Examining the feasibility and effectiveness of a culturally adapted participation-focused stroke self-management program in a day-rehabilitation setting: A randomized pilot study

ABSTRACT

Background: Stroke survivors find it difficult to participate in daily activities, despite their improvement throughout the rehabilitation process. Thus, it has been questioned whether day-rehabilitation services provide adequate preparation for participation and reintegration into the community. Self-management programs can improve survivors’ self-efficacy to manage their condition and participation. Improving Participation After Stroke Self-Management program (IPASS) is an occupational therapy-based group intervention developed in the United States, which has been effective in improving participation outcomes.

Objective: To evaluate the feasibility and effectiveness of the IPASS adapted for an Israeli population of individuals admitted to a day-rehabilitation center after stroke.

Methods: A single-center, randomized, assessor-blind study was conducted. Eligible participants were randomized to receive the IPASS (intervention group), in addition to standard individual therapy or standard care only (control group). Feasibility was based on attendance rate and a feedback questionnaire. Effectiveness was evaluated with the Functional Independence Measure (FIM), the Reintegration to Normal Living Index (RNLI) and self-efficacy questionnaires.

Results: Sixty participants were included, of which 39 completed baseline and post-intervention evaluations. The intervention group improved significantly in the FIM scores (p < .01), as compared to the control group (p > .05). Moderate effect sizes (≥0.35) were found for the FIM and RNLI, and large effect sizes (≥0.65) for two subcategories in the participation self-efficacy questionnaire.

Conclusions: The results support the feasibility of the adapted IPASS, and show a trend for positive effects in improving participation and self-efficacy in managing participation in home and community activities, for an Israeli post-stroke population.     

Study to assess the effectiveness of modified constraint-induced movement therapy in stroke subjects: A randomized controlled trial

Background and Purpose:

The purpose of this study was to assess the effectiveness of modified constraint induced movement therapy (m-CIMT) in stroke subjects.

Materials and Methods:

A total of forty sub-acute stroke subjects were randomly assigned to either a m-CIMT (n = 20) or in a control group (n = 20). The m-CIMT group (14 men, 6 women; mean age = 55.2 years) consisted of structured 2 h therapy sessions emphasizing affected arm use, occurring 5 times/week for 2 weeks. A mitt was used to restrain the unaffected arm for 10 h/day for 2 week. The control group (11 men, 9 women; mean age = 56.4 years) consisted of conventional rehabilitation for time-matched exercise program. The outcome measures were evaluated at pre- and post-intervention by using the Wolf Motor Function Test (WMFT) and Fugl-Meyer assessment (FMA) of motor recovery after stroke.

Results:

After intervention significant effects were observed in m-CIMT group on WMFT (pre-test and post-test score was 28.04 ± 6.58, 13.59 ± 2.86; P =0.003). Similarly on FMA (pre- and post-test score was 31.15 ± 6.37, 55.7 ± 6.4; P = 0.00).

Conclusion:

There is a significant improvem ent in upper extremity function so it indicates that m-CIMT is effective in improving the motor function of the affected arm in stroke subjects. However, its long-term effect has not proved since there was no follow-up after intervention.     

Cost effectiveness of the occupation-based approach for subacute stroke patients: result of a randomized controlled trial

Background and purpose: The cost effectiveness of occupational therapy for subacute stroke patients is unclear in the extant literature. Consequently, this study determined the cost effectiveness of the occupation-based approach using Aid for Decision-Making in Occupation Choice (ADOC) for subacute stroke patients compared with an impairment-based approach.

Methods: We conducted an economic evaluation from a societal perspective alongside a pilot randomized controlled trial, with a single blind assessor for participants in 10 subacute rehabilitation units in Japan. The intervention group received occupation-based goal setting using ADOC, with interventions focused on meaningful occupations. The control group received an impairment-based approach focused on restoring capacities. For both groups, occupational-therapy intervention was administered more than five times per week, for over 40 min each time, and they received physical and speech therapy prior to discharge. The main outcomes were quality-adjusted life years (QALYs) and total costs. Further, sensitivity analyses were performed to examine the influence of parameter uncertainty on the base case results.

