Brain computer interface training with motor imagery and functional electrical stimulation for patients with severe upper limb paresis after stroke: a randomized controlled pilot trial.

BACKGROUND: Restorative Brain-Computer Interfaces (BCI) that combine motor imagery with visual feedback and functional electrical stimulation (FES) may offer much-needed treatment alternatives for patients with severely impaired upper limb (UL) function after a stroke. OBJECTIVES: This study aimed to examine if BCI-based training, combining motor imagery with FES targeting finger/wrist extensors, is more effective in improving severely impaired UL motor function than conventional therapy in the subacute phase after stroke, and if patients with preserved cortical-spinal tract (CST) integrity benefit more from BCI training. METHODS: Forty patients with severe UL paresis (< 13 on Action Research Arm Test (ARAT) were randomized to either a 12-session BCI training as part of their rehabilitation or conventional UL rehabilitation. BCI sessions were conducted 3-4 times weekly for 3-4 weeks. At baseline, Transcranial Magnetic Stimulation (TMS) was performed to examine CST integrity. The main endpoint was the ARAT at 3 months post-stroke. A binominal logistic regression was conducted to examine the effect of treatment group and CST integrity on achieving meaningful improvement. In the BCI group, electroencephalographic (EEG) data were analyzed to investigate changes in event-related desynchronization (ERD) during the course of therapy. RESULTS: Data from 35 patients (15 in the BCI group and 20 in the control group) were analyzed at 3-month follow-up. Few patients (10/35) improved above the minimally clinically important difference of 6 points on ARAT, 5/15 in the BCI group, 5/20 in control. An independent-samples Mann-Whitney U test revealed no differences between the two groups, p = 0.382. In the logistic regression only CST integrity was a significant predictor for improving UL motor function, p = 0.007. The EEG analysis showed significant changes in ERD of the affected hemisphere and its lateralization only during unaffected UL motor imagery at the end of the therapy. CONCLUSION: This is the first RCT examining BCI training in the subacute phase where only patients with severe UL paresis were included. Though more patients in the BCI group improved relative to the group size, the difference between the groups was not significant. In the present study, preserved CTS integrity was much more vital for UL improvement than which type of intervention the patients received. Larger studies including only patients with some preserved CST integrity should be attempted.

Estimating Day-to-Day Circadian Rhythm in Patients with Severe Acquired Brain Injury at the Beginning of In-Hospital Rehabilitation.

BACKGROUND: Patients with severe acquired brain injury (sABI) are likely to have a disturbed circadian rhythm in the early phase of neurorehabilitation. Circadian rhythm and sleep play an important role in the rehabilitation of patients with severe acquired brain injury (sABI). Research has also pointed out the importance of investigating novel ways of assessing sleep and circadian rhythm in patients with acquired brain injury. Established methods fail to apply to the heterogeneous and fluctuant biological or behavioral signals of the patients with sABI. Accelerometry (ACC) has proven a useful measure of circadian rhythm in sABI patients. However, ACC is unavailing if patients have limited motor activity due to a low consciousness level or severe paresis. Heart rate (HR) could be a viable alternative. In this study, we aim to present a novel model for the estimation of circadian rhythm and rhythm characteristics in both motor-active and -inactive patients using ACC and HR. Furthermore, we aim to present the results of the model in patients with sABI during their first three weeks of subacute in-hospital neurorehabilitation. METHODS: An explorative observational study. Continuous recordings of ACC and electrocardiography were conducted. The suggested model was applied to examine circadian rhythms. RESULTS: This study has proven the feasibility of a novel model for the analysis of circadian rhythm. Twenty-nine patients were included, 20 motor active and nine motor inactive. Estimates of rhythm characteristics have been presented along with estimates of circadian rhythm presence or absence for both groups. CONCLUSIONS: The model has been successfully applied in a population of patients with sABI. The circadian rhythm of patients undergoing in-hospital neurorehabilitation is fluctuating across time and highly variant between subjects within the first three weeks after admission to sub-acute neurorehabilitation.

Determinants of Different Aspects of Upper-Limb Activity after Stroke.

