Three-Dimensional Balance Training Using Visual Feedback on Balance and Walking Ability in Subacute Stroke Patients: A Single-Blinded Randomized Controlled Pilot Trial

Background: Trunk-activating exercises for balance are important because trunk weakness is relevant to the functional performance of individuals with stroke. This study aimed to explore the effects of three-dimensional balance training using visual feedback on balance and walking ability in subacute stroke patients. Methods: Twenty-four participants with subacute stroke were randomly assigned to the experimental or control group. Each group underwent twenty sessions (30 min/day, 5 days/week for 4 weeks). Patients were assessed using the Berg balance scale, gait parameters (gait speed, cadence, step length, and double-limb support period) using GAITRite, and activity-specific balance confidence score, before and after the intervention. Results: The three-dimensional balance training using visual feedback exhibited greater changes in the Berg balance scale, gait speed, cadence, step length, double-limb support period, and activity-specific balance confidence compared with the control group. Statistical analyses showed significant differences in Berg balance scale (P?=?.012; 95% CI, 2.585-6.415), gait speed (P?=?.001; 95% CI, .079-.155), cadence (P?=?.001; 95% CI, 1.622-4.392), step length (P?=?.003; 95% CI, 1.864-3.908), double-limb support period (P?=?.003; 95% CI, ?3.259 to ?0.761) and activity-specific confidence (P?=?.008; 95% CI, 6.964-14.036) between groups. Conclusion: Three-dimensional balance training using visual feedback may be more effective than conventional training in improving balance, walking ability, and activity-specific balance confidence in patients with subacute stroke.     

Functional Electrical Stimulation With Exercises for Standing Balance and Weight Transfer in Acute Stroke Patients: A Feasibility Randomized Controlled Trial

Objectives: To test parameters needed for the design of a larger trial including the following: 1) identifying eligible participants, recruitment, and retention rates; 2) the feasibility and acceptability of delivering functional electrical stimulation (FES) to the gluteus maximus and quadriceps femoris for acute stroke patients in a hospital rehabilitation setting; 3) the outcome measures; 4) obtaining initial estimates of effect size; and 5) clarifying the relevant control group. Materials and Methods: Twenty‐one people with acute stroke—mean age = 68 (min to max: 33–87) years; weeks postonset = 4.6 (min to max: 1–14)—were randomized to three groups to receive two weeks of balance training with FES, balance training alone, or usual care. Symmetry in normal standing, weight transfer onto the affected limb, balance, mobility, and speed of walking were assessed before, shortly after the end of training, and two weeks later by a blinded assessor. Results: 1) FES was successfully delivered but not with the planned eight sessions; 2) no trends in favor of FES were found; and 3) 4% of those screened took part but approaching 20% might be recruited in the future, no single outcome measure was suitable for all participants, and more routine physiotherapy was delivered to the control group. Conclusions: FES is feasible in this patient group but further feasibility and definitive trials are required.     

Item Analysis of the Berg Balance Scale in Individuals with Subacute and Chronic Stroke

Abstract

Purpose: The Berg Balance Scale (BBS) is one of the most commonly applied clinical measures of balance for individuals with stroke. This study used item analysis methods to investigate various psychometric aspects of the BBS in participants with subacute and chronic stroke. Methods: Secondary analysis of data from 69 participants was included. The Rasch measurement model was used to generate item fit statistics for each item of the BBS and assess scale precision across the continuum of balance. Results: Two of the 14 items of the BBS (standing on one foot and tandem standing) demonstrated misfit. The hierarchical scale demonstrated decreased precision at the higher end of the balance continuum. Discussion: The original instructions for the BBS indicate that the individual tested can choose the limb utilized in the single-limb stance and tandem stance items. Administration of these test items in this way to individuals with stroke may contribute to item misfit. Standardization of administration of the BBS to routinely use the involved lower extremity may support higher item difficulty, contribute to improved scale precision, and decrease the ceiling effect of the scale previously reported. Conclusion: The ability of participants to self-select the assessed lower extremity is most likely contributing to item misfit for 2 of the 14 BBS items. Standardized administration of these items may improve the ability of the BBS to more accurately measure initial balance impairment, as well as changes in balance due to spontaneous recovery and rehabilitation interventions.     

