A mobile application-based post-stroke care strategy for survivors and their caregivers for prevention and management of post-stroke complications - "Stroke Home Care:" Development and feasibility.

Objectives: In developing nations such as India, a disparity exists between the available resources for stroke rehabilitation and the substantial burden of stroke cases. Consequently, the provision of cost-effective and multidisciplinary post-stroke rehabilitation care to stroke survivors becomes of paramount importance. The utilization of mobile applications (apps) for stroke care has been on the rise, offering a personalized and pragmatic solution with the potential for wider reach in settings constrained by limited resources. To address the unmet needs in the prevention and management of post-stroke complications, we conceptualized a strategy known as a mobile application-based post-stroke care strategy for both survivors and their caregivers. Materials and Methods: The scope of the app's focus was determined based on the incidence of post-stroke complications within a prospective cohort of stroke patients, in conjunction with existing literature. An initial "web-based mobile app" prototype was crafted to align with the identified focus area. Before the development of the final app version, a feasibility study was conducted involving 30 participant dyads (comprising a patient and a caregiver). Content validity was evaluated by a panel of 20 stroke experts encompassing neurologists, nurses, physiotherapists, and psychologists. Results: The "Stroke Home Care" (SHC) mobile app was conceived as a web-based educational tool aimed at preventing and managing post-stroke complications. It seeks to train caregivers of immobile stroke patients in the administration of preventive and therapeutic care procedures, thereby potentially enhancing survivors' quality of life and alleviating caregivers' burden. The feasibility and validity studies indicated "high satisfaction" levels among most caregivers and experts (>75%), with the remainder expressing "satisfaction" and no "dissatisfaction" regarding app utilities. Stroke experts unanimously deemed the app "appropriate", with consensus on contents, video quality, video length, and voice clarity. Caregivers reported "satisfactory" user experiences, encountering no issues during app installation or operation. Suggestions from both caregivers and experts were integrated into the final app version. Conclusion: The "SHC" app represents a feasible and well-received innovation tailored for the use by caregivers of stroke survivors. Consequently, the initial feasibility of the developed app serves as a precursor to a randomized controlled clinical trial aimed at substantiating its effectiveness within the post-stroke survivor and caregiver population. Notably, within resource-constrained contexts, this app has the potential to be a pivotal tool for post-stroke care.

Improving orientation with respect to gravity enhances balance and gait recovery after stroke: DOBRAS cohort.

BACKGROUND: Lateropulsion is a deficit in body orientation with respect to gravity, frequent after stroke. Although it is a primary factor affecting mobility, the impact of its attenuation on balance and gait recovery has never been investigated. Moreover, most studies on the lateropulsion time-course focus on severe forms suspected to have a poor recovery, which is not proven. OBJECTIVES: To investigate lateropulsion attenuation and test 2 hypotheses: 1) lateropulsion attenuation greatly contributes to balance and gait recovery and 2) severe forms of lateropulsion recover slower than moderate forms. METHODS: This longitudinal study involved individuals included in the Determinants of Balance Recovery After Stroke (DOBRAS) cohort, after a first-ever hemispheric stroke, with data collected on day 30 (D30), D60 and D90 post-stroke. Body orientation with respect to gravity was assessed using the Scale for Contraversive Pushing (both scores and severity grouping), in parallel with balance (Postural Assessment Scale for Stroke) and gait (modified Fugl-Meyer Gait Assessment). RESULTS: Among the 106 eligible individuals (mean age 66.5 [SD 9.7] years), on D30, 43 (41%) were considered upright and 63 (59%) showed lateropulsion: 30 (28%) moderate and 33 (31%) severe. Most individuals with lateropulsion (73%) improved their body orientation, progressing from severe to moderate lateropulsion, or becoming upright. However, half were still not upright on D90. The improvement in body orientation had a large impact on mobility, especially in individuals with severe lateropulsion, in whom it explained about 50% of balance and gait recovery between D30 and D60, then 20% (D60-D90). For moderate lateropulsion, its attenuation explained about 20% of balance and gait recovery until D90. Lateropulsion attenuation was not slower in individuals with severe forms. CONCLUSIONS: Lateropulsion attenuation enhances balance and gait recovery in individuals after stroke suggesting that specific rehabilitation of body orientation with respect to gravity might help to recover mobility. REGISTRATION: NCT03203109.