We examined factors associated with different aspects of upper-limb (UL) activity in chronic stroke to better understand and improve UL activity in daily life. Three different aspects of UL activity were represented by four sensor measures: (1) contribution to activity according to activity ratio and magnitude ratio, (2) intensity of activity according to bilateral magnitude, and (3) variability of activity according to variation ratio. We combined data from a Belgian and Danish patient cohort (n = 126) and developed four models to determine associated factors for each sensor measure. Results from standard multiple regression show that motor impairment (Fugl−Meyer assessment) accounted for the largest part of the explained variance in all sensor measures (18−61%), with less motor impairment resulting in higher UL activity values (p < 0.001). Higher activity ratio, magnitude ratio, and variation ratio were further explained by having the dominant hand affected (p < 0.007). Bilateral magnitude had the lowest explained variance (adjusted R2 = 0.376), and higher values were further associated with being young and female. As motor impairment and biological aspects accounted for only one- to two-thirds of the variance in UL activity, rehabilitation including behavioral strategies might be important to increase the different aspects of UL activity.

Changes in Upper Limb Capacity and Performance in the Early and Late Subacute Phase After Stroke.

BACKGROUND: The course of spontaneous biological recovery indicates that no essential improvements in upper limb (UL) capacity should be expected 3 months after stroke. Likewise, UL performance as assessed with accelerometers does not seem to increase. However, this plateau may not apply to all patients with stroke. OBJECTIVES: This study aimed to investigate the changes in UL capacity and performance from 3 to 6 months post-stroke, and the association between patients' UL capacity and actual UL performance. METHODS: This study was a secondary analysis of a prospective longitudinal cohort study. Patients with UL impairment and first or recurrent stroke were included. Their UL capacity was assessed at 3 and 6 months with the Action Research Arm Test (ARAT) and UL performance was examined with accelerometry and expressed as a use ratio. The association between ARAT and use ratio was examined with multiple regression analyses. RESULTS: Data from 67 patients were analyzed. It was shown that UL capacity as assessed with ARAT still improved from 3 to 6 months. A clinically meaningful improvement (≥ 6 points on ARAT) was found in 16 (46%) of the 35 patients whose scores allowed for such an increase. Improvements were mainly observed for patients with ARAT scores in the range of 15-51 at 3 months. Conversely, UL performance did not change. Three and 6 months after stroke respectively 69% and 64% of the variation in use ratio was explained by ARAT. CONCLUSION: While a substantial part of patients improved their UL capacity, UL performance did not change from 3 to 6 months post-stroke. Strategies to remind patients of including their affected UL may encourage the transfer from better capacity to increased performance.

Evaluation of rest-activity cycles in patients with severe acquired brain injury: an observational study.

BACKGROUND: There is little knowledge about rest-activity cycles (RAC) in patients with severe-acquired brain injury (sABI) during early in-hospital rehabilitation. This study aimed to investigate if patients with sABI displayed unconsolidated RACs at the beginning of in-hospital rehabilitation, and how these changed over time. METHODS: This study was a prospective observational study. All patients consecutively admitted to one ward were screened for eligibility. We recorded accelerometric activity for 20 days. The Daytime Activity Ratio (DAR) of activity between daytime (7-22) and the total activity during the entire day was calculated and used to estimate consolidation. RESULTS: Fifty-five patients were screened and 20 patients were included. Complete day 1 & 2 data was obtained on 18 patients. Fifty-six percentage of these had a consolidated RAC at the beginning of rehabilitation. On day 19 & 20, complete data could be obtained from 15 patients, 80% of these had consolidation of RAC. When comparing these a significant mean increase of 5.8% 95%CI(0.52; 11.01) in DAR was found p < .05, and the model of all data also showed a significant increase in median DAR over time p < .01. CONCLUSION: RAC consolidation improves over time in patients admitted for in-hospital early neurorehabilitation.

Prediction of Upper Limb use Three Months after Stroke: A Prospective Longitudinal Study.