Aerobic Training Efficacy in Inflammation,Neurotrophins, and Function in Chronic Stroke Persons: A Randomized Controlled Trial Protocol

Background: Neuroinflammation is an important part of stroke pathophysiology and has both detrimental and beneficial effects after stroke. Besides that the enhancement of neurotrophins seems to be related to improvements in stroke recovery. Evidences suggest that exercise plays a role in modulating anti-inflammatory and neurotrophic effects. However, little is known about its impact in stroke survivors, mainly in chronic stroke. The purpose of this study is to investigate the efficacy of moderate-intensity treadmill exercise in changing inflammatory mediators, interleukin-6 (IL-6), soluble tumor necrosis factor receptors I and II (sTNFRI, sTNFRII), interleukin-10 (IL-10), and brain-derived neurotrophic factor (BDNF) levels in chronic stroke patients. The secondary objective is to investigate the effects of training in improve mobility and exercise capacity. Methods: This is a randomized controlled trial. Chronic stroke patients will be randomized to an experimental or control group, and will receive group interventions three times per week, over 12 weeks. The experimental group will receive moderate-intensity (60%-80% of maximum heart rate reserve) treadmill exercise. Control group will perform walking training on the ground (<40% of maximum heart rate reserve). Primary outcomes include IL-6, sTNFRI, sTNFRII, IL-10, and BDNF levels. Secondary outcomes include mobility and exercise capacity. Outcomes will be measured at baseline, postintervention, and at the 4-week follow-up. Discussion: The findings of this trial have the potential to provide important insights regarding the effects of an aerobic physical program in the inflammatory process and in the neuronal plasticity in stroke persons and its impact on mobility and exercise capacity.     

Effects of Exergame on Patients' Balance and Upper Limb Motor Function after Stroke: A Randomized Controlled Trial

Background: Stroke is a major cause of motor incapacity in adults and the elderly population, requiring effective interventions capable of contributing to rehabilitation. Different interventions such as use of exergames are being adopted in the motor rehabilitation and balance area, as they act as motivating instruments, making therapies more pleasurable. Objective: The aim of this study was to investigate the effects of exergame on patients’ balance and upper limb motor function after stroke. Methods: This study is a randomized controlled trial. Thirty-one participants of both genders, mean age of 76 years, were assigned to the experimental or control groups; the experimental group (n = 16) underwent exergame rehabilitation using Motion Rehab AVE 3D, and the control group (n = 15) underwent conventional physiotherapy. Both EG and GC sessions happened twice a week, for 30 minutes each, over a 12 weeks period, resulting in 24 sessions. All sessions were composed of similar exercises, with same purpose and elapsed time (5 minutes). Instruments applied to verify inclusion criteria were a sociodemographic questionnaire and clinical aspects and a Mini-Mental State Examination. At baseline and after 12 weeks of intervention, the Modified Ashworth Scale, the Fugl-Meyer Assessment, and the Berg Balance Scale were used. Results: In both groups, patients obtained significant improvement from baseline values in all analyzed variables (shoulder, elbow, and forearm; wrist; hand; and balance) (P < .001). In the intergroup comparison, there were significant differences between the 2 groups for changes in values from preintervention to postintervention of shoulder, elbow and forearm (P = .001), and total (P = .002). Conclusion: Exergame rehabilitation in poststroke patients can be an efficient alternative for restoring balance and upper limb motor function and might even reduce treatment time.     

Pelvic Belt Wearing during Exercise Improves Balance of Patients with Stroke: A Randomized,Controlled, Preliminary Trial

ObjectivesTo investigate whether wearing a pelvic belt during a trunk stability exercise program positively affects balance in patients with stroke.Materials and MethodsTwenty-four patients with stroke were randomly allocated to the experimental or control group and performed a 60-min general physical therapy and an additional 30-min trunk stability exercise (five times/week for 6 weeks). Those in the experimental and control groups performed the trunk stability exercises with and without wearing the pelvic belt, respectively.ResultsThe experimental group showed a significantly greater magnitude of improvements in balance than the control group (Postural Assessment Scale for Stroke: +18.3%, F (1, 22)=14.350, p=.001, η²=.395; Berg Balance Scale: +11%, F (1, 22)=19.062, p=.000, η²=.464; Timed Up and Go Test: ?10.5%, F (1, 22)=8.562, p=.008, η²=.280; center of pressure path length with eyes open: ?15.1%, F (1, 22)=6.770, p=.016, η²=.235; center of pressure path length with eyes closed: -19.5%, F (1, 22)=9.256, p=.006, η²=.296; center of pressure path velocity with eyes open: -22.6%, F (1, 22)=37.747, p=.000, η²=.632; center of pressure path velocity with eyes closed: ?13.9%, F (1, 22)=6.511, p=.018, η²=.228, respectively).ConclusionsWearing a pelvic belt while performing trunk stability exercise programs could be a more effective approach for improving balance in patients with stroke.     

