Upper Limb Energy Demand During Unilateral Arm Crank Submaximal Exercise Testing in Individuals With Chronic Stroke

ObjectiveTo investigate upper limb (UL) energy demand during unilateral arm crank submaximal exercise testing in individuals with stroke compared with healthy controls and the relationship between UL energy demand and UL activity in individuals with stroke.DesignCross-sectional, observational study.SettingResearch laboratory.ParticipantsIndividuals with chronic stroke (n=14) and controls (n=12), matched for age, sex, and body mass index (N=26).InterventionsNot applicable.Main Outcome MeasuresUL energy demand was measured as peak oxygen consumption (V̇o₂)/peak load during unilateral arm crank submaximal exercise testing. UL activity was measured using the Box and Block Test (BBT) and Grooved Pegboard Test (GPT).ResultsThe energy demand of the paretic side compared with the nonparetic side of the stroke group was 0.43 mL/kg/min/W (95% confidence interval, 0.03-0.83, P=.005) greater than the dominant compared with the nondominant side of the control group. The median difference between sides in peak V̇o₂/peak load was 52% for the group with stroke compared with 11% for the control group. Positive correlations between the median percentage difference between the paretic and the nonparetic side of peak V̇o₂/peak load and BBT were 0.72 (P=.004) and of V̇o₂/peak load and GPT was 0.77 (P=.002).ConclusionsThe higher energy demand of the paretic UL during unilateral arm crank submaximal exercise testing than the nonparetic and both UL of the controls together with the strong relationship between energy demand and UL activity suggest that the energy demand of the paretic UL has the potential to affect real-life UL activity after stroke.     

Effect of a Novel Perturbation-Based Pinch Task Training on Sensorimotor Performance of Upper Extremity for Patients With Chronic Stroke: A Pilot Randomized Controlled Trial

ObjectiveTo investigate the effects of perturbation-based pinch task training on the sensorimotor performance of the upper extremities of patients with chronic stroke via a novel vibrotactile therapy system.DesignA single-blinded randomized controlled trial.SettingA university hospital.ParticipantsPatients with chronic stroke (N=19) randomly assigned into either an experimental group or a control group completed the study.InterventionsIn addition to 10 minutes of traditional sensorimotor facilitation, each participant in the experimental group received 20 minutes of perturbation-based pinch task training in each treatment session, and the controls received 20 minutes of task-specific motor training twice a week for 6 weeks.Main Outcome MeasuresThe scores for the primary outcome, Semmes-Weinstein monofilament (SWM), and those for the secondary outcomes, Fugl-Meyer Assessment (FMA), amount of use, quality of movement (QOM) on the Motor Activity Log (MAL) scale, and box and block test (BBT), were recorded. All outcome measures were recorded at pretreatment, post treatment, and 12-week follow-up.ResultsThere were statistically significant between-group differences in the training-induced improvements revealed in the SWM results (P=.04) immediately after training and in the BBT results (P=.05) at the 12-week follow-up. The changes in muscle tone and in the QOM, SWM, and BBT scores indicated statistically significant improvements after 12 sessions of treatment for the experimental group. For the control group, a significant statistical improvement was found in the wrist (P<.001) and coordination (P=.01) component of the FMA score.ConclusionsThis study indicated that the perturbation-based pinch task training has beneficial effects on sensory restoration of the affected thumb in patients with chronic stroke.     

Unilateral Strength Training of the Less Affected Hand Improves Cortical Excitability and Clinical Outcomes in Patients With Subacute Stroke: A Randomized Controlled Trial

