Efficacy and Dose of Rehabilitation Approaches for Severe Upper Limb Impairments and Disability during Early Acute and Subacute Stroke: A Systematic Review

Objective. The purpose of this study was to examine the evidence regarding the efficacy of rehabilitation approaches for improving severe upper limb impairments and activity during acute and early subacute stroke, taking into consideration the dosage of therapy. Methods. Randomized controlled trials from PubMed, Web of Science, and Scopus databases were searched by 2 independent researchers. Studies were selected if they involved active rehabilitation interventions that were conducted in the acute stage (<7 days after stroke) or the early subacute stage (>7 days–3 months after stroke), with the aim of improving severe upper limb motor impairments and disability. Data were extracted on the basis of the type and effect of rehabilitation interventions, and on the dosage (duration, frequency, session length, episode difficulty, and intensity). Study quality was assessed using the Physiotherapy Evidence Database Scale. Results. Twenty-three studies (1271 participants) with fair to good methodological quality were included. Only 3 studies were performed in the acute stage. Regardless of the type of intervention, upper limb rehabilitation was found to be beneficial for severe upper limb impairments and disability. Robotic therapy and functional electrical stimulation were identified as the most popular upper limb interventions; however, only a limited number of studies showed their superiority over a dose-matched control intervention for severe upper limb impairments in the subacute stage. A longer rehabilitation session length (<60 minutes) did not seem to have a larger impact on the magnitude of improved upper limb impairments. Conclusion. Different rehabilitation approaches seem to improve severe upper limb impairments and disability in the subacute stage after stroke; however, they are not distinctly superior to standard care or other interventions provided at the same dosage. Impact. Robotic therapy and functional electrical stimulation add variety to rehabilitation programs, but their benefit has not been shown to exceed that of standard care. Further research is necessary to identify the impact of dose (eg, intensity) on upper limb motor impairments and function, especially in the acute stage

Entrainment and synchronization to auditory stimuli during walking in healthy and neurological populations : a methodological systematic review

Background: Interdisciplinary work is needed for scientific progress, and with this review, our interest is in the scientific progress toward understanding the underlying mechanisms of auditory-motor coupling, and how this can be applied to gait rehabilitation. Specifically we look into the process of entrainment and synchronization; where entrainment is the process that governs the dynamic alignments of the auditory and motor domains based on error-prediction correction, whereas synchronization is the stable maintenance of timing during auditory-motor alignment. Methodology: A systematic literature search in databases PubMed and Web of Science were searched up to 9th of August 2017. The selection criteria for the included studies were adult populations, with a minimum of five participants, investigating walking to an auditory stimulus, with an outcome measure of entrainment, and synchronization. The review was registered in PROSPERO as CRD42017080325. Objectives: The objective of the review is to systematically describe the metrics which measure entrainment and synchronization to auditory stimuli during walking in healthy and neurological populations. Results: Sixteen articles were included. Fifty percent of the included articles had healthy controls as participants (N = 167), 19% had neurological diseases such as Huntington's and Stroke (N = 76), and 31% included both healthy and neurological [Parkinson's disease (PD) and Stroke] participants (N = 101). In the included studies, six parameters were found to capture the interaction between the human movement and the auditory stimuli, these were: cadence, relative phase angle, resultant vector length, interval between the beat and the foot contact, period matching performance, and detrended fluctuation analysis. Conclusion: In this systematic review, several metrics have been identified, which measure the timing aspect of auditory-motor coupling and synchronization of auditory stimuli in healthy and neurological populations during walking. The application of these metrics may enhance the current state of the art and practice across the neurological gait rehabilitation. These metrics also have current shortcomings. Of particular pertinence is our recommendation to consider variability in data from a time-series rather than time-windowed viewpoint. We need it in view of the promising practical applications from which the studied populations may highly benefit in view of personalized medical care

A Systematic Review of International Clinical Guidelines for Rehabilitation of People With Neurological Conditions: What Recommendations Are Made for Upper Limb Assessment?

Conclusions: We present a comprehensive, critical, and original summary of current recommendations. Defining a core set of measures and agreed protocols requires international consensus between experts representing the diverse and multi-disciplinary field of neurorehabilitation including clinical researchers and practitioners, rehabilitation technology researchers, and commercial developers. Current lack of guidance may hold-back progress in understanding function and recovery. Together with a Delphi consensus study and an overview of systematic reviews of outcome measures it will contribute to the development of international guidelines for upper limb assessment in neurological conditions.This review formed part of the COST Action TD 1006A European Network on Robotics for Neurorehabilitation. It was an interdisciplinary EU-funded research network concentrating on the coordination of European research in the area of rehabilitation robotics

An overview of systematic reviews on upper extremity outcome measures after stroke

