Maximum tolerable daily dose of mirror movement therapy ankle exercises after stroke: an early phase dose screening study.

BACKGROUND: Mirror movement therapy may reduce lower limb motor impairment after stroke. The dose is unknown. OBJECTIVE: identify the maximum tolerable dose a day (MTD) of lower limb mirror movement therapy DESIGN: 3 + 3 cohort rule-based, dose escalation/de-escalation study. After undertaking baseline measures participants performed mirror movement therapy for 14 consecutive days. Participants then undertook outcome measures. Cohort One trained for 15 minutes daily. Subsequent cohorts exercised at a dose set according to pre-set rules and the modified Fibonacci sequence. The study stopped when the difference between set doses for consecutive cohorts was 10% or less. SETTING: Participants' homes (intervention) and a movement analysis laboratory (measures). PARTICIPANTS: Adults discharged from statutory stroke rehabilitation services. INTERVENTION: Mirror movement therapy ankle exercises. OUTCOME MEASURES: Motricity Index (primary) and bilateral time symmetry from movement onset to peak activation of Tibialis Anterior muscles during standardised sit-to-stand (secondary). RESULTS: Five cohorts of three participants were included (n = 15). Mean (SD) age and time after stroke were 61 (9) years and 35 (42) months respectively. Set daily doses for the five cohorts were: 15, 30, 50, 40 then 35 minutes. The set dose for a subsequent cohort (six) would have been 38 minutes thus the difference from cohort five would have been three minutes i.e., 9% different. Therefore, the study stopped CONCLUSION: The identified MTD of lower limb mirror therapy was 35 minutes daily when frequency was set at seven days a week and duration as two weeks. CLINICAL TRIAL REGISTRATION NUMBER: NCT04339803 (ClinicalTrials.gov) CONTRIBUTION OF THE PAPER: This early phase study found that the maximum tolerable dose per day (MTD) of mirror movement therapy ankle exercises was 35 minutes when frequency was set at seven days a week and duration as two weeks. The optimal therapeutic dose will therefore be somewhere in the range of 15 (starting dose) to 35 minutes per day. Further dose articulation studies are required to identify the optimal therapeutic dose before use of findings in clinical practice. This study is the first step in that research process.

Uptake of Technology for Neurorehabilitation in Clinical Practice: A Scoping Review.

OBJECTIVE: Technology-based interventions offer many opportunities to enhance neurorehabilitation, with associated research activity gathering pace. Despite this fact, translation for use in clinical practice has lagged research innovation. An overview of the current "state of play" regarding the extent of clinical uptake and factors that might influence use of technologies is required. This scoping review explored the uptake of technologies as neurorehabilitation interventions in clinical practice and factors that are reported to influence their uptake. METHODS: This systematic scoping review was conducted with narrative synthesis and evidence mapping. Studies of any design reporting uptake or implementation of technology (wearable devices, virtual reality, robotics, and exergaming) for movement neurorehabilitation after stroke and other neurological conditions were sought via a formal search strategy in MEDLINE (Ovid), CINAHL, AMED, and Embase. Full-text screening and data extraction were completed independently by 2 reviewers. RESULTS: Of 609 studies returned, 25 studies were included after title, abstract, and full-text screening. Studies investigated a range of technologies at various stages of development. Only 4 of the included studies explored the sustained use of technology in practice. The following 5 themes representing experiences of technology use emerged: perceived usefulness, technology design, social interaction, integration with services, and suggested improvements to enhance uptake. CONCLUSION: Reporting of uptake and use of neurorehabilitation technologies in clinical practice is limited. The synthesis provided comprehensive knowledge of barriers to and facilitators of uptake to be considered in future protocols, including a steep learning curve required to engage with technology, a need for a supportive organizational culture, and a need for user involvement in both design and development. IMPACT: This scoping review has provided indicators from current evidence of important factors to consider in the planning of research into and clinical implementation of technologies for neurorehabilitation. It serves to support an evidence-based, user-centered platform for improved research on and translation of technologies in neurorehabilitation clinical practice.

Integrating an approach to personalised self-management support in stroke and neurorehabilitation service contexts: People1st - a quality improvement initiative.

