Perinatal stroke: mapping and modulating developmental plasticity.

Most cases of hemiparetic cerebral palsy are caused by perinatal stroke, resulting in lifelong disability for millions of people. However, our understanding of how the motor system develops following such early unilateral brain injury is increasing. Tools such as neuroimaging and brain stimulation are generating informed maps of the unique motor networks that emerge following perinatal stroke. As a focal injury of defined timing in an otherwise healthy brain, perinatal stroke represents an ideal human model of developmental plasticity. Here, we provide an introduction to perinatal stroke epidemiology and outcomes, before reviewing models of developmental plasticity after perinatal stroke. We then examine existing therapeutic approaches, including constraint, bimanual and other occupational therapies, and their potential synergy with non-invasive neurostimulation. We end by discussing the promise of exciting new therapies, including novel neurostimulation, brain-computer interfaces and robotics, all focused on improving outcomes after perinatal stroke.

Decline in Rehab Transfers Among Rehab-Eligible Stroke Patients During the COVID-19 Pandemic.

OBJECTIVE: To characterize differences in disposition arrangement among rehab-eligible stroke patients at a Comprehensive Stroke Center before and during the COVID-19 pandemic. MATERIALS AND METHODS: We retrospectively analyzed a prospective registry for demographics, hospital course, and discharge dispositions of rehab-eligible acute stroke survivors admitted 6 months prior to (10/2019-03/2020) and during (04/2020-09/2020) the COVID-19 pandemic. The primary outcome was discharge to an inpatient rehabilitation facility (IRF) as opposed to other facilities using descriptive statistics, and IRF versus home using unadjusted and adjusted backward stepwise logistic regression. RESULTS: Of the 507 rehab-eligible stroke survivors, there was no difference in age, premorbid disability, or stroke severity between study periods (p>0.05). There was a 9% absolute decrease in discharges to an IRF during the pandemic (32.1% vs. 41.1%, p=0.04), which translated to 38% lower odds of being discharged to IRF versus home in unadjusted regression (OR 0.62, 95%CI 0.42-0.92, p=0.016). The lower odds of discharge to IRF persisted in the multivariable model (aOR 0.16, 95%CI 0.09-0.31, p<0.001) despite a significant increase in discharge disability (median discharge mRS 4 [IQR 2-4] vs. 2 [IQR 1-3], p<0.001) during the pandemic. CONCLUSIONS: Admission for stroke during the COVID-19 pandemic was associated with a significantly lower probability of being discharged to an IRF. This effect persisted despite adjustment for predictors of IRF disposition, including functional disability at discharge. Potential reasons for this disparity are explored.

Use of Head and Neck Magnetic Resonance Angiography to Explore Neurological Function Recovery and Impact of Rehabilitation Nursing on Patients with Acute Stroke.

OBJECTIVE: To analyze neurological function recovery and the impact of rehabilitation nursing in patients with cerebral stroke after treatment to aid clinical diagnosis and treatment of cerebral stroke. METHODS: The study comprised 140 patients who were hospitalized in the neurology department for magnetic resonance angiography examination. Patients were divided into a treatment group (70 patients) and a control group (70 patients) based on treatment plan. Digital subtraction angiography was regarded as the gold standard diagnostic examination. In patients in both groups, magnetic resonance angiography features of the M1 segment of the middle cerebral artery and diagnostic specificity and sensitivity were recorded. An activities of daily living score was used to assess neurological function of patients before and after rehabilitation. RESULTS: The activities of daily living scores of patients in both groups increased significantly after treatment (P < 0.05); the scores of patients in the treatment group increased more significantly (P < 0.05). The total effective rate was 89% in the treatment group and 60% in the control group. The difference between the 2 groups was statistically significant (P < 0.05). After treatment, the degree of M1 segment stenosis in both groups was better than before treatment, and the number of collateral circulation branches was increased; the improvements in the treatment group were more significant (P < 0.05). CONCLUSIONS: Rehabilitation nursing could greatly improve the stenosis of blood vessels in patients with acute cerebral stroke and promote the establishment of collateral circulation, thereby effectively enhancing the recovery of neurological function and strengthening the ability of patients to perform activities of daily living.

Age-Related Disparities in the Quality of Stroke Care and Outcomes in Rehabilitation Hospitals: The Australian National Audit.

