Effects of Virtual Reality Compared to Conventional Therapy on Balance Poststroke: A Systematic Review and Meta-Analysis

Objective: The objective of this study was to systematically review the effect of virtual reality on balance as compared to conventional therapy alone poststroke. Methods: The databases of PubMed, Cochrane, and Ovid were searched using select keywords. The randomized controlled trials published between January 2000 and August 2017 in English language were included if they assessed the effect of virtual reality on balance ability compared to conventional therapy alone in adults’ poststroke. The Physiotherapy Evidence Database scale was used to assess the methodological quality. Results: Fourteen papers were included in this review. The experimental groups largely (n = 13) used virtual reality in combination with conventional therapy. Among the high quality studies, significant between-group improvement favoring virtual reality in combination with conventional therapy was found on Berg Balance Scale (n = 7) and Timed Up and Go Scale (n = 7) when compared to conventional therapy alone. The studies were limited by low powered, small sample sizes ranging from 14 to 40, and lack of blinding, concealed allocation, and reporting of missing data. Thirteen homogenous (n = 348, I² = 37.6%, P = .083) studies were included in the meta-analysis using Berg Balance Scale. Significant improvement was observed in the experimental group compared to control group with a medium effect size of .64, confidence interval of .36-.92. Conclusions: The findings of this review indicate that virtual reality when combined with conventional therapy is moderately more effective in improving balance than conventional therapy alone in individuals’ poststroke.     

Meteorological Factors and Seasonal Stroke Rates: A Four-year Comprehensive Study

Introduction: There is a growing body of evidence suggesting that acute cardiovascular events including stroke are not distributed randomly over time but instead depend on months/season of the year. We report the impact of meteorological variables in extremely hot and arid climate on stroke. Methods: Acute stroke patients admitted from January 2014 to December 2017 were included. The data included demographics, clinical risk factors, temperature, solar radiation, relative humidity, dew point, wind speed, and atmospheric pressure. We calculated stroke rates/100,000/month. Results: There were 3654 cases of stroke (ischemic stroke [IS]: 2956 [80.9%]; and intracerebral hemorrhage [ICH]: 698 [19.1%]) with no difference in hematocrit, creatinine, and blood urea between hot and cold seasons (p > .05). We observed a positive significant correlation of IS with the mean temperature (AOR: 1.023; 95% CI: 1.009-1.036; P = .001) and mean solar radiation (AOR: 1.268; 95% CI: 1.021-1.575; P = .032) showing a 2.3% and 26.8% higher risk relative to ICH respectively, a negative correlation between IS with relative humidity (AOR: 0.99; 95% CI: 0.984-0.997; P = .002), and atmospheric pressure (AOR: 0.977; 95% CI: 0.966-0.989; P < .001) was observed, 1% increase in the relative humidity correlate with 2.4% and 1% lower risk of IS incidence relative to ICH respectively. Conclusion: We demonstrated a distinct seasonal pattern in the incidence of stroke with an increase in IS rates relative to ICH during the summer months with higher solar radiations that cannot be explained by physiological measures suggestive of dehydration or hem-concentration.     

Toward Improving Poststroke Aphasia: A Pilot Study on the Growing Use of Telerehabilitation for the Continuity of Care

Background: Aphasia is a quite common and very disabling symptom following stroke, negatively affecting patient's quality of life. Aim of the study is to evaluate the effectiveness of a rehabilitation training for aphasia that employ a touch-screen tablet using a virtual reality rehabilitation system (VRRS-Tablet). Material and Methods: Thirty patients with aphasia due to ischemic or hemorrhagic stroke were randomized into either the control or the experimental group and assessed by means of a specific neuropsychological evaluation. The study lasted 6 months and included 2 phases. During the former, the experimental group underwent an experimental linguistic treatment performed using the VRRS-Tablet, while the control group was trained with a traditional linguistic treatment. In the latter, the control groups were delivered to territorial services, while the experimental group was provided with the VRRS-Tablet. Results: The experimental group improves in all the investigated areas, except for writing, while the control group only improves in comprehension, depression, and quality of life. Conclusions: Our study has demonstrated the effectiveness of a home-based telerehabilitation program specific for poststroke aphasia. The use of telerehabilitation by means of VRRS-Tablet could be one of the best solutions to treat aphasic patients after their discharge, promoting continuity of care by monitoring functional outcomes, maintaining preserved abilities, reducing depression, and improving linguistic functions, besides the psychological well-being.     