Background Although use of standardized and scientifically sound outcome measures is highly encouraged in clinical practice and research, there is still no clear recommendation on which tools should be preferred for upper extremity assessment after stroke. As the aims, objectives and methodology of the existing reviews of the upper extremity outcome measures can vary, there is a need to bring together the evidence from existing multiple reviews. The purpose of this review was to provide an overview of evidence of the psychometric properties and clinical utility of upper extremity outcome measures for use in stroke, by systematically evaluating and summarizing findings from systematic reviews. Methods A comprehensive systematic search was performed including systematic reviews from 2004 to February 2014. A methodological quality appraisal of the reviews was performed using the AMSTAR-tool. Results From 13 included systematic reviews, 53 measures were identified of which 13 met the standardized criteria set for the psychometric properties. The strongest level of measurement quality and clinical utility was demonstrated for Fugl-Meyer Assessment, Action Research Arm Test, Box and Block Test, Chedoke Arm and Hand Activity Inventory, Wolf Motor Function Test and ABILHAND. Conclusions This overview of systematic reviews provides a comprehensive systematic synthesis of evidence on which outcome measures demonstrate a high level of measurement quality and clinical utility and which can be considered as most suitable for upper extremity assessment after stroke. This overview can provide a valuable resource to assist clinicians, researchers and policy makers in selection of appropriate outcome measures

Physical Activity Level, Barriers, and Facilitators for Exercise Engagement for Chronic Community-Dwelling Stroke Survivors in Low-Income Settings: A Cross-Sectional Study in Benin

After a stroke incident, physical inactivity is common. People with stroke may perceive several barriers to performing physical activity (PA). This study aimed to document the PA level and understand the barriers and facilitators to engaging in PA for community-dwelling stroke survivors in Benin, a lower middle-income country. A cross-sectional study was conducted in three hospitals in Benin. Levels of PA were recorded by means of the Benin version of the International Physical Activity Questionnaire long form (IPAQ-LF-Benin), which is validated for stroke survivors in Benin. The perceived exercise facilitators and barriers were assessed by the Stroke Exercise Preference Inventory-13 (SEPI-13). A descriptive analysis and associations were performed with a Confidence Interval of 95% and <0.05 level of significance. A total of 87 participants (52 men, mean age of 53 ± 10 years, mean time after a stroke of 11 (IQR: 15) months and an average of 264.5 ± 178.9 m as distance on the 6 min walking test (6MWT) were included. Overall, stroke survivors in Benin reached a total PA of 985.5 (IQR: 2520) metabolic equivalent (METs)-minutes per week and were least active at work, domestic, and leisure domains with 0 MET-minutes per week. The overview of PA level showed that 52.9% of participants performed low PA intensity. However, 41.4% performed moderate PA or walking per day for at least five days per week. Important perceived barriers were lack of information (45.3%), hard-to-start exercise (39.5%), and travelling to places to exercise (29.9%). The preference for exercise was with family or friends, outdoors, for relaxation or enjoyment (90.2%), and receiving feedback (78.3%). Several socio-demographic, clinical, and community factors were significantly associated with moderate or intense PA (p < 0.05) in stroke survivors in this study. Our findings show that the PA level among chronic stroke survivors in Benin is overall too low relative to their walking capacity. Cultural factors in terms of the overprotection of the patients by their entourage and/or the low health literacy of populations to understand the effect of PA on their health may play a role. There is a need for new approaches that consider the individual barriers and facilitators to exercise

Exercise dosage to facilitate the recovery of balance, walking, and quality of life after stroke

Background: Although aerobic training (AT) and resistance training (RT) are recommended after stroke, the optimal dosage of these interventions and their effectiveness on balance, walking capacity, and quality of life (QoL) remain conflicting. Objective: Our study aimed to quantify the effects of different modes, dosages and settings of exercise therapy on balance, walking capacity, and QoL in stroke survivors. Methods: PubMed, CINHAL, and Hinari databases were searched for randomised controlled trials (RCTs) evaluating the effects of AT and RT on balance, walking, and QoL in stroke survivors. The treatment effect was computed by the standard mean differences (SMDs). Results: Twenty-eight trials (n = 1571 participants) were included. Aerobic training and RT interventions were ineffective on balance. Aerobic training interventions were the most effective in improving walking capacity (SMD = 0.37 [0.02, 0.71], p = 0.04). For walking, capacity, a higher dosage (duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve) of AT interventions demonstrated a significantly greater effect (SMD = 0.58 [0.12, 1.04], p = 0.01). Combined AT and RT improved QoL (SMD = 0.56 [0.12, 0.98], p = 0.01). Hospital located rehabilitation setting was effective for improving walking capacity (SMD = 0.57 [0.06, 1.09], p = 0.03) compared with home and/or community and laboratory settings. Conclusions: Our findings showed that neither AT nor RT have a significant effect on balance. However, AT executed in hospital-located settings with a higher dose is a more effective strategy to facilitate walking capacity in chronic stroke. In contrast, combined AT and RT is beneficial for improving QoL. Clinical implications: A high dosage of aerobic exercise, duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve is beneficial for improving walking capacity

Detrended fluctuation analysis of gait dynamics when entraining to music and metronomes at different tempi in persons with multiple sclerosis