INTRODUCTION: Stroke affects all ages. Despite increased incidence in those <65 years, little is known about age-based differences in inpatient rehabilitation management and outcomes. OBJECTIVES: To investigate management and outcomes, comparing younger (<65 years) and older (≥65 years) patients with stroke, who received inpatient rehabilitation. METHODS: Multicentre, cross-sectional study using data from Australian hospitals who participated in the Stroke Foundation national stroke rehabilitation audit (2016-2018). Chi-square tests compared characteristics and care by age. Multivariable regression models were used to compare outcomes by age (e.g. length of stay). Models were adjusted for sex, stroke type and severity factors. RESULTS: 7,165 audited cases from 127 hospitals; 23% <65 years (66% male; 72% ischaemic stroke). When compared to older patients, younger patients were more likely male (66% vs 52%); identify as Aboriginal or Torres Strait Islander (6% vs 1%); be less disabled on admission; receive psychology (46% vs 34%) input, and community reintegration support, including return to work (OR 1.47, 95% CI 1.03, 2.11), sexuality (OR 1.60, 95% CI 1.39, 1.84) and self-management (OR 1.39, 95% CI 1.23, 1.57) advice. Following adjustment, younger patients had longer lengths of stay (coeff 3.54, 95% CI 2.27, 4.81); were more likely to be independent on discharge (aOR 1.96, 95% CI 1.68, 2.28); be discharged to previous residences (aOR 1.64, 95% CI 1.41, 1.91) and receive community rehabilitation (aOR: 2.27, 95% CI 1.91, 2.70). CONCLUSIONS: Age-related differences exist in characteristics, management and outcomes for inpatients with stroke accessing rehabilitation in Australia.

What is the future for immersive virtual reality in memory rehabilitation? A systematic review.

BACKGROUND: A growing interest in non-pharmacological approaches aimed at cognitive rehabilitation and cognitive enhancement pointed towards the application of new technologies. The complex virtual reality (VR) presented using immersive devices has been considered a promising approach. OBJECTIVE: The article provides a systematic review of studies aimed at the efficacy of VR-based rehabilitation. First, we shortly summarize literature relevant to the role of immersion in memory assessment and rehabilitation. METHODS: We searched Web of Science, ScienceDirect, and PubMed with the search terms "memory rehabilitation", "virtual reality", "memory deficit". Only original studies investigating the efficacy of complex three-dimensional VR in rehabilitation and reporting specific memory output measures were included. RESULTS: We identified 412 citations, of which 21 met our inclusion criteria. We calculated appropriate effect sizes for 10 studies including control groups and providing descriptive data. The effect sizes range from large to small, or no effect of memory rehabilitation was present, depending on the control condition applied. Summarized studies with missing control groups point out to potential positive effects of VR but do not allow any generalization. CONCLUSIONS: Even though there are some theoretical advantages of immersive VE over non-immersive technology, there is not enough evidence yet to draw any conclusions.

Qualitative Study of Chinese Stroke Caregivers' Caregiving Experience During the COVID-19 Pandemic.

BACKGROUND AND PURPOSE: The coronavirus disease 2019 (COVID-19) outbreak has led to disruptions in health care service delivery worldwide, inevitably affecting stroke survivors requiring ongoing rehabilitation and chronic illness management. To date, no published research has been found on stroke caregiving during the COVID-19 pandemic. This study aimed to explore Hong Kong stroke caregivers' caregiving experiences in the midst of this difficult time. METHODS: Individual semistructured interviews were conducted with 25 Chinese adult primary stroke caregivers from May to June 2020 via telephone. Interviews were transcribed verbatim and analyzed using an interpretive description approach and constant comparison strategy. RESULTS: Five themes of the stroke caregiving experience during the COVID-19 pandemic emerged: care service adversities, additional caregiving workload and strain, threatened relationship between caregiver and stroke survivors, threats to caregivers' physical and psychological well-being, and needs for continuing caregiving roles. Our findings suggested that caregivers have worsened physical and psychological well-being because of increases in care burden with simultaneously reduced formal and informal support. The relationship between caregiver and stroke survivor was subsequently affected, placing some survivors at heightened risk of abuse. CONCLUSIONS: Our study provides valuable findings about stroke caregiving experiences and needs during the pandemic. Delivery of psychological support, telemedicine, and household hygiene resources would be useful to mitigate caregivers' psychological distress during the COVID-19 pandemic.

