Cognitive Reserve Modifies the Relationship Between Neural Function,Neural Injury and Upper-Limb Recovery After Stroke

ObjectiveTo investigate whether cognitive reserve modifies the relationship between functional connectivity, lesion volume, stroke severity and upper-limb motor impairment and recovery in stroke survivors.MethodsTen patients with first-ever ischemic middle cerebral artery stroke completed the Cognitive Reserve Index Questionnaire at baseline. Upper-limb motor impairment and functional connectivity were assessed using the Fugl-Meyer Assessment and electroencephalography respectively at baseline and 3-months post-stroke. A debiased weighted phase lag index was computed to estimate functional connectivity between electrodes. Partial least squares (PLS) regression identified a connectivity model that maximally predicted variance in the degree of upper-limb impairment. Regression models were generated to determine whether cognitive reserve modified the relationship between neural function (functional connectivity), neural injury (lesion volume), stroke severity (National Institutes of Health Stroke Scale) and upper-limb motor impairment at baseline and recovery at 3-months (Fugl-Meyer Assessment).ResultsThe addition of cognitive reserve to a regression model with a dependent variable of upper-limb motor recovery and independent variables of functional connectivity between the ipsilesional motor cortex and parietal cortex, stroke severity and lesion volume improved model efficiency (?BIC=-7.07) despite not reaching statistical significance (R²=0.90, p=0.07). Cognitive reserve did not appear to improve regression models examining motor impairment at baseline.ConclusionsPreliminary observations suggest cognitive reserve might modify the relationship between neural function, neural injury, stroke severity and upper-limb motor recovery. Further investigation of cognitive reserve in motor recovery post-stroke appears warranted.     

Transcranial Magnetic Stimulation-EEG Biomarkers of Poststroke Upper-Limb Motor Function

BackgroundMotor evoked potentials obtained with transcranial magnetic stimulation (TMS) can provide valuable information to inform stroke neurophysiology and recovery but are difficult to obtain in all stroke survivors due to high stimulation thresholds.ObjectiveTo determine whether transcranial magnetic stimulation evoked potentials (TEPs) evoked using a lower stimulus intensity, below that necessary for recording motor evoked potentials, could serve as a marker of poststroke upper-limb motor function and were different compared to healthy adults.MethodsEight chronic stroke survivors (66 ± 21 years) and 15 healthy adults (53 ± 10 years) performed a motor function task using a customized grip-lift manipulandum. TMS was applied to the lesioned motor cortex, with TEPs recorded using simultaneous high-definition electroencephalography (EEG).ResultsStroke participants demonstrated greater hold ratio with the manipulandum. Cluster-based statistics revealed larger P30 amplitude in stroke participants, with significant clusters over frontal (P = .016) and parietal-occipital electrodes (P = .023). There was a negative correlation between the N45 peak amplitude and hold ratio in stroke participants (r = ?.83, P = .02), but not controls.ConclusionsTEPs can be recorded using lower stimulus intensities in chronic stroke. The global P30 TEP response differed between stroke participants and healthy controls, with results suggesting that the TEP can be used as a biomarker of upper-limb behavior.     

Response to Speech and Language Therapy According to Artery Involvement and Lesion Location in Post-stroke Aphasia

PurposeAphasia is one of the most common complications after stroke and occurs in 21–38% of the patients during acute period. The present study aimed to investigate the response to speech and language therapy according to artery involvement and lesion location in patients with post-stroke aphasia.MethodThe medical records of 107 patients with post-stroke aphasia (mean age, 58.8 ± 14.8 years) who were admitted to a single rehabilitation center for usual care after stroke were reviewed. Location of the ischemic lesion and involved artery was determined assessing the brain MRI of the patients. All the patients received 24 sessions speech and language therapy (3 days a week) as a part of 8-week rehabilitation program. Evaluation of the aphasia was performed with Gülhane Aphasia Test-2 (GAT-2) at baseline and at the end of the rehabilitation program.ResultsBaseline GAT-2 scores was significantly worse in patients with middle cerebral artery (MCA) involvement compared to patients with other artery involvements (p = 0.007). While the GAT-2 scores of patients with MCA involvement were improved significantly after speech and language therapy (p < 0.001), the changes in those with anterior cerebral artery (ACA) and posterior cerebral artery (PCA) involvements were not significant (p > 0.05).ConclusionsThe present findings suggested that speech functions might be more affected in ischemic lesion of MCA and response to SLT might be better in patients with MCA involvement.     