The Effectiveness of Fluidotherapy in Poststroke Complex Regional Pain Syndrome: A Randomized Controlled Study

Objective: To evaluate whether combining fluidotherapy to conventional rehabilitation program provides additional improvements on pain severity, upper extremity functions, and edema volume in patients with poststroke complex regional pain syndrome (CRPS). Design: Randomized controlled trial. Setting: Training and research hospital. Participants: Thirty hemiplegic patients with subacute stage CRPS type-1 of the upper extremity. Interventions: The patients randomly divided into 2 groups. Both groups received a 3 week conventional rehabilitation program (5 days/week, 2-4 hours/day). Experimental group received 15 sessions additional fluidotherapy application to the affected upper extremity (40 °C, 20 minutes in continuous mode, 5 sessions/week). Main Outcome Measures: We evaluated the distal upper arm edema with a volumeter. Other used clinical assessment scales were Brunnstrom recovery stages of the arm and hand for motor recovery, motor items of the functional independence measure for functional status, visual analog scale for pain severity, and the painDETECT questionnaire for presence and the severity of neuropathic pain. Results: The mean age of the participants was 64.3 ± 11.66 (28-84). At the post-treatment evaluation, significant improvements were revealed regarding to the edema volume, pain visual analog scale, painDETECT and functional independence measure scores, and the Brunnstrom stages of upper extremity and hand in both groups (P < .05). But among the parameters mentioned above, only the decrease in edema volume and the painDETECT scores were greater in fluidotherapy group than the control group (P < .05). Conclusions: Addition of the fluidotherapy to the conventional rehabilitation program provides better improvements on neuropathic pain and edema volume in subacute stage poststroke CRPS.     

The Effect of Occupation-Based Bilateral Upper Extremity Training in a Medical Setting for Stroke Patients: A Single-Blinded,Pilot Randomized Controlled Trial

Background: Occupation used in occupation-based intervention requires the use of 2 naturally coordinated hands. Objective: To investigate by implementing occupation-based bilateral upper extremity training in medical setting to stroke patients and determine its effect in patients’ bilateral upper extremity function recovery. Methods: A total of 20 patients were randomly assigned to the experimental group (occupation-based bilateral upper extremity training) or control group (task-based bilateral upper extremity training). The intervention of the 2 groups was conducted 30 minutes a day, 5 times a week, and 4 weeks long. The outcome was assessed using the Canadian Occupational Performance Measure, Stroke Impact Scale, Action Research Arm Test, the Yonsei-Bilateral Activity Test, Accelerometer, and participants were assessed at baseline and after 4 weeks. Results: There was a significant change in the satisfaction and performance status of occupational performance, strength, Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL), emotion, participant recovery in stroke recovery, gross movement in the function of the affected side, satisfaction in perform bilateral upper extremity in the experimental group compared to the control group. Conclusions: The clinical significance of this study is that this study demonstrated the effectiveness and usefulness of the training in the actual medical setting in improving upper extremity function and psychosocial factors.     