PURPOSE: People living with stroke and neurological conditions access rehabilitation at different times but self-management is often viewed as what happens post-discharge. Personalised models that integrate self-management support within everyday care are now advocated but this may require practitioners to change their behaviour to adopt and sustain new ways of working. The People1st project evaluated integration of an existing Supported Self-Management programme ("Bridges") across varied stroke and neurorehabilitation service contexts. MATERIALS AND METHODS: Mixed-method evaluation of training for groups of healthcare practitioners across 24 UK National Health Service (NHS) Trusts, exploring how learning from Bridges was assimilated and enacted in practice, on an individual and collective basis. RESULTS: Staff growth in confidence and skill around supported self-management was demonstrated. Transformations to practice included changes to: the structure of, and language used in, patient interactions; induction/training processes to increase potential for sustainability; and sharing of successes. Bridges helped practitioners make changes that brought them closer to their professional ideals. Engaged leadership was considered important for successful integration. CONCLUSIONS: Bridges was successfully integrated within a wide range of stroke and neurorehabilitation service contexts, enabled by an approach in line with practitioners' values-based motivations. Further work is required to explore sustainability and impact on service users. Implications for rehabilitationPersonalised models of care and support for self-management are advocated for people living with stroke and neurological conditions; this requires practitioners to be supported to change behaviour and practices to adopt and sustain new ways of working.Staff from a wide variety of backgrounds in neurorehabilitation and stroke can learn collaboratively about self-management practices via the Bridges programme and can integrate those practices into their service contexts.Bridges can take practitioners closer to their professional ideals of caring and making a difference and empowers them to initiate change.Organisational commitment and engaged leadership are required to facilitate a culture of support for self-management in practice.

Neurophysiological changes accompanying reduction in upper limb motor impairments in response to exercise-based virtual rehabilitation after stroke: systematic review.

BACKGROUND: Virtual reality-augmented therapist-delivered exercise-based training has promise for enhancing upper limb motor recovery after stroke. However, the neurophysiological mechanisms are unclear. OBJECTIVE: To find if neurophysiological changes are correlated with or accompany a reduction in motor impairment in response to virtual reality-aided exercise-based training. DATA SOURCES: Databases searched from inception to August 2020: MEDLINE, AMED, EMBASE, PUBMED, COCHRANE, CINHAL, PROQUEST and OPEN GREY. ELIGIBILITY CRITERIA: Studies that investigated virtual reality-augmented exercise-based training for the upper limb in adults with stroke, and, measured motor impairment and neurophysiological outcomes. Studies that combined VR with another technology were excluded. DATA EXTRACTION AND SYNTHESIS: Using pre-prepared proformas, three reviewers independently: identified eligible studies, assessed potential risk-of-bias, and extracted data. A critical narrative synthesis was conducted. A meta-analysis was not possible because of heterogeneity in participants, interventions and outcome measures. RESULTS: Of 1387 records identified, four studies were eligible and included in the review. Overall, included studies were assessed as having high potential risk-of-bias. The VR equipment, and control interventions varied between studies. Two studies measured motor impairment with the Fugl-Meyer Assessment but there was no commonality in the use of neurophysiological measures. One study found improvement in neurophysiological measures only. The other three studies found a reduction in motor impairment and changes in neurophysiological outcomes, but did not calculate correlation coefficients. CONCLUSION: There is insufficient evidence to identify the neurophysiological changes that are correlated with, or accompany, reduction in upper limb motor impairment in response to virtual reality-augmented exercise-based training after stroke. Systematic Review Registration Number PROSPERO 2017 CRD42017071312.

Identification of neuromuscular targets for restoration of walking ability after stroke: Precursor to precision rehabilitation.