Objectivizing Measures of Post-Stroke Hand Rehabilitation through Multi-Disciplinary Scales.

There is a wide variety of tools and measures for rehabilitation outcomes in post-stroke patients with impairments in the upper limb and hand, such as paralysis, paresis, flaccidity, and spasticity. However, there is a lack of general recommendations for selecting the most appropriate scales, tests, and instruments to objectively evaluate therapy outcomes. Reviews on upper limb and hand measurements reveal that clinicians' choices of tools and methods are highly varied. Some clinicians and medical teams continue to employ non-standard and unverified metrics in their research and measurements. This review article aims to identify the key parameters, assessed by outcome measures and instruments, that play a crucial role in upper limb and hand rehabilitation for post-stroke patients, specifically focusing on the recovery of hand function. The review seeks to assist researchers and medical teams in selecting appropriate outcome measures when evaluating post-stroke patients. We analyze the measured factors and skills found in these outcome measures and highlight useful tools that diversify assessments and enhance result objectivity through graphical representation. The paper also describes trends and new possibilities in hand outcome measures. Clinicians frequently use proven devices, such as EMG, goniometers, and hand dynamometers. Still, there is a growing trend towards incorporating technologies, such as pose and position estimation, using artificial intelligence, or custom hand grip measurement devices. Researchers are increasingly adopting scales previously successful in orthopedic and surgical patients, recognizing their potential for objectivizing outcomes in neurological patients with post-stroke hand complications. The review included only adults over the age of 18. Outcome measures were tested for usefulness in the rehabilitation of stroke patients.

Goal-setting and personalization under the International Classification of Functioning, Disability, and Health framework: Community reintegration program for post-stroke patients.

Background: Body functions and structures, activities, and participation are the core components in the International Classification of Functioning, Disability, and Health (ICF) to identify post-stroke patients' health conditions. The specification of health conditions enhances the outcomes of post-stroke rehabilitation. Purpose: This study aimed to explore the extent and the processes in an ICF-based post-stroke rehabilitation program (ICF-PSRP) that could enhance patients' community reintegration level. Methods: Post-stroke patients who completed the ICF-PSRP participated in intake and pre-discharge individual face-to-face semi-structured interviews. In addition, case therapists were invited to a face-to-face semi-structured group interview. Clinician experts were invited to complete an interview with the same interview contents as case therapists but in an online format. All interview recordings were analyzed with the Framework analysis. Patients' treatment goals were mapped with the ICF Core Set for Stroke. Results: Out of 37 invited post-stroke patients, thirty-three of them completed the interview. Three case therapists and five clinicians completed the interviews. The goals set by the patients and their caregivers showed a broadening of their scope over the course of the program. The changes in scope ranged from the activities to the participation and environmental components. Increases in patient-therapist interactions played an essential role in the goal-setting process, which were integral to personalizing the treatment content. These characteristics were perceived by all parties who contributed to the program outcomes. Conclusion: The application of ICF's principles and core components offers a useful framework for enhancing post-stroke patients' community reintegration level. Future studies should explore the way in which patient-therapist interaction, exposure to environmental factors, and personalized interventions maximize the benefits of applying this framework to the community integration of post-stroke patients.

Ankle-targeted exosuit resistance increases paretic propulsion in people post-stroke.