In persons with multiple sclerosis (PwMS), synchronizing walking to auditory stimuli such as to music and metronomes have been shown to be feasible, and positive clinical effects have been reported on step frequency and perception of fatigue. Yet, the dynamic interaction during the process of synchronization, such as the coupling of the steps to the beat intervals in music and metronomes, and at different tempi remain unknown. Understanding these interactions are clinically relevant, as it reflects the pattern of step intervals over time, known as gait dynamics. 28 PwMS and 29 healthy controls were instructed to walk to music and metronomes at 6 tempi (0-10% in increments of 2%). Detrended fluctuation analysis was applied to calculate the fractal statistical properties of the gait time-series to quantify gait dynamics by the outcome measure alpha. The results showed no group differences, but significantly higher alpha when walking to music compared to metronomes, and when walking to both stimuli at tempi+8,+10% compared to lower tempi. These observations suggest that the precision and adaptation gain differ during the coupling of the steps to beats in music compared to metronomes (continuous compared to discrete auditory structures) and at different tempi (different inter-beat-intervals)

Between-Day Reliability of the Gait Characteristics and Their Changes During the 6-Minute Walking Test in People With Multiple Sclerosis

Background: Gait characteristics and their changes during the 6-minute walking test (6MWT) in people with multiple sclerosis (pwMS) have been described in the literature, which one may refer to as walking fatigability in the body function level of the International Classification of Functioning, Disability, and Health. However, whether these metrics are reliable is unknown. Objective: To investigate the between-day reliability of the gait characteristics and their changes in pwMS and healthy controls (HCs). Methods: Forty-nine pwMS (EDSS 4.82 ± 1.22 and 54.7 ± 9.36 years) and 23 HCs (50.6 ± 6.1 years) performed the 6MWT, as fast as possible but safely while wearing Inertial Measurement Units. Gait characteristics were measured in the pace, rhythm, variability, asymmetry, kinematics, coordination, and postural control domains and were obtained in intervals of 1 minute during the 6MWT. In addition, gait characteristics change in the last minute compared with the first minute were calculated for all gait variables using a fatigability index (ie, distance walking index). The intraclass correlation coefficient (ICC), Bland-Altman Plots, and Standard error of measurement were applied to investigate reliability. Results: Reliability of gait characteristics, minute-by-minute, and for their changes (ie, using the fatigability index) ranged from poor to excellent (pwMS: ICC 0.46-0.96; HC: ICC 0.09-0.97 and pwMS: ICC 0-0.72; HC: ICC 0-0.77, respectively). Conclusion: Besides coordination, at least 1 variable of each gait domain showed an ICC of moderate or good reliability for gait characteristics changes in both pwMS and HC. These metrics can be incorporated into future clinical trials and research on walking fatigability.Clinical Trial Registration: NCT05412043

European evidence-based recommendations for clinical assessment of upper limb in neurorehabilitation (CAULIN): data synthesis from systematic reviews, clinical practice guidelines and expert consensus

Background: Technology-supported rehabilitation can help alleviate the increasing need for cost-effective rehabilitation of neurological conditions, but use in clinical practice remains limited. Agreement on a core set of reliable, valid and accessible outcome measures to assess rehabilitation outcomes is needed to generate strong evidence about effectiveness of rehabilitation approaches, including technologies. This paper collates and synthesizes a core set from multiple sources; combining existing evidence, clinical practice guidelines and expert consensus into European recommendations for Clinical Assessment of Upper Limb In Neurorehabilitation (CAULIN). Methods: Data from systematic reviews, clinical practice guidelines and expert consensus (Delphi methodology) were systematically extracted and synthesized using strength of evidence rating criteria, in addition to recommendations on assessment procedures. Three sets were defined: a core set: strong evidence for validity, reliability, responsiveness and clinical utility AND recommended by at least two sources; an extended set: strong evidence OR recommended by at least two sources and a supplementary set: some evidence OR recommended by at least one of the sources. Results: In total, 12 measures (with primary focus on stroke) were included, encompassing body function and activity level of the International Classification of Functioning and Health. The core set recommended for clinical practice and research: Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT); the extended set recommended for clinical practice and/or clinical research: kinematic measures, Box and Block Test (BBT), Chedoke Arm Hand Activity Inventory (CAHAI), Wolf Motor Function Test (WMFT), Nine Hole Peg Test (NHPT) and ABILHAND; the supplementary set recommended for research or specific occasions: Motricity Index (MI); Chedoke-McMaster Stroke Assessment (CMSA), Stroke Rehabilitation Assessment Movement (STREAM), Frenchay Arm Test (FAT), Motor Assessment Scale (MAS) and body-worn movement sensors. Assessments should be conducted at pre-defined regular intervals by trained personnel. Global measures should be applied within 24 h of hospital admission and upper limb specific measures within 1 week. Conclusions: The CAULIN recommendations for outcome measures and assessment procedures provide a clear, simple, evidence-based three-level structure for upper limb assessment in neurological rehabilitation. Widespread adoption and sustained use will improve quality of clinical practice and facilitate meta-analysis, critical for the advancement of technology-supported neurorehabilitation.The European Network on Robotics for NeuroRehabilitation (Working Group 1) developed these recommendations. Their work was funded by the European Co-Operation in Science and Technology (COST Action TD1006) programme. The funding body had no role in or infuence on the selected approach and synthesis, analysis, and interpretation of data and in writing the manuscript