A Single-center Comparison Using Exoskeleton Rehabilitation for Cerebrovascular Accidents and Traumatic Brain Injury in a Cohort of Hispanic Patients

Background Traumatic brain injury (TBI) is one of the leading causes of disability in the United States. The EKSO GT Bionics® (EKSO®) is a robotic exoskeleton approved by the Federal Drug Administration (FDA) for rehabilitation following a cerebrovascular accident (CVA or stroke) and recently received approval for use in patients with TBI. The aim of the study was to examine if the use of exoskeleton rehabilitation in patients with TBI will produce beneficial outcomes. Methods This retrospective chart-review reports the use of the (EKSO®) robotic device in the rehabilitation of patients with TBI compared to patients with CVA. We utilized data from a single, private rehabilitation hospital for patients that received post-CVA or post-TBI robotic exoskeleton intervention. All patients that used the exoskeleton were discharged from the hospital between 01/01/2017 to 04/30/2020. Ninety-four percent of patients in the CVA groups and 100% of patients in the TBI group were of Hispanic or Latino ethnicity. Gains in total Functional Independence Measure (FIM), walking and cognition, and length of stay in the rehabilitation facility were measured. Results Patients in the TBI group (n = 11) were significantly younger than the patients in the CVA group (n = 66; p \u3c 0.05). Both groups spent a similar amount of time active, number of steps taken, and the number of sessions in the exoskeleton. Both groups also started with similar admission FIM scores. The FIM gain in the TBI group was similar to that of the CVA group (37.5 and 32.0 respectively). The length of stay between groups was not different either. Conclusions The use of exoskeleton rehabilitation in patients with TBI appear to produce similar outcomes as for patients with CVA, prompting further attention of this intervention for this type of injury. Trial registration: Retrospectively registered on 07/09/2020 in clinicaltrials.gov number NCT4465019

Simultaneous bilaternal training for improving arm function after stroke

Background Simultaneous bilateral training, the completion of identical activities with both arms simultaneously, is one intervention to improve arm function and reduce impairment. Objectives To determine the effects of simultaneous bilateral training for improving arm function after stroke. Search strategy We searched the Cochrane Stroke Trials Register (last searched August 2009) and 10 electronic bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2009), MEDLINE, EMBASE, CINAHL and AMED (August 2009). We also searched reference lists and trials registers. Selection criteria Randomised trials in adults after stroke, where the intervention was simultaneous bilateral training compared to placebo or no intervention, usual care or other upper limb (arm) interventions. Primary outcomes were performance in activities of daily living (ADL) and functional movement of the upper limb. Secondary outcomes were performance in extended activities of daily living and motor impairment of the arm. Data collection and analysis Two authors independently screened abstracts, extracted data and appraised trials. Assessment of methodological quality was undertaken for allocation concealment, blinding of outcome assessor, intention-to-treat, baseline similarity and loss to follow up. Main results We included 18 studies involving 549 relevant participants, of which 14 (421 participants) were included in the analysis (one within both comparisons). Four of the 14 studies compared the effects of bilateral training with usual care. Primary outcomes: results were not statistically significant for performance in ADL (standardised mean difference (SMD) 0.25, 95% confidence interval (CI) -0.14 to 0.63); functional movement of the arm (SMD -0.07, 95% CI -0.42 to 0.28) or hand (SMD -0.04, 95% CI -0.50 to 0.42). Secondary outcomes: no statistically significant results. Eleven of the 14 studies compared the effects of bilateral training with other specific upper limb (arm) interventions. Primary outcomes: no statistically significant results for performance of ADL (SMD -0.25, 95% CI -0.57 to 0.08); functional movement of the arm (SMD -0.20, 95% CI -0.49 to 0.09) or hand (SMD -0.21, 95% CI -0.51 to 0.09). Secondary outcomes: one study reported a statistically significant result in favour of another upper limb intervention for performance in extended ADL. No statistically significant differences were found for motor impairment outcomes. Authors' conclusions There is insufficient good quality evidence to make recommendations about the relative effect of simultaneous bilateral training compared to placebo, no intervention or usual care. We identified evidence that suggests that bilateral training may be no more (or less) effective than usual care or other upper limb interventions for performance in ADL, functional movement of the upper limb or motor impairment outcome