BACKGROUND: Individualized, targeted, and intense training is the hallmark of successful gait rehabilitation in people post-stroke. Specifically, increasing use of the impaired ankle to increase propulsion during the stance phase of gait has been linked to higher walking speeds and symmetry. Conventional progressive resistance training is one method used for individualized and intense rehabilitation, but often fails to target paretic ankle plantarflexion during walking. Wearable assistive robots have successfully assisted ankle-specific mechanisms to increase paretic propulsion in people post-stroke, suggesting their potential to provide targeted resistance to increase propulsion, but this application remains underexamined in this population. This work investigates the effects of targeted stance-phase plantarflexion resistance training with a soft ankle exosuit on propulsion mechanics in people post-stroke. METHODS: We conducted this study in nine individuals with chronic stroke and tested the effects of three resistive force magnitudes on peak paretic propulsion, ankle torque, and ankle power while participants walked on a treadmill at their comfortable walking speeds. For each force magnitude, participants walked for 1 min while the exosuit was inactive, 2 min with active resistance, and 1 min with the exosuit inactive, in sequence. We evaluated changes in gait biomechanics during the active resistance and post-resistance sections relative to the initial inactive section. RESULTS: Walking with active resistance increased paretic propulsion by more than the minimal detectable change of 0.8 %body weight at all tested force magnitudes, with an average increase of 1.29 ± 0.37 %body weight at the highest force magnitude. This improvement corresponded to changes of 0.13 ± 0.03 N m kg- 1 in peak biological ankle torque and 0.26 ± 0.04 W kg- 1 in peak biological ankle power. Upon removal of resistance, propulsion changes persisted for 30 seconds with an improvement of 1.49 ± 0.58 %body weight after the highest resistance level and without compensatory involvement of the unresisted joints or limb. CONCLUSIONS: Targeted exosuit-applied functional resistance of paretic ankle plantarflexors can elicit the latent propulsion reserve in people post-stroke. After-effects observed in propulsion highlight the potential for learning and restoration of propulsion mechanics. Thus, this exosuit-based resistive approach may offer new opportunities for individualized and progressive gait rehabilitation.

Design, development, and evaluation of an interactive personalized social robot to monitor and coach post-stroke rehabilitation exercises.

Socially assistive robots are increasingly being explored to improve the engagement of older adults and people with disability in health and well-being-related exercises. However, even if people have various physical conditions, most prior work on social robot exercise coaching systems has utilized generic, predefined feedback. The deployment of these systems still remains a challenge. In this paper, we present our work of iteratively engaging therapists and post-stroke survivors to design, develop, and evaluate a social robot exercise coaching system for personalized rehabilitation. Through interviews with therapists, we designed how this system interacts with the user and then developed an interactive social robot exercise coaching system. This system integrates a neural network model with a rule-based model to automatically monitor and assess patients' rehabilitation exercises and can be tuned with individual patient's data to generate real-time, personalized corrective feedback for improvement. With the dataset of rehabilitation exercises from 15 post-stroke survivors, we demonstrated our system significantly improves its performance to assess patients' exercises while tuning with held-out patient's data. In addition, our real-world evaluation study showed that our system can adapt to new participants and achieved 0.81 average performance to assess their exercises, which is comparable to the experts' agreement level. We further discuss the potential benefits and limitations of our system in practice.

Unmet needs in long-term outpatient rehabilitative care: a qualitative and multi-perspective study in Japan.

PURPOSE: This study explores the experiences and unmet needs related to post-discharge long-term rehabilitation from triadic perspective of male patients with stroke, caregivers, and rehabilitation professionals. METHODS: This is an exploratory qualitative study using in-depth interviews conducted in two outpatient rehabilitation facilities in Japan. Nine male patients with stroke, ten caregivers, and five rehabilitation professionals participated in this study. The data were coded, followed by thematic analysis. RESULTS: Patients who did not achieve further physical recovery regardless of their efforts experienced a loss of motivation and lost sight of their goals. Moreover, caregivers regarded such patients as lazy and reported feeling frustrated with them. Furthermore, patients and caregivers had unmet needs regarding communication with professionals and psychological and emotional care. In contrast, professionals perceived time constraints on outpatient rehabilitation service provision and sometimes narrowed the scope of the care approach to physical function aspects for providing services efficiently. They also expressed difficulties in identifying patients' needs, values, and meaningful goals. CONCLUSIONS: These findings suggest that in Japanese post-stroke outpatient rehabilitation, there is a need to adopt a comprehensive care approach, enhance the quality of communication, and involve caregivers in the rehabilitation process in limited-resource situations.IMPLICATIONS FOR REHABILITATIONIn long-term outpatient rehabilitation services in the community, stroke patients and their caregivers often face a physical recovery plateau.A comprehensive approach such as enhancing the quality of communication and providing psychological and emotional care -other than physical rehabilitation- is needed, particularly once the patient physical recovery stagnates.Involving caregivers in the rehabilitation process may be helpful for rehabilitation professionals to understand a potential problem that the patient cannot express but the caregiver can.It can be crucial to develop strategies that enable the rehabilitation professionals to provide a comprehensive care approach and prevent too much reliance on physical rehabilitation under the time-constraint situation in outpatient rehabilitation services.

A checklist-based survey for early mobilization of stroke unit patients in an Italian region.