Factors related to daily step counts of stroke patients during hospitalization in a convalescent rehabilitation ward

ObjectivesClarifying the factors related to decreased physical activity in post-stroke patients is essential for effective disease management. This study aimed to examine the factors influencing the amount of daily steps taken by post-stroke patients in a convalescent rehabilitation ward during activities other than rehabilitation (non-rehabilitation steps).Materials and methodsEighty-nine post-stroke patients (60.8±14.4 years; 55 men) were enrolled. The inclusion criteria were walking independently within the ward and having a walking speed of ≥24 m/min. Data on patient clinical characteristics including age, sex, body mass index, stroke type, hemiparetic side, and time from stroke onset were collected. Stroke impairment and motor and cognitive functional disabilities were assessed using the Stroke Impairment Assessment Set and the Functional Independence Measure, respectively. The non-rehabilitation steps were calculated by subtracting the steps during the rehabilitation activities from the total steps using Fitbit Flex2.ResultsThe average number of non-rehabilitation steps was 4,523±2,339 steps/day. The hierarchical multiple regression analysis revealed that sex, motor disability, and the interaction term of stroke impairment with cognitive disability were significantly related to non-rehabilitation steps. Simple slope analysis demonstrated that the stroke impairment slope was steeper at lower levels than at higher levels of cognitive disability for non-rehabilitation steps.ConclusionsIn addition to independent effects of sex and motor disability, this study found that stroke impairment and cognitive disability were interactively related to non-rehabilitation steps in post-stroke patients in a convalescent rehabilitation ward. These findings may provide useful information for managing physical activity in post-stroke patients after hospital discharge.     

Effects of Motor Imagery as a Complementary Resource on the Rehabilitation of Stroke Patients: A Meta-Analysis of Randomized Trials

BackgroundStroke is the second leading cause of death and a leading cause of disability worldwide. Motor imagery is a technique that can be utilized in the rehabilitation process to improve the lives of patients with a functional disability acquired by this pathology.AimTo evaluate the effects of motor imagery as a complementary intervention for the rehabilitation of stroke patients.MethodsWe conducted a systematic review in MEDLINE/PubMed, Scopus, Web of Science, and PEDro databases. We included randomized controlled trials (RCTs) that used motor imagery as a complementary resource for the rehabilitation of patients affected by stroke, who had motor function and functional independence as outcomes.ResultsOf the 1,473 studies found, ten RCTs were included. Regarding the interventions, motor imagery was associated with traditional rehabilitation, virtual reality, physical practice, structured progressive circuit class therapy, and electromyography. The upper and lower extremity performance were accessed through the Fugl-Meyer Assessment (FMA) and gait speed, respectively. Although the practice of motor imagery at least twice a week during three weeks showed to be effective in improving the motor performance of post-stroke patients, the studies’ protocols present a high heterogeneity, with training session times lasting between 30 to 180 minutes and a post-stroke invention window of one to 12 months.ConclusionsMotor imagery has been shown to be an efficacious technique in the treatment of post-stroke patients when used as a complement to traditional rehabilitation techniques. However, greater standardization of interventions and studies with higher methodological quality are required to determine further conclusions.     

Changes of cortico-cortical neural connections associated with motor functional recovery after stroke

ObjectivesDuring functional recovery after stroke, some neural connections in the brain are augmented and new neural networks are constructed to compensate for impaired neurological functions. Recently, it was reported that the extent of cortico-cortical neural connections can be estimated by correlation analysis based on electroencephalography (EEG). The purpose of this study was to investigate changes of correlation coefficients in the cerebral cortex with motor functional recovery after stroke.Materials and methodsTwenty-two post-stroke hemiparetic patients admitted to our rehabilitation ward (mean age at admission: 71.4 ± 12.9 years old), were studied. For the evaluation of hemiparesis, Fugl-Meyer Assessment (FMA) was applied. All subjects underwent EEG with electrodes placed according to the international 10-20 system for correlation analysis, on admission to our ward and 4 weeks after admission. EEG data were analyzed with the program software FOCUS (NIHON KOHDEN, Japan), and squared correlation coefficients in some cortico-cortical areas of the cerebral cortex were calculated.ResultsThe correlation coefficients in some cortico-cortical areas of the lesional hemisphere, such as C3-F3 or C4-F4, C3-F7 or C4-F8, and F3-F7 or F4-F8, significantly increased with rehabilitation training. The change of the correlation coefficient in F3-F7 or F4-F8 and F7-T3 or F8-T4 in the lesional hemisphere was significantly correlated with the change of the upper-limb FMA.ConclusionsThe augmentation of cortico-cortical connections, represented by an increase of the correlation coefficient in the lesional hemisphere, may contribute to motor functional recovery, especially in hemiparetic upper limbs, after stroke.     