Interventions for post-stroke fatigue

BACKGROUND: Post-stroke fatigue (PSF) is a common and distressing problem after stroke. The best ways to prevent or treat PSF are uncertain. Several different interventions can be argued to have a rational basis. OBJECTIVES: To determine whether, among people with stroke, any intervention reduces the proportion of people with fatigue, fatigue severity, or both; and to determine the effect of intervention on health-related quality of life, disability, dependency and death, and whether such intervention is cost effective. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched May 2014), Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014, Issue 4), MEDLINE (1950 to May 2014), EMBASE (1980 to May 2014), CINAHL (1982 to May 2014), AMED (1985 to May 2014), PsycINFO (1967 to May 2014), Digital Dissertations (1861 to May 2014), British Nursing Index (1985 to May 2014), PEDro (searched May 2014) and PsycBITE (searched May 2014). We also searched four ongoing trials registries, scanned reference lists, performed citation tracking of included trials and contacted experts. SELECTION CRITERIA: Two review authors independently scrutinised all titles and abstracts and excluded obviously irrelevant studies. We obtained the full texts for potentially relevant studies and three review authors independently applied the inclusion criteria. We included randomised controlled trials (RCTs) that compared an intervention with a control, or compared different interventions for PSF. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias for each included trial. The primary outcomes were severity of fatigue, or proportion of people with fatigue after treatment. We performed separate analyses for trials investigating efficacy in treating PSF, trials investigating efficacy in preventing PSF and trials not primarily investigating efficacy in PSF but which reported fatigue as an outcome. We pooled results from trials that had a control arm. For trials that compared different potentially active interventions without a control arm, we performed analyses for individual trials without pooling.We calculated standardised mean difference (SMD) as the effect size for continuous outcomes and risk ratio (RR) for dichotomous outcomes. We pooled the results using a random-effects model and assessed heterogeneity using the I(2) statistic. We performed separate subgroup analyses for pharmacological and non-pharmacological interventions. We also performed sensitivity analyses to assess the influence of methodological quality. MAIN RESULTS: We retrieved 12,490 citations, obtained full texts for 58 studies and included 12 trials (three from the 2008 search and nine from the 2014 search) with 703 participants. Eight trials primarily investigated the efficacy in treating PSF, of which six trials with seven comparisons provided data suitable for meta-analysis (five pharmacological interventions: fluoxetine, enerion, (-)-OSU6162, citicoline and a combination of Chinese herbs; and two non-pharmacological interventions: a fatigue education programme and a mindfulness-based stress reduction programme). The fatigue severity was lower in the intervention groups than in the control groups (244 participants, pooled SMD -1.07, 95% confidence interval (CI) -1.93 to -0.21), with significant heterogeneity between trials (I(2) = 87%, degrees of freedom (df) = 6, P value < 0.00001). The beneficial effect was not seen in trials that had used adequate allocation concealment (two trials, 89 participants, SMD -0.38, 95% CI -0.80 to 0.04) or trials that had used adequate blinding of outcome assessors (four trials, 198 participants, SMD -1.10, 95% CI -2.31 to 0.11).No trial primarily investigated the efficacy in preventing PSF.Four trials (248 participants) did not primarily investigate the efficacy on fatigue but other symptoms after stroke. None of these interventions showed any benefit on reducing PSF, which included tirilazad mesylate, continuous positive airway pressure for sleep apnoea, antidepressants and a self management programme for recovery from chronic diseases. AUTHORS' CONCLUSIONS: There was insufficient evidence on the efficacy of any intervention to treat or prevent fatigue after stroke. Trials to date have been small and heterogeneous, and some have had a high risk of bias. Some of the interventions described were feasible in people with stroke, but their efficacy should be investigated in RCTs with a more robust study design and adequate sample sizes

"Functional electrical stimulation (FES) impacted on important aspects of my life" - A qualitative exploration of chronic stroke patients' and carers' perceptions of FES in the management of dropped foot.

Our purpose was to explore the impact of functional electrical stimulation (FES), as applied in the management of dropped foot, on patients with chronic stroke and their carers. A qualitative phenomenological study was undertaken. Participants were recruited from the Lothian FES clinic. Data were collected by using semistructured face-to-face interviews and analysed by using the framework of interpretative phenomenological analysis (IPA). Thirteen patients and nine carers consented to participate in the study. The overarching theme that emerged from the data was that "FES impacted on important aspects of my life." Four subthemes were identified: 1) "Walking with FES is much better"; 2) "FES helped regain control of life"; 3) "Feeling good comes with using FES"; and 4) "FES is not perfect but it is of value." This study provides insights into the perceptions of patients and carers of the impact of FES. These results have implications for clinicians delivering an FES service for the management of dropped foot after stroke. © Informa Healthcare. USA, Inc