ObjectivesTo investigate whether unilateral strength training helps improve cortical excitability and clinical outcomes after stroke.DesignRandomized controlled trial.SettingRehabilitation sciences research center.ParticipantsPatients with subacute stroke (N=26) were randomly assigned to a control group (n=13) or the experimental group (n=13).InterventionsParticipants in both groups received conventional physiotherapy. The experimental group also received unilateral strength training of the less affected wrist extensors. Interventions were applied for 4 weeks (12 sessions, 3 d/wk).Main Outcome MeasuresCortical excitability in both the ipsilesional hemisphere (ipsiH) and contralesional hemisphere (contraH) was assessed by measuring resting motor threshold (RMT), active motor threshold (AMT), motor evoked potential (MEP), and cortical silent period (CSP) at baseline and after the 4-week intervention period. Clinical outcomes were obtained by evaluating wrist extension strength in both the more affected and less affected hands, upper extremity motor function, activities of daily living (ADL), and spasticity.ResultsThe experimental group showed greater MEP amplitude (P=.001) in the ipsiH and shorter CSP duration in both the ipsiH (P=.042) and contraH (P=.038) compared with the control group. However, the reductions in RMT and AMT in both hemispheres were not significantly different between groups. Improvements in wrist extension strength in the more affected (P=.029) and less affected (P=.001) hand, upper extremity motor function (P=.04), and spasticity (P=.014) were greater in the experimental group. No significant difference in ADLs was detected between groups.ConclusionsA combination of unilateral strength training and conventional physiotherapy appears to be a beneficial therapeutic modality for improving cortical excitability and some clinical outcomes in patients with stroke.     

Exoskeleton-Assisted Anthropomorphic Movement Training (EAMT) for Poststroke Upper Limb Rehabilitation: A Pilot Randomized Controlled Trial

ObjectiveTo investigate the feasibility of exoskeleton-assisted anthropomorphic movement training (EAMT) and its effects on upper extremity motor impairment, function, and kinematics after stroke.DesignA single-blind pilot randomized controlled trial.SettingStroke rehabilitation inpatient unit.ParticipantsParticipants with a hemiplegia (N=20) due to a first-ever, unilateral, subacute stroke who had a score of 8-47 on the Fugl-Meyer Assessment for Upper Extremity (FMA-UE).InterventionsThe exoskeleton group received EAMT therapy that provided task-specific training under anthropomorphic trajectories and postures. The control group received conventional upper limb therapy. For both groups, therapy was delivered at the same intensity, frequency, and duration: 45 minutes daily, 5 days per week, for 4 weeks.Main Outcome MeasuresPrimary outcome: feasibility analysis. Secondary outcomes: FMA-UE, Action Research Arm Test (ARAT), modified Barthel Index (MBI), and kinematic metrics during exoskeleton therapy.ResultsTwenty participants with subacute stroke were recruited and completed all therapy sessions. EAMT therapy was feasible and acceptable for the participants. The recruitment rate, retention rate, and number of therapists required for EAMT therapy were acceptable compared with other robotic trials. EAMT was determined to be safe, as no adverse event occurred except tolerable muscle fatigue in 2 participants. There were significant between-group differences in the change scores of FMA-UE (difference, 4.30 points; P=.04) and MBI (difference, 8.70 points; P=.03) in favor of EAMT therapy. No significant between-group difference was demonstrated for the change scores of ARAT (P=.18). Participants receiving EAMT showed significant improvements in kinematic metrics after treatment (P<.01).ConclusionsOur results indicate that EAMT is a feasible approach and may improve upper extremity motor impairment, activities of daily living, and kinematics after stroke. However, fully powered randomized controlled trials are warranted to confirm the results of this pilot study and explore the underlying mechanisms by which EAMT therapy might work.     

Efficacy of Robot-Assisted Training on Rehabilitation of Upper Limb Function in Patients With Stroke: A Systematic Review and Meta-analysis

ObjectiveTo systematically evaluate the effect of robot-assisted training (RAT) on upper limb function recovery in patients with stroke, providing the evidence-based medical basis for the clinical application of RAT.Data SourcesWe searched online electronic databases up to June 2022, including PubMed, The Cochrane Library, Scopus, Web of Science, EMBASE, WanFang Data, CNKI, and VIP full-text databases.Study SelectionRandomized controlled trials of the effect of RAT on upper extremity functional recovery in patients with stroke.Data ExtractionThe Cochrane Collaboration Tool for Assessing the Risk of Bias was used to assess study quality and risk of bias.Data SynthesisFourteen randomized controlled trials involving 1275 patients were included for review. Compared with the control group, RAT significantly improved upper limb motor function and daily living ability. The overall differences were statistically significant, Fugl-Meyer Assessment for the Upper Extremity (FMA-UE; standard mean difference=0.69; 95% confidence interval, 0.34, 1.05; P=.0001), modified Barthel Index (standard mean difference=0.95; 95% confidence interval, 0.75, 1.15; P<.00001), whereas the differences in modified Ashworth Scale, FIM, and Wolf Motor Function Test scores were not statistically significant.Subgroup AnalysisCompared with the control group, the differences between FMA-UE and modified Barthel Index at 4 and 12 weeks of RAT, there were statistically significant, the differences of FMA-UE and modified Ashworth Scale in patients with stroke in the acute and chronic phases were statistically significant.ConclusionThe present study showed that RAT can significantly enhance the upper limb motor function and activities of daily life in patients with stroke undergoing upper limb rehabilitation.     