Assessment of backward walking unmasks mobility impairments in post-stroke community ambulators

Background: While over half of stroke survivors recover the ability to walk without assistance, deficits persist in the performance of walking adaptations necessary for safe home and community mobility. One such adaptation is the ability to walk or step backward. Post-stroke rehabilitation rarely includes backward walking (BW) assessment and BW deficits have not been quantified in post-stroke community ambulators.

Objective: To quantify spatiotemporal and kinematic BW characteristics in post-stroke community ambulators and compare their performance to controls.

Methods: Individuals post-stroke (n = 15, 60.1 ± 12.9 years, forward speed: 1.13 ± 0.23 m/s) and healthy adults (n = 12, 61.2 ± 16.2 years, forward speed: 1.40 ± 0.13 m/s) performed forward walking (FW) and BW during a single session. Step characteristics and peak lower extremity joint angles were extracted using 3D motion analysis and analyzed with mixed-method ANOVAs (group, walking condition).

Results: The stroke group demonstrated greater reductions in speed, step length and cadence and a greater increase in double-support time during BW compared to FW (p < .01). Compared to FW, the post-stroke group demonstrated greater reductions in hip extension and knee flexion during BW (p < .05). The control group demonstrated decreased plantarflexion and increased dorsiflexion during BW, but these increases were attenuated in the post-stroke group (p < .05).

Conclusions: Assessment of BW can unmask post-stroke walking impairments not detected during typical FW. BW impairments may contribute to the mobility difficulties reported by adults post-stroke. Therefore, BW should be assessed when determining readiness for home and community ambulation.     

Does training with traditionally presented and virtually simulated tasks elicit differing changes in object interaction kinematics in persons with upper extremity hemiparesis?

Abstract

Objective:

To contrast changes in clinical and kinematic measures of upper extremity movement in response to virtually simulated and traditionally presented rehabilitation interventions in persons with upper extremity hemiparesis due to chronic stroke.

Design:

Non-randomized controlled trial.

Setting:

Ambulatory research facility.

Participants:

Subjects were a volunteer sample of twenty one community-dwelling adults (mean age: 51?±?12 years) with residual hemiparesis due to stroke more than 6 months before enrollment (mean: 74?±?48 months), recruited at support groups. Partial range, against gravity shoulder movement and at least 10° of active finger extension were required for inclusion. All subjects completed the study without adverse events.

Interventions:

A 2 weeks, 24-hour program of robotic/virtually simulated, arm and finger rehabilitation activities was compared to the same dose of traditionally presented arm and finger activities.

Results:

Subjects in both groups demonstrated statistically significant improvements in the ability to interact with real-world objects as measured by the Wolf Motor Function Test (P?=?0.01). The robotic/virtually simulated activity (VR) group but not the traditional, repetitive task practice (RTP) group demonstrated significant improvements in peak reaching velocity (P?=?0.03) and finger extension excursion (P?=?0.03). Both groups also demonstrated similar improvements in kinematic measures of reaching and grasping performance such as increased shoulder and elbow excursion along with decreased trunk excursion.

Conclusions:

Kinematic measurements identified differing adaptations to training that clinical measurements did not. These adaptations were targeted in the design of four of the six simulations performed by the simulated activity group. Finer grained measures may be necessary to accurately depict the relative benefits of dose matched motor interventions.     