Finger extensor variability in TMS parameters among chronic stroke patients

BACKGROUND: This study determined the reliability of topographic motor cortical maps and MEP characteristics in the extensor digitorum communis (EDC) evoked by single-pulse TMS among patients with chronic stroke. METHODS: Each of ten patients was studied on three occasions. Measures included location of the EDC hotspot and center of gravity (COG), threshold of activation and average amplitude of the hotspot, number of active sites, map volume, and recruitment curve (RC) slope. RESULTS: Consistent intrahemispheric measurements were obtained for the three TMS mapping sessions for all measured variables. No statistically significant difference was observed between hemispheres for the number of active sites, COG distance or the RC slope. The magnitude and range of COG movement between sessions were similar to those reported previously with this muscle in able-bodied individuals. The average COG movement over three sessions in both hemispheres was 0.90 cm. The average COG movement in the affected hemisphere was 1.13 (± 0.08) cm, and 0.68 (± 0.04) cm) for the less affected hemisphere. However, significant interhemispheric variability was seen for the average MEP amplitude, normalized map volume, and resting motor threshold. CONCLUSION: The physiologic variability in some TMS measurements of EDC suggest that interpretation of TMS mapping data derived from hemiparetic patients in the chronic stage following stroke should be undertaken cautiously. Irrespective of the muscle, potential causes of variability should be resolved to accurately assess the impact of pharmacological or physical interventions on cortical organization as measured by TMS among patients with stroke

Ocena zakresu ruchomości stawu kolanowego i skokowego kończyny niedowładnej u chorych z niedowładem połowicznym po incydentach mózgowo-naczyniowych

B a c k g r o u n d. Cerebrovascular accident (stroke) is one of the most serious health problems in the developed countries. Patients who conclude early stroke rehabilitation (i.e. 2-3 months after the stroke) should be able to walk unassisted or with little help.O b j e c t i v e.  The aim of this paper is to analyze the effectiveness of early specialized stroke rehabilitation by means of proprioceptive neuromuscular facilitation (PNF), based on the analysis of mobility ranges of knee and ankle joints of the affected limbs in patients after CVA.M a t e r i a l  a n d  m e t h o d s. The study encompassed 30 subjects who had suffered from stroke and participated in PNF rehabilitation at the hospital stroke ward. Among subjects, there were 13 men and 17 women, aged ± 66.1. On average, patients spent 28 days at the ward. The first exam was carried out prior to  rehabilitation , on the admission day, while the follow-up exam was conducted on the day the patient left the ward.R e s u l t s.  Noticeable reduction of deficits in knee and ankle joint motion of the affected limb was observed. The second exam proved significant increase in bending ranges of the affected limb. Range of limb strengthening did not change. Subjects with left-sided hemiparesis displayed greater mobility deficits in motion ranges of knee and ankle joints, compared to right-sided hemiparesis patients.C o n c l u s i o n s. Using PNF in early rehabilitation noticeably improved mobility of the affected limbs in patients after CVA.Wstęp. Udar mózgu jest jednym z najpoważniejszych problemów zdrowotnych społeczeństw z krajów uprzemysłowionych. Chory kończący wczesną rehabilitację poudarową, czyli 2-3 miesiące od udaru powinien chodzić samodzielnie lub z niewielką pomocą.C e l e m   p r a c y była analiza skuteczności wczesnej specjalistycznej rehabilitacji poudarowej, realizowanej metodą PNF, w oparciu o analizę zakresu ruchomości stawu kolanowego i skokowego kończyny niedowładnej u osób po mózgowym incydencie naczyniowym.M a t e r i a ł  i  m e t o d y. Badaniem objęto 30 osób po mózgowym incydencie naczyniowym poddanych wczesnej rehabilitacji metodą PNF na pododdziale udarowym. Grupę badawczą stanowiło 13 mężczyzn i 17 kobiet, o średniej wieku ± 66,1. Czas przebywania chorego na oddziale wynosił średnio 28 dni. Pierwsze badanie wykonano przed rozpoczęciem usprawniania w dniu przyjęcia chorego, a kontrolne w dniu wypisu z oddziału udarowego.W y n i k i. Stwierdzono wyraźną redukcję deficytów w stawie kolanowym i skokowym kończyny niedowładnej. W badaniu drugim wykazano znaczny wzrost zakresu ruchu zginania w kończynie niedowładnej. Wartość ruchu wyprostu pozostała bez zmian. Grupa chorych z niedowładem lewostronnym charakteryzowała się znacznie większymi ograniczeniami zakresów poszczególnych ruchów czynnych stawu kolanowego oraz skokowego górnego i dolnego niż grupa chorych z niedowładem prawostronnym.W n i o s k i. Stosowanie metody PNF we wczesnej rehabilitacji wyraźnie usprawniło funkcjonowanie kończyny niedowładnej chorych po przebytym mózgowym incydencie naczyniowym

Four Effective and Feasible Interventions for Hemi-inattention Post CVA: Systematic Review and Collaboration for Knowledge Translation in an Inpatient Rehab Setting.