Effects of a 4-Week Self-Ankle Mobilization with Movement Intervention on Ankle Passive Range of Motion,Balance, Gait,and Activities of Daily Living in Patients with Chronic Stroke: A Randomized Controlled Study

Goal

To compare the effects of a 4-week self-ankle mobilization with movement training program with those of self-ankle mobilization with movement with a 10° inclined board in patients with chronic stroke.

Mirror Illusion for Sensori-Motor Training in Stroke: A Randomized Controlled Trial

Background

Poststroke, sensory deficits are not uncommon. In spite of the close association between the sensory and motor recovery, the deficits are usually underemphasized. Mirror therapy (MT), a neural-based approach for the motor deficit has not been explored for the sensory impairment. The objective of the present study was to develop and determine the effect of a MT program for sensori-motor impairment among poststroke subjects.

Effects of Comprehensive Swallowing Intervention on Obstructive Sleep Apnea and Dysphagia After Stroke: A Randomized Controlled Trial

ObjectiveThis study aims to explore the effects of comprehensive swallowing intervention on obstructive sleep apnea (OSA) and dysphagia in stroke patients.MethodsWe performed a randomized controlled trial in stroke patients with obstructive sleep apnea (OSA) complicated by dysphagia, divided into treatment group and control group. The treatment group underwent comprehensive swallowing intervention and received swallowing care for 4 weeks, while the control group received only swallowing care. Outcome measurements were obtained at baseline and after the 4-week intervention, evaluated by polysomnography (PSG), videoendoscopic swallowing study (VFSS) synchronized surface electromyography (sEMG), oropharyngeal magnetic resonance imaging (MRI) and swallowing assessment scales.ResultsSixty patients with stroke (30 treatment and 30 control) were eligible to participate in this study. There were no significant differences in any assessment between two groups at baseline. After a 4-week intervention, compared with to control group, there was a significant decrease in the apnea-hypopnea index (AHI) and oxygen desaturation index (ODI), and increased mean and minimal oxygen saturation (SaO₂), amplitudes of suprahyoid muscle group (ASUPMG) and subhyoid muscle group (ASUBMG). Moreover, the posterior palatal distance (PPD), posterior lingual distance (PLD) and minimal cross-sectional area (MCSA) were obviously elevated in the treatment group. Additionally, the scores of Gugging swallowing screen (GUSS) and VFSS were significantly increased in the treatment group, compared to control group.ConclusionsThe comprehensive swallowing intervention had therapeutic effects on OSA and dysphagia after stroke, and the mechanism was related to enhancing oropharyngeal muscle strength and changing upper airway structure.     

Fragility Index in Randomized Controlled Trials of Ischemic Stroke

Objective: The fragility index (FI), a minimum number of events in 1 arm of a clinical trial required to revert the statistically significant result to nonsignificant, has recently been developed as an easy-to-understand novel metric to evaluate the robustness of randomized controlled trials (RCTs). Here, we evaluated the FI of RCTs in the field of neurology, particularly in studies of ischemic stroke. Methods: Previous literature published between June 1, 2012 and May 31, 2018 were reviewed from the MEDLINE database by the authors. The original article reporting the significant RCT result, of which a dichotomous outcome was set as its primary outcome measure, was included to evaluate the robustness of the result by calculating the FI. In addition, recent studies examining FI in other clinical fields were reviewed and summarized. Results: In the 25 eligible RCT studies, the median total number of study participants was 206 (inter quartile range: 144-450) and the median FI was 7 (inter quartile range: 4-15.0). The FI showed a strong negative correlation with the observed P value. There was no significant difference in the FI between RCTs with and without acute settings. Our median FI was higher than the median FI of 2.5 of previous studies examining FI in other clinical fields, as only 20% (5 of 25) of studies included in our study had an FI less than 2.5. Conclusion: Our results suggest that many RCTs in the field of ischemic stroke have a fair robustness, when compared to those in other clinical fields.     