Stroke Recovery Program with Modified Cardiac Rehabilitation Improves Mortality,Functional & Cardiovascular Performance

BackgroundPhysical activity and exercise after stroke is strongly recommended, providing many positive influences on function and secondary stroke prevention. The purpose of this study was to investigate the effect of a stroke recovery program (SRP) integrating modified cardiac rehabilitation on mortality and functional outcomes for stroke survivors.MethodsThis study used a retrospective analysis of data from a prospectively collected stroke rehabilitation database which followed 449 acute stroke survivors discharged from an inpatient rehabilitation facility between 2015 and 2020. For 1-year post-stroke, 246 SRP-participants and 203 nonparticipants were compared. The association of the SRP including modified cardiac rehabilitation with all-cause mortality and functional performance was assessed using the following statistical techniques: log rank test, Cox proportional hazard model and linear mixed effect models. Cardiovascular performance over 36 sessions of modified cardiac rehabilitation was assessed using linear effect model with Tukey procedure. The primary outcome measure was 1-year all-cause mortality rate. Secondary outcomes were functional performance measured in Activity Measure of Post-Acute Care scores and cardiovascular performance measured in metabolic equivalent of tasks times minutes.ResultsThe SRP-participants had: (1) a significantly reduced 1-year post-stroke mortality rate from hospital admission corresponding to a four-fold reduction in mortality (P = 0.005, CI for risk ratio = [0.08, 0.71]), (2) statistically and clinically significant improvement of function in all Activity Measure of Post-Acute Care domains (P < 0.001 for all, 95% CI for differences in Basic Mobility [5.9, 10.1], Daily Activity [6.2, 11.8], and Applied Cognitive [3.0, 6.8]) compared to the matched cohort and (3) an improvement in cardiovascular performance over 36 sessions with an increase of 78% metabolic equivalent of tasks times minutes (P < 0.001, 95% CI [70.6, 85.9%]) compared to baseline.ConclusionsStroke survivors who participated in a comprehensive stroke recovery program incorporating modified cardiac rehabilitation had decreased all-cause mortality, improved overall function, and improved cardiovascular performance.     

Clinical application of backward walking training to improve walking function,balance, and fall-risk in acute stroke: a case series

Background: With limited inpatient rehabilitation (IR) length of stays for patients post-stroke, it is critical to maximize the effectiveness of interventions to address their balance and gait speed deficits. Backward walking (BW) is an emerging training approach; however, its application to patient populations consistent with those in IR is limited.

Objectives: To describe the effects of an additional BW training program to standard IR care on balance, walking ability and fall-risk in a heterogenic caseload of adults <2 weeks post-stroke with a broad range of lesion locations and physical sequelae.

Methods: Eight patients with first-time stroke (5 male; average age 66.5 ± 11.7 years; average stroke onset 7.6 ± 1.6 days; 6 right hemiparesis) participated in 10-daily sessions that included 20 min of over ground BW training for each session, in addition to standard IR. Standard outcome measures were used to assess balance, walking ability and fall-risk at admission and post-intervention.

Results: All eight patients demonstrated improvements in all outcomes with a clinically meaningful increase in forward walking speed, as measured by 10MWT. Four participants exceeded fall-risk cut-off scores for all balance-related outcome measures.

Conclusions: In a diverse patient population early after stroke, individuals successfully participated in an additional BW training program. Despite the patients’ acuity and severe impairments in walking, significant gains in balance and walking function were noted. This program may be useful in improving outcomes with patient characteristics commonly seen in IR.     

Factors affecting rehabilitation and use of upper limb after stroke: views from healthcare professionals and stroke survivors

Background: Training of the upper limb (UL) is limited in stroke rehabilitation, and about 50% of stroke survivors do not regain useful function in their upper limb.

Objectives: This study explored what factors affect rehabilitation and use of upper limb after stroke from a stroke survivor and healthcare professional perspective to better understand low engagement in UL rehabilitation in the chronic stages of stroke.

Method: Eight chronic stroke survivors and 21 healthcare professionals took part in semi-structured interviews or in one of three focus groups, respectively.

Results: Thematic analysis revealed three main themes: Availability of resources, Healthcare professional–patient relationship, and Psychosocial factors. Availability of resources and Healthcare professional–patient relationship indicated that due to resource pressures and a lack of communication and education, positive upper limb rehabilitation behaviors (e.g. engaging and integrating the upper limb in daily activity) were not always established in the early stages post-stroke. Psychosocial factors illustrated the cognitive and psychological barriers to sustained engagement with upper limb rehabilitation.