Hearing Impairment,Loneliness, Social Isolation,and Cognitive Function: Longitudinal Analysis Using English Longitudinal Study on Ageing

ObjectiveThis study examines the relationships between hearing impairment and cognitive function among older adults, and whether that association is mediated by loneliness and social isolation.MethodsData were drawn from English Longitudinal Study of Ageing (ELSA) wave two (2004/2005) until wave seven (2014/2015). The study sample consisted of 8,199 individuals aged 50 years or older. Cognitive function was measured using episodic memory. We performed analysis using a generalized structural equation modeling (GSEM) technique.ResultsGSEM analysis shows that the direct effect of hearing impairment on episodic memory was negative and significant (β = ?0.29, p <0.001). Loneliness and social isolation mediated that effect. Hearing impairment was positively associated with loneliness (β = 0.10, p <0.001) and social isolation (β = 0.04, p <0.001). Loneliness (β = ?0.08, p <0.001) and social isolation (β = ?0.09, p = 0.001) were significantly associated with lower memory scores.ConclusionThe link between hearing impairment and episodic memory was partly mediated by loneliness and social isolation. Interventions to improve the social networks of older adults with hearing impairment are likely to be beneficial in preventing cognitive decline. Thus, the importance of maintaining social relationships among older adults, especially those with hearing impairment is highlighted.     

Repeated Use of 6-min Walk Test with Immediate Knowledge of Results for Walking Capacity in Chronic Stroke: Clinical Trial of Fast versus Slow Walkers

Aim: This study aimed to determine the effects of repeated use of the 6-minute walk test (6MWT) with immediate knowledge of results (KR) on the walking capacity by comparing fast and slow walkers in patients with chronic hemiparesis. Methods: Twenty-five subjects were allocated to 2 groups depending on their walking speed¹: Group 1 (fast walkers, n₁ = 11): greater than equal to .8 m/s and² Group 2 (slow walkers, n₂ = 14): less than .8 m/s. All subjects underwent the 6MWT once a day, 5 days a week, for 4 weeks (a total of 20 sessions). The 6MWT was performed on a 30-m path with immediate KR; subjects informed the time taken to walk each 30-m path. Outcome measures included the 6MWT and 10-meter walk test (10MWT). Measurements were taken before and after 4 weeks. Results of within-group comparisons showed significant improvements in the 10MWT and 6MWT for both groups pre- and post-test (P < .05). Furthermore, in between-group comparison, results of Group 1 differences were greater between pre- and post-test in the 10MWT and 6MWT values as compared to Group 2 (P < .05). These findings indicate that repeated use of the 6MWT with immediate KR may be beneficial to enhance walking capacity in patients with chronic stroke, with more favorable changes in better poststroke walking speed.     

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.     

Effects of capsaicin on swallowing function in stroke patients with dysphagia: A randomized controlled trial

Background/AimsDysphagia is a common complication after acute stroke. While there are several innovative treatments being tested to improve the swallowing function of stroke patients with dysphagia, our aim is to explore the use of readily available natural capsaicin in stroke patients with dysphagia.Study designA randomized, double-blind study.MethodsSixty-nine hospitalized stroke patients were enrolled in this study. The capsaicin intervention group received thermal tactile stimulation with supplementation of natural capsaicin and additional nectar viscosity boluses. The control group received stimulation and boluses with placebo. Swallowing function was evaluated before and after the 3-week treatment, using Volume-Viscosity Swallow Test, Eating Assessment Tool, Standardized Swallowing Assessment, and Water Swallow Test.ResultsThe score decreases in the Eating Assessment Tool and Standardized Swallowing Assessment of the capsaicin intervention group were significantly greater than that of the placebo control group (P < .01). Among the 60 patients, the capsaicin intervention group exhibited effectiveness in a higher number of patients (n = 27, 90%) than the placebo group (n = 9, 30%, P < .001).ConclusionsRegular use of natural capsaicin could promote the recovery of swallow function in stroke patients with dysphagia. The ample availability of natural capsaicin could provide a low cost, easily accessible, and safe alternative method to address dysphagia in stoke patients.     