Vagus Nerve Stimulation Paired With Upper-Limb Rehabilitation After Stroke: 2- and 3-Year Follow-up From the Pilot Study

ObjectiveTo assess whether a long-term home-based intervention using Paired VNS therapy is feasible and whether the benefits of Paired VNS therapy are maintained beyond 1 year.DesignA long-term follow-up study.SettingThree centers in the United States and 1 in the United Kingdom.ParticipantsAdults with chronic ischemic stroke (n=15) with moderate to severe arm and hand impairment.InterventionsParticipants were implanted with a VNS device followed by 6 weeks of in-clinic therapy with Paired (Active) or control VNS followed by home-based rehabilitation through day 90 (blinded phase). The control VNS group then crossed over to receive 6 weeks of in-clinic Active VNS. Participants in both groups then continued a long-term home exercise program with self-administered Active VNS.Main Outcome MeasuresFugl-Meyer Assessment for Upper Extremity (FMA-UE) and Wolf Motor Function Test (WMFT) Functional scores were evaluated at the end of in-clinic therapy and day 90. Since both groups were subsequently receiving home-based rehabilitation with Active VNS during the long term, follow-up outcome assessments were pooled for the analyses at 6, 9, and 12 months, as previously reported. Here, we report pooled analysis of outcomes beyond 1 year.ResultsOne year after Paired VNS therapy, FMA-UE improved by an average of 9.2±8.2 points, as previously reported. Overall, the 2- and 3-year FMA-UE gain from baseline was 11.4±8.7 (P<.001) and 14.8±10.2 points (P<.001), respectively. At years 2 and 3, FMA-UE improved by an additional 2.9 (P=.03 for change vs year 1, n=14) and 4.7 (P=.02 for change vs year 1, n=14) points, respectively. At year 1, 73% (11/15) of participants were responders (FMA-UE change ≥6) and by year 3, 85.7% (12/14) were responders. At years 2 and 3, the WMFT score improved by an additional 0.21 points (P=.03 for change vs year 1, n=15) and 0.42 points (P=.01 for change vs year 1, n=13), respectively. Responder rate (WMFT change ≥0.4) was 46.6% (7/15), 73.3% (11/15), and 69.2% (9/13) at years 1, 2, and 3, respectively. Long-term significant improvements were also observed for Motor Activity Log (MAL) and Stroke Impact Scale, Hand section (SIS-Hand). There were no serious long-term adverse events from the stimulation.ConclusionsSignificant effects of Paired VNS therapy at 1 year were maintained at years 2 and 3, and further improvements in both impairment and function were observed in years 2 and 3. These changes were associated with improvements in measures of activity and participation.     

Rehabilitation of the upper arm early after stroke: Video games versus conventional rehabilitation. A randomized controlled trial