Conclusion: The findings indicate that stroke survivors and healthcare professionals have very similar understandings of barriers to UL activity, and positive upper limb rehabilitation behaviors are not always established early in recovery post-stroke. Increased resources and healthcare professional–patient relationships seem key factors to establishing positive perceptions of UL rehabilitation. Addressing psychosocial issues and resource limitations may help sustain engagement with UL rehabilitation.     

Comprehensive Use of Dynamic Electrical Neurostimulation and Botulinum Toxin Therapy in Patients with Post-Stroke Spasticity

BackgroundAcute cerebrovascular accident poses a threat to the health of the nation. Dynamic electric neurostimulation decreases the excitability of the receptor apparatus, optimize microcirculatory processes, analgesic and antispasmodic effects.MethodsThis article discusses the rehabilitation of 96 men and women with post-stroke spasticity, mean age of 60.51 ± 4.9 years, in the early recovery period after ischemic stroke, randomized into 4 equal groups: Group 1 received botulinum toxin therapy in combination with dynamic electric neurostimulation and basic therapy, including massage and therapeutic exercises; Group 2 -botulinum toxin therapy and basic therapy; Group 3 – dynamic electric neurostimulation and basic therapy; Group 4 – basic therapy only. Study methods included the use of the Modified Asworth Scale to assess spasticity, the Rivemead Motor Assessment test, and goniometry to assess the range of joint movements.ResultsDuring a three-week observation, it was found that the inclusion of botulinum toxin therapy and dynamic electrical neurostimulation in the standard therapy of post-stroke spasticity in patients after ischemic stroke in the early recovery period contributed to patients’ recovery.ConclusionsBotulinum toxin therapy and dynamic electrical neurostimulation contributed to a more significant decrease in spasticity in the proximal and distal parts of the paretic upper extremity. It is also increased the amplitude of voluntary movements in the affected shoulder, elbow, and wrist joints, compared to the separate use of botulinum toxin therapy and dynamic electric neurostimulation as part of basic rehabilitation.     

Transcranial direct current stimulation associated with physical-therapy in acute stroke patients - A randomized,triple blind,sham-controlled study

BackgroundTranscranial Direct Current Stimulation has been increasing in popularity in the last few years. Despite vast amounts of articles on the use of tDCS on stroke patients, very little has been done during the acute phase.ObjectivesMeasure the effects of tDCS on functional and sensory outcomes throughout the first year post onset of stroke.Methods50 acute stroke patients were randomized and placed into either the treatment or sham group. Anodal tDCS was applied (2 mA, 20 min) 5 times a week during the first month post stroke. Patients were evaluated with the Wolf Motor Function Test, the Semmes Weinstein Monofilament Test, the Upper Extremity section (UEFM), the Lower Extremity section (LEFM) and the Somatosensory section of the Fugl Meyer Test, the Tardieu Spasticity Scale, the Stroke Impact Scale (SIS), the Hospital Anxiety and Depression Scale (HADS) and the Barthel Index. Evaluations were held at 48 h post stroke, week 1, 2, 3, 4, 3 months, 6 months and 1 year.ResultsThere were statistically and clinically significant improvements after tDCS in all functional motor outcomes, and somatosensory functions. Differences between both groups for the main outcome (WMFT time) were 51% (p = 0.04) at one month, and 57% (p = 0.02) at one year.ConclusiontDCS seems to be an effective adjuvant to conventional rehabilitation techniques. If applied in the acute stages of stroke, functional recovery is not only accelerated, but improved, and results are maintained up to one-year post stroke.     

Rasch analysis of the upper-limb subscale of the stroke rehabilitation assessment of movement (STREAM) tool in an acute stroke cohort Rasch analysis of the upper-limb subscale of the STREAM tool in an acute stroke population

Background: Stroke is a leading cause of disability worldwide. The most common impairment resulting from stroke is upper-limb weakness.

Objectives: To determine the usefulness and psychometric validity of the upper-limb subscale of the STREAM in an acute stroke population.

Methods: Rasch Analysis, including unidimensionality assumption testing, determining model fit, and analysis of: reliability, residual correlations, and differential item functioning.

Results: 125 individuals were assessed using the upper-limb subscale of the Stroke Rehabilitation Assessment of Movement (STREAM) tool. Rasch analysis suggests the STREAM is a unidimensional measure. However, when scored using the originally proposed method (0–2), or using the response pattern (0–5) neither variant fit the Rasch model (p < 0.05). Although, the reliability was good (Person-Separation Index – 0.847 and 0.903, respectively). Correcting for the disordered thresholds, and thereby producing the new scoring pattern, led to substantial improvement in the overall fit (chi-square probability of fit – 22%), however, the reliability was slightly reduced (PSI – 0.806).