BACKGROUND: A major goal of upper limb (UL) rehabilitation after stroke is to facilitate the use of the paretic arm in daily life activities. PURPOSE: To examine if UL impairment two weeks after stroke can predict real-life UL use at three months. Furthermore, to identify additional factors which contribute to future UL use, and characteristics of patients who do not achieve normal UL use. METHODS: This study included patients with stroke ≥ 18 years. UL impairment was assessed by Fugl-Meyer upper extremity motor assessment (FM). Use ratio between affected and unaffected UL was assessed with accelerometers at three months after stroke. The association between FM score and UL use ratio was investigated with linear regression models and adjusted for secondary variables. Non-normal use was examined by a logistic regression. RESULTS: Eighty-seven patients were included. FM score two weeks after stroke predicted 38% of the variance in UL use ratio three months after stroke. A multivariate regression model predicted 55%, and the significant predictors were FM, motor-evoked potential (MEP) status, and neglect. Non-normal use could be predicted with a high accuracy based on MEP and/or neglect. In a logistic regression sensitivity for prediction of non-normal use was 0.93 and specificity was 0.75. CONCLUSION: Better baseline capacity of the paretic UL predicted increased use of the arm and hand in daily life. Non-normal UL use could be predicted reliably based on the absence of MEPs and/or presence of neglect.

Cost-analysis of virtual reality training based on the Virtual Reality for Upper Extremity in Subacute stroke (VIRTUES) trial.

OBJECTIVES: Stroke is a major cause of lasting disability worldwide. Virtual reality (VR) training has been introduced as a means of increasing the effectiveness of rehabilitation by providing large doses of task-related training with many repetitions and different modes of feedback. As VR is increasingly used in neurorehabilitation, cost considerations are important. METHODS: A cost-analysis was conducted based on the Virtual Reality for Upper Extremity in Subacute stroke (VIRTUES) trial, a recent international randomized controlled observer-blind multicenter trial. Average therapist time required per therapy session may differ between VR and conventional training (CT), leading to potential cost savings due to a therapist being able to supervise more than one patient at a time. Exploratory cost analyses are presented to explore such assumptions. RESULTS: Based on our calculations, VR incurs extra costs as compared with CT when the same amount of therapist contact is provided, as was the case in VIRTUES. However, the exploratory analyses demonstrated that these costs may be rapidly counterbalanced when time for therapist supervision can be reduced. CONCLUSIONS: Extra costs for VR can be outweighed by reduced therapist time and decreasing VR system costs in the nearer future, and not least by increased patient motivation.

Is upper limb virtual reality training more intensive than conventional training for patients in the subacute phase after stroke? An analysis of treatment intensity and content.

BACKGROUND: Virtual reality (VR) training is thought to improve upper limb (UL) motor function after stroke when utilizing intensive training with many repetitions. The purpose of this study was to compare intensity and content of a VR training intervention to a conventional task-oriented intervention (CT). METHODS: A random sample of 50 video recordings was analyzed of patients with a broad range of UL motor impairments (mean age 61y, 22 women). Patients took part in the VIRTUES trial and were randomized to either VR or CT and stratified according to severity of paresis. A standardized scoring form was used to analyze intensity, i.e. active use of the affected UL expressed in % of total time, total active time and total duration of a training session in minutes, content of training and feedback. Two raters collected data independently. Linear regression models as well as descriptive and graphical methods were used. RESULTS: Patients in the VR group spent significantly more time actively practicing with an activity rate of 77.6 (8.9) % than patients in the CT 67.3 (13.9) %, (p = .003). This difference was attributed to the subgroup of patients with initially severe paresis (n = 22). While in VR severely impaired patients spent 80.7 % (4.4 %) of the session time actively; they reached 60.6 (12.1) % in CT. VR and CT also differed in terms of tasks and feedback provided. CONCLUSION: Our results indicate that patients with severely impaired UL motor function spent more time actively in VR training, which may influence recovery. The upcoming results of the VIRTUES trial will show whether this is correlated with an increased effect of VR compared to CT. TRIAL REGISTRATION: ClinicalTrials.gov NCT02079103 , February 27, 2014.

Virtual reality training for upper extremity in subacute stroke (VIRTUES): study protocol for a randomized controlled multicenter trial.

BACKGROUND: Novel virtual reality rehabilitation systems provide the potential to increase intensity and offer challenging and motivating tasks. The efficacy of virtual reality systems to improve arm motor function early after stroke has not been demonstrated yet in sufficiently powered studies. The objective of the study is to investigate whether VR training as an adjunct to conventional therapy is more effective in improving arm motor function in the subacute phase after stroke than dose-matched conventional training, to assess patient and therapist satisfaction when working with novel virtual reality training and to calculate cost-effectiveness in terms of resources required to regain some degree of dexterity. METHODS/DESIGN: Randomized controlled observer-blind trial. DISCUSSION: Virtual reality systems are promising tools for rehabilitation of arm motor function after stroke. Their introduction in combination with traditional physical and occupational therapy may enhance recovery after stroke, and at the same time demand little personnel resources to increase training intensity. The VIRTUES trial will provide further evidence of VR-based treatment strategies to clinicians, patients and health economists. TRIAL REGISTRATION: ClinicalTrials.gov NCT02079103.