Results: The final number of participants was 24 in each of the two groups. In terms of QALYs, the intervention group is significantly higher than the control group (p = 0.001, difference 95% CI: 0.002–0.008) and total costs are not statistically significant. Applying a willingness-to-pay threshold of JPY 5 million/QALY, the probability of the occupation-based approach using ADOC being cost effective was estimated to be 65.3%.

Conclusions: The results show that the occupation-based approach is associated with significantly improved QALYs and has potential cost effectiveness, compared with the impairment-based approach.     

Improvement of spontaneous language in stroke patients with chronic aphasia treated with music therapy: a randomized controlled trial

Aim of the study: The aim of this research is to evaluate the effects of active music therapy (MT) based on free-improvisation (relational approach) in addition to speech language therapy (SLT) compared with SLT alone (communicative-pragmatic approach: Promoting Aphasic's Communicative Effectiveness) in stroke patients with chronic aphasia. Materials and methods: The experimental group (n = 10) was randomized to 30 MT individual sessions over 15 weeks in addition to 30 SLT individual sessions while the control group (n = 10) was randomized to only 30 SLT sessions during the same period. Psychological and speech language assessment were made before (T0) and after (T1) the treatments. Results: The study shows a significant improvement in spontaneous speech in the experimental group (Aachener Aphasie subtest: p = 0.020; Cohen's d = 0.35); the 50% of the experimental group showed also an improvement in vitality scores of Short Form Health Survey (chi-square test = 4.114; p = 0.043). Conclusions: The current trial highlights the possibility that the combined use of MT and SLT can lead to a better result in the rehabilitation of patients with aphasia than SLT alone.     

The effect of a whole-body vibration therapy on the sitting balance of subacute stroke patients: a randomized controlled trial

Background: The use of a whole-body vibration (WBV) therapy has recently been applied and investigated as a rehabilitation method for subacute stroke patients.

Objective: To evaluate the effects of a WBV therapy on recovery of balance in subacute stroke patients who were unable to gain sitting balance.

Methods: The conventional rehabilitation group (CG) received conventional physical therapy, including sitting balance training by a physical therapist, for 30 min a one session, for twice a day for five days a week for two weeks. The whole-body vibration group (VG) received one session of conventional physical therapy, and received WBV therapy instead of conventional physical therapy for 30 min a day for five days a week for two weeks.

Results: There were 15 patients in the CG and 15 patients in the VG who completed the two-week therapy. After the two-week therapy, both groups showed functional improvement. Patients in the VG improved functional ambulation categories, Berg balance scale, trunk impairment scale scores. But, no statistically significant correlations between the therapeutic methods and outcomes were observed in either group.

Conclusion: Our results suggest that WBV therapy led to improvement of the recovery in balance recovery for subacute stroke patients. Because the WBV therapy was as effective as conventional physical therapy, we can consider a WBV therapy as a clinical method to improve the sitting balance of subacute stoke patients.     

Mental practice for upper limb motor restoration after stroke: an updated meta-analysis of randomized controlled trials

Objectives: Stroke is a common refractory disease that may cause dysfunctions in the motor system. The study aimed to evaluate the effects of mental practice (MP) compared with other methods on upper limb motor restoration after stroke.

Methods: Eligible studies were identified from Pubmed, Embase, and The Cochrane Library. The study quality was assessed with the Cochrane risk assessment tool and heterogeneity test was performed using I² statistic and Q test. Random- and fixed-effects models were used and data were reported as weighted mean difference (WMD) and 95% confidence intervals (CIs). The publication bias was examined by Egger’s test and the sensitivity analysis was conducted by ignoring one literature at a time to observe whether this document could reverse the merged results.

Results: Total of 12 randomized controlled trials were identified. No evidence of publication bias was found. In a fixed-effect model, MP (experimental group) resulted in a significantly larger increase in Fugl-Meyer assessment (FMA) compared with other exercise methods (control group) (WMD = 2.0702, 95% CI: 1.2354–2.905, Z = 4.8606, P < 0.001). In a random-effect model, a significant pooled outcome was obtained for action research arm test (ARAT) (WMD = 4.0936, 95% CI: 1.9900–6.1971, Z = 3.8141, P < 0.001). Sensitivity analysis revealed that the merged WMDs of FMA and ARAT were not reversed.

