespiratory fitness (VO2 peak), which increased after cardiorespiratory training (mean difference (MD) 3.40 mL/kg/min, 95% CI 2.98 to 3.83; 9 studies, 438 participants; moderate-certainty evidence). There was no evidence of any serious adverse events. Lack of data prevents conclusions about effects of training on mood, quality of life, and cognition. Lack of data also meant benefits at follow-up (i.e. after training had stopped) were unclear but some mobility benefits did persist. Risk of bias varied across studies but imbalanced amounts of exposure in control and intervention groups was a common issue affecting many comparisons. AUTHORS' CONCLUSIONS: Few deaths overall suggest exercise is a safe intervention but means we cannot determine whether exercise reduces mortality or the chance of death or dependency. Cardiorespiratory training and, to a lesser extent mixed training, reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve fitness, balance and the speed and capacity of walking. The magnitude of VO2 peak increase after cardiorespiratory training has been suggested to reduce risk of stroke hospitalisation by ˜7%. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription, the range of benefits and any long-term benefits.

Safety of Performing a Graded Exercise Test Early after Stroke and Transient Ischemic Attack.

BACKGROUND: Low cardiorespiratory fitness (CRF) is a predictor of stroke risk and poor outcome poststroke. Fitness levels are rarely assessed in the acute phase and it is unclear if it is safe for stroke survivors and people with transient ischemic attack (TIA) to perform a graded exercise test to assess fitness. OBJECTIVE: To determine if people within 14 days post stroke can safely perform a graded exercise test. DESIGN: Observational study. SETTING: Research institute. PARTICIPANTS: People with stroke or TIA admitted to an acute stroke unit. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Safety of performing a graded exercise test early post stroke. Safety outcomes were (1) occurrence of an adverse event or (2) <85% blood oxygen saturation (SpO2 ). Participants performed a graded exercise test on a recumbent stepper at a research institute <2 weeks postevent. CRF was determined by measuring peak volume of oxygen uptake (VO2peak ) using a metabolic cart. RESULTS: Twenty-nine participants were enrolled in the study (median age 69 years; interquartile range 58-75). Sixteen were diagnosed with TIA and 13 with a mild stroke. Twenty-eight participants completed the test; one participant was unable to perform the test due to back pain. The test was terminated due to standardized stopping criteria in 26 cases (5 = volitional fatigue, 6 = unable to keep required cadence, 15 = reaching 85% HRmax ), one due to safety (ie, SpO2 < 85%), and one was inadvertently terminated before stopping criteria were reached. Average CRF determined by the exercise test was low; mean VO2peak of 16.2 ± 4.5 mL/kg/min for men (n = 20) and 12.4 ± 3.6 mL/kg/min for women (n = 8). CONCLUSIONS: Determining exercise capacity early post stroke and TIA using a graded exercise test appears to be safe in patients with mild deficits. This information should be useful to plan tailored exercise programs. Further research should focus on determining safety of exercise testing in more severely affected stroke survivors.

A systematic review protocol of timing, efficacy and cost effectiveness of upper limb therapy for motor recovery post-stroke.

BACKGROUND: Improving upper limb (UL) motor recovery after stroke represents a major clinical and scientific goal. We aim to complete three systematic reviews to estimate the (1) association between time to start of UL therapy and motor recovery, (2) relative efficacy of different UL therapy approaches post-stroke and (3) cost-effectiveness of UL therapy interventions. METHODS: We have designed a systematic review protocol to address three systematic review questions that were each registered with PROSPERO. The search will be conducted in MEDLINE, EMBASE, and Cochrane Controlled Register of Trials. We will include randomised controlled trials, non-randomised clinical trials, before-after studies and observational studies of adult stroke survivors with an average stroke onset < 6 months, undergoing hospital-based therapy to improve UL function. Eligible interventions will aim to promote UL functional recovery. Two reviewers will independently screen, select and extract data. Study risk of bias will be appraised using appropriate tools. Clinical measures of motor recovery will be investigated (primary measure Fugl Meyer UL assessment), as well as measures of health-related quality of life (primary measure EQ-5D) and all cost-effectiveness analyses completed. Secondary outcomes include therapy dose (minutes, weeks, repetitions as available) and safety (i.e. adverse events, serious adverse events). A narrative synthesis will describe quality and content of the evidence. If feasible, we will conduct random effects meta-analyses where appropriate. DISCUSSION: We anticipate the findings of this review will increase our understanding of UL therapy and inform the generation of novel, data-driven hypotheses for future UL therapy research post-stroke. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018019367, http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018111629, http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018111628.