External Validation of a Dynamic Prediction Model for Upper Limb Function After Stroke.

Objective: To externally validate the dynamic prediction model for prediction of upper limb (UL) function 6 months after stroke. The dynamic prediction model has been developed and cross-validated on data from 4 Dutch studies. Design: Data from a prospective Danish cohort study were used to assess prediction accuracy. Setting: A Danish neurorehabilitation hospital. Participants: In this external validation study, follow-up data for 80 patients in the subacute phase after stroke (N=80), mean age 64 (SD11), 43% women, could be obtained. They were assessed at 2 weeks, 3 months, and 6 months after stroke with the Action Research Arm Test (ARAT), Fugl-Meyer Motor Assessment upper limb (FMA), and Shoulder Abduction (SA) Finger Extension (FE), (SAFE) test. Intervention: Not applicable. Main Outcome Measures: Prediction accuracy at 6 months was examined for 3 categories of ARAT (0-57 points): mild (48-57), moderate (23-47), and severe (0-22). Two individual predictions of ARAT scores at ±6 months post-stroke were computed based on, respectively, baseline (2 weeks) and 3 months ARAT, FE, SA values. The absolute individual differences between observed and predicted ARAT scores were summarized. Results: The prediction model performed best for patients with relatively good UL motor function, with an absolute error median (IQR) of 3 (2-9), and worst for patients with severe UL impairment, with a median (IQR) of 30 (3-39) at baseline. In general, prediction accuracy substantially improved when data obtained 3 months after stroke was included compared with baseline at 2 weeks after stroke. Conclusion: We found limited clinical usability due to the lack of prediction accuracy 2 weeks after stroke and for patients with severe UL impairments. The dynamic prediction model could probably be refined with data from biomarkers.

"Stroke - 65 plus. Continued active life." A randomized controlled trial of a self-management neurorehabilitation intervention for elderly people after stroke.

PURPOSE: Post-stroke sequelae among elderly often lead to a more inactive life while carrying a risk of overburdening close relatives. The objective of the present study was to determine if a novel self-management neuro-rehabilitation intervention added to usual treatment for people with stroke over the age of 65 years improved their self-efficacy. METHODS: This randomised controlled trial included participants two weeks before discharge from subacute rehabilitation. All participants received usual treatment. The intervention entailed an add-on of six to eight self-management sessions lasting 45-60 min within a period of nine months after discharge. This novel neuro-rehabilitation intervention focused on promoting growth, development and self-efficacy by facilitating the participants' self-management strategies regarding their activities and social network. All participants were assessed at baseline, three months and nine months after discharge. The primary outcome was self-efficacy measured by the Stroke Self-Efficacy Questionnaire. RESULTS: Sixty-nine individuals with stroke aged > 65 years were randomised. Their mean(SD) age was 76(6) years; 32 (46%) were female. No significant difference was found between the groups at baseline. Improvement recorded in the intervention group did not significantly differ from that of the control group with regard to primary outcome or secondary outcomes. CONCLUSIONS: This novel self-management intervention had no significant effect measured by the primary outcome self-efficacy or quality of life. Furthermore, no impact was observed on participation and autonomy compared with usual treatment.Clinical trial registration-URL: ClinicalTrials.gov, NCT03183960. Registered on 12 June 2017.

The present study testing a novel self-management neuro-rehabilitation intervention for people with stroke aged more than 65 years failed to improve self-efficacy, quality of life, and impact on participation and autonomy.Post hoc analyzes showed a lower caregiver burden at three and nine months in the intervention group as compared to the control group.The approach of perceiving the stroke individual and the informal caregiver as one unit (dyad), involving both in decisions regarding everyday activities and roles in everyday life especially within their shared part of life, appears important and warrants further development.

Cross-cultural adaptation of the Functional Ambulation Categories (FAC) in Danish patients with acquired brain injury.