BACKGROUND: Although early mobilization (EM) is recommended by most guidelines in acute stroke patients, there is a paucity of tools to perform a standardized patient risk assessment prior to EM in stroke units (SUs). OBJECTIVE: This survey aimed at assessing (1) the usefulness of an ad hoc checklist for a standardized approach to EM in SUs and (2) the relationship between EM achieved by this checklist and SU characteristics. METHODS: This survey was carried out in 10 SUs in Piedmont, Italy. The EM checklist was based on 15 "items", including quantitative/qualitative, clinical and management features. RESULTS: A total of 250 completed checklists were assessed. EM, defined as out-of-bed activity within 72 h of admission, was reached by 174 patients (69.6%), according to the checklist. There was a statistically significant association between the admission NIHSS score and EM. Hypotension at mobilization was observed in 29/250 patients (11.6%) and was significantly associated with EM. A total of 6 falls (2.4%) were reported. Nurses were most frequently involved in EM, either alone (40.8%) or with another professional. CONCLUSION: A large percentage of acute stroke patients managed to achieve a safe EM in the SUs that adopted the novel checklist. These results suggest that this checklist may well be a user-friendly, reliable tool to assist SU professionals in deciding whether to mobilize or not, by means of a standardized approach.

Post-Stroke Experiences and Rehabilitation Needs of Community-Dwelling Chinese Stroke Survivors: A Qualitative Study.

Stroke survivors encounter significant limitations in daily life activities and face increased risk of health complications such as stroke recurrence. Considering the escalating demand for personalised community rehabilitation services, this qualitative study was conducted to understand the current recovery experiences, needs, and expectations of community-dwelling stroke survivors. Fifty stroke survivors were recruited from two tertiary teaching hospitals and community centres in two provinces in mainland China. Semi-structured interviews were carried out, and participants were asked to describe their experiences of stroke, current lifestyles, exercise habits, and rehabilitation needs and expectations. Resulting data were thematically analysed. The majority of participants were first-time stroke survivors (80%) and lived with their family or caregivers (92%). Four main themes and twelve sub-themes emerged from the data: (1) shifts in social life, (2) shaken sense of self and perceived helplessness, (3) complex rehabilitation needs, and (4) perceptions and patterns of physical activity. Findings suggest that though survivors recognised their need for further rehabilitation, their demands remained unmet due to a combination of personal and external factors such as limited mobility and the absence of supportive companions and accessible facilities. The enhancement and diversification of home rehabilitation strategies are therefore necessary to make community rehabilitation more accessible and equitable.

Customized Manual Muscle Testing for Post-Stroke Upper Extremity Assessment.

In neuro-rehabilitation, the assessment of post-stroke patients' motor function of damaged upper extremities (UEs) is essential. Clinicians need clear and concise assessment instruments to monitor progress recorded in intensive rehabilitation sessions. One such instrument is Manual Muscle Testing (MMT), which, in our view, requires a modified scoring model aimed at improving the assessment process of patients' motor and functional UE status, and recording their step-by-step-progress, especially if patients undergo a short length of hospitalization (of about 10 therapy days). Hence, this paper presents a new scoring system developed by the authors. This systemresults in a more precise MMT grading scale, which has more grades and can provide a more specific muscular assessment, while offering more clarity in quantifying patients' progress after physical therapy. A prospective study was made of 41 post-stroke patients with upper extremity (UE) impairments. To determine the validity of the assessment tool for hypothesizing, and the unidimensionality and internal consistency of the customized model, exploratory and confirmatory factor analysis (CFA) with a structural equation model (SEM), Cronbach's Alpha, and Pearson correlation coefficients were used with Fugl−Meyer (FM) assessments, the Modified Ashworth Scale (MAS), AROM, and the Modified Rankin Scale (MRS). Considering the unidimensionality of the instrument used, we performed a linear regression to identify whether certain movements performed segmentally by the manually evaluated muscles influence the measured manual score of the whole UE. All indices suggested a good model fit, and a Cronbach's Alpha of 0.920 suggested strong internal consistency. The Pearson correlation coefficient of the MMT-customized score with AROM was 0.857, p < 0.001; that with FMUE was 0.905, p < 0.001; that with MRS was −0.608, p = 0.010; and that with MAS was −0.677, p < 0.001. The linear regression results suggest that wrist extensors, shoulder abductors, and finger flexors can influence the manual assessment of the muscle strength of the whole UE, thereby improving post-stroke patient management. The results of our research suggest that, using the proposed scoring, MMT may be a useful tool for UE assessment in post-stroke patients.