Purpose: To locate, evaluate, and summarize the evidence for effective and feasible interventions to treat hemi-inattention in inpatient rehabilitation settings and ensure knowledge translation with a collaborating clinician Timothy Rich, OTR/L and his team at Harborview Medical Center. Design: Systematic literature review, participatory active research with a collaborating clinician, and knowledge translation. Methods: Included studies that tested effectiveness of mirror therapy (MT), transcutaneous electric nerve stimulation (TENS), limb activation therapy (LAT), and visual scanning therapy (VST). 11 databases were searched to yield 31 articles included in a critically appraised topic (CAT) table. A concise protocol for each intervention was then provided to participating clinicians at an in-service training. A follow-up survey was completed to assess the degree of knowledge translation that had occurred which resulted in a positive response. Conclusion: There is evidence for the effectiveness of VST, TENS, LAT and MT to treat hemi-inattention. Combined interventions were often more effective than when used individually. It is suggested that further research be conducted to address the advisability of a multi-contextual approach to VST in order to maximize generalization to functional tasks in a variety of natural environments

Effectiveness of Low Electrical Sensory Stimulation from Transcutaneous Electrical Nerve Stimulation (TENS) in Promoting Upper Extremity Functionality of Two Individuals Post-stroke

The purpose of this study was to examine the effects of low sensory electrical stimulation provided by a TENS unit on improving hand functionality in the treatment of patients post-stroke. An A-B-A single-subject design was used and two subjects participated in this study; one was a 70-year-old female who was 6 years post-stroke and one was a 63-year-old male 2 years post-stroke. For participant 1, there was no significant change in active extension of the first three digits but significant improvement in little finger active extension was shown when the intervention was introduced. The large light object subtest from the Jebsen-Taylor Hand Function Test was modified for participant 1 and the time she required to perform this subtest varied. There was no significant change in the Action Research Arm Test for participant 1. For participant 2, there was a significant improvement in index finger extension in the B phase and no significant change in active extension of other fingers. There was no significant change in finger flexion for all fingers except the little finger. There was no significant change in the large light objects subtest and there was significant change in the A2 phase in the writing subtest from the Jebsen-Taylor Hand Function Test. There was no significant change in the Action Research Arm Test grip subtest. There was significant change in the Action Research Arm Test pinch subtest. However, there were many internal and external factors contributing to the study results. The findings from this study suggest that future study is needed to achieve a better understanding of the low sensory stimulation provided by a TENS unit on promoting upper extremity function in clients post-stroke

Activity-promoting gaming systems in exercise and rehabilitation

Commercial activity-promoting gaming systems provide a potentially attractive means to facilitate exercise and rehabilitation. The Nintendo Wii, Sony EyeToy, Dance Dance Revolution, and Xbox Kinect are examples of gaming systems that use the movement of the player to control gameplay. Activity-promoting gaming systems can be used as a tool to increase activity levels in otherwise sedentary gamers and also be an effective tool to aid rehabilitation in clinical settings. Therefore, the aim of this current work is to review the growing area of activity-promoting gaming in the context of exercise, injury, and rehabilitation

Designing a Curriculum to Meet the Needs of Caregivers of Patients who had a Cerebral Vascular Accident (CVA) Living in Local Communities in Zimbabwe

Background: Cerebral Vascular Accident (CVA), or stroke, has become an epidemic in Zimbabwe with the incidence rising significantly over the past two decades. Most patients in Zimbabwe who have had a CVA are initially admitted into a hospital for the acute phase of care and later discharged back to the community and into the care of their family. Although caregivers are forced to suddenly take on a critical role in the daily care and rehabilitation of the person who has had a stroke and continues to have disabilities, there is little to prepare someone for these responsibilities at the time the patient returns home or even in the weeks and months following. Caregiver support, which can be extended through education in how to assist the patient with daily routines and mobility, has been shown to improve the quality of life of patients and caregivers. The need to develop a standardized curriculum for use with family and other primary caregivers was identified by faculty involved in health professions education at the University of Zimbabwe College of Health Sciences. The primary purpose of the curriculum was to meet the needs of caregivers responsible for individuals who had a CVA and returned to live in their local communities in Zimbabwe. Purpose: Thus, the purpose of this paper is to describe the process of curriculum development, from needs assessment through curricular design and evaluation, as an opportunity to demonstrate how physical therapists and other allied health professionals can address community need through curriculum design. Methods: A questionnaire was developed to ascertain curricular content from the people who had a stroke and designated caregivers. Results: Intended outcomes of the curriculum included evidence of (1) decreased caregiver burden among caregivers responsible for people who have survived a stroke and returned to live in their local communities in Zimbabwe; and (2) increased function and health related quality of life of the patient who has had a stroke and of their caregiver over a period of one year. Conclusion: Although this curriculum was designed specifically to meet the needs of caregivers in Zimbabwe, the process for curriculum development and the curriculum content can be adapted in many other countries and for other rehabilitation related situations