PURPOSE: The Functional Ambulation Categories (FAC) is a measurement tool used to classify walking ability according to the amount of physical support required. In this study, the FAC is translated into Danish and the reliability and validity of the FAC are established in a population of patients with acquired brain injury (ABI). METHODS: The study took place in a neuro-rehabilitation setting. The translation process followed an accepted forward-backward translation method in six steps. For the assessment of clinometric properties a cross-sectional study design was applied. Interrater reliability was assessed with weighted Cohen's kappa. Construct validity of the FAC was assessed with Spearman's rho by correlating the FAC to walking velocity assessed with the 10-meter walk test and to the number of daily steps assessed with accelerometers. RESULTS: The FAC was successfully translated into Danish. For the assessment of clinometric properties, 53 patients were included. Almost perfect interrater reliability was found (κ = 0.92, p < 0.0001). Construct validity was high between FAC and walking velocity (r2 = 0.87, p < 0.0001) and moderate between FAC and the number of daily steps (r2 = 0.62, p < 0.0001). CONCLUSION: The Danish version of the FAC was found reliable and valid for use in-patients with ABI.

A systematic review on functional electrical stimulation based rehabilitation systems for upper limb post-stroke recovery.

Background: Stroke is one of the most common neurological conditions that often leads to upper limb motor impairments, significantly affecting individuals' quality of life. Rehabilitation strategies are crucial in facilitating post-stroke recovery and improving functional independence. Functional Electrical Stimulation (FES) systems have emerged as promising upper limb rehabilitation tools, offering innovative neuromuscular reeducation approaches. Objective: The main objective of this paper is to provide a comprehensive systematic review of the start-of-the-art functional electrical stimulation (FES) systems for upper limb neurorehabilitation in post-stroke therapy. More specifically, this paper aims to review different types of FES systems, their feasibility testing, or randomized control trials (RCT) studies. Methods: The FES systems classification is based on the involvement of patient feedback within the FES control, which mainly includes "Open-Loop FES Systems" (manually controlled) and "Closed-Loop FES Systems" (brain-computer interface-BCI and electromyography-EMG controlled). Thus, valuable insights are presented into the technological advantages and effectiveness of Manual FES, EEG-FES, and EMG-FES systems. Results and discussion: The review analyzed 25 studies and found that the use of FES-based rehabilitation systems resulted in favorable outcomes for the stroke recovery of upper limb functional movements, as measured by the FMA (Fugl-Meyer Assessment) (Manually controlled FES: mean difference = 5.6, 95% CI (3.77, 7.5), P < 0.001; BCI-controlled FES: mean difference = 5.37, 95% CI (4.2, 6.6), P < 0.001; EMG-controlled FES: mean difference = 14.14, 95% CI (11.72, 16.6), P < 0.001) and ARAT (Action Research Arm Test) (EMG-controlled FES: mean difference = 11.9, 95% CI (8.8, 14.9), P < 0.001) scores. Furthermore, the shortcomings, clinical considerations, comparison to non-FES systems, design improvements, and possible future implications are also discussed for improving stroke rehabilitation systems and advancing post-stroke recovery. Thus, summarizing the existing literature, this review paper can help researchers identify areas for further investigation. This can lead to formulating research questions and developing new studies aimed at improving FES systems and their outcomes in upper limb rehabilitation.

Is modified constraint-induced movement therapy more effective than bimanual training in improving arm motor function in the subacute phase post stroke? A randomized controlled trial.

OBJECTIVE: To compare the effect of modified constraint-induced movement therapy (mCIMT) to bimanual task-related training for patients in the subacute phase post stroke. DESIGN: A single-blinded randomized controlled trial. SETTINGS: Inpatient and outpatient rehabilitation clinics and the patient's home. SUBJECTS: Thirty patients in the subacute phase post stroke (2-16 weeks) were randomized to modified constraint-induced movement therapy with an emphasis on unimanual tasks, or bimanual task-related training, emphasizing bimanual tasks. All trained with a therapist 4 hours a week for four weeks, followed by a 2-3 hours daily self-training program. Patients in the modified constraint-induced movement therapy group were supposed to wear a restraining mitt on the unaffected hand for 4 hours a day for four weeks. MAIN MEASURES: Blinded assessments at pre and post treatment and after three months with Action Research Arm Test as a primary outcome measure, Nine-Hole Peg Test and Motor Activity Log. RESULTS: Power calculations suggested an inclusion of 60 patients, but due to recruitment difficulties the trial was stopped after an interim analysis at 30 patients. There was no difference in change (P > 0.05) between the groups on any of the measures, neither at post treatment nor at follow-up assessments. From pre-intervention to follow-up assessment the modified constraint-induced movement therapy group obtained a mean change score of 17.77 (14.66) on Action Research Arm Test, the bimanual group 15.47 (13.59). CONCLUSION: Bimanual training was as effective as modified constraint-induced movement therapy in improving arm motor function. Wearing a mitt seems unnecessary for most patients in the subacute phase post stroke when focused affected arm training is provided.