BackgroundFew rehabilitation methods have proven their efficacy in increasing sensori-motor recovery and/or function of the upper limb (UL) after stroke. Video games (VGs) are promising tools in this indication.ObjectiveTo compare UL rehabilitation by using VGs and conventional rehabilitation (CR) in patients with sub-acute stroke.DesignSingle-blind, multicentric trial, with central randomization and stratification by center.SettingPhysical and rehabilitation medicine departments of 2 university hospitals.ParticipantsAdults within 3 months after a first vascular cerebral accident, with UL Fugl Meyer Score (UL-FMS) < 30/66 and without major cognitive impairment.InterventionA 45-min additional session of conventional occupational therapy (OT) or a VG-based OT session as add-on therapy to usual rehabilitation programs, 5 days/week for 6 weeks.Main Outcome MeasuresPrimary outcome: UL-FMS. Secondary outcome: Box and Block Test (BBT), Wolf Motor Function test (WMFT), Motor Activity Log (MAL), Barthel Index and quality of life (SF-36).ResultsWe included 51 patients (20 women) at a mean (SD) of 27.2 (19.4) days post-stroke (mean age 58 years [range 24–83]), 26 in the CR group and 25 in the VG group (23 in each group at 6-month follow-up). The mean duration of the additional rehabilitation session was similar in both groups: 29.3 (4.3) vs 28.0 (4.4) min in CR and VG groups. Shoulder pain occurred in 4 patients in the VG group versus 7 in the CR group. At day 45, gain in UL-FMS did not significantly differ between the groups (CR mean 17.8 [14.6] vs VG 24.1 [14.8]; P = 0.10), whereas gain in BBT was doubled in the VG group (CR 7.4 [12.2] vs VG 15.7 [16.3]; P = 0.02). At 6-month follow-up, the study was inconclusive about between-group differences in UL-FMS, BBT and other criteria. Post-hoc analysis showed that gains in UL-FMS or BBT were significantly higher in the VG than CR group for patients included within 30 days post-stroke.ConclusionIn general, we cannot conclude that video gaming and conventional OT led to different long-term sensorimotor recovery of the UL after sub-acute stroke. However, when applied within the first month after stroke, video gaming was more efficient than conventional rehabilitation on both sensorimotor recovery and gross grasping function.Trial registrationClinicalTrials.gov (NCT01554449).     

Effect of Intensive Physiotherapy Training for Children With Congenital Zika Syndrome: A Retrospective Cohort Study

ObjectiveTo investigate the effect of intensive physiotherapy training on the motor function of children with congenital Zika syndrome (CZS).DesignA retrospective cohort study.SettingA support center for children with microcephaly.ParticipantsChildren (N=7) aged 14 to 18 months old who were diagnosed with CZS and previously monitored more than 1 year.InterventionsA 2-stage protocol repeated uninterruptedly for 1 year. In the first stage, the children were submitted to 1 hour of conventional physiotherapy and 1 hour of suit therapy 5 times a week for 4 weeks. The second stage consisted of 1 hour of suit therapy 3 times a week for 2 weeks.Main Outcome MeasuresGross motor function measure (GMFM) and body weight.ResultsSix evaluations were conducted approximately 3 months apart. An increase in the overall GMFM score was observed between the first and second (P=.046), first and third (P=.018), first and fourth (P=.018), first and fifth (P=.043), and first and sixth evaluations (P=.018). Differences in the scores of the individual GMFM dimensions were found only for dimension A (lying and rolling) between the first and fourth evaluations (P=.027) and for dimension B (sitting) between the first and third (P=.018), first and fourth (P=.046), and first and sixth evaluations (P=.027). No difference was found in body weight between the first and sixth evaluations (P=.009). During follow-up, only 1 child required hospitalization, and another had increased irritability.ConclusionsChildren with CZS were able to perform 2 hours of motor physiotherapy daily with no serious complications, resulting in an increase or stabilization in GMFM scores.     

Kinematic upper extremity performance in people with near or fully recovered sensorimotor function after stroke

Background: Clinical scales for upper extremity motor function may not capture improvement among higher functioning people with stroke. Objective: To describe upper extremity kinematics in people with stroke who score within the upper 10% of the Fugl-Meyer Assessment (FMA-UE) and explore the ceiling effects of the FMA-UE. Design: A cross-sectional study design was used. Participants: People with stroke were included from the Stroke Arm Longitudinal Study at University of Gothenburg together with 30 healthy controls. The first analysis included participants who achieved FMA-UE score > 60 within the first year of stroke (assessed at 3 days, 2 weeks, 4 weeks, 3 months, or 12 months post stroke). The second analysis included participants with submaximal FMA-UE (60–65 points, n = 24) or maximal FMA-UE score (66 points, n = 21) at 3 months post stroke. Measurements: The kinematic analysis of a standardized drinking task included movement time, velocity and strategy, joint angles of the elbow, and shoulder and trunk displacement. Results: The high FMA-UE stroke group showed deficits in seven of eight kinematic variables. The submaximal FMA-UE stroke group was slower, had lower tangential and angular peak velocity, and used more trunk displacement than the controls. In addition, the maximal FMA-UE stroke group showed larger trunk displacement and arm abduction during drinking and lower peak angular velocity of the elbow. Conclusions: Participants with near or fully recovered sensorimotor function after stroke still show deficits in movement kinematics; however, the FMA-UE may not be able to detect these impairments.     