Reimagining Stroke Rehabilitation and Recovery Across the Care Continuum: Results From a Design-Thinking Workshop to Identify Challenges and Propose Solutions.

Systems for stroke rehabilitation and recovery are variable and fragmented; stroke survivors often experience gaps in care with detrimental effects on their recovery. We designed and hosted a multidisciplinary and interactive workshop to discuss challenges facing patients recovering from stroke and to brainstorm solutions. Forty-one participants including clinicians, researchers, and stroke survivors attended the workshop. Participants were surveyed beforehand about challenges facing stroke recovery and results were tabulated as a word cloud. An interactive, design-thinking exercise was conducted that involved completing workbooks, hands-on prototype designing, and presentations, which were then analyzed through qualitative content analysis using an inductive approach. High frequency words in the word cloud of survey responses included access, fragmented, and uncertainty. Qualitative analysis revealed 6 major challenge themes including poor (1) transitions in and (2) access to care; (3) barriers to health insurance; (4) lack of patient support; (5) knowledge gaps; and (6) lack of standardized outcomes. Eleven unique solutions were proposed that centered around new technologies, health care system changes, and the creation of new support roles. Analysis of the alignment between the challenges and solutions revealed that the single proposed solution that solved the most identified challenges was a "comprehensive stroke clinic with follow-up programs, cutting edge treatments, patient advocation and research." Through our interactive design-thinking workshop process and inductive thematic analysis, we identified major challenges facing patients recovering from stroke, collaboratively proposed solutions, and analyzed their alignment. This process offers an innovative approach to reaching consensus among interdisciplinary stakeholders.

Acute stroke care during the first phase of COVID-19 pandemic in Norway.

OBJECTIVES: The aim of the present study was to investigate how the initial phase of the COVID-19 pandemic affected the hospital stroke management and research in Norway. MATERIALS AND METHODS: All neurological departments with a Stroke Unit in Norway (n = 17) were invited to participate in a questionnaire survey. The study focused on the first lockdown period, and all questions were thus answered in regard to the period between 12 March and 15 April 2020. RESULTS: The responder rate was 94% (16/17). Eighty-one % (13/16) reported that the pandemic affected their department, and 63% (10/16) changed their stroke care pathways. The number of new acute admissions in terms of both strokes and stroke mimics decreased at all 16 departments. Fewer patients received thrombolysis and endovascular treatment, and multidisciplinary stroke rehabilitation services were less available. The mandatory 3 months of follow-up of stroke patients was postponed at 73% of the hospitals. All departments conducting stroke research reported a stop in ongoing projects. CONCLUSION: In Norway, hospital-based stroke care and research were impacted during the initial phase of the COVID-19 pandemic, with likely repercussions for patient care and outcomes. In the future, stroke departments will require contingency plans in order to protect the entire stroke treatment chain.

The functional assessment for control of trunk (FACT): An assessment tool for trunk function in stroke patients.

BACKGROUND: The Functional Assessment for Control of Trunk (FACT) was developed to evaluate trunk function after stroke. However, only a few studies used FACT to show functional outcome. OBJECTIVE: This study aimed to validate the FACT predictive ability for functional outcome following stroke and create an English version of the FACT. METHODS: This retrospective, observational study was conducted with patients aged≥65 years with stroke. Patients were divided into two groups according to the median FACT score at admission: trunk impairment or high trunk function group. Multiple regression analysis was performed for Functional Independence Measure (FIM) gain and FIM efficiency to examine the relationship between trunk function assessed by FACT at admission and functional prognosis. RESULTS: 105 participants (mean age, 80.2±7.6, 57.1%were men) were included. Of these, 48 (45.7%) and 57 (54.3%) were categorized to the trunk impairment group and high trunk function group, respectively. FACT score at admission was associated with FIM gain (coefficient = 0.875, P = 0.001) and FIM efficiency (coefficient = 0.015, P = 0.016) after adjusting for confounders. CONCLUSIONS: Trunk impairment at admission assessed by FACT could predict functional prognosis. The English version of FACT was created and further demonstrated the validity of FACT.

Assessment of responsiveness of four hand-related scales in stroke patients.