Activity and rest in patients with severe acquired brain injury: an observational study.

OBJECTIVE: To examine activity levels, types of activities and their distribution across the day in patients with severe acquired brain injury including disorders of consciousness admitted to subacute neurorehabilitation. METHODS: In this observational cross-sectional study, a modified behavioural mapping tool was used to document activity of patients admitted to a specialized rehabilitation ward for three consecutive days from 8.00 am to 8.00 pm. Observers walked a fixed route and returned to each patient every 10 min. RESULTS: Complete data was obtained in 1722/1728 observations on eight patients. Patients were registered as being in any activity in 55.6% and resting or sleeping in 30.3% of all observations. Patients were alone for 50.4% and were lying or sitting for 98.5% of the time. The major part (45%) of rehabilitation activities occurred during the morning before noon. The odds of being engaged in a rehabilitation activity were significantly different from afternoon and evening p = 0.02. Patients with higher function were more active. CONCLUSION: Patients with severe ABI were involved in some kind of activity for more than half the day and resting approximately 1/3 of the day. Health personnel and visitors were present in most activities.Implications for rehabilitationRehabilitation of patients with severe acquired brain injury (ABI) comprises a high level of a broad range of activities and interactions.In order to truly offer round the clock rehabilitation, rehabilitation hospitals need to focus on delivering rehabilitation activities evenly across the waking hours.The long periods of daytime sleep and rest in patients with severe ABI should be further examined as there might be a potential to intensify rehabilitation.

A model of healthy aging based on smartphone interactions reveals advanced behavioral age in neurological disease.

Smartphones offer unique opportunities to trace the convoluted behavioral patterns accompanying healthy aging. Here we captured smartphone touchscreen interactions from a healthy population (N = 684, ∼309 million interactions) spanning 16 to 86 years of age and trained a decision tree regression model to estimate chronological age based on the interactions. The interactions were clustered according to their next interval dynamics to quantify diverse smartphone behaviors. The regression model well-estimated the chronological age in health (mean absolute error = 6 years, R2 = 0.8). We next deployed this model on a population of stroke survivors (N = 41) to find larger prediction errors such that the estimated age was advanced by 6 years. A similar pattern was observed in people with epilepsy (N = 51), with prediction errors advanced by 10 years. The smartphone behavioral model trained in health can be used to study altered aging in neurological diseases.

Machine Learning for Motor Imagery Wrist Dorsiflexion Prediction in Brain-Computer Interface Assisted Stroke Rehabilitation.

Stroke is a life-changing event that can affect the survivors' physical, cognitive and emotional state. Stroke care focuses on helping the survivors to regain their strength; recover as much functionality as possible and return to independent living through rehabilitation therapies. Automated training protocols have been reported to improve the efficiency of the rehabilitation process. These protocols also decrease the dependency of the process on a professional trainer. Brain-Computer Interface (BCI) based systems are examples of such systems where they make use of the motor imagery (MI) based electroencephalogram (EEG) signals to drive the rehabilitation protocols. In this paper, we have proposed the use of well-known machine learning (ML) algorithms, such as, the decision tree (DT), Naive Bayesian (NB), linear discriminant analysis (LDA), support vector machine (SVM), ensemble learning classifier (ELC), and artificial neural network (ANN) for MI wrist dorsiflexion prediction in a BCI assisted stroke rehabilitation study conducted on eleven stroke survivors with either the left or right paresis. The doubling sub-band selection filter bank common spatial pattern (DSBS-FBCSP) has been proposed as feature extractor and it is observed that the ANN based classifier produces the best results.