Conclusions: Mental practice is effective on upper limb motor restoration after stroke. It is recommended to treat with MP to improve the outcome of stroke.     

全膝关节置换后系统康复的随机对照

背景：国内外对人工全膝关节置换后的康复有较多的研究,但往往局限于一种康复方法。 目的：分析系统康复对人工全膝关节置换后康复进程的影响。 方法：选择行单侧人工全膝关节置换的50例骨性关节炎患者,随机分为两组,干预组置换前给予康复指导,置换后由康复治疗师给予康复锻炼,同时行CPM锻炼和冷敷,对照组给予传统CPM锻炼。 结果与结论：干预组置换后24 h~6 d疼痛目测类比评分均低于对照组(P < 0.05),置换后2 d~6周时膝关节活动度高于对照组(P < 0.05),置换后2,6周时HSS评分高于对照组(P < 0.05),两组均无局部切口并发症发生。说明人工全膝关节置换后系统康复可加快康复进程,减轻患者疼痛,改善关节活动度,且不会增加并发症。     

Bimanual motor skill learning and robotic assistance for chronic hemiparetic stroke: a randomized controlled trial

Using robotic devices might improve recovery post-stroke, but the optimal way to apply robotic assistance has yet to be determined. The current study aimed to investigate whether training under the robotic active-assisted mode improves bimanual motor skill learning(biMSkL) more than training under the active mode in stroke patients. Twenty-six healthy individuals(HI) and 23 chronic hemiparetic stroke patients with a detectable lesion on MRI or CT scan, who demonstrated motor deficits in the upper limb, were randomly allocated to two parallel groups. The protocol included a two-day training on a new bimanual cooperative task, LIFT-THE-TRAY, under either the active or activeassisted modes(where assistance decreased in a pre-determined stepwise fashion) with the bimanual version of the REAplan? robotic device. The hypothesis was that the active-assisted mode would result in greater biMSkL than the active mode. The biMSkL was quantified by a speed-accuracy trade-off(SAT) before(T1) and immediately after(T2) training on days 1 and 2(T3 and T4). The change in SAT after 2 days of training(T4/T1) indicated that both HI and stroke patients learned and retained the bimanual cooperative task. After 2 days of training, the active-assisted mode did not improve biMSkL more than the active mode(T4/T1) in HI nor stroke patients. Whereas HI generalized the learned bimanual skill to different execution speeds in both the active and active-assisted subgroups, the stroke patients generalized the learned skill only in the active subgroup. Taken together, the active-assisted mode, applied in a pre-determined stepwise decreasing fashion, did not improve biMSkL more than the active mode in HI and stroke subjects. Stroke subjects might benefit more from robotic assistance when applied "as-needed." This study was approved by the local ethical committee(Comité d'éthique médicale, CHU UCL Namur, MontGodinne, Yvoir, Belgium; Internal number: 54/2010, Eudra CT number: NUB B039201317382) on July 14, 2016 and was registered with ClinicalTrials.gov(Identifier: NCT03974750) on June 5, 2019.     

A one-year follow-up after modified constraint-induced movement therapy for chronic stroke patients with paretic arm: a prospective case series study

Abstract

Background:

Despite the confirmed short-term effects of constraint-induced movement therapy, the long-term effects have not been sufficiently verified in terms of functional improvement of the affected arm.

Objective:

To evaluate the long-term effects and relationship between arm use in activities of daily living and arm improvement with modified constraint-induced movement therapy in chronic stroke patients.

Methods:

At 1 year after completing modified constraint-induced movement therapy, arm function (Fugl-Meyer Assessment) and amount of daily arm use (motor activity log) were assessed.