OBJECTIVES: Restoration of walking is a priority for stroke survivors and key target for physical therapies. Upright pedalling (UP) can provide functional walking-like activity using a variety of muscle synergies; it is unclear which synergies might be most useful for recovery of walking. Objectives here were as follows: to examine whether neuromuscular measures derived during UP might identify targets for walking rehabilitation after stroke and to determine test-retest repeatability and concurrent validity of the measures. DESIGN: This was a prospective correlational study. SETTING: The study was carried out in a movement science laboratory. PARTICIPANTS: The participants were 18 adults with stroke (StrS) and 10 healthy older adults (HOA). INTERVENTION/MEASUREMENT: StrS and HOA took part in two identical measurement sessions. During UP, surface electromyography and kinematic data were recorded and then processed to derive three measures: reciprocal activity of quadriceps and hamstrings; percentage muscle activity "on" according to crank angle; and smoothness of movement. RESULTS: HOA and StrS demonstrated differences in reciprocal muscle activity (p = .044) and quadriceps activity according to crank angle (p = .034) but pedalled similarly smoothly (p = .367). For muscle activation according to crank angle in StrS, intraclass correlation coefficients (95% confidence interval) showing acceptable repeatability were 0.46 [0.32, 0.58] affected quadriceps; 0.43 [0.28, 0.56] affected hamstrings; and 0.67 [0.56, 0.75] unaffected quadriceps. CONCLUSION: Muscle activation according to crank angle is a promising measure of lower limb impairment during functional activity after stroke; subsequent investigation should determine magnitude of variance between testing sessions. Reciprocal activity of quadriceps and hamstrings muscles and quadriceps activity according to crank angle are both potential targets for physical therapies to improve motor recovery. Further investigations are warranted.

Evidence-based practice 'on-the-go': using ViaTherapy as a tool to enhance clinical decision making in upper limb rehabilitation after stroke, a quality improvement initiative.

Recovery of upper limb function after stroke is currently sub-optimal, despite good quality evidence showing that interventions enabling repetitive practice of task-specific activity are effective in improving function. Therapists need to access and engage with such evidence to optimise outcomes with people with stroke, but this is challenging in fast-paced stroke rehabilitation services. This quality improvement project aimed to investigate acceptability and service impact of a new, international tool for accessing evidence on upper limb rehabilitation after stroke-'ViaTherapy'-in a team of community rehabilitation therapists. Semi-structured interviews were undertaken at baseline to determine confidence in, and barriers to, evidence-based practice (EBP) to support clinical decision making. Reported barriers included time, lack of access to evidence and a research-practice disconnect. The clinicians then integrated use of 'ViaTherapy' into their practice for 4 weeks. Follow-up interviews explored the accessibility of the tool in community rehabilitation practice, and its impact on clinician confidence, treatment planning and provision. Clinicians found the tool, used predominantly in mobile device app format, to be concise and simple to use, providing evidence 'on-the-go'. Confidence in accessing and using EBP grew by 22% from baseline. Clinicans reported changes in intensity of delivery of interventions, as rapid access to recommended doses via the tool was available. Following this work, the participating health and social care service provider changed provision of therapists' technology to enable use of apps. Barriers to use of EBP in stroke rehabilitation persist; the baseline situation here supported the need for more accessible means of integrating best evidence into clinical processes. This quality improvement project successfully integrated ViaTherapy into clinical practice, and found that the tool has potential to underpin positive changes in upper limb therapy service delivery after stroke, by increasing accessibility to, use of and confidence in EBP. Definitive evaluation is now indicated.

Effects of acute caffeine on anxiety-related behavior in rats chronically exposed to the drug, with some evidence of possible withdrawal-reversal.

For 20days male and female PVG/c hooded rats were provided with caffeinated (approximately 50mg/kg/day) or unadulterated drinking water, and then their anxiety-related behavior was observed in an open field and elevated plus maze. Their choices of a brightness change were also observed in a Y maze to assess any caffeine effects on spatial memory. 24h later, all rats were tested again following an intraperitoneal injection of 50mg/kg acute caffeine, or vehicle. Earlier chronic caffeine decreased ambulation, walking, rearing, center occupancy and increased immobility in the open field thereby suggesting increased anxiety. However, occupancy of the plus-maze open arms and the Y-maze novel arm were increased by caffeine for male rats, but decreased for females probably because of sex differences in control levels of the response rather than to drug effects on anxiety and memory respectively. Following caffeine withdrawal, acute caffeine had the opposite effect to chronic treatment namely, increased open-field ambulation, walking, center occupancy and decreased immobility and defecation for caffeine-naïve rats that were suggestive of decreased anxiety. Similar but more consistent effects (plus decreased emergence latencies from a darkened start box into the open field) also typified the caffeine-experienced rats which in this case may have been accentuated by caffeine withdrawal-reversal. There was no evidence of either chronic or acute caffeine affecting spatial memory measured in the Y maze. There were also examples of lower overall activity and higher anxiety in male rats, than in females, and some sex-dependent caffeine effects.