Recovery of upper extremity motor function post stroke with regard to eligibility for constraint-induced movement therapy.

PURPOSE: To examine eligibility for modalities such as constraint-induced movement therapy (CIMT) and modified CIMT (mCIMT) in the subacute phase after stroke and to define the share of patients who should be offered this treatment. METHODS: A prospective, repeated-measures design was used. A total of 100 consecutive patients with arm paresis 1 to 2 weeks post stroke were screened. Eligible for CIMT were patients who were cognitively intact, medically stable, and able to extend the wrist and 3 fingers 10° as a lower limit. The active range of motion was registered, and motor function was assessed by the Action Research Arm Test (ARAT) and the Nine Hole Peg Test at 1 to 2 weeks, 4 weeks, and 3 months post stroke. RESULTS: From 100 patients, 54 were excluded from motor assessment, mostly due to cognitive impairments. Of the remaining 46 patients, 21 (46%) were eligible according to motor function of the hand at 1 to 2 weeks post stroke, whereas in the other patients motor function was either too good or too poor. The share of patients eligible declined to 31% after 4 weeks and 15% after 3 months. Within 3 months, 60% reached reasonable dexterity, expressed by an ARAT score ≯ 51, all receiving standard rehabilitation. CONCLUSION: Results indicate that eligibility for CIMT or mCIMT should not be considered before 4 weeks post stroke because much improvement in arm function was shown to occur during the first month post stroke with standard rehabilitation.

Patients' and Health Professionals' Experiences of Group Training to Increase Intensity of Training after Acquired Brain Injury: A Focus Group Study.

BACKGROUND: Increased intensity of training in the subacute phase after acquired brain injury facilitates plasticity and enhances better function. Group training can be a motivating factor and an effective means of increasing intensity. Reports on patients' and health care professionals' experiences on increasing the amount of active practice through group training during in-patient rehabilitation after acquired brain injury have been limited. METHODS: Two focus groups, patients and health care professionals, participated each in two interviews, before and after implementation of the Activity block, i.e., 2-hour daily intensive group training. The data from the interviews were analyzed from a phenomenological perspective. RESULTS: Three categories emerged from the data analyzes (i) training intensity, (ii) motivation and meaningfulness, and (iii) expectations and concerns. Both groups experienced that the training after implementation of the Activity block had become more intense and that motivation was increased induced by the group setting. Also, both groups found self-management enhanced. Some challenges were also reported. Patients expressed concerns to finding a balance between rest and activity, while the health professionals mentioned practical challenges, i.e., planning the content of the day and finding their role in the Activity block. CONCLUSION: Activity block benefitted a heterogeneous group of patients with acquired brain injury and was perceived as an overall positive experience by patients and health personnel. Matching the training to the individuals' need for support, finding a balance between rest and activity and using tasks that support patients' motivation, appeared important.

Knowledge and application of upper limb prediction models and attitude toward prognosis among physiotherapists and occupational therapists in the clinical stroke setting.

BACKGROUND: A substantial body of research on prediction models for upper limb (UL) function after stroke has emerged during recent years. Despite considerable evidence supporting the use of prediction models, their implementation into clinical practice has not been examined. OBJECTIVES: To investigate whether physiotherapists (PTs) and occupational therapists (OTs) who evaluate and rehabilitate stroke patients know about and apply prediction models for the recovery of UL function. Furthermore, to examine their attitudes toward prognosis for UL function in clinical practice. METHODS: The authors developed an online survey using REDCap®, specifically aimed to investigate this study's objectives. Physiotherapists and occupational therapists from Danish hospitals with acute stroke or rehabilitation wards were invited to participate. Data were analyzed using STATA 15.1. RESULTS: Of the 380 therapists invited, 58% responded to the survey. Among those, 35% reported that they knew of prediction models for UL function after stroke. More physiotherapists than occupational therapists were familiar with prediction models (p = .03). Of all respondents, 9% confirmed the use of prediction models for UL function in clinical practice. Most therapists (89%) stated that it was important to know how UL function will develop after stroke. CONCLUSIONS: Results from this study indicate that prediction models for UL function after stroke are not yet a part of daily practice in Danish stroke rehabilitation. At the same time, knowledge of prognosis seems to be relevant for most therapists in their clinical work.