Results:

Fourteen post-stroke patients with mild to moderate impairment of arm function were analyzed. One year after completing modified constraint-induced movement therapy, participants consistently showed improvements in arm function and amount of daily arm use (analysis of variance: Fugl-Meyer Assessment, P?<?0.001; Motor Activity Log, P?<?0.001). For the Fugl-Meyer Assessment, post-hoc tests detected significant improvements (pre versus post, P?=?0.009; pre versus 1 year, P?<?0.0001; post versus 1 year, P?<?0.036). For the Motor Activity Log, post-hoc tests also detected significant improvements (pre versus post, P?=?0.0001; pre versus 1 year, P?<?0.0001; post versus 1 year, P?=?0.0014). The magnitude of the change in Fugl-Meyer Assessment score correlated significantly with the change in Motor Activity Log score (R?=?0.778, P?=?0.001).

Conclusions:

Among post-stroke patients with mild to moderate impairments of arm function, modified constraint-induced movement therapy without any other rehabilitation after intervention may improve arm function and increase arm use for 1 year. In addition, increasing arm use may represent an important factor in improving arm function, and vice versa.     

Mirror therapy and treadmill training for patients with chronic stroke: a pilot randomized controlled trial

Background: Previous lower-limb mirror therapy research has focused on non-weight bearing interventions.

Objectives: The primary aim of this study was to investigate the effect and feasibility of a combination of mirror therapy and treadmill training on post-stroke lower-limb recovery compared to a placebo intervention.

Methods: All patients (N = 30) walked on a treadmill for 30 min per day, 3 days per week, for 4 weeks. The mirror therapy and treadmill training group (n = 15) walked on the treadmill while viewing a reflection of their non-paretic limb in a mirror positioned in their mid-sagittal plane. The placebo group (n = 15) received no mirror visual feedback due to an altered mirror position. Primary outcome measures: Ten Metre Walk Test (10MWT) and Six Minute Walk Test (6MWT). Secondary outcome measures: Modified Ashworth Scale (MAS) and Fugl-Meyer Assessment-Lower Extremity (FMA-LE). Feasibility was appraised by examining participant compliance and any adverse events.

Results: No significant between group differences were demonstrated for the 10MWT, 6MWT or FMA-LE at post-training or 3-month follow-up assessment. A significant between group difference on the MAS was demonstrated in the reduction of ankle dorsiflexion muscle tone (p = 0.006) and ankle plantarflexion muscle tone (p = 0.01) in the mirror therapy group compared to the placebo group at post-training assessment but not at 3-month follow-up.

Conclusion: Our study reveals that in our group of patients with chronic stroke, mirror therapy combined with treadmill training facilitated significant reductions in ankle muscle tone (p < 0.05) compared to a placebo intervention.     

Occupational therapy in multiple system atrophy: a pilot randomized controlled trial.

There is some evidence that rehabilitation therapies may be useful in progressive neurological conditions, but this usefulness has not been studied in multiple system atrophy (MSA) to date. The aim of this small pilot study was to identify the feasibility of a larger randomized controlled trial of occupational therapy and to report preliminary data on the impact of occupational therapy on disability, mood, and health-related quality of life in patients with MSA. Patient groups were comparable for age, gender distribution, type of MSA, and severity. The active occupational therapy intervention group experienced a significant reduction of Unified Parkinson's Disease Rating Scale (total score and Activities of Daily Living [ADL] section), and PDQ-39 scores (total scores and ADL subsection). An occupational therapy program may improve functional abilities in patients with mild to moderate MSA. A larger multicenter study is needed.     

Improving balance with wobble board exercises in stroke patients: single-blind,randomized clinical trial

Background: A primary objective in stroke rehabilitation is to restore functional balance, in order to reduce falls.

Objectives: To identify the efficacy and safety of wobble board exercises when combined with conventional physiotherapy, in improving balance in hemiplegic patients following ischemic strokes.

Methods: A block-randomized, controlled, observer blinded, superiority trial was conducted on ambulatory hemiplegic patients following ischemic strokes of middle cerebral artery territory. Subjects in the control group received a conventional physiotherapy regime. Subjects in the intervention group received training on a wobble board combined with conventional physiotherapy. Main Outcome measures were the improvement of Four-Square Step Test (FSST) and the Berg Balance Scale (BBS), both of which assess functional balance at the end of 6 weeks.