Prognostic Value of Clot Burden Score in Acute Ischemic Stroke after Reperfusion Therapies: A Systematic Review and Meta-Analysis

Background and Aim: Clot burden score (CBS) was designed to weight the thrombus status in cerebral anterior circulation. We performed a systematic review and meta-analysis to investigate the prognostic value of CBS in acute ischemic stroke (AIS) patients undergoing reperfusion therapies. Methods: We searched relevant databases for eligible articles reporting CBS in AIS patients. The effect sizes of good functional outcome, recanalization, or hemorrhagic transformation (HT) were pooled with random-/fixed-effect models. Sensitivity analyses and heterogeneity tests were performed. Results: Fifteen eligible studies enrolling 3302 AIS patients undergoing reperfusion therapies were included. AIS patients with per 1-point increase CBS were associated with good functional outcome (pooled odds ratio [OR]: 1.15, 95% confidence interval [CI]: 1.09-1.20) and high rate of recanalization (pooled OR: 1.27, 95% CI: 1.14-1.40). Results from categorical groups indicated high CBS at baseline was associated with higher likelihood of good functional outcome (pooled OR: 1.59, 95% CI: 1.30-1.94) and superior recanalization rates (pooled OR: 2.53, 95% CI: 1.79-3.57). Further stratified analyses showed in intravenous thrombolysis (IVT) alone group, increasing CBS was associated with good functional outcome (continuous pooled OR: 1.18, 95% CI: 1.10-1.27; categorical pooled OR: 3.38, 95% CI: 2.01-5.69) or recanalization (categorical pooled OR: 4.13, 95% CI: 2.00-8.51), but not in endovascular therapy alone group. No significant association was found between CBS and HT. Conclusions: CBS could be a predictor for AIS after reperfusion therapies in functional outcome and successful recanalization particularly in patients receiving IVT alone; while CBS might not be a predictor for HT.     

The Construction and Evaluation of Executive Attention Training to Improve Selective Attention,Focused Attention,and Divided Attention for Older Adults With Mild Cognitive Impairment: A Randomized Controlled Trial

ObjectivesTo examine the immediate and long-term effects of executive attention training on selective attention, focused attention, and divided attention in older adults with mild cognitive impairment.MethodsA double-blind, multisite randomized controlled trial at five sites. Seventy participants (mean age: 78.19 ± 7.22 years) were assigned to an experimental group (executive attention training, n = 35) or an active control group (n = 35). The training duration was the same for both groups (45 minutes per session, 3 times per week, 18 sessions in total). Primary outcome measure was selective attention (Digit Span Task). Secondary outcome measures included focused attention (Stroop Color Word Test) and divided attention (Trail-Making Test Part B). Data were collected at pretest, post-test, 3-month follow-up, and 6-month follow-up.ResultsIn GEE analysis, findings indicated a significant improvement in selective attention at post-test, whereas divided attention showed significant reducing omission error at 3-month follow-up. There was no significant effect of group in focused attention associated with the executive attention training compared with active control group.ConclusionThe executive attention training significantly improved selective attention and divided attention performance. Future studies should identify transfer effects of attention training, and that can employ early screening to provide integrated attention training, and decrease its relevant risks on competency in performing daily activities, such as falling and driving.     

Temporal Trends in Clinical Characteristics and Door-to-Needle Time in Patients Receiving Intravenous Tissue Plasminogen Activator: A Retrospective Study of 4 Hospitals in Japan

Background: Intravenous recombinant tissue plasminogen activator (rt-PA) has become a common treatment for acute ischemic stroke and has highly time-dependent benefits. We aimed to clarify temporal trends regarding the frequency and characteristics of patients receiving rt-PA and explore factors associated with door-to-needle time (DNT) in Japanese emergency hospitals. Methods: Consecutive patients who received intravenous rt-PA for acute ischemic stroke from October 2005 to December 2015 were retrospectively registered from 4 hospitals. Temporal trends in the frequency and characteristics of patients receiving rt-PA and factors associated with DNT were investigated. Results: A total of 750 patients, including 688 (420 men, median 75 years old) with out-of-hospital stroke, were registered. The frequency of patients receiving intravenous rt-PA for acute ischemic stroke continuously increased from 1.8% in 2005 to 9.5% in 2015. The proportion of patients who were elderly or had prestroke disability increased over time, while pretreatment stroke severity declined. The DNT gradually decreased (median 105 minutes in 2005, 61 minutes in 2015). According to multivariate regression analysis with correction for multiple comparisons, activation of a code stroke system (standardized partial regression coefficient (β) ?.50, P < .001, q < .001), onset-to-door time (β ?.15, P < .001, q < .001), pretreatment with antithrombotic agents (β .12, P < .001, q = .001), and year of treatment (β .11, P = .007, q = .011) were associated with DNT. Conclusions: Intravenous rt-PA was widely adopted in Japanese emergency hospitals. Characteristics of patients receiving intravenous rt-PA have changed over the past decade. Several factors, including the year of treatment, were associated with DNT, which has shortened over time.     