Aggression Prevention Training for Individuals With Dementia and Their Caregivers: A Randomized Controlled Trial

ObjectiveInternational appeals call for interventions to prevent aggression and other behavioral problems in individuals with dementia (IWD). Aggression Prevention Training (APT), based on intervening in three contributors to development of aggression (IWD pain, IWD depression, and caregiver–IWD relationship problems) aims to reduce incidence of aggression in IWD over 1 year.DesignRandomized, controlled trial.SettingThree clinics that assess, diagnose, and treat dementia.ParticipantsTwo hundred twenty-eight caregiver–IWD dyads who screened positive for IWD pain, IWD depression, or caregiver–IWD relationship problems randomized to APT or Enhanced Usual Primary Care (EU-PC).InterventionAPT, a skills-based intervention delivered over 3 months to address pain/depression/caregiver–IWD relationship issues. EU-PC included printed material on dementia and community resources; and eight brief, weekly support calls.MeasurementsThe primary outcome was incidence of aggression over 1 year, determined by the Cohen Mansfield Agitation Inventory-Aggression Subscale. Secondary outcomes included pain, depression, caregiver–IWD relationship, caregiver burden, positive caregiving, behavior problems, and anxiety.ResultsAggression incidence and secondary outcomes did not differ between groups. However, in those screening positive for IWD depression or caregiver–IWD relationship problems, those receiving EU-PC had significant increases in depression and significant decreases in quality of the caregiver–IWD relationship, whereas those receiving APT showed no changes in these outcomes over time.ConclusionThe cost to patients, family, and society of behavioral problems in IWD, along with modest efficacy of most pharmacologic and nonpharmacologic interventions, calls for more study of novel preventive approaches.     

Virtual Reality in Upper Extremity Rehabilitation of Stroke Patients: A Randomized Controlled Trial

Objective

Virtual reality game system is one of novel approaches, which can improve hemiplegic extremity functions of stroke patients. We aimed to evaluate the effect of the Microsoft Xbox 360 Kinect video game system on upper limb motor functions for subacute stroke patients.

A Comparative Study of Two Tube Feeding Methods in Patients with Dysphagia After Stroke: A Randomized Controlled Trial

Background: Dysphagia is a common symptom seen in stroke patients, it not only affects patients' nutrition supply, but also causes aspiration pneumonia. To solve the problem of nutritional support for patients with dysphagia after stroke, nasogastric tubes are routinely indwelling to provide nutrition in China. However, this feeding method sometimes causes food reflux, aspiration, pneumonia, and often affects the patients’ comfort and self-image acceptance. Aim: The aim of this study was to determine whether a new feeding method called intermittent oroesophageal (IOE) tube feeding compared with continuous nasogastric tube feeding as a practical and beneficial mean of decreasing the rate of stroke associated pneumonia (SAP), and improving patients’ swallowing function, comfort, psychological status. Design: This was an assessor-blinded, single-center, randomized controlled trial. Methods: Ninety-seven hospitalized stroke patients with dysphagia in the rehabilitation department from January to December 2018 were randomized to a control group and an intervention group. Patients in both groups received routine nursing, rehabilitation treatment and swallowing therapy. Patients in the intervention group were given IOE tube feeding, while those in the control group were fed by indwelling nasogastric tube. Outcomes were assessed at admission, discharge or the end of the tube feeding. Results: The incidence of SAP in the intervention group was 16.33% lower than that (31.25%) in the control group; the comfort score (2.08 ± .64), anxiety score (10.98 ± 2.28), depression score (7.39 ± 2.16) were lower than those (3.02 ± .70), (12.10 ± 2.18), (8.42 ± 2.34) in the control group. The improvement rate of swallowing function in the intervention group was 83.67% higher than that (66.67%) in the control group (all P < .05). Conclusions: The IOE tube feeding compared with continuous tube feeding may reduce the incidence of SAP, and improve patients’ swallowing function, comfort, psychological status in patients with dysphagia after stroke.