Conclusions: The study proposes a new scoring method for the upper-limb subscale of the STREAM outcome measure in the acute stroke population.     

Cardiovascular fitness is improved post-stroke with upper-limb Wii-based Movement Therapy but not dose-matched constraint therapy

Introduction: Post-stroke cardiovascular fitness is typically half that of healthy age-matched people. Cardiovascular deconditioning is a risk factor for recurrent stroke that may be overlooked during routine rehabilitation. This study investigated the cardiovascular responses of two upper limb rehabilitation protocols.

Methods: Forty-six stroke patients completed a dose-matched program of Wii-based Movement Therapy (WMT) or modified Constraint-induced Movement Therapy (mCIMT). Heart rate and stepping were recorded during early (day 2)- and late (day 12–14)-therapy. Pre- and post-therapy motor assessments included the Wolf Motor Function Test and 6-min walk.

Results: Upper limb motor function improved for both groups after therapy (WMT p = 0.003, mCIMT p = 0.04). Relative peak heart rate increased from early- to late-therapy WMT by 33% (p < 0.001) and heart rate recovery (HRR) time was 40% faster (p = 0.04). Peak heart rate was higher and HRR faster during mCIMT than WMT, but neither measure changed during mCIMT. Stepping increased by 88% during Wii-tennis (p < 0.001) and 21% during Wii-boxing (p = 0.045) while mCIMT activities were predominantly sedentary. Six-min walk distances increased by 8% (p = 0.001) and 4% (p = 0.02) for WMT and mCIMT, respectively.

Discussion: Cardiovascular benefits were evident after WMT as both a cardiovascular challenge and improved cardiovascular fitness. The peak heart rate gradient across WMT activities suggests this therapy can be further individualized to address cardiovascular needs. The mCIMT data suggest a cardiovascular stress response.

Conclusions: This is the first study to demonstrate a cardiovascular benefit during specifically targeted upper limb rehabilitation. Thus, WMT not only improves upper limb motor function but also improves cardiovascular fitness.     

根据Brunnstrom分期制定针对性康复方案对脑卒中患者康复效果的影响

目的探讨Brunnstrom分期制定针对性康复方案对脑卒中患者康复效果的影响作用。方法选取90例脑卒中患者采用随机数字表法分为实验组和对照组各45例,实验组依据Brunnstrom分期制定针对性康复方案,对照组给予常规康复治疗方法。结果康复治疗前实验组和对照组的Fugl-Meyer运动功能评分法(FAM)、改良Barthel指数(MBI)、运动功能评估量表(MAS)、美国国立卫生研究院神经功能缺损量表(NIHSS)评分和脑卒中专用生存质量量表(SS-QOL)评分差异均不具有统计学意义(P0.05)。康复治疗后实验组的FAM评分(48.2±7.6)分、MBI评分(58.2±11.6)分、MAS评分(33.7±6.2)分和SS-QOL评分(44.8±5.3)分均高于对照组的(29.6±5.7)分、(53.6±9.8)分、(29.6±5.7)分和(40.2±5.0)分,差异均具有统计学意义(P0.05);实验组NIHSS评分(13.5±3.8)分显著低于对照组的(15.7±4.0)分,差异具有统计学意义(P0.05)。结论 Brunnstrom分期制定针对性康复方案较常规康复治疗对脑卒中患者具有更加显著的康复效果,具有提高患者生活质量的作用。     