Hematoma Expansion Predictors: Laboratory and Radiological Risk Factors in Patients with Acute Intracerebral Hemorrhage: A Prospective Observational Study

BackgroundIntracerebral hemorrhage (ICH) is considered a devastating neurologic emergency and carried a higher morbidity and mortality rates. Early hematoma expansion (HE) is considered one of the poor prognostic factors after ICH. Consequently, determination of the possible risk factors for HE could be effective in early detection of high-risk patients and hence directing management course aiming to improving ICH outcome.MethodsOne-hundred and thirty-six spontaneous ICH patients were included and prospectively evaluated for the presence of HE. Demographic, laboratory, and certain radiological factors were studied and compared between those with HE and those without, the in-hospital mortality rates were assessed as well.ResultsHE was observed in 30% of the studied cohort, those who developed HE had more neurologic impairment (Glasgow coma scale, median 9; National Institute of Health Stroke Scale, median 34), and higher in-hospital mortality rate (53.6%) than those without HE. HE was related to the presence of higher red blood cell distribution width (RDW), reduced total cholesterol, low-density lipoprotein-C (LDL-C), and Ca levels. Among the radiological factors, hematoma density (heterogeneous), and shape (irregular) are highly related to the occurrence of HE. The computed tomography angiography (CTA) spot sign among patients with ICH was associated with HE development.ConclusionsAbnormal RDW; low cholesterol, LDL, and Ca level; heterogeneous density, irregular shape hemorrhage, and presence of CTA spot sign were associated with the development of HE in the setting of spontaneous ICH.     

Plasma Levels of miR-125b-5p and miR-206 in Acute Ischemic Stroke Patients After Recanalization Treatment: A Prospective Observational Study

Introduction: Multiple microRNAs (miRNAs) participate in the response to hypoxic/ischemic and ischemia-reperfusion events. However, the expression of these miRNAs in circulation from patients with acute ischemic stroke (AIS) receiving recanalization treatment has not been examined, and whether they are associated with the severity and outcome of stroke is still unknown. Materials and methods: In this prospective cohort study, plasma levels of miR-125b-5p, miR-15a-3p, miR-15a-5p, and miR-206 were measured at 24 hours after thrombolysis with or without endovascular treatment in 94 patients with AIS, as determined by qRT-PCR. Stroke severity was assessed based on National Institutes of Health Stroke Scale (NIHSS) score and infarct lesion. Intracranial haemorrhage (ICH) was recorded. An unfavorable outcome was defined as a modified Rankin Scale score greater than 2 at day 90 after stroke. Results: miR-125b-5p and miR-206 levels were correlated with NIHSS scores (P = .014 and P = .002) and cerebral infarction volumes (P = .025 and P = .030). miR-125b-5p levels were significantly higher in patients with an unfavorable outcome than in patients with a favorable outcome (P = .002) and showed good diagnostic accuracy in discriminating the presence of an unfavorable outcome (area under the curve .735, 95% confidence interval .623-.829, P < .001). No association was found between different miRNAs and ICH. Conclusions: In AIS patients after thrombolysis with or without endovascular treatment, miR-125b-5p is a novel prognostic biomarker highly associated with an unfavorable outcome. miR-125b-5p and miR-206 levels are associated with stroke severity.