Three Ways to Improve Arm Function in the Chronic Phase After Stroke by Robotic Priming Combined With Mirror Therapy,Arm Training,and Movement-Oriented Therapy

ObjectiveTo examine the effects of bilateral robotic priming combined with mirror therapy (R-mirr) vs bilateral robotic priming combined with bilateral arm training (R-bilat), relative to the control approach of bilateral robotic priming combined with movement-oriented training (R-mov) in patients with stroke.DesignA single-blind, preliminary, randomized controlled trial.SettingFour outpatient rehabilitation settings.ParticipantsOutpatients with stroke and mild to moderate motor impairment (N=63).InterventionsPatients received 6 weeks of clinic-based R-mirr, R-bilat, or R-mov for 90 min/d, 3 d/wk, plus a transfer package at home for 5 d/wk.Main Outcome MeasuresFugl-Meyer Assessment Upper Extremity subscale (FMA-UE), ABILHAND, and Stroke Impact Scale v3.0 scores before, immediately after, and 3 months after treatment as well as lateral pinch strength and accelerometry before and immediately after treatment.ResultsThe posttest results favored R-mirr over R-bilat and R-mov on the FMA-UE score (P<.05). Follow-up analysis revealed that significant improvement in FMA-UE score was retained at the 3-month follow-up in the R-mirr over R-bilat or R-mov (P<.05). Significant improvements were not observed in the R-mirr over R-bilat and R-mov on other outcomes.ConclusionsBetween-group differences were only detected for the primary outcome, FMA-UE. R-mirr was more effective at enhancing upper limb motor improvement, and the effect has the potential to be maintained at 3 months of follow-up.     

Prevalence and Related Factors for Poststroke Complex Regional Pain Syndrome: A Retrospective Cross-Sectional Cohort Study

ObjectiveThe objective of this study was to evaluate the prevalence of poststroke complex regional pain syndrome (CRPS) to estimate related factors for poststroke CRPS in patients with first-ever stroke.DesignThis was a retrospective cross-sectional cohort study of adult patients (age >18y) with stroke who were admitted to rehabilitation unit from December 2014 to May 2018 in Korea.SettingSingle acute rehabilitation unit of university hospital.ParticipantsParticipants (N=313) diagnosed with first-ever stroke were identified from the stroke rehabilitation registry of our institute.InterventionsNot applicable.Main Outcome MeasuresPrevalence of poststroke CRPS based on clinical features and 3-phase bone scintigraphy and the related factors of poststroke CRPS.ResultsA total of 313 records were analyzed, including demographic, clinical characteristics, and functional variables. Poststroke CRPS was found in 8.94% (28 of 313) patients with first-ever stroke. Logistic regression analysis showed that Fugl Meyer Assessment of Upper Extremity (FMA-UE) score was a significant associated factor for the presence of CRPS (odds ratio, 0.96; 95% confidence interval, 0.94-0.98; P=.003). The cutoff value of 76 points for FMA-UE score yielded moderate accuracy in identifying of poststroke CRPS (92.6% sensitivity, 65.8% specificity, and 0.85 area under the curve).ConclusionsThe prevalence of poststroke CRPS was 8.94% in patients with first-ever stroke. The FMA-UE score was associated with the poststroke CRPS. Therefore, in patients with low FMA-UE score, prevention and high suspicion of post-stroke CRPS is necessary.     

Predicting Clinically Significant Changes in Motor and Functional Outcomes After Robot-Assisted Stroke Rehabilitation

Objective

To investigate the predictors of minimal clinically important changes on outcome measures after robot-assisted therapy (RT).