Results: Thirty patients were randomly assigned for intervention (n = 15) and control (n = 15) groups. One patient dropped out from the study, leaving 29 eligible for the analysis. Intervention and control groups were comparable in sociodemographic characteristics and pre-test scores of balance. A repeated-measures MANOVA showed a significant difference in improvement of balance between the two study groups after 6 weeks [F(1,28) = 32.6,p = .000; Wilk’s lambda = .46]. The improvement of mean score of balance in interventional group was greater than in the control group [BBS:9.5 (intervention group),5.5 (control group); FSST:3.9 (intervention group),1.7 (control group)]. There were no injuries in both groups.

Conclusions: Wobble board exercises, when combined with the conventional physiotherapy, are safe and effective in restoring functional balance in patients with hemiplegia following ischemic strokes.     

TENS and optokinetic stimulation in neglect therapy after cerebrovascular accident: a randomized controlled study

Background:  In a randomized controlled type Ib study, the effectiveness of three different forms of therapy for the treatment of visual neglect was assessed by comparing therapy outcomes in three groups of patients after cerebrovascular accidents.
Methods:  A control group received only standard exploration training, whilst the second and third group received exploration training combined with either contralateral transcutaneous electrical nerve stimulation (TENS) or optokinetic stimulation (OKS) respectively.
Results:  It was found that exploration training alone resulted in no improvement on both standard neglect tests (NTs) and everyday-relevant measures of reading and writing performance. In contrast, the groups receiving TENS or OKS showed significant improvements in both sets of measures with the difference that for the TENS group the improvement in NT scores at the end of therapy had disappeared 1-week later. However, both treatments resulted in significant improvements in reading and writing which were still present upon retesting 1-week after the end of therapy.
Conclusion:  Both methods can be recommended for neglect therapy and are superior to exploration therapy alone.     

Effect of a stroke support service in Germany: a randomized trial

Purpose: This trial investigated the effect of a stroke support service on physical functioning in post-stroke outpatients.

Methods: The randomized trial took place in two urban hospitals in Germany. The intervention covered a post-discharge stroke support service including following components: outreach work (via telephone contact and home-visit), informational events, training sessions, online portal, and written patient information. The control group received optimized standard care by written patient information. The primary outcome measure was physical function assessed by the physical scale of the stroke impact scale (SIS) 2.0 at baseline and after 12?months follow-up. Secondary outcomes covered health-related quality of life, depression, somatization, reinfarcts, and mortality. Use of health services was recorded.

Results: A total of 265 patients were randomized either to the intervention (n?=?130) or to the control group (n?=?135); n?=?230 patients were analyzed after 12?months. The mean group difference on the physical SIS scale was ??2.7 points (95% CI, ??5.5–0.2) in favor of the control group. The overall risk of mortality in the control versus the intervention group was 11.6and 3.9%, respectively (hazard ratio 0.32, 95% CI, 0.12–0.88). All other outcomes were neither statistically nor clinically relevant, different between the two study groups.

Conclusion: An additional stroke support service did not improve physical function, health-related quality of life, depression, somatization, or reinfarcts in stroke patients. Data suggest a lower overall risk of mortality in the intervention group.     

Effects of dynamic lycra orthosis as an adjunct to rehabilitation after botulinum toxin-A injection of the upper-limb in adults following stroke: A single-blinded randomized controlled pilot study

ABSTRACT

Background

Dynamic lycra splints are proposed to modify hypertonicity due to their characteristics – neutral warmth, circumferential pressure, and creating a low-intensity prolonged stretch on hypertonic muscles – to contribute to increased sensory awareness of the involved limb.     

Development and feasibility of a sedentary behavior intervention for stroke: a case series

Background and Objective: High levels of sedentary behavior are prevalent among people with stroke and contribute to elevated risk for recurrent stroke. Few interventions reduce sedentary behavior post-stroke. The ABLE intervention aims to reduce sedentary behavior using activity monitoring, activity scheduling, problem-solving, and self-assessment to promote engagement in meaningful daily activities. The purpose of this study was to assess the feasibility (tolerability, acceptability, reliability, safety) of the ABLE intervention after stroke and describe trends in sedentary behavior at baseline and 4 weeks.