Self-reporting scales are commonly utilized in determining appropriate treatment strategies and follow-up in hand-related disorders. Responsiveness is described as the ability of a scale to detect clinically significant changes. We aimed to evaluate responsiveness of Michigan Hand Outcomes Questionnaire (MHQ), Duruöz Hand Index (DHI), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and ABILHAND questionnaire in stroke patients. Fifty-one stroke patients were assessed in this descriptive study. Participants received conventional stroke rehabilitation program consisting of 30 sessions. Brunnstrom stages of the stroke patients were recorded before and after treatment. MHQ, DHI, DASH, ABILHAND questionnaire and patient satisfaction scores were filled in by participants before and after the conventional rehabilitation program. Significant improvements were found in MHQ, DHI, DASH, ABILHAND, patient satisfaction scores and Brunnstrom motor recovery stages after the rehabilitation program (p < 0.001). Responsiveness values of the scales were calculated as MHQ (effect size (ES) = - 0.74; standardized response mean (SRM) = - 1.25), DHI (ES = 0.64; SRM = 1.22), DASH (ES = 0.71; SRM = 1.01), and ABILHAND (ES = - 0.55; SRM = - 1.22). Our study revealed that MHQ, DHI, DASH and ABILHAND are responsive scales in detecting treatment-related changes in stroke patients. MHQ, DHI, DASH and ABILHAND can be used in the evaluation of treatment responses in stroke patients.

Digital health in stroke medicine: what are the opportunities for stroke patients?

PURPOSE OF REVIEW: The European Stroke Organisation published a European Stroke Action Plan (SAP-E) for the years 2018-2030. The SAP-E addresses the entire chain of care from primary prevention through to life after stroke. Within this document digital health tools are suggested for their potential to facilitate greater access to stroke care. In this review, we searched for digital health solutions for every domain of the SAP-E. RECENT FINDINGS: Currently available digital health solutions for the cerebrovascular disease have been designed to support professionals and patients in healthcare settings at all stages. Telemedicine in acute settings has notably increased the access to tissue plasminogen activator and thrombectomy whereas in poststroke settings it has improved access to rehabilitation. Moreover, numerous applications aim to monitor vital signs and prescribed treatment adherence. SUMMARY: SAP-E with its seven domains covers the whole continuum of stroke care, where digital health solutions have been considered to provide utility at a low cost. These technologies are progressively being used in all phases of stroke care, allowing them to overcome geographical and organizational barriers. The commercially available applications may also be used by patients and their careers in various context to facilitate accessibility to health improvement strategies.

Advances in Stroke: Therapies Targeting Stroke Recovery.

Stroke recovery therapies promote favorable neural plasticity, both during spontaneous recovery and the chronic phase. Activity-based therapies based on intense practice, some aided by integration of computers and telehealth, have shown promise. These studies emphasize key therapeutic variables such as dose, intensity, and timing. Preclinical drug studies have shown promise, but human translation has been challenged by identifying the target patient subgroup, requirements for concomitant training, and aligning biomarkers with preclinical evidence.

Trends and Technologies in Rehabilitation of Foot Drop: A Systematic Review.

INTRODUCTION: Foot Drop (FD) is a condition, which is very commonly found in post-stoke patients; however it can also be seen in patients with multiple sclerosis, and cerebral palsy. It is a sign of neuromuscular damage caused by the weakness of the muscles. There are various approaches of FD's rehabilitation, such as physiotherapy, surgery, and the use of technological devices. Recently, researchers have worked on developing various technologies to enhance assisting and rehabilitation of FD. AREAS COVERED: This review analyzes different types of technologies available for FD. This include devices that are available commercially or still under research. 101 studies published between 2015 and 2020 were identified for the review, many were excluded due to various reasons, e.g., were not robot-based devices, did not include FD as one of the targeted diseases, or was insufficient information. 24 studies that met our inclusion criteria were assessed. These studies were further classified into two different categories: robot-based ankle-foot orthosis (RAFO) and Functional Electrical Stimulation (FES) devices. EXPERT OPINION: Studies included showed that both RAFO and FES showed considerable improvement in the gait cycle of the patients. Future trends are inclining towards integrating FES with other neuro-concepts such as muscle-synergies for further developments.

Rehabilitation of cortically induced visual field loss.