Design

Observational cohort study.

Setting

Outpatient rehabilitation clinics.

Participants

A cohort of outpatients with stroke (N=55).

Interventions

Patients with stroke received RT for 90 to 105min/d, 5d/wk, for 4 weeks.

Main Outcome Measures

Outcome measures, including the Fugl-Meyer Assessment (FMA) and Motor Activity Log (MAL), were measured before and after the intervention. Potential predictors include age, sex, side of lesion, time since stroke onset, finger extension, Box and Block Test (BBT) score, and FMA distal score.

Results

Statistical analysis showed that the BBT score (odds ratio[OR]=1.06; P=.04) was a significant predictor of clinically important changes in the FMA. Being a woman (OR=3.9; P=.05) and BBT score (OR=1.07; P=.02) were the 2 significant predictors of clinically significant changes in the MAL amount of use subscale. The BBT score was the significant predictor of an increased probability of achieving clinically important changes in the MAL quality of movement subscale (OR=1.07; P=.02). The R² values for the 3 logistic regression models were low (.114−.272).

Conclusions

The results revealed that patients with stroke who had greater manual dexterity measured by the BBT appear to have a higher probability of achieving clinically significant motor and functional outcomes after RT. Further studies are needed to evaluate other potential predictors to improve the models and validate the findings.     

Utility of a unilateral accelerometer for monitoring upper extremity use in subacute stroke patients after discharge from hospital

ABSTRACT

This study was to investigate the utility of a unilateral accelerometer, which is commonly used for monitoring upper extremity performance, in subacute stroke patients by comparing its use with other upper extremity assessments. Twenty-four participants were recruited and required to wear an accelerometer on the affected wrist for 3 hours daily for the first 4 weeks after discharge from hospital. Assessments included Fugl-Meyer Assessment–Upper Extremity (FMA-UE), Action Research Arm Test (ARAT), Box and Block Test (BBT), and self-reporting Motor Activity Log (MAL). Assessments were made at 0, 4, 8, and 12 weeks after hospital discharge. How long the device was worn, movement amount, and movement percentage were extracted from the accelerometer. Throughout the 12-week observation, significant improvements in the participants were shown by the FMA-UE, ARAT, and BBT (p < 0.001, p = 0.026, and p < 0.001, respectively), but no significant change could be found using MAL or the accelerometer parameters across time (p = 0.068 to 0.999). There was moderate-to-good correlation among the assessments; however, no significant correlation was obtained between any of the assessments and the accelerometer data. We suggest that the unilateral accelerometer might not be useful to reflect actual arm functions in daily activities.     

Use of thoracic spine manipulation in the treatment of adhesive capsulitis: a case report

Abstract

Adhesive capsulitis (AC) is a common and disabling shoulder condition seen in physical therapy, and there is no clear consensus as to the best treatment approach. Recently there has been emerging evidence that manual therapy directed at the thoracic spine may be beneficial for patients with shoulder pain; however, this has not been examined specifically in patients with AC. The purpose of this paper is to present the case of 59-year-old female referred to physical therapy with a diagnosis of AC. The patient presented with complaints of left shoulder pain and significant limitations in range of motion (ROM) and upper extremity function. The initial treatment included exercises and manual therapy directed at the glenohumeral and scapulothoracic joints, and after 10 visits only minimal progress had been made. Further examination revealed mobility and ROM deficits in the thoracic spine, and manual therapy directed at this region was incorporated into her treatment. After the first session of thoracic spine manual therapy (TSMT) a 25 degree improvement was noted in active shoulder flexion. After four total visits of TSMT substantial improvements in pain, ROM, and function were noted compared to those made during the first 10 visits. This case adds to the emerging evidence that manual therapy directed at the thoracic spine should be considered for patients with shoulder pain.     