Clinical Presentation: Participants (n = 5) who were 6 months to 2 years post-stroke, ambulatory, and reported ≥6 h of daily sitting time.

Intervention: Twelve ABLE intervention sessions (3x/week for 4 weeks) conducted in participants’ homes. The ABLE intervention includes activity monitoring, activity scheduling, self-assessment, and collaborative problem-solving.

Results: All feasibility benchmarks were met for three participants. Two participants met tolerability and safety benchmarks but did not meet acceptability and reliability benchmarks. Variability in feasibility and sedentary behavior outcomes may be related to baseline levels of sedentary behavior and social support.

Conclusions: The ABLE intervention was tolerable and safe. The intervention protocol was refined to enhance reliability and acceptability. Future studies should estimate the effects of the ABLE intervention.     

Increasing physical activity in stroke survivors using STARFISH,an interactive mobile phone application: a pilot study

Background: Following stroke, people are generally less active and more sedentary which can worsen outcomes. Mobile phone applications (apps) can support change in health behaviors. We developed STARFISH, a mobile phone app-based intervention, which incorporates evidence-based behavior change techniques (feedback, self-monitoring and social support), in which users’ physical activity is visualized by fish swimming.

Objective: To evaluate the potential effectiveness of STARFISH in stroke survivors.

Method: Twenty-three people with stroke (12 women; age: 56.0 ± 10.0 years, time since stroke: 4.2 ± 4.0 years) from support groups in Glasgow completed the study. Participants were sequentially allocated in a 2:1 ratio to intervention (n = 15) or control (n = 8) groups. The intervention group followed the STARFISH program for six weeks; the control group received usual care. Outcome measures included physical activity, sedentary time, heart rate, blood pressure, body mass index, Fatigue Severity Scale, Instrumental Activity of Daily Living Scale, Ten-Meter Walk Test, Stroke Specific Quality of Life Scale, and Psychological General Well-Being Index.

Results: The average daily step count increased by 39.3% (4158 to 5791 steps/day) in the intervention group and reduced by 20.2% (3694 to 2947 steps/day) in the control group (p = 0.005 for group–time interaction). Similar patterns of data and group–time interaction were seen for walking time (p = 0.002) and fatigue (p = 0.003). There were no significant group–time interactions for other outcome measures.

Conclusion: Use of STARFISH has the potential to improve physical activity and health outcomes in people after stroke and longer term intervention trials are warranted.     

The effect of water-based exercises on balance in persons post-stroke: a randomized controlled trial

Objective: Water-based exercises have been used in the rehabilitation of people with stroke, but little is known about the impact of this treatment on balance. This study examined the effect of water-based exercises compared to land-based exercises on the balance of people with sub-acute stroke.

Methods: In this single-blind randomized controlled study, 32 patients with first-time stroke discharged from inpatient rehabilitation at West Park Healthcare Centre were recruited. Participants were randomized into W (water-based + land; n = 17) or L (land only; n = 15) exercise groups. Both groups attended therapy two times per week for six weeks. Initial and progression protocols for the water-based exercises (a combination of balance, stretching, and strengthening and endurance training) and land therapy (balance, strength, transfer, gait, and stair training) were devised. Outcomes included the Berg Balance Score, Community Balance and Mobility Score, Timed Up and Go Test, and 2 Minute Walk Test.

Results: Baseline characteristics of groups W and L were similar in age, side of stroke, time since stroke, and wait time between inpatient discharge and outpatient therapy on all four outcomes. Pooled change scores from all outcomes showed that significantly greater number of patients in the W-group showed improvement post-training compared to the L-group (p < 0.05). More patients in W-group showed change scores exceeding the published minimal detectable change scores.

Discussion: A combination of water- and land-based exercises has potential for improving balance. The results of this study extend the work showing benefit of water-based exercise in chronic and less-impaired stroke groups to patients with sub-acute stroke.