Acupuncture and Traditional Chinese Herbal Medicine Integrated With Conventional Rehabilitation for Post-stroke Functional Recovery: A Retrospective Cohort Study.

Background: Stroke leads to tremendous impacts on patients and the healthcare system. It is crucial to explore the potential management of rehabilitation. Acupuncture and traditional Chinese herbal medicine (TCHM) integrated with conventional rehabilitation benefit post-stroke functional recovery. Methods: We retrospectively reviewed the medical records of all patients included in the Integrated Traditional Chinese-Western Medicine care program for stroke (ITCWM-stroke care program) in 2019 in Taipei Tzu Chi Hospital to investigate the effects of acupuncture and TCHM integrated with conventional rehabilitation on National Institutes of Health Stroke Scale (NIHSS) and Barthel Index (BI) scores before and after the program. Results: A total of 255 stroke inpatients were retrieved and divided into acupuncture and acupuncture + TCHM group by hemorrhagic and ischemic stroke types, respectively. All the patients were recruited in the program at the early subacute phase after stroke onset. Of the hemorrhagic and ischemic stroke subjects, the NIHSS and BI total scores were significantly improved in the acupuncture and acupuncture + TCHM groups. The subgroup analysis results showed that in subjects with a baseline BI score ≤ 40, the acupuncture + TCHM group significantly improved BI total score better than the acupuncture group in both hemorrhagic (p < 0.05) and ischemic (p < 0.05) stroke subjects. Conclusion: Acupuncture and TCHM integrated with conventional rehabilitation significantly improve stroke patients' functional recovery at the early subacute phase. Acupuncture + TCHM contributes to better activities of daily living (ADL) improvements in stroke patients with a baseline BI score ≤ 40. We suggest integrating acupuncture and TCHM into the post-stroke rehabilitation strategy, especially for stroke patients with poor ADL function.

Augmented activity of the forearm extensor muscles induced by vibratory stimulation of the palm of the hand in individuals with subacute post-stroke hemiplegia.

PRIMARY OBJECTIVE: To examine whether vibration to the palm of the hand induces motor activity in the forearm muscles of individuals with post-stroke and healthy young adults. We hypothesized that the vibration would induce antagonistic muscle activities via the motor cortex. RESEARCH DESIGN: Observational study using the between- and within-subjects mixed design. METHODS AND PROCEDURES: Vibratory stimulation was applied to the palm of the paretic and non-paretic hands in seven post-stroke hemiplegia, and of the right hand in 22 healthy young adults in the eyes-closed and eyes-open conditions. Surface electromyography (sEMG) was recorded from the forearm extensors and flexors and the sEMG amplitudes were analyzed. MAIN OUTCOMES AND RESULTS: The extensor activities were significantly larger than that of the flexors in all hands. Especially, the extensor activities were augmented when the eyes were open in the paretic and non-paretic hands. Moreover, there was greater muscle activity in the non-paretic hand compared with the paretic hand. CONCLUSIONS: These novel findings revealed that vibration to the palm augmented the activity of the antagonistic forearm extensors, especially in the paretic hand, which was induced via top-down cortical modulation. Thus, it can be utilized to improve the impaired forearm extensors in post-stroke rehabilitation.

The role of goal adjustment during rehabilitation from stroke.

We investigated motivational regulation involving adjustment of recovery goals in post-stroke rehabilitation via standard in-clinic physiotherapy and in-home telerehabilitation (TR). We used a secondary dataset collected at 11 US sites as part of a clinical trial using video games and game control pads designed to induce certain arm movements required for recovery (n = 124; Mage  = 61.44, SD = 13.30). Participants were randomly assigned to either the TR or in-clinic condition and underwent 36 therapy sessions, reporting on their activity-inherent enjoyment for 6-8 weeks. Compared with the in-clinic patients and TR patients with high game performance, TR patients with lower game performance reported lower activity-inherent enjoyment, which is an important motivational resource for successful recovery. The results suggest that these differences occur because TR patients become discouraged by low game score feedback, which may have signaled a poor prospect for recovery. However, the results also suggest that low game performers who successfully adjusted their recovery goals were resilient to the impact of low game score feedback on their motivational resources and satisfaction with therapy. The findings suggest that goal adjustment may be particularly beneficial when patients are discouraged by feedback indicating suboptimal recovery prospects.