Towards Upright Pedalling to drive recovery in people who cannot walk in the first weeks after stroke: movement patterns and measurement.

OBJECTIVES: To examine whether people who are within 31days of stroke onset are able to produce controlled lower limb movement, and phasic activity in antagonistic lower limb muscle groups, during Upright Pedalling (UP). DESIGN: Observational study. SETTING: Acute stroke unit within a University Hospital. PARTICIPANTS: Eight adults between 3 and 30days from stroke onset, with unilateral lower limb paresis and unable to walk without assistance. Participants were considered fit to participate as assessed by a physician-led medical team and were able to take part in UP for one, one minute session. INTERVENTION: Participants took part in one session of instrumented UP at their comfortable cadence, as part of a feasibility study investigating UP early after stroke. OUTCOME MEASURES: Reciprocal activation of lower limb muscles derived from muscle activity recorded with surface EMG, quantified using Jaccards Coefficient (J); smoothness of pedalling determined from standard deviations of time spent in each of eight 45° wheel position bins ("S-Ped"). Motor behavioural measures: Motricity Index, Trunk Control Test, Functional Ambulatory Categories. RESULTS: Participants were all unable to walk (FAC 0) with severe to moderate lower limb paresis (Motricity Index score/100 median 48.5, IQR 32 to 65.5). Smooth pedalling was observed; some participants pedalling similarly smoothly to healthy older adults, with a variety of muscle activation patterns in the affected and unaffected legs. CONCLUSION: These observational data indicate that people with substantial paresis early after stroke and who cannot walk, can produce smooth movement during UP using a variety of muscle activation strategies.

Positive post-disaster images: A daydream machine?

This study explores the impact of post-earthquake images inserted in a vigilance task, in terms of performance, self-reports of task-focus, and cerebral activity using functional near-infrared spectroscopy (fNIRS). Vigilance tasks present a sequence of stimuli in which only a few are pre-designated critical or target stimuli requiring an overt response from the participant. Seventy-one residents participated (51 women, 20 men) by taking part in a vigilance task with task-irrelevant images inserted in the sequence. There were three conditions consisting positive (emotive inducing), negative (emotive inducing), and control (devoid of meaning) images embedded in the vigilance task to assess possible impacts on vigilance performance. The images were obtained through crowdsourcing and represented parts of the city 3-4 years post-earthquake. Task performance was assessed with signal detection theory metrics of sensitivity A' and bias ß''. This enables the separation of an individual's ability to accurately discriminate critical signals from non-critical stimuli (sensitivity) and shifts in their willingness to respond to any stimuli whether critical or not (bias). Individuals viewing the positive images, relating to progress, rebuild, or aesthetic aspects within the city, had a more conservative response bias (they responded less to both rare critical and distractor stimuli) than those in the other conditions. These individuals also reported lower task-focus, as would be expected. However, contrary to expectations, indicators of cerebral activity (fNIRS) did not differ significantly between the experimental groups. These results, when combined, suggest that mind wandering events may be being generated when exposed to positive post-earthquake images.

Strain-dependent effects of acute caffeine on anxiety-related behavior in PVG/c, Long-Evans and Wistar rats.

To assess the possibility that acute caffeine's behavioral action might depend on rats' strain, effects of 50mg/kg of the drug were observed on activity, anxiety-related behavior and habituation learning in male and female rats from three different strains, namely PVG/c, Long-Evans and Wistar. All subjects were tested in an open field, an elevated plus maze and a light-dark box. For the three strains combined, increased occupancy of the center of the open field and entries of the open plus-maze arms with caffeine suggested caffeine-induced anxiolysis, whereas increased grooming in the open field, decreased rearing in the plus maze and increased risk assessment in the light-dark box were consistent with anxiogenesis. Caffeine also reduced open-field rearing only for PVG/c rats, and entries into and occupation of the light side of the light-dark box only for Long-Evans rats, and increased total defecation in the three types of apparatus for all three strains combined. Overall, caffeine appeared to be mainly anxiogenic. The drug also increased open-field ambulation for PVG/c rats and walking for all rats, but decreased open-field ambulation and entries into the plus maze closed arms for Wistar rats alone. In general, Wistar rats appeared to be the least and Long-Evans the most anxious of the three strains investigated. Caffeine also decreased within-session habituation of open-field ambulation for PVG/c rats alone, thereby suggesting strain-dependent interference with non-associative learning and short-term memory. Several overall sex differences were also observed that supported female rats being more active and less anxious than males.