Mood and Cognitive Trajectories Over the First Year after Mild Ischemic Stroke

ObjectivesCognitive and mood dysfunction are major contributors to post-stroke disability. The longer-term trajectories of mood and cognition post-stroke remain unclear, as do which cognitive domains decline, improve, or remain stable after stroke, and in which patients. We aimed to characterize the cognitive trajectories of mild ischemic stroke survivors over one year compared to stroke-free controls, and to investigate whether symptoms of anxiety and depression were associated with cognitive function.Materials and methodsAll participants were tested with a neuropsychological test battery at 3-months and 12-months post-stroke, assessing attention/processing speed, memory, visuospatial function, executive function, and language. Anxiety and depression symptomatology were also assessed at both timepoints.ResultsStroke participants (N=126, mean age 68.44 years ±11.83, 87 males, median [Q1, Q3] admission NIHSS=2 [1, 4]) performed worse on cognitive tests and endorsed significantly higher depression and anxiety symptomatology than controls (N=40, mean age=68.82 years ±6.33, 25 males) at both timepoints. Mood scores were not correlated with cognitive performance. Stroke participants' scores trended higher across cognitive domains from 3- to 12-months but statistically significant improvement was only observed on executive function tasks.ConclusionStroke participants performed significantly worse than controls on all cognitive domains following mild ischemic stroke. Stroke participants only exhibited statistically significant improvement on executive function tasks between 3- and 12- months. Whilst anxiety and depression symptoms were higher in stroke participants, this was not correlated with cognitive performance. Further studies are needed to understand factors underlying cognitive recovery and decline after stroke.     

Effect of repetitive transcranial magnetic stimulation combined with robot-assisted training on wrist muscle activation post-stroke

ObjectiveTo compare the effects of active assisted wrist extension training, using a robotic exoskeleton (RW), with simultaneous 5 Hz (rTMS + RW) or Sham rTMS (Sham rTMS + RW) over the ipsilesional extensor carpi radialis motor cortical representation, on voluntary wrist muscle activation following stroke.MethodsThe two training conditions were completed at least one week apart in 13 participants >1-year post-stroke. Voluntary wrist extensor muscle activation (motor unit (MU) recruitment thresholds and firing rate modulation in a ramp-hold handgrip task), ipsilesional corticospinal excitability (motor evoked potential [MEP] amplitude) and transcallosal inhibition were measured Pre- and Post-training.ResultsFor MUs active both Pre and Post training, greater reductions in recruitment thresholds were found Post rTMS + RW training (p = 0.0001) compared to Sham rTMS + RW (p = 0.16). MU firing rate modulation increased following both training conditions (p = 0.001). Ipsilesional MEPs were elicited Pre and Post in only 5/13 participants. No significant changes were seen in ipsilesional corticospinal excitability and transcallosal inhibition measures (p > 0.05).ConclusionsFollowing a single rTMS + RW session in people >1-year post-stroke, changes were found in voluntary muscle activation of wrist extensor muscles. Alterations in ipsilesional corticospinal or interhemispheric excitability were not detected.SignificanceThe effects of rTMS + RW on muscle activation warrant further investigation as post-stroke rehabilitation strategy.     

Effect of task-based bilateral arm training on upper limb recovery after stroke: A systematic review and meta-analysis

ObjectiveUpper limb recovery is a crucial component of stroke rehabilitation aimed to maximize functional activities and reduce disability. Using both arms post stroke is essential to carry out many functional activities but the evidence on bilateral arm training (BAT) is understudied. To investigate the evidence for efficacy of task-based BAT on upper limb recovery, function, and participation post stroke.MethodsWe included 13 randomized controlled trials, and methodological quality was assessed using Cochrane risk of bias tool and the PEDro scale. The outcome measures such as Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), Box and Block Test (BBT), Modified Barthel Index (MBI), Functional Independence Measure (FIM), and Stroke Impact Scale (SIS) were synthesized and analysed based on ICF.ResultsWhen comparing BAT with control group, BAT showed improvement in the pooled standard mean difference (SMD) of FMA-UE (SMD= 0.62, 95% confidence interval (CI), 0.12 to 1.12, p = 0.01; I²=83%). The control group showed significant improvement in MAL-QOM (SMD= -0.10, 95%CI, -0.77 to 0.58, p = 0.78; I²=89%). Compared to conventional group, BAT showed a significant improvement in BBT (SMD= 0.52, 95%CI, 0.04 to 1.00, p = 0.03; I²=0%). When compared with BAT, unimanual training yielded a significant improvement (SMD= -0.60, 95%CI, -0.98 to -0.22, p = 0.002; I²=0%) in MAL-QOM. In real-life participation, the control group showed improvement in SIS (SMD= -0.17, 95% (CI), -0.70 to 0.37, p = 0.54; I²=48%) over BAT.ConclusionsTask-based BAT appears to improve upper limb motor function post stroke. The benefits of task-based BAT on activity performance and participation in real life are not statistically significant.