Invasive cortical stimulation.

The field of neuromodulation, at its essence, aims to apply electrical stimulation to the brain to ameliorate various pathology. Many methods of applying this stimulation exist, including invasive and non-invasive means. In the realm of invasive stimulation, stimulation of the cortex remains one of the earliest techniques investigated, yet one of the most underutilized today. Evidence for the efficacy of direct invasive cortical stimulation continues to mount, especially in recent years. In this chapter we will review the evidence for the use of invasive cortical stimulation as it applies to neuropathic pain, epilepsy, psychiatric disease, movement disorders, tinnitus, and post-stroke recovery, as well explore some potential mechanisms and future directions of the technique.

Telerehabilitation of Post-Stroke Patients as a Therapeutic Solution in the Era of the Covid-19 Pandemic.

(1) Background: Due to the pandemic caused by the SARS-CoV-2 virus, rehabilitation centres have become less available for neurological patients. This is the result of efforts to physically distance society, to try to slow the spread of the pathogen. Health care facilities were mainly restricted to urgent cases, while most physiotherapy treatments, mainly for patients with chronic conditions, were suspended. Some countries have seen a reduction in acute stroke hospital admissions of from 50% to 80%. One solution to the above problem is the use of telerehabilitation in the home environment as an alternative to inpatient rehabilitation. (2) Aim of the study: The purpose of this review is to analyse the benefits and limitations of teletherapy in relation to the functional condition of post-stroke patients. (3) Methods: Selected publications from 2019 to 2021 on the telerehabilitation of stroke patients were reviewed. The review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. (4) Results: Studies have proven that teletherapy significantly improves the functional condition of post-stroke patients, resulting in improved quality of life and faster return to independence (while maintaining maximum possible precautions related to the SARS-CoV-2 virus pandemic). (5) Conclusions: Analysis of the study results showed comparable effectiveness of rehabilitation in the tele system to inpatient therapy. However, it should be emphasised that patients undergoing telerehabilitation must meet strict conditions to be eligible for this type of treatment program. However, the strength of the evidence itself supporting the effectiveness of this method ranks low due to the limited number of randomised control trials (RCT), small number of participants, and heterogeneous trials.

What can virtual reality offer to stroke patients? A narrative review of the literature.

BACKGROUND: Studies demonstrated the efficacy of virtual reality (VR) as a method supporting the post-stroke neuro-rehabilitation process by activating motor learning processes. Nevertheless, stroke is frequently accompanied by serious psychological problems including depression, which is associated with an increased risk of mortality, lower post-stroke physical activity, and higher disability in stroke patients. OBJECTIVES: To explore the current use of VR as a method supporting the neuro-rehabilitation process, both in physical and psychological dimensions. METHODS: An exploratory review was conducted with a narrative synthesis. PubMed was used for literature search. Search includes the use of VR in physical rehabilitation, and as support therapy in psychiatric disorders. Both primary research and systematic reviews were included. RESULTS: In neurological disorders rehabilitation, out of 22 studies, 16 concerned stroke survivors. In psychiatric disorders, 44 literature reviews were included. CONCLUSION: The studies confirmed the effectiveness of various forms of VR treatment in the alleviation of psychological and behavioral problems and psychiatric disorders. There is a shortage of VR-based technological solutions that would, besides physical rehabilitation, offer stroke patients therapeutic tools to alleviate psychological disturbance and improve the patient's mood and motivation. Such solutions will most likely become a field of intensive research in the coming years.

Nutritional improvement is associated with better functional outcome in stroke rehabilitation: A cross-sectional study using controlling nutritional status.