Incentives for Uptake of and Adherence to Outpatient Stroke Rehabilitation Services: A 3-Arm Randomized Controlled Trial

ObjectiveTo determine if rehabilitation uptake and adherence can be increased by providing coordinated transportation (increased convenience) and eliminating out-of-pocket costs (reduced expense).DesignThree-arm randomized controlled trial.SettingStroke units of 2 Singapore tertiary hospitals.ParticipantsSingaporeans or permanent residents 21 years or older who were diagnosed as having stroke and were discharged home with physician's recommendation to continue outpatient rehabilitation (N=266).InterventionsA Transportation Incentives arm (T), which provides free transportation services, a Transportation & Sessions Incentives arm (T&S), offering free transportation and prescribed stroke rehabilitation sessions, and a control arm, Education (E), consisting of a stroke rehabilitation educational program.Main Outcome MeasuresThe primary study outcome was uptake of outpatient rehabilitation services (ORS) among patients poststroke and key predefined secondary outcomes being number of sessions attended and adherence to prescribed sessions.ResultsUptake rate of ORS was 73.0% for E (confidence interval [CI], 63.8%-82.3%), 81.8% for T (CI, 73.8%-89.8%), and 84.3% for T&S (CI, 76.7%-91.8%). Differences of T and T&S vs E were not statistically significant (P=.22 and P=.10, respectively). However, average number of rehabilitation sessions attended were significantly higher in both intervention arms: 5.50±7.65 for T and 7.51±9.52 for T&S vs 3.26±4.22 for control arm (E) (T vs E: P=.017; T&S vs E: P<.001). Kaplan-Meier analysis indicated that persistence was higher for T&S compared with E (P=.029).ConclusionsThis study has demonstrated a possibility in increasing the uptake of and persistence to stroke ORS with free transportation and sessions. Incentivizing survivors of stroke to take up ORS is a new strategy worthy of further exploration for future policy change in financing ORS or other long-term care services.     

Effectiveness and Safety of Clopidogrel vs Aspirin in Elderly Patients With Ischemic Stroke

ObjectiveTo evaluate the risks of recurrent stroke and major bleeding events with clopidogrel and aspirin use among patients aged 80 years or older.Patients and MethodsThis retrospective cohort study was conducted using the Full Population Data of the Health and Welfare Database in Taiwan. Patients aged 80 years or older who received monotherapy with clopidogrel or aspirin following hospitalization for primary acute ischemic stroke between January 1, 2009, and December 31, 2018, were included. Inverse probability of treatment weighting was used to balance measured covariates between clopidogrel and aspirin users. Measured outcomes included recurrent acute ischemic stroke, acute myocardial infarction, composite cardiovascular events (recurrent stroke or acute myocardial infarction), intracranial hemorrhage, major gastrointestinal tract bleeding, and composite major bleeding events (intracranial hemorrhage or major gastrointestinal tract bleeding).ResultsA total of 15,045 patients were included in the study, 1979 of whom used clopidogrel and 13,066 who used aspirin following hospitalization for primary acute ischemic stroke. Clopidogrel use was associated with significantly lower risk of recurrent acute ischemic stroke (hazard ratio [HR], 0.89; 95% CI, 0.83 to 0.96; P=.002), composite cardiovascular events (HR, 0.88; 95% CI, 0.82 to 0.95; P<.001), intracranial hemorrhage (HR, 0.71; 95% CI, 0.56 to 0.90; P=.005), and composite major bleeding events (HR, 0.89; 95% CI, 0.80 to 0.99; P=.04) compared with aspirin use.ConclusionIn patients aged 80 years or older with primary acute ischemic stroke, clopidogrel users had lower risks of recurrent stroke and the composite cardiovascular events compared with aspirin users. Clopidogrel users also had lower risks of intracranial hemorrhage and the composite major bleeding events compared with aspirin users.     

Optimal Multifield Functional Electrical Stimulation Parameters for the “Turn on the Light” Task and Related Upper Limb Kinematics Repeatability in Poststroke Subjects

ObjectiveTo characterize the optimal functional electrical stimulation (FES) parameters that assist the turn on the light task (TOTL) on poststroke participants and to analyze the related upper limb (UL) kinematics repeatability.DesignCross-sectional study.SettingHuman movement research center.ParticipantsPoststroke individuals (N=11) with history of a single unilateral stroke that resulted in a motor control dysfunction of the contralesional UL.InterventionsFES based on surface multifield technology applied to the contralesional wrist and finger extensors during the TOTL.Main Outcome MeasuresFES outcome metrics (virtual electrodes, stimulation duration, intensity) and kinematic metrics (end-point kinematics [absolute and relative duration, mean and peak velocities, relative instant of peak velocity, index of curvature, number of movement units] and joint kinematics [shoulder, elbow, wrist end position and range of movement]). Outcome measures were assessed 2 times with a 72-hour maximum time interval.ConclusionIt was possible to establish reliable FES parameters that assisted the TOTL on poststroke participants. These stimulation parameters led to high to very high repeatability in terms of UL kinematics for most of the cases.     