Evidence for anxiolytic effects of acute caffeine on anxiety-related behavior in male and female rats tested with and without bright light.

Male and female PVG/c rats were observed in an open field (OF) and an elevated plus maze (EPM) either with or without a bright light stressor (600-692 lx) following an intraperitoneal injection of saline, 25 or 50mg/kg of caffeine. One week later, the same rats were observed under the same drug and lighting conditions but in the opposite apparatus to that experienced earlier. Either the higher or both doses of caffeine decreased anxiety as indicated by increased OF rearing and decreased grooming, immobility and corner occupancy (in the presence of bright light). A similar interpretation applied to caffeine-related increased entries into and observations in the EPM open arms for males only, and increased entries into the open arms for females alone in the presence of bright light. Bright light increased anxiety as shown by longer latencies of emergence into the OF and decreased ambulation and, for males only, decreased center occupancy and increased corner occupancy. Fewer entries into the open arms in the presence of bright light for females only also suggested heightened anxiety. Apart from one OF and one EPM measure, bright light did not appear to markedly influence the effects of caffeine which were concluded to be primarily anxiolytic, with males being more affected than females. Although the central mechanisms responsible for caffeine's anxiolytic action remain to be established, it is possible that antagonism of A2A adenosine receptors might somehow be involved.

Effects of lower limb reciprocal pedalling exercise on motor function after stroke: a systematic review of randomized and nonrandomized studies.

This review systematically synthesized current evidence on the effects of lower limb reciprocal pedalling exercise on motor function poststroke. Detailed analysis of single studies in the review revealed multiple instances of heterogeneity including outcome measures; therefore we decided to avoid undertaking a single, potentially misleading meta-analysis. We found that despite beneficial (although nondefinitive) effects on balance, functional independence, and muscle strength, it is not possible to make clinical recommendations that support or refute the use of reciprocal pedalling exercise to enhance recovery of motor function after stroke. Our findings provide proof-of-concept for pedalling interventions and provide a foundation for subsequent research, suggesting a need for further standardized, controlled clinical trials of clearly described pedalling interventions for stroke survivors and with subsequent transparent reported findings.

Clinical efficacy and prognostic indicators for lower limb pedalling exercise early after stroke: study protocol for a pilot randomised controlled trial.

BACKGROUND: It is known that repetitive, skilled, functional movement is beneficial in driving functional reorganisation of the brain early after stroke. This study will investigate a) whether pedalling an upright, static exercise cycle, to provide such beneficial activity, will enhance recovery and b) which stroke survivors might be able to participate in pedalling. METHODS/DESIGN: Participants (n = 24) will be up to 30 days since stroke onset, with unilateral weakness and unable to walk without assistance. This study will use a modified exercise bicycle fitted with a UniCam crank. All participants will give informed consent, then undergo baseline measurements, and then attempt to pedal. Those able to pedal will be entered into a single-centre, observer-blinded randomised controlled trial (RCT). All participants will receive routine rehabilitation. The experimental group will, in addition, pedal daily for up to ten minutes, for up to ten working days.Prognostic indicators, measured at baseline, will be: site of stroke lesion, trunk control, ability to ambulate, and severity of lower limb paresis.The primary outcome for the RCT is ability to voluntarily contract paretic lower limb muscle, measured by the Motricity Index. Secondary outcomes include ability to ambulate and timing of onset and offset of activity in antagonist muscle groups during pedalling, measured by EMG. DISCUSSION: This protocol is for a trial of a novel therapy intervention. Findings will establish whether there is sufficient evidence of benefit to justify proceeding with further research into clinical efficacy of upright pedalling exercise early after stroke. Information on potential prognostic indicators will suggest which stroke survivors could benefit from the intervention. TRIAL REGISTRATION: ISRCTN: ISRCTN45392701.