OBJECTIVE: To investigate the relationship between changes in nutritional status and the functional outcome of adult post-stroke patients hospitalized for rehabilitation. DESIGN: A cross-sectional study. SUBJECTS: Post-stroke patients (n = 134) who were admitted to a convalescent rehabilitation ward. METHODS: On admission and discharge, the nutritional status of each subject was assessed using the "controlling nutritional status" system. Activities of daily living were assessed using the Functional Independence Measure (FIM). Patients were divided into 2 categories: (i) those whose nutritional status improved or remained normal during the rehabilitation; and (ii) all others. RESULTS: The median age of patients was 65.5 years. Although there were no significant differences between the 2 categories in most characteristics, the FIM efficiency was significantly higher (0.230 in the improved category and 0.133 in the other; p < 0.001). Multiple linear regression analysis showed that the improved category as a variable was independently associated with greater FIM efficiency (p < 0.001). CONCLUSION: Improvement or maintenance of nutritional status was associated with better functional recovery in post-stroke rehabilitation in adult patients of all ages.

Pilot trial of a tele-rehab intervention to improve outcomes after stroke in Ghana: A feasibility and user satisfaction study.

BACKGROUND: Tele-rehabilitation after stroke holds promise for under-resourced settings, especially sub-Saharan Africa (SSA), with its immense stroke burden and severely limited physical therapy services. OBJECTIVE: To preliminarily assess the feasibility and outcomes of mobile technology-assisted physical therapy exercises for stroke survivors in Ghana. METHODS: We conducted a prospective, single arm, pre-post study involving 20 stroke survivors recruited from a tertiary medical center, who received a Smartphone with the 9zest Stroke App® to deliver individualized, goal-targeted 5-days-a-week exercise program that was remotely supervised by a tele-therapist for 12 weeks. Outcome measures included changes in stroke levity scale scores (SLS), Modified Rankin score (MRS), Montreal Cognitive Assessment (MOCA), and feasibility indicators. RESULTS: Among study participants, mean ±â€¯SD age was 54.6 ±â€¯10.2 years, 11 (55%) were men, average time from stroke onset was 6 months. No participants dropped out. Compared with baseline status, mean ±â€¯SD scores on SLS improved from 7.5 ±â€¯3.1 to 11.8 ±â€¯2.2 at month 1 (p < 0.0001) and 12.2 ±â€¯2.4 at month 3 (p < 0.0001), MOCA scores improved from 18.2 ±â€¯4.3 to 20.4 ±â€¯4.7 at month 1 (p = 0.14), and 22.2 ±â€¯7.6 at month 3 (p = 0.047). Mean ±â€¯SD weekly sessions performed by participants per month was 5.7 ±â€¯5.8 and duration of sessions was 25.5 ±â€¯16.2 min. Erratic internet connectivity negatively affected full compliance with the intervention, although satisfaction ratings by study participants were excellent. CONCLUSION: It is feasible to administer an m-health delivered physical therapy intervention in SSA, with high user satisfaction. Randomized trials to assess the efficacy and cost-effectiveness of this intervention are warranted.

Neuroplasticidad y ácidos grasos omega 3 en adultos mayores / Neuroplasticity and omega-3 fatty acids in older adults

El aumento en la expectativa de vida ha llevado a que las enfermedades neurodegenerativas relacionadas con la vejez sean más investigadas. Las diversas intervenciones no farmacológicas en el campo de las demencias tienen su punto de partida en el concepto de neuroplasticidad o capacidad plástica del cerebro. Se conoce como neuroplasticidad a la capacidad cerebral para minimizar los efectos de las lesiones a través de cambios estructurales y funcionales, lo que permite al cerebro reaccionar o ajustarse a cambios ambientales internos y externos bajo condiciones fisiológicas y patológicas, a través modificaciones morfológicas extensas, como las que se observan en la regeneración de axones, formación de nuevas sinapsis, promoción de la neurogénesis, hasta sutiles cambios moleculares que alteran la respuesta celular a los neurotransmisores. Se ha propuesto como una de las estrategias en el tratamiento de la Enfermedad de Alzheimer, el deterioro cognitivo leve y las intervenciones post ACV la suplementación con ácidos grasos poliinsaturados (AGPI). Los AGPI omega 3 (AGPI ω-3) poseen múltiples mecanismos de acción en el cerebro y en el sistema vascular que podrían generar cierta protección contra el declive cognitivo y la demencia. Los estudios encontrados que fueron realizados en humanos corresponden a pacientes con deterioro cognitivo leve y enfermedad de Alzheimer (EA) leve a moderada y en un solo trabajo se evaluó la suplementación con omega 3 en pacientes post ACV. Aunque la evidencia clínica es algo contradictoria, probablemente en gran parte debido a cuestiones metodológicas, diversos estudios han demostrado que los AGPI ω-3 pueden mejorar la función cognitiva en los individuos adultos sanos y atenuar el deterioro cognitivo en el envejecimiento y EA leve. En los pacientes con EA moderada no se observaron cambios significativos. Hasta hoy no existen resultados concluyentes para incluir a los AGPI omega 3 como parte de un protocolo de tratamiento en enfermedades neurodegenerativas. Se necesitan más estudios aleatorizados controlados para definir el tiempo, dosis y momento adecuado para la prescripción de estos ácidos grasos.