PURPOSE OF REVIEW: Homonymous visual field defects are a common sequela of stroke, and are assumed to be permanent within a few weeks of the event. Because consensus about the efficacy of rehabilitation is lacking, visual therapy is rarely prescribed. Here, we review current rehabilitation options and strategies in the translational pipeline that could change these perspectives. RECENT FINDINGS: The mainstays of available therapy for homonymous visual defects are compensation training and substitution, which allow patients to better use their spared vision. However, early clinical studies suggest that vision can partially recover following intensive training inside the blind field. Research into the relative efficacy of different restorative approaches continues, providing insights into neurophysiologic substrates of recovery and its limitations. This, in turn, has led to new work examining the possible benefits of earlier intervention, advanced training procedures, noninvasive brain stimulation, and pharmacological adjuvants, all of which remain to be vetted through properly powered, randomized, clinical trials. SUMMARY: Research has uncovered substantial visual plasticity after occipital strokes, suggesting that rehabilitative strategies for this condition should be more aggressive. For maximal benefit, poststroke vision-restorative interventions should begin early, and in parallel with strategies that optimize everyday use of an expanding field of view.

Effects of walking distance over robot-assisted training on walking ability in chronic stroke patients.

An understanding of the dose-response during training is important to identify the rehabilitation programs to obtain the improvement in chronic stroke patients. The purpose of this study was to determine whether distance-dose (distance walked across all sessions) during robot-assisted training affects the change of walking speed and distance in chronic stroke patients after intervention. Fifteen chronic stroke patients were enrolled in this study. The patients performed 8 gait training sessions using the Hybrid Assistive Limb (HAL) for 3 weeks. Gait speed, stride length, cadence, and 2-minute walk test (2MWT) were measured before and post-intervention. Total walking distance (distance walked across all sessions) in individual patients were also measured. Gait speed, stride length, cadence, and 2-minute walk test (2MWT) improved significantly after training. The average of walking distance for 8 sessions in individual patients was 3793.3 ± 2105.3 m. Moreover, the change of gait speed (r = 0.53) and 2MWT (r = 0.70) were positively correlated with the walking distance during 8 sessions. This study of finding demonstrated that greater total distance walked over all sessions of training using the HAL is directly associated with the better walking outcomes in patients with chronic stroke. Further researches with a larger number of patients and a control group are needed to quantify the study results more precisely.

Percutaneous Endoscopic Gastrostomy and Mortality After Stroke in England From 2007 to 2018: A Retrospective Cohort Study.

BACKGROUND AND PURPOSE: Swallowing difficulties are common poststroke. National clinical guidelines recommend feeding by percutaneous endoscopic gastrostomy (PEG) when oral nutrition cannot be maintained although survival benefit might be short term. It is unknown whether a decade of general care improvements have impacted upon PEG provision and outcomes. This retrospective cohort study examined PEG placement and mortality poststroke in England. METHODS: National Health Service Hospital Episode Statistics and Office for National Statistics mortality data between April 2007 and March 2018 were linked to identify all admissions in England with stroke-related International Classification of Diseases codes (I61, I63, and I64)±PEG insertion and deaths at 3, 6, and 12 months. Linear and logistic regression examined trends over time and mortality. RESULTS: Patients (923 236) with stroke underwent 17 532 PEG procedures (mean rate 1.9%), with an average reduction of -27 procedures/year ([95% CI, -56 to 1.4]; P=0.06) despite an average increase of 1804 stroke admissions/year. Mortality decreased among cases without a PEG procedure: -190 deaths/year ([95% CI, -276 to -104]; P<0.001) at 3 months, -167 deaths/year ([95% CI, -235 to -98]; P<0.001) at 6 months and -103 deaths/year ([95% CI, -157 to -50]; P<0.01) at 12 months; and also reduced following PEG insertion: -28 deaths/year ([95% CI, -35 to -20]; P<0.001) at 3 months, -33 deaths/year ([95% CI, -46 to -20]; P<0.01) at 6 months and -30 deaths/year ([95% CI, -48 to -13]; P<0.01) at 12 months. With all years combined, PEG insertion was weakly associated with reduced mortality at 3 months (odds ratio, 0.94 [95% CI, 0.90-0.97]) but significantly higher mortality at 6 months (odds ratio, 1.69 [95% CI, 1.64-1.75]) and 12 months (odds ratio, 2.14 [95% CI, 2.08-2.20]). CONCLUSIONS: PEG procedures and subsequent deaths have decreased in the context of general mortality reductions after hospitalization for stroke, but survival at 6 and 12 months remains significantly worse for patients with PEG placement.