Physiotherapy After Volar Plating of Wrist Fractures Is Effective Using a Home Exercise Program

Krischak GD, Krasteva A, Schneider F, Gulkin D, Gebhard F, Kramer M. Physiotherapy after volar plating of wrist fractures is effective using a home exercise program.

Objective

To determine the effect of 2 different postoperative therapy approaches after operative stabilization of the wrist fractures: treatment by a physical therapist with 12 sessions and an unassisted home exercise program.

Design

Randomized controlled cohort study.

Setting

Hospital-based care, primary center of orthopedic surgery.

Participants

Volunteers (N=48) with fractures of the distal radius after internal fixation with locking plates. There were 46 patients available for follow-up after exclusion of 2 participants due to physiotherapy sessions in excess of the study protocol.

Interventions

Not applicable.

Main Outcome Measures

Evaluation of grip strength using a Jamar dynamometer, range of motion (ROM), and Patient Related Wrist Evaluation (PRWE).

Results

After a 6-week period of postoperative treatment, the patients (n=23) performing an independent home exercise program using a training diary showed a significantly greater improvement of the functionality of the wrist. Grip strength reached 54% (P=.003), and ROM in extension and flexion 79% (P<.001) of the uninjured side. Ulnar and radial abduction was also higher in this group. In contrast, patients who were treated by a physical therapist achieved grip strength equal to 32%, and ROM in extension and flexion of 52% of the uninjured side. Patients who were performing the home training after operation recorded an improved wrist function with a nearly 50% lower value (P<.001) in the PRWE score.

Conclusions

In the postoperative rehabilitation of wrist fractures, instructions in a home exercise program are an effective alternative to prescribed physical therapy treatment.     

The strength of the ankle dorsiflexors has a significant contribution to walking speed in people who can walk independently after stroke: an observational study

Dorsch S, Ada L, Canning CG, Al-Zharani M, Dean C. The strength of the ankle dorsiflexors has a significant contribution to walking speed in people who can walk independently after stroke: an observational study.ObjectiveTo investigate the relationship between the strength of muscles of the affected lower limb and walking speed after stroke.DesignA cross-sectional observational study.SettingUniversity laboratory.ParticipantsStroke survivors (N=60; mean age ± SD, 69±11y) 1 to 6 years poststroke, able to walk 10m independently without aids.InterventionsNot applicable.Main Outcome MeasuresMaximum isometric strength of 12 muscle groups (hip flexors/extensors, adductors/abductors, internal/external rotators, knee flexors/extensors, ankle dorsiflexors/plantarflexors, invertors/evertors) of the affected lower limb was measured using hand-held dynamometry. Comfortable walking speed was measured using the ten-meter walk test.ResultsUnivariate analysis revealed that strength of the hip flexors (r=.35, P=.01), hip extensors (r=.29, P=.03), hip internal rotators (r=.30, P=.02), hip adductors (r=.29, P=.03), knee extensors (r=.27, P=.03), knee flexors (r=.30, P=.02), ankle dorsiflexors (r=.50, P=.00), ankle plantarflexors (r=.29, P=.03), and ankle evertors (r=.33, P=.01) were all positively associated with walking speed. Multivariate analysis (n=58) revealed that the combined strength of the ankle dorsiflexors and the hip flexors accounted for 34% of the variance in walking speed (P<.001). The ankle dorsiflexors accounted for 31% of the variance (P<.001).ConclusionsThe strength of muscle groups other than the lower limb extensors, particularly the ankle dorsiflexors, has an important role in determining walking speed after stroke.