The increase in life expectancy has led to the fact that the neurodegenerative diseases related to old age are being more and more researched. The various non-pharmacological interventions in the field of dementias have their starting point in the concept of neuroplasticity or plastic capacity of the brain. Neuroplasticity is known as the brain capacity to minimize the effects of injuries through structural and functional changes, allowing the brain to react or adjust to internal and external environmental changes under physiological and pathological conditions, through extensive morphological modifications, as the ones observed in the regeneration of axons, formation of new synapses, promotion of neurogenesis, to subtle molecular changes that alter the cellular response to neurotransmitters. It has been proposed as one of the strategies in the treatment of Alzheimer's Disease (AD), mild cognitive impairment (MCI) and poststroke interventions with polyunsaturated fatty acid (PUFA) supplementation. The omega-3 PUFAs (ω-3PUFA) have multiple mechanisms of action in the brain and vascular system that could provide some protection against cognitive decline and dementia. The studies found that were performed in humans correspond to patients with mild cognitive impairment and mild to moderate AD and in only one study, supplementation with omega-3 in poststroke patients was evaluated. Although clinical evidence is somehow contradictory, probably largely due to methodological issues, several studies have shown that ω-3 PUFAs may improve cognitive function in healthy adult individuals and attenuate cognitive impairment in aging and mild AD. No significant changes were observed in patients with moderate AD. Until today, there are no conclusive results to include omega-3 PUFAs as part of a treatment protocol in neurodegenerative diseases. Further randomized controlled studies are needed to define the time, dose and appropriate timing for the prescription of these fatty acids.

Efficacy of transcranial alternating current stimulation over bilateral mastoids (tACSbm) on enhancing recovery of subacute post-stroke patients.

BACKGROUND AND AIMS: Transcranial alternating current stimulation (tACS) offers another method of non-invasive brain stimulation in post-stroke rehabilitation. Because it is not known if tACS over bilateral mastoids (tACSbm) can promote the functional recovery in subacute post-stroke patients, we wish to learn the effect of tACSbm on improving neurological function and intracranial hemodynamics of subacute post-stroke patients. METHODS: Sixty subacute post-stroke patients (mean age: 65.4 ± 9.8 years), 15 to 60 days after the onset, were randomly assigned to receiving 15 sessions of usual rehabilitation program without (n = 30) or with tACSbm (20 Hz and < 400 µA for 30-min; n = 30). The outcome measures included the NIH Stroke Scale (NIHSS) and measures of intracranial hemodynamics before and after treatment. RESULTS: At the fifteenth session, when compared with the baseline, the mean NIHSS scores of the patients in the tACSbm group had significantly a larger decrease [18.3 ± 2.6 vs. 10.8 ± 2.7; p < 0.001] than that of the control group [19.1 ± 2.7 vs. 13.0 ± 2.4] [F(1,54) = 4.29, p = 0.043]. After both the first and fifteenth sessions, compared with the control group, the mean blood flow velocity (MFVs) of the tACSbm group had significantly larger increase in the MCA, ACA, and PCA (p < 0.001), the Gosling pulsatility index (PI) of the tACSbm group had also significantly larger decline in the MCA, ACA, and PCA than that of the control group (p < 0.001). The best predictor of the changes in the NIHSS scores was the decline in the pulsatility index in the vascular territory of both lesional and non-lesional MCA measured by the end of the last treatment session. CONCLUSIONS: tACSbm appeared to be effective for enhancing patients' functional recovery and cerebral hemodynamics in the subacute phase. The extent of recovery seems to be associated with the decline of the resistance in vascular bed of the main cerebral arteries. The mechanisms behind this effect should be explored further through research.